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01.12.2014 | Research article | Ausgabe 1/2014 Open Access

BMC Family Practice 1/2014

A qualitative study on clinicians’ perceptions about the implementation of a population risk stratification tool in primary care practice of the Basque Health Service

BMC Family Practice > Ausgabe 1/2014
Regina Sauto Arce, Amaia Saenz De Ormijana, Juan F Orueta, Marie-Pierre Gagnon, Roberto Nuño-Solinís
Wichtige Hinweise

Electronic supplementary material

The online version of this article (doi:10.​1186/​1471-2296-15-150) contains supplementary material, which is available to authorized users.

Competing interests

The authors have no financial competing interests to declare.
RNS and JFO declare what might be considered non-financial competing interests. JFO was the principal researcher responsible for the project of population risk stratification using the Adjusted Clinical Groups Predictive Model for the public Basque Health Service (Osakidetza). RNS is the Director of O + Berri, main funding agency of the stratification project. Nevertheless, these authors’ contribution to this work was limited to its conception, design and coordination, as well as technical advice concerning the tool. Hence, their interests have not influenced the results presented here.

Authors’ contributions

RSA facilitated one of the focus groups, co-conducted analysis and participated in the drafting of this paper. RSA (Degree in Business Studies) is Senior Researcher at O + berri. ASO designed the study, provided methodological support, co-conducted analysis and participated in the drafting of this paper. ASO (RN, BScHs in Nursing, MSc, PhD Cand) works as clinical nurse at an acute care hospital of the public Basque Health Service, Osakidetza. JFO participated in the design of the study, the organisation of the focus groups, and the drafting of the background section of this paper. JFO is paediatrician, and Head of the PC centre of Astrabudua (belonging to the public Basque Health Service, Osakidetza). MPG contributed to the analysis and presentation of results. MPG (PhD in Community Health) is Associate Professor at the Faculty of Nursing Sciences at Université Laval and researcher at the Research Centre of the CHU de Québec. RNS conceived the study and participated in its design and coordination. RNS (Degree in Economics and Business Administration, MSc in Health Economics) is Director of O + berri. All authors participated in critically reviewing the manuscript and approving its final version.



A prospective Population Risk Stratification (PRS) tool was first introduced in the public Basque Health Service in 2011, at the level of its several Primary Care (PC) practices. This paper aims at exploring the new tool’s implementation process, as experienced by its potential adopters/users, ie. PC clinicians (doctors and nurses). Findings could help guide future PRS implementation strategies.


Three focus groups exploring clinicians’ opinions and experiences related to the PRS tool and its implementation in their daily practice were conducted. A purposive sample of 12 General Practitioners and 11 PC nurses participated in the groups. Discussions were digitally recorded, transcribed verbatim and analysed by two independent researchers using thematic analysis based on Graham et al.’s Knowledge Translation Theory.


Exploring PC clinicians’ experience with the new PRS tool, allowed us to identify certain elements working as barriers and facilitators in its implementation process. This series of closely interrelated elements, which emerged as relevant in building up the complex implementation process of the new tool, as experienced by the clinicians, can be grouped into four domains: 1) clinicians’ characteristics as potential adopters, 2) clinicians’ perceptions of their practice settings where PRS is to implemented, 3) clinicians’ perceptions of the tool, and 4) the implementation strategy used by the PRS promoter.


Lessons from the implementation process under study point at the need to frame the implementation of a new PRS tool within a wider strategy encouraging PC clinicians to orientate their daily practice towards a population health approach. The PRS tool could also improve the perceived utility by its potential adopters, by bringing it closer to the clinicians’ needs and practice, and allowing it to become context-sensitive. This would require clinicians being involved from the earliest phases of conceptualisation, design and implementation of the new tool, and mounting efforts to improve communication between clinicians and tool promoters.
Graham et al.’s Knowledge Translation Theory proved a suitable framework to explore the implementation process of a new PRS tool in the public Basque Health Service’s PC practice, and hence to identify implementation barriers and facilitators as experienced by the clinicians.
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