Lead/Presenter: Susan Stockdale, COIN - Los Angeles
All Authors: Stockdale SE (Center for the Study of Healthcare Innovation, Implementation, and Policy), Bergman AA (Center for the Study of Healthcare Innovation, Implementation, and Policy), Hamilton AB (Center for the Study of Healthcare Innovation, Implementation, and Policy) Rose DE (Center for the Study of Healthcare Innovation, Implementation, and Policy) Yano EM (Center for the Study of Healthcare Innovation, Implementation, and Policy) Rubenstein LV (Center for the Study of Healthcare Innovation, Implementation, and Policy)
The VHA devoted substantial resources toward implementing PACT, VHA's medical home model, but current evidence shows considerable variation in PACT implementation nationwide in primary care. Evidence-Based Quality Improvement (EBQI) is a multi-faceted implementation strategy that has been successful for accelerating adoption of key PACT features, including increased non-face-to-face visits, reduced in-person visits, improved patient-reported access, and reduced primary care provider burnout. These findings, however, are of limited usefulness without a better understanding of whether and how key EBQI features were implemented. We assessed fidelity to three key EBQI features over four study years (2010-2014).
EBQI-PACT was implemented in one region using a modified stepped-wedge design, and included 9 primary care sites and 7 cross-site, topic-focused workgroups. Key features included: 1) Leadership-frontlines priority-setting process for primary care QI; 2) EBQI learning collaborative with bi-weekly calls and in-person learning sessions; and, 3) support for using data/evidence to inform EBQI projects; 4) facilitation and project management-focused support. We reviewed project files to assess fidelity based on explicit participation criteria. We used qualitative analysis of 73 interviews to assess stakeholder perceptions of EBQI-PACT. Participants included multi-level, interprofessional leaders; primary care providers; staff; and researchers.
Site/workgroup EBQI teams submitted 72 QI projects over 4 rounds of priority-setting. 24 leaders approved 26 QI projects. Sites/workgroups with longer duration in the project had higher fidelity for participation in priority-setting. Participation in EBQI collaborative activities was higher for collaborative learning sessions than for bi-weekly telephone calls. Most EBQI teams showed high or medium fidelity for using data/evidence. Low data use corresponded with low participation in bi-weekly calls, indicating possible lack of connection with EBQI resources/supports. Stakeholders identified bi-directional communication between leaders and EBQI teams; cross-site learning and sharing; and project management and data support as critical for EBQI-PACT fidelity.
Multi-level participation in priority-setting, EBQI collaborative learning sessions, and data/evidence use to inform QI are key features of the EBQI-PACT implementation approach that can accelerate achievement of key PACT goals.
Healthcare system leaders should consider incorporating key features of EBQI to improve implementation of evidence-based interventions.