The Role of Management Support in Implementing Innovative Clinical Practices Carol VanDeusen Lukas,...

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

Center for Organization, Leadership and Management Research 2

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?

3Center for Organization, Leadership and Management Research

Conceptual Model of Management Support for

Innovation Implementation

Organizational support

Personal leadership support

Implementation climate: o Problem recognition

Implementation policies and procedures: o Communication & training o Team collect, review data o Performance feedback

Innovation implementation

Based on Klein K, Conn AB, Sorra JS. Implementing computerized technology: an organizational analysis. J Applied Psych. 2001, 86(5)


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


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


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


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

8Center for Organization, Leadership and Management Research

Conceptual Model of Management Support for Innovation

Implementation

Organizational support

Personal leadership commitment

Implementation climate: o Problem recognition

Implementation policies and procedures: o Communication & training o Team collect, review data o Performance feedback

Innovation implementation

Based on Klein K, Conn AB, Sorra JS. Implementing computerized technology: an organizational analysis. J Applied Psych. 2001, 86(5)


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


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


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


Measures of Extent of Implementation

Clinic Area Proportion of Full Implementation

(Source: Facility POC matrix)

Extent 10 Key Principles of ACA Have Been Implemented*

(Source: Staff Survey)

Standardized

Composite Measure

Primary Care 63% 2.87 49.62

Audiology 66% 3.36 52.55

Cardiology 66% 2.89 50.25

Eye Care 62% 3.08 50.6

Orthopedics 59% 2.81 49.54

Urology 65% 2.90 50.38

Overall 64% 2.87

*Single survey item asking with a five-point response scale ranging from 1=”not at all” to 5=”to a great extent.”


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


Regression analysis for path 1:

Step 1 Personal leadership support .36** R-squared .13 F 11.04

Step 2 Problem recognition NS R-squared change NS F NS

Overall model Overall R-squared .13 Adjusted R-squared .12 F(1, 74) 11.04**


Regression analysis for path 2:

Step 1 Organizational support .37** R-squared .11 F 9.49*

Step 2 Communication & training .45*** Team collect, review data NS Performance feedback -.22* R-squared change .23 F 20.45**

Overall model Overall R-squared .35 Adjusted R-squared .32 F(3, 72) 12.80***


Regression analysis for combined model:

Step 1 Organizational support .37** Personal leadership support NS Communication & training .45*** Team collect, review data NS Performance feedback -.22* Problem recognition NS Overall model R-squared .35 Adjusted R-squared .32 F(3,72) 12.80***


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


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?

The Role of Management Support in Implementing Innovative Clinical Practices Carol VanDeusen Lukas,...

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