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2015 HSR&D/QUERI National Conference Abstract

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1035 — Access and Scheduling Audit Survey 2014: An Example of Inductive and Manifest Content Analysis Utilizing Distributed Coding for Very Rapid Analysis of Very Large Qualitative Data Sets

Sayre GG, Seattle/Denver COIN; Helfrich CD, Seattle/Denver COIN; Francis J, Office of Informatics and Analytics; Fihn SD, Office of Informatics and Analytics;

Objectives:
In response to concerns about excessive waits for appointments and irregular scheduling procedures, a very rapid, national audit was conducted to determine whether deviations from scheduling policies (e.g., failing to correctly elicit "desired" appointment date) were isolated or systemic problems. In order to understand the scope and nature of problematic activities, we conducted a qualitative analysis of narrative site-visit data.

Methods:
We used Inductive and Manifest Content Analysis to analyze field notes collected by audit teams that conducted 3,772 interviews at 140 parent VAMC facilities (combined VAMC and community-based outpatient clinics [CBOCs]). Of these, 2,218 were conducted with non-clinicians (narratives were not collected from clinicians) and of these, 1,962 respondents provided narrative information. An initial inductive content analysis identified discrete categories of problematic scheduling practices after which the entire dataset was coded independently by 14 coders using a manifest content analysis approach. Obstacles to appropriate scheduling practices were identified using simultaneous inductive content analysis approach.

Results:
Coding and analysis were completed from May 16th -June 10th 2014. Most respondents (93%) described previously selecting "desired date" from among available clinic dates, rather than determining desired date based upon the Veteran's preferred date or the date requested by the provider, as prescribed by VA policy. At 79 sites, at least one respondent reported being instructed to alter dates previously entered. At 2 sites, respondents believed someone other than a scheduler routinely altered recorded dates to improve reported waiting times. At 15 sites, respondents reported feeling threatened or coerced to follow inappropriate practices and a small number reported punitive actions after raising concerns with supervisors. Barriers to following correct scheduling practices included an undue focus on performance measures, complicated scheduling policies, inadequate staffing, and low morale.

Implications:
Our analyses depict how embedded researchers in a healthcare system can rapidly deploy rapid qualitative assessment and, in the case, identify how a cultural focus on meeting performance goals could drive some front-line, middle, and senior managers to manipulate VA's mandate scheduling processes.

Impacts:
Based on these findings, VA undertook a massive overhaul of its approach to patient access and its performance management systems.