The Veterans Health Administration (VHA) needs to develop efficient ways to broadly implement evidence based practices and foster a learning organization culture that systematically and continuously applies research to improve VA healthcare. Recognizing this need, VHA Health Services Research and Development (HSR&D) invited applications in the fall of 2003 for collaboration HSR&D investigators and Integrated Service Networks (VISNs) on a) implementing and evaluating an evidenced-based interventions or b) undergoing and evaluating an organizational or structural change to transform the VISN in to a learning organization that can efficiently implement evidence-based practices. Collaborations are intended to help improve clinical services locally within participating VISNs and provide templates for expanding successful changes nationwide.
Despite recognition that successful implementation of evidence-based clinical practices (EBCPs) usually depends on the on the structure and processes of the larger healthcare organization in which new clinical practices are introduced, the processes and dynamics of implementation are not well understood. The aim of this project was to deepen that understanding by testing an organizational model that we hypothesized would strengthen the ability of healthcare organizations to implement evidence-based clinical practices. The research objectives were to: - Test the hypothesis that medical centers with high fidelity to the organizational model would be more successful in improving system use of a selected EBCP; - Identify and analyze organizational factors that affect model implementation; - Test the feasibility of intervention activities to introduce and support the model.
The three-year study used a mixed-methods pre-post comparison-group design to implement and evaluate the organizational model in medical centers in 3 VISNs in the Department of Veterans Affairs. The model posits that the implementation of evidence-based practices will be enhanced through the presence of three interacting components in the organization: 1) active leadership commitment to quality, 2) robust clinical process redesign to incorporate evidence-based practices into routine operations, and 3) use of management structures and processes to support and align redesign. The target clinical practice was hand-hygiene compliance. One VISN was randomly assigned to the intervention arm that implemented the organizational model; two VISNs were assigned to a comparison arm that participated in a more limited data feedback strategy. Measures included: 1) ratings of implementation fidelity, as measured on a 0-4 scale at the site level supported by narrative evidence by research team; 2) percent compliance with national hand-hygiene guidelines for each site, as measured through structured observations by medical center staff; 3) staff ratings of team effectiveness and facility emphasis on quality, as measured through a written survey; and 4) factors affecting model implementation, as identified qualitatively through interviews and quantitatively through staff surveys
Early analyses focused on comparative case studies of the 7 medical centers in the intervention arm of the study. Analyses support the hypothesis that greater fidelity to the model was associated with higher compliance with hand-hygiene guidelines. Final overall fidelity ratings ranged from 1.42 to 3.95, indicating considerable variability in fidelity to the model design. Sites clustered in two groups by implementation ratings, both overall and by the individual components. Sites with high fidelity (3.17 to 3.95) showed much larger effect sizes for improvement in hand-hygiene compliance (0.48 to 0.92) than sites with low fidelity (fidelity, 1.42 to 2.15; effect sizes, -0.22 to 0.14). Qualitative analyses indicate that the model components interact and are mutually reinforcing. Extent of implementation fidelity was affected by force fields of positive and negative factors in each medical center in three categories: urgency to improve hand-hygiene compliance, organizational environment and improvement climate. Sites that were best able to achieve implementation of the organizational model were those that shared the urgency to improve compliance with hand hygiene; had no major aspects of the organizational environment that interfered with implementation; and had a positive improvement climate including staff experience and skills with quality improvement, organizational values for improvement where staff felt safe trying and speaking about necessary changes, and good fit between the approach of this intervention with the site's usual quality improvement approaches.
The immediate impact among participating medical centers was greater improvement in hand-hygiene practices in the medical centers with strong presence of the organizational model in comparison with medical centers with weaker presence. More generally, the results suggest that the implementation of evidence-based clinical practices, particularly those like hand hygiene that cut across multiple processes of care, is a complex process in which there are many possibilities for failure. The results provide the basis for a refined understanding of relationships among the components of the organizational model that was tested and the factors in the organizational context affecting them. From this understanding, we can both draw practical lessons for future implementation efforts and contribute to the theoretical understanding of the dynamics of the implementation of evidence-based practices.
- VanDeusen Lukas C, Engle RL, Holmes SK, Parker VA, Petzel RA, Nealon Seibert M, Shwartz M, Sullivan JL. Strengthening organizations to implement evidence-based clinical practices. Health care management review. 2010 Jul 1; 35(3):235-45.
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