At the heart of the Institute of Medicine's "Crossing the Quality Chasm" was the need to address the improvement of quality of care through major changes in how health care is organized. Their central tenet was that only through significant, sustained and innovative efforts to reorganize the health care system were substantive gains in quality of care and health outcomes possible. VA's reorganization of care presaged this report by having already launched significant internal restructuring of the care delivery system, including changes in delivery models (e.g., primary care teams, service lines) and adoption of new technologies (e.g., CPRS) and management strategies (e.g., reminders, guideline implementation, performance audit/feedback). While these organizational changes in the aggregate have been found to be associated with substantial gains in VA quality over time and in comparison to Medicare, relatively little is known about the discrete organizational characteristics in VA facilities that have specifically contributed to these changes and which structural features will foster ongoing quality improvement. The need for identifying the organizational influences on quality is all the more important given recent research that indicates that structural differences in how care is organized may explain a greater proportion of the variance in performance than that explained by patient factors alone.
Our objectives are to collaboratively develop a VA clinical practice system assessment survey that meets the combined operational and research needs of the VA Office of Quality & Performance (OQP) and HSR&D investigators by measuring organizational traits of VA facilities that may be associated with performance, including fixed and mutable characteristics that will support the design and adaptation of future quality improvement (QI) policies, practices and interventions. Two key aims will guide the organizational assessment: (1) the ability to benchmark VA health care organizational characteristics with those of non-VA health care settings, plans, and organizations, and (2) the ability to examine time trends in organizational change based on previous VA organizational survey data.
Using a participatory, multi-method approach, we developed, pilot tested, administered the first part of the survey series (Chief of Staff and Primary Care modules) and to adapt the Primary Care (PC) module for web-administration to a random sample of Community-Based Outpatient Clinics (CBOCs). To develop the organizational survey, we reviewed the published literature, integrate expert opinion and cull organizational measures from an array of existing survey tools; content finalization was achieved through iterative review, priority-setting and pilot testing to assure a field-worthy instrument that minimizes response burden while maximizing information yield. Key informants were identified and selected on the basis of the knowledge/familiarity of each individual VA facility (e.g., Chief of Staff, Primary Care Director). The unit of analysis is each geographically distinct site of care, including all VA medical centers and large community-based outpatient clinics (e.g., those serving 4,000+ patients and delivering 20,000+ visits/year) based on VA Outpatient Clinic file data queries. Field preparation and survey administration activities relied on the tailored design method and build on extensive prior experience fielding similar surveys in VA. Data will be 100% double-entered using detailed question-by-question specifications, followed by data reduction, scale development and basic survey analysis.
The Chief of Staff Module was fielded in May 2006 through September 2006 with an 86% response rate. The Primary Care Module will be administered in Fall 2006.
Understanding structural variations and their links to quality of care will help inform the design of more effective QI policies and practices and enable improved "fit" of QI interventions to individual VA facilities. Ultimately, evaluation of the organizational influences on quality of care in VA settings will foster evidence-based practice changes that will have substantial potential for improving the quality of chronic disease and preventive care, as well as veterans' ratings of the quality of care they receive in VA facilities.
- Brunner J, Chuang E, Goldzweig C, Cain CL, Sugar C, Yano EM. User-centered design to improve clinical decision support in primary care. International journal of medical informatics. 2017 Aug 1; 104:56-64.
- Chou AF, Rose DE, Farmer M, Canelo I, Yano EM. Organizational Factors Affecting the Likelihood of Cancer Screening Among VA Patients. Medical care. 2015 Dec 1; 53(12):1040-9.
- Kilbourne AM, Greenwald DE, Hermann RC, Charns MP, McCarthy JF, Yano EM. Financial incentives and accountability for integrated medical care in Department of Veterans Affairs mental health programs. Psychiatric services (Washington, D.C.). 2010 Jan 1; 61(1):38-44.
- Jackson GL, Yano EM, Edelman D, Krein SL, Ibrahim MA, Carey TS, Lee SY, Hartmann KE, Dudley TK, Weinberger M. Veterans Affairs primary care organizational characteristics associated with better diabetes control. The American journal of managed care. 2005 Apr 1; 11(4):225-37.
- Wilk AS, Kerr EA, Hofer TP, Holleman RG, Klamerus ML, Rose DE, Yano EM. Re-examining facility-level effects on diabetes care quality for Veterans. Presented at: American Society of Health Economists Annual Conference; 2016 Jun 12; Philadelphia, PA.
- Rowneki M, sambamoorth U, Tseng CL, Rose D, Jani N, Soroka O, Pogach L, Yano EM, Helmer DA. Understanding geographic variations in preventable hospitalizations. Presented at: VA East Orange VAMC Research Exposition Meeting; 2016 May 23; East Orange, NJ.
- Rose DE, Klap RS, Farmer Coste MM, Mitchell MN, Canelo IA, Yano EM. Use of Provider Feedback and Clinical Champions Associated with Depression Screening : Findings from the External Peer Review Program and VHA Clinical Practice Organizational Survey, 2007. Poster session presented at: VA HSR&D National Meeting; 2011 Feb 16; Washington, DC.
- Bryson CL, Au DH, Blough DK, Fihn SD, Jackson GL, Maciejewski ML, Piette JD, Perkins MW, Sharp ND, Yano EM, Liu C. Organizational Factors Do Not Explain Large Facility Variation in Medication Adherence. Poster session presented at: AcademyHealth Annual Research Meeting; 2010 Jun 28; Boston, MA.
- Mohammed-Rajput N, Doebbeling BN, Yano EM. The impact of organizational and IT factors on clinical decision support adoption. Plenary presentation. Paper presented at: National Library of Medicine Training Conference; 2010 Jun 15; Arlington, VA.
- Chou AF, Yano EM, Lanto A, Canelo IA, Doebbeling BN. Identifying organizational factors facilitating the implementation of evidence-based quality improvement efforts. Paper presented at: Healthcare Organizational Research Association Annual Conference; 2010 Jun 6; Berkeley, CA.
- Rose DE, Mitchell MN, Canelo IA, Yano EM. VA primary care clinics: National survey results from organizational surveys of VA primary care directors, 2007. Poster session presented at: VA HSR&D Rural Health / VA Office of Rural Health Field-Based Meeting; 2010 May 5; Portland, ME.
- Yano EM, Doebbeling BN, Canelo IA, Lanto AB, Asch SM. Primary care provider attitudes’ toward VA’s Computerized Patient Record System. Poster session presented at: AcademyHealth Annual Research Meeting; 2009 Jun 28; Chicago, IL.
- Yano EM. The VA primary care revolution: Lessons for patient-centered medical homes. Paper presented at: Society of General Internal Medicine Annual Meeting; 2009 May 15; Miami, FL.
- Yano EM. Mental health-primary care integration: Influences of the state of primary care practice on implementation. Presented at: VA Syracuse VAMC Center for Integrated Healthcare Seminar; 2009 Mar 19; Syracuse, NY.
- Farmer Coste MM, Yano EM, Sherman SE, Lanto AB, Riopelle DD. Implementation of Smoking Cessation Treatment Guidelines: Do Strategies Around Counseling Translate to Treatment? Poster session presented at: VA HSR&D National Meeting; 2009 Feb 13; Baltimore, MD.
- McCarthy JF, Post EP, Austin K, Kim H, Yano E, Zivin KZ, Hoggatt K, Kilbourne AM, Blow FC, Valenstein MT. Adoption of Primary Care-Mental Health Integrated Care Models, FY99-04 Associations with Suicide Risk among Patients with Depression. Paper presented at: VA HSR&D National Meeting; 2009 Feb 13; Baltimore, MD.
- Chou AF, Lanto AB, Canelo I, Doebbeling BF, Fleming B, Yano EM. Identifying organizational factors facilitating the design and development of evidence-based quality improvement efforts. Poster session presented at: AcademyHealth Annual Research Meeting; 2008 Jun 10; Washington, DC.
- Haggstrom DA, Doebbeling BM, Jones LE, Yano EM. Degree of Cancer Care Coordination among Primary Care, Gastroenterology, and Oncology through Service Agreements. Poster session presented at: AcademyHealth Annual Research Meeting; 2008 Jun 8; Washington, DC.
- Chou AF, Doebbeling BN, Fleming B, Yano EM. Identifying organizational dimensions underlying the implementation of quality improvement efforts in VHA. Paper presented at: VA HSR&D National Meeting; 2008 Feb 15; Baltimore, MD.
- Saleem JJ, Doebbeling BN, Flanagan ME, Haggstrom DA, Woodward-Hagg HK, Yano. Approaches to Design and Implementation of Clinical Decision Support in the VA: Relationship to Staff Sufficiency. Paper presented at: VA HSR&D National Meeting; 2008 Feb 14; Baltimore, MD.
- Doebbeling N, Saleem J, Flanagan E, Yano EM. Extent of Implementation of Clinical Decision Support in VHA: Results of a National Survey. Poster session presented at: VA HSR&D National Meeting; 2008 Feb 13; Baltimore, MD.
- Haggstom A, Doebbeling N, Yano M. Degree of Cancer Care Coordination among Primary Care, Gastroenterology, and Oncology through Service Agreements. Poster session presented at: VA HSR&D National Meeting; 2008 Feb 13; Baltimore, MD.
- Haggstrom DA, Doebbeling BN, Yano EM. Colorectal cancer practice arrangements in VHA. Paper presented at: VA HSR&D National Meeting; 2008 Feb 13; Baltimore, MD.
- Yano EM. Organizational Readiness for Quality Improvement. Paper presented at: AcademyHealth Annual Research Meeting; 2005 Jun 1; Boston, MA.
- Jackson GL, Lee SY, Edelman D, Weinberger M, Yano EM. Inclusion of Nurse Practitioners in Primary Care and Control of Diabetes. Paper presented at: VA HSR&D National Meeting; 2005 Feb 1; Baltimore, MD.