Implementation Evaluation of a Complex Intervention to Improve Timeliness of Care for Veterans with Transient Ischemic Attack

Background: The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurologic Symptoms (PREVENT) program was designed to address systemic barriers to providing timely guideline-concordant care for patients with transient ischemic attack (TIA). Objective: We evaluated an implementation bundle used to promote local adaptation and adoption of a multi-component, complex quality improvement (QI) intervention to improve the quality of TIA care Bravata et al. (BMC Neurology 19:294, 2019). Design: A stepped-wedge implementation trial with six geographically diverse sites. Participants: The six facility QI teams were multi-disciplinary, clinical staff. Interventions: PREVENT employed a bundle of key implementation strategies: team activation; external facilitation; and a community of practice. This strategy bundle had direct ties to four constructs from the Consolidated Framework for Implementation Research (CFIR): Champions, Reflecting & Evaluating, Planning, and Goals & Feedback. Main measures: Using a mixed-methods approach guided by the CFIR and data matrix analyses, we evaluated the degree to which implementation success and clinical improvement were associated with implementation strategies. The primary outcomes were the number of completed implementation activities, the level of team organization and > 15 points improvement in the Without Fail Rate (WFR) over 1 year. Key results: Facility QI teams actively engaged in the implementation strategies with high utilization. Facilities with the greatest implementation success were those with central champions whose teams engaged in planning and goal setting, and regularly reflected upon their quality data and evaluated their progress against their QI plan. The strong presence of effective champions acted as a pre-condition for the strong presence of Reflecting & Evaluating, Goals & Feedback, and Planning (rather than the other way around), helping to explain how champions at the +2 level influenced ongoing implementation. Conclusions: The CFIR-guided bundle of implementation strategies facilitated the local implementation of the PREVENT QI program and was associated with clinical improvement in the national VA healthcare system

Simple roads to failure, complex paths to success: an evaluation of conditions explaining perceived fit of an organizational occupational health intervention

Organizational occupational health interventions (OOHIs) that are perceived by employees as relevant for their workplace are more likely to be implemented successfully, yet little is known about the conditions that produce such perceptions. This study identifies the conditions that create a perception among employees that an intervention fits their organization as well as the conditions that result in low levels of perceived fit. We used two-wave data from 40 Danish preschools a that underwent a quasi-experimental OOHI. Perceived fit was assessed through employee ratings at follow-up, while survey responses from implementation team members at five time points were used to assess four context and fourteen process factors. The results of a coincidence analysis showed that high levels of perceived fit were achieved through two paths. Each path consisted of a lack of co-occurring changes together with either very high levels of managerial support (path_1) or a combination of implementation team role clarity, staff involvement, and team learning (path_2). In contrast, low levels of perceived fit were brought about by single factors: limited leader support, low degree of role clarity, or concurrent organizational changes. The findings reveal the complexity involved in implementing OOHIs and offer insights into reasons they may fail