From Learning to Doing: Identifying, Implementing, and Spreading - - PowerPoint PPT Presentation

From Learning to Doing: Identifying, Implementing, and Spreading Promising Practices in the VA Healthcare System

AcademyHealth Annual Research Meeting New Orleans, LA June 27, 2017

George L. Jackson, Ph.D., MHA

Center for Health Services Research in Primary Care – Durham VA Health Care System Department of Population Health Sciences – Duke University Division of General Internal Medicine – Duke University

Background

The Veterans Health Administration (VHA) is the largest integrated health care delivery system in the United States.

• > 1,700 sites of care
• > 300,000 employees
• > 6.74 million Veterans served each year

While VHA is a leader in the delivery of high quality health care, it has lacked consistency in the application of best practices. Starting in October 2015, VHA leadership sought to develop a method to effectively identify,

diffuse, and sustain best practices in this large, diverse system.

Key priorities for continued improvement include enhancing access, care coordination, employee engagement, quality and safety, and Veterans’ trust and experience.

• Setting and aligning overall organizational goals
• Reducing system-level barriers to implementation
• Providing initial implementation support and resources
• Packaging and endorsing new promising practices
• Having “evidence” that a promising practice has “worked” in similar clinical settings
• Linking organization-wide goals with local facility needs and objectives
• Identifying promising practices
• Identifying opportunities to improve clinical and administrative processes
• Empowering front-line staff

Is the Learning Health System Top Down or Bottom Up?

Diffusion of Excellence Initiative Objectives

Identify and scale innovations across VHA, while:

Empowering employees to promote innovation sharing and drive a supportive culture of continuous improvement Institutionalizing processes and mechanisms for systematically diffusing and implementing promising practices throughout the system Minimizing negative variation, and standardizing practices by diffusing innovative and industry recognized best practices across the system

Elnahal SM, Clancy CM, Shulkin DJ. A Framework for Disseminating Clinical Best Practices in the VA Health System. JAMA. 2017;317(3):255-256.

Diffusion of Excellence Initiative Partners

• VA treatment facilities, Veterans Integrated Service Networks, and VA Central Office
• Developers of the Diffusion of Excellence Initiative
• Office of the Under Secretary for Health
• Office of Quality, Safety, and Value
• Center for Innovation
• Office of Rural Health
• Operational Home
• Office of Strategic Integration
• Veterans Engineering Resource Center Program
• Diffusion Team Contractors
• Atlas Research
• Enterprise Resource Performance, Inc.
• Evaluation Team – Funded by the VA Quality Enhancement Research Initiative (QUERI)
• Durham VA Center for Health Services Research in Primary Care
• Ann Arbor VA Center for Clinical Management Research (CCMR)
• Bedford/Boston VA Center for Healthcare Organization and Implementation Research (CHOIR)

DoE Model for Disseminating Best Practices

Find the Champions

Local champions, or ‘early adopters,’ serve as sharks in a ‘shark tank’ style event. Those selected as implementers identify local champions to lead.

Replicate

Establish Consistency & Standardize

Leverage national program office leader support to select those ready for national rollout and support standard development and scaling.

Sustain and Improve

Establish a robust operations center for managing and tracking outcomes, in parallel with implementation.

Identify Promising Practices

Solicit practices nationally and engage staff at all levels, including projects from the VA Innovators Network and Communities of Practice, to evaluate them using a rigorous set of criteria.

Adapt and Replicate

Leverage Diffusion Council governance structure to engage field staff and leaders during initial replication to support issue resolution; Use advanced technology tools and project management resources to track and monitor progress.

Elnahal SM, Clancy CM, Shulkin DJ. A Framework for Disseminating Clinical Best Practices in the VA Health System. JAMA. 2017;317(3):255-256.

Current Shark Tank Process

Shark Tank Selection Process

260 Submissions 40 Semifinalists 20 Finalists

13 Gold Status

January 2016 November 2016

435 Submissions 119 Semifinalists 20 Finalists

12 Gold Status

356 Submissions 100 Semifinalists 19 Finalists

~10 Gold Status

June 2017

8 Designated for National Rollout

How We Have Conceptualized the Development of a Partnered Evaluation

DEI Objectives Steps in Model for Disseminating Best Practices Understanding the Current State of the Program (preliminary data) Evaluation Questions / Specific Aims Evaluation Methods Practical Decisions That Can Be Made As a Result of Evaluation

Short-term Evaluation / Panning Activities Specific Evaluation Aims Evaluation Methods that Help Provide Actionable Results that Can Also Be Described in the Literature and Presentations Review of Current State of the Diffusion of Excellence Initiative

Specific Aims

Aims Focused on Shark Tank and Adoption Decisions for Promising Practices

Aim 1: Identify factors associated with participation in the DEI. 1a: Utilize quantitative analyses to identify organizational factors associated with proposing gold status practices and separately choosing to participate as a Shark. 1b: Chart the rate of diffusion of gold status practices across the VA. 1c: Utilize qualitative interviews of facility directors to identify organizational and leadership factors associated with choosing/not choosing to participate as a Shark. Aim 2: Examine Shark decision making processes when choosing to bid resources for implementation of gold status practices and relate processes to perceived organizational readiness for change (ORC). 2a: Understand the process through which Sharks select gold status practices to adopt. 2b: Determine the association between specific decision making processes and measured ORC. 2c: Develop tools to support explicit decisions in the Shark Tank.

Specific Aims

Aim Focused on the Process of Implementing Gold Status Practices

Aim 3: Conduct process evaluations to understand influences on implementation success within implementing facilities and grassroots facilities. 3a: Assess pre-implementation ORC for implementing gold status practices. 3b: Conduct a qualitative assessment of potential influences on implementation of gold status practices. 3c: Explore the association of pre-implementation ORC with implementation outcomes. Aim Focused on the Synthesis of Findings Across the Full Life-Cycle of the DEI Aim 4: Utilize qualitative comparative analysis methods to identify pathways toward broader diffusion and successful implementation of gold status practices.

Theories and Frameworks Utilized for the Evaluation

• Theory of Organizational Readiness for Change1
• Consolidated Framework for Implementation Research (CFIR)2
• Theory of Diffusion of Innovations3

1-Weiner BJ. A theory of organizational readiness for change. Implement Sci. 2009;4:67. 2-Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4:50. 3-Rogers EM. Diffusion of Innovations. 4th ed. New York, NY: The Free Press; 1995.

Key Data Source – VA Diffusion of Excellence Hub

As of April 2017 – 502 reports of implemented projects have been placed in the Hub Developed and maintained by the Veterans Engineering Resource Center Program: VA Center for Applied Systems Engineering

Spread of Round 1 Gold Status Practices to Individual VA Medical Centers

As of April 2017: Access, Quality and Safety, Care Coordination, and Employee Engagement

20 40 60 80 100 120 140 Audiology and Optometry Direct Scheduling Flu Self Reporting Desktop Icon Access Data Dashboard Journey to Open Access Same Day Access suing RNCM Chair Visits Increasing Access to Primary Care Advanced Care Planning via Group Visits eScreeing Unit Tracking Board Code Tray Redesign WAKE Score for Recovery from Anesthesia Sedation External (Non- VA) Comparative Data Regional Liver Tumor Board

Access 67% Quality and Safety 25% Care Coordination 4% Employee Engagement 4%

“Sharks” Consider a Variety of Factors when Deciding What to Implement

Preliminary Insights Into Factors Influencing Implementation Process Internal to Facility

• Needed motivation/tension for change increased when there was a clear

imperative to meet patient needs and address VA priorities.

• Need for a collaborative process among facility stakeholders when deciding to take on

implementing a new process.

• Leaders of the implementation process vary in roles within the VA, stakeholder

networks within their facility, and level of authority.

• Leadership engagement varies.
• Attending meetings and monitoring progress
• Working to reduce barriers to implementation
• Providing protected time to those responsible for implementation

Preliminary Insights into Factors Influencing Implementation Process External to Facility

• Complex information technology requirements may reduce the ability to

translate best practices to new facilities.

• Providing information about best practices that is too complex may reduce the

effectiveness in encouraging implementation.

• Having external change agents/facilitators is important to implementation.
• Implementation sites that successfully bid resources during the Shark Tank get 6 months of

intensive implementation assistance.

• Individuals who originated the Gold Status practices provide tangible

assistance to early adopters of the practice.

A Partnered Team – DEI Evaluation Workgroup, Collaborators, and Team (current and former members)

Office of Quality, Safety, and Value Shereef Elnahal (Founder and Director of DEI) Tina Shah VA Center for Innovation Andrea Ippolito (Co-Chair, Diffusion Council) Office of Strategic Integration Frederick (Rick) Kotler (Senior Medical Advisor) Sankalpa (Kalpa) Subbu (Senior Project Manager) Kimberly Brown Gabriela Garrity Kristiann Dickson Sotonya Motton Atlas Research & Enterprise Resource Performance, Inc. Thalia Sirjue (Diffusion Team Lead) Melissa Davoust Hillary Peabody Carole Greenwell Eliza Spencer Rachel Hudak Priyanka Surio Tyler Lederer Quality Enhancement Research Initiative Amy Kilbourne Melissa Braganza Nick Bowersox VA Center for Applied Systems Engineering Meetesh Kumar (Diffusion Hub Team Leader) Xu (Lisa) Miao Robert Morgan Durham VA HSR&D Center of Innovation George Jackson (evaluation corresponding PI) Hayden Bosworth Eugene Oddone Heather King Maren Olsen Jennifer Lindquist Brandolyn White Ann Arbor VA HSR&D Center of Innovation Laura Damschroder (evaluation PI) Julie Lowery Caitlin Reardon Andrea Nevedal Bedford/Boston VA HSR&D Center of Innovation Thomas Houston (evaluation PI) Sarah Cutrona Tim Hogan Kathryn DeLaughter Stephanie Shimada Allen Gifford

Contact Information and Disclaimer

George L. Jackson, Ph.D., MHA Center for Health Services Research in Primary Care Durham Veterans Affairs Health Care System george.l.jackson@duke.edu General Question about the Diffusion of Excellence Initiative diffusion@atlasresearch.us Disclaimer The views expressed in this presentation are those of the presenter and do not reflect the position or policy of the Department of Veterans Affairs or the United States government. Results presented here are preliminary.