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Reducing wait times for clinic appointments
is a high and visible priority for VA, and has
been for several years. In 2000, in an environment
of growing demand for VA health
care and long wait times for clinic appointments
in many areas, VA launched a national
program, the Advanced Clinic Access (ACA)
Initiative, to reduce wait times in targeted
clinic areas across the system.
ACA, by now widely-recognized across VA,
is a well-established set of 10 clinical operational
practices called key change principles
for organizing and managing clinics so that
patients have access to the medical care they
need—when and where they want it. To
encourage and support the use of these
principles, the ACA Initiative, working
originally with the Institute for Healthcare
Improvement (IHI), built an extensive infrastructure,
including: a national steering
committee, a full-time national clinical director,
a person designated to lead ACA in
every VISN and most medical centers, and
a network of clinical access coaches to stimulate
peer networks of advocacy and support.
As intended, the infrastructure has continued to strengthen and expand and is
now referred to as VHA Systems Redesign.
An important component of the original
ACA Initiative was a comprehensive evaluation
of the implementation and effectiveness of
ACA. The evaluation, based on the experience
of clinics in 78 VAMCs in 2003, was commissioned
by the ACA Steering Committee
and conducted by the HSR&D Management
Decision and Research Center (MDRC), now
the Center for Organization, Leadership,
and Management Research (COLMR).1
The evaluation found that successful ACA
implementation, defined as the use of a high
proportion of the ACA principles, was significantly
associated with shorter wait times,
with the relationship stronger in primary
care than across specialty clinics. Underlying
this overall good news, however, was substantial
variation across clinics and medical
centers in the extent to which the ACA
principles were implemented. In order to
implement ACA more consistently, it is important
to understand the factors that account
for this variation: Why were some
clinics more successful in implementing
ACA principles than others?
While the ACA infrastructure provided important
resources and support for ACA,
local factors were also important. The ACA
efforts at the national and VISN levels interacted
with people, processes, and structures
within medical centers and their
clinics. One source of variation in factors
affecting implementation is the six clinic
areas targeted by ACA (primary care, orthopedics,
eye care, cardiology, audiology, and
urology). Each of the six clinic areas is
based in its own professional history and
practices, and each clinic area approached
ACA differently. However, across target
clinic areas, five factors were significantly
associated with successful ACA implementation:
- Strong management support for ACA,
as demonstrated in concrete actions of: appointing
an ACA oversight body to elevate
the visibility of ACA, incorporating ACA
into facility priorities, holding managers accountable
for improvement-related performance,
explicitly designating champions
for each clinic area, reporting on ACA
progress and lessons at meetings of senior
managers, and targeting resources to remove
obstacles to ACA implementation.
- Clinic teams having the knowledge
and skill needed to do their work well
and make changes successfully, as reflected
in: seeking information and effectively
using that information; using data
regularly to design, test, and track process
improvements; regularly assessing team
progress; and learning from efforts of others
to implement ACA.
- Clinic staff review of ACA wait time
performance data that is trustworthy and
timely so that clinic teams providing care
can assess the current level of the problem
and monitor the impact of improvement
efforts.
- Adequate clinic resources, reflected
in primary care by more exam rooms and in
specialty care by greater use of consulting
physicians.
- High demand for care in primary care
(but not specialty care), as evidenced by a
high number of patients on the wait list,
suggesting that greater unmet demand provides
an impetus for change.
Attention to these factors promises not only
to strengthen future implementation of
ACA, but also to offer lessons in implementing
other complex clinical innovations.
-
Lukas CV, et al. Implementation of a Clinical Innovation:
the Case of Advanced Access in the Department
of Veterans Affairs. Journal of Ambulatory Care Management,
2008; 32(2): 94-108.
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