1047. A Multi-Hospital Safety Improvement Effort and the Dissemination of New Knowledge
Peter D Mills, PhD, MS, Field Office Veterans Affairs National Center for Patient Safety, White River Junction VAMC, WB Weeks, Veterans Affairs National Quality Scholars Fellowship Program, VHA and Field Office Veterans Affairs National Center for Patient Safety, White River Junction, M Caudill-Slosberg,
Veterans Affairs National Quality Scholars Fellowship Program, VHA, BC Surott Kimberly,
Field Office Veterans Affairs National Center for Patient Safety, White River Junction VAMC
Objectives: We wanted to determine how information about complex medical process improvements is disseminated in a large medical system, both within and between hospitals and to determine organizational characteristics that are associated with enhanced dissemination.
Methods: We examined teams from twenty-two VA hospitals that participated in a 9-month facilitated quality improvement project designed to improve safety in high-hazard areas. By surveying other units within participating hospitals and other regional hospitals we were able to determine the level of dissemination of information generated during and after the project. Participating hospitals provided data on measures of improvement and organizational characteristics.
Results: While the participating hospitals benefited from the quality improvement effort, changes were implemented only 9% of the time on other units within the participating hospital, and only 2% of the time in other regional hospitals. After 12 months, there was no additional implementation within participating hospitals, while other regional hospitals were implementing changes 10% of the time. In addition, while some change-team characteristics predicted success for the team, they were not related to the teamís ability to disseminate information.
Conclusions: While participating teams benefited from the quality improvement effort, other units within the hospital and within the region rarely implemented changes.
Impact: Aggressive strategies are required to spread knowledge and improvement beyond teams participating in translation efforts. Personal commitment from senior leadership, dissemination strategies that push information to clinicians, and monitoring progress at the regional level are all needed for dissemination of complex medical information to occur.