Determinants, strategies, and outcomes of implementing an enhanced dosimetry quality assurance checklist in radiation oncology: A qualitative implementation science study

Radiation oncology has a long history of developing in-house health information technology (HIT) tools such as quality assurance (QA) checklists, yet there is little guidance from professional bodies on how to implement these tools in complex clinical environments. Building on our previous work that used human-centered participatory co-design, the Task-User-Representation-Function (TURF) framework, and multi-method usability evaluations to design and develop an enhanced dosimetry QA checklist (DQC), this study investigated the barriers and facilitators (determinants) to implementing the enhanced DQC in a radiation oncology clinic, examined implementation strategies, proposed an implementation framework for QA checklists in radiation oncology, and assessed four implementation outcomes: acceptability, appropriateness, feasibility, and adoption. We conducted a qualitative implementation study using an abductive research approach at an academic medical center. All key stakeholders (dosimetrists, physicists, trainees, and software developers) participated in semi-structured interviews, field observations, and surveys across pre-implementation, implementation, and post-implementation phases. Data were analyzed using a hybrid inductive-deductive approach, with deductive coding guided by an adapted Consolidated Framework for Implementation Research (CFIR) mapped to the Unified Theory of Acceptance and Use of Technology and by the Expert Recommendations for Implementing Change (ERIC) compilation. We identified 4 CFIR constructs and 12 sub-constructs as barriers, with structural characteristics and planning showing the highest negative valence, and 5 CFIR constructs and 19 sub-constructs as facilitators, with relative advantage, culture, and leadership engagement showing the highest positive valence. Participants' suggestions mapped to 19 ERIC strategies in 7 clusters, and the CFIR-ERIC matching tool identified 14 evidence-based strategies in 4 clusters that informed a proposed phased implementation framework. Acceptability, appropriateness, and feasibility scores improved significantly from pre-implementation to implementation for all professional roles (p<0.05), yet adoption reached 100% only in the sixth week of implementation. These findings highlight the value of combining subjective and objective implementation outcomes and provide a practical, evidence-based framework for implementing in-house QA checklists in radiation oncology that warrants validation in diverse settings.