Testing Implementation Strategies for Anticoagulation Improvement in - PowerPoint PPT Presentation

Testing Implementation Strategies for Anticoagulation Improvement in Clinical Pharmacy Clinics: A Qualitative Study Megan B. McCullough PhD, Chris Gillespie PhD, Beth Ann Petrakis MPA, Angela Park PharmD, Ellen Jones PharmD, Carol VanDeusen Lukas EdD, Adam J Rose, MD 1

VA Disclaimer The views expressed in this presentation are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the U.S. government. 2

The Intervention: Anticoagulation Clinic Improvement Initiative (ACCII) Across 8 VA medical centers, Pharmacists are asked to:  Use evidence-based dosing algorithm.  Adopt standard processes of care.  Use a dashboard to measures site-level TTR performance and related process measures.  Utilize improvement approaches to increase standardization At the regional level:  Establish 2 dedicated positions to lead the ACC improvement across the 8 centers. 3

RESEARCH OBJECTIVE  Strategy bundle implemented in 4 year pharmacist-focused intervention across 8 medical centers in VA New England. • audit and feedback • blended internal-external facilitation • small tests of cyclical change, • ongoing consultation  How sites related to this “bundle” and the outcome of successful implementation 4 examined.

Methods  Semi-structured interviews • All frontline ACC staff annually for 4 years. • Interviewed pharmacy leaders (Chiefs & Assoc. Chiefs of Pharmacy) year 1 and year 4 (N=22) • The external facilitators (who delivered the intervention) (N=5)  Analysis guided by Promoting Action on Research Implementation in Health Services (PARIHS) framework deductively combined with inductive thematic analysis. 5

Interviews: Clinical Pharmacists, Pharmacy Leadership, EF Team Wave 1 67 Wave 2 63 Wave 3 62 Wave 4 57 TOTAL ALL 4 years 249 (includes local leaders) External Facilitation Team 5 (delivered the intervention) 6

PARIHS Constructs and ACCII  Evidence  Context  Facilitation 7

Overall Results Sites with greater improvement had:  Integrated and used all implementation strategies  Spread strategies throughout entire clinical team  Had support from managers so full implementation of strategies could occur 8

Overall Results Sites with less successful implementation:  Had less leadership support and lower engagement  They divided the bundle of strategies (i.e., pursued some but not all of them) 9

Improvement on TTR and process measures among the 8 VISN 1 sites. Sites are ranked from most- to least- improved on TTR (Rose et al. Annals of Pharmacotherapy. In press) . Site Change in TTR All of VISN 1 +2.8% Site A +5.4% Site B +3.8% Site C +3.3% Site D +3.1% Site E +2.7% 10 Site F +2.4% Site G +1.1%

Implementation Strategies (Powell et al 2015)  Audit and feedback  Blended internal-external facilitation  Small tests of cyclical change  Ongoing consultation 11

Leadership & Manager Support High Site: “…I remember those first few meetings and who are all these people around the table, and why do they want us to change things.. But as the project became more transparent it was not challenging for me to have those discussions with my manager, and for him to have those with his manager, and just explain why it was important…” Low Site: “I get very pumped up about the project and I'm ready to…do every PDSA and I wanna see how changes can be made…because I believe that this clinic could be more efficient and increasing TTR I think is really important…But then when I come back to my own management…I get deflated pretty quickly.” 12

Integrating and Using IS Bundle High site: “ I think it’s networking, it’s allowed us…to know each other…and I think that makes everybody more …It just makes it very easy for us to coordinate…we kind of just work with each other easier and I like that aspect of it, plus it helps us to generate ideas and support each other and I think that drives… improvement.” Low site: “…we feel more like we've withdrawn from the project than anything else…that kind of was a decision made by people above…me…when administrative work was 13 deemed more important…”

Spread Strategies High performing site: “ I just like having my patients be safe and healthy and for most of them, that's having an INR within range. But I feel like now in the back of my head getting our TTR up is sort of always there…I feel like I never was as concerned about it before.” Lower performing sites “I didn’t feel like our clinic was going anywhere. It was just kind of stagnating…there was not platform for progress. And there was no 14 leadership to do that...”

Small Tests of Change  Higher sites engaged with this process more than lower sites 15

Ongoing Consultations:  Challenged sites received additional improvement support  Leadership Engagement  Local Improvement Workshops  Anticoagulation team development at sites  Competition and Goal Setting within and across sites 16

Some Challenges  Relationship building takes time  Introducing and applying small tests of change requires a culture shift  Validity and reliability of measurement system is key and requires trust  Local leadership engagement was slow to develop → this resulted in changing strategies in the area of ongoing consultation 17

Implications  Study suggests how and why bundling can be effective in successful implementation as well as where it might not.  Findings can guide researchers who seek to choose and then incorporate a strategy bundle on how to do this.  Multi-site complex implementation in clinical pharmacy demonstrates that building improvement capacity pays dividends and how synergistic the relationship between pharmacy and IS could be 18

Relationship between Uptake of ACCII and successful IF and EF Uptake Levels High Medium Low Uptake component ACC dosing algorithm Algorithm is implemented and used a high Algorithm is inconsistently used Algorithm is rarely used among all percentage of the time by all staff among staff staff Dashboard Dashboard is used not only to measure Dashboard used to measure Dashboard used rarely to measure performance but as tool for targeting performance and only one or two performance and rarely or not at all patients needing more attention. features used inconsistently as a tool. as a tool. Most or all staff increasing use of Often only select staff use the Little to no general usage and little or dashboard dashboard with little or no general no select staff usage usage Participation in ACC Site regularly sends appropriate IF to Site inconsistently sends s IF to Site rarely or never sends IF to Coordinators Internal participate participate participate Facilitation (IF) group Participation in ACC journal Staff regularly participate and contribute Staff unevenly participate and Staff rarely or never participate and club by IF and staff contribute contribute Participation in PDSA cycles IF has staff regularly participate IF has staff inconsistently participate IF has staff rarely participate related to ACC improvement lead by IF IF facilitates feedback from IF regularly elicits feedback IF inconsistently elicits feedback IF rarely participate frontline staff to EF on improvement work 19 Site seeks out and/or accepts IF & site reaches out for assistance and IF and site unevenly reach out for IF and site does not reach out for assistance by External remains in contact with EF team assistance from EF team assistance and does not respond to Facilitation ACC Improvement offers of assistance by EF team Team TTR begins to improve TTR begins to improve TTR show some improvement TTR shown little improvement