Implementing a patient centered medical home in the Veterans health administration: Perspectives of primary care providers

Solimeo, Samantha L.; Stewart, Kenda R.; Stewart, Gregory; Rosenthal, Gary E.

doi:10.1016/j.hjdsi.2014.07.004

Cited by 11 publications

(12 citation statements)

References 18 publications

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“…The process of reorganizing and tailoring PACT for women Veterans requires meaningful and continual engagement of stakeholders in order to be successful and sustained [14,15]. Studies of PACT implementation have found that "vertically aligned expectations," i.e., clearly articulated leadership support and engagement throughout an organizational hierarchy, are critical to provider performance in this medical home model [16]. In a highly hierarchical organization such as VHA, multilevel stakeholder engagement means engagement of leadership from the regional level to facility and service-line leadership, to clinic-level leadership and providers delivering care to women Veterans [2].…”

Section: Discussionmentioning

confidence: 99%

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

Hamilton

Brunner

Cain

et al. 2017

Behav. Med. Pract. Policy Res.

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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.

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Section: Discussionmentioning

confidence: 99%

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

Hamilton

Brunner

Cain

et al. 2017

Behav. Med. Pract. Policy Res.

View full text Add to dashboard Cite

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“…As the parallel component within a convergent mixed methods design, qualitative data were drawn from participant interviews conducted as part of a larger study of VHA teams. Data from these interviews have been previously published in medical studies describing specific role experiences within VHA teams (Patterson et al, 2015;Solimeo, Ono, Stewart, Lampman, Rosenthal, & Stewart, 2017;Solimeo, Stewart, Stewart, & Rosenthal, 2014;Stewart et al, 2015;True et al, 2014). These role experiences have been published in the medical literature as predominantly descriptive, atheoretical reports.…”

Section: Methods and Analysismentioning

confidence: 99%

Those with the Most Find It Hardest to Share: Exploring Leader Resistance to the Implementation of Team-based Empowerment

Stewart

Astrove

Reeves

et al. 2017

AMJ

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We use a convergent parallel mixed methods approach to explore barriers to the successful implementation of a team-based empowerment initiative within the Veterans Health Administration. Although previous research has suggested that leaders often actively obstruct empowerment initiatives, little is known about the reasons behind and effects of such hindering. Using a longitudinal quasi-experimental design, we support a hypothesis that higher-status physician leaders are less successful than lower-status nonphysician leaders in implementing team-based empowerment. In parallel, we analyze qualitative data obtained through interviews conducted during early months of the teambased empowerment initiative to identify common themes for why and how leaders facilitated or obstructed implementation. Leader identity work and leader delegation were identified as themes explaining (1) why higher-status leaders struggled with the new empowering role and (2) how specific leader actions either facilitated or inhibited sharing of tasks and leadership. Results suggest that team-based empowerment creates a status threat for high-status leaders who then struggle to protect their old identity as someone with distinct professional capabilities, which in turn leads to improper delegation behavior. Therefore, in order for team-based empowerment to succeed, leaders may need to change their perceptions of who they are before they will change what they do.

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“…This descriptive, qualitative study comes out of a mixed methods formative evaluation that: examined barriers to team formation and function and supported regional implementation through formative evaluation. Detailed description of the larger evaluation and interview guide development are reported elsewhere (11). Briefly, interview questions were informed by: a review of medical home implementation literature; data collected at PACT training sessions; and the evidence gap pertaining to team function, inter-and intra-professional role clarity and delegation, and cultures of practice.…”

Section: Methodsmentioning

confidence: 99%

“…Briefly, interview questions were informed by: a review of medical home implementation literature; data collected at PACT training sessions; and the evidence gap pertaining to team function, inter-and intra-professional role clarity and delegation, and cultures of practice. Nurses were asked to discuss their job satisfaction; team function and development; role negotiation, and perceived barriers to PACT implementation (11,12). In this manuscript we report our analysis of qualitative interview data collected from PACT RNs and LPNs as part of the larger study of barriers to PACT implementation.…”

Section: Methodsmentioning

confidence: 99%

Implications of the Patient-Centered Medical Home for Nursing Practice

Stewart

Lampman

et al. 2015

JONA: The Journal of Nursing Administration

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Implementing a patient centered medical home in the Veterans health administration: Perspectives of primary care providers

Cited by 11 publications

References 18 publications

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

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

Those with the Most Find It Hardest to Share: Exploring Leader Resistance to the Implementation of Team-based Empowerment

Implications of the Patient-Centered Medical Home for Nursing Practice

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