BACKGROUND/RATIONALE:
The purpose of this CDA was to develop my capability to study healthcare organizational context to support evidence-based practice (EBP) implementation. The EBP for this CDA is the metabolic monitoring guideline for medical treatment of Veterans with serious mental illness (SMI) who are treated with antipsychotics (AP). APs are prescribed to over 220,000 Veterans for schizophrenia, bipolar disorder, schizoaffective disorder, and post-traumatic stress disorder (PTSD). AP use is associated with metabolic risk such as rapid weight gain and increased risk of diabetes and cardiovascular diseases. Veterans with diabetes generally receive metabolic risk management (e.g., glucose and cholesterol screening) in accordance with guidelines. However, metabolic screening for non-diabetic Veterans treated with APs is substantially lower.

OBJECTIVE(S):
The Model for Understanding Success in Quality (MUSIQ) defines context in QI as characteristics of the team developing QI, the microsystem implementing QI, as well as organization factors. However, MUSIQ requires elaboration in at least two areas. First, an assumption of MUSIQ is that QI will be implemented in one clinical microsystem (i.e., frontline unit). However, improving metabolic screening requires involvement of primary care (PC) and mental health (MH); two interacting clinical microsystems. Second, MUSIQ identifies provider involvement as a key factor in QI success, but does not posit how context affects provider involvement in QI. To elaborate MUSIQ in these two ways we propose the following specific aims:
Specific Aim 1: Develop a model of how interacting microsystems affect how QI can be tailored to implement metabolic screening EBP at a VA medical center (VAMC) using qualitative ethnography (Study 1).
Specific Aim 2: Determine how interacting microsystems influence provider involvement in QI in VISN1 through a mixed methods study (Study 2).

METHODS:
Study 1 used a three-year ethnography to study how interacting PC and MH microsystems impact how QI is tailored to implement metabolic screening EBP. Twelve interviews were conducted with microsystem leaders, QI team members, and microsystem (i.e., PC and MH) members over a two year implementation and sustainability period. We measured intervention success using administrative data from all Veterans with SMI who are treated with AP to determine whether or not Veterans are receiving recommended screening and follow-up. Study 2 used mixed methods to investigate a national effort to improve metabolic screening. Provider involvement in QI was measured through a survey as well as administrative data. Qualitative interviews were used to identify unmeasured variables that may have impacted provider involvement.

FINDINGS/RESULTS:
Not yet available.

IMPACT:
This CDA is significant for Veterans' health in two ways. First, AP medications are associated with the development of metabolic disorders, and metabolic treatment of AP is generally poor. This CDA will stimulate work to improve screening and follow-up of metabolic screening. Second, this CDA will develop knowledge that is practically useful for VISN1 top leaders and will be generalizable across VHA to address other multispecialty QI problems.

This CDA is significant in terms of the findings regarding metabolic screening, the findings in terms of quality improvement within VA, and also in developing my capability to study healthcare organizational context to support evidence-based practice implementation. Regarding metabolic screening, we have found that improvements can be made at high cost by creating a metabolic screening clinic that can improve screening rates, but does not impact the attitudes and behavioral controls of mental health providers. We have also detailed specific barriers regarding the qualities of the metabolic screening innovation, the recipients of the innovation, and the context in which the innovation was implemented. Regarding quality improvement within VA, this CDA demonstrates the challenges in cross-disciplinary quality improvement and suggests that improving quality when responsibility is shared across disciplines is likely to be costly. Potential interventions are either the creation of a clinic to specifically target the improvement goal, or in-depth work within each medical center to address perceived barriers to implementation in order to improve attitudes and perceived behavioral control.

Regarding my capability to study healthcare context in VA, I am now well-trained to conduct quality improvement research. I have completed Lean/Six Sigma Black Belt training, and intend to be certified within a year. I have completed several courses on methods of longitudinal analysis that I have applied in my published research, and have drawn upon to propose a highly innovative application of a methodology to study health care processes as patterns of healthcare utilization over time. This will enable me to determine how interventions result in changes to the healthcare processes (e.g., metabolic screening and follow-up) that are directly linked to patient outcomes.

PUBLICATIONS:

Journal Articles

1. Oppel EM, Mohr DC, Benzer JK. Let's be civil: Elaborating the link between civility climate and hospital performance. Health care management review. 2019 Jul 1; 44(3):196-205.
2. Creech SK, Benzer JK, Ebalu T, Murphy CM, Taft CT. National implementation of a trauma-informed intervention for intimate partner violence in the Department of Veterans Affairs: first year outcomes. BMC health services research. 2018 Jul 24; 18(1):582.
3. Mignogna J, Martin LA, Harik J, Hundt NE, Kauth M, Naik AD, Sorocco K, Benzer J, Cully J. "I had to somehow still be flexible": exploring adaptations during implementation of brief cognitive behavioral therapy in primary care. Implementation science : IS. 2018 Jun 5; 13(1):76.
4. Soley-Bori M, Stefos T, Burgess JF, Benzer JK. Relational Climate and Health Care Costs: Evidence From Diabetes Care. Medical care research and review : MCRR. 2020 Apr 1; 77(2):131-142.
5. Rodriguez-Paras C, Tippey K, Brown E, Sasangohar F, Creech S, Kum HC, Lawley M, Benzer JK. Posttraumatic Stress Disorder and Mobile Health: App Investigation and Scoping Literature Review. JMIR mHealth and uHealth. 2017 Oct 26; 5(10):e156.
6. Lipschitz JM, Benzer JK, Miller C, Easley SR, Leyson J, Post EP, Burgess JF. Understanding collaborative care implementation in the Department of Veterans Affairs: core functions and implementation challenges. BMC health services research. 2017 Oct 10; 17(1):691.
7. Creech SK, Macdonald A, Benzer JK, Poole GM, Murphy CM, Taft CT. PTSD symptoms predict outcome in trauma-informed treatment of intimate partner aggression. Journal of consulting and clinical psychology. 2017 Oct 1; 85(10):966-974.
8. Creech SK, Trotman A, Michaelson G, Benzer JK, Copeland LA. Parenting Behaviors and PTSD Symptoms Predict Child Psychosocial Problems and Parenting Satisfaction in a Sample of U.S. Veterans and Service Members. Military Behavioral Health. 2017 Jun 12; 5(4):374-383.
9. Benzer JK, Cramer IE, Labonte A, Charns MP, Seibert MN, Burgess J. Repurposing a program evaluation for Parkinson's Disease for a Healthcare Management Research Study. SAGE Research Methods Cases. 2017 Jun 1; http://dx.doi.org/10.4135/9781526425904.
10. Benzer JK, Meterko M, Singer SJ. The patient safety climate in healthcare organizations (PSCHO) survey: Short-form development. Journal of evaluation in clinical practice. 2017 Aug 1; 23(4):853-859.
11. Soley-Bori M, Benzer JK, Burgess JF. Longitudinal Analysis of Quality of Diabetes Care and Relational Climate in Primary Care. Health services research. 2018 Apr 1; 53(2):1042-1064.
12. Young GJ, Rickles NM, Benzer JK, Dangi A. Management of Medicare Part D Prescription Drug Plans and Medication Adherence: A Conceptual Framework and Empirical Analysis. Medical care. 2017 Jan 1; 55(1):37-42.
13. Benzer JK, Charns MP, Hamdan S, Afable M. The role of organizational structure in readiness for change: A conceptual integration. Health Services Management Research. 2017 Feb 1; 30(1):34-46.
14. Labonte AJ, Benzer JK, Burgess JF, Cramer IE, Meterko M, Pogoda TK, Charns MP. The Effects of Organization Design and Patient Perceptions of Care on Switching Behavior and Reliance on a Health Care System Across Time. Medical care research and review : MCRR. 2016 Apr 1; 73(2):182-204.
15. Benzer JK, Mohr DC, Evans L, Young G, Meterko MM, Moore SC, Nealon Seibert M, Osatuke K, Stolzmann KL, White B, Charns MP. Team Process Variation Across Diabetes Quality of Care Trajectories. Medical care research and review : MCRR. 2016 Oct 1; 73(5):565-89.
16. Benzer JK, Cramer IE, Burgess JF, Mohr DC, Sullivan JL, Charns MP. How personal and standardized coordination impact implementation of integrated care. BMC health services research. 2015 Oct 2; 15(1):448.
17. Benzer JK, Miller CJ, Mohr DC, Burgess JF, Charns MP. Industrial-Organizational psychology programs need to differentiate from business schools: One opportunity in behavioral health. Science & practice perspectives / a publication of the National Institute on Drug Abuse, National Institutes of Health. 2014 Jul 25; 7(3):351-355.
18. Creech SK, Benzer JK, Liebsack BK, Proctor S, Taft CT. Impact of coping style and PTSD on family functioning after deployment in Operation Desert Shield/Storm returnees. Journal of traumatic stress. 2013 Aug 1; 26(4):507-11.

Conference Presentations

1. Creech SK, Benzer JK, Meyer E, DeBeer B, Kimbrel N, Gulliver S, Morissette S. An Examination of Gender Differences in the Association Between Post-Deployment PTSD Symptoms and Relationship Functioning in a Sample of Returning Veterans. Poster session presented at: University of Texas at Austin School of Social Work Annual Military Social Work Conference; 2016 Sep 16; Austin, TX.
2. Creech SK, MacDonald A, Benzer JK, Poole G, Murphy CM, Taft CT. Examining PTSD Symptoms as a Predictor of Intimate Partner Violence Intervention Outcome. Poster session presented at: International Family Violence and Child Victimization Research Conference; 2016 Sep 14; Manchester, NH.
3. Oppel EM, Mohr DM, Benzer JK. Civility Climate Effects on Patient and Employee Perceptions of Hospital Care Performance. Poster session presented at: Academy of Management Annual Meeting; 2016 Aug 9; Anaheim CA.
4. Sasangohar F, Benzer JK, Kum H, Creech SK. Collaborative Management of PTSD Treatment through Smartphone Apps Validated through Patient-Centered Design. Poster session presented at: National Institute of Mental Health Annual Conference; 2016 Aug 1; Washington, DC.
5. Brown EK, Benzer JK, Creech SK, Kum HC, Lawley M, Sasangohar F. Collaborative Management of PTSD Treatment through Smartphone Apps: What is Available and Accessible? Poster session presented at: AcademyHealth Annual Research Meeting; 2016 Jun 20; Boston, MA.
6. Evans L, Benzer JK, Garcia H, Finley E, Burgess JF. Are Relative Value Units a Useful Measure of Workload Among Mental Health Providers in the Veterans Health Administration (VA)? Poster session presented at: AcademyHealth Annual Research Meeting; 2016 Jun 20; Boston, MA.
7. Lipschitz J, Benzer JK, Miller CJ, Easley S, Leyson J, Post E, Burgess JF. Functions and Implementation of Integrated Team-Based Care Management Services for Depression. Poster session presented at: AcademyHealth Annual Research Meeting; 2016 Jun 20; Boston, MA.
8. Mohr DM, Benzer JK, Charns MP. The Role of Integration and Geographical Distance in Relational Coordination Between Primary Care and Specialists in the Veterans Health Administration. Poster session presented at: AcademyHealth Annual Research Meeting; 2016 Jun 20; Boston, MA.
9. Benzer JK, Mohr DC, Evans, L, Young G, Meterko MM, Moore SC, Nealon Seibert M, Osatuke K, Stolzmann KL, Charns MP. The Role of Team Processes for Improving Diabetes Quality of Care. Poster session presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 8; Philadelphia, PA.

DRA: Mental, Cognitive and Behavioral Disorders, Health Systems, Diabetes and Other Endocrine Disorders
DRE: Prevention, Technology Development and Assessment, Treatment - Preclinical
Keywords: none
MeSH Terms: none