BACKGROUND/RATIONALE:
Occupational health is currently being tasked with assuming a central role in coordinating employee screening and clearance for duty; we propose a needs assessment to understand (and thereby prepare operational partners to facilitate) their preparedness for this role. Policies and guidance around COVID-19 are evolving and both online media and internal VA forums suggest frontline clinicians are struggling to keep up with the current processes at their facility. Understanding factors that support occupational health provider readiness for assuming new (and dynamically changing) roles to implement COVID-19 policies can facilitate successful implementation. This will be particularly critical as guidance continues to evolve and change and real time process change in the field becomes key to protecting VA patient, provider, and staff safety. Guidance circulated on March 15 from the Deputy Under Secretary for Health for Operations and Management allows for asymptomatic health personnel who are exposed to COVID-19 patients to continue to work after consultation with the Occupational Healthcare (OH) Provider. Additionally, the guidelines provide that if any employee becomes symptomatic at work, they are required to report to OH for a health screen. However, OH may not be currently equipped with appropriate personal protective equipment at all facilities to handle such process recommendations (i.e. in some sites, symptomatic employees should report to ER or another designated place per local resource distribution and process). OH providers also may not have the relevant experience to identify and design improved processes for their site. If VA is going to encourage potentially contagious but asymptomatic health personnel to work through potential exposure to minimize staff shortages, we also need to ensure we have fully-resourced and functioning processes in place to support identification of COVID-19 positive employees. This is particularly critical for protecting not only employees but for vulnerable patients living in nursing homes and community living centers. VA is establishing taskforces to take on these larger issues; we can contribute by understanding role readiness of OH.

OBJECTIVE(S):
AIM1. NEEDS ASSESSMENT: Understand challenges and opportunities facing occupational health providers assuming new roles in their facility following distribution of COVID-19 guidance.
Aim 1a: produce lightning report.
Aim 1b: Use rapid content analysis techniques to synthesize comments posted by OH providers on their actively-used national internal VA forum.
AIM2. REAL TIME DISSEMINATION: Partner with national OH leadership to facilitate real-time dissemination of findings and shared learnings across sites (e.g. post on SharePoint, share results on national calls etc.).
AIM3. SURVEY DEVELOPMENT: Develop and pilot a survey to capture OH provider role and site readiness for implementing COVID-19 Guidance (critical preparation for future COVID-19 waves).

METHODS:
NEEDS ASSESSMENT AIM1a: In order to minimize contact time with frontline clinicians we will first use rapid qualitative analytic techniques to synthesize content posted by OH providers on their national internal VA forum. We will specifically identify current pain points (informed by Design Thinking) and challenges as well as shared learnings and local successes. We will synthesize this content within 6 weeks and supply operational partners with a "Lightning Report" (a rapid qualitative methodology published by Co-I Dr. Brown-Johnson of Stanford University).

AIM1b: In partnership with occupational health leadership we will conduct ~20 semi-structed interviews with occupational health providers nationally through a rapid quality improvement exempted IRB approval. Given the time-sensitive nature of getting to the field, we are classifying the interviews as QI which is appropriate in part because there is no/low risk to participating providers. Interviews cover occupational health roles in implementing COVID-19 guidance, changes they are making at their sites, process gaps and failures, the facilitators/barriers to their expanded role or to change at the site if they instituted or changed a process, role of site leadership and middle managers in providing support, learnings for other sites, role readiness and provider self-efficacy to take on expanded roles listed under COVID-19 guidance, and how to produce cross-disciplinary role agreement (clear role definition and role negotiation mechanisms). We are adapting interview guides from Drs. Giannitrapani, Yano, and Rubenstein's previous work on evidence-based quality improvement.

REAL TIME DISSEMINATION AIM2: We will present learnings from rapid synthesis to all sites via SharePoint in partnership with national occupational health leadership. This allows for real-time shared learning across facilities. Occupational health advisor S. Giannitrapani APRN will lead a field call to disseminate findings to frontline providers. We will record this field call and use it as a focus group. Methodologically this will also serve as a member check to validate rapid synthesis results. We will partner with OH leadership on any other dissemination strategies they would find most helpful.

SURVEY DEVELOPMENT AIM3: We will develop a brief survey to capture occupational health provider role and site readiness. We will capture measures routinely used in VA research for age, time in clinic, position, tenure or years in VA, gender and race/ethnicity. Other items capturing provider perceptions of organizational readiness for the intervention (new COVID-19 guidance) will be adapted from ORCA, the organization readiness for change assessment. On its own, ORCA is a 74 item survey that divides into 3 domains: evidence, context and facilitation. This is too long to be feasible and we are often acting in advance of strong evidence. The consolidated framework for implementation research (CFIR) framework has sub-components that have been mapped to the items ORCA. When mapped to CFIR constructs it offers a briefer list of sub scales. We will use 20 ORCA items to capture readiness for implementation concepts such as "leadership engagement" and "available resources". We will explore additional items to capture role self-efficacy and role-readiness and cross-disciplinary role agreement. We will undertake cognitive interviewing to inform tailoring of items and explore hosting a virtual expert panel (led by Dr. Singer) to review findings from AIMS 1&2 prior to survey finalization.

FINDINGS/RESULTS:
A lightning report summarizing the needs of EOH providers was circulated to EOH leaders in central office by September 30, 2020. This report synthesized early findings from both the listserv and the first ten interviews.

Ultimately we conducted interviews from July 2020 to March 2021 with 43 EOH providers from 26 VA sites optimizing for geographic spread. The sites represented 13 rural serving and 13 urban serving healthcare systems. Respondents were 22 MDs, 17 NPs or PAs, 4 RNs.

We present findings in three content areas.
1. Employee occupational health (EOH) providers expressed five interdependent needs to support the vastly expanding role of EOH providers in the national VHA system. Needs included: 1) infrastructure to support employee population management, including tools that facilitate infection control measures such as contact tracing (e.g., employee-facing electronic health records, coordinated databases); 2) mechanisms for information-sharing across settings (e.g., VHA listserv), especially for changing policy and protocols; 3) sufficiently-resourced staffing using detailing to align EOH needs with human resource capital; 4) connected and resourced local and national leaders; 5) strategies to support healthcare worker mental health.


2. Following emergency authorization of the COVID-19 vaccines in December 2020, we shifted our focus to identify strategies for supporting COVID-19 vaccination of healthcare workers. Our analysis revealed a framework of five key strategies recommended or followed by EOH across sites. Strategies included: 1) Leverage diverse skillsets through multidisciplinary effort; 2) "Focus like a laser"- invest in processes and align resources with priorities; 3) Expect and accommodate vaccine buy-in occurring over time; 4) Overcome misinformation through trustworthy communication, openly discussing rational fears, and inviting shared decision-making; 5) Use existing and newly developed communication channels to foster sharing and learning across teams and sites.

3. A crucial role that rapidly emerged for EOH during COVID-19 pandemic was the need to support the mental health of overwhelmed and overburdened healthcare workers. According to EOH providers, work-related mental health concerns in healthcare workers included work overload, burnout, lack of work-life balance, traumatic work deployments, and bereavement grief over the loss of many patients. Strategies employed by EOH to support the mental health needs of healthcare workers includes: 1) bridging the gap in access to mental health services by connecting healthcare workers to resources offered across various VHA departments (e.g., Employee Assistance Programs); 2) Facilitate EOH role in crisis management (e.g., Appoint temporary primary care providers for healthcare workers who lacked access to psychotropic medications); and 3) Follow-up with providers detailed for stressful, high-risk temporary positions.

IMPACT:
Local EOH providers have had a role to play in navigating trade-offs between staff shortages and potential spread, staff mental health burdens, and the fact that all frontline clinicians fall into the high-risk category simultaneously. In this needs assessment we have identified how to support occupational health's role to site success. Facilitating shared learnings may help sites in preparation phase learn from EOH experience at sites with active COVID-19 Cases. Conducting a needs assessment has also helped understand EOH needs in the case of multiple COVID-19 waves or in advance of future infectious pandemics.

PUBLICATIONS:

Journal Articles

1. O'Hanlon CE, Lindvall C, Giannitrapani KF, Garrido M, Ritchie C, Asch S, Gamboa RC, Canning M, Lorenz KA, Walling AM, ImPACS Expert Panel. Expert Stakeholder Prioritization of Process Quality Measures to Achieve Patient- and Family-Centered Palliative and End-of-Life Cancer Care. Journal of palliative medicine. 2021 Sep 1; 24(9):1321-1333. [view]
2. Giannitrapani KF, Fereydooni S, Silveira MJ, Azarfar A, Glassman PA, Midboe A, Zenoni M, Becker WC, Lorenz KA. How Patients and Providers Weigh the Risks and Benefits of Long-Term Opioid Therapy for Cancer Pain. JCO oncology practice. 2021 Jul 1; 17(7):e1038-e1047. [view]