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Arlene A Schmid1,2,3,4, John R Kapoor5, Edward J Miech1, Deborah Kuehn6, Mary I Dallas7, Robert D Kerns8, Albert C Lo9,10, John Concato11,12, Michael S Phipps13,14,15, Cody D Couch13, Eileen Moran13, Linda S Williams1,2,3,16, Layne A Goble17,18, Dawn M Bravata1,2,3,191Department of Veteran Affairs (VA) Health Services Research & Development (HSR&D) Center of Excellence on Implementing Evidence-Based Practice (CIEBP), 2VA HSR&D Stroke Quality Enhancement Research Initiative (QUERI) Program, Richard L Roudebush VA Medical Center, Indianapolis, IN, USA; 3Regenstrief Institute, Indianapolis, IN, USA; 4Department of Occupational Therapy, Indiana University, IN, USA; 5Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL, USA; 6Nursing Service, 7Physical Medicine and Rehabilitation Service, 8Psychology Service, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA; 9Departments of Neurology, Community Health, and Engineering at Brown University, Providence, RI, USA; 10Providence Veterans Administration Medical Center, Providence, RI, USA; 11Clinical Epidemiology Research Center (CERC), Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA; 12Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA; 13Department of Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA; 14Robert Wood Johnson Clinical Scholars Program, 15Department of Neurology, Yale University School of Medicine, New Haven, CT, USA; 16Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA; 17Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA; 18Veterans Administration Medical Center, Charleston, SC, USA; 19Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN, USABackground: Managing cerebrovascular risk factors is complex and difficult. The objective of this program evaluation was to assess the effectiveness of an outpatient Multidisciplinary Stroke Clinic model for the clinical management of veterans with cerebrovascular disease or cerebrovascular risk factors.Methods: The Multidisciplinary Stroke Clinic provided care to veterans with cerebrovascular disease during a one-half day clinic visit with interdisciplinary evaluations and feedback from nursing, health psychology, rehabilitation medicine, internal medicine, and neurology. We conducted a program evaluation of the clinic by assessing clinical care outcomes, patient satisfaction, provider satisfaction, and costs.Results: We evaluated the care and outcomes of the first consecutive 162 patients who were cared for in the clinic. Patients had as many as six clinic visits. Systolic and diastolic blood pressure decreased: 137.2 ± 22.0 mm Hg versus 128.6 ± 19.8 mm Hg, P = 0.007 and 77.9 ± 14.8 mm Hg versus 72.0 ± 10.2 mm Hg, P = 0.004, respectively as did low-density lipoprotein (LDL)-cholesterol (101.9 ± 23.1 mg/dL versus 80.6 ± 25.0 mg/dL, P = 0.001). All patients had at least one major change recommended in their care management. Both patients and providers reported high satisfaction levels with the clinic. Veterans with stroke who were cared for in the clinic had similar or lower costs than veterans with stroke who were cared for elsewhere.Conclusion: A Multidisciplinary Stroke Clinic model provides incremental improvement in quality of care for complex patients with cerebrovascular disease at costs that are comparable to usual post-stroke care.Keywords: clinical management of stroke, cost, blood pressure management, clinical outcome

Chronic pain is prevalent, is costly, and exerts an emotional toll on patients and providers. Little is known about chronic pain in veterans of the recent military conflicts in Afghanistan and Iraq (OEF/OIF/OND [Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn] veterans). This study's objective was to ascertain veterans' perceptions of a multicomponent intervention tested in a randomized controlled trial for OEF/OIF/OND veterans with chronic musculoskeletal pain (ESCAPE: Evaluation of Stepped Care for Chronic Pain). Qualitative interviews were conducted with patients in the intervention arm of ESCAPE. Questions related to veterans' experiences with trial components, overall perceptions of the intervention, strengths, and suggestions for improvement. Twenty-six veterans (21% of total intervention patients) participated. Patients were purposefully sampled to include treatment responders (defined as >=30% reduction in pain-related disability or pain severity) and non-responders. Non-completers (completed <50% of the trial) were also sampled. Qualitative analysis was guided by grounded theory, using constant comparative methodology. Both responders and non-responders spoke about their evolving understanding of their pain experience during the trial, and how this new understanding helped them to manage their pain more effectively. This evolution is reported under 2 themes: 1) learning to recognize physical and psychosocial factors related to pain; and 2) learning to manage pain through actions and thoughts. PERSPECTIVE: Responders and non-responders both described making connections between their pain and other factors in their lives, and how these connections positively influenced how they managed their pain. Traditional quantitative measures of response to pain interventions may not capture the full benefits that patients report experiencing. [ABSTRACT FROM AUTHOR]

Objective: To evaluate nationwide implementation of a Guidebook designed to standardize safety practices across VA-delivered and VA-purchased care (i.e., Community Care) and identify lessons learned and strategies to improve them., Data Sources and Study Setting: Qualitative data collected from key informants at 18 geographically diverse VA facilities across 17 Veterans Integrated Services Networks (VISNs)., Study Design: We conducted semi-structured interviews from 2019 to 2022 with VISN Patient Safety Officers (PSOs) and VA facility patient safety and quality managers (PSMs and QMs) and VA Facility Community Care (CC) staff to assess lessons learned by examining organizational contextual factors affecting Guidebook implementation based on the Consolidated Framework for Implementation Research (CFIR)., Data Collection/extraction Methods: Interviews were conducted virtually with 45 facility staff and 10 VISN PSOs. Using directed content analysis, we identified CFIR factors affecting implementation. These factors were mapped to the Expert Recommendations for Implementing Change (ERIC) strategy compilation to identify lessons learned that could be useful to our operational partners in improving implementation processes. We met frequently with our partners to discuss findings and plan next steps., Principal Findings: Six CFIR constructs were identified as both facilitators and barriers to Guidebook implementation: (1) planning for implementation; (2) engaging key knowledge holders; (3) available resources; (4) networks and communications; (5) culture; and (6) external policies. The two CFIR constructs that were only barriers included: (1) cosmopolitanism and (2) executing implementation., Conclusions: Our findings suggest several important lessons: (1) engage all collaborators involved in implementation; (2) ensure end-users have opportunities to provide feedback; (3) describe collaborators' purpose and roles/responsibilities clearly at the start; (4) communicate information widely and repeatedly; and (5) identify how multiple high priorities can be synergistic. This evaluation will help our partners and key VA leadership to determine next steps and future strategies for improving Guidebook implementation through collaboration with VA staff., (Published 2024. This article is a U.S. Government work and is in the public domain in the USA.)

Purpose: Evaluations of organizational-level interventions to prevent work-related illness have identified enabling factors, but knowledge of necessary and sufficient conditions for intervention success is needed. The aim was to identify difference-making factors that distinguish intervention groups with and without a positive intervention effect on sickness absence., Methods: An organizational-level intervention designed to decrease sickness absence by providing support from process facilitators was implemented at eight healthcare workplaces in Sweden between 2017 and 2018. We applied coincidence analysis (CNA) to analyze 34 factors and determine which factors were necessary and sufficient for a successful implementation of tailored interventional measures on an organizational level (dichotomous) and reduced sickness absence (trichotomous)., Results: Two factors perfectly explained both the presence and absence of a successful implementation: "a high sense of urgency" and "good anchoring and participation from the strategic management". The presence of either of these factors alone was sufficient for successful implementation, whereas the joint absence of both conditions was necessary and sufficient for the absence of successful implementation and an intervention effect. In addition, high employee participation was both necessary and sufficient for a high intervention effect. For organizations without high employee participation, successful implementation led to a medium-effect size., Conclusions: This study identified participation as a difference-maker in the implementation process. Participation from different stakeholders turned out to be important in different phases. When implementing organizational-level interventions, high participation from both strategic management and employees appears to be crucial in terms of the intervention's effect on sickness absence., (© 2024. The Author(s).)

Background: Increasing community care (CC) use by veterans has introduced new challenges in providing integrated care across the Veterans Health Administration (VHA) and CC. VHA's well-recognized patient safety program has been particularly challenging for CC staff to adopt and implement. To standardize VHA safety practices across both settings, VHA implemented the Patient Safety Guidebook in 2018. The authors compared national- and facility-level trends in VHA and CC safety event reporting post-Guidebook implementation., Methods: In this retrospective study using patient safety event data from VHA's event reporting system (2020-2022), the research team examined trends in patient safety events, adverse events, close calls (near misses), and recovery rates (ratio of close calls to adverse events plus close calls) in VHA and CC using linear regression models to determine whether the average changes in VHA and CC safety events at the national and facility levels per quarter were significant., Results: A total of 499,332 safety events were reported in VHA and CC. Although VHA patient safety event trends were not significant (p > 0.05), there was a significant negative trend for adverse events (p = 0.02) and positive trends for close calls (p = 0.003) and recovery rates (p = 0.004). In CC there were significant negative trends for patient safety events and adverse events (p = 0.02) and a significant positive trend for recovery rates (p = 0.03). There was less variation in VHA than in CC facilities with significant decreases (for example, interquartile ranges in VHA and CC were 0.03 vs. 0.05, respectively)., Conclusion: Fluctuations in different safety events over time were likely due to the disruption of care caused by COVID-19 as well as organizational factors. Notably, the increases in recovery rates reflect less staff focus on harmful events and more attention to close calls (preventable events). Although safety practice adoption from VHA to CC was feasible, additional implementation strategies are needed to sustain standardized safety reporting across settings., (Copyright © 2023 The Joint Commission. Published by Elsevier Inc. All rights reserved.)

Policy implementation is a key component of scaling effective chronic disease prevention and management interventions. Policy can support scale-up by mandating or incentivizing intervention adoption, but enacting a policy is only the first step. Fully implementing a policy designed to facilitate implementation of health interventions often requires a range of accompanying implementation structures, like health IT systems, and implementation strategies, like training. Decision makers need to know what policies can support intervention adoption and how to implement those policies, but to date research on policy implementation is limited and innovative methodological approaches are needed. In December 2021, the Johns Hopkins ALACRITY Center for Health and Longevity in Mental Illness and the Johns Hopkins Center for Mental Health and Addiction Policy convened a forum of research experts to discuss approaches for studying policy implementation. In this report, we summarize the ideas that came out of the forum. First, we describe a motivating example focused on an Affordable Care Act Medicaid health home waiver policy used by some US states to support scale-up of an evidence-based integrated care model shown in clinical trials to improve cardiovascular care for people with serious mental illness. Second, we define key policy implementation components including structures, strategies, and outcomes. Third, we provide an overview of descriptive, predictive and associational, and causal approaches that can be used to study policy implementation. We conclude with discussion of priorities for methodological innovations in policy implementation research, with three key areas identified by forum experts: effect modification methods for making causal inferences about how policies' effects on outcomes vary based on implementation structures/strategies; causal mediation approaches for studying policy implementation mechanisms; and characterizing uncertainty in systems science models. We conclude with discussion of overarching methods considerations for studying policy implementation, including measurement of policy implementation, strategies for studying the role of context in policy implementation, and the importance of considering when establishing causality is the goal of policy implementation research., (© 2023. The Author(s) 2023.)

In 2019, the Indianapolis VA developed a Wellness Clinic in partnership with the Young Men's Christian Associations (YMCA) to comprehensively address Veterans' chronic pain. Our specific aims were twofold: (1) to evaluate the implementation of the Veterans Health Indiana (VHI) Wellness Clinic on patient utilisation and (2) to evaluate patient functioning.We conducted a mixed-methods evaluation, which included the extraction of VA administrative data to identify a patient cohort; the conduct of chart review to extract clinic utilisation, clinical outcomes collected during pain-related healthcare services and comorbidities; and semistructured interviews with Veteran patients who used the VHI Wellness Clinic in different patterns to identify challenges and facilitators to clinic utilisation. We applied configurational analysis to a Veteran sample who had their first visit to the VHI Wellness Clinic in March/April 2019 to pinpoint difference-making factors linked to Veterans' successful participation.The cohort included 312 Veterans (83% male), mean age of 55.4 years. The configurational model included six factors: participation in physical therapy, pain psychology or pain education sessions (22%); presence of any 'no-shows' (57% had 0); history of depression (39%) and clinic referral source (51% self-referred from primary care). The model consisted of four different pathways to successful participation, explaining 60% of cases in the higher-participation group with 86% consistency. Patient outcomes after clinic utilisation demonstrated a significant reduction in self-reported pain and pain catastrophising across time. Moreover, patients reported distance to clinic as both a facilitator and challenge.This mixed-methods analysis identified specific biopsychosocial factors and clinical services directly linked to higher Veteran participation in a new VA-YMCA Wellness Clinic. The VHI Wellness Clinic embedded within a YMCA facility is a feasible and efficacious healthcare delivery model for primary care patients experiencing chronic pain. Additional marketing to clinical providers for referrals and to patients to extend its reach is needed., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

It is well-established in the field of implementation science that the context in which an intervention is delivered can play a crucial role in how well it is implemented. However, less is known about how organizational context or capacity relates to efficacy outcomes, particularly with health promotion interventions delivered outside of healthcare settings. The present study examined whether organizational capacity indicators were linked to key efficacy outcomes in an evidence-based cancer control intervention delivered in 13 African American churches in Maryland. Outcomes included increases in colorectal cancer knowledge and self-report colonoscopy screening behavior from baseline to follow-up. We used Coincidence Analysis to identify features of organizational capacity that uniquely distinguished churches with varying levels of cancer knowledge and screening. Indicators of organizational capacity (e.g., congregation size, prior health promotion experience) were from an existing measure of church organizational capacity for health promotion. A single solution pathway accounted for greater increases in colorectal cancer knowledge over 12 months, a combination of two conditions: conducting 3 or more health promotion activities in the prior 2 years together with not receiving any technical assistance from outside partners in the prior 2 years. A single condition accounted for greater increases in colonoscopy screening over 24 months: churches that had conducted health promotion activities in 1-4 different topical areas in the prior 2 years. Findings highlight aspects of organizational capacity (e.g., prior experience in health promotion) that may facilitate intervention efficacy and can help practitioners identify organizational settings most promising for intervention impact., Competing Interests: Competing and financial interests: The authors declare that they have no competing or financial interests.

Introduction: The Veteran Affairs (VA) Office of Rural Health (ORH) funded the Veterans Health Administration (VHA) National TeleNeurology Program (NTNP) as an Enterprise-Wide Initiative (EWI). NTNP is an innovative healthcare delivery model designed to fill the patient access gap for outpatient neurological care especially for Veterans residing in rural communities. The specific aim was to apply the RE-AIM framework in a pragmatic evaluation of NTNP services., Materials and Methods: We conducted a prospective implementation evaluation. Guided by the pragmatic application of the RE-AIM framework, we conceptualized a mixed-methods evaluation for key metrics: (1) reach into the Veteran patient population assessed as total NTNP new patient consult volume and total NTNP clinical encounters (new and return); (2) effectiveness through configurational analysis of conditions leading to high Veteran satisfaction and referring providers perceived effectiveness; (3) adoption and implementation by VA sites through site staff and NTNP interviews; (4) implementation success through perceived management, implementation barriers, facilitators, and adaptations and through rapid qualitative analysis of multiple stakeholders' assessments; and (5) maintenance of NTNP through monitoring quarterly TeleNeurology consultation volume., Results: NTNP was successfully implemented in 13 VA Medical Centers over 2 years. The total NTNP new patient consult volume in fiscal year 2021 (FY21) was 836 (58% rurally residing); this increased to 1,706 in fiscal year 2022 (FY22) (55% rurally residing). Total (new and follow-up) NTNP clinical encounters were 1,306 in FY21 and 3,730 in FY22. Overall, the sites reported positive experiences with program implementation and perceived that the program was serving Veterans with little access to neurological care. Veterans also reported high satisfaction with the NTNP program. We identified the patient level of perceived excellent teleneurologist-patient communications, reduced need to drive to get care, and that NTNP provided care that the Veteran otherwise could not access as key factors related to high Veteran satisfaction., Conclusions: The VA NTNP demonstrated substantial reach, adoption, effectiveness, implementation success, and maintenance over the first 2 years of the program. The NTNP was highly acceptable to both the clinical providers making the referrals and the Veterans receiving the referred video care. The pragmatic application of the RE-AIM framework to guide implementation evaluations is appropriate, comprehensive, and recommended for future applications., Competing Interests: HM was employed by the Regenstrief Institute, Inc. TM, EM, LM and LW were affiliated scientists with the Regenstrief Institute, Inc. but did not receive any salary or funding for this evaluation. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Damush, Wilkinson, Martin, Miech, Tang, Taylor, Daggy, Bastin, Islam, Myers, Penney, Narechania, Schreiber and Williams.)

Objective: To study factors associated with systolic blood pressure(SBP) control for patients post-discharge from an ischemic stroke or transient ischemic attack(TIA) during the early months of the COVID-19 pandemic compared to pre-pandemic periods within the Veterans Health Administration(VHA)., Materials and Methods: We analyzed retrospective data from patients discharged from Emergency Departments or inpatient admissions after an ischemic stroke or TIA. Cohorts consisted of 2,816 patients during March-September 2020 and 11,900 during the same months in 2017-2019. Outcomes included primary care or neurology clinic visits, recorded blood pressure readings and average blood pressure control in the 90-days post-discharge. Random effect logit models were used to compare clinical characteristics of the cohorts and relationships between patient characteristics and outcomes., Results: The majority (73%) of patients with recorded readings during the COVID-19 period had a mean post-discharge SBP within goal (<140 mmHg); this was slightly lower than the pre-COVID-19 period (78%; p=0.001). Only 38% of the COVID-19 cohort had a recorded SBP in the 90-days post-discharge compared with 83% of patients during the pre-pandemic period (p=0.001). During the pandemic period, 29% did not have follow-up primary care or neurologist visits, and 33% had a phone or video visit without a recorded SBP reading., Conclusions: Patients with an acute cerebrovascular event during the initial COVID-19 period were less likely to have outpatient visits or blood pressure measurements than during the pre-pandemic period; patients with uncontrolled SBP should be targeted for follow-up hypertension management., Competing Interests: Declaration of Competing Interest The authors declare that they have no competing interests, (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Objectives: To understand the impact of the coronavirus disease-2019 pandemic on sleep services within the United States Department of Veterans Affairs using separate surveys from "pre-COVID" and pandemic periods., Methods: Data from a pre-pandemic survey (September to November 2019) were combined with data from a pandemic-period survey (August to November 2020) to Veterans Affairs sleep medicine providers about their local sleep services within 140 Veterans Affairs facilities)., Results: A total of 67 (47.9%) facilities responded to the pandemic online survey. In-lab diagnostic and titration sleep studies were stopped at 91.1% of facilities during the pandemic; 76.5% of facilities resumed diagnostic studies and 60.8% resumed titration studies by the time of the second survey. Half of the facilities suspended home sleep testing; all facilities resumed these services. In-person positive airway pressure clinics were stopped at 76.3% of facilities; 46.7% resumed these clinics. Video telehealth was either available or in development at 86.6% of facilities and was considered a lasting addition to sleep services. Coronavirus disease-2019 transmission precautions occurred at high rates. Sleep personnel experienced high levels of stress, anxiety, fear, and burnout because of the pandemic and in response to unexpected changes in sleep medicine care delivery., Conclusions: Sleep medicine services within the Veterans Affairs evolved during the pandemic with many key services being interrupted, including in-lab studies and in-person positive airway pressure clinics. Expansion and initiation of telehealth sleep services occurred commonly. The pandemic adversely affected sleep medicine personnel as they sought to maintain access to care., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: All authors have read this manuscript and approve of its submission. This work was produced at VA Connecticut Healthcare System, West Haven, CT and Richard L Roudebush VA Medical center in Indianapolis, IN. All authors, except for Dr W Claibe Yarbrough, MD, received salary support from the Addressing Sleep Apnea Post-Stroke/TIA clinical trial (NCT04322162). All authors have no conflicts of interest in the publication of this study., (© The Author(s) 2023.)

Background: Emerging research has demonstrated that organizational efforts at becoming secondary traumatic stress (STS)-informed can improve the overall well-being of the workforce, especially when implementation activity by a champion team is high. Questions remain, however, regarding the mechanisms that enable these improvements., Method: This study uses configurational analysis to determine necessary and sufficient conditions to produce reductions in STS symptoms in workers as well as organizational improvements toward being more STS-informed in a cohort survey of 6,033 professionals working with individuals exposed to trauma representing 52 organizations. The Secondary Traumatic Stress Informed Organizational Assessment (STSI-OA) was used to measure professional's perceptions of how well the unit addressed secondary trauma in the workplace, and the Secondary Traumatic Stress Scale (STSS) assessed traumatic stress symptoms in respondents. Champions' activity was scored using the categories suggested by Shea., Results: For the STSS outcome, either a STSI-OA positive increase of 10 or more points or high levels of champion problem-solving were independently sufficient for an improvement in the outcome. The STSI-OA model had two pathways: high levels of peer engagement via the scaling up of innovations using PDSAs or the combination of facilitation of peer knowledge and skills together with working in a child welfare organization. Either pathway was sufficient by itself to yield the STSI-OA outcome., Conclusions: Identifying and cultivating the champions' use of problem-solving and peer engagement strategies can transform the threat posed by indirect trauma exposure into an opportunity for shared experience and healing., Plain Language Summary: Organizational champions are individuals or teams that strive to promote change within their workplace. These champions are integral to spreading innovative ideas and strategies and creating organization-wide changes ( Powell et al., 2015). However, little is known about the processes or specific strategies that make champions successful. One area in which champions are needed is in improving organizations' response to and understanding of secondary traumatic stress (STS), among those in helping professions that are indirectly exposed to trauma through the traumatic stories of those they work with. In fact, research has shown that organizational efforts to address STS improve the well-being of individual professionals within that organization ( Sprang et al., 2021). The present study sought to better understand what champion-related processes or conditions led to organizational change in addressing the effects of indirect exposure and improving symptoms related to STS. Results showed that organizational change in addressing STS and champions' problem-solving strategies resulted in reductions in individual professionals' STS symptoms. Furthermore, champions' use of peer engagement or sharing of knowledge among peers in child welfare settings led to improvements at an organizational level. These results show that organization-level change can have a direct impact on individual well-being and there are specific champion activities that can promote this change. Specifically, results demonstrate a need to identify and support champions' use of problem-solving and peer engagement strategies to turn the individual and organizational threat posed by indirect trauma into an opportunity for shared healing., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

Researchers need approaches for analyzing complex phenomena when assessing contingency relationships where specific conditions explain an outcome only when combined with other conditions. Using a mixed methods design, we paired configurational methods and qualitative thematic analysis to model contingency in veteran community reintegration outcomes, identifying combinations of conditions that led to success or lack of success in community reintegration among US military veterans. This pairing allowed for modeling contingency at a detailed level beyond the capabilities of either approach alone. Our analysis revealed multiple contingent relationships at work in explaining reintegration, including social support, purpose, cultural adjustment, and military separation experiences. This study contributes to the field of mixed methods by pairing a mathematical cross-case method with a qualitative method to model contingency., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2022.)

Background: Veteran Directed Care (VDC) aims to keep Veterans at risk for nursing home placement in their communities. VA medical centers (VAMCs) purchase VDC from third-party organizational providers who then partner with them during implementation. Experiences with VDC implementation have varied., Objectives: We sought to identify conditions differentiating partnerships with higher enrollment (implementation success)., Methods: We conducted a case-based study with: qualitative data on implementation determinants two and eight months after program start, directed content analysis to assign numerical scores (-2 strong barrier to +2 strong facilitator), and mathematical modeling using Coincidence Analysis (CNA) to identify key determinants of implementation success. Cases consisted of VAMCs and partnering non-VAMC organizations who started VDC during 2017 or 2018. The Consolidated Framework for Implementation Research (CFIR) guided analysis., Results: Eleven individual organizations within five partnerships constituted our sample. Two CFIR determinants- Networks & Communication and External Change Agent-uniquely and consistently identified implementation success. At an inter-organizational partnership level, Networks & Communications and External Change Agent +2 (i.e., present as strong facilitators) were both necessary and sufficient. At a within-organization level, Networks & Communication +2 was necessary but not sufficient for the non-VAMC providers, whereas External Change Agent +2 was necessary and sufficient for VAMCs., Conclusion: Networks & Communication and External Change Agent played difference-making roles in inter-organizational implementation success, which differ by type of organization and level of analysis., Implications: This multi-level approach identified crucial difference-making conditions for inter-organizational implementation success when putting a program into practice requires partnerships across multiple organizations., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Published by Elsevier Inc.)

Obesity is a well-established risk factor for increased morbidity and mortality. Comprehensive lifestyle interventions, pharmacotherapy, and bariatric surgery are three effective treatment approaches for obesity. The Veterans Health Administration (VHA) offers all three domains but in different configurations across medical facilities. Study aim was to explore the relationship between configurations of three types of obesity treatments, context, and population impact across VHA using coincidence analysis. This was a cross-sectional analysis of survey data describing weight management treatment components linked with administrative data to compute population impact for each facility. Coincidence analysis was used to identify combinations of treatment components that led to higher population impact. Facilities with higher impact were in the top two quintiles for (1) reach to eligible patients and (2) weight outcomes. Sixty-nine facilities were included in the analyses. The final model explained 88% (29/33) of the higher-impact facilities with 91% consistency (29/32) and was comprised of five distinct pathways. Each of the five pathways depended on facility complexity-level plus factors from one or more of the three domains of weight management: comprehensive lifestyle interventions, pharmacotherapy, and/or bariatric surgery. Three pathways include components from multiple treatment domains. Combinations of conditions formed "recipes" that lead to higher population impact. Our coincidence analyses highlighted both the importance of local context and how combinations of specific conditions consistently and uniquely distinguished higher impact facilities from lower impact facilities for weight management., (Published by Oxford University Press on behalf of the Society of Behavioral Medicine 2022.)

Background: While technical assistance (TA) has been utilized by primary care organizations (PCOs) for electronic health record installation and medical home recognition, little is known about PCOs' use of TA to optimize pharmacist clinical services and integration in team-based care or population health programs. In 2019, the Connecticut Office of Health Strategy's State Innovation Model Program funded a no-cost TA initiative for 9 PCOs to initiate and/or advance pharmacist clinical services., Objective: To assess organizational, operational, and pharmacist factors that influenced PCO commitment to the TA program., Methods: During the TA program, data were collected from multiple sources including PCO demographic data; discussions and meetings with PCO medical, pharmacy, and administrative leaders; on-site workflow observations; and pharmacist coaching sessions. Configurational comparative methods were applied using the data collected during the TA program. Candidate factors were identified and calibrated on the basis of the researchers' knowledge of the TA program, organizational readiness for change models, implementation science frameworks, and published literature. Each candidate factor was iteratively assessed until 13 factors were selected and calibrated by independently assigning each factor a dichotomous value across PCOs. Calibration differences between the researchers were discussed until consensus was reached. Solutions were modeled using the Coincidence Analysis (cna) package in R and RStudio (RStudio, PBC)., Results: Of the 9 PCOs, 4 committed to participating in the TA program. Only 1 factor, the presence of a hired pharmacist, consistently distinguished PCOs that committed from those that did not, with 100% coverage and 80% consistency., Conclusion: PCO commitment to participate in the TA program was best explained by the factor of already having hired a pharmacist. These results can inform future efforts to engage PCOs in TA, primary care policy initiatives, and future research to understand factors influencing PCO success with pharmacist clinical services integration., (Copyright © 2022 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

Background and Aims: The Veterans Health Administration (VHA) provides care for more than 80,000 veterans with cirrhosis. This longitudinal, multimethod evaluation of a cirrhosis care quality improvement program aimed to (1) identify implementation strategies associated with evidence-based, guideline-concordant cirrhosis care over time, and (2) use qualitative interviews to operationalize strategies for a manualized intervention., Approach and Results: VHA providers were surveyed annually about the use of 73 implementation strategies to improve cirrhosis care in fiscal years 2018 (FY18) and 2019 (FY19). Implementation strategies linked to guideline-concordant cirrhosis care were identified using bivariate statistics and comparative configurational methods. Semistructured interviews were conducted with 12 facilities in the highest quartile of cirrhosis care to specify the successful implementation strategies and their mechanisms of change. A total of 106 VHA facilities (82%) responded at least once over the 2-year period (FY18, n = 63; FY19, n = 100). Facilities reported using a median of 12 (interquartile range [IQR] 20) implementation strategies in FY18 and 10 (IQR 19) in FY19. Of the 73 strategies, 35 (48%) were positively correlated with provision of evidence-based cirrhosis care. Configurational analysis identified multiple strategy pathways directly linked to more guideline-concordant cirrhosis care. Across both methods, a subset of eight strategies was determined to be core to cirrhosis care improvement and specified using qualitative interviews., Conclusions: In a national cirrhosis care improvement initiative, a multimethod approach identified a core subset of successful implementation strategy combinations. This process of empirically identifying and specifying implementation strategies may be applicable to other implementation challenges in hepatology., (© 2022 American Association for the Study of Liver Diseases. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.)

Objectives: The purpose of this study is to identify combinations of workplace conditions that uniquely differentiate high, medium, and low registered nurse (RN) ratings of appropriateness of patient assignment during daytime intensive care unit (ICU) work shifts., Methods: A collective case study design and coincidence analysis were employed to identify combinations of workplace conditions that link directly to high, medium, and low RN perception of appropriateness of patient assignment at a mid-shift time point. RN members of the study team hypothesized a set of 55 workplace conditions as potential difference makers through the application of theoretical and empirical knowledge. Conditions were derived from data exported from electronic systems commonly used in nursing care., Results: Analysis of 64 cases (25 high, 24 medium, and 15 low) produced three models, one for each level of the outcome. Each model contained multiple pathways to the same outcome. The model for "high" appropriateness was the simplest model with two paths to the outcome and a shared condition across pathways. The first path comprised of the absence of overtime and a before-noon patient discharge or transfer, and the second path comprised of the absence of overtime and RN assignment to a single ICU patient., Conclusion: Specific combinations of workplace conditions uniquely distinguish RN perception of appropriateness of patient assignment at a mid-shift time point, and these difference-making conditions provide a foundation for enhanced observability of nurses' work experience during hospital work shifts. This study illuminates the complexity of assessing nursing work system status by revealing that multiple paths, comprised of multiple conditions, can lead to the same outcome. Operational decision support tools may best reflect the complex adaptive nature of the work systems they intend to support by utilizing methods that accommodate both causal complexity and equifinality., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: To evaluate quality improvement sustainment for Transient Ischemic Attack (TIA) and identify factors influencing sustainment, which is a challenge for Learning Healthcare Systems., Methods: Mixed methods were used to assess changes in care quality across periods (baseline, implementation, sustainment) and identify factors promoting or hindering sustainment of care quality. PREVENT was a stepped-wedge trial at six US Department of Veterans Affairs implementation sites and 36 control sites (August 2015-September 2019). Quality of care was measured by the without-fail rate: proportion of TIA patients who received all of the care for which they were eligible among brain imaging, carotid artery imaging, neurology consultation, hypertension control, anticoagulation for atrial fibrillation, antithrombotics, and high/moderate potency statins. Key informant interviews were used to identify factors associated with sustainment., Results: The without-fail rate at PREVENT sites improved from 36.7% (baseline, 58/158) to 54.0% (implementation, 95/176) and settled at 48.3% (sustainment, 56/116). At control sites, the without-fail rate improved from 38.6% (baseline, 345/893) to 41.8% (implementation, 363/869) and remained at 43.0% (sustainment, 293/681). After adjustment, no statistically significant difference in sustainment quality between intervention and control sites was identified. Among PREVENT facilities, the without-fail rate improved ≥2% at 3 sites, declined ≥2% at two sites, and remained unchanged at one site during sustainment. Factors promoting sustainment were planning, motivation to sustain, integration of processes into routine practice, leadership engagement, and establishing systems for reflecting and evaluating on performance data. The only factor that was sufficient for improving quality of care during sustainment was the presence of a champion with plans for sustainment. Challenges during sustainment included competing demands, low volume, and potential problems with medical coding impairing use of performance data. Four factors were sufficient for declining quality of care during sustainment: low motivation, champion inactivity, no reflecting and evaluating on performance data, and absence of leadership engagement., Conclusions: Although the intervention improved care quality during implementation; performance during sustainment was heterogeneous across intervention sites and not different from control sites. Learning Healthcare Systems seeking to sustain evidence-based practices should embed processes within routine care and establish systems for reviewing and reflecting upon performance., Trial Registration: Clinicaltrials.gov ( NCT02769338 )., (© 2022. The Author(s).)

Background: Recent evidence suggests that community-wide mass drug administration (MDA) may interrupt the transmission of soil-transmitted helminths (STH), a group of intestinal worms that infect 1.5 billion individuals globally. Although current operational guidelines provide best practices for effective MDA delivery, they do not describe which activities are most essential for achieving high coverage or how they work together to produce effective intervention delivery. We aimed to identify the various packages of influential intervention delivery activities that result in high coverage of community-wide MDA for STH in Benin, India, and Malawi., Methods: We applied coincidence analysis (CNA), a novel cross-case analytical method, to process mapping data as part of the implementation science research of the DeWorm3 Project, a Hybrid Type 1 cluster randomized controlled trial assessing the feasibility of interrupting the transmission of STH using bi-annual community-wide MDA in Benin, India, and Malawi. Our analysis aimed to identify any necessary and/or sufficient combinations of intervention delivery activities (i.e., implementation pathways) that resulted in high MDA coverage. Activities were related to drug supply chain, implementer training, community sensitization strategy, intervention duration, and implementation context. We used pooled implementation data from three sites and six intervention rounds, with study clusters serving as analytical cases (N = 360). Secondary analyses assessed differences in pathways across sites and over intervention rounds., Results: Across all three sites and six intervention rounds, efficient duration of MDA delivery (within ten days) singularly emerged as a common and fundamental component for achieving high MDA coverage when combined with other particular activities, including a conducive implementation context, early arrival of albendazole before the planned start of MDA, or a flexible community sensitization strategy. No individual activity proved sufficient by itself for producing high MDA coverage. We observed four possible overall models that could explain effective MDA delivery strategies, all which included efficient duration of MDA delivery as an integral component., Conclusion: Efficient duration of MDA delivery uniquely stood out as a highly influential implementation activity for producing high coverage of community-wide MDA for STH. Effective MDA delivery can be achieved with flexible implementation strategies that include various combinations of influential intervention components., (© 2022. The Author(s).)

Background: Configurational methods are increasingly being used in health services research., Objectives: To use configurational analysis and logistic regression within a single data set to compare results from the two methods., Design: Secondary analysis of an observational cohort; a split-sample design involved randomly dividing patients into training and validation samples., Participants and Setting: Patients who had a transient ischaemic attack (TIA) in US Department of Veterans Affairs hospitals., Measures: The patient outcome was the combined endpoint of all-cause mortality or recurrent ischaemic stroke within 1 year post-TIA. The quality-of-care outcome was the without-fail rate (proportion of patients who received all processes for which they were eligible, among seven processes)., Results: For the recurrent stroke or death outcome, configurational analysis yielded a three-pathway model identifying a set of (validation sample) patients where the prevalence was 15.0% (83/552), substantially higher than the overall sample prevalence of 11.0% (relative difference, 36%). The configurational model had a sensitivity (coverage) of 84.7% and specificity of 40.6%. The logistic regression model identified six factors associated with the combined endpoint (c-statistic, 0.632; sensitivity, 63.3%; specificity, 63.1%). None of these factors were elements of the configurational model. For the quality outcome, configurational analysis yielded a single-pathway model identifying a set of (validation sample) patients where the without-fail rate was 64.3% (231/359), nearly twice the overall sample prevalence (33.7%). The configurational model had a sensitivity (coverage) of 77.3% and specificity of 78.2%. The logistic regression model identified seven factors associated with the without-fail rate (c-statistic, 0.822; sensitivity, 80.3%; specificity, 84.2%). Two of these factors were also identified in the configurational analysis., Conclusions: Configurational analysis and logistic regression represent different methods that can enhance our understanding of a data set when paired together. Configurational models optimise sensitivity with relatively few conditions. Logistic regression models discriminate cases from controls and provided inferential relationships between outcomes and independent variables., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: COVID-19 infection has disproportionately affected socially disadvantaged neighborhoods. Despite this disproportionate burden of infection, these neighborhoods have also lagged in COVID-19 vaccinations. To date, we have little understanding of the ways that various types of social conditions intersect to explain the complex causes of lower COVID-19 vaccination rates in neighborhoods., Methods: We used configurational comparative methods (CCMs) to study COVID-19 vaccination rates in Philadelphia by neighborhood (proxied by zip code tabulation areas). Specifically, we identified neighborhoods where COVID-19 vaccination rates (per 10,000) were persistently low from March 2021 - May 2021. We then assessed how different combinations of social conditions (pathways) uniquely distinguished neighborhoods with persistently low vaccination rates from the other neighborhoods in the city. Social conditions included measures of economic inequities, racial segregation, education, overcrowding, service employment, public transit use, health insurance and limited English proficiency., Results: Two factors consistently distinguished neighborhoods with persistently low COVID-19 vaccination rates from the others: college education and concentrated racial privilege. Two factor values together - low college education AND low/medium concentrated racial privilege - identified persistently low COVID-19 vaccination rates in neighborhoods, with high consistency (0.92) and high coverage (0.86). Different values for education and concentrated racial privilege - medium/high college education OR high concentrated racial privilege - were each sufficient by themselves to explain neighborhoods where COVID-19 vaccination rates were not persistently low, likewise with high consistency (0.93) and high coverage (0.97)., Conclusions: Pairing CCMs with geospatial mapping can help identify complex relationships between social conditions linked to low COVID-19 vaccination rates. Understanding how neighborhood conditions combine to create inequities in communities could inform the design of interventions tailored to address COVID-19 vaccination disparities., (© 2022. The Author(s).)

Implementation evaluations have increasingly taken into account how features of local context help determine implementation outcomes. The purpose of this study was to determine which contextual features of organizational capacity led directly to the RE-AIM Framework implementation outcomes of intervention reach and number of days taken to implement, in an implementation trial of a series of cancer education workshops conducted across 13 African American churches in Maryland. We used a configurational approach with Coincidence Analysis to identify specific features of organizational capacity that uniquely distinguished churches with implementation success from those that were less successful. Aspects of organizational capacity (e.g., congregation size, staffing/volunteers, health ministry experience) were drawn from an existing measure of church organizational capacity for health promotion. Solution pathways leading to higher intervention reach included: having a health ministry in place for 1-4 years; or having fewer than 100 members; or mid-size churches that had conducted health promotion activities in 1-4 different topics in the past 2 years. Solution pathways to implementing the intervention in fewer number of days included: having conducted 1-2 health promotion activities in the past 2 years; or having 1-5 part-time staff and a pastor without additional outside employment; or churches with a doctorally prepared pastor and a weekly attendance of 101-249 members. Study findings can inform future theory, research, and practice in implementation of evidence-based health promotion interventions delivered in faith-based and other limited-resource community settings. Findings support the important role of organizational capacity in implementation outcomes in these settings., Competing Interests: Competing and financial interests: The authors declare that they have no competing or financial interests.

Purpose: Mailed fecal immunochemical test (FIT) programs can facilitate colorectal cancer (CRC) screening. We sought to identify modifiable, clinic-level factors that distinguish primary care clinics with higher vs lower FIT completion rates in response to a centralized mailed FIT program., Methods: We used baseline observational data from 15 clinics within a single urban federally qualified health center participating in a pragmatic trial to optimize a mailed FIT program. Clinic-level data included interviews with leadership using a guide informed by the Consolidated Framework for Implementation Research (CFIR) and FIT completion rates. We used template analysis to identify explanatory factors and configurational comparative methods to identify specific combinations of clinic-level conditions that uniquely distinguished clinics with higher and lower FIT completion rates., Results: We interviewed 39 clinic leaders and identified 58 potential explanatory factors representing clinic workflows and the CFIR inner setting domain. Clinic-level FIT completion rates ranged from 30% to 56%. The configurational model for clinics with higher rates (≥37%) featured any 1 of the following 3 factors related to support staff: (1) adding back- or front-office staff in past 12 months, (2) having staff help patients resolve barriers to CRC screening, and (3) having staff hand out FITs/educate patients. The model for clinics with lower rates involved the combined absence of these same 3 factors., Conclusions: Three factors related to support staff differentiated clinics with higher and lower FIT completion rates. Adding nonphysician support staff and having those staff provide enabling services might help clinics optimize mailed FIT screening programs., (© 2022 Annals of Family Medicine, Inc.)

Background: Screening supports early detection and treatment of colorectal cancer (CRC). Provision of fecal immunochemical tests/fecal occult blood tests (FIT/FOBT) in primary care can increase CRC screening, particularly in populations experiencing health disparities. This study was conducted to describe clinical workflows for FIT/FOBT in Oregon primary care practices and to identify specific workflow processes that might be associated (alone or in combination) with higher (versus lower) CRC screening rates., Methods: Primary care practices were rank ordered by CRC screening rates in Oregon Medicaid enrollees who turned age 50 years from January 2013 to June 2014 (i.e., newly age-eligible). Practices were recruited via purposive sampling based on organizational characteristics and CRC screening rates. Data collected were from surveys, observation visits, and informal interviews, and used to create practice-level CRC screening workflow reports. Data were analyzed using descriptive statistics, qualitative data analysis using an immersion-crystallization process, and a matrix analysis approach., Results: All participating primary care practices (N=9) used visit-based workflows, and four higher performing and two lower performing used population outreach workflows to deliver FIT/FOBTs. However, higher performing practices (n=5) had more established workflows and staff to support activities. Visit-based strategies in higher performing practices included having dedicated staff identify patients due for CRC screening and training medical assistants to review FIT/FOBT instructions with patients. Population outreach strategies included having clinic staff generate lists and check them for accuracy prior to direct mailing of kits to patients. For both workflow types, higher performing clinics routinely utilized systems for patient reminders and follow-up after FIT/FOBT distribution., Conclusions: Primary care practices with higher CRC screening rates among newly age-eligible Medicaid enrollees had more established visit-based and population outreach workflows to support identifying patients due for screening, FIT/FOBT distribution, reminders, and follow up. Key to practices with higher CRC screening was having medical assistants discuss and review FIT/FOBT screening and instructions with patients. Findings present important workflow processes for primary care practices and may facilitate the implementation of evidence-based interventions into real-world, clinical settings., (© 2022. The Author(s).)

Background: While the Veterans Health Administration (VHA) MOVE! weight management program is effective in helping patients lose weight and is available at every VHA medical center across the United States, reaching patients to engage them in treatment remains a challenge. Facility-based MOVE! programs vary in structures, processes of programming, and levels of reach, with no single factor explaining variation in reach. Configurational analysis, based on Boolean algebra and set theory, represents a mathematical approach to data analysis well-suited for discerning how conditions interact and identifying multiple pathways leading to the same outcome. We applied configurational analysis to identify facility-level obesity treatment program arrangements that directly linked to higher reach., Methods: A national survey was fielded in March 2017 to elicit information about more than 75 different components of obesity treatment programming in all VHA medical centers. This survey data was linked to reach scores available through administrative data. Reach scores were calculated by dividing the total number of Veterans who are candidates for obesity treatment by the number of "new" MOVE! visits in 2017 for each program and then multiplied by 1000. Programs with the top 40 % highest reach scores (n = 51) were compared to those in the lowest 40 % (n = 51). Configurational analysis was applied to identify specific combinations of conditions linked to reach rates., Results: One hundred twenty-seven MOVE! program representatives responded to the survey and had complete reach data. The final solution consisted of 5 distinct pathways comprising combinations of program components related to pharmacotherapy, bariatric surgery, and comprehensive lifestyle intervention; 3 of the 5 pathways depended on the size/complexity of medical center. The 5 pathways explained 78 % (40/51) of the facilities in the higher-reach group with 85 % consistency (40/47)., Conclusions: Specific combinations of facility-level conditions identified through configurational analysis uniquely distinguished facilities with higher reach from those with lower reach. Solutions demonstrated the importance of how local context plus specific program components linked together to account for a key implementation outcome. These findings will guide system recommendations about optimal program structures to maximize reach to patients who would benefit from obesity treatment such as the MOVE!, (© 2021. The Author(s).)

Background: Facilitation is a complex, relational implementation strategy that guides change processes. Facilitators engage in multiple activities and tailor efforts to local contexts. How this work is coordinated and shared among multiple, external actors and the contextual factors that prompt and moderate facilitators to tailor activities have not been well-described., Methods: We conducted a mixed methods evaluation of a trial to improve the quality of transient ischemic attack care. Six sites in the Veterans Health Administration received external facilitation (EF) before and during a 1-year active implementation period. We examined how EF was employed and activated. Data analysis included prospective logs of facilitator correspondence with sites (160 site-directed episodes), stakeholder interviews (a total of 78 interviews, involving 42 unique individuals), and collaborative call debriefs (n=22) spanning implementation stages. Logs were descriptively analyzed across facilitators, sites, time periods, and activity types. Interview transcripts were coded for content related to EF and themes were identified. Debriefs were reviewed to identify instances of and utilization of EF during site critical junctures., Results: Multi-tiered EF was supported by two groups (site-facing quality improvement [QI] facilitators and the implementation support team) that were connected by feedback loops. Each site received an average of 24 episodes of site-directed EF; most of the EF was delivered by the QI nurse. For each site, site-directed EF frequently involved networking (45%), preparation and planning (44%), process monitoring (44%), and/or education (36%). EF less commonly involved audit and feedback (20%), brainstorming solutions (16%), and/or stakeholder engagement (5%). However, site-directed EF varied widely across sites and time periods in terms of these facilitation types. Site participants recognized the responsiveness of the QI nurse and valued her problem-solving, feedback, and accountability support. External facilitators used monitoring and dialogue to intervene by facilitating redirection during challenging periods of uncertainty about project direction and feasibility for sites. External facilitators, in collaboration with the implementation support team, successfully used strategies tailored to diverse local contexts, including networking, providing data, and brainstorming solutions., Conclusions: Multi-tiered facilitation capitalizing on emergent feedback loops allowed for tailored, site-directed facilitation. Critical juncture cases illustrate the complexity of EF and the need to often try multiple strategies in combination to facilitate implementation progress., Trial Registration: The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) is a registered trial ( NCT02769338 ), May 11, 2016-prospectively registered., (© 2021. The Author(s).)

Background: The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurologic Symptoms (PREVENT) program was a complex quality improvement (QI) intervention targeting transient ischemic attack (TIA) evidence-based care. The aim of this study was to evaluate program acceptability among the QI teams and factors associated with degrees of acceptability., Methods: QI teams from six Veterans Administration facilities participated in active implementation for a one-year period. We employed a mixed methods study to evaluate program acceptability. Multiple data sources were collected over implementation phases and triangulated for this evaluation. First, we conducted 30 onsite, semi-structured interviews during active implementation with 35 participants at 6 months; 27 interviews with 28 participants at 12 months; and 19 participants during program sustainment. Second, we conducted debriefing meetings after onsite visits and monthly virtual collaborative calls. All interviews and debriefings were audiotaped, transcribed, and de-identified. De-identified files were qualitatively coded and analyzed for common themes and acceptability patterns. We conducted mixed-methods matrix analyses comparing acceptability by satisfaction ratings and by the Theoretical Framework of Acceptability (TFA)., Results: Overall, the QI teams reported the PREVENT program was acceptable. The clinical champions reported high acceptability of the PREVENT program. At pre-implementation phase, reviewing quality data, team brainstorming solutions and development of action plans were rated as most useful during the team kickoff meetings. Program acceptability perceptions varied over time across active implementation and after teams accomplished actions plans and moved into sustainment. We observed team acceptability growth over a year of active implementation in concert with the QI team's self-efficacy to improve quality of care. Guided by the TFA, the QI teams' acceptability was represented by the respective seven components of the multifaceted acceptability construct., Conclusions: Program acceptability varied by time, by champion role on QI team, by team self-efficacy, and by perceived effectiveness to improve quality of care aligned with the TFA. A complex quality improvement program that fostered flexibility in local adaptation and supported users with access to data, resources, and implementation strategies was deemed acceptable and appropriate by front-line clinicians implementing practice changes in a large, national healthcare organization., Trial Registration: clinicaltrials.gov : NCT02769338 .

Purpose: We undertook a study to identify conditions and operational changes linked to improvements in smoking and blood pressure (BP) outcomes in primary care., Methods: We purposively sampled and interviewed practice staff (eg, office managers, clinicians) from a subset of 104 practices participating in EvidenceNOW-a multisite cardiovascular disease prevention initiative. We calculated Clinical Quality Measure improvements, with targets of 10-point or greater absolute improvements in the proportion of patients with smoking screening and, if relevant, counseling and in the proportion of hypertensive patients with adequately controlled BP. We analyzed interview data to identify operational changes, transforming these into numeric data. We used Configurational Comparative Methods to assess the joint effects of multiple factors on outcomes., Results: In clinician-owned practices, implementing a workflow to routinely screen, counsel, and connect patients to smoking cessation resources, or implementing a documentation change or a referral to a resource alone led to an improvement of at least 10 points in the smoking outcome with a moderate level of facilitation support. These patterns did not manifest in health- or hospital system-owned practices or in Federally Qualified Health Centers, however. The BP outcome improved by at least 10 points among solo practices after medical assistants were trained to take an accurate BP. Among larger, clinician-owned practices, BP outcomes improved when practices implemented a second BP measurement when the first was elevated, and when staff learned where to document this information in the electronic health record. With 50 hours or more of facilitation, BP outcomes improved among larger and health- and hospital system-owned practices that implemented these operational changes., Conclusions: There was no magic bullet for improving smoking or BP outcomes. Multiple combinations of operational changes led to improvements, but only in specific contexts of practice size and ownership, or dose of external facilitation., (© 2021 Annals of Family Medicine, Inc.)

"Implementation" of new initiatives in healthcare settings typically encompasses two distinct components: a "clinical intervention" plus accompanying "implementation strategies" that support putting the clinical intervention into day-to-day practice. A novel clinical intervention, for example, might consist of a new medication, a new protocol, a new device, or a new program. As clinical interventions are not self-implementing, however, they nearly always require effective implementation strategies in order to succeed. Implementation strategies set out to engage healthcare providers, staff and patients in ways that increase the likelihood of the new initiative being successfully adopted, a process that often involves behavior change and new ways of thinking by participants. One of the challenges in studying implementation is that it can be difficult to collect data about the status and progress of implementation, including participants' own perspectives and experiences concerning implementation to date. This protocol describes a novel method for collecting and analyzing data related to ongoing implementation called the Participant-Reported Implementation Update and Score, or PRIUS. The PRIUS method allows for the efficient and systematic capture of qualitative and quantitative data that can provide a detailed and nuanced account of implementation over time and from multiple viewpoints. This longitudinal method can enable researchers, as well as implementation leaders and organizational stakeholders, to monitor implementation progress more closely, conduct formative evaluation, identify improvement opportunities, and gauge the effect of any implementation changes on a rolling basis.

Background: As telemedicine adoption increases, so does the importance of building cohesion among physicians in telemedicine teams. For example, in acute telestroke services, stroke specialists provide rapid remote stroke assessment and treatment to patients at hospitals without stroke specialty care. In the National Telestroke Program (NTSP) of the U.S. Department of Veterans Affairs, a virtual (distributed) hub of stroke specialists throughout the country provides 24/7 consultations nationwide. We examined how these specialists adapted to distributed teamwork, and we identified cohesion-related factors in program development and support., Methods: We studied the virtual hub of stroke specialists employed by the NTSP. Semi-structured, confidential interviews with stroke specialists in the virtual hub were recorded and transcribed. We explored the extent to which these specialists had developed a sense of shared identity and team cohesion, and we identified factors in this development. Using a qualitative approach with constant comparison methods, two researchers coded each interview transcript independently using a shared codebook. We used matrix displays to identify themes, with special attention to team cohesion, communication, trust, and satisfaction., Results: Of 13 specialists with at least 8 months of NTSP practice, 12 completed interviews; 7 had previously practiced in telestroke programs in other healthcare systems. Interviewees reported high levels of trust and team cohesion, sometimes even more with their virtual colleagues than with co-located colleagues. Factors facilitating perceived team cohesion included a weekly case conference call, a sense of transparency in discussing challenges, engagement in NTSP development tasks, and support from the NTSP leadership. Although lack of in-person contact was associated with lower cohesion, annual in-person NTSP meetings helped mitigate this issue. Despite technical challenges in establishing a new telehealth system within existing national infrastructure, providers reported high levels of satisfaction with the NTSP., Conclusion: A virtual telestroke hub can provide a sense of team cohesion among stroke specialists at a level comparable with a standard co-located practice. Engaging in transparent discussion of challenging cases, reviewing new clinical evidence, and contributing to program improvements may promote cohesion in distributed telemedicine teams.

Background: The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurologic Symptoms (PREVENT) program was designed to address systemic barriers to providing timely guideline-concordant care for patients with transient ischemic attack (TIA)., Objective: We evaluated an implementation bundle used to promote local adaptation and adoption of a multi-component, complex quality improvement (QI) intervention to improve the quality of TIA care Bravata et al. (BMC Neurology 19:294, 2019)., Design: A stepped-wedge implementation trial with six geographically diverse sites., Participants: The six facility QI teams were multi-disciplinary, clinical staff., Interventions: PREVENT employed a bundle of key implementation strategies: team activation; external facilitation; and a community of practice. This strategy bundle had direct ties to four constructs from the Consolidated Framework for Implementation Research (CFIR): Champions, Reflecting & Evaluating, Planning, and Goals & Feedback., Main Measures: Using a mixed-methods approach guided by the CFIR and data matrix analyses, we evaluated the degree to which implementation success and clinical improvement were associated with implementation strategies. The primary outcomes were the number of completed implementation activities, the level of team organization and > 15 points improvement in the Without Fail Rate (WFR) over 1 year., Key Results: Facility QI teams actively engaged in the implementation strategies with high utilization. Facilities with the greatest implementation success were those with central champions whose teams engaged in planning and goal setting, and regularly reflected upon their quality data and evaluated their progress against their QI plan. The strong presence of effective champions acted as a pre-condition for the strong presence of Reflecting & Evaluating, Goals & Feedback, and Planning (rather than the other way around), helping to explain how champions at the +2 level influenced ongoing implementation., Conclusions: The CFIR-guided bundle of implementation strategies facilitated the local implementation of the PREVENT QI program and was associated with clinical improvement in the national VA healthcare system., Trial Registration: clinicaltrials.gov: NCT02769338.

Background: The Community of Practice (CoP) model represents one approach to address knowledge management to support effective implementation of best practices., Objective: We sought to identify CoP developmental strategies within the context of a national quality improvement project focused on improving the quality for patients receiving acute transient ischemic attack (TIA) care., Design: Stepped wedge trial., Participants: Multidisciplinary staff at six Veterans Affairs medical facilities., Interventions: To encourage site implementation of a multi-component quality improvement intervention, the trial included strategies to improve the development of a CoP: site kickoff meetings, CoP conference calls, and an interactive website (the "Hub")., Approach: Mixed-methods evaluation included data collected through a CoP attendance log; semi-structured interviews with site participants at 6 months (n = 32) and 12 months (n = 30), and CoP call facilitators (n = 2); and 22 CoP call debriefings., Key Results: The critical seeding structures that supported the cultivation of the CoP were the kickoffs which fostered relationships (key to the community element of CoPs) and provided the evidence base relevant to TIA care (key to the domain element of CoPs). The Hub provided the forum for sharing quality improvement plans and other tools which were further highlighted during the CoP calls (key to the practice element of CoPs). CoP calls were curated to create a positive context around participants' work by recognizing team successes. In addition to improving care at their local facilities, the community created a shared set of tools which built on their collective knowledge and could be shared within and outside the group., Conclusions: The PREVENT CoP advanced the mission of the learning healthcare system by successfully providing a forum for shared learning. The CoP was grown through seeding structures that included kickoffs, CoP calls, and the Hub. A CoP expands upon the learning collaborative implementation strategy as an effective implementation practice.

Background: Mailed fecal immunochemical testing (FIT) programs can improve colorectal cancer (CRC) screening rates, but health systems vary how they implement (i.e., adapt) these programs for their organizations. A health insurance plan implemented a mailed FIT program (named BeneFIT), and participating health systems could adapt the program. This multi-method study explored which program adaptations might have resulted in higher screening rates., Methods: First, we conducted a descriptive analysis of CRC screening rates by key health system characteristics and program adaptations. Second, we generated an overall model by fitting a weighted regression line to our data. Third, we applied Configurational Comparative Methods (CCMs) to determine how combinations of conditions were linked to higher screening rates. The main outcome measure was CRC screening rates., Results: Seventeen health systems took part in at least 1 year of BeneFIT. The overall screening completion rate was 20% (4-28%) in year 1 and 25% (12-35%) in year 2 of the program. Health systems that used two or more adaptations had higher screening rates, and no single adaptation clearly led to higher screening rates. In year 1, small systems, with just one clinic, that used phone reminders (n = 2) met the implementation success threshold (≥ 19% screening rate) while systems with > 1 clinic were successful when offering a patient incentive (n = 4), scrubbing mailing lists (n = 4), or allowing mailed FIT returns with no other adaptations (n = 1). In year 2, larger systems with 2-4 clinics were successful with a phone reminder (n = 4) or a patient incentive (n = 3). Of the 10 systems that implemented BeneFIT in both years, seven improved their CRC screening rates in year 2., Conclusions: Health systems can choose among many adaptations and successfully implement a health plan's mailed FIT program. Different combinations of adaptations led to success with health system size emerging as an important contextual factor.

Background: Implementation of multifaceted interventions typically involves many diverse elements working together in interrelated ways, including intervention components, implementation strategies, and features of local context. Given this real-world complexity, implementation researchers may be interested in a new mathematical, cross-case method called Coincidence Analysis (CNA) that has been designed explicitly to support causal inference, answer research questions about combinations of conditions that are minimally necessary or sufficient for an outcome, and identify the possible presence of multiple causal paths to an outcome. CNA can be applied as a standalone method or in conjunction with other approaches and can reveal new empirical findings related to implementation that might otherwise have gone undetected., Methods: We applied CNA to a publicly available dataset from Sweden with county-level data on human papillomavirus (HPV) vaccination campaigns and vaccination uptake in 2012 and 2014 and then compared CNA results to the published regression findings., Results: The original regression analysis found vaccination uptake was positively associated only with the availability of vaccines in schools. CNA produced different findings and uncovered an additional solution path: high vaccination rates were achieved by either (1) offering the vaccine in all schools or (2) a combination of offering the vaccine in some schools and media coverage., Conclusions: CNA offers a new comparative approach for researchers seeking to understand how implementation conditions work together and link to outcomes.

Background and Objectives: To identify the implementation barriers, facilitators, and conditions associated with successful outcomes from a clinical demonstration project to reduce potentially avoidable hospitalizations of long-stay nursing facility residents in 19 Indiana nursing homes., Research Design and Methods: Optimizing Patient Transfers, Impacting Medical quality, Improving Symptoms-Transforming Institutional Care (OPTIMISTIC) is a multicomponent intervention that includes enhanced geriatric care, transition support, and palliative care. The configurational analysis was used to analyze descriptive and quantitative data collected during the project. The primary outcome was reductions in hospitalizations per 1,000 eligible resident days., Results: Analysis of barriers, facilitators, and conditions for success yielded a model with 2 solution pathways associated with a 10% reduction in potentially avoidable hospitalizations per 1,000 resident days: (a) lower baseline hospitalization rates and investment of senior management; or (b) turnover by the director of nursing during the observation period. Conditions for success were similar for a 20% reduction, with the addition of increased resident acuity., Discussion and Implications: Key conditions for successful implementation of the OPTIMISTIC intervention include strong investment by senior leadership and an environment in which baseline hospitalization rates leave ample room for improvement. Turnover in the position of director of nursing also linked to successful implementation; this switch in leadership may represent an opportunity for culture change by bringing in new perspectives and viewpoints. These findings help define the conditions for the successful implementation of the OPTIMISTIC model and have implications for the successful implementation of interventions in the nursing facility more generally., (© The Author(s) 2020. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Implementation of new clinical programs across diverse facilities in national healthcare systems like the Veterans Health Administration (VHA) can be extraordinarily complex. Implementation is a dynamic process, influenced heavily by local organizational context and the individual staff at each medical center. It is not always clear in the midst of implementation what issues are most important to whom or how to address them. In recognition of these challenges, implementation researchers within VHA developed a new systemic approach to map the implementation work required at different stages and provide ongoing, detailed, and nuanced feedback about implementation progress., Methods: This observational pilot demonstration project details how a novel approach to monitoring implementation progress was applied across two different national VHA initiatives. Stage-specific grids organized the implementation work into columns, rows, and cells, identifying specific implementation activities at the site level to be completed along with who was responsible for completing each implementation activity. As implementation advanced, item-level checkboxes were crossed off and cells changed colors, offering a visual representation of implementation progress within and across sites across the various stages of implementation., Results: Applied across two different national initiatives, the SIPREP provided a novel navigation system to guide and inform ongoing implementation within and across facilities. The SIPREP addressed different needs of different audiences, both described and explained how to implement the program, made ample use of visualizations, and revealed both what was happening and not happening within and across sites. The final SIPREP product spanned distinct stages of implementation., Conclusions: The SIPREP made the work of implementation explicit at the facility level (i.e., who does what, and when) and provided a new common way for all stakeholders to monitor implementation progress and to help keep implementation moving forward. This approach could be adapted to a wide range of settings and interventions and is planned to be integrated into the national deployment of two additional VHA initiatives within the next 12 months.

Background: Questions persist about how learning healthcare systems should integrate audit and feedback (A&F) into quality improvement (QI) projects to support clinical teams' use of performance data to improve care quality., Objective: To identify how a virtual "Hub" dashboard that provided performance data for patients with transient ischemic attack (TIA), a resource library, and a forum for sharing QI plans and tools supported QI activities among newly formed multidisciplinary clinical teams at six Department of Veterans Affairs (VA) medical centers., Design: An observational, qualitative evaluation of how team members used a web-based Hub., Participants: External facilitators and multidisciplinary team members at VA facilities engaged in QI to improve the quality of TIA care., Approach: Qualitative implementation process and summative evaluation of observational Hub data (interviews with Hub users, structured field notes) to identify emergent, contextual themes and patterns of Hub usage., Key Results: The Hub supported newly formed multidisciplinary teams in implementing QI plans in three main ways: as an information interface for integrated monitoring of TIA performance; as a repository used by local teams and facility champions; and as a tool for team activation. The Hub enabled access to data that were previously inaccessible and unavailable and integrated that data with benchmark and scientific evidence to serve as a common data infrastructure. Led by champions, each implementation team used the Hub differently: local adoption of the staff and patient education materials; benchmarking facility performance against national rates and peer facilities; and positive reinforcement for QI plan development and monitoring. External facilitators used the Hub to help teams leverage data to target areas of improvement and disseminate local adaptations to promote resource sharing across teams., Conclusions: As a dynamic platform for A&F operating within learning health systems, hubs represent a promising strategy to support local implementation of QI programs by newly formed, multidisciplinary teams.

Background: Evidence-based programs such as mailed fecal immunochemical test (FIT) outreach can only affect health outcomes if they can be successfully implemented. However, attempts to implement programs are often limited by organizational-level factors., Objectives: As part of the Strategies and Opportunities to Stop Colon Cancer in Priority Populations (STOP CRC) pragmatic trial, we evaluated how organizational factors impacted the extent to which health centers implemented a mailed FIT outreach program., Design: Eight health centers participated in STOP CRC. The intervention consisted of customized electronic health record tools and clinical staff training to facilitate mailing of an introduction letter, FIT kit, and reminder letter. Health centers had flexibility in how they delivered the program., Main Measures: We categorized the health centers' level of implementation based on the proportion of eligible patients who were mailed a FIT kit, and applied configurational comparative methods to identify combinations of relevant organizational-level and program-level factors that distinguished among high, medium, and low implementing health centers. The factors were categorized according to the Consolidated Framework for Implementation Research model., Key Results: FIT tests were mailed to 21.0-81.7% of eligible participants at each health center. We identified a two-factor solution that distinguished among levels of implementation with 100% consistency and 100% coverage. The factors were having a centralized implementation team (inner setting) and mailing the introduction letter in advance of the FIT kit (intervention characteristics). Health centers with high levels of implementation had the joint presence of both factors. In health centers with medium levels of implementation, only one factor was present. Health centers with low levels of implementation had neither factor present., Conclusions: Full implementation of the STOP CRC intervention relied on a centralized implementation team with dedicated staffing time, and the advance mailing of an introduction letter., Trial Registration: ClinicalTrials.gov Identifier: NCT01742065 Registered 05 December 2012-Prospectively registered.

As the number of Veterans enrolled in the Veterans Health Administration (VHA) and at risk for needing Long Term Services and Supports increases, VHA is shifting from institutional to Home and Community Based Services, such as the Veteran-Directed Care (VDC) program. VDC is a multi-sector program implemented as a collaboration between individual VHA medical centers (VAMCs) and Aging and Disability Network Agencies (ADNAs), entities that sit outside the VHA. Factors that affect establishment of effective multi-sector programs such as VDC are poorly understood, limiting ability to effectively deliver and scale programs. We conducted a qualitative study to describe factors affecting the interorganizational implementation context of VDC. Using constructs from the Consolidated Framework for Implementation Research (CFIR), we interviewed VDC coordinators from seven different VAMC-ADNA partnerships that initiated the VDC program between 2017 and 2018. We identified eight CFIR determinants which manifested similarly for the VAMCs and ADNAs: evidence strength and quality, relative advantage, adaptability, tension for change, access to knowledge and information, self-efficacy; engaging, and champions. We identified three CFIR determinants that varied dramatically across VAMCs and ADNAs: available resources, implementation climate, and relative priority. Our results suggest that interorganizational context plays a critical and dynamic role within multi-sector collaborations.

Background: Cirrhosis is a rapidly increasing cause of global mortality. To improve cirrhosis care, the Veterans Health Administration (VHA) developed the Hepatic Innovation Team (HIT) Collaborative to support VA Medical Centers (VAMCs) to deliver evidence-based cirrhosis care. This randomized HIT program evaluation aims to develop and assess a novel approach for choosing and applying implementation strategies to improve the quality of cirrhosis care., Methods: Evaluation aims are to (1) empirically determine which combinations of implementation strategies are associated with successful implementation of evidence-based practices (EBPs) for Veterans with cirrhosis, (2) manualize these "data-driven" implementation strategies, and (3) assess the effectiveness of data-driven implementation strategies in increasing cirrhosis EBP uptake. Aim 1 will include an online survey of all VAMCs' use of 73 implementations strategies to improve cirrhosis care, as defined by the Expert Recommendations for Implementing Change taxonomy. Traditional statistical as well as configurational comparative methods will both be employed to determine which combinations of implementation strategies are associated with site-level adherence to EBPs for cirrhosis. In aim 2, semi-structured interviews with high-performing VAMCs will be conducted to operationalize successful implementation strategies for cirrhosis care. These data will be used to inform the creation of a step-by-step guide to tailoring and applying the implementation strategies identified in aim 1. In aim 3, this manualized implementation intervention will be assessed using a hybrid type III stepped-wedge cluster randomized design. This evaluation will be conducted in 12 VAMCs, with four VAMCs crossing from control to intervention every 6 months, in order to assess the effectiveness of using data-driven implementation strategies to improve guideline-concordant cirrhosis care., Discussion: Successful completion of this innovative evaluation will establish the feasibility of using early evaluation data to inform a manualized, user-friendly implementation intervention for VAMCs with opportunities to improve care. This evaluation will provide implementation support tools that can be applied to enhance the implementation of other evidence-based practices., Trial Registration: This project was registered at ClinicalTrials.Gov ( NCT04178096 ) on 4/29/20.

Importance: Patients with transient ischemic attack (TIA) are at high risk of recurrent vascular events. Timely management can reduce that risk by 70%; however, gaps in TIA quality of care exist., Objective: To assess the performance of the Protocol-Guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) intervention to improve TIA quality of care., Design, Setting, and Participants: This nonrandomized cluster trial with matched controls evaluated a multicomponent intervention to improve TIA quality of care at 6 diverse medical centers in 6 geographically diverse states in the US and assessed change over time in quality of care among 36 matched control sites (6 control sites matched to each PREVENT site on TIA patient volume, facility complexity, and quality of care). The study period (defined as the data period) started on August 21, 2015, and extended to May 12, 2019, including 1-year baseline and active implementation periods for each site. The intervention targeted clinical teams caring for patients with TIA., Intervention: The quality improvement (QI) intervention included the following 5 components: clinical programs, data feedback, professional education, electronic health record tools, and QI support., Main Outcomes and Measures: The primary outcome was the without-fail rate, which was calculated as the proportion of veterans with TIA at a specific facility who received all 7 guideline-recommended processes of care for which they were eligible (ie, anticoagulation for atrial fibrillation, antithrombotic use, brain imaging, carotid artery imaging, high- or moderate-potency statin therapy, hypertension control, and neurological consultation). Generalized mixed-effects models with multilevel hierarchical random effects were constructed to evaluate the intervention associations with the change in the mean without-fail rate from the 1-year baseline period to the 1-year intervention period., Results: Six facilities implemented the PREVENT QI intervention, and 36 facilities were identified as matched control sites. The mean (SD) age of patients at baseline was 69.85 (11.19) years at PREVENT sites and 71.66 (11.29) years at matched control sites. Most patients were male (95.1% [154 of 162] at PREVENT sites and 94.6% [920 of 973] at matched control sites at baseline). Among the PREVENT sites, the mean without-fail rate improved substantially from 36.7% (58 of 158 patients) at baseline to 54.0% (95 of 176 patients) during a 1-year implementation period (adjusted odds ratio, 2.10; 95% CI, 1.27-3.48; P = .004). Comparing the change in quality at the PREVENT sites with the matched control sites, the improvement in the mean without-fail rate was greater at the PREVENT sites than at the matched control sites (36.7% [58 of 158 patients] to 54.0% [95 of 176 patients] [17.3% absolute improvement] vs 38.6% [345 of 893 patients] to 41.8% [363 of 869 patients] [3.2% absolute improvement], respectively; absolute difference, 14%; P = .008)., Conclusions and Relevance: The implementation of this multifaceted program was associated with improved TIA quality of care across the participating sites. The PREVENT QI program is an example of a health care system using QI strategies to improve performance, and may serve as a model for other health systems seeking to provide better care., Trial Registration: ClinicalTrials.gov Identifier: NCT02769338.

Background: The Department of Veterans Affairs (VA) cares for more patients with hepatitis C virus (HCV) than any other US health care system. We tracked the implementation strategies that VA sites used to implement highly effective new treatments for HCV with the aim of uncovering how combinations of implementation strategies influenced the uptake of the HCV treatment innovation. We applied Configurational Comparative Methods (CCMs) to uncover causal dependencies and identify difference-making strategy configurations, and to distinguish higher from lower HCV treating sites., Methods: We surveyed providers to assess VA sites' use of 73 implementation strategies to promote HCV treatment in the fiscal year 2015. CCMs were used to identify strategy configurations that uniquely distinguished higher HCV from lower HCV treating sites., Results: From the 73 possible implementation strategies, CCMs identified 5 distinct strategy configurations, or "solution paths." These were comprised of 10 individual strategies that collectively explained 80% of the sites with higher HCV treatment starts with 100% consistency. Using any one of the following 5 solution paths was sufficient to produce higher treatment starts: (1) technical assistance; (2) engaging in a learning collaborative AND designating leaders; (3) site visits AND outreach to patients to promote uptake and adherence; (4) developing resource sharing agreements AND an implementation blueprint; OR (5) creating new clinical teams AND sharing quality improvement knowledge with other sites AND engaging patients. There was equifinality in that the presence of any one of the 5 solution paths was sufficient for higher treatment starts., Conclusions: Five strategy configurations distinguished higher HCV from lower HCV treating sites with 100% consistency. CCMs represent a methodological advancement that can help inform high-yield implementation strategy selection and increase the efficiency and effectiveness of future implementation efforts.

Background: Obstructive sleep apnea (OSA) can negatively impact patients' health status and outcomes. Positive airway pressure (PAP) reverses airway obstruction and may reduce the risk of adverse outcomes. Remote monitoring of PAP (as opposed to in-person visits) may improve access to sleep medicine services. This study aimed to evaluate the feasibility of implementing a clinical program that delivers treatment for OSA through PAP remote monitoring using external facilitation as an implementation strategy., Methods: Participants included patients with OSA at a Veteran Affairs Medical Center (VAMC). PAP adherence and clinical disease severity on treatment (measured by the apnea hypopnea index [AHI]) were the preliminary effectiveness outcomes across two delivery models: usual care (in-person) and Telehealth nurse-delivered remote monitoring. We also assessed visit duration and travel distance. A prospective, mixed-methods evaluation examined the two-tiered external facilitation implementation strategy., Results: The pilot project included N = 52 usual care patients and N = 38 Telehealth nurse-delivered remote monitoring patients. PAP adherence and disease severity were similar across the delivery modalities. However, remote monitoring visits were 50% shorter than in-person visits and saved a mean of 72 miles of travel (median = 45.6, SD = 59.0, mode = 17.8, range 5.4-220). A total of 62 interviews were conducted during implementation with a purposive sample of 12 clinical staff involved in program implementation. Weekly external facilitation delivered to both front-line staff and supervisory physicians was necessary to ensure patient enrollment and treatment. Synchronized, "two-tiered" facilitation at the executive and coordinator levels proved crucial to developing the clinical and administrative infrastructure to support a PAP remote monitoring program and to overcome implementation barriers., Conclusions: Remote PAP monitoring had similar efficacy to in-person PAP services in this Veteran population. Although external facilitation is a widely-recognized implementation strategy in quality improvement projects, less is known about how multiple facilitators work together to help implement complex programs. Two-tiered facilitation offers a model well-suited to programs where innovations span disciplines, disrupt professional hierarchies (such as those between service chiefs, clinicians, and technicians) and bring together providers who do not know each other, yet must collaborate to improve access to care.

Background: Transient ischemic attack (TIA) patients are at high risk of recurrent vascular events; timely management can reduce that risk by 70%. The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) developed, implemented, and evaluated a TIA quality improvement (QI) intervention aligned with Learning Healthcare System principles., Methods: This stepped-wedge trial developed, implemented and evaluated a provider-facing, multi-component intervention to improve TIA care at six facilities. The unit of analysis was the medical center. The intervention was developed based on benchmarking data, staff interviews, literature, and electronic quality measures and included: performance data, clinical protocols, professional education, electronic health record tools, and QI support. The effectiveness outcome was the without-fail rate: the proportion of patients who receive all processes of care for which they are eligible among seven processes. The implementation outcomes were the number of implementation activities completed and final team organization level. The intervention effects on the without-fail rate were analyzed using generalized mixed-effects models with multilevel hierarchical random effects. Mixed methods were used to assess implementation, user satisfaction, and sustainability., Discussion: PREVENT advanced three aspects of a Learning Healthcare System. Learning from Data: teams examined and interacted with their performance data to explore hypotheses, plan QI activities, and evaluate change over time. Learning from Each Other: Teams participated in monthly virtual collaborative calls. Sharing Best Practices: Teams shared tools and best practices. The approach used to design and implement PREVENT may be generalizable to other clinical conditions where time-sensitive care spans clinical settings and medical disciplines., Trial Registration: clinicaltrials.gov: NCT02769338 [May 11, 2016].

Background: Patients with transient ischemic attacks (TIA) are at high risk of subsequent vascular events. Hospitalization improves quality of care, yet admission rates for TIA patients vary considerably., Objectives: We sought to identify factors associated with the decision to admit patents with TIA., Design: We conducted a secondary analysis of a prior study's data including semi-structured interviews, administrative data, and chart review., Participants: We interviewed multidisciplinary clinical staff involved with TIA care. Administrative data included information for TIA patients in emergency departments or inpatient settings at VA medical centers (VAMCs) for fiscal years (FY) 2011 and 2014. Chart reviews were conducted on a subset of patients from 12 VAMCs in FY 2011., Approach: For the qualitative data, we focused on interviewees' responses to the prompt: "Tell me what influences you in the decision to or not to admit TIA patients." We used administrative data to identify admission rates and chart review data to identify ABCD 2 scores (a tool to classify stroke risk after TIA)., Key Results: Providers' decisions to admit TIA patients were related to uncertainty in several domains: lack of a facility TIA-specific policy, inconsistent use of ABCD 2 score, and concerns about facilities' ability to complete a timely workup. There was a disconnect between staff perceptions about TIA admission and facility admission rates. According to chart review data, staff at facilities with higher admission rates in FY 2011 reported consistent reliance on ABCD 2 scores and related guidelines in admission decision-making., Conclusions: Many factors contributed to decisions regarding admitting a patient with TIA; however, clinicians' uncertainty appeared to be a key driver. Further quality improvement interventions for TIA care should focus on facility adoption of TIA protocols to address uncertainty in TIA admission decision-making and to standardize timely evaluation of TIA patients and delivery of secondary prevention strategies.