Overcoming barriers to implementation: mapping implementation strategies in four hospital in home programs within the Veterans Health Administration.

The Hospital at Home model, called Hospital-in-Home (HIH) in the Department of Veterans Affairs, delivers coordinated, high-value care aligned with older adult and caregiver preferences. Documenting implementation barriers and corresponding strategies to overcome them can address challenges to widespread adoption. To evaluate HIH implementation barriers and identify strategies to address them, we conducted interviews with 8 HIH staff at 4 hospitals between 2010 and 2013. We utilized qualitative directed content analysis guided by the Consolidated Framework for Implementation Research (CFIR) and mapped identified barriers to possible strategies using the CFIR-Expert Recommendations for Implementing Change (ERIC) Matching Tool. We identified 11 barriers spanning 5 CFIR domains. Three implementation strategies - identifying and preparing champions, conducting educational meetings, and capturing and sharing local knowledge - achieved high expert endorsement for each barrier. A mix of strategies targeting resources, organizational readiness and fit, and leadership engagement should be considered to support the sustainability and spread of HIH.

Quality Improvement Efforts in VA Community Living Centers Following Public Reporting of Performance.

For two decades, the U.S. government has publicly reported performance measures for most nursing homes, spurring some improvements in quality. Public reporting is new, however, to Department of Veterans Affairs nursing homes (Community Living Centers [CLCs]). As part of a large, public integrated healthcare system, CLCs operate with unique financial and market incentives. Thus, their responses to public reporting may differ from private sector nursing homes. In three CLCs with varied public ratings, we used an exploratory, qualitative case study approach involving semi-structured interviews to compare how CLC leaders (n = 12) perceived public reporting and its influence on quality improvement. Across CLCs, respondents said public reporting was helpful for transparency and to provide an "outside perspective" on CLC performance. Respondents described employing similar strategies to improve their public ratings: using data, engaging staff, and clearly defining staff roles vis-à-vis quality improvement, although more effort was required to implement change in lower performing CLCs. Our findings augment those from prior studies and offer new insights into the potential for public reporting to spur quality improvement in public nursing homes and those that are part of integrated healthcare systems.

A Paucity of Data on Veterans 65 and Older and Risk of Suicide: A Systematic Review.

Older veterans are vastly underrepresented in studies that shape national suicide prevention strategies. This is of great concern because factors that impact younger veterans may not be as robust in later life. Although younger veterans have higher rate of suicide, the highest counts of death by suicide are in older veterans. However, it remains unclear from the extant literature what factors may influence increased or decreased risk of late-life suicide in veterans. The objective of this systematic review was to identify risk and protective factors related to suicide outcomes (i.e., ideation, attempt, death, or suicide-related behavior [SRB]) among older veterans. Furthermore, it offers data regarding future study directions and hypothesis generation for late-life suicide research and for informing potential intervention and prevention efforts in this area. We searched 4 databases from inception up to May 5, 2022. We screened 2,388 abstracts for inclusion and 508 articles required full text review. The final sample included 19 studies published between 2006 and 2022. We found five domains of factors studied (i.e., neuropsychiatric, social determinants of health, aging stereotypes, residential and supportive housing settings, and multifactorial-neuropsychiatric/mental health and physical health) with more risk factors than protective factors reported. Across the three suicide outcomes only neuropsychiatric factors were consistently identified as risk factors. Neuropsychiatric factors also comprised the largest group of risk factors studied. More innovative targets to consider for intervention and more innovative methods to predict suicide in late-life are needed. There is also continued necessity to design suicide prevention interventions for older veterans given lethality trends.

Sustainability of the Collaborative Chronic Care Model in Outpatient Mental Health Teams Three Years Post-Implementation: A Qualitative Analysis.

Our goal was to investigate the sustainability of care practices that are consistent with the collaborative chronic care model (CCM) in nine outpatient mental health teams located within US Department of Veterans Affairs (VA) medical centers, three to four years after the completion of CCM implementation. We conducted qualitative interviews (N = 30) with outpatient mental health staff from each of the nine teams. We based our directed content analysis on the six elements of the CCM. We found variable sustainability of CCM-based care processes across sites. Some care processes, such as delivery of evidence-based psychotherapies (EBPs) and use of measurement-based care (MBC) to guide clinic decision-making, were robustly maintained or even expanded within participating teams. In contrast, other care processes-which had in some cases been developed with considerable effort-had not been sustained. For example, care manager roles were diminished in scope or eliminated completely in response to workload pressures, frontline care needs, or the COVID-19 pandemic. Similarly, processes for engaging Veterans more fully in decision-making had generally been scaled back. Leadership support in the form of adequate team staffing and time to conduct team meetings were seen as crucial for sustaining CCM-consistent care. Given the potential impact of leadership turnover on sustainability in mental health, future efforts to implement CCM-based mental health care should strive to involve multiple leaders in implementation and sustainment efforts, lest one key departure undo years of implementation work. Our results also suggest that implementing CCM processes may best be conceptualized as a partnership across multiple levels of medical center leadership.

Developing Relational Coordination: A Qualitative Study of Outpatient Mental Health Teams.

Previous studies have shown Relational Coordination improves team functioning in healthcare settings. The aim of this study was to examine the relational factors needed to support team functioning in outpatient mental health care teams with low staffing ratios. We interviewed interdisciplinary mental health teams that had achieved high team functioning despite low staffing ratios in U.S. Department of Veterans Affairs medical centers. We conducted qualitative interviews with 21 interdisciplinary team members across three teams within two medical centers. We used directed content analysis to code the transcripts with a priori codes based on the Relational Coordination dimensions, while also being attentive to emergent themes. We found that all seven dimensions of Relational Coordination were relevant to improved team functioning: frequent communication, timely communication, accurate communication, problem-solving communication, shared goals, shared knowledge, and mutual respect. Participants also described these dimensions as reciprocal processes that influenced each other. In conclusion, relational Coordination dimensions can play pivotal roles in improving team functioning both individually and in combination. Communication dimensions were a catalyst for developing relationship dimensions; once relationships were developed, there was a mutually reinforcing cycle between communication and relationship dimensions. Our results suggest that establishing high-functioning mental health care teams, even in low-staffed settings, requires encouraging frequent communication within teams. Moreover, attention should be given to ensuring appropriate representation of disciplines among leadership and defining roles of team members when teams are formed.

An Environmental Scan of Suicide Prevention Resources for Older Veterans in Primary Care.

OBJECTIVES: Previous research has identified the critical role of primary care for suicide prevention. Although several suicide prevention resources for primary care already exist, it is unclear how many have been created specifically for older veterans. This environmental scan sought to assemble a compendium of suicide prevention resources to be utilized in primary care. METHODS: We searched four academic databases, Google Scholar, and Google to identify available suicide prevention resources. Data from 64 resources was extracted and summarized; 15 were general resources and did not meet inclusion criteria. RESULTS: Our scan identified 49 resources with three resources specifically developed for older veterans in primary care. Identified resources shared overlapping content, including implementing a safety plan and lethal means reduction. CONCLUSION: Although only 10 of the identified resources were exclusively primary care focused, many of the resources had content applicable to suicide prevention in primary care. CLINICAL IMPLICATIONS: Primary care providers can use this compendium of resources to strengthen suicide prevention work within their clinics including: safety planning, lethal means reduction, assessing for risk factors that place older veteran at increased risk of suicide, and mitigating risk factors through referral to programs designed to support older adult health and well-being.

Guardianship Before and Following Hospitalization.

When ethics committees are consulted about patients who have or need court-appointed guardians, they lack empirical evidence about several common issues, including the relationship between guardianship and prolonged, potentially medically unnecessary hospitalizations for patients. To provide information about this issue, we conducted quantitative and qualitative analyses using a retrospective cohort from Veterans Healthcare Administration. To examine the relationship between guardianship appointment and hospital length of stay, we first compared 116 persons hospitalized prior to guardianship appointment to a comparison group (n = 348) 3:1 matched for age, diagnosis, date of admission, and comorbidity. We then compared 91 persons hospitalized in the year following guardianship appointment to a second matched comparison group (n = 273). Mean length of stay was 30.75 days (SD = 46.70) amongst those admitted prior to guardianship, which was higher than the comparison group (M = 7.74, SD = 9.71, F = 20.75, p < .001). Length of stay was lower following guardianship appointment (11.65, SD = 12.02, t = 15.16, p < .001); while higher than the comparison group (M = 7.60, SD = 8.46), differences were not associated with guardianship status. In a separate analysis involving 35 individuals who were hospitalized both prior to and following guardianship, length of stay was longer in the year prior (M = 23.00, SD = 37.55) versus after guardianship (M = 10.37, SD = 10.89, F = 4.35, p = .045). In qualitative analyses, four themes associated with lengths of stay exceeding 45 days prior to guardianship appointment were: administrative issues, family conflict, neuropsychiatric comorbidity, and medical complications. Our results suggest that persons who are admitted to hospitals, and subsequently require a guardian, experience extended lengths of stay for multiple complex reasons. Once a guardian has been appointed, however, differences in hospital lengths of stay between patients with and without guardians are reduced.

Variation in statin prescription among veterans with HIV and known atherosclerotic cardiovascular disease.

BACKGROUND: People with HIV have increased atherosclerotic cardiovascular disease (ASCVD) risk, worse outcomes following incident ASCVD, and experience gaps in cardiovascular care, highlighting the need to improve delivery of preventive therapies in this population. OBJECTIVE: Assess patient-level correlates and inter-facility variations in statin prescription among Veterans with HIV and known ASCVD. METHODS: We studied Veterans with HIV and existing ASCVD, ie, coronary artery disease (CAD), ischemic cerebrovascular disease (ICVD), and peripheral arterial disease (PAD), who received care across 130 VA medical centers for the years 2018-2019. We assessed correlates of statin prescription using two-level hierarchical multivariable logistic regression. Median odds ratios (MORs) were used to quantify inter-facility variation in statin prescription. RESULTS: Nine thousand six hundred eight Veterans with HIV and known ASCVD (mean age 64.3 ± 8.9 years, 97% male, 48% Black) were included. Only 68% of the participants were prescribed any-statin. Substantially higher statin prescription was observed for those with diabetes (adjusted odds ratio [OR] = 2.3, 95% confidence interval [CI], 2.0-2.6), history of coronary revascularization (OR = 4.0, CI, 3.2-5.0), and receiving antiretroviral therapy (OR = 3.0, CI, 2.7-3.4). Blacks (OR = 0.7, CI, 0.6-0.9), those with non-coronary ASCVD, ie, ICVD and/or PAD only, (OR 0.53, 95% CI: 0.48-0.57), and those with history of illicit substance use (OR=0.7, CI, 0.6-0.9) were less likely to be prescribed statins. There was significant variation in statin prescription across VA facilities (10th, 90th centile: 55%, 78%), with an estimated 20% higher likelihood of difference in statin prescription practice for two clinically similar individuals treated at two comparable facilities (adjusted MOR = 1.21, CI, 1.18-1.24), and a greater variation observed for Blacks or those with non-coronary ASCVD or history of illicit drug use. CONCLUSION: In an analysis of large-scale VA data, we found suboptimal statin prescription and significant interfacility variation in statin prescription among Veterans with HIV and known ASCVD, particularly among Blacks and those with a history of non-coronary ASCVD.

Supporting Veterans with dementia to remain in the community: strategies used in 12 Veterans Health Administration programs.

The Veterans Health Administration (VA) provides services to growing numbers of Veterans with dementIa, individuals at heightened risk for hospitalizations and nursing home placement. Beginning in 2010, the VA funded 12 innovative pilot programs to improve dementia care and help Veterans remain at home. We conducted a retrospective qualitative analysis of program materials and interviews with physicians, nurses, social workers, and other personnel (n = 33) to understand the strategies these programs adopted. Interviews were conducted every 6 months between 2010-2013 (4-5 interviews per program) and focused on factors affecting program design and implementation, challenges, and strategies to reduce hospitalizations and nursing home placements. Programs varied considerably yet shared three overarching strategies to improve dementia care: involving and supporting family caregivers; engaging interdisciplinary teams; and improving coordination with other healthcare providers. Our results highlight the importance of adapting common dementia care strategies based on the local context and needs of individuals served.

Promoting high-functioning mental health treatment teams in the context of low staffing ratios.

BACKGROUND: Many previous studies of health care teamwork have taken place in clinical teams with high staffing ratios (i.e., high ratios of staff to patients). PURPOSE: The aim of this study was to identify clinicians' viewpoints of foundational resources necessary to support good team functioning in the context of low staffing ratios. METHODOLOGY: We used administrative data, validated with local mental health chiefs, to identify mental health teams that had achieved high team functioning despite low staffing ratios in U.S. Department of Veterans Affairs medical centers. Guided by a recently developed model of team effectiveness, the Team Effectiveness Pyramid, we conducted qualitative interviews with 21 team members across three teams within two medical centers. Interview questions focused on the resources needed to support good team functioning despite low staffing ratios. We used directed content analysis to analyze results. RESULTS: We found there were several domains of relevant resources: material, staffing, temporal, organizational, and psychological. These represent an expansion of the domains originally included in the Team Effectiveness Pyramid. CONCLUSIONS: Within the five domains, we identified key tensions to be addressed when forming teams, including the balances between providing care for new versus established patients, emphasizing shared caseloads within the team versus matching patients to clinicians based on individual expertise, and establishing reporting structures by clinical discipline versus team membership. PRACTICE IMPLICATIONS: Establishing high-functioning health care teams in the context of low staffing ratios requires attention to key resource domains and fundamental trade-offs in how teams are structured.

Social Connection and Psychosocial Adjustment among Older Male Veterans Who Return to the Community from VA Nursing Homes.

OBJECTIVES: The goal of this study was to examine psychosocial adjustment following transition from the nursing home (NH) to community and understand the ways in which adjustment intersects with social connection. METHODS: We conducted interviews with community-dwelling older male Veterans after they were discharged from an NH. Interviews focused on Veterans' experience during the transition process. We utilized conventional content analysis to inductively code the interviews. We reviewed evidence in each identified domain for common themes. RESULTS: We interviewed 13 NH residents after recent transitions from the NH back to the community. Four themes were identified: (1) access to and quality of social support network are important for social connection, (2) engagement in meaningful activities with family and friends improves well-being, (3) service providers form link to social connection, and (4) external stressors affect the quality of social connections. CONCLUSIONS: Identified themes aligned with respondents' social connectedness and perceived psychosocial and physical well-being. Our results suggest that social connectedness is one part of the larger milieu of healthy aging including the importance of engagement with social opportunities and having a purpose. CLINICAL IMPLICATIONS: Social connectedness is critical to assess for older adults transitioning between care settings. Developing screening tools and other interventions focused on social isolation are needed.

Prioritizing LTSS Quality: Exploring the Views of Older Adults, Families, and Professionals.

We conducted a cross-sectional survey involving 349 older adults, family members, and long-term services and supports (LTSS) professionals in Minnesota to assess their views on priorities for residential LTSS quality. We found considerable agreement among the three groups on the highest priorities to ensure the wellbeing of older adults who use LTSS: safety, dignity, and staffing. Relationships were also viewed as a high priority. However, older adults prioritized the physical environment over professionals, and they expressed more varied opinions on priorities overall. Older adults also consistently rated autonomy/choice as less important than other quality domains, a finding worth further exploration.

External facilitators' perceptions of internal facilitation skills during implementation of collaborative care for mental health teams: a qualitative analysis informed by the i-PARIHS framework.

BACKGROUND: Facilitation is a key strategy that may contribute to successful implementation of healthcare innovations. In blended facilitation, external facilitators (EFs) guide and support internal facilitators (IFs) in directing implementation processes. Developers of the i-PARIHS framework propose that successful facilitation requires project management, team/process, and influencing/negotiating skills. It is unclear what IF skills are most important in real-world settings, which could inform recruitment and training efforts. As prior qualitative studies of IF skills have only interviewed IFs, the perspectives of their EF partners are needed. Furthermore, little is known regarding the distribution of implementation tasks between IFs and EFs, which could impact sustainability once external support is removed. In the context of an implementation trial, we therefore: 1) evaluated IFs' use of i-PARIHS facilitation skills, from EFs' perspectives; 2) identified attributes of IFs not encompassed within the i-PARIHS skills; and 3) investigated the relative contributions of IFs and EFs during facilitation. METHODS: Analyses were conducted within a hybrid type II trial utilizing blended facilitation to implement the collaborative chronic care model within mental health teams of nine VA medical centers. Each site committed one team and an IF to weekly process design meetings and additional implementation activities over 12 months. Three EFs worked with three sites each. Following study completion, the EFs completed semi-structured qualitative interviews reflecting on the facilitation process, informed by the i-PARIHS facilitation skill areas. Interviews were analyzed via directed content analysis. RESULTS: EFs emphasized the importance of IFs having strong project management, team/process, and influencing/negotiating skills. Prior experience in these areas and a mental health background were also benefits. Personal characteristics (e.g., flexible, assertive) were described as critical, particularly when faced with conflict. EFs discussed the importance of clear delineation of EF/IF roles, and the need to shift facilitation responsibilities to IFs. CONCLUSIONS: Key IF skills, according to EFs, are aligned with i-PARIHS recommendations, but IFs' personal characteristics were also emphasized as important factors. Findings highlight traits to consider when selecting IFs and potential training areas (e.g., conflict management). EFs and IFs must determine an appropriate distribution of facilitation tasks to ensure long-term sustainability of practices. TRIAL REGISTRATION: Clinicaltrials.gov, September 7, 2015, #NCT02543840.

How hospitals select their patient safety priorities: An exploratory study of four Veterans Health Administration hospitals.

BACKGROUND: Hospitals face ongoing pressure to reduce patient safety events. However, given resource constraints, hospitals must prioritize their safety improvements. There is limited literature on how hospitals select their safety priorities. PURPOSE: The aim of this research was to describe and compare the approaches used by Veterans Health Administration (VA) hospitals to select their safety priorities. METHODOLOGY: Semistructured telephone interviews with key informants (n = 16) were used to collect data on safety priorities in four VA hospitals from May to December 2016. We conducted a directed content analysis of the interview notes using an organizational learning perspective. We coded for descriptive data on the approaches (e.g., set of cues, circumstances, and activities) used to select safety priorities, a priori organizational learning capabilities (learning processes, learning environment, and learning-oriented leadership), and emergent domains. For cross-site comparisons, we examined the coded data for patterns. RESULTS: All hospitals used multiple approaches to select their safety priorities; these approaches used varied across hospitals. Although no single approach was reported as particularly influential, all hospitals used approaches that addressed system level or national requirements (i.e., externally required activities). Additional approaches used by hospitals (e.g., responding to staff concerns of patient safety issues, conducting a multidisciplinary team investigation) were less connected to externally required activities and demonstrated organizational learning capabilities in learning processes (e.g., performance monitoring), learning environment (e.g., staff's psychological safety), and learning-oriented leadership (e.g., establishing a nonpunitive culture). PRACTICE IMPLICATIONS: Leaders should examine the approaches used to select safety priorities and the role of organizational learning in these selection approaches. Exclusively relying on approaches focused on externally required activities may fail to identify safety priorities that are locally relevant but not established as significant at the system or national levels. Organizational learning may promote hospitals' use of varied approaches to guide their selection of safety priorities and thereby benefit hospital safety improvement efforts.

The Collaborative Chronic Care Model for Mental Health Conditions: From Evidence Synthesis to Policy Impact to Scale-up and Spread.

BACKGROUND: Extensive evidence indicates that Collaborative Chronic Care Models (CCMs) improve outcome in chronic medical conditions and depression treated in primary care. Beginning with an evidence synthesis which indicated that CCMs are also effective for multiple mental health conditions, we describe a multistage process that translated this knowledge into evidence-based health system change in the US Department of Veterans Affairs (VA). EVIDENCE SYNTHESIS: In 2010, recognizing that there had been numerous CCM trials for a wide variety of mental health conditions, we conducted an evidence synthesis compiling randomized controlled trials of CCMs for any mental health condition. The systematic review demonstrated CCM effectiveness across mental health conditions and treatment venues. Cumulative meta-analysis and meta-regression further informed our approach to subsequent CCM implementation. POLICY IMPACT: In 2015, based on the evidence synthesis, VA Office of Mental Health and Suicide Prevention (OMHSP) adopted the CCM as the model for their outpatient mental health teams. RANDOMIZED IMPLEMENTATION TRIAL: In 2015-2018 we partnered with OMHSP to conduct a 9-site stepped wedge implementation trial, guided by insights from the evidence synthesis. SCALE-UP AND SPREAD: In 2017 OMHSP launched an effort to scale-up and spread the CCM to additional VA medical centers. Seventeen facilitators were trained and 28 facilities engaged in facilitation. DISCUSSION: Evidence synthesis provided leverage for evidence-based policy change. This formed the foundation for a health care leadership/researcher partnership, which conducted an implementation trial and subsequent scale-up and spread effort to enhance adoption of the CCM, as informed by the evidence synthesis.

Mental Health Integration in Geriatric Patient-Aligned Care Teams in the Department of Veterans Affairs.

OBJECTIVES: To inform geriatric mental health policy by describing the role of behavioral healthcare providers within a geriatric patient-aligned care team (GeriPACT), a patient-centered medical home model of care within the Veterans Health Administration (VHA), serving older veterans with chronic disease, functional dependency, cognitive decline, and psychosocial challenges, and/or those who have elder abuse, risk of long-term care placement, or impending disability. METHODS: The authors used mixed methods, consisting of a national survey and site visits between July 2016 and February 2017, at VHA outpatient clinics. The participants, 101 GeriPACTs at 44 sites, completed surveys, and 24 medical providers were interviewed. A standardized survey and semi-structured interview guide were developed based on the program handbook, with input from experts in the VHA Office of Geriatrics and Extended Care Services, guided by the Consolidated Framework for Implementation Science Research. RESULTS: Of surveyed GeriPACTs, 42.6% had a mental health provider on the team-a psychiatrist (28.7%) and/or psychologist (23.8%). Of these, the mean was 0.27 full-time equivalent psychiatrists and 0.44 full-time equivalent psychologists per team (suggested panel = 800 patients). In surveys, teams with behavioral health providers were more likely to manage psychosocial χ2 = 8.87, cognitive χ2 = 8.68, and depressive χ2 = 11.85 conditions in their panel than those without behavioral health providers. CONCLUSION: GeriPACT mental health integration is less than 50%. Population differences between general primary care and geriatric primary care may require different care approaches and provider competencies and need further study.

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.

Blended Facilitation as an Effective Implementation Strategy for Quality Improvement and Research in Nursing Homes.

BACKGROUND: Blended facilitation, which leverages the complementary skills and expertise of external and internal facilitators, is a powerful strategy that nursing stakeholders and researchers may use to improve implementation of quality improvement (QI) innovations and research performed in nursing homes. PROBLEM: Nursing homes present myriad challenges (eg, time constraints, top-down flow of communication, high staff turnover) to QI implementation and research. APPROACH: This methods article describes the theory and practical application of blended facilitation and its components (external facilitation, internal facilitation, relationship building, and skill building), using examples from a mixed QI and research intervention in Veterans Health Administration nursing homes. CONCLUSIONS: Blended facilitation invites nursing home stakeholders to be equal partners in QI and research processes. Its intentional use may overcome many existing barriers to QI and research performed in nursing homes and, by strengthening relationships between researchers and stakeholders, may accelerate implementation of innovative care practices.

Assessing Collaborative Care in Mental Health Teams: Qualitative Analysis to Guide Future Implementation.

The Collaborative Care Model (CCM) is an evidence-based approach for structuring care for chronic health conditions. Attempts to implement CCM-based care in a given setting depend, however, on the extent to which care in that setting is already aligned with the specific elements of CCM-based care. We therefore interviewed staff from ten outpatient mental health teams in the US Department of Veterans Affairs to determine whether care delivery was consistent or inconsistent with CCM-based care in those settings. We discuss implications of our findings for future attempts to implement CCM-based outpatient mental health care.

Staff-perceived Conflict between Resident-centered Care and Quality in the Skilled Nursing Facility: Are Both Possible?

OBJECTIVES: The purpose of this study was to understand if and how Veterans Affairs (VA) nursing home (CLC) staff experience difficulty in providing care that is both resident-centered (RCC) and concordant with quality standards. METHODS: Twelve VA CLCs were selected for site visits, stratified based on rankings on a composite quality measure (calculated from various indicators) and resident-centered care (RCC) progress (based on a culture change tool). Staff were interviewed about efforts and barriers to achieving goals in RCC and quality, and the interview transcripts systematically analyzed for themes. RESULTS: We interviewed 141 participants, including senior leaders, middle managers, and front-line staff. An emergent theme was conflict between RCC and quality, although participants varied in their perceptions of its impact. Participants perceived three conflict types: 1) between resident preferences and medically indicated actions; 2) between resident preferences and the needs or safety of others; and 3) limits of staff time or authority. CONCLUSIONS: CLC staff perceive conflicts between RCC and care consistent with quality imperatives. CLINICAL IMPLICATIONS: Variation in perceived RCC-quality conflicts suggests that policy clarifications and additional training may provide guidance in dealing with such dilemmas. It may be prudent to clearly communicate to what boundaries exist to RCC in the evolving CLC environment.