Anticipated Impacts on Veteran's Healthcare: The quality of mental healthcare in the US varies widely. Measurement-based quality improvement (MBQI) has been adopted within and outside the VA as one means of improving quality. However, the effectiveness of MBQI also varies and our knowledge of key determinants of its effectiveness is limited. The proposed study, the third submission of IIR 07-254, will contribute to improving veterans' healthcare by helping the VA identify facilitators and barriers to successful MBQI and address quality problems more effectively. Background/Rationale: This study examines MBQI conducted by VA inpatient mental health units addressing 5 new Joint Commission (JC) core measures for inpatient psychiatric services during the first year of the measures' nationwide implementation. The measures were developed by the JC and a multi- stakeholder panel to address known, meaningful quality deficits in inpatient mental healthcare. Pilot data from 196 hospitals confirmed that there are widespread opportunities for improvement. Prior studies of organizational factors associated with MBQI have primarily examined implementation of QI programs generally, without consideration of the content of what hospitals were trying to improve. In the proposed study-which is based on a conceptual model derived from organizational theory--we hypothesize that improvement in measure performance will be strongly associated with the fit between the measure and measure-specific organizational characteristics (culture, leadership, structure and resources). Objectives: The objectives of the proposed study are to: 1. Assess the extent of improvement in hospital performance on the JC measures for inpatient mental health care over the first four quarterly cycles of measurement and feedback. 2. Assess the contribution of fit between each JC quality measure and measure-spectific organizational characteristics of a hospital's mental health service on the service's improvement in measure performance. 3. Determine specific areas of good and poor fit for the JC measures within VA hospitals that are significantly associated with extent of improvement, in order to identify potential facilitators and barriers to improvement. Methods: 42 VA hospitals will be selected randomly from 21 VISNS for this cross-sectional study. After hospitals first year experience with the JC measures, we will conduct telephone interviews with hospital mental health service leaders and online surveys of inpatient clinicians, collecting quantitative and qualitative data. We will identify hospital organizational factors influencing improvement on each measure and conduct a series of multivariate analyses to assess the influence of these factors on improvement in measure performance. We will determine the amount of variation in improvement explained by general and measure-specific factors, and identify potential facilitators and barriers to improving performance.

Public Health Relevance

The Institute of Medicine and major research studies within and outside the VA have found that the quality of health care in the US varies widely. Within and outside the VA hospitals have adoped measurement-based quality improvement (MBQI) as one means to improve care, and thus enhance clinical outcomes and health among veterans. Yet, the effectiveness of MBQI is limited. Research studies have shown its effectiveness to be mixed. For many quality measures within and outside the VA, hospital performance varies widely and average performance shows room for improvement. This study aims to understand why some hospitals succeed and others fail on MBQI activities as well as why hospitals succeed in some activities and not others. We postulate that the fit between hospital organizational characteristics and QI objectives they address is strongly associated with the likelihood of effective QI. We have developed a clinician survey and interview protocol for hospital leaders to identify attributes of fit for a standardized quality-measure set recently adopted by inpatient psychiatric units nationwide. By testing the relationship between meaure-organization fit and QI performance, and identifying specific areas of fit and non-fit for individual measures, we expect to learn about facilitators and barriers to effective QI. A subsequent study will test an intervention to help hospitals perform QI more effectively by learning about faciliators and barriers to achieving their QI goals and adopting selected strategies and tools to improve performance.

National Institute of Health (NIH)
Veterans Affairs (VA)
Non-HHS Research Projects (I01)
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HSR-2 Determinants of Patient Response to Care (HSR2)
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VA Boston Health Care System
United States
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