Physician and Other Healthcare Personnel Responses to Hospital Stroke Quality of Care Performance Feedback: A Qualitative Study

Background Understanding how physicians and other healthcare personnel respond to hospital performance feedback initiatives may have important implications for quality improvement efforts. Our objective was to explore responses to the inaugural feedback of hospital performance on stroke quality of care measures among relevant physicians and personnel at the US Department of Veterans Health Administration (VHA) hospitals. Methods Qualitative interviews with hospital administrators, physicians, nurses and quality managers at 12 VHA hospitals in the USA after the inaugural national release of the report on quality of acute stroke care processes. Interview transcripts were analysed using an immersion/crystallisation approach to identify recurrent themes. Results Interviews were completed with 41 individuals at 12 VHA hospitals from diverse regions of the USA; the majority were clinicians, either physicians or nurses, and nearly all had 20 years of experience or more. Interviewees described general perceptions of internal performance feedback that were both positive and negative, such as the notion that performance feedback could provide value to clinicians and hospitals, but at the same time voiced concerns about being inundated with such data. Interviewees also expressed scepticism about public reporting of performance data, citing numerous concerns and limitations. However, when interviewees described specific experiences with performance feedback, nearly all reactions were positive, including excitement, interest and feeling validated about a job well done. Discussion Physicians and other healthcare personnel described hospital performance feedback on stroke quality of care measures to be broadly valuable but identified areas of concern related to the measurement process and public reporting

Using intervention mapping to develop and adapt a secondary stroke prevention program in Veterans Health Administration medical centers

Secondary stroke prevention is championed by the stroke guidelines; however, it is rarely systematically delivered. We sought to develop a locally tailored, evidence-based secondary stroke prevention program. The purpose of this paper was to apply intervention mapping (IM) to develop our locally tailored stroke prevention program and implementation plan. We completed a needs assessment and the five Steps of IM. The needs assessment included semi-structured interviews of 45 providers; 26 in Indianapolis and 19 in Houston. We queried frontline clinical providers of stroke care using structured interviews on the following topics: current provider practices in secondary stroke risk factor management; barriers and needs to support risk factor management; and suggestions on how to enhance secondary stroke risk factor management throughout the continuum of care. We then describe how we incorporated each of the five Steps of IM to develop locally tailored programs at two sites that will be evaluated through surveys for patient outcomes, and medical records chart abstraction for processes of care

Comparative responsiveness of pain outcome measures among primary care patients with musculoskeletal pain

BACKGROUND: Comparative responsiveness data are needed to inform choices about pain outcome measures. OBJECTIVES: To compare responsiveness of pain intensity, pain-related function, and composite measures, using data from a randomized trial and observational study. RESEARCH DESIGN: Analysis of responsiveness. SUBJECTS: A total of 427 adults with persistent back, hip, or knee pain were recruited from primary care. METHODS: Participants completed Brief Pain Inventory, Chronic Pain Grade (CPG), Roland disability, SF-36 bodily pain, and pain global rating of change measures. We used the global rating as the anchor for standardized response mean and receiver operating characteristic curve analyses. We used the distribution-based standard error of measurement to estimate minimally important change. To assess responsiveness to the trial intervention, we evaluated standardized effect size statistics stratified by trial arm. RESULTS: All measures were responsive to global improvement and all had fair-to-good accuracy in discriminating between participants with and without improvement. SF bodily pain was less responsive than other measures in several analyses. The 3-item PEG was similarly responsive to full Brief Pain Inventory scales. CPG and SF bodily pain were less responsive to the trial intervention and did not perform well among participants with hip/knee pain. Agreement between anchor and distribution-based methods was modest. CONCLUSIONS: If a brief measure is desired, the 3-item PEG is more responsive than the SF bodily pain scale. CPG and SF bodily pain scales may be relatively poor choices for trial outcome assessment. Both anchor and distribution-based methods should be considered when determining clinically important change

Key components of external facilitation in an acute stroke quality improvement collaborative in the Veterans Health Administration

Background Facilitation is a key component for successful implementation in several implementation frameworks; however, there is a paucity of research specifying this component. As part of a stroke quality improvement intervention in the Veterans Health Administration (VHA), facilitation plus data feedback was compared to data feedback alone in 11 VA medical facilities. The objective of this study was to elucidate upon the facilitation components of the stroke quality improvement. Methods We conducted a secondary evaluation of external facilitation using semi-structured interviews. Five facilitators and two program directors were interviewed. Qualitative analysis was performed on transcribed interviews to gain an understanding of the role and activities of external facilitators during the on-site and telephone facilitation. Quantitative frequencies were calculated from the self-reported time spent in facilitation tasks by facilitators. Results The external facilitators saw their role as empowering the clinical teams to take ownership of the process changes at the clinical sites to improve their performance quality. To fulfill this role, they reported engaging in a number of core tasks during telephone and on-site visits including: assessing the context in which the teams were currently operating, guiding the clinical teams through their planned changes and use of process improvement tools, identifying resources and making referrals, holding teams accountable for plan implementation with on-site visits, and providing support and encouragement to the teams. Time spent in facilitation activities changed across time from guiding change (early) to supporting efforts made by the clinical teams (later). Facilitation activity transitioned to more monitoring, problem solving, and intentional work to hand over the clinical improvement process to the site teams with the coach’s role being increasingly that of a more distant consultant. Overall, this study demonstrated that external facilitation is not an event but rather a process where relationships and responsibilities evolve over time. Conclusions This study shows that external facilitation involves core elements related to communication, relationship building, methods training, monitoring performance over time, and facilitating team-based problem solving. Importantly, this work demonstrates the fluid nature of external facilitation over time, as teams learn, grow, change, and experience changing contexts

Uncertainty as a Key Influence in the Decision To Admit Patients with Transient Ischemic Attack

Background Patients with transient ischemic attacks (TIA) are at high risk of subsequent vascular events. Hospitalization improves quality of care, yet admission rates for TIA patients vary considerably. Objectives We sought to identify factors associated with the decision to admit patents with TIA. Design We conducted a secondary analysis of a prior study’s data including semi-structured interviews, administrative data, and chart review. Participants We interviewed multidisciplinary clinical staff involved with TIA care. Administrative data included information for TIA patients in emergency departments or inpatient settings at VA medical centers (VAMCs) for fiscal years (FY) 2011 and 2014. Chart reviews were conducted on a subset of patients from 12 VAMCs in FY 2011. Approach For the qualitative data, we focused on interviewees’ responses to the prompt: “Tell me what influences you in the decision to or not to admit TIA patients.” We used administrative data to identify admission rates and chart review data to identify ABCD2 scores (a tool to classify stroke risk after TIA). Key Results Providers’ decisions to admit TIA patients were related to uncertainty in several domains: lack of a facility TIA-specific policy, inconsistent use of ABCD2 score, and concerns about facilities’ ability to complete a timely workup. There was a disconnect between staff perceptions about TIA admission and facility admission rates. According to chart review data, staff at facilities with higher admission rates in FY 2011 reported consistent reliance on ABCD2 scores and related guidelines in admission decision-making. Conclusions Many factors contributed to decisions regarding admitting a patient with TIA; however, clinicians’ uncertainty appeared to be a key driver. Further quality improvement interventions for TIA care should focus on facility adoption of TIA protocols to address uncertainty in TIA admission decision-making and to standardize timely evaluation of TIA patients and delivery of secondary prevention strategies

Facilitators and Barriers to Participation in a Peer Support Intervention for Veterans With Chronic Pain

OBJECTIVE: To understand facilitators and barriers to participation in a peer support intervention for self-management of chronic pain. METHODS: After completing a pilot intervention study, peer coaches and their veteran patients took part in a qualitative, semistructured interview to explore their experiences with the intervention. Data were analyzed using an immersion/crystallization approach. RESULTS: Three facilitators and 2 barriers to patient participation in a peer support intervention for veterans with chronic pain emerged. Facilitators were (1) having a shared identity as veterans, (2) being partnered with a person who also has chronic pain, and (3) support from the study staff. Barriers were (1) logistical challenges, and (2) challenges to motivation and engagement in the intervention. DISCUSSION: Awareness of facilitators and barriers to participation in a peer-supported self-management program for chronic pain, as well as strategies to capitalize on facilitators and mitigate barriers, are essential for further study and ultimate clinical implementation of such a program

The prospectively-reported implementation update and score (PRIUS): a new method for capturing implementation-related developments over time

BACKGROUND: Implementation of new programs within healthcare systems can be extraordinarily complex. Individuals within the same healthcare organization often have different perspectives on how implementation of a new program unfolds over time, and it is not always clear in the midst of implementation what issues are most important or how to address them. An implementation support team within the Veterans Health Administration (VHA) sought to develop an efficient method for eliciting an ongoing, detailed and nuanced account of implementation progress from multiple viewpoints that could support and inform active implementation of two new VHA programs. METHODS: The new Prospectively-Reported Implementation Update and Score ("PRIUS") provided a quick, structured, prospective and open-ended method for individuals to report on implementation progress. PRIUS updates were submitted approximately twice a month. Responding to the prompt "What are some things that happened over the past two weeks that seem relevant from your perspective to the implementation of this project?", individuals scored each update with a number ranging from + 3 to - 3. RESULTS: In 2016-17, individuals submitted over 600 PRIUS updates across the two QI projects. PRIUS-based findings included that staff from different services reported fundamentally different perspectives on program implementation. Rapid analysis and reporting of the PRIUS data led directly to changes in implementation. CONCLUSIONS: The PRIUS provided an efficient, structured method for developing a granular and context-sensitive account of implementation progress. The approach appears to be highly adaptable to a wide range of settings and interventions

Prime movers: Advanced practice professionals in the role of stroke coordinator

Background and purpose Following a stroke quality improvement clustered randomized trial and a national acute ischemic stroke (AIS) directive in the Veterans Health Administration in 2011, this comparative case study examined the role of advanced practice professionals (APPs) in quality improvement activities among stroke teams. Methods Semistructured interviews were conducted at 11 Veterans Affairs medical centers annually over a 3-year period. A multidisciplinary team analyzed interviews from clinical providers through a mixed-methods, data matrix approach linking APPs (nurse practitioners and physician assistants) with Consolidated Framework for Implementation Research constructs and a group organization measure. Conclusion Five of 11 facilities independently chose to staff stroke coordinator positions with APPs. Analysis indicated that APPs emerged as boundary spanners across services and disciplines who played an important role in coordinating evidence-based, facility-level approaches to AIS care. The presence of APPs was related to engaging in group-based evaluation of performance data, implementing stroke protocols, monitoring care through data audit, convening interprofessional meetings involving planning activities, and providing direct care. Implications for practice The presence of APPs appears to be an influential feature of local context crucial in developing an advanced, facility-wide approach to stroke care because of their boundary spanning capabilities

Inside help: An integrative review of champions in healthcare-related implementation

Background/aims: The idea that champions are crucial to effective healthcare-related implementation has gained broad acceptance; yet the champion construct has been hampered by inconsistent use across the published literature. This integrative review sought to establish the current state of the literature on champions in healthcare settings and bring greater clarity to this important construct. Methods: This integrative review was limited to research articles in peer-reviewed, English-language journals published from 1980 to 2016. Searches were conducted on the online MEDLINE database via OVID and PubMed using the keyword "champion." Several additional terms often describe champions and were also included as keywords: implementation leader, opinion leader, facilitator, and change agent. Bibliographies of full-text articles that met inclusion criteria were reviewed for additional references not yet identified via the main strategy of conducting keyword searches in MEDLINE. A five-member team abstracted all full-text articles meeting inclusion criteria. Results: The final dataset for the integrative review consisted of 199 unique articles. Use of the term champion varied widely across the articles with respect to topic, specific job positions, or broader organizational roles. The most common method for operationalizing champion for purposes of analysis was the use of a dichotomous variable designating champion presence or absence. Four studies randomly allocated of the presence or absence of champions. Conclusions: The number of published champion-related articles has markedly increased: more articles were published during the last two years of this review (i.e. 2015-2016) than during its first 30 years (i.e. 1980-2009).The number of champion-related articles has continued to increase sharply since the year 2000. Individual studies consistently found that champions were important positive influences on implementation effectiveness. Although few in number, the randomized trials of champions that have been conducted demonstrate the feasibility of using experimental design to study the effects of champions in healthcare

Geographic variation in poststroke depression among veterans with acute stroke

This study compared patterns of poststroke depression (PSD) detection among veterans with acute stroke in eight U.S. geographic regions. Department of Veterans Affairs (VA) medical and pharmacy data as well as Medicare data were used. International Classification of Diseases-9th Revision depression codes and antidepressant medication dispensing were applied to define patients’ PSD status 12 months poststroke. Logistic regression models were fit to compare VA PSD diagnosis and overall PSD detection between the regions. The use of VA medical data alone may underestimate the rate of PSD. Geographic variation in PSD detection depended on the data used. If VA medical data alone were used, we found no significant variation. If VA medical data were used along with Medicare and VA pharmacy data, we observed a significant variation in overall PSD detection across the regions after adjusting for potential risk factors. VA clinicians and policy makers need to consider enrollees’ use of services outside the system when conducting program evaluation. Future research on PSD among veteran patients should use VA medical data in combination with Medicare and VA pharmacy data to obtain a comprehensive understanding of patients’ PSD