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 .

Is the Learning Health System Top Down or Bottom Up? • 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

Diffusion of Excellence Initiative Objectives Identify Empowering employees and scale to promote innovation sharing and drive a supportive culture of continuous improvement innovations Institutionalizing processes and mechanisms across VHA, for systematically diffusing and implementing while: 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 Sustain and Improve Identify Promising Practices Establish a robust operations center for Solicit practices nationally and engage staff at all levels, managing and tracking outcomes, in parallel including projects from the VA Innovators Network and with implementation. Communities of Practice, to evaluate them using a rigorous set of criteria. Establish Consistency & Find the Champions Standardize Local champions, or ‘early adopters,’ serve as sharks in a ‘shark tank’ style event. Those Leverage national program office leader support selected as implementers identify local to select those ready for national rollout and champions to lead. support standard development and scaling. Adapt and Replicate 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 January 2016 November 2016 June 2017 435 Submissions 260 Submissions 356 Submissions 40 119 100 Semifinalists Semifinalists Semifinalists 20 20 19 Finalists Finalists Finalists ~10 13 Gold 12 Gold Gold Status Status Status 8 Designated for National Rollout

How We Have Conceptualized the Development of a Partnered Evaluation Understanding Practical the Current Steps in Model Evaluation Decisions That for State of the Evaluation DEI Objectives Questions / Can Be Made Disseminating Methods Program Specific Aims As a Result of Best Practices (preliminary Evaluation data) Review of Current State of the Short-term Specific Evaluation Methods that Help Diffusion of Excellence Initiative Evaluation / Evaluation Provide Actionable Results that Panning Aims Can Also Be Described in the Literature and Presentations Activities

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 Change 1 • Consolidated Framework for Implementation Research (CFIR) 2 • Theory of Diffusion of Innovations 3 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 140 Access 67% Quality and Safety 25% 120 Care Coordination 4% 100 Employee Engagement 4% 80 60 40 20 0 Audiology and Flu Self Access Data Journey to Same Day Increasing Advanced Care eScreeing Unit Tracking Code Tray WAKE Score for External (Non- Regional Liver Optometry Reporting Dashboard Open Access Access suing Access to Planning via Board Redesign Recovery from VA) Tumor Board Direct Desktop Icon RNCM Chair Primary Care Group Visits Anesthesia Comparative Scheduling Visits Sedation Data As of April 2017: Access, Quality and Safety, Care Coordination, and Employee Engagement

“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