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Reisinger HS, Ono SS, Paez MB. National Policy, Local Implementation: Reaching Out to Returning Reserve and National Guard Members and Their Families. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2011 May 5; Phoenix, AZ.
Background As the largest integrated health care system in the United States, the Veterans Health Administration (VHA) relies on national policy directives, mandated programs, and performance measures to sustain and improve quality health care. At the same time, local VA medical centers (VAMC) often have considerable autonomy to meet these national requirements. The objective of this study is to conduct an ethnographic formative evaluation of the local implementation of a nationally mandated VA policy-outreach to Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF)service members-and determine the impact of this policy on one VAMC's outreach efforts. Methods The study employs an ethnographic approach to formative evaluation. Data collection includes: archiving organizational documents; fieldnotes from observations of outreach events; and transcripts from semi-structured interviews with outreach personnel, service members, and family members. To date, interviews have been conducted with 10 family members, 9 service members, and 12 VA and non-VA outreach personnel from the catchment area of one VAMC. Textual data is content analyzed for top-level codes and more detailed coding is completed through subcoding and matrix analyses. Results The study is on-going. To date, national legislation and policy directives related to VA outreach have been compiled and mapped to implementation of local outreach programming at one VAMC. Results of thematic content analysis of policy documents, transcripts, and field notes indicate substantial variation in definitions and approaches to outreach. For example, the National Defense Authorization Act (NDAA) of 2008 presents a comprehensive definition of outreach and details specific elements for the Yellow Ribbon Reintegration Program for Reserve and National Guard service members. The NDAA of 2008 has in turn placed greater structure on how outreach is conducted at the local VAMC. This example, among others, demonstrates ways national policy initiatives can both facilitate and hinder the quality and effectiveness of the local implementation of such policies. Conclusions Improving quality of and access to healthcare exists in the tension between directives from national policy initiatives and local determinations of how to interpret and implement these policies. Ethnographic methods allow for careful examination of how national policy might be brought to bear in "real world" settings. By studying this tension, better policy can be written and new tools to effectively understand and implement these policies should be developed
