Strengthening organizations to implement evidence-based clinical practices.

OBJECTIVES: Despite recognition that implementation of evidence-based clinical practices (EBPs) usually depends on the structure and processes of the larger health care organizational context, the dynamics of implementation are not well understood. This project's aim was to deepen that understanding by implementing and evaluating an organizational model hypothesized to strengthen the ability of health care organizations to facilitate EBPs. CONCEPTUAL MODEL: The model posits that implementation of EBPs will be enhanced through the presence of three interacting components: active leadership commitment to quality, robust clinical process redesign incorporating EBPs into routine operations, and use of management structures and processes to support and align redesign. STUDY DESIGN: In a mixed-methods longitudinal comparative case study design, seven medical centers in one network in the Department of Veterans Affairs participated in an intervention to implement the organizational model over 3 years. The network was selected randomly from three interested in using the model. The target EBP was hand-hygiene compliance. Measures included ratings of implementation fidelity, observed hand-hygiene compliance, and factors affecting model implementation drawn from interviews. FINDINGS: Analyses support the hypothesis that greater fidelity to the organizational model was associated with higher compliance with hand-hygiene guidelines. High-fidelity sites showed larger effect sizes for improvement in hand-hygiene compliance than lower-fidelity sites. Adherence to the organizational model was in turn affected by factors in three categories: urgency to improve, organizational environment, and improvement climate. IMPLICATIONS: Implementation of EBPs, particularly those that cut across multiple processes of care, is a complex process with many possibilities for failure. The results provide the basis for a refined understanding of relationships among components of the organizational model and factors in the organizational context affecting them. This understanding suggests practical lessons for future implementation efforts and contributes to theoretical understanding of the dynamics of the implementation of EBPs.

Implementation of a clinical innovation: the case of advanced clinic access in the Department of Veterans Affairs.

Healthcare organizations seeking to improve clinical practices often have disappointing results because the planned innovations are not successfully implemented. To increase the understanding of implementation, we analyzed the national spread of an ambulatory innovation in the Department of Veterans Affairs. This study provides support for a conceptual model that posits that the extent to which a clinical innovation is implemented will be affected by factors in 3 domains: (1) intentional activities to introduce, spread, and support the innovation; (2) the attitudes and capabilities of clinic staff responsible for implementing the innovation; and (3) the context of the facility in which the innovation is being introduced. Among the strongest predictors of successful implementation, management support for the innovation and clinic team knowledge and skills to make changes successfully were significant across both primary care and specialty clinics.

An intensive care unit quality improvement collaborative in nine Department of Veterans Affairs hospitals: reducing ventilator-associated pneumonia and catheter-related bloodstream infection rates.

BACKGROUND: Measured adherence to evidence-based best practice in the intensive care unit (ICU) setting, as in all of health care, remains unacceptably low. In 2005 to 2006, the VA Midwest Health Care Network used a quality improvement collaborative (QIC) model to improve adherence with ICU best practices in widely varying ICU and hospital settings in nine Department of Veterans Affairs (VA) hospitals. METHODS: Interdisciplinary performance improvement teams at each of the participating sites implemented evidence-based ventilator and central line insertion bundles, interdisciplinary team rounds, and use of a daily patient ICU bedside checklist. RESULTS: Adherence with all five elements of the ventilator bundle improved from 50% in the first three months to 82% in the final three months of the intervention. Mean ventilator-associated pneumonia (VAP) rates decreased by 41% over the same time frame. Use of a central line insertion checklist to monitor adherence with the central line bundle increased from 58% in the first three months to 74% in the final three months of the intervention. Mean catheter-related bloodstream infection (CRBSI) rates decreased by 48% over the same time frame. Following completion of the collaborative, eight of the nine sites continued to report on adherence with the ventilator and central line bundles, the practice of interdisciplinary team rounds, and the use of an ICU patient checklist. The incidence of VAP and CRBSI in these eight sites declined in the 12-month period following the collaborative's completion, compared with the previous 12-month period. DISCUSSION: Implementing the ventilator and central line bundles was associated with a reduction in rates of VAPs and CRBSIs.

Health-related quality of life, functional impairment, and healthcare utilization by veterans: veterans' quality of life study.

OBJECTIVES: To describe the health status of veterans receiving care in a veterans integrated service network (VISN). DESIGN: Cross-sectional survey with prospective follow-up. SETTING: Former Upper Midwest VISN 13 (now a part of VISN 23), a regional Veterans Affairs (VA) network comprising five inpatient facilities and associated outpatient clinics. PARTICIPANTS: All veterans in VISN 13 who had at least one inpatient or outpatient encounter between October 1, 1997, and March 31, 1998. MEASUREMENTS: Health-related quality of life (HRQOL) assessed using subscales and component summaries from the 36-item short form for veterans (SF36-V), functional status assessed according to limitations in activities of daily living (ADLs), healthcare utilization assessed according to outpatient visits and hospitalizations, and death. RESULTS: Of 70,334 eligible veterans, 40,508 responded and reported baseline HRQOL significantly lower than that of the general U.S. population for the physical (35.6, P<.001) and mental (46.4, P<.001) component summary scores (PCS and MCS, respectively) of the SF36-V. Many reported complete inability or some difficulty in completing ADLs such as getting in and out of a chair (35.1%) and walking (45.3%). More than 58% indicated some degree of difficulty with at least one of the ADLs. In multivariate analysis, PCS and MCS were significantly associated with subsequent use of inpatient and outpatient care and with mortality. CONCLUSION: The low quality of life and associated high rates of health services utilization in VA patients imply a need for innovative strategies to improve the HRQOL and functional status of this population.

Monitoring the progress of system integration.

As providers of health care face the multiple challenges of today's health care environment, many believe that integrated delivery systems promise the structure needed to provide high-quality, cost-efficient care. They make structural and process changes with the expectation that those changes will improve system performance. But few systems actually measure progress in creating an integrated system. This article describes one health care system's strategy for introducing organizational measures to create an integrated system scorecard and focuses on the development, results, and use of the staff survey. The survey provides reliable indicators of system integration. Linking the survey results with network performance measures, in turn, provides managers with tools for judging whether system integration is associated with improved system performance.

Effects of high-involvement work systems on employee satisfaction and service costs in veterans healthcare.

Two strong imperatives for healthcare managers are reducing costs of service and attracting and retaining highly dedicated and competent patient care and support employees. Is there a trade-off or are there organizational practices that can further both objectives at the same time? High-involvement work systems (HIWS) represent a holistic work design that includes interrelated core features such as involvement, empowerment, development, trust, openness, teamwork, and performance-based rewards. HIWS have been linked to higher productivity, quality, employee and customer satisfaction, and market and financial performance in Fortune 1000 firms. Apparently, few prior studies have looked at the impacts of this holistic design within the healthcare sector. This research found that HIWS were associated with both greater employee satisfaction and lower patient service costs in 146 Veterans Health Administration centers, indicating that such practices pay off in both humanistic and financial terms. This suggests that managers implementing HIWS will incur real expenses that are likely to be more than offset by more satisfied employees, less organizational turmoil, and lower service delivery costs, which, in this study, amounted to over $1.2 million in savings for an average VHA facility.

Ten strategies to lower costs, improve quality, and engage patients: the view from leading health system CEOs.

Patient-centeredness--the idea that care should be designed around patients' needs, preferences, circumstances, and well-being--is a central tenet of health care delivery. For CEOs of health care organizations, patient-centered care is also quickly becoming a business imperative, with payments tied to performance on measures of patient satisfaction and engagement. In A CEO Checklist for High-Value Health Care, we, as executives of eleven leading health care delivery institutions, outlined ten key strategies for reducing costs and waste while improving outcomes. In this article we describe how implementation of these strategies benefits both health care organizations and patients. For example, Kaiser Permanente's Healthy Bones Program resulted in a 30 percent reduction in hip fracture rates for at-risk patients. And at Virginia Mason Health System in Seattle, nurses reorganized care patterns and increased the time they spent on direct patient care to 90 percent. Our experiences show that patient-engaged care can be delivered in ways that simultaneously improve quality and reduce costs.

Commentary: building human capital: discovery, learning, and professional satisfaction.

Physician satisfaction is an important contributor to a well-functioning health system. Mohr and Burgess report that physicians in the Veterans Health Administration (VA) who spend time in research have greater overall job satisfaction, that satisfaction tracks with aggregate facility research funding, and that satisfaction is higher among physicians working in VA facilities located on the same campus or within walking distance of an affiliated medical school. An environment conducive to research therefore not only advances science but also seems to be a key element of physician satisfaction. In addition to advancing scientific discovery and promoting greater physician satisfaction, these findings suggest that an environment of discovery and learning may yield benefits beyond specific academic endeavors and contribute more broadly to supporting health system performance.

Design, rationale, and baseline characteristics of a cluster randomized controlled trial of pay for performance for hypertension treatment: study protocol.

BACKGROUND: Despite compelling evidence of the benefits of treatment and well-accepted guidelines for treatment, hypertension is controlled in less than one-half of United States citizens. METHODS/DESIGN: This randomized controlled trial tests whether explicit financial incentives promote the translation of guideline-recommended care for hypertension into clinical practice and improve blood pressure (BP) control in the primary care setting. Using constrained randomization, we assigned 12 Veterans Affairs hospital outpatient clinics to four study arms: physician-level incentive; group-level incentive; combination of physician and group incentives; and no incentives (control). All participants at the hospital (cluster) were assigned to the same study arm. We enrolled 83 full-time primary care physicians and 42 non-physician personnel. The intervention consisted of an educational session about guideline-recommended care for hypertension, five audit and feedback reports, and five disbursements of incentive payments. Incentive payments rewarded participants for chart-documented use of guideline-recommended antihypertensive medications, BP control, and appropriate responses to uncontrolled BP during a prior four-month performance period over the 20-month intervention. To identify potential unintended consequences of the incentives, the study team interviewed study participants, as well as non-participant primary care personnel and leadership at study sites. Chart reviews included data collection on quality measures not related to hypertension. To evaluate the persistence of the effect of the incentives, the study design includes a washout period. DISCUSSION: We briefly describe the rationale for the interventions being studied, as well as the major design choices. Rigorous research designs such as the one described here are necessary to determine whether performance-based payment arrangements such as financial incentives result in meaningful quality improvements. TRIAL REGISTRATION: http://www.clinicaltrials.govNCT00302718.

Management perspectives on research contributions to practice through collaboration in the U.S. Veterans Health Administration: QUERI Series.

The Quality Enhancement Research Initiative (QUERI) is a unique quality improvement program designed to connect health services researchers to Veterans Health Administration (VHA) management and operations, as well as to provide the science and initiative for making change. Through this process, QUERI stakeholders have learned that success and impact in improving healthcare quality and outcomes largely depends on coordination and collaboration among numerous VHA programs and organizations working to develop and implement evidence-based clinical policies, practices, and quality improvement strategies. This Commentary discusses some of these collaborative efforts and perceived successes in achieving common goals from the viewpoints of two closely involved VHA Operations/Support stakeholders. The Commentary is part of a Series of articles documenting implementation science frameworks and tools developed by the U.S. Department of Veterans Affairs Quality Enhancement Research Initiative (QUERI).

Improving patient access to the Veterans Health Administration's primary care and specialty clinics.

BACKGROUND: During the past four years the Veterans Health Administration (VHA) has been engaged in a national effort to improve access for patients to its 1,826 primary care, audiology, cardiology, eye care, orthopedics, and urology clinics by using the principles of open access or "advanced clinic access." The strategy entailed the development of successful cases to demonstrate the methods of advanced clinic access and provide evidence of its benefits for providers as well as patients in primary care and specialty clinics. RESULTS: Four clinics--one primary care clinic and three specialty care clinics--showed dramatic improvement in waiting times for appointments (reductions range from 20 days in urology to 78 days in primary care). DISCUSSION: Beyond the four case studies, hundreds of other clinics in the VHA are also applying advanced clinic access principles in their work. The diversity across the VHA suggests that the principles of advanced clinic access are robust across settings and types of clinics. However, the experience of other organizations with different structures and patient populations needs to be reported to fully demonstrate the generalizability of these results. Many of the changes were put in place during the project's final 18 months. Additional data will be needed to demonstrate sustained improvement.