Enhancing PACT Implementation through Qualitative Research
Since 2010, VHA has been implementing the Patient Aligned Care Teams (PACT) model as the standard of care for delivering primary care services. Implementation of the underlying patient-centered medical home model requires fundamental change in the organization of care, with the primary work unit moving from individual providers to interdisciplinary teams. During this transition we have worked as part of the PACT Demonstration Laboratory Initiative to conduct a multi-faceted, mixed-methods formative evaluation of implementation. Our underlying objective, as with any project applying implementation science, has been to inform successful and sustainable adoption of evidence-based practice into everyday care delivery.
Qualitative Data Contributions: Three Examples
Although an important part of our effort has been the collection and analysis of quantitative data, we have also relied heavily on qualitative research to help us better understand the contextual factors contributing to both barriers and facilitators of implementation. Interviews, participant observations and open-ended responses to surveys have helped us learn directly from front-line personnel involved with the transformation of primary care delivery. These data have not only helped us better understand the implementation process but have provided our operation partners with ongoing insight regarding approaches for improving facilitation. We illustrate the unique contributions of qualitative data by highlighting three specific examples where qualitative analysis has helped inform and guide PACT implementation.
Our first example represents a collaborative effort where investigators from the VISN 4 and VISN 23 PACT Demonstration Laboratories undertook a joint analysis of qualitative data collected through semistructured interviews with early PACT adopters. We examined findings from separate evaluation efforts and identified common, recurrent implementation issues, despite one lab's metropolitan setting (VISN 4) and the other's rural setting (VISN 23). Combining information collected through independent evaluations enabled us to develop a theoretical framework with which to understand team-, clinic-, and health care system-level factors contributing to implementation success. The resulting framework delineates the interconnected importance of such elements as: team-driven role negotiation; psychological safety; teamdirected clinic grids; co-location of PACT members; and coordinated priority setting by health care system leadership, among others.1
A second example comes from the VISN 22 PACT Demonstration Laboratory where investigators used multiple waves of qualitative interviews with VISN and health care system leadership and PACT teamlet members to identify best practices and challenges for PACT implementation. Although team-based care was perceived initially by many as having a positive impact on patients, early implementation challenges reported by leaders and teamlet members included lack of crossdisciplinary role agreement, chronic understaffing, lack of training in teambased care, and inadequate implementation of PACT features, such as teamlet huddles. We used information such as this to identify best practices and develop an evidence-based quality improvement approach to PACT implementation (EBQI-PACT), which has been associated with accelerated achievement of PACT goals, including lower provider burnout, lower use of face-to-face visits and higher non-face-to-face care.2
A third example comes from multiple national surveys that have been conducted to assess the adoption of PACT practices. The VISN 23 PACT Demonstration Laboratory is currently conducting thematic analysis of over 3,000 open-ended responses collected as part of a 2016 national survey. We have identified several key areas of concern among primary care personnel working to implement PACT, the most prominent being: challenges caused by understaffing and lack of role coverage; feelings of stress and overload; and a need for additional support from facility and service line leadership. This work complements an earlier analysis conducted by the national PACT Demonstration Lab Initiative evaluation team using national survey data collected in 2012.3
Insights into Implementation
These three examples highlight how the Offices of Primary Care Services and Primary Care Operations' foresight to fund the PACT Demonstration Laboratory Initiative has been beneficial for facilitating the complex implementation of PACT. As with all change initiatives of such magnitude, implementation has moved forward in a somewhat protracted fashion, with certain facilities and individuals making more rapid progress than others. In this setting, qualitative research methods have been particularly useful for identifying specific implementation barriers and facilitators. Qualitative techniques have also provided a conduit for front-line staff to share their experiences with leadership and have helped build partnerships with operational leaders. Our formative approach to evaluation has provided insight into implementation as it occurs. We have routinely shared our ongoing discoveries with leaders at multiple levels, who have used the insights generated to shape subsequent PACT rollout efforts. The ongoing dialogue has directly informed our evaluation focus and design over these past seven years. Qualitative techniques have thus provided a primary mechanism for closing the research-practice gap often associated with implementation science.