Go backSearch Session number: 1045

Abstract title: Strategies that Improved Knowledge of the VA CHF Practice Guideline Did Not Increase Compliance

Author(s):
BJ BootsMiller - Program in Health Services Research, Iowa City VAMC and Department of Internal Medicine, The University of Iowa College of Medicine
KF Welke - Division of Cardiothoracic Surgery, The University of Iowa Hospitals and Clinics and College of Medicine
KD McCoy - Program in Health Services Research, Iowa City VAMC and Department of Internal Medicine, The University of Iowa College of Medicine
TE Vaughn - Department of Health Management and Policy, University of Iowa College of Public Health
MM Ward - Department of Health Management and Policy, University of Iowa College of Public Health
RF Woolson - Department of Biostatistics, University of Iowa College of Public Health
BN Doebbeling - Program in Health Services Research, Iowa City VAMC, The University of Iowa, Departments of Internal Medicine and Epidemiology, Colleges of Medicine and Public Health

Objectives: Provider compliance with clinical practice guidelines (CPG) is influenced by organizational structure and processes developed to implement the guidelines. CPGs are implemented by individual facilities whose relationships with VISNs can influence how these processes are enacted. The purpose of this study is to assess the impact of facility procedures and VISN leadership on provider knowledge of and compliance with the VA Congestive Heart Failure (CHF) CPG.

Methods: We surveyed key informants involved in quality management and CPG implementation at 138 VAMCs. Respondents rated the extent to which their facility employed structures and procedures to support the change and the extent to which their VISN provided direction for CPG implementation and quality improvement. Generalized estimating equations logistic regression models were constructed relating provider knowledge and compliance to facility change processes and VISN leadership.

Results: There were 173 respondents representing 126 facilities (91 percent). Facility processes associated with provider knowledge of the CHF guideline included a well planned implementation process (p < 0.001), resource allocation to support change (p < 0.001), and establishment of appropriate checkpoints and deadlines (p < 0.001). The only factor associated with provider compliance was the establishment of appropriate checkpoints and deadlines (p=0.04). A similar pattern was observed with VISN leadership factors. Provider knowledge was associated with VISN leadership providing direction for quality improvement activities (p=0.01), providing support for CPG implementation (p=0.04), designating a champion for CPG (p=0.01), and fostering facility collaboration in implementation (p=0.03). The only VISN leadership item associated with compliance was monitoring the pace of guideline implementation (p=0.01).

Conclusions: Facility procedures and VISN leadership activities that increase provider knowledge of the CHF guideline were not sufficient to ensure compliance. Checkpoints and deadlines imposed by facilities and VISN leadership to monitor the pace of guideline implementation increase compliance with the CHF guideline. The VISN has an important role in assuring that implementation is proceeding. The facility leadership’s role is best focused on establishing an action plan with deadlines for specific steps.

Impact statement: To ensure provider compliance with future VA CPGs, facilities and VISN leaderships should emphasize monitoring of the implementation process.