The Role of Management Support in Implementing
Innovative Clinical Practices
Carol VanDeusen Lukas, EdD
Mark M. Meterko, PhD
David Mohr, PhD
Marjorie Nealon Seibert, MBA
Center for Organization, Leadership and Management Research
Health Services Research and Development Service
Office of Research and Development
Department of Veterans Affairs
June 2005
Research questions:
• Leadership is widely seen as an important factor in
the implementation of innovative clinical practices
– Implementation = putting into practice
• How does leadership – or more broadly,
management support – affect implementation?
– What aspects important?
– Through what paths influence?
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Conceptual Model of
Management Support for
Innovation Implementation
Personal leadership
support
Implementation climate:
o Problem recognition
Innovation
implementation
Organizational support
Implementation policies and
procedures:
o Communication & training
o Team collect, review data
o Performance feedback
Based on Klein K, Conn AB, Sorra JS. Implementing
computerized technology: an organizational analysis.
J Applied Psych. 2001, 86(5)
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Research context:
Advanced Clinic Access in VA
• In 2000, the Department of Veterans Affairs (VA)
launched a national initiative to diffuse Advanced
Clinic Access (ACA) in VA
• Diffusion focused on six target clinic areas across VA
to implement ACA:
– Primary care
– Cardiology
– Orthopedics
— Audiology
— Eye care
— Urology
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ACA 10 key change principles:
• Practices for managing clinics so patients have
access to medical care when they want it:
–
–
–
–
–
–
–
–
–
–
Work down the backlog
Reduce demand
Understand supply and demand
Reduce appointment types
Plan for contingencies
Manage the constraint
Optimize the care team
Synchronize patient, provider and information
Predict and anticipate patient needs at time of appointment
Optimize rooms and equipment
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Infrastructure to support ACA diffusion:
• To support diffusion, VA built an infrastructure that
includes:
– A national steering committee
– A national clinical director
– A person designated to lead ACA in every VA network, or
VISN, and most medical centers (called points of contact or
POCs)
– A network of physician coaches to provide peer networks of
advocacy and support.
• In the end, ACA implementation is local
– Encouraged and supported by not mandated
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Study design and data sources:
• Design
– Observational study of 78 VA medical centers sampled to
represent variation in appointment wait time and size in July
2002
• Data sources
– Structured telephone interviews with facility ACA points of
contact (POCs) in 76 of 78 study VA medical centers in
February-April 2003
– Reports of implementation of ACA 10 key changes by POCs
in February-May 2003
– Mailed survey completed by 3870 staff (42%) in the 78 study
medical centers during July-August 2003
• Focus here on primary care
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Conceptual Model of Management
Support for Innovation
Implementation
Organizational support
Implementation policies and
procedures:
o Communication & training
o Team collect, review data
o Performance feedback
Innovation
implementation
Personal leadership
commitment
Implementation climate:
o Problem recognition
Based on Klein K, Conn AB, Sorra JS. Implementing
computerized technology: an organizational analysis.
J Applied Psych. 2001, 86(5)
Center for Organization, Leadership and Management Research
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Predictor variables:
• Personal leadership support to clinic staff (7-item scale,
alpha=.93) E.g., agreement that
– Senior management talks about ACA
– Senior management reviews our progress in making change
– Leadership in my clinic area gives high priority to reducing wait time
• Organizational support for ACA (8-item scale, alpha=.78)
E.g.,
–
–
–
–
Managers are held accountable for ACA performance measures
Local ACA champions have been explicitly designated for clinic areas
Local resources have been used to directly support ACA
Facility operations and infrastructure have been improved for ACA
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Mediating variables:
• Problem recognition (2-item scale, alpha=.84)
– Agreement that reducing wait time is important goal and awareness
that effort is underway to reduce
• Team review, collect data (3-item scale, alpha=.88)
– Team uses data to test changes and track progress, and believes
data accurate
• Communication & training (6-item scale, alpha=.85)
E.g.,
– Have internal collaboratives, consultation from ACA experts,
resource materials, discussion at meetings
• Performance feedback (2-item scale, alpha=.66)
– Reports presented to clinic staff; hot spot reports used
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Dependent variable:
• Proportion of full implementation
– ACA point of contact matrix
– By target clinic area
• Extent 10 key change principles implemented
– 1-5 scale on staff survey
– By target clinic area
• Composite measure
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Measures of Extent of Implementation
Proportion of Full
Implementation
(Source: Facility POC matrix)
Extent 10 Key Principles of
ACA Have Been
Implemented*
(Source: Staff Survey)
Standardized
Composite Measure
Primary Care
63%
2.87
49.62
Audiology
66%
3.36
52.55
Cardiology
66%
2.89
50.25
Eye Care
62%
3.08
50.6
Orthopedics
59%
2.81
49.54
Urology
65%
2.90
50.38
Overall
64%
2.87
Clinic Area
*Single survey item asking with a five-point response scale ranging from 1=”not at all” to 5=”to a great extent.”
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Analysis strategy:
• Multiple regression analyses to identify factors affecting
ACA implementation:
– Separate stepwise regressions for two hypothesized
paths of influence
– Simultaneous regression of all variables in single
model
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Regression analysis for path 1:
Step 1
Personal leadership support
R-squared
F
.36**
.13
11.04
Step 2
Problem recognition
R-squared change
F
NS
NS
NS
Overall model
Overall R-squared
Adjusted R-squared
F(1, 74)
.13
.12
11.04**
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Regression analysis for path 2:
Step 1
Organizational support
R-squared
F
.37**
.11
9.49*
Step 2
Communication & training
Team collect, review data
Performance feedback
R-squared change
F
.45***
NS
-.22*
.23
20.45**
Overall model
Overall R-squared
Adjusted R-squared
F(3, 72)
.35
.32
12.80***
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Regression analysis for combined model:
Step 1
Organizational support
Personal leadership support
Communication & training
Team collect, review data
Performance feedback
Problem recognition
.37**
NS
.45***
NS
-.22*
NS
Overall model
R-squared
Adjusted R-squared
F(3,72)
.35
.32
12.80***
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Summary and conclusions:
• Considered separately, two aspects of management
support were significantly related to ACA implementation
• But when combined, personal leadership support drops
out
• Suggests that for successful implementation of clinical
innovations,
– Support by leadership and problem recognition by staff
is not enough
– More concrete practical organizational support and
implementation tools are needed
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Next research steps:
• Measuring implementation of complex interventions
• Test model in other settings
• Investigate factors that dropped out as significant
predictors/ mediators:
– Personal leadership support
– Problem recognition
– Team review, collect data
• Are there situations in which management support is
not crucial to successful implementation?
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