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2019 HSR&D/QUERI National Conference Abstract

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1038 — Spreading VA's emergency department rapid access clinics (ED-RAC): Role of champions and local contexts in explaining implementation outcomes

Lead/Presenter: Lauren Penney,  Elizabeth Dole Center of Excellence
All Authors: Penney LS (Elizabeth Dole Center of Excellence; University of Texas Health San Antonio), Moreau JL (Center for Study of Healthcare Innovation, Implementation and Policy), Miake-Lye I (Evidence-based Synthesis Program Center) Lewis D (Center for Improvement Coordination) D'Amico A (Pittsburgh VAMC) Lee K (OSI VERC) Scott B (OSI VERC) Kirsh S (VHA Clinical Practice Management) Cordasco KM (Center for Study of Healthcare Innovation, Implementation and Policy; UCLA Geffin School of Medicine)

Characteristics and activities of effective implementation champions, and their relationships with local implementation contexts, have not been well-described. To study the interplay of champion and local context in spread initiatives, we used data from the Veterans Health Administration (VA) Emergency Department (ED) Rapid Access Clinic (ED-RAC) initiative, which spread an intervention to directly schedule post-ED specialty care appointments for Veterans prior to ED discharge.

Twenty-four VA medical centers participated in ED-RAC spread (Aug 2017-Aug 2018), in which a coaching team worked with champions at each medical center. We administered champion questionnaires every 6-8 weeks, collected field notes from group and one-on-one coaching meetings, and interviewed a convenience sample of 12 champions to track medical centers' implementation progress, barriers and facilitators to progress, and champions' characteristics and activities. We classified each medical center as being an advanced adopter (implemented in > = 2 clinics), basic adopter (1 clinic), or non-adopter (not implemented). We used hybrid deductive-inductive qualitative analyses of all data sources to identify themes and assess for patterns across medical centers' contextual factors and ED-RAC adoption.

At the end of the spread initiative, four medical centers were advanced adopters, seven were basic adopters, and 13 were non-adopters of ED-RAC. Implementation progress was linked to champions' ability to gain buy-in from and coordinate efforts with service-line leaders (e.g., specialty care, informatics, clerical); having time to devote to implementation efforts; and ability to troubleshoot when confronted with implementation challenges. The breadth and depth of champions' professional relationships within the medical center, and their ability to leverage these relationships, were additional salient themes. Approaches and mechanisms for obtaining stakeholder buy-in and coordinating efforts varied by local organizational context. Champions were more effective when processes like ED-RAC were already in place locally and/or ED-RAC aligned with current local priorities.

Successful champions overcame local barriers by drawing on networks and resources, however other contextual factors limited or facilitated their efforts.

In champion-based spread initiatives, coaching strategies and intensity may need to be tailored to champion characteristics and local contexts to help champions build relationships and identify local sources of support.