265 Discussion the identification of barriers for using PROMs mainly performed in the adult care setting (18-25). In a paper series of case studies regarding the use of implementation science for PROM/PREM implementation, which includes Chapter 6, Stover et al. (21) indicated that barriers for PROM implementation were consistent across populations and settings, while facilitators were more context-specific. Implementation strategies can help to overcome the identified barriers. The paper series showed that identified implementation strategies in the different studies almost all match the ‘Expert Recommendations for Implementing Change’ (ERIC) (26), suggesting the value of these strategies independent of setting (21). During the retrospective assessment of the KLIK PROM portal (Chapter 6), we used the CFIR-ERIC matching tool to identify implementation strategies (27). The strategy ‘identify and prepare champions’ was identified as the most effective strategy to address the mentioned barriers in the KLIK PROM portal. This means that we should identify an individual of the health care team that supports the implementation and can help to overcome indifference or resistance that implementation of the KLIK PROM portal can provoke at an organizational level (26). This strategy was not innovative for the KLIK PROM implementation, as we already were aware of the helping role of the champion. The KLIK implementation always starts at request of a health care team and therefore a large part of the team is motivated to implement PROMs. We noticed that it is particularly helpful if the opinion of one of the motivated team members is highly valued by their colleagues, as this team member can function as a champion and can motivate their colleagues to change (28). In our opinion, a bottom-up implementation as opposed to a top-down approach, which is regularly seen in PROM implementation initiatives, is valuable. However, (financial) support from management and the board of the hospital is necessary to enhance the sustainability of change. We are currently working on the identified ERIC strategies to improve the KLIK PROM implementation. For example, we assess key stakeholders for readiness (i.e., we conduct evaluation meetings with the multidisciplinary teams and pay attention to the more reluctant team members to better understand their underlying resistance), inform local opinion leaders (i.e., we talk about the added value of using PROMs at conferences and symposia. This information is picked up by opinion leaders who talk about it with their colleagues), access new funding, and tailoring strategies (i.e., we tailor implementation strategies to address identified barriers). In addition, we added information about the evidence of implementing PROMs in the KLIK training 9
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