Lead/Presenter: Elizabeth Yano, COIN - Los Angeles
All Authors: Yano EM (VA Los Angeles HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy)
Hamilton AB (VA Los Angeles HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy)
Chow B (VA Los Angeles HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy)
Canelo I (VA Los Angeles HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy)
Chuang E (UCLA Fielding School of Public Health)
Brunner J (VA Los Angeles HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy)
Rubenstein LV (VA Los Angeles HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy)
Objectives:
VA policy guidance for PACT implementation was not originally adapted for special populations, including women Veterans (WVs), whose numerical minority, comorbid physical and mental health (MH) burdens, and need for gender-specific care complicates primary care (PC) delivery. We tested an evidence-based quality improvement (EBQI) approach to tailoring PACT to meet WVs' needs.
Methods:
We tested EBQI in a 12-VAMC cluster randomized trial, using an unbalanced 2:1 allocation to accommodate anticipated variations in EBQI implementation (8E:4C). In this study, EBQI included multilevel VISN stakeholder panel meetings for consensus on QI priorities, EBQI team training, external practice facilitation, formative feedback, and across-site collaboration calls. Feedback reports were drawn from baseline patient surveys (computer-assisted telephone interviews of random sample of WVs with 3+ PC and/or women's health (WH) visits in past year), provider/staff surveys (web surveys of census in general PC and WH clinics), key stakeholder interviews (VISN, VAMC, clinic), teamlet interviews (random samples of general PC/WH clinic members), and quality metrics by gender.
Results:
EBQI VAMCs completed 1-3 QI projects each over 24-months, including improved follow-up of abnormal breast cancer screening (27% increase in documentation, 6-day average decline in follow-up), follow-up of abnormal cervical cancer screening ( < 50% to 85% received correct recommendations), testing/reporting cervical cytology (72% to 96% compliance), assignment of new patients to designated WH providers (75% to 100%), visit comprehensiveness (0% to 80% obtaining labs before first appointment), PACT team functioning (increased team climate scores and quality metrics, reduced fractured days and burnout), residents' trauma-sensitive communication with WV patients (increased knowledge, communication, satisfaction scores), and proactive identification of WVs in MH crisis/distress (pre-visit MH handoffs; improved patient, provider, staff satisfaction). Multiple QI projects are being spread within their VISNs.
Implications:
VAMCs participating in EBQI made substantial gains in a wide range of QI targets aligned with VISN priorities and adapted to local contexts, with researchers providing training, technical support and formative data but otherwise without additional direct funding.
Impacts:
EBQI impacts fostered employee engagement and implementation and diffusion of promising practices to enhance PACT care, and have led to operations partner adoption of EBQI for use among low-performing VAMCs.