Carol VanDeusen Lukas

Transformational change in health care systems: an organizational model.

Background: The Institute of Medicines 2001 report Crossing the Quality Chasm argued for fundamental redesign of the U.S. health care system. Six years later, many health care organizations have embraced the reports goals, but few have succeeded in making the substantial transformations needed to achieve those aims. Purposes: This article offers a model for moving organizations from short-term, isolated performance improvements to sustained, reliable, organization-wide, and evidence-based improvements in patient care. Methodology: Longitudinal comparative case studies were conducted in 12 health care systems using a mixed-methods evaluation design based on semistructured interviews and document review. Participating health care systems included seven systems funded through the Robert Wood Johnson Foundations Pursuing Perfection Program and five systems with long-standing commitments to improvement and high-quality care. Findings: Five interactive elements appear critical to successful transformation of patient care: (1) Impetus to transform; (2) Leadership commitment to quality; (3) Improvement initiatives that actively engage staff in meaningful problem solving; (4) Alignment to achieve consistency of organization goals with resource allocation and actions at all levels of the organization; and (5) Integration to bridge traditional intra-organizational boundaries among individual components. These elements drive change by affecting the components of the complex health care organization in which they operate: (1) Mission, vision, and strategies that set its direction and priorities; (2) Culture that reflects its informal values and norms; (3) Operational functions and processes that embody the work done in patient care; and (4) Infrastructure such as information technology and human resources that support the delivery of patient care. Transformation occurs over time with iterative changes being sustained and spread across the organization. Practice Implications: The conceptual model holds promise for guiding health care organizations in their efforts to pursue the Institute of Medicine aims of fundamental system redesign to achieve dramatically improved patient care.

Comprehensive programs for preventing pressure ulcers: a review of the literature

PURPOSE: To enhance the learner’s competence in pressure ulcer (PrU) prevention through a literature review of comprehensive programs. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES: After participating in this educational activity, the participant should be better able to: 1. Analyze the findings of the PrU prevention program studies found in the literature review. 2. Apply research findings to clinical practice. OBJECTIVE: The objective of this study was to examine the evidence supporting the combined use of interventions to prevent pressure ulcers (PrUs) in acute care and long-term-care facilities. DESIGN: A systematic review of the literature describing multifaceted PrU prevention programs was performed. Articles were included if they described an intervention implemented in acute care settings or long-term-care facilities, incorporated more than 1 intervention component, involved a multidisciplinary team, and included information about outcomes related to the intervention. MAIN RESULTS: Twenty-four studies were identified. Recurring components used in the development and implementation of PrU prevention programs included preparations prior to the start of a program, PrU prevention best practices, staff education, clinical monitoring and feedback, skin care champions, and cues to action. Ten studies reported PrU prevalence rates; 9 of them reported decreased prevalence rates at the end of their programs. Of the 6 studies reporting PrU incidence rates, 5 reported a decrease in incidence rates. Four studies measured care processes: 1 study reported an overall improvement; 2 studies reported improvement on some, but not all, measures; and 1 study reported no change. CONCLUSIONS: There is a growing literature describing multipronged, multidisciplinary interventions to prevent PrUs in acute care settings and long-term-care facilities. Outcomes reported in these studies suggest that such programs can be successful in reducing PrU prevalence or incidence rates. However, to strengthen the level of evidence, sites should be encouraged to rigorously evaluate their programs and to publish their results.

Strengthening organizations to implement evidence-based clinical practices.

OBJECTIVES Despite recognition that implementation of evidence-based clinical practices (EBPs) usually depends on the structure and processes of the larger health care organizational context, the dynamics of implementation are not well understood. This projects aim was to deepen that understanding by implementing and evaluating an organizational model hypothesized to strengthen the ability of health care organizations to facilitate EBPs. CONCEPTUAL MODEL: The model posits that implementation of EBPs will be enhanced through the presence of three interacting components: active leadership commitment to quality, robust clinical process redesign incorporating EBPs into routine operations, and use of management structures and processes to support and align redesign. STUDY DESIGN In a mixed-methods longitudinal comparative case study design, seven medical centers in one network in the Department of Veterans Affairs participated in an intervention to implement the organizational model over 3 years. The network was selected randomly from three interested in using the model. The target EBP was hand-hygiene compliance. Measures included ratings of implementation fidelity, observed hand-hygiene compliance, and factors affecting model implementation drawn from interviews. FINDINGS Analyses support the hypothesis that greater fidelity to the organizational model was associated with higher compliance with hand-hygiene guidelines. High-fidelity sites showed larger effect sizes for improvement in hand-hygiene compliance than lower-fidelity sites. Adherence to the organizational model was in turn affected by factors in three categories: urgency to improve, organizational environment, and improvement climate. IMPLICATIONS Implementation of EBPs, particularly those that cut across multiple processes of care, is a complex process with many possibilities for failure. The results provide the basis for a refined understanding of relationships among components of the organizational model and factors in the organizational context affecting them. This understanding suggests practical lessons for future implementation efforts and contributes to theoretical understanding of the dynamics of the implementation of EBPs.

Implementation of a clinical innovation: the case of advanced clinic access in the Department of Veterans Affairs.

Healthcare organizations seeking to improve clinical practices often have disappointing results because the planned innovations are not successfully implemented. To increase the understanding of implementation, we analyzed the national spread of an ambulatory innovation in the Department of Veterans Affairs. This study provides support for a conceptual model that posits that the extent to which a clinical innovation is implemented will be affected by factors in 3 domains: (1) intentional activities to introduce, spread, and support the innovation; (2) the attitudes and capabilities of clinic staff responsible for implementing the innovation; and (3) the context of the facility in which the innovation is being introduced. Among the strongest predictors of successful implementation, management support for the innovation and clinic team knowledge and skills to make changes successfully were significant across both primary care and specialty clinics.

Monitoring the progress of system integration.

As providers of health care face the multiple challenges of todays health care environment, many believe that integrated delivery systems promise the structure needed to provide high-quality, cost-efficient care. They make structural and process changes with the expectation that those changes will improve system performance. But few systems actually measure progress in creating an integrated system. This article describes one health care systems strategy for introducing organizational measures to create an integrated system scorecard and focuses on the development, results, and use of the staff survey. The survey provides reliable indicators of system integration. Linking the survey results with network performance measures, in turn, provides managers with tools for judging whether system integration is associated with improved system performance.

Team effectiveness and organizational context in the implementation of a clinical innovation.

Objectives The study examined the relationship between care delivery team effectiveness, management support, organizational culture, and the extent of implementation of a clinical innovation. Methods The study involved 6 target clinic areas in 78 Department of Veterans Affairs medical centers that participated in the national implementation of Advanced Clinic Access (ACA). Primary data were collected through staff surveys and structured interviews; secondary analyses were conducted using administrative databases. Hierarchical linear models were used to test the influence of team effectiveness and organizational context on implementation ratings. Results and Conclusions Team effectiveness as measured by team knowledge and skills was significantly associated with the extent of ACA implementation in both primary and specialty care. Team functioning was significant only in primary care. Management support as measured by personal leadership support for quality improvement and the importance of reduced wait times was also significantly associated with ACA implementation, but practical management support and organizational culture were not. Team effectiveness partially mediated the relationship between extent of implementation and personal leadership support. Findings support the underlying theory that implementation of clinical innovations depends on both individual staff and a more complex dynamic of individuals operating within work units in the larger organization.

VA’s Expansion of Supportive Housing: Successes and Challenges on the Path Toward Housing First

OBJECTIVES The U.S. Department of Veterans Affairs (VA) is transitioning to a Housing First approach to placement of veterans in permanent supportive housing through the use of rental vouchers, an ambitious organizational transformation. This qualitative study examined the experiences of eight VA facilities undertaking this endeavor in 2012. METHODS A multidisciplinary team interviewed facility leadership, midlevel managers, and frontline staff (N=95 individuals) at eight VA facilities representing four U.S. regions. The team used a semistructured interview protocol and the constant comparative method to explore how individuals throughout the organizations experienced and responded to the challenges of transitioning to a Housing First approach. RESULTS Frontline staff faced challenges in rapidly housing homeless veterans because of difficult rental markets, the need to coordinate with local public housing authorities, and a lack of available funds for move-in costs. Staff sought to balance their time spent on housing activities with intensive case management of highly vulnerable veterans. Finding low-demand sheltering options (that is, no expectations regarding sobriety or treatment participation, as in the Housing First model) for veterans waiting for housing presented a significant challenge to implementation of Housing First. Facility leadership supported Housing First implementation through resource allocation, performance monitoring, and reliance on midlevel managers to understand and meet the challenges of implementation. CONCLUSIONS The findings highlight the considerable practical challenges and innovative solutions arising from a large-scale effort to implement Housing First, with particular attention to the experiences of individuals at all levels within an organization.

Predicting healthcare employees' participation in an office redesign program: Attitudes, norms and behavioral control

BackgroundThe study examined the extent to which components based on a modified version of the theory of planned behavior explained employee participation in a new clinical office program designed to reduce patient waiting times in primary care clinics.MethodsWe regressed extent of employee participation on attitudes about the program, group norms, and perceived behavioral control along with individual and clinic characteristics using a hierarchical linear mixed model.ResultsPerceived group norms were one of the best predictors of employee participation. Attitudes about the program were also significant, but to a lesser degree. Behavioral control, however, was not a significant predictor. Respondents with at least one year of clinic tenure, or who were team leaders, first line supervisor, or managers had greater participation rates. Analysis at the clinic level indicated clinics with scores in the highest quartile clinic scores on group norms, attitudes, and behavioral control scores were significantly higher on levels of overall participation than clinics in the lowest quartile.ConclusionFindings suggest that establishing strong norms and values may influence employee participation in a change program in a group setting. Supervisory level was also significant with greater responsibility being associated with greater participation.

Hospital Conversions from for-Profit to Nonprofit Status: The other Side of the Story

The authors examined, on a case-by-case basis, the community impact of 15 for-profit hospitals that converted to nonprofit status. These for-profit conversions have been occurring in numbers comparable with those of nonprofit conversions (i.e., nonprofit hospitals that convert to for-profit status), but have attracted far less attention. For each for-profit conversion, the authors compared the change in uncompensated care with the loss to the local community in property tax revenue. In 11 of the 15 cases, the conversion was followed by some level of increase in uncompensated care. However, only three of these conversions produced enough additional uncompensated care to offset the loss in property tax revenue to the community. This analysis, while only a starting point for addressing the community impact of for-profit conversions, suggests that for-profit conversions do not uniformly promote the welfare of the communities where they occur.

What roles do middle managers play in implementation of innovative practices

Background: Middle managers play key roles in hospitals as the bridge between senior leaders and frontline staff. Yet relatively little research has focused on their role in implementing new practices. Purpose: The aim of this study was to expand the understanding of middle managers’ influence in organizations by looking at their activities through the lens of two complementary conceptual frameworks. Methodology/Approach: We analyzed qualitative data from 17 Veterans Affairs Medical Centers with high and low potential to change organizational practices. We analyzed 98 interviews with staff ranging from senior leaders to frontline staff to identify themes within an a priori framework reflecting middle manager activities. Findings: Analyses yielded 14 emergent themes that allowed us to classify specific expressions of middle manager commitment to implementation of innovative practices (e.g., facilitate improvement innovation, garner staff buy-in). In comparing middle manager behaviors in high and low change potential sites, we found that most emergent themes were present in both groups. However, the activities and interactions described differed between the groups. Practice Implications: Middle managers can use the promising strategies identified by our analyses to guide and improve their effectiveness in implementing new practices. These strategies can also inform senior leaders striving to guide middle managers in those efforts.