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.

Factors Differentiating Nursing Homes With Strong Resident Safety Climate: A Qualitative Study of Leadership and Staff Perspectives.

The current qualitative study assessed leadership and staff perceptions related to resident safety at Department of Veterans Affairs (VA) nursing homes with a range of safety climates. We recruited a purposive sample of six VA nursing homes from geographically diverse regions of the United States and with diverse overall safety climate ratings. We conducted semi-structured phone interviews with 43 senior and middle level nursing home leaders and frontline providers (medical and nursing). We performed a thematic analysis of interview data to assess participant perceptions of factors that influence resident safety at higher and lower safety climate sites. Analyses identified two factors that differentiated VA nursing homes with high safety climate ratings from those with medium or low ratings: (1) communication about resident safety, particularly the important role of accessibility of physicians and managers; and (2) leadership support for and responsiveness to resident safety issues raised by frontline staff. Findings from high safety climate nursing homes underscore the importance of leadership accessibility, communication, support, and follow through regarding resident safety concerns. These results may provide a basis for designing safety climate interventions, such as those designed to improve communication, teamwork, and quality improvement structures and processes. [Journal of Gerontological Nursing, 49(2), 13-17.].

Characterizing patient attitudes and beliefs towards testosterone therapy in Veterans Affairs: A qualitative study.

OBJECTIVE: We examined patient attitudes and beliefs and provider perspectives on patients' attitudes and beliefs towards testosterone therapy in Veterans Affairs (VA). METHODS: We used a thematic analysis approach to understand variation in patient attitudes and beliefs towards testosterone at six VA sites with high and low levels of testosterone prescribing in VA. Semi-structured phone interviews with 18 patients and 22 providers at these sites were transcribed and coded using a priori theoretical constructs and emergent themes. A cross-case matrix of coded data was used to evaluate themes related to patient-level factors. RESULTS: Patients' beliefs toward testosterone did not differ across sites. Patients, not providers, generally initiated conversations about testosterone. We identified five key domains related to patient beliefs and provider perceived patient beliefs towards testosterone: reasons for initiating testosterone, patient information sources and expectations about testosterone, receptivity towards discontinuation of testosterone, patient/provider engagement in information sharing, and self-advocacy by the patients in decision-making. CONCLUSIONS: Patient factors play an important role in testosterone prescribing decisions. PRACTICE IMPLICATIONS: By considering these patient factors, providers can potentially help create a partnership with patients and foster shared decision-making for testosterone and other, similar medications.

A Citation Review of 83 Dissemination and Implementation Theories, Models, or Frameworks Utilized in U.S.-Based Aging Research.

BACKGROUND AND OBJECTIVES: Dissemination-implementation.org outlines 110 theories, models, and frameworks (TMFs): we conducted a citation analysis on 83 TMFs, searching Web of Science and PubMed databases. RESEARCH DESIGN AND METHODS: Search terms were broad and included "aging," "older," "elderly," and "geriatric." We extracted each TMF in identified articles from inception through January 28, 2022. Included articles must have used a TMF in research or quality improvement work directly linked to older adults within the United States. RESULTS: We reviewed 2,681 articles of which 295 articles cited at least one of 56 TMFs. Five TMFs represented 50% of the citations: Reach, Effectiveness, Adoption, Implementation, and Maintenance 1.0, Consolidated Framework for Implementation Research, Greenhalgh Diffusion of Innovation in Service Organizations, Quality Enhancement Research Initiative, Community-Based Participatory Research, and Promoting Action on Research Implementation in Health Services. TMF application varied and there was a steady increase in TMF citations over time, with a 2- to 3-fold increase in citations in 2020-2021. We identified that only 41% of TMF use was meaningful. DISCUSSION AND IMPLICATIONS: Our results suggest TMF utilization is increasing in aging research, but there is a need to more meaningful utilize TMFs. As the population of older adults continues to grow, there will be increasing demand for effective evidence-based practices and models of care to be quickly and effectively translated into routine care. Use of TMFs is critical to building such evidence and to identifying and evaluating methods to support this translation.

Achieving transformation to lean management systems in health care.

OBJECTIVE: To understand what factors and organizational dynamics enable Lean transformation of health care organizations. DATA SOURCES: Primary data were collected through two waves of interviews in 2016-2017 with leaders and staff at seven veterans affairs medical centers participating in Lean enterprise transformation. STUDY DESIGN: Using an observational study design, for each site we coded and rated seven potential enablers of transformation. The outcome measure was the extent of Lean transformation, constructed by coding and rating 11 markers of depth and spread of transformation. Using multivalue coincidence analysis (CNA), we identified enablers that distinguished among sites having different levels of transformation. We identified representative quotes for the enablers. DATA COLLECTION METHODS: We interviewed 121 executive leaders, middle managers, expert consultants, systems redesign staff, frontline supervisors, and staff. PRINCIPAL FINDINGS: Two sites achieved high Lean transformation, three medium, and two low. Together leadership support and capability development were sufficient for the three-level Lean transformation outcomes with 100% consistency and 100% coverage. High scores on both corresponded to high Lean transformation; medium on either one corresponded to medium transformation; and low on both corresponded to low transformation. Additionally, low scores in communication and availability of data and very low scores in alignment characterized low-transformation sites. Sites with high leadership support also had a high veteran engagement. CONCLUSIONS: This multisite study develops a novel measure of the extent of organization-wide Lean transformation and uses CNA to identify enablers linked to transformation. It provides insights into why and how some organizations are more successful at transformation than others. Findings support the applicability of the organization transformation model that guided the study and highlight the roles of executive leadership and capability development in the dynamics of transformation.

Assessing the sustainability of compliance with surgical site infection prophylaxis after discontinuation of mandatory active reporting: study protocol.

BACKGROUND: Surgical site infections are common. Risk can be reduced substantially with appropriate preoperative antimicrobial administration. In 2005, the VA implemented the Surgical Care Improvement Project (SCIP) in the setting of high rates of non-compliance with antimicrobial prophylaxis guidelines. SCIP included public reporting of evidenced-based antimicrobial guideline compliance metrics in high-risk surgeries. SCIP was highly successful and led to high rates of adoption of preoperative antimicrobials and early discontinuation of postoperative antimicrobials (>95%). The program was retired in 2015, as the manual measurement and reporting process was costly with limited expected additional benefit. To our knowledge, no studies have assessed whether the gains achieved by SCIP were sustained since active support for the program was discontinued. Furthermore, there has been no investigation of the spread of antimicrobial prophylaxis guideline adoption beyond the limited set of procedures that were included in the program. METHODS: Using a mixed methods sequential exploratory approach, this study will (1) quantitatively measure compliance with SCIP metrics over time and across all procedures in the five major surgical specialties targeted by SCIP and (2) collect qualitative data from stakeholders to identify strategies that were effective for sustaining compliance. Diffusion of Innovation Theory will guide assessment of whether improvements achieved spread to procedures not included under the umbrella of the program. Electronic algorithms to measure SCIP antimicrobial use will be adapted from previously developed methodology. These highly novel data mining algorithms leverage the rich VA electronic health record and capture structured and text data and represent a substantial technological advancement over resource-intensive manual chart review or incomplete electronic surveillance based on pharmacy data. An interrupted time series analysis will be used to assess whether SCIP compliance was sustained following program discontinuation. Generalized linear models will be used to assess whether compliance with appropriate prophylaxis increased in all SCIP targeted and non-targeted procedures by specialty over the duration the program's active reporting. The Dynamic Sustainability Framework will guide the qualitative methods to assess intervention, provider, facility, specialty, and contextual factors associated with sustainability over time. Barriers and facilitators to sustainability will be mapped to implementation strategies and the study will yield an implementation playbook to guide future sustainment efforts. RELEVANCE: Sustainability of practice change has been described as one of the most important, but least studied areas of clinical medicine. Learning how practices spread is also a critically important area of investigation. This study will use novel informatics strategies to evaluate factors associated with sustainability following removal of active policy surveillance and advance our understanding about these important, yet understudied, areas.

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.

Virtual external implementation facilitation: successful methods for remotely engaging groups in quality improvement.

BACKGROUND: Relatively little guidance exists on how to use virtual implementation facilitation to successfully implement evidence-based practices and innovations into clinical programs. Yet virtual methods are increasingly common. They have potentially wider reach, emergent public health situations necessitate their use, and restrictions on resources can make them more attractive. We therefore outline a set of principles for virtual external implementation facilitation and a series of recommendations based on extensive experience successfully using virtual external implementation facilitation in a national program. MODEL AND RECOMMENDATIONS: Success in virtual external implementation facilitation may be achieved by facilitators applying three overarching principles: pilot everything, incorporate a model, and prioritize metacognition. Five practical principles also help: plan in advance, communicate in real time, build relationships, engage participants, and construct a virtual room for participants. We present eight concrete suggestions for enacting the practical principles: (1) assign key facilitation roles to facilitation team members to ensure the program runs smoothly; (2) create small cohorts of participants so they can have meaningful interactions; (3) provide clarity and structure for all participant interactions; (4) structure program content to ensure key points are described, reinforced, and practiced; (5) use visuals to supplement audio content; (6) build activities into the agenda that enable participants to immediately apply knowledge at their own sites, separate from the virtual experience; (7) create backup plans whenever possible; and (8) engage all participants in the program. These principles represent a novel conceptualization of virtual external implementation facilitation, giving structure to a process that has been, to date, inadequately described. The associated actions are demonstrably useful in supporting the principles and offer teams interested in virtual external implementation facilitation concrete methods by which to ensure success. Our examples stem from experiences in healthcare. But the principles can, in theory, be applied to virtual external implementation facilitation regardless of setting, as they and the associated actions are not setting specific.

Evidence-based practice and patient-centered care: Doing both well.

BACKGROUND: Health care organizations increasingly strive to deliver care that is both evidence based and patient centered. Although often complementary, fundamental contradictions may exist between these goals, and the organizational culture and infrastructure necessary to be successful in one domain may inherently diminish performance in the other. PURPOSE: We assessed the relationship between evidence-based practice (EBP) and patient-centered care (PCC) by seeking to identify specific behavioral and process mechanisms, along with organizational characteristics that distinguish medical centers that are able to provide inpatient care that is both evidence based and patient centered from those where performance is either mixed or low in both domains. METHODOLOGY/APPROACH: We analyzed interview data from 142 employees at 12 Veterans Affairs Medical Centers selected based on EBP and PCC performance (high, low, or mixed) using a priori constructs consistent with organizational literature, as well as emergent themes. RESULTS: We confirmed that tensions may arise when attempting to deliver both EBP and PCC and found unique characteristics of organizations that do both well. High-performing sites exhibited organizational cultures of empowerment where both EBP and PCC expectations were emphasized; provided formal and informal institutional supports and structures with regard to PCC and EBP; and fostered multidisciplinary, multidirectional approaches to care and communication that facilitated delivery of both EBP and PCC. CONCLUSIONS AND PRACTICE IMPLICATIONS: Organizations that excel in providing both EBP and PCC exhibit unique characteristics and processes. Recognizing that some characteristics such as culture are difficult to change, these findings nonetheless highlight areas that could be enhanced by medical centers striving to deliver care that is both evidence based and patient centered.

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.

Veterans Perceptions of Satisfaction and Convenience with Anticoagulants for Atrial Fibrillation: Warfarin versus Direct Oral Anticoagulants.

BACKGROUND: Atrial fibrillation (AFib) is associated with high morbidity and mortality. Traditionally, AFib was treated with warfarin, yet recent evidence suggests patients may favor direct oral anticoagulants (DOACs). Variation in preferences is common and we explored patients' perceptions of satisfaction and convenience of DOACs versus warfarin within the Veterans Health Administration (VA). PATIENTS AND METHODS: We administered a cross-sectional survey, the Perception of Anticoagulant Treatment Questionnaire 2 (PACT-Q2), to Veterans residing in New England, age ≥65, diagnosed with AFib, and actively taking anticoagulant medication in fiscal year 2018. Survey recipients were randomly selected among patients on warfarin (n=200) or DOACs (n=200). A selection of survey respondents agreed to a follow-up semi-structured interview (n=16) to further investigate perceptions of satisfaction and convenience. RESULTS: Of 400 patients, 187 completed the PACT-Q2 survey (49% on DOACs; 51% on warfarin). DOACs received significantly higher convenience ratings than warfarin (87.6, SD 13.5 vs 81.1, SD 18.8; p=0.007); there was no difference in satisfaction (64.2, SD 20.5 SD, warfarin vs, 67.3, SD 19.4, DOACs). Interview results showed that participants perceived their treatment to be convenient. However, participants expressed challenges related to the convenience of taking warfarin or DOACs, such as warfarin users having to follow dietary recommendations or DOAC users desiring some additional monitoring to answer questions or concerns. Overall, warfarin and DOAC users reported satisfaction with ongoing monitoring methods, although a few DOAC users expressed uncertainties with the frequency of monitoring. For most participants, concerns about side effects did not differ by anticoagulant type nor affect satisfaction. CONCLUSION: Our survey and interview results showed variable patient satisfaction and perceptions of convenience with both DOACs and warfarin. Although DOACs are increasingly prescribed for AFib, some Veterans felt that regular follow-up on warfarin was advantageous. Our findings demonstrate the importance of patient-centered decision-making in AFib treatment in the VA patient population.

Understanding the Context of High- and Low-Testosterone Prescribing Facilities in the Veterans Health Administration (VHA): a Qualitative Study.

BACKGROUND: Inappropriate testosterone use and variations in testosterone prescribing patterns exist in the Veterans Health Administration (VHA) despite the presence of clinical guidelines. OBJECTIVE: We examined system and clinician factors that contribute to patterns of potentially inappropriate testosterone prescribing in VHA. DESIGN: Qualitative study using a positive deviance approach to understand practice variation in high- and low-testosterone prescribing sites. PARTICIPANTS: Twenty-two interview participants included primary care and specialty clinicians, key opinion leaders, and pharmacists at 3 high- and 3 low-testosterone prescribing sites. APPROACH: Semi-structured phone interviews were conducted, transcribed, and coded using a priori theoretical constructs and emergent themes. Case studies were developed for each site and a cross-case matrix was created to evaluate variation across high- and low-prescribing sites. KEY RESULTS: We identified four system-level domains related to variation in testosterone prescribing: organizational structures and processes specific to testosterone prescribing, availability of local guidance on testosterone prescribing, well-defined dissemination process for local testosterone polices, and engagement in best practices related to testosterone prescribing. Two clinician-level domains were also identified, specifically, structured initial testosterone prescribing process and specified follow-up testosterone prescribing process. High- and low-testosterone prescribing sites systematically varied in the four system-level domains, while the clinician-level domains looked similar across all sites. The third high-prescribing site was unusual in that it exhibited the four domains similar to the 3 low-prescribing sites at the time of our visit. This site had greatly reduced its prescribing of testosterone in the interim. CONCLUSIONS: Findings suggest that local organizational factors play an important role in influencing prescribing. Sites have the potential to transform their utilization patterns by providing access to specialty care expertise, an electronic health record-based system to facilitate guideline-concordant prescribing, well-defined dissemination processes for information, guidance from multiple sources, and clarity regarding best practices for prescribing.

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.

Collaborative capacity and patient-centered care in the Veterans' Health Administration Community Living Centers.

INTRODUCTION: Previous research in acute care settings has shown that collaborative capacity, defined as the way providers collaborate as equal team members, can be improved by the ways in which an organization supports its staff and teams. This observational cross-sectional study examines the association between collaborative capacity and supportive organizational context, supervisory support, and person-centered care in nursing homes to determine if similar relationships exist. METHODS: We adapted the Care Coordination Survey for nursing homes and administered it to clinical staff in 20 VA Community Living Centers. We used random effects models to examine the associations between supportive organizational context, supervisory support, and person-centered care with collaborative capacity outcomes including quality of staff interactions, task independence, and collaborative influence. RESULTS: A total of 723 Community Living Center clinical staff participated in the Care Coordination Survey resulting in a response rate of 29%. We found that teamwork and collaboration-measured as task interdependence, quality of interactions and collaborative influence-did not differ significantly between Community Living Centers but did differ significantly across occupational groups. Moreover, staff members' experiences of teamwork and collaboration were positively associated with supportive organizational context and person-centered care. DISCUSSION: Our findings suggest that elements of organizational context are important to facilitating collaborative capacity. Additionally, investing in staffing, rewards, and person-centered care may improve teamwork.

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.

Is Variation in Resident-Centered Care and Quality Performance Related to Health System Factors in Veterans Health Administration Nursing Homes?

The purpose of this research was to explore and compare common health system factors for 5 Community Living Centers (ie Veterans Health Administration nursing homes) with high performance on both resident-centered care and clinical quality and for 5 Community Living Centers (CLC) with low performance on both resident-centered care and quality. In particular, we were interested in "how" and "why" some Community Living Centers were able to deliver high levels of resident-centered care and high quality of care, whereas others did not demonstrate this ability. Sites were identified based on their rankings on a composite quality measure calculated from 28 Minimum Data Set version 2.0 quality indicators and a resident-centered care summary score calculated from 6 domains of the Artifacts of Culture Change Tool. Data were from fiscal years 2009-2012. We selected high- and low-performing sites on quality and resident-centered care and conducted 12 in-person site visits in 2014-2015. We used systematic content analysis to code interview transcripts for a priori and emergent health system factor domains. We then assessed variations in these domains across high and low performers using cross-site summaries and matrixes. Our final sample included 108 staff members at 10 Veterans Health Administration CLCs. Staff members included senior leaders, middle managers, and frontline employees. Of the health system factors identified, high and low performers varied in 5 domains, including leadership support, organizational culture, teamwork and communication, resident-centered care recognition and awards, and resident-centered care training. Organizations must recognize that making improvements in the factors identified in this article will require dedicated resources from leaders and support from staff throughout the organization.

Identifying and overcoming implementation challenges: Experience of 59 noninstitutional long-term services and support pilot programs in the Veterans Health Administration.

BACKGROUND: From 2010 to 2013, the Department of Veterans Affairs (VA) funded a large pilot initiative to implement noninstitutional long-term services and supports (LTSS) programs to support aging Veterans. Our team evaluated implementation of 59 VA noninstitutional LTSS programs. PURPOSE: The specific objectives of this study are to (a) examine the challenges influencing program implementation comparing active sites that remained open and inactive sites that closed during the funding period and (b) identify ways that active sites overcame the challenges they experienced. METHODOLOGY: Key informant semistructured interviews occurred between 2011 and 2013. We conducted 217 telephone interviews over four time points. Content analysis was used to identify emergent themes. The study team met regularly to define each challenge, review all codes, and discuss discrepancies. For each follow-up interview with the sites, the list of established challenges was used as a priori themes. Emergent data were also coded. RESULTS: The challenges affecting implementation included human resources and staffing issues, infrastructure, resources allocation and geography, referrals and marketing, leadership support, and team dynamics and processes. Programs were able to overcome challenges by communicating with team members and other areas in the organization, utilizing information technology solutions, creative use of staff and flexible schedules, and obtaining additional resources. DISCUSSION: This study highlights several common challenges programs can address during the program implementation. The most often mentioned strategy was effective communication. Strategies also targeted several components of the organization including organizational functions and processes (e.g., importance of coordination within a team and across disciplines to provide good care), infrastructure (e.g., information technology and human resources), and program fit with priorities in the organization (e.g., leadership support). IMPLICATIONS: Anticipating potential pitfalls of program implementation for future noninstitutional LTSS programs can improve implementation efficiency and program sustainability. Staff at multiple levels in the organization must fully support noninstitutional LTSS programs to address these challenges.

Identifying barriers to culture change: A qualitative analysis of the obstacles to delivering resident-centered care.

A growing number of healthcare organizations have moved from traditional, institutional nursing home models to ones that emphasize culture change, or resident-centered care (RCC). In 2006, the Department of Veterans Affairs (VA) began implementing a number of changes to VA nursing homes, now called Community Living Centers (CLCs), to provide veterans with a more resident-centered and homelike environment. This study aimed to understand the barriers CLC staff face when delivering RCC. Ten CLCs were included on the basis of their performance levels on RCC and quality of care. Semistructured interviews that focused on facility efforts in RCC and quality were conducted with all levels of staff. Interviews were systematically content coded. We found similarities and differences in barriers reported at high- and low-performing sites. Staff across all performance levels cited 5 main categories of barriers to delivering RCC: staffing, resources, acuity of residents, RCC and quality of care conflicts, and regulations. Staff in high-performing sites reported fewer barriers to RCC, although 1 barrier cited was difficulty coordinating RCC across departments. Staff in low-performing sites reported additional categories of barriers related to administrator turnover/lack of guidance, CLC culture/staff morale, and difficulty working with residents and families. As RCC continues to spread, it is important to anticipate the barriers to implementing these practices. Particular focus on regulatory, leadership, organizational, workforce, and process factors may help organizations avoid or reduce barriers to RCC. Given their training and skill set, mental health providers may be uniquely situated to assist staff in overcoming these barriers. (PsycINFO Database Record

What roles do middle managers play in implementation of innovative practices?

BACKGROUND: Middle managers play key roles in hospitals as the bridge between senior leaders and frontline staff. Yet relatively little research has focused on their role in implementing new practices. PURPOSE: The aim of this study was to expand the understanding of middle managers' influence in organizations by looking at their activities through the lens of two complementary conceptual frameworks. METHODOLOGY/APPROACH: We analyzed qualitative data from 17 Veterans Affairs Medical Centers with high and low potential to change organizational practices. We analyzed 98 interviews with staff ranging from senior leaders to frontline staff to identify themes within an a priori framework reflecting middle manager activities. FINDINGS: Analyses yielded 14 emergent themes that allowed us to classify specific expressions of middle manager commitment to implementation of innovative practices (e.g., facilitate improvement innovation, garner staff buy-in). In comparing middle manager behaviors in high and low change potential sites, we found that most emergent themes were present in both groups. However, the activities and interactions described differed between the groups. PRACTICE IMPLICATIONS: Middle managers can use the promising strategies identified by our analyses to guide and improve their effectiveness in implementing new practices. These strategies can also inform senior leaders striving to guide middle managers in those efforts.

Organizational Characteristics of Veterans Affairs Clinics With High and Low Utilization of Clozapine.

OBJECTIVE: Twenty to thirty percent of patients with schizophrenia experience treatment resistance. Clozapine is the only medication proven effective for treatment-resistant schizophrenia. However, in most settings less than 25% of patients with treatment-resistant schizophrenia receive clozapine. This study was conducted to identify facilitators of and barriers to clozapine use to inform development of interventions to maximize appropriate clozapine utilization. METHODS: Seventy semistructured phone interviews were conducted with key informants of clozapine processes at U.S. Department of Veterans Affairs medical centers in various U.S. regions, including urban and rural areas, with high (N=5) and low (N=5) rates of clozapine utilization. Interviewees included members of mental health leadership, psychiatrists, clinical pharmacists, and advanced practice nurses. Interviews were analyzed by using an emergent thematic strategy to identify barriers and facilitators related to clozapine prescribing. RESULTS: High utilization was associated with integration of nonphysician psychiatric providers and clear organizational processes and infrastructure for treatment of severe mental illness, for example, use of clozapine clinics and mental health intensive case management. Low utilization was associated with a lack of champions to support clozapine processes and with limited-capacity care systems. Obstacles identified at both high- and low-utilization sites included complex, time-consuming paperwork; reliance on a few individuals to facilitate processes; and issues related to transportation for patients living far from care facilities. CONCLUSIONS: Implementation efforts to organize, streamline, and simplify clozapine processes; development of a multidisciplinary clozapine clinic; increased capacity of existing clinics; and provision of transportation are reasonable targets to increase clozapine utilization.