Developing a relational playbook for cardiology teams to cultivate supportive learning environments, enhance clinician well-being, and veteran care.

Introduction: Despite the Veterans Health Administration (VA) efforts to become a learning health system (LHS) and high-reliability organization (HRO), interventions to build supportive learning environments within teams are not reliably implemented, contributing to high levels of burnout, turnover, and variation in care. Supportive learning environments build capabilities for teaching and learning, empower teams to safely trial and adapt new things, and adopt highly reliable work practices (eg, debriefs). Innovative approaches to create supportive learning environments are needed to advance LHS and HRO theory and research into practice. Methods: To guide the identification of evidence-based interventions that cultivate supportive learning environments, the authors used a longitudinal, mixed-methods design and LHS and HRO frameworks. We partnered with the 81 VA cardiac catheterization laboratories and conducted surveys, interviews, and literature reviews that informed a Relational Playbook for Cardiology Teams. Results: The Relational Playbook resources and 50 evidence-based interventions are organized into five LHS and HRO-guided chapters: Create a positive culture, teamwork, leading teams, joy in work, communication, and high reliability. The interventions are designed for managers to integrate into existing meetings or trainings to cultivate supportive learning environments. Conclusions: LHS and HRO frameworks describe how organizations can continually learn and deliver nearly error-free services. The Playbook resources and interventions translate LHS and HRO frameworks for real-world implementation by healthcare managers. This work will cultivate supportive learning environments, employee well-being, and Veteran safety while providing insights into LHS and HRO theory, research, and practice.

Learning environments, reliability enhancing work practices, employee engagement, and safety climate in VA cardiac catheterization laboratories.

OBJECTIVE: To characterize the relationship between learning environments (the educational approaches, cultural context, and settings in which teaching and learning happen) and reliability enhancing work practices (hiring, training, decision making) with employee engagement, retention, and safety climate. DATA SOURCE: We collected data using the Learning Environment and High Reliability Practices Survey (LEHRs) from 231 physicians, nurses, and technicians at 67 Veterans Affairs cardiac catheterization laboratories who care for high-risk Veterans. STUDY DESIGN: The association between the average LEHRs score and employee job satisfaction, burnout, intent to leave, turnover, and safety climate were modeled in separate linear mixed effect models adjusting for other covariates. DATA COLLECTION: Participants responded to a web-only survey from August through September 2020. PRINCIPAL FINDINGS: There was a significant association between higher average LEHRs scores and (1) higher job satisfaction (2) lower burnout, (3) lower intent to leave, (4) lower cath lab turnover in the previous 12 months, and (5) higher perceived safety climate. CONCLUSIONS: Learning environments and use of reliability enhancing work practices are potential new avenues to support satisfaction and safety climate while lowering burnout, intent to leave, and turnover in a diverse US health care workforce that serves a vulnerable and marginalized population.

Timely Colonoscopy After Positive Fecal Immunochemical Tests in the Veterans Health Administration: A Qualitative Assessment of Current Practice and Perceived Barriers.

INTRODUCTION: The Veterans Health Administration introduced a clinical reminder system in 2018 to help address process gaps in colorectal cancer screening, including the diagnostic evaluation of positive fecal immunochemical test (FIT) results. We conducted a qualitative study to explore the differences between facilities who performed in the top vs bottom decile for follow-up colonoscopy. METHODS: Seventeen semistructured interviews with gastroenterology (GI) providers and staff were conducted at 9 high-performing and 8 low-performing sites. RESULTS: We identified 2 domains, current practices and perceived barriers, and most findings were described by both high- and low-performing sites. Findings exclusive to 1 group mainly pertained to current practices, especially arranging colonoscopy for FIT-positive patients. We observed only 1 difference in the perceived barriers domain, which pertained to primary care providers. DISCUSSION: These results suggest that what primarily distinguishes high- and low-performing sites is not a difference in barriers but rather in the GI clinical care process. Developing and disseminating patient education materials about the importance of diagnostic colonoscopy, eliminating in-person precolonoscopy visits when clinically appropriate, and involving GI in missed colonoscopy appointments and outside referrals should all be considered to increase follow-up colonoscopy rates. Our study illustrates the challenges of performing a timely colonoscopy after a positive FIT result and provides insights on improving the clinical care process for patients who are at substantially increased risk for colorectal cancer.

The Impacts of COVID-19 on Veterans Affairs Catheterization Laboratory Staff During the First Months of the US Response.

BACKGROUND: The COVID-19 pandemic has altered catheterization laboratory (cath lab) practices in diverse ways. OBJECTIVE: The aim of this study was to understand the impact of COVID-19 on Veterans Affairs (VA) procedural volume and cath lab team experience. METHODS: Procedural volume and COVID-19 patient data were obtained from the Clinical, Assessment, Reporting and Tracking Program. A mixed methods survey was emailed to VA cath lab staff asking about the COVID-19 response. Descriptive and manifest content analyses were conducted. RESULTS: Procedural volume decreased from April to September 2020. One hundred four patients with known COVID-19 were treated. Survey response rate was 19% of staff (n = 170/902) from 83% of VA cath labs (n = 67/81). Reassignment to other units, confusion regarding COVID-19 testing, personal protective equipment use, and low patient volume were reported. Anxiety, burnout, and leadership's role on team morale were described. CONCLUSIONS: Some teams adapted. Others expressed frustration over the lack of control over their practice. Leaders should routinely assess staff needs during the current and future crises.

A pilot study to assess the learning environment and use of reliability enhancing work practices in VHA cardiac catheterization laboratories.

INTRODUCTION: A learning health system (LHS) harnesses data and analytics to learn from clinical encounters to implement the best care with high reliability. The 81 Veterans Health Administration (VHA) cardiac catheterization laboratories (cath lab) are a model LHS. The quality and safety of coronary procedures are monitored and reported by the Clinical Assessment, Reporting and Tracking (CART) Program, which has identified variation in care across cath labs. This variation may be due to underappreciated aspects of LHSs, the learning environment and reliability enhancing work practices (REWPs). Learning environments are the educational approaches, context, and settings in which learning occurs. REWPs are the organizational practices found in high reliability organizations. High learning environments and use of REWPs are associated with improved outcomes. This study assessed the learning environments and use of REWPs in VHA cath labs to examine factors supportive of learning and high reliability. METHODS: In 2018, the learning organization survey-27 and the REWP survey were administered to 732 cath lab staff. Factor analysis and linear models were computed. Unit-level analyses and site ranking (high, low) were conducted on cath labs with >40% response rate using Bayesian methods. RESULTS: Surveys from 40% of cath lab staff (n = 294) at 84% of cath labs (n = 68) were included. Learning environment and REWP strengths across cath labs include the presence of training programs, openness to new ideas, and respectful interaction. Learning environment and REWP gaps include lack of structured knowledge transfer (eg, checklists) and low use of forums for improvement. Survey dimensions matched established factor structures and demonstrated high reliability (Cronbach's alpha >.76). Unit-level analyses were conducted for 29 cath labs. One ranked as high and four as low learning environments. CONCLUSIONS: This work demonstrates an approach to assess local learning environments and use of REWPs, providing insights for systems working to become a LHS.