Senior management (SM) support is critical to sustaining improvement in quality of care and patient safety and to the development of organizations that continuously improve. Less clear is how support can be effectively translated to practical actions by managers, especially senior medical center managers. Leveraging Frontline Expertise (LFLE) is a practical program for engaging SMs with frontline staff (FLS) in identifying and addressing quality and patient safety improvement opportunities in work systems. LFLE consists of four iterative components: 1) information gathering, 2) action planning, 3) improvement actions, and 4) feedback with staff.
Study objectives were to: 1) implement LFLE with fidelity in order to engage senior management, gain their buy-in, participation and follow through; 2) describe the implementation strategies in each site, including both study team and local site activities; 3) evaluate the effects of the LFLE intervention on quality and safety-related practices and organizational climate in intervention work areas; and 4) analyze the organizational and process factors that affect LFLE implementation and sustainability.
The design was a three-year, mixed-methods implementation intervention at 12 VA medical centers (VAMCs). We recruited study sites from a pool of VAMCs that expressed commitment to implementing LFLE. Primary data collection from LFLE participants included: 1) semi-structured interviews conducted during site visits; 2) feedback questionnaires about LFLE implementation; 3) pre/post-implementation organizational surveys. Implementation fidelity was measured qualitatively through an analytic framework based on interview notes. Effectiveness was measured quantitatively based on pre/post changes in Organizational Characteristics Survey (OCS) responses. Implementation processes and organizational factors affecting LFLE were analyzed qualitatively from interviews, implementation records, and survey data.
Objective 1: We recruited 12 sites for study participation - six "early implementer" (EI) and six "late implementer" (LI) sites. At the end of our study, three EI and LI sites had completed implementation of at least one LFLE cycle in either the OR or ICU. The remaining six sites did not implement LFLE primarily due to changes in the Medical Center Director (MCD). We provided sites with a detailed implementation manual. However, the extent to which sites implemented LFLE with fidelity differed. SMs demonstrated commitment to LFLE by communicating with FLS about program goals and purpose, dedicating time to personal involvement, providing resources, and deploying existing organizational structures to accomplish LFLE goals. However, SMs encountered numerous challenges, primarily competing priorities and time demands, lack of buy-in among all SMs, and longstanding intractable organizational issues.
Objective 2: Some of the implementation strategies used by sites included: using the manual, tailoring LFLE activities to fit organizational processes, and identifying champions. Some of the strategies used by the study team to facilitate implementation included: developing educational materials, conducting educational site visits, providing ongoing consultation, and creating a learning collaborative. Overall, we received positive feedback from sites about the strategies we used.
Objective 3: We administered the OCS at the beginning and near the end of LFLE implementation. Across the 6 sites, 283 FLS responded to the initial survey; only 56 of the initial FLS responded to the second survey. From the 36 questions in the survey, we created 11 scales. With the exception of the time for reflection scale, scale internal consistency was adequate (alpha > .80).
Ten of the 11 scales increased between time 1 and 2, indicating improvement (adequate resources was the exception). For 4 of the scales (quality of work unit environment, comfort in asking for help, level of quality and safety, and understanding of organizational goals), the increase was statistically significant and for 1 (cooperation in improvement activities) almost significant (p = 0.06). For 2 of the scales (encouragement of new ideas and importance of improvement), the increase, though not statistically significant (0.10 < p < 0.20) was noticeable, given the relatively small size of the sample. For the other 3 scales (SM support, reflection, and SM response to problems), the increase was not statistically significant (p > 0.20). The lack of larger improvement on the SM support and response to problems scales (key tenets of LFLE) may be because most of the SMs did not provide visible feedback at the conclusion of LFLE cycles; thus, FLS often did not attribute recognized changes to the LFLE program. Overall, the improvement in scale scores suggests value from LFLE.
Objective 4: Although SMs demonstrated commitment to LFLE implementation, the numerous challenges that SMs encountered, at times, impeded the momentum and sustainability of LFLE implementation. Overall, FLS and SM felt LFLE contributed to staff support and empowerment. Both groups appreciated the opportunity to engage with each other in dialogue about work system challenges and ways to address those challenges. However, while many improvements were implemented through LFLE, FLS at some sites felt that LFLE had not prompted enough action. FLS would have preferred more consistent, thorough communication and feedback about actions taken (or not) on the work system challenges they had identified. SM, on the other hand, felt challenged to actively listen to FLS identify issues while not disagreeing or jumping to resolutions too quickly. Also, contrary to FLS perceptions, SM typically felt that sufficient feedback had been provided to FLS on actions taken.
The study impacted Veterans' healthcare by improving the ability of VAMCs to improve continuously and incorporate new practices into hospital clinical/administrative services that provide high value in safety, quality, and efficiency of care. Significant improvement opportunities were identified as quality and safety concerns by FLS during the information gathering process and subsequently addressed. Examples include: redesigned an inventory system for on demand items (OR), developed a process for ordering cataract surgery supplies (OR), and provided residents with additional education and training on how to write orders for patients (ICU).
None at this time.