Implementing eScreening technology in four VA clinics: a mixed-method study

BackgroundHealthcare professionals’ job satisfaction is a critical indicator of healthcare performance, pivotal in addressing challenges such as hospital quality outcomes, patient satisfaction, and staff retention rates. Existing evidence underscores the significant influence of healthcare leadership on job satisfaction. Our study aims to assess the impact of leadership support on the satisfaction of healthcare professionals, including physicians, nurses, and administrative staff, in China’s leading hospitals.MethodsA cross-sectional survey study was conducted on healthcare professionals in three leading hospitals in China from July to December 2021. These hospitals represent three regions in China with varying levels of social and economic development, one in the eastern region, one in the central region, and the third in the western region. Within each hospital, we employed a convenience sampling method to conduct a questionnaire survey involving 487 healthcare professionals. We assessed perceived leadership support across five dimensions: resource support, environmental support, decision support, research support, and innovation encouragement. Simultaneously, we measured satisfaction using the MSQ among healthcare professionals.ResultsThe overall satisfaction rate among surveyed healthcare professionals was 74.33%. Our study revealed significant support from senior leadership in hospitals for encouraging research (96.92%), inspiring innovation (96.30%), and fostering a positive work environment (93.63%). However, lower levels of support were perceived in decision-making (81.72%) and resource allocation (80.08%). Using binary logistic regression with satisfaction as the dependent variable and healthcare professionals’ perceived leadership support, hospital origin, job role, department, gender, age, education level, and professional designation as independent variables, the results indicated that support in resource provision (OR: 4.312, 95% CI: 2.412 ∼ 7.710) and environmental facilitation (OR: 4.052, 95% CI: 1.134 ∼ 14.471) significantly enhances healthcare personnel satisfaction.ConclusionThe findings underscore the critical role of leadership support in enhancing job satisfaction among healthcare professionals. For hospital administrators and policymakers, the study highlights the need to focus on three key dimensions: providing adequate resources, creating a supportive environment, and involving healthcare professionals in decision-making processes.

Screening and referral for Social and Behavioral Determinants of Health (SDOH) are increasingly recommended in clinical guidelines and consensus statements. It is important to understand barriers and facilitators to implementation of standardized SDOH screening and referral practices, as well as the scope of current existing SDOH screening. We conducted a mixed-methods study to understand the current state of SDOH screening and to assess the barriers and facilitators to implementing a standardized SDOH screening and referral practice in Boston community health centers (CHCs) for pediatric patients. We requested all SDOH screening documents from 15 Boston CHCs and conducted provider and staff focus groups at intervention sites of an SDOH implementation pilot in Boston. All CHCs screened in some form for SDOH, but there was no agreement on which domains to screen. Participating CHCs screened for a mean of 8 SDOH domains (range, 5 to 16). Overall, 16 SDOH domains emerged. From the focus groups, 5 themes emerged: 1) provider perspectives, 2) work flow, 3) prior experience, 4) site resources and staffing, and 5) sustainability. There was little agreement among participants within each theme, as all were seen as barriers and facilitators depending on the respondent. This study highlights the various SDOH screening methods currently used in Boston CHCs, and the need for workflow and process individualization of SDOH screening and referral. Providers and clinical staff should be part of the discussion when implementing SDOH screening and referral procedures to ensure appropriate work flow, staff buy-in, and to maximize resources available.

The siloed nature of maternity care has been noted as a system-level factor negatively impacting maternal outcomes. Veterans Health Administration (VA) provides multi-specialty healthcare before, during, and after pregnancy but purchases obstetric care from community providers. VA providers may be unaware of perinatal complications, while community-based maternity care providers may be unaware of upstream factors affecting the pregnancy. To optimize maternal outcomes, the VA has initiated a system-level surveillance and review process designed to improve non-obstetric care for veterans experiencing a pregnancy. This quality improvement project aimed to describe the VA-based maternal mortality review process and to report maternal mortality (pregnancy-related death up to 42 days postpartum) and pregnancy-associated mortality (death from any cause up to 1 year postpartum) among veterans who use VA maternity care benefits. Pregnancies and pregnancy-associated deaths between fiscal year (FY) 2011–2020 were identified from national VA databases. All deaths underwent individual chart review and abstraction that focused on multi-specialty care received at the VA in the year prior to pregnancy until the time of death. Thirty-two pregnancy-associated deaths were confirmed among 39,720 pregnancies (PAMR = 80.6 per 100,000 live births). Fifty percent of deaths occurred among individuals who had experienced adverse social determinants of health. Mental health conditions affected 81%. Half (n = 16, 50%) of all deaths occurred in the late postpartum period (43–365 days postpartum) after maternity care had ended. More than half of these late postpartum deaths (n = 9, 56.2%) were related to suicide, homicide, or overdose. Integration of care delivered during the perinatal period (pregnancy through postpartum) from primary, mental health, emergency, and specialty care providers may be enhanced through a system-based approach to pregnancy-associated death surveillance and review. This quality improvement project has implications for all healthcare settings where coordination between obstetric and non-obstetric providers is needed.

Adult code cart redesign: Clinical implications.

Introduction: In order to achieve the best possible outcomes for patients requiring resuscitation (PRRs) in the emergency department (ED), health care providers (HCPs) must provide an efficient, multi-disciplinary and coordinated response. A quality improvement (QI) project was undertaken to improve HCP response to PRRs at two tertiary care hospital EDs in Toronto. Methods: We conducted a before-and-after mixed-method survey to evaluate the perception of the adequacy of HCP response and clarity of HCP role when responding to PRRs. The results were compared using the Chi-square test. Qualitative responses to the first survey were also used to inform the development of the QI project. Through interviews of key stakeholders and with continuous input from front-line ED HCPs, a multi-disciplinary team modified the ED resuscitation protocol. This included standardized pre-hospital communication form with paramedics, ED-wide overhead announcement of ‘Code Resus’, dedicated HCPs assigned to respond to PRRs, and specific duties assigned to each responder. Change initiatives were reinforced through education and posters in the ED. Six months after implementation, a second survey was conducted to evaluate the sustained effects of the intervention. Results: Baseline measures indicated that 16 of 52 (30.8%) nurses surveyed believed their role was often or always apparent to themselves and others when they attended to a PRR (on a 5-point rating scale). This proportion increased to 35 of 55 (63.6%) nurses in the post-implementation survey (p < 0.001). Regarding adequacy of the number of HCPs responding to PRRs, 17 of 39 (43.6%) physicians and 23 of 53 (43.4%) nurses surveyed thought the appropriate number of HCPs responded to PRRs; the remainder thought that there were too few or too many HCPs. In the post-implementation survey, 34 of 41 (82.9%) physicians (p < 0.001) and 36 of 56 (64.3%) nurses (p = 0.029) surveyed felt that the appropriate number of HCPs attended to PRRs. Conclusion: Using a quality improvement approach, we identified and quantified perceived deficiencies in HCP response to PRRs in the ED. Through feedback-based modifications of the ED resuscitation protocol and by engaging HCP stakeholders, change initiatives were implemented to improve HCP response. As a result, this project achieved significant and sustained improvements in HCPs’ perceived response to PRRs.

Enhancing team communication to improve implementation of a supervised walking program for hospitalized veterans: Evidence from a multi-site trial in the Veterans Health Administration.

PurposeThe aim of this paper is gaining a deeper understanding of potential negative effects of (smart)phone use at work. The authors do so by exploring mediating mechanisms and boundary conditions between leader phubbing, leaders snubbing their followers by glancing at their phones during an interaction; and follower (1) work engagement and (2) performance.Design/methodology/approachThe authors conducted a survey-based time-lagged, multi-source and team-based study of leaders (N = 93) and their followers (N = 454).FindingsResults of this paper showed that leader phubbing negatively relates to follower (1) work engagement and (2) performance through less perceived leader support. Contradictory to the hypothesis, the relationship between leader phubbing and perceived leader support was negative for male leaders only.Originality/valueThe authors contribute to existing research by (1) adding perceived support as an important mediator between leader phubbing and work engagement/performance, (2) exploring the effects of leader gender and (3) adding information on the cultural robustness of the leader phubbing phenomenon by testing it outside the Western work context.

Introduction: This Doctor of Nursing Practice project aimed to enhance the knowledge and confidence of the San Diego Veterans Health Administration’s (VASD) Intensive Care Unit (ICU) medical providers in goals-of-care discussions (GOCD). Additionally, this project aimed to improve the documentation of these discussions. Background: Delays in GOCD can lead to futile medical and surgical interventions, inappropriate antibiotic use, and higher rates of mental health conditions in patients and their loved ones. Earlier GOCD are associated with lower ventilation and resuscitation rates, earlier hospice enrollment, reduced ICU admissions, lower financial costs, and better patient and caregiver quality of life. However, medical providers caring for patients in VASD and other hospital settings are often underprepared or hesitant to facilitate GOCD. As a result, these discussions are frequently delayed and documented inconsistently. Methods: This project implemented three education sessions on an evidence-based standardized tool for facilitating GOCD to 14 physicians within their first five postgraduate years. Participants were then instructed to use the tool with every admitted patient and document GOCD in a life-sustaining treatment (LST) note. Pre- and post-implementation surveys containing the Advanced Care Planning Self-Efficacy scale (ACP-SE) were administered. The frequency of LST was recorded for the three months before and during training. Results: Pre-survey data showed an average ACP-SE score of 3.23 out of 5, with 5 indicating the highest provider GOCD self-efficacy rating. Half of those surveyed reported having received no prior training in GOCD. The post-survey ACP-SE average was 4.54; however, four out of the 14 participants completed the post-survey. LST note documentation in the ICU began at 16.9% of total admissions and increased by 1% during the project. Evaluation: New medical providers at the VASD ICU may benefit from additional education and practice in GOCD. Moreover, on-site peer champions, financial incentives, and supervisory involvement may optimize post-survey data collection and LST documentation. Provider self-efficacy with and documentation of GOCD at the VASD ICU may benefit from further quality improvement projects, documentation policy updates, and evidence-based education interventions. Keywords: advance care planning, education, goals of care, self-efficacy, life-sustaining treatment, intensive care unit

BackgroundConsensus guidelines recommend multimodal chronic pain treatment with increased use of non-pharmacological treatment modalities (NPM), including as first-line therapies. However, with many barriers to NPM uptake in US healthcare systems, NPM use may vary across medical care settings. Military veterans are disproportionately affected by chronic pain. Many veterans receive treatment through the Veterans Health Administration (VHA), an integrated healthcare system in which specific policies promote NPM use.ObjectiveTo examine whether veterans with chronic pain who utilize VHA healthcare were more likely to use NPM than veterans who do not utilize VHA healthcare.DesignCross-sectional nationally representative study.ParticipantsUS military veterans (N = 2,836).Main MeasuresIn the 2019 National Health Interview Survey, veterans were assessed for VHA treatment, chronic pain (i.e., past 3-month daily or almost daily pain), symptoms of depression and anxiety, substance use, and NPM (i.e., physical therapy, chiropractic/spinal manipulation, massage, psychotherapy, educational class/workshop, peer support groups, or yoga/tai chi).Key ResultsChronic pain (45.2% vs. 26.8%) and NPM use (49.8% vs. 39.4%) were more prevalent among VHA patients than non-VHA veterans. After adjusting for sociodemographic characteristics, psychiatric symptoms, physical health indicators, and use of cigarettes or prescription opioids, VHA patients were more likely than non-VHA veterans to use any NPM (adjusted odds ratio [aOR] = 1.52, 95% CI: 1.07–2.16) and multimodal NPM (aOR = 1.80, 95% CI: 1.12–2.87) than no NPM. Among veterans with chronic pain, VHA patients were more likely to use chiropractic care (aOR = 1.90, 95% CI = 1.12–3.22), educational class/workshop (aOR = 3.02, 95% CI = 1.35–6.73), or psychotherapy (aOR = 4.28, 95% CI = 1.69–10.87).ConclusionsAmong veterans with chronic pain, past-year VHA use was associated with greater likelihood of receiving NPM. These findings may suggest that the VHA is an important resource and possible facilitator of NPM. VHA policies may offer guidance for expanding use of NPM in other integrated US healthcare systems.

Collaboration, Cooperation Improve Care Model

Health care systems are increasingly interested in becoming whole health systems that include complementary and integrative health (CIH) approaches. The nation's largest health care system, the Veterans Health Administration (VA), has been transforming to such a system. However, anecdotal evidence suggested that many VA medical centers have faced challenges in implementing CIH approaches, whereas others have flourished. We report on a large-scale, research-operations partnered effort to understand the challenges faced by VA sites and the strategies used to address these to better support VAs implementation of CIH nationally. We conducted semi-structured, in-person qualitative interviews with 149 key stakeholders at 8 VA medical centers, with content based on Greenhalgh's implementation framework. For analysis, we identified a priori categories of content aligned with Greenhalgh's framework and then generated additional categories developed inductively, capturing additional implementation experiences. These categories formed a template to aid in coding data. VA sites commonly reported that nine key factors facilitated CIH implementation: (1) organizing individual CIH approaches into one program instead of spreading across several departments; (2) having CIH strategic plans and steering committees; (3) strong, professional, and enthusiastic CIH program leads and practitioners; (4) leadership support; (5) providers' positive attitudes toward CIH; (6) perceptions of patients' attitudes; (7) demonstrating evidence of CIH effectiveness; (8) champions; and (9) effectively marketing. Common challenges included are: (1) difficulties in hiring; (2) insufficient/inconsistent CIH funding; (3) appropriate patient access to CIH approaches; (4) difficulties in coding/documenting CIH use; (5) insufficient/inappropriate space; (6) insufficient staff's and provider's time; and (7) the health care cultural and geographic environments. Sites also reported several successful strategies supporting CIH implementation. VA sites experience both success and challenges with implementing CIH approaches and have developed a wide range of strategies to support their implementation efforts. This information is potentially useful to other health care organizations considering how best to support CIH provision.

Meaningful Cost Reduction: Penny Wise, Pound Foolish

Local Implementation of Alcohol Screening and Brief Intervention at Five Veterans Health Administration Primary Care Clinics: Perspectives of Clinical and Administrative Staff

Whole health: the vision and implementation of personalized, proactive, patient-driven health care for veterans.

BackgroundChildhood obesity negatively impacts physical health, mental wellbeing and shortens life expectancy1. A 2017 audit of children attending our district hospital’s outpatient clinics (OPC) and rapid response unit (RRU) revealed:...