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Lean management is a strategy for improving health care experiences of patients. While best practices for engaging patients in quality improvement have solidified in recent years, few reports specifically address patient engagement in Lean activities. This study examines the benefits and challenges of incorporating patient engagement strategies into the Veterans Health Administration's (VA) Lean transformation.: We conducted a multisite, mixed-methods evaluation of Lean deployment at 10 VA medical facilities, including 227 semistructured interviews with stakeholders, including patients.Interviewees noted that a patient-engaged Lean approach is mutually beneficial to patients and health care employees. Benefits included understanding the veteran's point of view, uncovering inefficient aspects of care processes, improved employee participation in Lean events, increased transparency, and improved reputation for the organization. Challenges included a need for focused time and resources to optimize veteran participation, difficulty recruiting a diverse group of veteran stakeholders, and a lack of specific instructions to encourage meaningful participation of veterans.As the first study to focus on patient engagement in Lean transformation efforts at the VA, this study highlights ways to effectively partner with patients in Lean-based improvement efforts. Lessons learned may also help optimize patient input into quality improvement more generally.

Background The Veterans Health Administration piloted a nationwide Lean Enterprise Transformation program to optimize delivery of services to patients for high value care. Purpose Barriers and facilitators to Lean implementation were evaluated. Methods Guided by the Lean Enterprise Transformation evaluation model, 268 interviews were conducted, with stakeholders across 10 Veterans Health Administration medical centers. Interview transcripts were analyzed using thematic analysis techniques. Results Supporting the utility of the model, facilitators and barriers to Lean implementation were found in each of the Lean Enterprise Transformation evaluation model domains: (a) impetus to transform, (b) leadership commitment to quality, (c) improvement initiatives, (d) alignment across the organization, (e) integration across internal boundaries, (f) communication, (g) capability development, (h) informed decision making, (i) patient engagement, and (j) organization culture. In addition, three emergent themes were identified: staff engagement, sufficient staffing, and use of Lean experts (senseis). Conclusions Effective implementation required staff engagement, strategic planning, proper scoping and pacing, deliberate coaching, and accountability structures. Visible, stable leadership drove Lean when leaders articulated a clear impetus to change, aligned goals within the facility, and supported middle management. Reliable data and metrics provided support for and evidence of successful change. Strategic early planning with continual reassessment translated into focused and sustained Lean implementation. Practice implications Prominent best practices identified include (a) reward participants by broadcasting Lean successes; (b) provide time and resources for participation in Lean activities; (c) avoid overscoping projects; (d) select metrics that closely align with improvement processes; and (e) invest in coaches, informal champions, process improvement staff, and senior leadership to promote staff engagement and minimize turnover.

Precision medicine promises to improve patient outcomes, but much is unknown about its adoption within health-care systems. A comprehensive implementation plan is needed to realize its benefits. We convened 80 stakeholders for agenda setting to inform precision medicine policy, delivery, and research. Conference proceedings were audio-recorded, transcribed, and thematically analyzed. We mapped themes representing opportunities, challenges, and implementation strategies to a logic model, and two implementation science frameworks provided context. The logic model components included inputs: precision medicine infrastructure (clinical, research, and information technology), big data (from data sources to analytics), and resources (e.g., workforce and funding); activities: precision medicine research, practice, and education; outputs: precision medicine diagnosis; outcomes: personal utility, clinical utility, and health-care utilization; and impacts: precision medicine value, equity and access, and economic indicators. Precision medicine implementation challenges include evidence gaps demonstrating precision medicine utility, an unprepared workforce, the need to improve precision medicine access and reduce variation, and uncertain impacts on health-care utilization. Opportunities include integrated health-care systems, partnerships, and data analytics to support clinical decisions. Examples of implementation strategies to promote precision medicine are: changing record systems, data warehousing techniques, centralized technical assistance, and engaging consumers. We developed a theory-based, context-specific logic model that can be used by health-care organizations to facilitate precision medicine implementation.

Telehealth enables access to genetics clinicians, but impact on care coordination is unknown.To assess care coordination and equity of genetic care delivered by centralized telehealth and traditional genetic care models.This cross-sectional study included patients referred for genetic consultation from 2010 to 2017 with 2 years of follow-up in the US Department of Veterans Affairs (VA) health care system. Patients were excluded if they were referred for research, cytogenetic, or infectious disease testing, or if their care model could not be determined.Genetic care models, which included VA-telehealth (ie, a centralized team of genetic counselors serving VA facilities nationwide), VA-traditional (ie, a regional service by clinical geneticists and genetic counselors), and non-VA care (ie, community care purchased by the VA).Multivariate regression models were used to assess associations between patient and consultation characteristics and the type of genetic care model referral; consultation completion; and having 0, 1, or 2 or more cancer surveillance (eg, colonoscopy) and risk-reducing procedures (eg, bilateral mastectomy) within 2 years following referral.In this study, 24 778 patients with genetics referrals were identified, including 12 671 women (51.1%), 13 193 patients aged 50 years or older (53.2%), 15 639 White patients (63.1%), and 15 438 patients with cancer-related referrals (62.3%). The VA-telehealth model received 14 580 of the 24 778 consultations (58.8%). Asian patients, American Indian or Alaskan Native patients, and Hawaiian or Pacific Islander patients were less likely to be referred to VA-telehealth than White patients (OR, 0.54; 95% CI, 0.35-0.84) compared with the VA-traditional model. Completing consultations was less likely with non-VA care than the VA-traditional model (OR, 0.45; 95% CI, 0.35-0.57); there were no differences in completing consultations between the VA models. Black patients were less likely to complete consultations than White patients (OR, 0.84; 95% CI, 0.76-0.93), but only if referred to the VA-telehealth model. Patients were more likely to have multiple cancer preventive procedures if they completed their consultations (OR, 1.55; 95% CI, 1.40-1.72) but only if their consultations were completed with the VA-traditional model.In this cross-sectional study, the VA-telehealth model was associated with improved access to genetics clinicians but also with exacerbated health care disparities and hindered care coordination. Addressing structural barriers and the needs and preferences of vulnerable subpopulations may complement the centralized telehealth approach, improve care coordination, and help mitigate health care disparities.

To assess the value of genetic testing from the perspective of the Department of Veterans Affairs (VA) clinical leadership. We administered an Internet-based survey to VA clinical leaders nationwide. Respondents rated the value (on a 5-point scale) of each of six possible reasons for genetic testing. Bivariate and linear regressions identified associations between value ratings and environmental, organizational, provider, patient, and encounter characteristics. Respondents (n = 353; 63% response rate) represented 92% of VA medical centers. Tests that inform clinical management had the highest value rating (58.6%), followed by tests that inform disease prevention (56.4%), reproductive options (50.1%), life planning (43.9%), and a suspected (39.9%) or established (32.3%) diagnosis. Factors positively associated with high value included a culture that fosters adoption of genomics, specialist versus primary care provider, genetic tests available on laboratory menus, availability of genetic testing guidelines, clinicians knowing when to request genetics referrals, and availability of genetics professionals. Our results demonstrate the varied value of genetic testing from the perspective of clinical leadership within a health-care system. Engaging organizational leadership in understanding the various reasons for genetic testing and its value beyond clinical utility may increase adoption of genetic tests to support patient-centered care. Genet Med advance online publication 15 December 2016

The Veterans Health Administration piloted a nationwide Lean Enterprise Transformation program to optimize delivery of services to patients for high value care.Barriers and facilitators to Lean implementation were evaluated.Guided by the Lean Enterprise Transformation evaluation model, 268 interviews were conducted, with stakeholders across 10 Veterans Health Administration medical centers. Interview transcripts were analyzed using thematic analysis techniques.Supporting the utility of the model, facilitators and barriers to Lean implementation were found in each of the Lean Enterprise Transformation evaluation model domains: (a) impetus to transform, (b) leadership commitment to quality, (c) improvement initiatives, (d) alignment across the organization, (e) integration across internal boundaries, (f) communication, (g) capability development, (h) informed decision making, (i) patient engagement, and (j) organization culture. In addition, three emergent themes were identified: staff engagement, sufficient staffing, and use of Lean experts (senseis).Effective implementation required staff engagement, strategic planning, proper scoping and pacing, deliberate coaching, and accountability structures. Visible, stable leadership drove Lean when leaders articulated a clear impetus to change, aligned goals within the facility, and supported middle management. Reliable data and metrics provided support for and evidence of successful change. Strategic early planning with continual reassessment translated into focused and sustained Lean implementation.Prominent best practices identified include (a) reward participants by broadcasting Lean successes; (b) provide time and resources for participation in Lean activities; (c) avoid overscoping projects; (d) select metrics that closely align with improvement processes; and (e) invest in coaches, informal champions, process improvement staff, and senior leadership to promote staff engagement and minimize turnover.

Robust evidence about the value of clinical genomic interventions (CGIs), such as genetic/genomic testing or clinical genetic evaluation, is limited. We obtained stakeholders’ perspectives on outcomes from CGIs to help inform their value. We used an adapted Delphi expert panel process. Two anonymous survey rounds assessed the value of 44 CGI outcomes and whether a third party should pay for them, with discussion in between rounds. Sixty-six panelists responded to the first-round survey and 60 to the second. Policy-makers/payers gave the lowest ratings for value and researchers gave the highest. Patients/consumers had the most uncertainty about value and payment by a third party. Uncertainty about value was observed when evidence of proven health benefit was lacking, potential harms outweighed benefits for reproductive outcomes, and outcomes had only personal utility for individuals or family members. Agreement about outcomes for which a third party should not pay included prevention through surgery with unproven health benefits, establishing ancestry, parental consanguinity, and paternity. Research is needed to understand factors contributing to uncertainty and stakeholder differences about the value of CGI outcomes. Reaching consensus will accelerate the creation of metrics to generate the evidence needed to inform value and guide policies that promote availability, uptake, and coverage of CGIs.

Precision medicine promises to improve patient outcomes, but much is unknown about its adoption within health-care systems. A comprehensive implementation plan is needed to realize its benefits.We convened 80 stakeholders for agenda setting to inform precision medicine policy, delivery, and research. Conference proceedings were audio-recorded, transcribed, and thematically analyzed. We mapped themes representing opportunities, challenges, and implementation strategies to a logic model, and two implementation science frameworks provided context.The logic model components included inputs: precision medicine infrastructure (clinical, research, and information technology), big data (from data sources to analytics), and resources (e.g., workforce and funding); activities: precision medicine research, practice, and education; outputs: precision medicine diagnosis; outcomes: personal utility, clinical utility, and health-care utilization; and impacts: precision medicine value, equity and access, and economic indicators. Precision medicine implementation challenges include evidence gaps demonstrating precision medicine utility, an unprepared workforce, the need to improve precision medicine access and reduce variation, and uncertain impacts on health-care utilization. Opportunities include integrated health-care systems, partnerships, and data analytics to support clinical decisions. Examples of implementation strategies to promote precision medicine are: changing record systems, data warehousing techniques, centralized technical assistance, and engaging consumers.We developed a theory-based, context-specific logic model that can be used by health-care organizations to facilitate precision medicine implementation.

Adoption and implementation of evidence-based genetic and genomic medicine have been slow. We describe a methodology for identifying the influence of organizational factors on adoption and implementation of these services in health-care organizations.We illustrate a three-component, mixed-methods health services research approach, including expert panels, qualitative interviews with key informants, and quantitative surveys completed by key informants.This research approach yielded a baseline assessment of existing genetic health-care models in the Veterans Health Administration and identified organizational barriers to and facilitators of adoption. In aggregate, the panel and key informant strategies created a communication network of relevant organizational stakeholders and a detailed foundation of organizational knowledge from which to design tools and models for implementation-level genetic/genomic translation.Expert panel and key informant strategies can be used to create a backdrop of stakeholder involvement and baseline organizational knowledge within which to plan translation research and to inform strategic planning and policies for adoption and implementation of genetic services in health-care organizations.

To characterize the delivery of genetic consultative services for adults, we examined the prevalence and organizational determinants of genetic consult availability and the organization of these services in the Veterans Health Administration. We conducted a Web-based survey of Veterans Health Administration clinical leaders. We summarized facility characteristics using descriptive statistics. Multivariate logistic regression assessed associations between organizational characteristics and consult availability. We received 353 survey responses from key informants representing 141 Veterans Affairs Medical Centers. Clinicians could obtain genetic consults at 110 (78%) Veterans Affairs Medical Centers. Cancer genetic and neurogenetic consults were most common. Academic affiliation (odds ratio = 3.0; 95% confidence interval: 1.1–8.6) and provider education about genetics (odds ratio = 2.9; 95% confidence interval: 1.1–7.8) were significantly associated with consult availability. The traditional model of multidisciplinary specialty clinics or coordinated services between geneticists and other providers was most prevalent, although variability in the organization of these services was described, with consults available on-site, at another Veterans Affairs Medical Center, via telegenetics, or at non–Veterans Health Administration facilities. The emerging model of nongeneticists integrating genetics into their practices was also reported, with considerable variability by specialty. Both traditional and emerging models for genetic consultation are available in the Veterans Health Administration; however, there is variability in service organization that could influence quality of care. Genet Med 16 8, 609–619.

Objectives Health care organizations have used different strategies to implement quality improvement (QI) programs but with only mixed success in implementing and spreading QI organization-wide. This suggests that certain organizational strategies may be more successful than others in developing an organization's improvement capability. To investigate this, our study examined how the primary focus of grant-funded QI efforts relates to (1) key measures of grant success and (2) organization-level measures of success in QI and organizational learning. Methods Using a mixed-methods design, we conducted one-way analyses of variance to relate Veterans Affairs administrative survey data to data collected as part of a 3.5-year evaluation of 29 health care organization grant recipients. We then analyzed qualitative evidence from the evaluation to explain our results. Results We found that hospitals that focused on developing organizational infrastructure to support QI implementation compared with those that focused on training or conducting projects rated highest (at α = .05) on all 4 evaluation measures of grant success and all 3 systemwide survey measures of QI and organizational learning success. Conclusions This study adds to the literature on developing organizational improvement capability and has practical implications for health care leaders. Focusing on either projects or staff training in isolation has limited value. Organizations are more likely to achieve systemwide transformation of improvement capability if their strategy emphasizes developing or strengthening organizational systems, structures, or processes to support direct improvement efforts.

As healthcare reimbursement is increasingly tied to value-of-service, it is critical for the genetic counselor (GC) profession to demonstrate the value added by GCs through outcomes research. We conducted a rapid systematic literature review to identify outcomes of genetic counseling. Web of Science (including PubMed) and CINAHL databases were systematically searched to identify articles meeting the following criteria: 1) measures were assessed before and after genetic counseling (pre-post design) or comparisons were made between a GC group vs. a non-GC group (comparative cohort design); 2) genetic counseling outcomes could be assessed independently of genetic testing outcomes, and 3) genetic counseling was conducted by masters-level genetic counselors, or non-physician providers. Twenty-three papers met the inclusion criteria. The majority of studies were in the cancer genetic setting and the most commonly measured outcomes included knowledge, anxiety or distress, satisfaction, perceived risk, genetic testing (intentions or receipt), health behaviors, and decisional conflict. Results suggest that genetic counseling can lead to increased knowledge, perceived personal control, positive health behaviors, and improved risk perception accuracy as well as decreases in anxiety, cancer-related worry, and decisional conflict. However, further studies are needed to evaluate a wider array of outcomes in more diverse genetic counseling settings.

There are currently multiple paths through which genetic counselors can acquire advanced knowledge and skills. However, outside of continuing education opportunities, there are few formal training programs designed specifically for the advanced training of genetic counselors. In the genetic counseling profession, there is currently considerable debate about the paths that should be available to attain advanced skills, as well as the skills that might be needed for practice in the future. The Association of Genetic Counseling Program Directors (AGCPD) convened a national committee, the Committee on Advanced Training for Certified Genetic Counselors (CATCGC), to investigate varied paths to post-master's training and career development. The committee began its work by developing three related grids that view career advancement from the viewpoints of the skills needed to advance (skills), ways to obtain these skills (paths), and existing genetic counselor positions that offer career change or advancement (positions). Here we describe previous work related to genetic counselor career advancement, the charge of the CATCGC, our preliminary work in developing a model through which to view genetic counselor advanced training and career advancement opportunities, and our next steps in further developing and disseminating the model.

Objective To identify and characterize patient–provider communication patterns during disclosure of Alzheimer's disease genetic susceptibility test results and to assess whether these patterns reflect differing models of genetic counseling. Methods 262 genetic counseling session audio-recordings were coded using the Roter Interactional Analysis System. Cluster analysis was used to distinguish communication patterns. Bivariate analyses were used to identify characteristics associated with the patterns. Results Three patterns were identified: Biomedical-Provider-Teaching (40%), Biomedical-Patient-Driven (34.4%), and Psychosocial-Patient-Centered (26%). Psychosocial-Patient-Centered and Biomedical-Provider-Teaching sessions included more female participants while the Biomedical-Patient-Driven sessions included more male participants ( p =0.04). Conclusion Communication patterns observed reflected the teaching model primarily, with genetic counseling models less frequently used. The emphasis on biomedical communication may potentially be at the expense of more patient-centered approaches. Practice implications To deliver more patient-centered care, providers may need to better balance the ratio of verbal exchange with their patients, as well as their educational and psychosocial discussions. The delineation of these patterns provides insights into the genetic counseling process that can be used to improve the delivery of genetic counseling care. These results can also be used in future research designed to study the association between patient-centered genetic counseling communication and improved patient outcomes.

If we are to improve the quality of our schools, we must know the facts about them. This is why we need a national census of educational quality, states this writer, who suggests the kind of testing that can give us such a census—one that will check on both minimum competence and excellence.

A Nation at Risk, the 1983 Report of the President's Commission on Excellence in Education, hit a national nerve because it confirmed the diagnosis most Americans had already made, separately, privately, sometimes despairingly, about the "rising tide of mediocrity" in our schools. The Report brought all the separate, private facts together and made them public. A shared experience made public is a powerful force in a democracy. It brought people together and energized them. In state after state, efforts to turn the tide began almost at once, but no one expects instant results. Americans everywhere know that the tide of mediocrity rose for almost two decades. They understand that it will take sustained effort to reverse it. They do not expect to restore excellence overnight, but they do need to know whether we are making progress as a nation, and at what rate. That is why we need a national census of educational quality. A national census of educational quality is no substitute for needed local assessments or for the hosts of other special-purpose assessments that are conducted sporadically in varying parts of the country, but it is no mere summary of them either. Summarizing a collection of partial assessments arranged in a series of discontinuous sequences full of gaps and holes is a slow and uncertain business. By the time the point is clear, much time elapses, and much damage may be done. A national census, a steady monitoring of the overall quality of American education over time based on a national test administered annually to a national sample of students could and should shorten our response time