Qualitative Evaluation of the VHA Telegenomics Clinic Implementation Process VA Boston Center for Healthcare Organization & Implementation Research (CHOIR) • Barbara Lerner, PhD, MS (PI) • Nathalie McIntosh, PhD • Mark Meterko, PhD • Shannon Wiltsey-Stirman, PhD VA Genomic Medicine Service (GMS) • Vickie Venne, MS, LGC Health Services Research & Development Quality Enhancement Research Initiative (QUERI) Project Number: RRP 12-535 (PI: Lerner)
Background - Telegenomics • Genomics Medicine Service – Based at the Salt Lake City VA • Telehealth based genetic counseling service – Lack access to expertise in the VA and rural areas – Includes 5 licensed genetic counselors – First patient seen in 2011 • Inter-facility telehealth program – GMS acts as remote provider with full access to EHR at participating hospitals
Coordination & Interdependencies: Telegenomics Implementation Telehealth Clinic Technician Provider Facility Technology Coordinator PATIENT Center Director/ ITS Chief of Staff GMS HIMS(CAC/ADPAC) Group Privacy Officer Chief of Pathology
Presentation Objective • Identify the factors that contribute to the efficient implementation of the Telegenomic Clinic Program at VHA facilities.
Study Design • Qualitative Semi-structured interviews • Five facilities – Facility selection process • High vs. Low Implementation based on efficiency • Extreme case purposeful sampling • Efficiency measures – Subjective • GMS staff ratings – Objectives • # of contacts GMS staff had and the facility to address problems • # of system tests required prior to launch
Study Facilities Efficiency Quartile Facilities Level Bottom 4 th A Inefficient Bottom 4 th B Inefficient Top 1 st C Efficient Top 1 st D Efficient Top 1 st E Efficient
Study Design • Semi-structured interviews with key informants 1. Facility Telehealth Coordinator (FTC) 2. Chief of Staff 3. Chief of Pathology 4. Information Privacy Officer (ISO) 5. Information Technology Technician 6. Telehealth Clinical Technologist (TCT) 7. Clinical Application Coordinator (CAC) 8. Referring Providers Interviews/facility: Range: 5-8 Mean: 7.2 Total: 36
Consolidated Framework for Implementation Research (CFIR) Domains Characteristics Intervention Process of of the Inner Setting Outer Setting Characteristics Implementation Individuals Evidentiary Structural Patient needs Knowledge Planning support characteristics & resources Constructs Relative Networks & Organizational Self-efficacy Engaging advantage communication connectedness Adaptability Stage of change Culture Peer pressure Executing Identification External Reflecting & Trialability with Climate policies & evaluating organization incentives Readiness for Complexity implementation Damschroder, et al. Implementation Science, 2009
Data Collection & Analysis Interviews Conducted Interview Coding Interview Coding (Coder 2) (Coder 1) Scored Scored (Coder 2) (Coder 1) CFIR Scoring Consensus Dichotomized Score Damschroder, L & Lowery, J. Evaluation of a large-scale weight management program using the consolidated framework for implementation research (CFIR). Implementation Science 2013.
Coding & Rating the Constructs Rating Criteria -2 • Negative influence; • At least two interviewees describe explicit examples -1 • Negative influence in the organization; 0 • General statements but without concrete examples 0 • No evidence of positive or negative influence; • Credible or reliable interviewees contradict each other +1 • Positive influence; • General statements but without concrete examples 1 +2 • Positive influence; • At least two interviewees describe explicit examples Missing • Not asked about construct; or responses did not Damschroder & Lowery, Implementation Science 2013. correspond to the intended construct Damschroder & Lowery, Implementation Science 2013.
Dichotomized Rating Results Inefficient Efficient Facilities Facilities Domain Construct Site A Site B Site C Site D Site E Readiness for 1 1 1 0 0 Implementation Inner Setting Networks & 1 1 1 0 0 Communication Implementation 1 1 1 1 0 Climate Engaging Implementation 1 1 1 0 0 Process of Planning 1 1 1 0 0 Executing 1 1 0 0 0
Dichotomized Rating Results Inefficient Efficient Facilities Facilities Domain Construct Site A Site B Site C Site D Site E Readiness for 1 1 1 0 0 Implementation Inner Setting Networks & 1 1 1 0 0 Communication Implementation 1 1 1 1 0 Climate Engaging Implementation Tangible and immediate indicators of organizational 1 1 1 0 0 Process of commitment to its decision to implement an intervention. Planning 1 1 1 0 0 Executing 1 1 0 0 0
Dichotomized Rating Results Inefficient Efficient Facilities Facilities Domain Construct Site A Site B Site C Site D Site E Readiness for 1 1 1 0 0 Implementation Inner Setting Networks & 1 1 1 0 0 Communication Implementation “ Good working relationships with other departments is “ I cannot stress to anybody in telehealth how important it is The nature and quality of webs of social networks and the 1 1 1 1 0 Climate essential. The secret is baking. Cookies are on the nature of quality of formal and informal communications to be friends with everybody. You need to know your CACS, agenda! ” Engaging Implementation within an organization. your ADPACs, the HMS Department head. If they know you 1 1 1 0 0 Process of … and respect you, it's going to make your life so much (High performing FTC) Planning easier. You've gotta be buddies with them. Write your 1 1 1 0 0 thank-you cards. Do your SPOT Awards. I'm not above Executing bribing people. I bring people food.” 1 1 0 0 0 (High performing FTC)
Dichotomized Rating Results Inefficient Efficient Facilities Facilities Domain Construct Site A Site B Site C Site D Site E Readiness for 1 1 1 0 0 Implementation Inner Setting Networks & 1 1 1 0 0 Communication Implementation 1 1 1 1 0 Climate Engaging Implementation 1 1 1 0 0 Process of The absorptive capacity for change, shared receptivity of involved individuals to an intervention. Planning 1 1 1 0 0 Executing 1 1 0 0 0
Dichotomized Rating Results Inefficient Efficient Facilities Facilities Domain Construct Site A Site B Site C Site D Site E Readiness for 1 1 1 0 0 Implementation Inner Setting Attracting and involving appropriate individuals in the Networks & 1 1 1 implementation through a strategy of social marketing, 0 0 Communication education, training, etc. Implementation 1 1 1 1 0 Climate Engaging Implementation 1 1 1 0 0 Process of Planning 1 1 1 0 0 Executing 1 1 0 0 0
Dichotomized Rating Results Inefficient Efficient Facilities Facilities Domain Construct Site A Site B Site C Site D Site E Readiness for 1 1 1 0 0 Implementation Inner Setting Networks & 1 1 1 0 0 Communication The degree to which a scheme or method of behavior and Implementation tasks for implementing an intervention are developed in 1 1 1 1 0 Climate advance and the quality of those schemes or methods. Engaging Implementation 1 1 1 0 0 Process of Planning 1 1 1 0 0 Executing 1 1 0 0 0
Dichotomized Rating Results Inefficient Efficient Facilities Facilities Domain Construct Site A Site B Site C Site D Site E Readiness for 1 1 1 0 0 Implementation Inner Setting Networks & 1 1 1 0 0 Communication Implementation Carrying out or accomplishing the implementation 1 1 1 1 0 Climate according to plan. Engaging Implementation 1 1 1 0 0 Process of Planning 1 1 1 0 0 Executing 1 1 0 0 0
Conclusions Primary Drivers of Effective Implementation Domains Characteristics Intervention Process of of the Inner Setting Outer Setting Characteristics Implementation Individuals Evidentiary Structural Patient needs Knowledge Planning support characteristics & resources Constructs Relative Networks & Organizational Self-efficacy Engaging advantage communication connectedness Adaptability Stage of change Culture Peer pressure Executing External Identification Reflecting & Trialability Climate policies/ with organization evaluating incentives Readiness for Complexity implementation
Recommendations • Programmable & Feedback Coordination Theory – Programmable Coordination 1. Creating templates and instructions for tasks, 2. Explicit understanding of the role and expectations of each team member – Feedback Coordination 1. Kick-off meeting to with all are involved in the process 2. Regular meetings & communication with all parties Young & Charns, Health Services Research. 1998
Limitations • Limited number of facilities evaluated • Retrospective evaluation • In one facility the original FTC was no longer available to interview
Thank You! • Facilities and Interviewees • Research Team Nathalie McIntosh, PhD Mark Meterko, PhD Shannon Wiltsey-Stirman, PhD Vickie Venne, MS, LGC • Genomic Medicine Service • barbara.lerner@va.gov • VA HSR&D/QUERI Quality Enhancement Research Initiative (QUERI) Project Number: RRP 12-535 (PI: Lerner)
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