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Introducing a new performance measure into practice: Attitude and behavior shifts among frontline staff

McCullough MB, Petrakis BA, Gillespie CK, Park AM, Lukas CV, Rose AJ. Introducing a new performance measure into practice: Attitude and behavior shifts among frontline staff. Poster session presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 9; Philadelphia, PA.

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Objectives: While quality measurement is widely accepted, important areas of healthcare remain unmeasured. Our research team developed an evidence-based quality measure: percent time in therapeutic range (TTR) with warfarin, and introduced this measure as part of the VISN 1 Anticoagulation Improvement Intervention (ACCII). In order to understand how a performance measure is or is not adopted and accepted, we describe how staff responded to the introduction of this measure into practice. Methods: We conducted an average of 50 semi-structured interviews with frontline anticoagulation clinic (ACC) staff annually for three years across 8 medical centers. Interview questions included asking about TTR, the dashboard that measured TTR, and general attitudes about being measured. We analyzed interview data guided by Promoting Action on Research Implementation in Health Services (PARIHS) to identify opinions about evidence as well as an emergent thematic analysis to assess attitude change. Results: In Year 1, the majority of staff indicated resistance or discomfort with being measured. In Year 2, sites that improved TTR felt better at being measured than sites without improved TTR. At Year 3, a larger shift in attitude about measurement occurred across all sites. Most ACC staff embraced the new measure and felt that being measured motivated healthy internal and cross-site competition. In Year 3, there was a few staff at lower-performing sites who remained unconvinced of the value of quality measurement. Implications: We describe how staff moved from skepticism to acceptance of a new performance measure, and indeed the entire idea of being measured, over a 2-year period. Those who improved least on TTR continued to express skepticism about the measure itself, although it is unclear in which direction this phenomenon operates. There may be a certain segment of staff that remain resistant to evidence and change overall; however significant gains can be made. Impacts: Most performance measures have focused on physicians, but we learned substantial improvement can be made by also measuring what others, like clinical pharmacists, contribute to health care. Our findings will help guide others through the process of designing and implementing novel quality measures to examine heretofore unmeasured areas of care

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