Engaging multilevel stakeholders in an implementation trial of evidence-based quality improvement in VA women’s health primary care

Abstract

The Veterans Health Administration (VHA) has undertaken primary care transformation based on patient-centered medical home (PCMH) tenets. VHA PCMH models are designed for the predominantly male Veteran population, and require tailoring to meet women Veterans' needs. We used evidence-based quality improvement (EBQI), a stakeholder-driven implementation strategy, in a cluster randomized controlled trial across 12 sites (eight EBQI, four control) that are members of a Practice-Based Research Network. EBQI involves engaging multilevel, inter-professional leaders and staff as stakeholders in reviewing evidence and setting QI priorities. The goal of this analysis was to examine processes of engaging stakeholders in early implementation of EBQI to tailor VHA's medical home for women. Four inter-professional regional stakeholder planning meetings were conducted; these meetings engaged stakeholders by providing regional data about gender disparities in Veterans' care experiences. Subsequent to each meeting, qualitative interviews were conducted with 87 key stakeholders (leaders and staff). Stakeholders were asked to describe QI efforts and the use of data to change aspects of care, including women's health care. Interview transcripts were summarized and coded using a hybrid deductive/inductive analytic approach. The presentation of regional-level data about gender disparities resulted in heightened awareness and stakeholder buy-in and decision-making related to women's health-focused QI. Interviews revealed that stakeholders were familiar with QI, with regional and facility leaders aware of inter-disciplinary committees and efforts to foster organizational change, including PCMH transformation. These efforts did not typically focus on women's health, though some informal efforts had been undertaken. Barriers to engaging in QI included lack of communication across clinical service lines, fluidity in staffing, and lack of protected time. Inter-professional, multilevel stakeholders need to be engaged in implementation early, with data and discussion that convey the importance and relevance of a new initiative. Stakeholder perspectives on institutional norms (e.g., gender norms) and readiness for population-specific QI are useful drivers of clinical initiatives designed to transform care for clinical subpopulations.

The science of stakeholder engagement in research: classification, implementation, and evaluation

“…Stakeholders must be able to access and review the data with sufficient time to critique and perhaps add to the data, as well discuss project purpose. We found it difficult to evaluate the process used by Hamilton et al given the brief discussion on this topic [15].…”

“…A key aspect of CBPR is the engagement of appropriate stakeholders, in all phases of the work and in a collaborative process that recognizes the strengths and assets of partners. Hamilton et al discuss the process used for stakeholder engagement in evidence-based quality improvement research [15]; however, there are aspects of the process that are unclear and other components that appear to be more limited in implementation than is optimal, with implementation falling somewhere between cooperation and collaboration in our classification scheme. As demonstrated in the work of Hamilton et al, there are four key constructs to consider when engaging multilevel stakeholders in the research process: (1) commitment of stakeholders to the process and the goals of the project; (2) capacity of stakeholders to participate in the process and engage in research activities; (3) commitment of researchers to meaningfully engaged stakeholders; and (4) trust among researchers and stakeholders [15].…”

“…Because the process is iterative and subject to change, flexibility is required for all stakeholders. Hamilton et al do not fully describe how resources, such as time, were negotiated for and among EBQI teams [15].…”

“…What was clear was that some teams functioned well and others struggled. The level of detail provided only allows us to speculate on the reasons for the differences [15]. It is possible that without clear goals, assignment of responsibility and periodic communication, interest, and effort may have waned.…”

“…We commend the authors for their use of evidence-based data driven approaches to develop shared priorities with the understanding that targeted initiatives work better than global initiatives [15]. However, we encourage them and others to take this work further to include meaningful engagement of patients (or the community/ population impacted by the proposed work), including efforts for the development of processes for continued communication, decision-making, shared vision, change management, and implementation (at initiation), which are the key elements of an engaged processes.…”