An intervention to improve time in the therapeutic range (TTR) for anticoagulation care (AC) in VISN 1 has been funded by the Stroke QUERI (SDP#12-249, PI: Rose). Preliminary results are positive, but some sites are encountering implementation barriers. This is a concern for the current intervention, but also more generally for the success of future QUERI interventions. Leadership is a factor in several implementation science models. However, the organizational dynamics that middle managers need to negotiate in order to support interventions are not well enough understood. The purpose of this study is to identify how organization context impacts middle manager support (i.e., behaviors) and engagement (i.e., motivation) relative to the AC/TTR intervention.
This project has three research questions: 1) How does middle manager support influence implementation of the AC/TTR intervention; 2) What organization context factors influence the engagement of middle managers; and 3) What factors could serve as an impetus to promote engagement of senior and middle managers.
Interview data were collected over nine months with twelve middle managers, four members of the implementation team, and eleven senior leaders selected from the VA Medical Centers, VISN 1, and Pharmacy Benefits Management. Analysts coded qualitative data gathered from these semi-structured interviews on implementation and contextual factors influencing implementation in NVivo10 software. Analysts then created single site-summaries and conducted cross-site analysis using a consensus process.
Research Question 1: How does middle manager support influence implementation of the AC/TTR intervention?
The main challenge with the AC/TTR intervention is that it introduces additional work to busy clinicians who may already be satisfied with their current practices. AC staff track TTR through a clinical dashboard, work to influence patients to maintain their TTR, and work to reduce loss to follow up. Middle managers have a role in supporting frontline staff by influencing frontline providers to recognize that the intervention represents good clinical care and is important to the medical center. Practices for influencing staff included reporting the TTR in monthly meetings, sending email reminders, and engaging residents in quality improvement projects. Middle managers were also reported to support the intervention by protecting time to do intervention-related work. Finally, middle managers were involved in providing additional resources (e.g. staff and space). Staffing was commonly reported as an important issue; either as a key to success or a remaining barrier. Middle managers reported both hiring new staff to address the needs of this initiative, and also reallocating existing staff (e.g., from primary care to anticoagulation).
Research Question 2: What organization context factors influence the engagement of middle managers?
The creation of a VISN clinical dashboard to report TTR was important for concretely demonstrating that some sites were improving faster than others. This was supplemented by active efforts from the implementation team to educate middle managers and providers regarding the importance of improving TTR and how other sites had successfully improved TTR. At least half of the medical centers reported that their engagement was high because this was seen as a VISN project. VISN projects were perceived by middle managers as more visible to quadrad members and this visibility increases middle managers' power in negotiating for resources. Middle managers in at least half of the sites reported that senior leader involvement increases their engagement since hiring new staff requires the involvement of senior leaders and reallocation of staff requires negotiation with other middle managers, as well as with unions. Senior leaders included the local chief of staff, local quality assurance, and also influential clinical leaders in different medical services. Hiring new staff requires the involvement of senior leaders. Reallocation of staff requires negotiation with other middle managers, as well as with unions.
Research Question 3: What factors could serve as an impetus to promote engagement of senior and middle managers?
Middle managers report that they are willing to improve anticoagulation practices. There were no disagreements regarding the quality of the evidence supporting new practices. However, improvements require middle managers to both influence their staff and also influence other leaders above them as they request new staff or reallocate staff from other areas. The VISN improvement team noted that there was a need to protect time for projects that could improve workload management. The dashboard was reported to be particular useful tool for both managers and clinicians. One middle manager emphasized the necessity of retaining this dashboard after the project completed because it had become part of clinicians' work processes. Larger medical centers have more complex management structures, and may require support from both the chiefs of pharmacy and also associate chiefs and clinical coordinators. A key finding was that middle managers perceived that the AC/TTR was an important intervention because the VISN promoted it. However, interviews with VISN leaders suggest that their efforts were mostly passive. As an example of how VISN leaders provided only lukewarm support, TTR was included in regular VISN meetings, but it was not an area of particular emphasis. The VISN could have a stronger role in engaging senior and middle managers by clearly communicating the importance of the intervention to medical center leaders and holding them accountable for performance improvements. This would likely increase TTR improvement rates.
Our results suggest that the AC/TTR intervention is challenging because it introduces additional work to busy clinicians who may already be satisfied with their current practices. The implementation of the intervention was strengthened by a perception of VISN support, and a clinical dashboard that is useful to both managers and clinicians. Senior leader support (at the VISN level) was perceived to be helpful, but in fact was limited to providing resources and persuading others of intervention importance. Middle managers had a critical role in deciding how to influence clinicians and senior leaders. Contrary to expectations, middle managers did not engage with managers in other services, likely due to a perception that the benefits of such collaboration did not justify the cost in terms of manager effort.
None at this time.