Session number: 1014
Abstract title: Organizational Structures Support Implementation and Adherence to VA Clinical Practice Guidelines
Author(s):
TE Vaughn - Department of Health Management and Policy, University of Iowa College of Public Health
KF Welke - Division of Cardiothoracic Surgery, The University of Iowa Hospitals and Clinics and College of Medicine
MM Ward - Department of Health Management and Policy, University of Iowa College of Public Health
KD McCoy - Program in Health Services Research, Iowa City VAMC and Department of Internal Medicine, The University of Iowa College of Medicine
BJ BootsMiller - Program in Health Services Research, Iowa City VAMC and Department of Internal Medicine, The University of Iowa College of Medicine
RF Woolson - Department of Biostatistics, University of Iowa College of Public Health
BN Doebbeling - Program in Health Services Research, Iowa City VAMC, Departments of Internal Medicine and Epidemiology, The University of Iowa Colleges of Medicine and Public Health
Objectives: Organizational structures and processes are the primary means for implementing and supporting new programs to improve quality of care and patient outcomes. Organizational culture and climate are often cited as critical for effectively employing such structures and processes. We examined the relationships between compliance with several clinical practice guidelines (CPG) and organizational climate, guideline committee membership, and working style.
Methods: We surveyed key informants at 138 VAMCs regarding provider compliance with three guidelines: chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and major depressive disorder (MDD). Leadership support, organizational climate, and committee structures and processes were assessed using a five point Likert scale. Responses were dichotomized (great/very great=1; other responses=0). Generalized estimating equation regression models with logistic link were used to identify factors associated with compliance for at least two of these CPGs.
Results: Data from 126 VAMCs (91 percent) were provided. General organizational climate factors positively associated with compliance for at least two CPGs included senior administrative support for quality in general and for guidelines specifically, cooperation between physicians and senior administration, a culture fostering flexibility, and cooperation between departments and communication between physicians and nurses. Specific guideline-related factors positively associated with compliance included clinical department input into implementation, teamwork, coordination of guideline implementation with other quality initiatives, and implementation step monitoring. Guideline committee composition and specifically balanced membership across professions were positively associated with compliance. Committee working style attributes positively associated with compliance were members engaged in the process, effective contribution of members in discussions, and productive meetings.
Conclusions: Two factors critical to establish the context for CPG compliance are administrative leadership and a climate of interdisciplinary cooperation and teamwork related to quality generally and to CPGs specifically. Specific committee membership is less important than balance across professions and engagement of all members.
Impact statement: Care for VAMC patients can be improved by visible administrative support for quality, by careful management of collaborative professional relations, and by training guideline coordinators in meeting management.