QUERI Implementation Practice- 11 -Department of Veteran Affairs

March 13, 2012

# Pick up on page 8,   42:09

# Department of Veteran Affairs

**QUERI Implementation Practice Seminar**

**“Fit to Stick” Spreading Effective Interventions in Healthcare**

**March 13, 2012**

**Presenter: John Øvretveit**

Moderator:  Well excellent.  Well then I’m going to introduce Dr. Brian Mittman.  He is the director of the Center for Implementation Practice and Research Support, also known as CIPRS.  And he will be introducing our speaker for today.  So, Brian, I’d like to turn it over to you at this time.  

Brian Mittman:  Okay.  Thanks again, Molly.  And I’d like to say that at this point our speaker needs no introduction.  I think he is vying for the award of most frequent presenter in the cyberseminar series, but I will provide a brief introduction to Professor John Øvretveit. 

He’s with the Karolinska Institutet in Sweden, spending the winter months with us in Southern California at CIPRS rather than in cold environment of Stockholm.  He will be speaking this morning, this afternoon on the issue of scale up in spread of innovations. 

Briefly this is an issue that’s attracting increased interest on the part of the implementation and research community based on the recognitions that where we are able to successfully facilitate implementation and adoption of innovation within a small group of clinics, or hospitals or sites participating in a project that success does not necessarily lead directly to a broader scale of the spread.  The scale up and spread barriers require the same kinds of intensive effort as the initial implementation. 

So from a research perspective these issues are important, but clearly from the practice and policy perspective as well, especially within an organization like VA that does take pride in its degree of innovativeness and the desire to constantly improve and adopt new programs.  The barriers of scale up and spread are significant for practice policy purposes as well.  And so the hope is that Professor Øvretveit’s presentation provides us with all the answers and guidance that we need, but we look forward to the presentation and to your questions at the end of the session. 

John Øvretveit:  Thank you very much, Brian, and also big thanks the CIPRS and also Linda Rubenstein.  Brian has been particularly helpful.  I won’t blame the mistakes on him. Those were all mine, but working here with Brian and also with Lisa and her team has allowed me to understand much more about this subject to take some of this back, not just to our work in Sweden where we have 21 different health systems across which spread proven treatments, but also in our work in developing countries and with NGOs in areas where spread and scale are really a big issue.  So I benefited greatly from being at some of the forefront research here and also in the VA where and you are doing terrific work.  And I think the direction that the work needs to go down in terms of being even more practical and applied is one of the subjects are we getting to. 

So as regards to the outcome, what are the...  of this seminar what I’ll be talking about is about moving from a project where an intervention has been reasonably well tested, may even be a trial or guidelines that incorporate research and how to start getting that into everyday practice in first of all a small number of services which I’ll call limited spread Phase 2.  And I will make a separation between that and the greater take up of the proven practice in what I’ll call the second possible chasm that may be between a local spread and then wider national spread. 

I’ll be talking about the research on this subject and talking about some of the missing research and also some of the methods and approaches we might use to fill that gap. So in terms of the outline I’ll explore the problem and illustrate some of the issues.  Then I’ll talk about what research there is to help people working on this and the research needed.  

So I’ll characterize on slide three the problem that essentially we know more about what works than about how to enable ordinary services say fifty percent at least to use it.  And I’m talking about effective treatments, effective care practices and effective service delivery models, for example from a care model. 

And we see that there is a fairly slow and patchy uptake of these in services.  There is a tremendous—there is great potential to reduce avoidable suffering and reduce costs as well if we had faster and wider uptake.  And we know this because we also know that there are ways to put them into practice more quickly so that there’s the beginning of knowledge about implementation and spread we can draw on.  So it’s an opportunity we now have. 

As regards to research problems I’m going to show you what the knowledge about what works and for implementation is not known much or used by practitioners.  Now some of you might say well that’s not a research problem.  I think it now is much more so.  The researchers have much more of a duty and indeed more of a requirement to move beyond the [roll of] overall application research into taking an active role in I won’t say advocating but let’s call it social marketing their research. 

I also think that a challenge is the underdeveloped methods to finding and developing effective implementation spread approach.  And I’ll talk about what I mean by spread approach later.  

I don’t think this path of research in the research priority and I think that’s an issue.  And I hope that will change.  I think there is time to just change it.  And I think some of the attitudes towards research and implementation spreads are also the rewards in this sort of research are not encouraging of this kind of research.  It’s often viewed as too much on the applied end and not real research.  And I’ll come back to those parts later.  

So what I’m going to now is on slide six is just giving an example.  And I’m—this isn’t a real example but it’s close to a real one.  Let’s talk about a Type 1 spread.  And this is first of all there’s a local test of a thing called an automatic telephone assessment for depression in diabetes.  And this is done in one primary care center. 

Now let me put this simply.  The primary care center it starts to use an innovation whereby a service calls people with diabetes to invite them to go through a series of questions on an automatic telephone assessment.  

Now in one sense it’s an amusing thing and only could be developed in America, but if you think it through you could see some sense to this both in terms of the cost and potential benefits if it’s good detection, but the idea of would if you’re really depressed would you answer the phone?  Secondly, would you go through some sort of robot asking you questions and give your most personal data over the phone like this?  

So that is to help you understand what the intervention is and some of the issues here anyway, but the findings of this focused local test was yes it is low cost and there is pretty good detection and it allowed our primary care people to do follow-up treatments.  And patients gave better appearance in their diabetes and there is some indication that certainly the treatments for depression were effective especially amongst of the older folks. 

And there is evidence of the less utilization.  Now that sort of evidence is a bit laboring because it’s a local test and people can well argue well actually there are other explanations for these changes in adherence and utilization.  And we’ll get on to that in the next slide in the trial, but anyway this local test that looked encouraging and promising was presented by the team that did this experiment at a network meeting of primary care physicians. 

And they got a couple of local leaders on their side to say well actually this looked good and worth supporting.  And to some degree because of the charisma and enthusiasm of the team for this there were a number of naysayers that said where actually this isn’t strong enough evidence, but many others said, yeah, this is good to try out and go with.  

So there was a rapid take up in the local primary care unit in that area, but actually didn’t spread beyond simply because, well one reason being is that it wasn’t published or much known about.  It was sort of informally known. 

So let’s go to the second example where it’s the same intervention, the automatic telephone assessment, but it’s a trial that compares one center doing this with another center who don’t do it.  And the findings were pretty much the same that actually there is a cost savings which it is patients with diabetes, et cetera, et cetera being this still wobbly  test or spared evaluation was published.  We’re just looking at two centers and not many patients being compared.  

And the result was well a resounding thud.  No one took any notice.  And now after the research funding finished there wasn’t any budget or time for this system and it was slowly dropped or were not that the telephone service was dropped.  So let’s go to the third example. 

And what we’ve got here is a proper American large scale “put some money into it and let’s check this one out”, 90 primary health care centers with 90 matched all over the country versus usual care as before.  And the findings, well there was because this was a proper study there were discrepancies between what the telephone assessments revealed and what the experts identified in terms of depression. 

We don’t know which of these is actually closer to the real occurrence of depression. Some people say the experts aren’t always a better judge, but the surprising thing was that there were comparable reductions in utilization and comparable benefits.

Again this was published stronger evidence, but again no one took any notice.  And again after the research funding for this and the support to actually get the follow-up to happen there was no budget or time for many of the centers to keep running it, no word on the study of which centers kept doing it. 

Now this is not a real example.  It’s a sort of a characterization of what I think might be expected.  And I’m interested in your views and so it’s poll time.  Does this fit with your experience of understanding of the literature for all of the three types?  So sorry about this, but time requires that you say is this for all of these three types more or less fits with your understanding. It’s one for yes, two no not at all, and three for well it does fit partially. 

Moderator:  Thank you, John. The poll question is up on our attendees’ screens at this time.  And the answers are flooding in.  We’ve had about fifty percent response rate right now so we’ll give it a few more seconds before I share the results with everyone.  And just for anybody this is your first time joining us just go ahead and click on that circle next to the answer that best fits your opinion and that is it’s that simple.  So we’ve now had about sixty percent of people vote and we’ll give it just a few more seconds. 

Okay.  The responses have stopped coming in so I’m going to go ahead, and close it and share the results.  And to do so I’m going to take back screen view for just a second and, John, if you want to talk through those results feel free. 

John Øvretveit:  So well oh goodness sixty-three say that’s it.  Now only four percent, I am surprised actually, and a partial fit thirty-two, well that’s interesting also is which of those types makes sense and which doesn’t.  So to some degree we’re reflecting some people’s understanding of the literature and maybe their experience as well.  

So what I’ll do is go on to give my speculations about what might explain this.  And we all have our theories.  Here’s John’s theory is that the first small-scale local test where it’s spread locally but not beyond, well why didn’t it spread further?  

Well first of all the evidence was limited so there was an evidence weakness I think, but this was countered by the enthusiasm and the late stepping in of the key two leaders saying and we’ll put some money to support others to introduce this.  And we’re not going to wait for stronger evidence.  

Also this being America there was a low-cost offer by the telephone service to try and get a foothold in this potentially important market.  So the telephone service that was contracted to do, run this system made it very advantageous, or put it this way reduced the barriers to other centers using.  And then we have the charismatic trio of medical leader, nurse and social worker together arguing the case and doing a great triple act in presenting it and telling it, and like I said the sympathetic local leaders.  

So the type two moving on to eleven, here we had a one site trial, slightly stronger evidence, not much stronger, but basically the study would only get published in a scientific IT journal and people don’t read that.  There wasn’t any push by the pioneers or others selling and there was no infrastructure for spread so that went nowhere.  

The third where we have the ninety sites doing it compared to ninety not doing it, well there were questions about the sensitivity and the specificity of the telephone assessment, but again no practitioners wrote about it and it wasn’t as it were widely covered in the professional media, no push, no funding.  So that disappeared. 

So on thirteen we’ve got kind of a summary of where I’m up to a bit.  Why is there such a chasm between a project or a set of guidelines and it being widely taken up?  And it is better to think of this another way, which is why do you actually expect that this should being would automatically spread for every proven or promising care practice or intervention of which there are hundreds if not thousands?  

There was the question about actually is it proven enough and the issue about the telephone assessment, but no one reads it anyway.  Now I think there are some other questions going on here is there are others have doubts about would it work in our setting.  I mentioned the issues about infrastructure and support for this and also the little push to get it out there beyond the charismatic trio locally. 

And then there are chasms between systems and services so you could see how it might spread within one VA VISN or in one VA division with a bit of infrastructure and push, but it wouldn’t jump hosts of it between the VA and Kaiser or others.  There is no real crossing system infrastructure unless you’ve got some sort of collaborative thing going.  

So there are chasms there that one needs to think about.  And a key issue is the funding. 

Now let me now move from that to a real example of a chasm.  This is a chasm from looking at guidelines to widespread use.  And this is quite an old study, but an interesting one that puts together these three, four concept framework.  

And this was looking at the implementation of guidelines for vaccinations in pediatrics and I think it was in the early ‘80s actually.  And the concept was how many physicians were aware of the guidelines.  They simply oh yes there’s a guideline on that.  

How many physicians agreed with the guidelines saying, yeah that makes sense.  It’s a good guideline, but then how many actually adopted, they decide, and that means to follow for some patients those really beginning adoption?  

And then there’s adherence.  Did they follow the guidelines rigorously and appropriately for all patients?  So you would call that fidelity.  

Now interesting on an aside I’ll come back to is this also is a very good framework for looking at patient treatment adherence.  And I’m surprised that to my knowledge no one has used it for that.  

Now what we’ve got on the next one is an actual review that used these concepts to review research into awareness to adherence for guidelines.  And they were able from the data to draw these different graphs to show how much people who were aware of the guidelines actually rigorously adhered to it with all patients and all time.  

And you see some interesting differences the different guidelines that throws up to more interesting questions.  And again we won’t theorize about this, but if we go, we see from the aspirin, the stable angina that quite a few people go through the full implementation on that one, but then if we look at beta blockers twenty percent of those who agree actually adopt.  And then they once they adopt they adhere to that, which is interesting. 

Now if we turn to controlling LDLs cholesterol we see a big drop from the green to actually beginning to adopt it, but if you begin to adopt it most people actually adopt it properly and keep going with it, which is interesting, but then one of the most interesting ones is the chronic heart failure form of therapy.  And here eighty percent of those who adopt it and a big drop there between starting to use it and actually adhering to the guideline appropriately with all patients.  

So this is way of thinking or one way of conceptualizing or thinking about spreads which we might come back to.  Now here’s John’s—you know John.  He’s always theorizing about evidence, but this is based on observation of an experience both HIV AIDS and other programs in developing countries, but also Western innovations.  

Basically some things spread rapidly.  You have to work hard to stop them, minimally invasive surgery.  And there’s often compelling cost savings behind that.  

Some things spread slowly and in patches.  And we’ve seen some interesting examples of that with preventing admission of high users in hot spots mapping innovations in that area.  

Some things are proven, but there’s actually a very low uptake.  The evidence is great, but it doesn’t spread straight from the research fridge.  Some things spread fast in spite of negative evidence, possibly because people don’t know about the negative evidence, and a very good Rand study, Teryl Nuckols on smart IV pumps and some of the dangers that certainly the early ones. 

Now what was this?  Oh the critic is saying they are also very interesting, but which things spread rapidly, and which don’t and why?  What’s going on here?  You say you are researchers.  What’s your explanation?  

Well there are two possible explanations.  One is sort of well here’s the theory.  And then the other is well here’s the evidence that might explain that.  And I think we’re a bit better on theories than we are on the evidence for each of those because this there’s not a lot of research in that particular area and I’ll come back to that.  

So here’s a simple summary.  We’ve seen this before.  The seed is the evidence-based intervention or the concept, the idea.  And you have to have the implementers, plant and nurture it.  And I’m calling them here the bridging implementers that they make the bridge from the projects or the trials and their actions and plan are part of this box. 

But then there is the climate and the soil.  And part of that is to support infrastructure that the implementers have, those features of the local organization that are supportive of the gardener.  And they’ve also a wider environment like the financing issues and regulation issues. 

And the way, the quick way to remember this and this isn’t totally accurate, but to say we’re talking here about a product.  Is there enough push but you also need pull as well.  And that’s a quick way to remember this.  

And I got this idea, these ideas from visiting the folks at Stanford and looking at their research into technological innovations in Silicon Valley and what works and what doesn’t.  And you can get a lot sold if you have a really big push, but what the magic is is to understand the pull and then to put your venture capital into the product.  And you hardly have to do much push.  Or put it this way, the money you put into the push really, really gets sucked up in the pull. 

And some of those ideas might be worth thinking about as a simple way of thinking about bridging this chasm from tests and guidelines.  So there are features of the product that are important.  And then there are features of the push.  And if you’ve got enthusiastic and the right implementers and with a good plan this can go a long way. 

Now interestingly on the pull side of things basically the service that hosts or takes it out this is the local environment has to experience it as a problem.  It has also to fit with the values and make sense.  It must not be rejected by the host in the sense of just that people think its worthwhile spending their time and effort on it and that there is enough people who think that. 

Now services are capable of adopting it.  This is you can argue well this might be a push that actually to enable or part of the push side is you’ve got to have an infrastructure and that will support those people in their change and resources, but you could say will actually it’s a pull things.  You can argue that either way. 

The environment should not be hostile.  It may even be helpful.  For example it may be mandated and may be financed there.  And there may be other factors if we start looking at the in phase two to three spread, which is the national.  There may be other issues there. 

So the point here is this is a quick way of summarizing some of the issues that local personalities are very important, but also is the evidence, but also the fact that you can call on peers to say well this what we did, and so to not just the raw evidence of yes it is effective and positive, but you also have peers that can describe their situation and how they did it like in a collaborative.  And thirty percent is like your implementation is basically if you’ve got the skills, charisma, the clinical leaders that are behind it, but a lot of it is nothing to do with you.  It’s just acquirement and whether your context enables it with infrastructure and also issues like those [trying it] with the payoff to it. 

I’m going to have to move on quite quickly.  I’ll jump over this one to raise questions about whether there’s another chasm going from local more widely to go straight on to the help that research can give to chasm bridgers.  And what I’ve got, what we’ve got here and the role model, Evel Knieval research entrepreneurs that don’t take no for an answer, now for those in another generation Evel Knieval was very popular internationally, maybe even more popular in the States as being a hero or madman who jumped chasms.  

And the point of this is to say there are some Evel Knieval researcher entrepreneurs examples with the Eric Coleman on the transitions, Peter Pronovast. I would put Lisa in that category with in the TIDES depression care, other even put Steven Asch there with chronic heart failure in HIV and AIDS.  And these are researchers who realize that actually thrown over the wall the more research is not good enough.  It’s not where it ends. It’s there is something good here that can make a difference with people and save lives if not save a lot of suffering.  And we’ve got to get it out there and we are going to find a way.  

Now the point here is that leaders are important, but they’re not the only ingredient.  And we shouldn’t...  our spread of these wonderful innovations that can make such a difference shouldn’t depend on having unusual leaders who will not take no for an answer, and should be more of an integrated future of our system that actually this isn’t just a one-off.  This is how we do business.  We have a pipeline for finding and putting into practice in an organized way. 

To a certain extent the whole QUERI program is one of those.  So let’s look at what research can give to other chasm bridgers.  This picture of poor old Evel was some meant to come up later, but I’d better start with that because everyone is interested.  The point here is that actually there are just as there are Eric Colemans and Steve Aschs there are also quite a few people who have just got burned out and gave up and said I just can’t get any traction on this.  And Evel had a few broken bones as well. 

What I’m—I won’t have time to go through all of this, but some of the research that we can give to certainly practiced-based chasm bridgers is...  a very useful one is the Health Research Educational Trust assessment tool that I’ll talk about next.  Useful also are concept... ways of thinking about what in health spread, thinking about different spread approaches and implementations, so I’m going to go through this very quickly as time is running out. 

The research-based assessment tool, do look it up.  It’s evidence based and there are information about how it’s developed.  There are different categories and you can work out readiness for spread scale of your organization. 

Now I’m going to go on to implementation approaches which is... this is one set of ways of thinking about the issue.  The first one is a distinction between the intervention, the essentially... I’m gonna call the intervention the product or the content of the intervention.  We’ll distinguish it from how that is implemented.  And that’s not a common sense of the term.

And ultimately you can argue it’s not useful when implementation involves iterative production so that your implementation in many ways is a key part of the intervention where you’re changing or developing the intervention context as you go through implementation, which is what ties in some of the PACT  programs there.  So just to illustrate that here’s an example of a complex intervention content or product and it’s the central line associated drug stream to actually bundle CDC guidelines boiled down to the really short guidelines. 

And the next one is one implementation approach which most of you are familiar with is a breakthrough collaborative method is a to find and then get the content into practice.  And it may or may not require an elaborate plan do check testing depending on how much people adapt to it. 

Now the next one then is here is a set of ideas about four elements to look at when you are looking at an intentional spread program.  First of all go start where the money is. Is there money to pay for the spread? 

So if we think about a collaborative pro-pre program and many programs have to be paid for and for one year or two, and some of the money and resources comes from ordinary services that some of the people with their budgets so that there has to be money.  And there also has to be a structure so there are groups at all levels for example IHI or VHA collaborative breakthrough organizers that run it, and I’m showing there are three levels of structure groups and accountability.  

Then there has to be systems which is we’ll know the issues about project teams saying well we didn’t have time or we couldn’t collect the data.  And they need to be systems that make it quicker and easier for the project team to get the data to do measurement and do feedback.  And they have to be other systems. 

Steps and methods is the last of these four elements, which is basically the planning, and then the learning sessions and the telephone calls between and maybe post-collaborative follow-up. And these are the sequence of activities.  And this is one way of saying actually these are the four key things to look at when you’re looking at intentional spread. 

So that’s summarized in the next slide which is simply summarizes it and says what those are.  So the next slide and I’m to move fast now, so this FSSS is this the theory then?  Well I’ll leave that to you to say and saying it’s a in my observation of many different spread and implementation programs this is what I’ve picked out as the key things that would help us define and differentiate different approaches to spread. 

And what I’m going to argue is that some implementation approaches are more suited to some interventions than others.  And I’m going to argue that you should match the type of intervention that is to be spread with your approach to implementation.  I’ll illustrate this on two. 

Therefore I mean to change individual physician prescribing.  Then this approach may be more effective than doing a collaborative.  Basically you have investment in operations and support. You have a structure of nationally credible researchers, local physician opinion leaders, peer project teams and you have a group of academic detailers in one-to-one. 

And then you have systems to give people data back on their prescribing, but you could potentially use as a basis for paying traditions to share savings.  And then you have the systematic steps of training, feedback, academic detailing.  And that’s a different approach to a collaborative, for example in Finland we’ve had some major success with changing physician prescribing using that sort of approach characterized in that way, but if we are looking at implementing at clinical decisions thought system on top of an existing EMR, and it may be a system about alerts for prescribing, what I’m going to argue is that your FSS is going to be different or needs to be different. 

And then if you’re implementing a chronic care [inaudible] type disease management model or a falls prevention program then it’s going to need to be different.  And basically the finance structure systems and systematic steps framework allows you to explore what way the implementation approach is similar and different.  And you could look at different national or regional spreads to examine what’s going on. 

So there are also as their context match and I’ll jump over that and go towards the conclusions now that we need to finish off shortly.  This title, “Fit to Stick,” what’s going on here?  What’s this about?  

It has two meanings.  First of all is it fit and ready to be spread?  And there is a big debate and set of issues about how much evidence you need and how many different places before you really put money and time into intentional spread.  

You may not have the opportunity to answer that question because people may be already doing it.  The issue is actually you need to stop people spreading this one.  

So is it tested enough?  The second meaning is does it fit in terms of spread, square peg in a round hole?  Is it matched?  It has to fit the context. 

And that relates to the “Goldilocks Implementation Principle.” Improvement has to be different but not too different for it to be implemented unless you give it a major push and you make changes to give it a big pull, and to some extent with some safety innovations that’s what happens is the “Goldilocks Implementation Principle” did not apply in -- let me think.  I’m trying to think of one of the joint commission safety goals, maybe ventilator associated pneumonia prevention or rapid response team. It violated the Goldilocks Principle, but there was enough push and joint commission, I wouldn’t say, well I supposed it is mandated.  And also there is a little bit of evidence of the business case.  

So now let me go on to the research agenda.  I won’t have time to cover all the four subjects, but this is as it were my suggestion of our research agenda for those interested in pioneering this issue. What I’m going to do is say why the implementation research is important.  I’m going to say that practitioners have questions that we’re just not addressing in part because our methods are not well developed for that.  And I’m going to say something about yes but also be compassionate for the researchers because the way we are paid, rewarded and promoted make it very difficult for us to be getting into this area.  I think that’s changing, but I won’t talk about slide 36 because we don’t have time. 

What I’m going to do is go on to page... the next slide which is to say where I’m talking about is the translation 3 bit on the right.  Most of the money and research is on the earlier translations.  And I’m going to argue or I’m going to raise the question would a bit more research and finance into the T, the translation 3 looking at interventions to providers to use the treatment and indeed the patients pay back more than some of the earlier bits?  

And there’s an interesting debate there.  Let me put it another way and my—and this was inspired by Ross Glasgow who did it, illustrated it very well. 

If you look at implementation pathways that might agree to adherence,  if you get fifty percent of services decide, yeah, we’ll adopt this, and then that’s the service, but then there’s the clinicians, fifty percent of them say, yeah, okay I’ll do that, but then you’ve got the patients.  Well only fifty percent of them do it.  Only fifty percent of them adhere correctly.  

Basically after six months you’ve got about two percent of patients who are actually benefitting.  And what’s that going to be after two years if we look at a proven intervention for example stroke and heart attack?

So here’s another way of illustrating why implementation research is important.  Supposing you’re a social venture capitalist, would you put your hundred million into better drug treatment research or into implementation research?  

Well if you’re a real venture capitalist you’d put it into something you can pay and then make money on.  And but maybe more knowledge about putting it into practice would be of much greater social benefits than some of the research which is done.  

And what are the questions that this research needs to answer?  Well there are questions hanging there that decision makers have which are not well answered.  For example how certain do we need to be before we spread it?  I know there are some of them that are not bothered about that, but if Frank’s system is doing it well that’s good enough for us.  We should put this into practice. 

Local applicability, what do we actually have to do to copy it?  What are the time and money costs and the savings?  What will the current financing system mean that we actually, if we did make this change, will we actually start losing money as a result of all that time and effort?  And that’s a big debate at the moment.  And one, well, anyway, I think there are very interesting changes in the States over the next two years with the ACA coming into place that is going to change some of those equations.  

I’m going to move straight on because I want to give a chance for questions or points.  Going on to some of the strategies that we might use to develop answers, well that was covered in the—some of that was covered in the cyberseminar.  

The next one is one is a research agenda.  And here I think is an important topic.  First one is describing different successful and unsuccessful spreads.  And I think the VA is a perfect place to be looking at some improvement interventions that were maybe taken up in one VISN or even in one medical center system.  

And there was an intention to spread it, but it went nowhere, but on the other hand there were others where there was really quite successful spread.  And I think that—I think by exploring that the VA could make a major contribution to research in this field by looking at that.  

And also we can check out because some other factors are controlled is there actually a phase two to phase three issue, a chasm between local and national within the VA?  Secondly, we could test hypotheses that different categories of interventions need different spread strategies.  We’ve used that trend work to test that.

And just to give a feel for what I’m talking about is there are a group of interventions that are around primarily provider behavior change.  And they are either simple or complex.  There are some which show a much more involving service delivery that involves provider behavior change, but also pretty major organizational change.  

And I suppose [inaudible] a chronic care model, team-based care approaches, but then I would suggest that in information communication technology intervention may be there are a range of those that may be different.  And then there may be a method intervention. 

I’m going to finish off there if any a chance for reactions, but the research needed one if we go through—so the research challenges this is about being fair on us researchers to say the way research is structured doesn’t make it easy to get into those sorts of issues, but then I think in many ways Lisa Rubenstein and Steve Asch have shown and you can go a fair way on that.  And I would say that this is certainly a very interesting final frontier where people...  it’s really the end of the translation pipeline if you accept that message for that this is where some of the biggest difference can be made, more resources on the website, which is the next one so I won’t go into that.   

And I think I’ve got the [inaudible] that spread to there as well. 

Brian Mittman:  Thank you.  So I think we have time for a couple of questions that came in during the seminar.  There are others that we will try to answer after the seminar by email.  The first question is do you comment on the value of focusing on the organizational context or the climate soil factor?  To what extent does this problem as solvable by basically strengthening the context?  

John Øvretveit:  There are two aspects to context.  One is the—well in fact context is in layers.  There is facility.  There is I suppose VISN level.  Then there’s possibly national.  And then there’s outside the VA and what’s going on there. 

And I think the chances of spread are affected by what goes on at all of those levels.  Now in theory you would need to... I won’t say create.  There’s no way of making a nurturing climate for a specific spread by working on all of those levels, but you can certainly identify influences at each of those levels that make it nearly impossible, however much, however hard you try and however strong the evidence is to get something into place if you’ve got... if the financing is all wrong or if it’s not, it’s simply not a VA priority.  Then it—don’t try and push water up hill. 

So I’ve forgotten what the question was.  What was it?

Brian Mittman:  Is to what extent is strengthening the context of physicians to overcome many areas you discussed?

John Øvretveit:  Well I think we’re not there yet.  I think the issue is very much pay attention to context.  And the argument would be well you only pay attention to context if you do something about it.  My argument is well certainly be aware of the context factors that make it just impossible to get good spread on a particular item.  

Now for other things that are a priority then it’s useful to identify some of the hostile influences in context.  And now you could say, yeah, well is that research or is that really what people in services should be doing?

And I think that’s what this sort of work directs to is it really does break down the boundaries between research and operations and opens up the possibility of much more practical research to work with operations to identify those things.  

Brian Mittman:  And we are at the top of the hour, but to the extent that the next question may be a yes/ no question let me try to fit it in.  The question is whether full implementation is ultimately a function of accountability if we have appropriate pressure and expectations and accountability from VA central office.  Is that sufficient to achieve spread?

John Øvretveit:  Well it is in Russia or it was in Russia.  I don’t know if we’re looking at the States, all of these different regions and then we add in physicians because, just because many physicians are salaried in the VA doesn’t mean they always do what they’re told to do.  And I think there is exactly the same issue in Kaiser and other systems.  

So I don’t think there’s—you have to sell things to people, and put the case, and persuade and understand why it is and isn’t in their advantage to do something.  You can’t do everything by direct—well you can’t do much to all by directive, certainly from what I’ve seen in this country. 

Brian Mittman:  Great.  Thank you.  And I thank you again for the presentation and sharing your work with us, Molly, back to you. 

Moderator:  I would like to second that.  Thank you very much for sharing your expertise and thank you to John and Debbie for helping coordinate this session.  And as we are past the top of the hour this will conclude it.  I will send any unanswered questions in writing to John and Brian and hopefully we can get some written responses back which I will then disseminate to all of our attendees, so look for your follow-up e-mails.  Thanks again for joining us and this does conclude today’s HSR&D cyberseminar.  

John Øvretveit:  And a big thanks to Molly for her work on this.  

Moderator:  Happy to do it.  We’re just lucky to have you presenting.  Thanks, John. 

**[End of Recording]**