BACKGROUND/RATIONALE:
VA's reorganization of care presaged the IoM Quality Chasm report by having already launched internal restructuring, including changes in delivery models, adoption of new technologies, and implementation of new management strategies. In the aggregate, these organizational changes have been found to be associated with substantial gains in VA quality over time and in comparison to Medicare. Yet remarkably little is known about the discrete changes in VA facilities that specifically contributed to these gains or the contextual factors that affected the ability of local facilities to deploy changes needed to accommodate reorganization policies and practice changes. The overarching goal of this study was to use unique data sources to provide an empirically tested substrate for informing evidence-based management, practice and policy for the next wave of VA transformational initiatives and to foster translation of VA's successes to core administrative and clinical practice knowledge to other health care systems, organizations and health plans.

OBJECTIVE(S):
Our research objective was therefore to evaluate the organizational and contextual determinants of VA's quality transformation. As a result, we had three aims:
Aim #1: To evaluate the organizational changes associated with VA performance over VA's reorganization.
Aim #2: To determine the area contextual factors that may have influenced organizational changes over the course of the VA's reorganization and accompanying performance.
Aim #3: To use expert panel methods to integrate and apply findings to produce evidence-based management guidelines in support of ongoing VA quality improvement and translation of lessons to other health care settings.

METHODS:
To accomplish Aims #1-2, we merged and analyzed data from three national VA organizational surveys, 5 years of VA performance data, matched patient-level covariates and area contextual characteristics. For Aim #3, we convened an expert panel comprised of national, network and facility VA leaders using a modified Delphi process to critically review/synthesize results from Aims #1-2 to develop evidence-based management guidelines.

FINDINGS/RESULTS:
We documented the wide array of longitudinal organizational changes that served as the foundation of VA's quality transformation, demonstrating early advances in staffing, policy development and practice arrangements. However, we also found significant rescissions in policy and procedures that backtracked early gains supporting primary care delivery by 1999. Yet, early investment in primary care staffing and practice arrangements yielded important dividends for the trajectory of organizational change and post-reorganization performance when sustained. We also found that contextual factors (e.g., urban/rural location, primary care shortage area, size) had substantial impacts on local structural/process changes and ultimately performance.

IMPACT:
Our findings reflect the challenges and successes behind the VA Journey for Change of the mid-1990s, enabled by an unusual level of concordance of mission and vision from the highest levels of VA to the everyday work of frontline clinicians and managers. Some of the changes accomplished during 1993-96 were deconstructed during 1996-99, raising issues about how to sustain initiatives and create enduring new ways of doing business. We anticipate that the lessons from the previous quality transformation have important implications for the medical home and cultural transformations currently underway.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Hade EM, Murray DM, Pennell ML, Rhoda D, Paskett ED, Champion VL, Crabtree BF, Dietrich A, Dignan MB, Farmer M, Fenton JJ, Flocke S, Hiatt RA, Hudson SV, Mitchell M, Monahan P, Shariff-Marco S, Slone SL, Stange K, Stewart SL, Strickland PA. Intraclass correlation estimates for cancer screening outcomes: estimates and applications in the design of group-randomized cancer screening studies. Journal of The National Cancer Institute. Monographs. 2010 Jan 1; 2010(40):97-103. [view]
2. Chou AF, Rose DE, Farmer M, Canelo I, Yano EM. Organizational Factors Affecting the Likelihood of Cancer Screening Among VA Patients. Medical care. 2015 Dec 1; 53(12):1040-9. [view]

Conference Presentations

1. Rubenstein L, Damschroder LJ, Hagedorn H, Smith S, Dougherty D, McIvor L, Garner L. Applying Implementation Science to Improve Health Care Quality and Performance. Paper presented at: AcademyHealth Annual Research Meeting; 2012 Jun 25; Orlando, FL. [view]
2. Kilbourne A, Rubenstein LV, Sales A, Shekelle PG. Developing Evidence-Based Implementation Strategies: Roadmaps for Learning Healthcare Systems. Presented at: AcademyHealth Annual Research Meeting; 2014 Jun 9; San Diego, CA. [view]
3. Yano EM. Primary care revolution before VA’s quality transformation: Success stories in the Veterans Health Administration. Paper presented at: University of Minnesota Improving Primary Care for Chronic Illness Symposium; 2009 Jun 4; Brooklyn Center, MN. [view]
4. Rubenstein LV, Danz MS, Hempel S, Lim YW, Shanman RM, Stockdale S, Shekelle PG. Responsive Innovation Evidence Reviews to Support Quality Improvement Initiatives. Poster session presented at: AcademyHealth Annual Research Meeting; 2012 Jun 24; Orlando, FL. [view]
5. Yano EM, Rose DE, Mitchell MN, Canelo IA. Rural/urban differences in implementation of primary care programs at VHA during the Quality Transformation: 1993, 1996 and 1999. Poster session presented at: VA HSR&D Rural Health / VA Office of Rural Health Field-Based Meeting; 2010 May 5; Portland, ME. [view]
6. Yano EM. VA primary care delivery arrangements: Results of a national survey. Paper presented at: VA Primary Care and Preventive Medicine Conference; 2008 May 20; Washington, DC. [view]

DRA: Health Systems
DRE: none
Keywords: Implementation, Management
MeSH Terms: none