Heart Failure (HF) Netw

VA Providers: 

An Innovative Strateg

Implementation 

Anju Sahay PhD 

Paul Heidenreich MD, MS 

CHRONIC HEART FAILURE (CHF

VA Palo Alto 
Funded by HSR&D: CHF 0

Conflict of Interest: NON
Purpose 

To describe our experience w

formation and use of a Com

of Practice (CoP) of VA prov

as a strategy to improve ca

heart failure patients. 
Background 

 Heart failure (HF) is associated with 

mortality and poor quality of life. 

 Moreover, it is the most common me

reason for admission within and outsVA health care system. 

 Reducing admission and readmission 

HF are goals of CHF QUERI, VA in genon-VA partner organizations like the for Healthcare Improvement. 
About Social Network

• There is growing interest in the use o

networks to facilitate knowledge exch

health-care settings. 

• Creating connectedness among provi

EBP in the treatment of specific disea

foster exchange of best practices. 

• Social network structures provide opp

for members to connect and share in
Social Network: Examp

• Condition-specific networks have been 

among providers with similar clinical intere

• In British Columbia, a heart failure provi

has been created among cardiologists, intefamily physicians, nurses, pharmacists, diesocial workers. 

• A network for New York providers treating 

with tuberculosis was associated with a 

increase in the number of individuals receobserved therapy (Klein, 1995). 

• Montreal Stroke Network 
Communities of Practice (

• CoPs are a type of informal learning o• They are gaining popularity in the he• CoPs have 3 fundamental elements: 

i. a domain of knowledge ii. a community of people iii. a shared practice 

• Wenger (2002) has described CoPs a

people who share a concern, a set of or a passion about a topic, and who dtheir knowledge and expertise in this interacting on an ongoing basis”. 
Building CoPs through S

Network: Examples 

• There is growing evidence of CoPs b

developed as social networks. 

• Norman and Huerta (2006) have ex

building foundations for a CoP using and social network methodologies. 

• Poissant (2005) reported that emerg

with the Montreal Stroke Network wsuccessful in developing and implemcritical inputs, such as referral tools accelerated patients’ transition betwcare to rehab. 
Conceptual Frameworks 

Implementation 

• We have conceptualized the HF Networ• We have used 2 complementary theore

frameworks for implementation: 

 The Promoting Action on Resear

Implementation in Health Servic

(PARIHS) framework (2008) accordwhich successful implementation is of evidence, context and facilitation. 

 Rogers' Diffusion of Innovation 

(2003) indicates that opinion leaders critical role in shepherding an innova
● CHF QUERI has formed a CoP called: 

Heart Failure (HF) Network 

● It is a national network of VA provide

interested in improving quality of carfailure patients. 

● It is supported by:  - The Office of Patient Care Services- Dr. John Rumsfeld, Director National Cardiology Program 

About the HF Netwo
Goals of HF Network 

1. Share evidence-based HF programs 

facilitate their implementation 

2. Understand the context (e.g. cultur

leadership style, resources) at facili

3. Learn about barriers and facilitators 

improving HF care 

4. Establish collaborations/networking 

members of the HF Network 

5. Provide opportunities to identify/inv

champions at facilities 
Formation of HF Netwo

● HF Network was formed in July 200● Chiefs of Cardiology or Chiefs of Med

each VA facility were contacted via e-and/or phone to identify providers intin heart failure and quality of care. 

● Identified providers were invited to jo

were asked to identify any additional 

● Multi-disciplinary/multi-level members● Members do not have to be providers 

managers) 
Formation of HF Network (

● Goal to include providers/staff from A

Health Care Systems. 

● Members can drop out by sending an ● 1st session (in-person annual meetin

held on September 11, 2006 in Se
VA Nursi Service 

Connectedness of HF Netwo

VA Stakeholders 

Heart 

Failure 

(HF) 

Network 

VA Office of Patient Care Services 

Contact: John Rumsfeld MD, PhD 

L

 C Q C

Partnerships 

CHF 

QUERI 

Cardiovascular Field Advisory 

Committee Contact: 

Marthe Moseley PhD, RN 

VA Nursing Service 

VA GRECC Associate Director / 

Clinical Group Network Contact: 

Kenneth Shay DDS, MS 

 C Q P O

C CP PN R P P T O

M

H

Facilities (N=150) 

VA Medical Centers and 

VA Health Care Systems 

VA Office of Principal Deputy Under 

Secretary for Health Contact: 

Robert Jesse MD, PhD 
How Does HF Network W

● Conduct bi-monthly live meetings

* a

annual in-person meeting

* at a maj

conference. 

● Communicate via: - E-mails - Conference calls - CHF QUERI / HF Network websit - SharePoint site - Periodic surveys

* 

* Referred as “session” of t
Active Participation in the HF 

●

“ACTIVE” membership is defined as in at least one of the following activiti

 - Attend bi-monthly live meeting and/conference call - Attend annual in-person meeting at  conference (Heart Failure Society of 

- Complete a survey - Submit “Letter of Intent” to CHF QU

QUERI’s RRP or SDP proposals, or foQUERI’s core funds 
Current Membership 

● 910+ members ● 150 facilities ● 1-13 members at each facil● 1- 6 years of membership (

July 2006 onwards) 
Activities 

• Bi-monthly live meetings/confere• HF programs • Toolkits • Tools • SharePoint site as a discussion f• VA HF Experts • Research projects • Quality improvement (QI) projec• Solicitation for QUERI proposals • Surveys 
Activities: 

Bi-monthly live meetings/conferenc

As of 2012 • 7 Annual meetings and conference ca• 28 Bi-monthly live meetings/conferen Plan for bi-monthly meetings: 

- Announcements - Updates- Presentations with focus on barrie facilitators followed by discussion  from different facilities for followin a) Funded research project b) Quality improvement project a
Activities: 

Bi-monthly live meetings/conference call

Website: http://www.queri.research.va.gov/chf/networks/sScreenshot of webpage is below 
Activities: 

SharePoint site 

• CHF QUERI has a SharePoint on the i• All members are provided immediate • Members may:  - Discuss current topics related to the  improvement of care for HF patients - Share/exchange new ideas, news &  - Provide comments and feedback - Keep updated on conference calls aimportant announcements • Minimal traffic / SharePoint not really 
Activities: 

Tools 

CHF QUERI has various tools for: • HF NURSES: “Heart Failure Nurse Edu

conference was co-organized by CHF Dr. Mike Pham from the Palo Alto VA

 - Website: http://www.queri.research.va.gov/c

 nurse_education/default.cfm 

• HF PATIENTS:

 - HF Assessment Tool for self-manage track their health condition.  - Patient education materials  - Caregiver education materials 
Activities: 

Quality Improvement (QI) Project - “He

(HF) Provider Toolkit” 

• We have developed a comprehensive 

based (EB) “HF Toolkit for Provide

• Funding: CHF QUERI core funds • Goal: To provide EB comprehensive t

providers to better manage their HF p

• Toolkit materials are available throug

links and downloadable PDF documen
Method: • HF Network members were asked to 

existing tools 

• We reviewed existing quality tools be

recommended by non-VA HF organiz

AHA-GWTG & HFSA. 

• A multidisciplinary committee of VA c

nurses, pharmacists and a HF patien

screened and rated these tools. 

• Selected tools are organized into 18 

Activities: 

QI Project - “Heart Failure (HF) Provider T
HF Network Membership 

All members (July 2006 – October 2012) 

N=1110 

Current members 

N=910 

Attended 0 session 

All members 

n=325 

Current members 

n=223 

Attended 1-2 sessions 

All members 

n=416 

Current members 

n=344 

Attended 3-9 sessions 

All members 

n=273 

Current members 

n=241 

Att

All and Current HF Network M
Types of Members 

VFVCSNPQO
New Members Joinin

HF Network in Years 1

0 

50 

100 150 200 250 

Year 1 Year 2 Year 3 Year 4 Year 5 

# of Members 
Total Participation in HF Net

by Types of Members in Yea

0 

200 400 

600 800 

1000 1200 1400 

VACO & VISN 

leadership 

Facility 

leadership 

Chief of 

Cardiology 

Staff 

Physician 

Nurse 

# of Members 
HF Network Participation By 

0% 

10% 20% 30% 40% 50% 60% 70% 80% 90% 

100% 

Network Participation 

% VA Facilities 
HF Network Participatio

Academic Characteris

P=NS P=0.02 P=0.07 
HF Network Participation 

Volume 

P=0.02 P=0.006 
Is the HF Network Effe

• Formative evaluation of the HF Network 

to assess its value and make appropriatrefinements in the implementation strat

• We have adopted a “phased” approach 

formative evaluation of the HF Network 

• PHASE 1 is complete using mixed m

 - Survey: 115 members completed a w

 survey (32% response rate)

 - Interview: 17 members participated 

 structured phone interviews 

question-specific content an
Is the HF Network Effect

Research Project - VA H2H Initia

• Conducted a randomized trial titled 

“Implementation of the Hospital (H2H) Heart failure Initiative” 

• Funding: QUERI SDP: 09-160 • Goal: 1. Enroll VA facilities on H2H w

 2. Initiate projects to reduce HF • Method: i) Identified 122 facilities wi discharges over 2 years  ii) Randomized 1:1 to usual  Network activation 
Using the HF Network to Imp

National Quality Initiative 

0 

10 20 30 40 50 60 

VA Intervention facilities VA Control 

Percent Enrolled 

H2H Enrollment at Six months 
0 5 

10 

15 20 25 30 

Initiated Planne

Number of Projects 

Intervention Control 

New Projects Due to VA H2H Initiative 

Using the HF Network to Imp

a National Quality Initiative 
Using the HF Network to Imp

a National Quality Initiative 

0 

10 20 30 40 50 60 70 80 90 

100 

VA Other 

Percent Enrolled 

Facility Enrollment in H2H: 2012 
HF Network Participation and 

of Care 

CMS and Joint Commission Inpatient Performance Meas
HF Network Participation and 

Outcome Following a HF Dis

P=0.12 

P=0.17 
Results from Phase 1 Form

Evaluation of the HF Netw
Survey: Which of the following activ

been helpful to YOU? 

0 5 

10 15 20 

25 30 35 40 45 50 

HF programs 

presented 

Learning 

about barriers 

& facilitators 

Discussion 

about 

implementing 

changes based 

on IHI’s 5 

Million Lives 

Campaign 

Opportunity to 

collaborate 

with CHF 

QUERI 

Opportu

collabo

with o

provid

within t

Netw

% Agreed 
Survey: Overall, did participation in the H

sessions influence YOU in terms of the fo

0 

10 20 

30 40 50 60 70 80 90 

100 

% Agreed 
Survey: Benefit of Participation 

HF Network for Influential Mem

0 5 

10 15 20 25 

Self Not 

Influential 

Self 

Somewhat 

Influential 

Self Very 

Influential 

# of Respondents 

Participation Not Beneficial Participation Somewhat Beneficial Participation Very Beneficial 
Goals of the HF Network (rev

1. Share evidence-based HF programs 

updates in HF care 

2. Understand the context (e.g., facilit

leadership style, HF program) 

3. Learn about barriers and facilitators 

improve HF care 

4. Establish collaborations/networking 

members of the HF Network 

5. Provide opportunities to identify/inv

champions at facilities 
Interview: Which goals do YOU thi

0 

10 20 30 40 50 60 70 

% Agreed 

been achieved by the HF Network at le

moderate extent? 
Interview: What do you believe are 

significant BARRIERS to the succes

HF Network in achieving these go

1. Limited time 2. Short-staffed 3. Limited resources/info 4. Poor communication 5. Other (e.g., administrative difficultie

implementing new HF protocols; difffacilities in pt flow and difficulty tranbest practices between facilities) 
Interview: What do you believe ar

1. Moral support (supervisory/network2. Information on utilization (informat

shared with the purpose of future improvements 

3. Forms of Media (which helps disper

information such as phones and em

4. Other (e.g., person’s own commitm

specialty care; and continuing to heideas in HF care) 

significant FACILITATORS to the suc

HF Network in achieving these g
Interview: Members’ perceptions o

HF Network 

 “I have several people calling me...we are sharing a 

knowledge so everyone doesn’t have to start at “gr(Nurse Practitioner) 

 “What I learn and bring out of the program [session

share with the 2 physician extenders and the other (Clinician) 

 “These national calls are extremely helpful. Like I sa

to a facility like us where we don’t have the expertiscould really be off the mark in our management of wdoing here to us.” (Nurse) 

 “So to me, it seems like it’s a very nice way for the d

facilities to share what’s worked and what’s not worbrainstorm and share different ideas, so other peoptake that and also implement those at their site.” (P
Planning Phase 2

Formative Evaluation of the HF 
Phase 2: Formative Evaluation P

•••

Survey and interview guide are being to conduct Phase 2 of the formative eRRP proposal has been submitted to funding for this evaluation. CHF QUERI core funds will also be us
Phase 2: Formative Evaluation 

(contd.) 

• Mixed methods approach will be use• SURVEY: - All current HF Network members will complete a web-based survey. - Non-HF Network members (n=40) complete a web-based survey • INTERVIEW: 

-

Selected HF Network members (n

participate in semi-structured phone 
Conclusions 

• As a CoP the HF Network has provided 

forum to share and exchange ideas, antactic and explicit knowledge. 

• Variety of activities provide opportunitie

members to find “best-fit” in own area o

• Results from formative evaluation will b a. Make modifications to improve its v participating members and VHA lea b. Growth of similar CoPs within social  focusing on other health conditions 
Contact Info 

Anju Sahay PhD, Palo Alto VA 

anju.sahay@va.gov 

Paul Heidenreich MD, MS, Palo 

paul.heidenreich@va.gov