The research team, led by Rachel Forbes, Marissa C. Kuo, and Elisa J. Gordon, conducted a prospective, cross-sectional, single-center study using a mixed-methods concurrent triangulation design. They interviewed twenty clinicians and implementation science experts, drawn from the kidney transplant program and Vanderbilt Health’s Center for Clinical Quality and Implementation Research, along with twenty-three patients who had been referred to, waitlisted for, or had received a kidney transplant at the center. Semi-structured interviews were conducted by Microsoft Teams between late February and late April 2024, with clinician interviews averaging fifty-five minutes and patient interviews averaging thirty-three minutes. During the interviews, participants also completed descriptive surveys, allowing the researchers to compare qualitative themes with quantitative ratings and strengthen the validity of their findings.

The analytical backbone of the study was the Consolidated Framework for Implementation Research 2.0, an evidence-based determinant framework comprising thirty-eight constructs across five domains: Innovation Characteristics, Individual Characteristics, Inner Setting, Outer Setting, and Process. In this study, Innovation Characteristics referred to the dashboard itself, Individual Characteristics to the people who would create and use it, Inner Setting to the hospital system, Outer Setting to the surrounding community and state, and Process to the strategies used to deploy it. Transcripts were analyzed using deductive coding guided by the framework, with each transcript independently coded by at least two research team members. Inter-rater reliability was assessed iteratively until the team reached a Cohen’s kappa coefficient above 0.80, and coding discrepancies were resolved through consensus discussions.

The results paint a strikingly optimistic picture. Perceived facilitators included Inner Setting constructs of mission alignment, culture, tension for change, compatibility, and structural characteristics, along with the Individual Characteristics construct of high-level leaders. Participants anticipated that the dashboard would align with the institution’s commitment to patient-centered care, fit naturally into center workflow, and enjoy strong leadership support. One clinician explained that the dashboard highly aligned with the transplant center’s mission of providing lifesaving organs to anyone who could benefit from them, noting that large groups of patient populations lack access to transplant and that the tool would help fix that. Another emphasized that the culture of the transplant center, where people at every level are passionate about helping patients get transplanted, would motivate everyone to step up if findings showed inequities that needed addressing.

Leadership support emerged as a particularly powerful facilitator. Participants anticipated that the transplant center’s and organization’s leadership would provide strong project buy-in because leadership had already demonstrated support for endeavors promoting equitable care. One respondent noted that leadership would have a vested interest in supporting the dashboard for advancing the goal of increasing transplant volumes by identifying and overcoming barriers to transplantation. Respondents recognized the need for sustained and proactive leadership involvement to ensure the dashboard’s effective integration and sustainability within clinical workflows, viewing leadership support not simply as administrative endorsement but as a prerequisite for securing organizational commitment, allocating resources, and sustaining implementation over time.

Perceived barriers, by contrast, were concentrated in the Innovation Characteristics construct of costs and the Inner Setting constructs of access to knowledge and information, information technology infrastructure, and work infrastructure. Financial costs were expected to support information technology development, staff training and time, and interventions arising from dashboard findings. Yet participants generally distinguished between the initial investment required to develop the dashboard and the relatively limited resources anticipated for long-term maintenance. One clinician remarked that while it would cost money, once the original design was established it should become fairly automatic, and that the cost would not be astronomical if the institution valued the project. Another noted that short-term resources would be needed but that long-term requirements would be minimal once the system was in place.

Work infrastructure concerns reflected the realities of a busy academic hospital. Participants worried about how dashboard implementation would add responsibilities to an already overextended workforce, with one noting that people get comfortable with a certain workflow and that adding something else can throw a monkey wrench into how they work. Respondents identified potential challenges of integrating the dashboard into existing workflows, including pre-determining dashboard content, defining data elements and visualization standards, developing mechanisms for maintenance, and determining how findings would be used and disseminated. The potential for variation in dashboard data collection or interpretation was seen as threatening consistency and reliability. Information technology infrastructure was another widely recognized barrier, with respondents emphasizing the importance of securing health IT’s support and identifying team members with expertise in health science informatics to ensure the dashboard could be built within the existing electronic health record.

Beyond barriers and facilitators, the study generated concrete design recommendations. All surveyed clinicians and patients agreed to include six of the eight evaluation phases in the dashboard, including the total number of patients referred for transplantation, the percentage of referred patients who were waitlisted, and the percentages who received a kidney transplant overall, a deceased donor transplant, or a living donor transplant. All clinicians agreed to include eight of the twenty-five social drivers of health listed, with leading variables including patient age, access to healthcare services, and healthcare communications. Patients suggested also tracking pre-referral phases such as the severity of kidney failure, adherence to dialysis, and access to living donors, along with reasons for delays during evaluation and post-transplant outcomes. Notably, clinicians expressed a preference for including more social drivers in the dashboard than patients did, which the researchers attributed to clinicians’ commitment to upholding institutional values of equity, quality improvement, and access to transplant care.

The researchers argue that the asymmetry between barriers and facilitators is what makes the dashboard so promising. Perceived barriers were largely modifiable, while perceived facilitators were immutable and integral to the institution’s core values, which would facilitate implementation. The study also identified a reverse causal relationship compared with existing business management literature: rather than the dashboard creating mission alignment, existing institutional values were expected to facilitate dashboard adoption. The team plans to integrate the dashboard into the electronic health record, updated in real time, and to use it during routine quarterly Quality Assurance and Performance Improvement meetings where the full multidisciplinary transplant team will review and monitor results. They emphasize engaging the entire team when discussing dashboard data because it takes a collective effort to address these things, and recommend establishing a safe space for discussion with expectations that not all identified disparities can be acted upon immediately.

The implications extend beyond one transplant center. In 2021, the Organ Procurement and Transplantation Network developed an Equity in Access to Transplant dashboard to assess the impact of social drivers on waitlisting and transplantation, but that dashboard does not assess the impact of social drivers from referral throughout the evaluation process, which the proposed Equity Dashboard aims to do. The Vanderbilt team’s next steps entail building the dashboard and conducting a modified Delphi method including clinicians and patients to refine dashboard variables and integration into existing workflows, with special consideration granted to patient-prioritized variables identified through the present study. The researchers do not anticipate designing the dashboard to be patient-facing, since the transplant center may not be equipped to address upstream, nonmodifiable risk factors contributing to disparities, which could lead patients to misinterpret the data. As a single-center study, the findings may not generalize to other transplant programs, and the researchers acknowledge limitations including low patient participation rates attributed to the opt-in portal recruitment approach and the exclusion of non-English speakers, which may underestimate barriers faced by the very populations the dashboard aims to track. Nevertheless, the convergence between qualitative themes and quantitative survey responses strengthens confidence that the proposed dashboard content reflects stakeholder priorities rather than isolated opinions, and future research will evaluate the dashboard’s implementation on patients’ actual transplant access.

Subject of Research: Barriers and facilitators to implementing an electronic equity dashboard for identifying disparities in kidney transplant access

Article Title: Barriers and facilitators to developing an equity dashboard to identify disparities in kidney transplant access: a mixed methods study

Article References: Forbes, R., Kuo, M. C., Frazee, M. D., Rogers, J. L., Vimalathas, P., Brooks, H. L., & Gordon, E. J. (2026). Barriers and facilitators to developing an equity dashboard to identify disparities in kidney transplant access: a mixed methods study. Frontiers in Transplantation, 5, Article 1906784. https://doi.org/10.3389/frtra.2026.1906784

Image Credits: AI Generated

DOI: 10.3389/frtra.2026.1906784

Keywords: kidney transplant, health equity, equity dashboard, transplant disparities, social drivers of health, implementation science, electronic health record, Consolidated Framework for Implementation Research, mixed methods, transplant evaluation, Quality Assurance and Performance Improvement, patient-centered care