Lessons Learned From a Multisite Evaluation of Geriatric and Extended Care Programs.

With the increased use of multisite evaluation and implementation studies in health care, our team of evaluators reflects on our evaluation of a large-scale multiyear geriatric and extended care program implementation. We share lessons from conducting multiple rounds of data collection, analyses, and reporting. We also identify some key factors that can facilitate or hinder multisite evaluation efforts involving programs with different models of implementation. This article strives to improve the quality of large-scale evaluations of health programs implementation. Knowledge gained from this complex evaluation will inform public health programs funders, implementers, and key program staff to better plan for, engage in, and benefit from effective complex evaluations to promote health in diverse settings.

Patient-centred care is a way of doing things: How healthcare employees conceptualize patient-centred care.

BACKGROUND: Patient-centred care is now ubiquitous in health services research, and healthcare systems are moving ahead with patient-centred care implementation. Yet, little is known about how healthcare employees, charged with implementing patient-centred care, conceptualize what they are implementing. OBJECTIVE: To examine how hospital employees conceptualize patient-centred care. RESEARCH DESIGN: We conducted qualitative interviews about patient-centred care during site four visits, from January to April 2013. SUBJECTS: We interviewed 107 employees, including leadership, middle managers, front line providers and staff at four US Veteran Health Administration (VHA) medical centres leading VHA's patient-centred care transformation. MEASURES: Data were analysed using grounded thematic analysis. Findings were then mapped to established patient-centred care constructs identified in the literature: taking a biopsychosocial perspective; viewing the patient-as-person; sharing power and responsibility; establishing a therapeutic alliance; and viewing the doctor-as-person. RESULTS: We identified three distinct conceptualizations: (i) those that were well aligned with established patient-centred care constructs surrounding the clinical encounter; (ii) others that extended conceptualizations of patient-centred care into the organizational culture, encompassing the entire patient-experience; and (iii) still others that were poorly aligned with patient-centred care constructs, reflecting more traditional patient care practices. CONCLUSIONS: Patient-centred care ideals have permeated into healthcare systems. Additionally, patient-centred care has been expanded to encompass a cultural shift in care delivery, beginning with patients' experiences entering a facility. However, some healthcare employees, namely leadership, see patient-centred care so broadly, it encompasses on-going hospital initiatives, while others consider patient-centred care as inherent to specific positions. These latter conceptualizations risk undermining patient-centred care implementation by limiting transformational initiatives to specific providers or simply repackaging existing programmes.

Evaluating the Implementation of Project Re-Engineered Discharge (RED) in Five Veterans Health Administration (VHA) Hospitals.

BACKGROUND: Improving the process of hospital discharge is a critical priority. Interventions to improve care transitions have been shown to reduce the rate of early unplanned readmissions, and consequently, there is growing interest in improving transitions of care between hospital and home through appropriate interventions. Project Re-Engineered Discharge (RED) has shown promise in strengthening the discharge process. Although studies have analyzed the implementation of RED among private-sector hospitals, little is known about how hospitals in the Veterans Health Administration (VHA) have implemented RED. The RED implementation process was evaluated in five VHA hospitals, and contextual factors that may impede or facilitate the undertaking of RED were identified. METHODS: A qualitative evaluation of VHA hospitals' implementation of RED was conducted through semistructured telephone interviews with personnel involved in RED implementation. Qualitative data from these interviews were coded and used to compare implementation activities across the five sites. In addition guided by the Practical, Robust Implementation and Sustainability Model (PRISM), cross-site analyses of the contextual factors were conducted using a consensus process. RESULTS: Progress and adherence to the RED toolkit implementation steps and intervention components varied across study sites. A majority of contextual factors identified were positive influences on sites' implementation. CONCLUSION: Although the study sites were able to tailor and implement RED because of its adaptability, redesigning discharge processes is a significant undertaking, requiring additional support/resources to incorporate into an organization's existing practices. Lessons learned from the study should be useful to both VHA and private-sector hospitals interested in implementing RED and undertaking a care transition intervention.

Housing First and the Risk of Failure: A Comment on Westermeyer and Lee (2013).

Over the last 5 years, community policies in response to homelessness have shifted toward offering permanent housing accompanied by treatment supports, without requiring treatment success as a precondition. The US Department of Veterans Affairs (VA) has embraced this "Housing First" approach. A 2013 report sounds a contrarian note. In a 16-person quasi-experimental study, 8 veterans who entered VA's permanent supportive housing did poorly, whereas 8 veterans who remained in more traditional treatment did well. In this commentary, we suggest that the report was problematic in the conceptualization of the matters it sought to address and in its science. Nonetheless, it highlights challenges that must not be ignored. From this report and other research, we now know that even more attention is required to support clinical recovery for Housing First clients. Successful implementation of Housing First requires guidance from agency leaders, and their support for clinical staff when individual clients fare poorly.

Strategies for Aligning Physicians to System Redesign Goals at Eight Safety-Net Systems.

BACKGROUND: Facing recent economic and regulatory pressures, safety-net systems (SNSs) are redesigning their organizations to improve care delivery, remain financially viable, and maintain competitive positions. Aligning physicians with redesign goals is a priority, particularly as many SNSs shift toward patient-centered, population health-focused models. No previous work has examined efforts to align physicians to safety net redesign efforts. METHODS: This qualitative study, conducted at eight SNSs, examined challenges faced in a changing health care environment, as well as strategies and resources to address them. RESULTS: Strategies clustered in two categories: physician role definition and organizational infrastructure. Physician role definition strategies were (1) changing payment and employment arrangements, (2) changing clinical roles, (3) increasing physician involvement in quality improvement, and (4) strengthening physician leadership in clinical and quality roles. Organizational infrastructure strategies were (1) ensuring medical center leadership support and integration, (2) utilizing data to drive physician behavior, and (3) addressing competing allegiances with academia. All sites reported multifaceted approaches but differed in specific strategies employed, facilitators noted, and challenges encountered. DISCUSSION: The findings highlight the need to implement multiple strategies to align physicians in redesign efforts. They suggest that all health systems, whether SNSs or not, can capitalize on qualities of physicians and existing infrastructural and leadership elements to achieve physician alignment. However, they must contend with and address challenges of competing allegiance (for example, academic, physician organization, hospital), as well as resistance to changing clinical roles and payment structures.

Comprehensive programs for preventing pressure ulcers: a review of the literature.

OBJECTIVE: The objective of this study was to examine the evidence supporting the combined use of interventions to prevent pressure ulcers (PrUs) in acute care and long-term-care facilities. DESIGN: A systematic review of the literature describing multifaceted PrU prevention programs was performed. Articles were included if they described an intervention implemented in acute care settings or long-term-care facilities, incorporated more than 1 intervention component, involved a multidisciplinary team, and included information about outcomes related to the intervention. MAIN RESULTS: Twenty-four studies were identified. Recurring components used in the development and implementation of PrU prevention programs included preparations prior to the start of a program, PrU prevention best practices, staff education, clinical monitoring and feedback, skin care champions, and cues to action. Ten studies reported PrU prevalence rates; 9 of them reported decreased prevalence rates at the end of their programs. Of the 6 studies reporting PrU incidence rates, 5 reported a decrease in incidence rates. Four studies measured care processes: 1 study reported an overall improvement; 2 studies reported improvement on some, but not all, measures; and 1 study reported no change. CONCLUSIONS: There is a growing literature describing multipronged, multidisciplinary interventions to prevent PrUs in acute care settings and long-term-care facilities. Outcomes reported in these studies suggest that such programs can be successful in reducing PrU prevalence or incidence rates. However, to strengthen the level of evidence, sites should be encouraged to rigorously evaluate their programs and to publish their results.

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.

Building Systemwide Improvement Capability: Does an Organization's Strategy for Quality Improvement Matter?

OBJECTIVES: Health care organizations have used different strategies to implement quality improvement (QI) programs but with only mixed success in implementing and spreading QI organization-wide. This suggests that certain organizational strategies may be more successful than others in developing an organization's improvement capability. To investigate this, our study examined how the primary focus of grant-funded QI efforts relates to (1) key measures of grant success and (2) organization-level measures of success in QI and organizational learning. METHODS: Using a mixed-methods design, we conducted one-way analyses of variance to relate Veterans Affairs administrative survey data to data collected as part of a 3.5-year evaluation of 29 health care organization grant recipients. We then analyzed qualitative evidence from the evaluation to explain our results. RESULTS: We found that hospitals that focused on developing organizational infrastructure to support QI implementation compared with those that focused on training or conducting projects rated highest (at α = .05) on all 4 evaluation measures of grant success and all 3 systemwide survey measures of QI and organizational learning success. CONCLUSIONS: This study adds to the literature on developing organizational improvement capability and has practical implications for health care leaders. Focusing on either projects or staff training in isolation has limited value. Organizations are more likely to achieve systemwide transformation of improvement capability if their strategy emphasizes developing or strengthening organizational systems, structures, or processes to support direct improvement efforts.

Survey-assessed quality and organizational factors related to quality in Pursuing Perfection hospitals.

BACKGROUND: The goal of the Pursuing Perfection (P2) program was to encourage organizations to push quality improvement to new levels of excellence. As part of an evaluation of P2, we surveyed employees at the 7 participating P2 organizations to (1) assess their perceptions of patient care quality and improvement progress and (2) examine perceived performance on organizational and workgroup characteristics associated with quality. METHODS: Many survey questions were drawn from existing conceptual models and survey instruments. We used factor analysis to create new scales from questions that were not part of established scales. We used correlation coefficients and multivariable models to examine relationships among variables. RESULTS AND CONCLUSIONS: Variables most strongly associated with perceived quality included standardized and simplified care processes resulting in coordinated care and smooth handoffs, a clear sense of organizational direction and clear action plans, and communication with staff about reasons for change and improvement progress made. Of those variables with a strong relationship to quality, ones with relatively low mean ratings included workgroup coordination; sufficient resources and support for improvement; training; and efficient use of people, time, and energy. These are important areas on which management should focus to improve employee ratings of quality.

Predicting healthcare employees' participation in an office redesign program: attitudes, norms and behavioral control.

BACKGROUND: The study examined the extent to which components based on a modified version of the theory of planned behavior explained employee participation in a new clinical office program designed to reduce patient waiting times in primary care clinics. METHODS: We regressed extent of employee participation on attitudes about the program, group norms, and perceived behavioral control along with individual and clinic characteristics using a hierarchical linear mixed model. RESULTS: Perceived group norms were one of the best predictors of employee participation. Attitudes about the program were also significant, but to a lesser degree. Behavioral control, however, was not a significant predictor. Respondents with at least one year of clinic tenure, or who were team leaders, first line supervisor, or managers had greater participation rates. Analysis at the clinic level indicated clinics with scores in the highest quartile clinic scores on group norms, attitudes, and behavioral control scores were significantly higher on levels of overall participation than clinics in the lowest quartile. CONCLUSION: Findings suggest that establishing strong norms and values may influence employee participation in a change program in a group setting. Supervisory level was also significant with greater responsibility being associated with greater participation.

Evaluation of the Department of Veterans Affairs community-based outpatient clinics.

OBJECTIVE: This paper describes the history of the Department of Veterans Affairs (VA) Community-Based Outpatient Clinics (CBOCs), CBOC Performance Evaluation Project, and characteristics of CBOCs within the VA, and summarizes the findings and implications of the CBOC Performance Evaluation Project. SUBJECTS: There were 139 CBOCs in operation at the end of fiscal year 1998. Ninety-eight percent of CBOCs offered primary health care, and 28% offered primary health care and primary mental health care. The average CBOC was 70.7 miles from its parent VAMC. Sixty-one percent of the CBOCs were located in urban areas and 39% were in rural areas. Sixty-four percent of the CBOCs were VA-staff and 36% were contract. RESULTS: The details of the project's findings are reported in four companion papers that describe, respectively, health care access and utilization, cost of care, patient perceptions of care, and quality of care in VA CBOCs. For most measures, CBOC performance was equivalent to their parent VAMCs. However, there were a few areas of potential concern: CBOCs had fewer patients that reported having one provider or team in charge of care; CBOC patients had fewer specialty visits; and CBOCs served a smaller percent of women and black persons. CONCLUSION: CBOCs appear to be performing comparably to their parent medical centers but will benefit from ongoing monitoring.