Browsing by Author "Baird, Sean A."

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    Acceptability of a complex team-based quality improvement intervention for transient ischemic attack: a mixed-methods study
    (BMC, 2021-05-12) Damush, Teresa M.; Penney, Lauren S.; Miech, Edward J.; Rattray, Nicholas A.; Baird, Sean A.; Cheatham, Ariel J.; Austin, Charles; Sexson, Ali; Myers, Laura J.; Bravata, Dawn M.; Medicine, School of Medicine
    Background: The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurologic Symptoms (PREVENT) program was a complex quality improvement (QI) intervention targeting transient ischemic attack (TIA) evidence-based care. The aim of this study was to evaluate program acceptability among the QI teams and factors associated with degrees of acceptability. Methods: QI teams from six Veterans Administration facilities participated in active implementation for a one-year period. We employed a mixed methods study to evaluate program acceptability. Multiple data sources were collected over implementation phases and triangulated for this evaluation. First, we conducted 30 onsite, semi-structured interviews during active implementation with 35 participants at 6 months; 27 interviews with 28 participants at 12 months; and 19 participants during program sustainment. Second, we conducted debriefing meetings after onsite visits and monthly virtual collaborative calls. All interviews and debriefings were audiotaped, transcribed, and de-identified. De-identified files were qualitatively coded and analyzed for common themes and acceptability patterns. We conducted mixed-methods matrix analyses comparing acceptability by satisfaction ratings and by the Theoretical Framework of Acceptability (TFA). Results: Overall, the QI teams reported the PREVENT program was acceptable. The clinical champions reported high acceptability of the PREVENT program. At pre-implementation phase, reviewing quality data, team brainstorming solutions and development of action plans were rated as most useful during the team kickoff meetings. Program acceptability perceptions varied over time across active implementation and after teams accomplished actions plans and moved into sustainment. We observed team acceptability growth over a year of active implementation in concert with the QI team's self-efficacy to improve quality of care. Guided by the TFA, the QI teams' acceptability was represented by the respective seven components of the multifaceted acceptability construct. Conclusions: Program acceptability varied by time, by champion role on QI team, by team self-efficacy, and by perceived effectiveness to improve quality of care aligned with the TFA. A complex quality improvement program that fostered flexibility in local adaptation and supported users with access to data, resources, and implementation strategies was deemed acceptable and appropriate by front-line clinicians implementing practice changes in a large, national healthcare organization.
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    Multi-tiered external facilitation: the role of feedback loops and tailored interventions in supporting change in a stepped-wedge implementation trial
    (BMC, 2021-07-27) Penney, Lauren S.; Damush, Teresa M.; Rattray, Nicholas A.; Miech, Edward J.; Baird, Sean A.; Homoya, Barbara J.; Myers, Laura J.; Bravata, Dawn M.; Medicine, School of Medicine
    Background: Facilitation is a complex, relational implementation strategy that guides change processes. Facilitators engage in multiple activities and tailor efforts to local contexts. How this work is coordinated and shared among multiple, external actors and the contextual factors that prompt and moderate facilitators to tailor activities have not been well-described. Methods: We conducted a mixed methods evaluation of a trial to improve the quality of transient ischemic attack care. Six sites in the Veterans Health Administration received external facilitation (EF) before and during a 1-year active implementation period. We examined how EF was employed and activated. Data analysis included prospective logs of facilitator correspondence with sites (160 site-directed episodes), stakeholder interviews (a total of 78 interviews, involving 42 unique individuals), and collaborative call debriefs (n=22) spanning implementation stages. Logs were descriptively analyzed across facilitators, sites, time periods, and activity types. Interview transcripts were coded for content related to EF and themes were identified. Debriefs were reviewed to identify instances of and utilization of EF during site critical junctures. Results: Multi-tiered EF was supported by two groups (site-facing quality improvement [QI] facilitators and the implementation support team) that were connected by feedback loops. Each site received an average of 24 episodes of site-directed EF; most of the EF was delivered by the QI nurse. For each site, site-directed EF frequently involved networking (45%), preparation and planning (44%), process monitoring (44%), and/or education (36%). EF less commonly involved audit and feedback (20%), brainstorming solutions (16%), and/or stakeholder engagement (5%). However, site-directed EF varied widely across sites and time periods in terms of these facilitation types. Site participants recognized the responsiveness of the QI nurse and valued her problem-solving, feedback, and accountability support. External facilitators used monitoring and dialogue to intervene by facilitating redirection during challenging periods of uncertainty about project direction and feasibility for sites. External facilitators, in collaboration with the implementation support team, successfully used strategies tailored to diverse local contexts, including networking, providing data, and brainstorming solutions. Conclusions: Multi-tiered facilitation capitalizing on emergent feedback loops allowed for tailored, site-directed facilitation. Critical juncture cases illustrate the complexity of EF and the need to often try multiple strategies in combination to facilitate implementation progress.
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    The Perils of a "My Work Here is Done" perspective: a mixed methods evaluation of sustainment of an evidence-based intervention for transient ischemic attack
    (BMC, 2022-07-04) Bravata, Dawn M.; Miech, Edward J.; Myers, Laura J.; Perkins, Anthony J.; Zhang, Ying; Rattray, Nicholas A.; Baird, Sean A.; Penney, Lauren S.; Austin, Curt; Damush, Teresa M.; Medicine, School of Medicine
    Background: To evaluate quality improvement sustainment for Transient Ischemic Attack (TIA) and identify factors influencing sustainment, which is a challenge for Learning Healthcare Systems. Methods: Mixed methods were used to assess changes in care quality across periods (baseline, implementation, sustainment) and identify factors promoting or hindering sustainment of care quality. PREVENT was a stepped-wedge trial at six US Department of Veterans Affairs implementation sites and 36 control sites (August 2015-September 2019). Quality of care was measured by the without-fail rate: proportion of TIA patients who received all of the care for which they were eligible among brain imaging, carotid artery imaging, neurology consultation, hypertension control, anticoagulation for atrial fibrillation, antithrombotics, and high/moderate potency statins. Key informant interviews were used to identify factors associated with sustainment. Results: The without-fail rate at PREVENT sites improved from 36.7% (baseline, 58/158) to 54.0% (implementation, 95/176) and settled at 48.3% (sustainment, 56/116). At control sites, the without-fail rate improved from 38.6% (baseline, 345/893) to 41.8% (implementation, 363/869) and remained at 43.0% (sustainment, 293/681). After adjustment, no statistically significant difference in sustainment quality between intervention and control sites was identified. Among PREVENT facilities, the without-fail rate improved ≥2% at 3 sites, declined ≥2% at two sites, and remained unchanged at one site during sustainment. Factors promoting sustainment were planning, motivation to sustain, integration of processes into routine practice, leadership engagement, and establishing systems for reflecting and evaluating on performance data. The only factor that was sufficient for improving quality of care during sustainment was the presence of a champion with plans for sustainment. Challenges during sustainment included competing demands, low volume, and potential problems with medical coding impairing use of performance data. Four factors were sufficient for declining quality of care during sustainment: low motivation, champion inactivity, no reflecting and evaluating on performance data, and absence of leadership engagement. Conclusions: Although the intervention improved care quality during implementation; performance during sustainment was heterogeneous across intervention sites and not different from control sites. Learning Healthcare Systems seeking to sustain evidence-based practices should embed processes within routine care and establish systems for reviewing and reflecting upon performance.
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    The Perils of a "My Work Here is Done" perspective: a mixed methods evaluation of sustainment of an evidence-based intervention for transient ischemic attack
    (Springer, 2022-07-04) Bravata, Dawn M.; Miech, Edward J.; Myers, Laura J.; Perkins, Anthony J.; Zhang, Ying; Rattray, Nicholas A.; Baird, Sean A.; Penney , Lauren S.; Austin , Curt; Damush, Teresa M.; Neurology, School of Medicine
    Background To evaluate quality improvement sustainment for Transient Ischemic Attack (TIA) and identify factors influencing sustainment, which is a challenge for Learning Healthcare Systems. Methods Mixed methods were used to assess changes in care quality across periods (baseline, implementation, sustainment) and identify factors promoting or hindering sustainment of care quality. PREVENT was a stepped-wedge trial at six US Department of Veterans Affairs implementation sites and 36 control sites (August 2015—September 2019). Quality of care was measured by the without-fail rate: proportion of TIA patients who received all of the care for which they were eligible among brain imaging, carotid artery imaging, neurology consultation, hypertension control, anticoagulation for atrial fibrillation, antithrombotics, and high/moderate potency statins. Key informant interviews were used to identify factors associated with sustainment. Results The without-fail rate at PREVENT sites improved from 36.7% (baseline, 58/158) to 54.0% (implementation, 95/176) and settled at 48.3% (sustainment, 56/116). At control sites, the without-fail rate improved from 38.6% (baseline, 345/893) to 41.8% (implementation, 363/869) and remained at 43.0% (sustainment, 293/681). After adjustment, no statistically significant difference in sustainment quality between intervention and control sites was identified. Among PREVENT facilities, the without-fail rate improved ≥2% at 3 sites, declined ≥2% at two sites, and remained unchanged at one site during sustainment. Factors promoting sustainment were planning, motivation to sustain, integration of processes into routine practice, leadership engagement, and establishing systems for reflecting and evaluating on performance data. The only factor that was sufficient for improving quality of care during sustainment was the presence of a champion with plans for sustainment. Challenges during sustainment included competing demands, low volume, and potential problems with medical coding impairing use of performance data. Four factors were sufficient for declining quality of care during sustainment: low motivation, champion inactivity, no reflecting and evaluating on performance data, and absence of leadership engagement. Conclusions Although the intervention improved care quality during implementation; performance during sustainment was heterogeneous across intervention sites and not different from control sites. Learning Healthcare Systems seeking to sustain evidence-based practices should embed processes within routine care and establish systems for reviewing and reflecting upon performance.