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C19 20-207 – HSR&D Study

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C19 20-207
A Needs Assessment for Facilitating the Role of VA Occupational Health Providers during COVID-19
Karleen F Giannitrapani MPH MA PhD
Palo Alto, CA
Funding Period: August 2020 - April 2021

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. AIM1a. Use rapid content analysis techniques13,14 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).13 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 agreement17 (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.23 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 CFIR24 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 AIMS1&2 prior to survey finalization

FINDINGS/RESULTS:
No findings to report at this time.

IMPACT:
In the coming weeks, local OH providers will have 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 will fall into the high-risk category simultaneously. In this needs assessment we identify how to support occupational health's role to site success. Facilitating shared learnings may help sites in preparation phase learn from OH experience at sites with active COVID-19 Cases. Conducting a needs assessment will also help understand OH needs in the case of multiple COVID-19 waves.

PUBLICATIONS:
None at this time.

DRA: None at this time.
DRE: None at this time.
Keywords: Care Coordination, Quality of Care
MeSH Terms: None at this time.

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