Background
Conceptual framework and contextual factor definitions
Contextual factor definitions
Strong contextual elements | Moderate contextual elements | Weak contextual elements | |
---|---|---|---|
Evidence | *The ACC dosing algorithm is valid and the evidence for use is compelling | *The dosing algorithm used inconsistently | *Little use of the algorithm |
*The dashboard is used regularly to address loss to follow-up and patients who need more attention | *Dashboard is used inconsistently and/or only for loss to follow-up | *Dashboard rarely used | |
Teamwork | *Good working relations | *Mediocre working relations—not clearly working toward a common goal | *Divided teams or non-functional teams |
*Ability to problem solve together | *Divided team | *Poor working relationships | |
*Team system in place to support each other | *Problem solving uneven | *Weak systems that provide little support | |
*Working together to a common goal | *Mediocre system of support | *Little common effort toward working toward a common goal | |
Communication | *Established effective communication pathways both formal and informal | *Moderately established and used communication pathways | *Dysfunctional communication pathways both formal or informal |
*Consistent pathways for new information to spread | *Inconsistent pathways for new information to spread | *Dysfunctional pathways for new information to spread | |
Leadership | *Supports and leads effective teamwork | *New to leadership or new to the VA | *Not supportive of effective teamwork |
*Inclusive decision making | *Uneven use of empowerment in learning and managing | *Disempowering environment for staff | |
*empowering learning and managing | *Less inclusive decision making | *Lack of role clarity roles | |
*Role clarity | *Less role clarity | *Low of interaction with staff | |
*Transformational leadership |
Site | Evidence | Teamwork | Communication | Leadership | Uptake |
---|---|---|---|---|---|
A | Strong | Strong | Strong | Moderate | High |
B | Moderate | Moderate | Moderate | Strong | High |
C | Moderate | Strong | Strong | Moderate | Medium |
D | Weak | Weak | Moderate | Moderate | Low |
E | Strong | Weak | Weak | Weak | Low |
Site A | Site B | Site C | Site D | Site E | |
---|---|---|---|---|---|
Evidence | + | 0 | 0 | - | 0 |
Teamwork | + | 0 | + | - | - |
Communication | + | 0 | + | - | - |
Leadership | 0 | + | - | 0 | - |
Cumulative impact on uptake | + | + | 0 | - | - |
The intervention
Methods
Sample and data collection
Table of sites and participants 2012 | |
---|---|
Feature | N |
Number of sites | 5 |
Number of staff interviewed | 51 |
Chief | 4 |
Middle managers (Associate chief, clinical coordinator, etc.) | 4 |
Pharmacist | 38 |
Pharmacy technician | 1 |
Nurse | 1 |
Clerk/Health technician | 3 |
Average number of participants per site | 7.4 |
Average length of interview | 39 minutes |
Data analysis
Uptake levels | High | Medium | Low |
---|---|---|---|
Uptake component | |||
ACC dosing algorithm | *Algorithm is implemented and used a high percentage of the time by all staff | *Algorithm is inconsistently used among staff | *Algorithm is rarely used among all staff |
Dashboard | *Dashboard is used not only to measure performance but as tool for targeting poor TTR patients for more monitoring | *Dashboard used to measure performance inconsistently and only one or two features used inconsistently as a tool | *Dashboard used rarely to measure performance and rarely or not at all as a tool |
Site specific QI work | *Initiated site specific improvements | *Site has thought of improvements but inconsistent initiation and follow through | *Site demonstrates no initiative and attempts few or no improvements |
* Shares results | *Staff inconsistently participate | *Staff rarely or never participate | |
*Staff regularly participate | |||
Site seeks out and/or accepts facilitation by ACC improvement team | *Site reaches out for assistance and responds to ACC improvement team | *Participation is inconsistent | *Site does not reach out or respond |
Participation in local ACC coordinators leadership team run by ACCII | *Site participates-attends meetings | *Site mostly participates-attends most but not all meetings | *Site often does not participate-attends meetings unevenly |
*Leader facilitates ACC coordinator participation | *Leader facilitates ACC coordinator participation most of the time | *Leader does not always facilitate ACC coordinator participation | |
TTR (Time in therapeutic range) | *TTR begins to improve | *TTR shows some movement but not much | *TTR shows no improvement |
Results
Evidence | Teamwork* | Communication | Leadership |
---|---|---|---|
-Already had a practice algorithm | -Culture of improvement where staff made suggestions | -In constant communication about workload | -New leader |
-Knowledgeable and comfortable with EBPs and working with algorithm. | -Organized and cooperated with each other | -Communicated about patients and patient issues | -Soon became an active supporter of the ACCII |
-Knew each other’s strengths and weaknesses | -Used all means available to talk (email, phone, Lync messenger, face-to-face) | -Always lets staff attend ACCII meetings | |
-Worked together for common good | -Site designed tracking system to manage patients before ACCII started | ||
-Team cited teamwork as their strength |
Evidence | Teamwork | Communication | Leadership* |
---|---|---|---|
-Already had a practice algorithm but did not use it or refer to it consistently | -Teamwork generally perceived as adequate, but staff somewhat divided | -Functional but uneven communication about patients and workload | -Recent promotion of ACC pharmacist to middle manager (MM) |
-Staff was unevenly open to a new algorithm | -Less cohesiveness as a team | -Used all means available to communicated (email, phone, IM, face to face) | -MM very supportive of ACCII |
-Concern about losing clinical judgment if just following an algorithm | -Less willingness to pitch in to even out the work load | -Deeper level of communication about quality improvement often lacking at outset | -MM interested in QI approaches & solicited staff ideas |
-Uneven interest in change and improvement | -Site designed tracking system to manage patients before ACCII started | -MM supported local coordinator (liaison to ACCII) | |
-MM supported by pharmacy leadership |
Evidence | Teamwork | Communication* | Leadership |
---|---|---|---|
-Strain of skepticism about the algorithm | -Organized, cooperated with each other | -Communicated about workload and patients | -Middle manager (MM) supportive of ACC team |
-Belief in clinical judgment of clinical pharmacists | -Knew strengths and weaknesses | -Staff noted communication as a strength | -MM vocalizes skepticism of algorithm; staff are aware |
-Algorithm thought to be good only for training inexperienced staff | -Worked together for common good | -Used all means available to communicate (email, phone, IM, face to face) | -Staff have respect for MM |
-Interested as a group in change and improvement | -Team was safe space to express ideas and concerns | -MM supports sending a staff person to ACCII meetings | |
-Team itself cites teamwork as their great strength | -Communication between ACC staff and leadership effective | -MM had support of pharmacy leadership |
Evidence | Teamwork* | Communication | Leadership |
---|---|---|---|
-Negative attitude toward algorithm | -Organized &cooperated with each other | -Adequate communication about workload and patients | -Middle manager (MM) did not micromanage and allowed fair amount of autonomy to ACCs |
-Great belief in clinical judgment of clinical pharmacists | -Worked together for long time | -Used all means available to talk (email, phone, IM, face to face) | -MM noted there is change fatigue |
-Discomfort with being asked to adopt an EBP | -Strong identification as a team with shared values and practices. | -Communication between ACC team and leadership was rare | -MM remained noncommittal regarding support of the ACCII |
-Relatively unaware of ACCII project | |||
-Team itself cited teamwork as their great strength |
Evidence* | Teamwork | Communication | Leadership |
---|---|---|---|
-Had not used an algorithm to date | -Not very organized and low cooperation overall | -Low level of intra-ACC staff communication | -Staff feel unevenly supported by leadership |
-Very interested in getting some guidance | -Internal divisions where some team members cooperate, but not others | -Used all means available to talk (email, phone, IM, face to face) | -Staff felt poorly informed about ACCII |
-Receptive to algorithm | -ACC staff note that they do not have great teamwork | -ACC staff note that communication among ACC team is strained | -Sense from staff that leadership is not very interested in ACCII |
-Concerned about workload implications of the 7 day return for out of range patients recommended by the algorithm | -Communication between ACC team and leadership was rare—ACC team had heard very little about the ACCII | -Leadership supported sending staff to ACCII meetings |
Cross-site interplay findings
“We have very strong communication…We try to be very thorough in our notes so that the next person picking it up will know exactly where it was left off, what the story is…. We use (Microsoft) Communicator. We use the phone and we use the spreadsheet to share info…and I think that we’re really good about talking to each other about difficult cases and that kind of helps us to make the best clinical decisions that we can. …we work really well as a team…we talk a lot and we communicate about what’s going on”.
“We are looking to optimize the process that we use… I think it’s a fabulous idea. I’m looking for ways that we can improve… so you are less likely to make mistakes or worry about making mistakes … what would be wonderful is if we could figure out who’s doing a better job with that kind of thing and how can we implement it here”.
“…It’s really individual specific…For some folks it’s…really good. Others, there’s a chronic lack of communication and lack of…intuition or empathy, you know, as far as what other people’s schedules are and… [this] impacts other people’s function”.
“[The middle manager] is so organized… [The manger] is wonderful”.
“[MM] is just so helpful and…she really understands the issues that we face and, I mean, she is obviously on board with anticoag project…”
“…I’m kind of willing to give it a shot. But …I think we might have some other pharmacists here that might want to use the clinical judgment card pretty frequently on that one”.
“…We’re such a good team, we really work together to help everybody and I think when you respect the person that you’re working with and that feeling is mutual I think it makes the clinic run a lot smoother. You know, I think patients are satisfied and… We really do work together as a team”.
“… if I have a question…Like, procedural stuff a lot of times I’ll ask…. If I have a quick question about…dosing or something like that, a lot of times I’ll ask [the middle manager]”.
“…to me you can’t categorize every patient into that algorithm. They don’t all fit and a lot of times it’s a gut feeling that you need to change a dose”.
“… [We] know that we can depend on each other and anyone’ll back you up and help you out”. Another noted“We all [have]… a similar philosophy, a similar training and a similar mindset, so I think our team play [emphasis in interview] works well…”
“Well we didn’t want to use that [the proposed QI tool]…and I don’t remember actually my own feelings about it but I remember that you know as a team we kind of shut it down…we decided to just stay with our way….”
“We didn’t want to use it [the proposed QI tool]…as a team we… said no”.
“I don’t keep my ear that close to the ground so, I just sit back and wait for official things to come…Just [heard from leadership] that it’s… [ACCII] coming…It’s [ACCI] in the works…”
“…I have seen a change in people’s attitudes towards…using the algorithm. I like it. [It] takes a little bit more time when we’re using [the algorithm] because we’re kind of dosing a little bit differently than we had in the past…and you kinda have to think things through a little bit more which isn’t a bad thing”.
“It [teamwork] is awful …There are certain people that will not be in a team, no matter how hard you try…I would love to have a team atmosphere and be able to count on everybody and feel like there’s trust and that we’re providing the best care, but we do not have that here”.
“…the other thing is communication…we don’t have staff meetings. We…just get emails…but nothing is really discussed among the group”.
“I think the hardest part of our job is communication…. the volume of our workload is very high so that’s challenging. We have so many patients that walk right in our door. …I think another challenge is the lack of communication among the pharmacists. With the clinical staff [some] have meetings with our [leadership] …they knew about all these…changes, however it doesn’t get trickled down to the rest of the clinic… we’re not [the entire staff] informed as to what’s happening”.
“…People here want to always make an impression, okay? Especially the people in management… They come around when there’s the photo op, I always like to say… On a daily basis, forget it, okay? That’s the way it is, you know”.