1. The Role of Management Support in Implementing Innovative Clinical Practices Carol VanDeusen Lukas, EdD Mark M. Meterko, PhD David Mohr, PhD Marjorie Nealon Seibert, MBA Center for Organization, Leadership and Management Research Health Services Research and Development Service Office of Research and Development Department of Veterans Affairs June 2005

2. Center for Organization, Leadership and Management Research2 Research questions: Leadership is widely seen as an important factor in the implementation of innovative clinical practices –Implementation = putting into practice How does leadership – or more broadly, management support – affect implementation? –What aspects important? –Through what paths influence?

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4. 4 Research context: Advanced Clinic Access in VA In 2000, the Department of Veterans Affairs (VA) launched a national initiative to diffuse Advanced Clinic Access (ACA) in VA Diffusion focused on six target clinic areas across VA to implement ACA: –Primary care — Audiology –Cardiology — Eye care –Orthopedics — Urology

5. Center for Organization, Leadership and Management Research5 ACA 10 key change principles: Practices for managing clinics so patients have access to medical care when they want it: –Work down the backlog –Reduce demand –Understand supply and demand –Reduce appointment types –Plan for contingencies –Manage the constraint –Optimize the care team –Synchronize patient, provider and information –Predict and anticipate patient needs at time of appointment –Optimize rooms and equipment

6. Center for Organization, Leadership and Management Research6 Infrastructure to support ACA diffusion: To support diffusion, VA built an infrastructure that includes: –A national steering committee –A national clinical director –A person designated to lead ACA in every VA network, or VISN, and most medical centers (called points of contact or POCs) –A network of physician coaches to provide peer networks of advocacy and support. In the end, ACA implementation is local –Encouraged and supported by not mandated

7. Center for Organization, Leadership and Management Research7 Study design and data sources: Design –Observational study of 78 VA medical centers sampled to represent variation in appointment wait time and size in July 2002 Data sources –Structured telephone interviews with facility ACA points of contact (POCs) in 76 of 78 study VA medical centers in February-April 2003 –Reports of implementation of ACA 10 key changes by POCs in February-May 2003 –Mailed survey completed by 3870 staff (42%) in the 78 study medical centers during July-August 2003 Focus here on primary care

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9. 9 Predictor variables: Personal leadership support to clinic staff (7-item scale, alpha=.93) E.g., agreement that – Senior management talks about ACA – Senior management reviews our progress in making change – Leadership in my clinic area gives high priority to reducing wait time Organizational support for ACA (8-item scale, alpha=.78) E.g., – Managers are held accountable for ACA performance measures – Local ACA champions have been explicitly designated for clinic areas – Local resources have been used to directly support ACA – Facility operations and infrastructure have been improved for ACA

10. Center for Organization, Leadership and Management Research10 Mediating variables: Problem recognition (2-item scale, alpha=.84) –Agreement that reducing wait time is important goal and awareness that effort is underway to reduce Team review, collect data (3-item scale, alpha=.88) –Team uses data to test changes and track progress, and believes data accurate Communication & training (6-item scale, alpha=.85) E.g., –Have internal collaboratives, consultation from ACA experts, resource materials, discussion at meetings Performance feedback (2-item scale, alpha=.66) –Reports presented to clinic staff; hot spot reports used

11. Center for Organization, Leadership and Management Research11 Dependent variable: Proportion of full implementation –ACA point of contact matrix –By target clinic area Extent 10 key change principles implemented –1-5 scale on staff survey –By target clinic area Composite measure

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13. Center for Organization, Leadership and Management Research13 Analysis strategy: Multiple regression analyses to identify factors affecting ACA implementation: –Separate stepwise regressions for two hypothesized paths of influence –Simultaneous regression of all variables in single model

14. Center for Organization, Leadership and Management Research14 Regression analysis for path 1:

15. Center for Organization, Leadership and Management Research15 Regression analysis for path 2:

16. Center for Organization, Leadership and Management Research16 Regression analysis for combined model:

17. Center for Organization, Leadership and Management Research17 Summary and conclusions: Considered separately, two aspects of management support were significantly related to ACA implementation But when combined, personal leadership support drops out Suggests that for successful implementation of clinical innovations, –Support by leadership and problem recognition by staff is not enough –More concrete practical organizational support and implementation tools are needed

18. Center for Organization, Leadership and Management Research18 Next research steps: Measuring implementation of complex interventions Test model in other settings Investigate factors that dropped out as significant predictors/ mediators: –Personal leadership support –Problem recognition –Team review, collect data Are there situations in which management support is not crucial to successful implementation?