scholarly journals The LEAP Program: Quality Improvement Training to Address Team Readiness Gaps Identified by Implementation Science Findings

2020 ◽  
Author(s):  
Laura J. Damschroder ◽  
Nicholas R. Yankey ◽  
Claire H. Robinson ◽  
Michelle B. Freitag ◽  
Jennifer A. Burns ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Training Program ◽  
Learning Community ◽  
Organizational Readiness ◽  
Audit And Feedback ◽  
Veterans Health ◽  
Health Administration ◽  
Program Satisfaction ◽  
Implementing Change ◽  
Assignment Completion

Abstract Background Integrating evidence-based innovations (EBIs) into sustained use is challenging; most implementations in health systems fail. Increasing frontline teams’ quality improvement (QI) capability may increase the implementation readiness and success of EBI implementation. Objectives Develop a QI training program (“Learn. Engage. Act. Process.” (LEAP)) and evaluate its impact on frontline obesity treatment teams to improve treatment delivered within the Veterans Health Administration (VHA). Design This was a pre-post evaluation of the LEAP program. MOVE! coordinators (N = 68) were invited to participate in LEAP; 24 were randomly assigned to four starting times. MOVE! coordinators formed teams to work on improvement aims. Pre-post surveys assessed team organizational readiness for implementing change and self-rated QI skills. Program satisfaction, assignment completion, and aim achievement were also evaluated. Participants VHA facility-based MOVE! teams. Interventions LEAP is a 21-week QI training program. Core components include audit and feedback reports, structured curriculum, coaching and learning community, and online platform. Main Measures Organizational readiness for implementing change (ORIC); self-rated QI skills before and after LEAP; assignment completion and aim achievement; program satisfaction. Key Results Seventeen of 24 randomized teams participated in LEAP. Participants' self-ratings across six categories of QI skills increased after completing LEAP (p< 0.0001). The ORIC measure showed no statistically significant change overall; the change efficacy subscale marginally improved (p < 0.08), and the change commitment subscale remained the same (p = 0.66). Depending on the assignment, 35 to 100% of teams completed the assignment. Nine teams achieved their aim. Most team members were satisfied or very satisfied (81–89%) with the LEAP components, 74% intended to continue using QI methods, and 81% planned to continue improvement work. Conclusions LEAP is scalable and does not require travel or time away from clinical responsibilities. While QI skills improved among participating teams and most completed the work, they struggled to do so amid competing clinical priorities.

Results of a Regional Effort to Improve Warfarin Management

2016 ◽  
Vol 51 (5) ◽  
pp. 373-379 ◽  
Author(s):  
Adam J. Rose ◽  
Angela Park ◽  
Christopher Gillespie ◽  
Carol Van Deusen Lukas ◽  
Al Ozonoff ◽  
...  
Keyword(s):  
Quality Improvement ◽  
New England ◽  
Audit And Feedback ◽  
Quality Improvement Initiative ◽  
Veterans Health ◽  
Health Administration ◽  
Process Of Care ◽  
Processes Of Care ◽  
Anticoagulation Control

Background: Improved anticoagulation control with warfarin reduces adverse events and represents a target for quality improvement. No previous study has described an effort to improve anticoagulation control across a health system. Objective: To describe the results of an effort to improve anticoagulation control in the New England region of the Veterans Health Administration (VA). Methods: Our intervention encompassed 8 VA sites managing warfarin for more than 5000 patients in New England (Veterans Integrated Service Network 1 [VISN 1]). We provided sites with a system to measure processes of care, along with targeted audit and feedback. We focused on processes of care associated with site-level anticoagulation control, including prompt follow-up after out-of-range international normalized ratio (INR) values, minimizing loss to follow-up, and use of guideline-concordant INR target ranges. We used a difference-in-differences (DID) model to examine changes in anticoagulation control, measured as percentage time in therapeutic range (TTR), as well as process measures and compared VISN 1 sites with 116 VA sites located outside VISN 1. Results: VISN 1 sites improved on TTR, our main indicator of quality, from 66.4% to 69.2%, whereas sites outside VISN 1 improved from 65.9% to 66.4% (DID 2.3%, P < 0.001). Improvement in TTR correlated strongly with the extent of improvement on process-of-care measures, which varied widely across VISN 1 sites. Conclusions: A regional quality improvement initiative, using performance measurement with audit and feedback, improved TTR by 2.3% more than control sites, which is a clinically important difference. Improving relevant processes of care can improve outcomes for patients receiving warfarin.

scholarly journals Adaptation of a quality improvement approach to implement eScreening in VHA healthcare settings: innovative use of the Lean Six Sigma Rapid Process Improvement Workshop

2021 ◽  
Vol 2 (1) ◽  
Author(s):  
James O. E. Pittman ◽  
Borsika Rabin ◽  
Erin Almklov ◽  
Niloofar Afari ◽  
Elizabeth Floto ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Survey Data ◽  
Implementation Strategy ◽  
Scale Up ◽  
Implementation Process ◽  
Interview Data ◽  
Self Report ◽  
Veterans Health ◽  
Health Administration ◽  
Health Technologies

Abstract Background The Veterans Health Administration (VHA) developed a comprehensive mobile screening technology (eScreening) that provides customized and automated self-report health screening via mobile tablet for veterans seen in VHA settings. There is agreement about the value of health technology, but limited knowledge of how best to broadly implement and scale up health technologies. Quality improvement (QI) methods may offer solutions to overcome barriers related to broad scale implementation of technology in health systems. We aimed to develop a process guide for eScreening implementation in VHA clinics to automate self-report screening of mental health symptoms and psychosocial challenges. Methods This was a two-phase, mixed methods implementation project building on an adapted quality improvement method. In phase one, we adapted and conducted an RPIW to develop a generalizable process guide for eScreening implementation (eScreening Playbook). In phase two, we integrated the eScreening Playbook and RPIW with additional strategies of training and facilitation to create a multicomponent implementation strategy (MCIS) for eScreening. We then piloted the MCIS in two VHA sites. Quantitative eScreening pre-implementation survey data and qualitative implementation process “mini interviews” were collected from individuals at each of the two sites who participated in the implementation process. Survey data were characterized using descriptive statistics, and interview data were independently coded using a rapid qualitative analytic approach. Results Pilot data showed overall satisfaction and usefulness of our MCIS approach and identified some challenges, solutions, and potential adaptations across sites. Both sites used the components of the MCIS, but site 2 elected not to include the RPIW. Survey data revealed positive responses related to eScreening from staff at both sites. Interview data exposed implementation challenges related to the technology, support, and education at both sites. Workflow and staffing resource challenges were only reported by site 2. Conclusions Our use of RPIW and other QI methods to both develop a playbook and an implementation strategy for eScreening has created a testable implementation process to employ automated, patient-facing assessment. The efficient collection and communication of patient information have the potential to greatly improve access to and quality of healthcare.

scholarly journals Increasing enrolment in a national VA transitions of care programme: a pre–post evaluation of a data dashboard and nudge-based intervention

2021 ◽  
Vol 28 (1) ◽  
pp. e100416
Author(s):  
Brigid Connelly ◽  
Chelsea Leonard ◽  
David Gaskin ◽  
Theodore Warsavage ◽  
Heather Gilmartin
Keyword(s):  
Performance Metrics ◽  
Transitions Of Care ◽  
Audit And Feedback ◽  
Veterans Health ◽  
Health Administration ◽  
Care Programme ◽  
Post Evaluation ◽  
The Difference ◽  
Two Phases ◽  
One Year

BackgroundThe rural transitions nurse programme (TNP) is a care coordination intervention for high-risk veterans. An interactive dashboard was used to provide real-time performance metrics to sites as an audit and feedback tool. One-year post implementation, enrolment goals were not met. Nudge emails were introduced to increase TNP veteran enrolment. This study evaluated whether veteran enrolment increased when feedback occurred through a dashboard plus weekly nudge email versus dashboard alone.Setting/populationThis observational study included veterans who were hospitalised and discharged from four Veterans Health Administration hospitals participating in TNP.MethodsVeteran enrolment counts between the dashboard phase and dashboard plus weekly nudge email phase were compared. Nudge emails included run charts of enrolment data. The difference of means for weekly enrolment between the two phases were calculated. After 3 months of nudge emails, a survey assessing TNP transitions nurse and physician champion perceptions of the nudge emails was distributed.ResultsThe average enrolment for the four TNP sites during the ~20-month dashboard only phase was 4.23 veterans/week. The average during the 3-month dashboard plus nudge email phase was 4.21 veterans/week. The difference in means was −0.03 (p=0.73). Adjusting for time trends had no further effect. Four nurses responded to the survey. Two nurses reported neutral and two reported positive perceptions of the nudge emails.ConclusionDrawing attention to metrics, through nudge emails, maintained, but did not increase TNP veteran discharges compared to dashboard feedback alone.

Abstract 244: Real World Evaluation of Implementing a Mock Cardiac Arrest Program

2020 ◽  
Vol 13 (Suppl_1) ◽  
Author(s):  
Brad Trumpower ◽  
Lee A Kamphuis ◽  
Joseph McEvoy ◽  
Pamela J Weber ◽  
Sarah Krein ◽  
...  
Keyword(s):  
Cardiac Arrest ◽  
Training Program ◽  
Program Implementation ◽  
Medical Center ◽  
Veterans Health ◽  
Health Administration ◽  
Response Team ◽  
Study Team ◽  
National Initiative ◽  
Data Elements

Introduction: In 2019, the Veterans Health Administration (VHA) began rolling out a national initiative to create a standardized mock code training program through the Resuscitation Education Initiative (REdI). We partnered with REdI and the local REdI Mock Code Program team at a Midwestern VA medical center to evaluate the launch of this mock cardiac arrest training program using a mixed methods approach. Methods: The REdI mock cardiac arrest program provided training to VA medical center clinical and non-clinical staff using didactic, small group, and hands-on simulation activities over a 2-day site visit in January 2019 where all facets of the resuscitation team were reviewed. Following this training visit at one VA medical center, 10 mock cardiac arrests were conducted between March 2019 and December 2019. One mock cardiac arrest included a hospital-wide activation and nine were conducted on individual units without activation of the cardiac arrest response team. The research team was composed of clinical and methodological experts who observed 8 of the mock cardiac arrests. We used an observation template to record structured data elements and take field notes during the mock code (e.g., how participants made decisions, assigned roles and quality of communication between the participants). At the end of the mock code, facilitators and the study team collected oral and written feedback from the participants. Results: In the 8 mock cardiac arrests observed, we identified 54 participants. Participants overwhelmingly rated the mock cardiac arrests as positive (83.3%, 45/54). Debriefing-feedback after the mock cardiac arrest was identified as the most helpful aspect (42.6%, 23/54). Areas for improving implementation of the mock cardiac arrest training program focused primarily on the need for a better introduction to the exercise. This included understanding the manikin’s functionality (9.3%, 5/54) and the expectation that participants should perform CPR just as they would in an actual cardiac arrest event (7.4%, 4/54). Two critical takeaways frequently cited by participants related to performance during the mock cardiac arrest were a need for better communication (20.4%, 11/54) and defined roles (18.5%, 10/54). Conclusions: Implementation of a mock cardiac arrest program was positively received by participants at a VA medical center. Moreover, participants identified both opportunities for improving resuscitation performance and optimizing learning experiences as part of program implementation.

scholarly journals Supporting the Implementation of Connected Care Technologies in the Veterans Health Administration: Cross-Sectional Survey Findings from the Veterans Engagement with Technology Collaborative (VET-C) Cohort

10.2196/21214 ◽  
2020 ◽  
Vol 12 (3) ◽  
pp. e21214
Author(s):  
Bella Etingen ◽  
Daniel J Amante ◽  
Rachael N Martinez ◽  
Bridget M Smith ◽  
Stephanie L Shimada ◽  
...  
Keyword(s):  
Health Care ◽  
Quality Improvement ◽  
Veterans Health Administration ◽  
Advanced Degree ◽  
Patient Portal ◽  
Veterans Health ◽  
Health Administration ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Clinical Records

Background Widespread adoption, use, and integration of patient-facing technologies into the workflow of health care systems has been slow, thus limiting the realization of their potential. A growing body of work has focused on how best to promote adoption and use of these technologies and measure their impacts on processes of care and outcomes. This body of work currently suffers from limitations (eg, cross-sectional analyses, limited patient-generated data linked with clinical records) and would benefit from institutional infrastructure to enhance available data and integrate the voice of the patient into implementation and evaluation efforts. Objective The Veterans Health Administration (VHA) has launched an initiative called the Veterans Engagement with Technology Collaborative cohort to directly address these challenges. This paper reports the process by which the cohort was developed and describes the baseline data being collected from cohort members. The overarching goal of the Veterans Engagement with Technology Collaborative cohort is to directly engage veterans in the evaluation of new VHA patient-facing technologies and in so doing, to create new infrastructure to support related quality improvement and evaluation activities. Methods Inclusion criteria for veterans to be eligible for membership in the cohort included being an active user of VHA health care services, having a mobile phone, and being an established user of existing VHA patient-facing technologies as represented by use of the secure messaging feature of VHA’s patient portal. Between 2017 and 2018, we recruited veterans who met these criteria and administered a survey to them over the telephone. Results The majority of participants (N=2727) were male (2268/2727, 83.2%), White (2226/2727, 81.6%), living in their own apartment or house (2519/2696, 93.4%), and had completed some college (1176/2701, 43.5%) or an advanced degree (1178/2701, 43.6%). Cohort members were 59.9 years old, on average. The majority self-reported their health status as being good (1055/2725, 38.7%) or very good (524/2725, 19.2%). Most cohort members owned a personal computer (2609/2725, 95.7%), tablet computer (1616/2716, 59.5%), and/or smartphone (2438/2722, 89.6%). Conclusions The Veterans Engagement with Technology Collaborative cohort is an example of a VHA learning health care system initiative designed to support the data-driven implementation of patient-facing technologies into practice and measurement of their impacts. With this initiative, VHA is building capacity for future, rapid, rigorous evaluation and quality improvement efforts to enhance understanding of the adoption, use, and impact of patient-facing technologies.

scholarly journals Protocol: A Multi-Modal, Physician-Centered Intervention to Improve Guideline-Concordant Prostate Cancer Imaging

2020 ◽  
Author(s):  
Danil V Makarov ◽  
Shannon Ciprut ◽  
Matthew Kelly ◽  
Dawn Walter ◽  
Michele G Shedlin ◽  
...  
Keyword(s):  
Prostate Cancer ◽  
Data Collection ◽  
Behavior Change ◽  
Cancer Imaging ◽  
Intervention Strategy ◽  
Theoretical Domains Framework ◽  
Audit And Feedback ◽  
Veterans Health ◽  
Health Administration ◽  
Multi Level

Abstract Background: Almost half of Veterans with localized prostate cancer receive inappropriate, wasteful staging imaging. Our team has explored the barriers and facilitators of guideline-concordant prostate cancer imaging and found that 1) patients with newly diagnosed prostate cancer have little concern for radiographic staging but rather focus on treatment, 2) physicians trust imaging guidelines but are apt to follow their own intuition, fear medico-legal consequences, and succumb to influence from imaging-avid colleagues. We used a theory-based approach to design a multi-level intervention strategy to promote guideline-concordant imaging to stage incident prostate cancer.Methods: We designed the Prostate Cancer Imaging Stewardship (PCIS) intervention: a multi-site, stepped wedge, cluster-randomized trial to determine the effect of a physician-focused behavioral intervention on Veterans Health Administration (VHA) prostate cancer imaging use. The multi-level intervention, developed according to the Theoretical Domains Framework (TDF) and Behavior Change Wheel, combines traditional physician behavior change methods with novel methods of communication and data collection. The intervention consists of three components: 1) a system of audit and feedback to clinicians informing individual clinicians and their sites about how their behavior compares to their peers’ and to published guidelines 2) a program of academic detailing with the goal to educate providers about prostate cancer imaging, and 3) a CPRS Clinical Order Check for potentially guideline-discordant imaging orders. The intervention will be introduced to 10 participating geographically-distributed study sites.Discussion: This study is a significant contribution to implementation science, providing VHA an opportunity to ensure delivery of high-quality care at the lowest cost using a theory-based approach. The study is ongoing. Preliminary data collection and recruitment have started; analysis has yet to be performed.Trial Registration: This study was prospectively registered on February 26, 2018, CliniclTrials.gov: NCT03445559 (2a)

Multi-tiered External Facilitation: The Role of Feedback Loops and Tailored Interventions in Supporting Change in a Stepped-Wedge Implementation Trial

2020 ◽  
Author(s):  
Lauren S Penney ◽  
Teresa M. Damush ◽  
Nicholas A. Rattray ◽  
Edward J. Miech ◽  
Sean A. Baird ◽  
...  
Keyword(s):  
Feedback Loops ◽  
Audit And Feedback ◽  
Veterans Health ◽  
Health Administration ◽  
Or Education ◽  
Implementation Support ◽  
Local Contexts ◽  
Support Team ◽  
Time Periods ◽  
External Facilitation

Abstract Background Facilitation is a complex, relational implementation strategy that guides change processes. Facilitators engage in multiple activities and tailor efforts to local contexts. The contextual factors that prompt facilitators to tailor activities have not been well-described. Methods We conducted a mixed methods evaluation of a trial to improve the quality of transient ischemic attack care. Six sites in the Veterans Health Administration received external facilitation (EF) before and during a 1-year active implementation period. We examined how EF was employed, perceived, and activated. Data analysis included prospective logs of facilitator correspondence with sites (160 site-directed episodes), stakeholder interviews (n=78), and collaborative call debriefs (n=22). Logs were descriptively analyzed across facilitators, sites, time periods, and activity types. Interview transcripts were coded for content related to EF and themes were identified. Debriefs were reviewed to identify instances of and utilization of EF during site critical junctures. Results Multi-tiered EF was supported by two groups (site-facing quality improvement [QI] facilitators and the implementation support team) that were connected by feedback loops. Each site received an average of 24 episodes of site-directed EF; most of the EF was delivered by the QI nurse. For each site, site-directed EF frequently involved networking (45%), preparation and planning (44%), process monitoring (44%), and/or education (36%). EF less commonly involved audit and feedback (20%), brainstorming solutions (16%), and/or stakeholder engagement (5%). However, site-directed EF varied widely across sites and time periods in terms of these facilitation types. Site participants recognized the responsiveness of the QI nurse, and valued her problem-solving, feedback, and accountability support. External facilitators used monitoring and dialogue to intervene by facilitating redirection during challenging periods of uncertainty about project direction and feasibility for sites. External facilitators, in collaboration with the implementation support team, successfully used strategies tailored to diverse local contexts, including networking, providing data, and brainstorming solutions. Conclusions Multi-tiered facilitation capitalizing on feedback loops allowed for tailored, site-directed facilitation that aligned with the types of supports that local participants valued. Critical juncture cases illustrate the complexity of EF and the need to often try multiple strategies in combination to facilitate implementation progress.

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