**Transcript of Cyberseminar**

**QUERI Implementation Research**

**Heart Failure Network of VA Providers: An Innovative Strategy for Implementation of Evidence Based Practices**

**Presenters: Anju Sahay, PhD;  Paul Heidenreich, MD**

**November 8, 2012**

**Heart Failure Network of VA Providers: An Innovative Strategy for Implementation of Evidence Based Practices**

**November 8, 2012**

Molly:We are at the top of the hour so at this time I would like to introduce our presenters. We have Dr. Anju Sahay and Dr. Paul Heidenreich; both work for the Chronic Heart Failure QUERI Group and they are located in VA Palo Alto, California. Dr. Sahay, are you ready to share your screen at this time?

Dr. Anju Sahay:Yes I am, Molly.

Molly:Great. All right. We are all set.

Dr. Anju Sahay:Thank you Molly. Paul and I would like to thank all of you for joining today’s presentation. We will be talking about the Heart Failure Network formed by the CHF QUERI and as Molly said, we are located here at the Palo Alto VA. There is no conflict of interest issues and funding for the Heart Failure Network has been provided by the CHF QUERI core funds.

The purpose of the Heart Failure Network and through this presentation is to describe our experience with the formation and use of a Community of Practice of VA providers as a strategy to improve care for heart failure patients and this was based on evidence based practices.

In terms of background, heart failure is associated with high mortality and poor quality of life. Moreover, it is the most common medical reason for admission within and outside of the VA Healthcare System. Reducing admission and readmission rates for heart failure are the goals of the CHF QUERI,VA in general, and non-VA partner organizations like the Institute for Healthcare Improvement.  

Now let us talk a little about social networks. There is growing interest in the use of social networks to facilitate knowledge exchange in healthcare settings. Research has shown that creating connectedness among providers using evidence-based practices in the treatment of specific disease may foster exchange of best practices. Also, social network structures provide opportunities for members to connect and share information. 

Here are some examples of existing social networks. These networks are condition specific and have been formed among providers with similar clinical interests. In British Columbia, Canada, there is a heart failure network of providers, which has different types of providers: cardiologists, internists, family physicians, nurses, pharmacists, dieticians, and social workers. In New York there is a network of providers focusing on tuberculosis and this network is associated with a 10-fold increase in the number of individuals receiving directly observed therapy. So, in other words, it is very effective. There is also a successful network in Montreal, which is the Montreal Stroke Network, and I will be talking a little more about it later.

Communities of Practice are emerging in a big way and they are a type of informal learning organization, gaining popularity specifically in the healthcare sector. According to Wenger, Communities of Practice are groups of people who share a concern, a set of problems or a passion about a topic, and who deepen their knowledge and expertise in this area by interacting on an ongoing basis. According to Wenger, the three fundamental elements make up a Community of Practice and these elements are: a) a domain of knowledge, which defines a set of issues; b) a community of people who care about this domain; c) shared practice that this community of people are developing to be effective in their domain.

Practice refers to a set of frameworks, ideas, tools, information, stories, and documents that a community people share among themselves. There are several examples where social Communities of Practice have been developed using social networks. Specifically, Norman and Huerta have examined building foundations for the Community of Practice using evaluation of social network methodologies. I just talked earlier about in Canada the Montreal Stroke Network and this network has different Communities of Practice which have been successful in developing and implementing critical inputs, such as referral tools that accelerate patients’ transition between acute care to rehabilitation.  

Specifically, our Heart Failure Network we have conceptualized this network as a Community of Practice and have used two complementary theoretical frameworks for implementation. The first one is PARIHS or Promoting Action on Research Implementation in Health Services. According to this framework, successful implementation is a function of three elements which are: evidence, context, and facilitation. Each of these elements has their own sub-elements. The other framework is Rogers’ Diffusion of Innovation Theory, which focuses on opinion leaders and their role in shepherding innovation.  

About this Heart Failure Network: this is a Community of Practice and it is a national network of VA providers who are interested in improving the quality of care for heart failure patients. Since the beginning this network has been supported by the Office of Patient Care Services, Dr. Bob Jesse was at that time Director for the National Cardiology Program and he was extremely supportive of this Heart Failure Network, and now Dr. John Rumsfeld is the director for the National Cardiology Program. He has continued to support this network.

The goals of this network are as follows: first, share evidence-based heart failure programs and facilitate their implementation. Understand the context; that is the culture, leadership style, and resources at the facilities. Third is, learn about barriers and facilitators to improve heart failure care. Fourth is, to establish collaborations, networking among members of the Heart Failure Network. Fifth is, to provide opportunities to identify and involve local champions at facilities.

So this network was formed in July 2006 and the way we started is that we had a list of names of Chiefs of Cardiology and Chiefs of Medicine at all VA facilities. So we sent an email to each of them asking them to identify providers at their facilities who would be interested in improving the quality of care and being involved with the Heart Failure Network; these providers were then contacted. When we say providers, they include administrators and quality managers so basically members who are these providers of the Heart Failure Network. It is a multidisciplinary group at multiple levels.  

Our goal was to include providers and staff from all VA facilities and so we do have members from all facilities. So members, at any time, can just send an email and ask to be removed. This is for different reasons; their role has changed, they are no longer interested in heart failure, or they just have too much on their plate. Also, the total number of members keeps changing because when providers leave the VA then we have to exclude them because this network is specifically for VA providers. We do keep getting emails from others, non-VA providers asking to join the network but we have to explain to them that we are willing to share our resources for the Heart Failure Network members but we cannot really include them as members.

So first we started the meeting was an in person annual meeting which was held in September 2006 in Seattle. This slide shows the connectedness of the Heart Failure Network members with VA stakeholders. On the left, we have the partnerships with different offices. The first one the Office of Principal Deputy Under Secretary, Dr. Jesse. Then, Office of Patient Care Services, GRECC and Nursing Service. We have members at all VA facilities and the different types of providers are there on the right side. We have leadership and administrators. We have VISN leadership and our executive committee members and local advisory board members also participate in this Heart Failure Network.

How does this network work? We have bimonthly live meetings or web-based meetings like the one that is going on right now with conference call.

Molly:I am sorry to interrupt. Brian, can you please mute your microphone. We are picking up the sound from your room. Sorry about that. Go ahead Anju.

Dr. Anju Sahay:So along with these bimonthly meetings we also, each year, we have an annual in-person meeting at a major heart failure conference which is the Heart Failure Society of America. The reason being, it is just so good. The value of face-to-face meetings and interacting and sharing and discussing is just so wonderful that members have really appreciated it. Earlier we could provide travel funds so we have more members attending that meeting, but as we all know, funds are an issue. But, we specifically are having it in conjunction with the Heart Failure Society of America’s meeting because many VA providers attend that meeting so it just works very well.  

We also communicate via emails, conference calls, then we have a website, which I will be showing shortly. We have a Share Point site and we have periodic surveys.  

Let me clarify through this presentation we will be talking about members attending sessions and by sessions we mean attending the bimonthly live meeting, annual in-person meeting, or completing a survey.  

Active participation in the Heart Failure Network and we have defined it as participating in at least one of the following activities: attend a bimonthly live meeting or conference call; attend annual in-person meeting at a major heart failure conference; completing a survey; or submitting letter of intent to CHF QUERI for QUERI funding. So, to date, we have received more than 120 letters of intent where members have expressed interest in submitting a QUERI proposal and many RRP proposals have been funded through this Heart Failure Network.

Our current membership: we have currently 910 members at each VA facility, and the members range from 1-13 members at each facility. Since the network started in 2006, we have completed six years of membership in the Heart Failure Network.

Here we will discuss some activities of the Heart Failure Network. We have the bimonthly live meeting conference calls. We have heart failure programs. We have toolkits and tools. We have a SharePoint site as a discussion forum. We have VA heart failure experts who other members may contact and have been contacting to get information and expertise with specific questions. We do research projects through the Heart Failure Network and we will be talking about one such project. We do quality improvement projections and again, I will be talking about one of them. We solicit for QUERI proposals and we conduct surveys; our most recent survey was because CHF QUERI is going in for three-year renewal and we are revising a strategic plan. So we conducted a survey with all the members of the Heart Failure Network asking them and getting their input about where should CHF QUERI be focusing in terms of our current goals and future goals. So this is really a wonderful way of getting input from all types of VA providers and leadership and staff.

So in terms of activities and bimonthly live meetings and conference calls to be specific, as of 2012 we have had seven annual in-person meetings and conference calls. We have had 28 bimonthly live meetings and conference calls. In the live meetings typically are the announcements, updates, and these are followed by two presentations by VA providers who discuss their programs and then there is open discussion with barriers, facilitators and lessons learned which have been very helpful to members. The first presentation focuses on a funded research project and the second one on quality improvement project at one facility. Sometimes we have non-VA presenters who talk about their projects or ongoing research, which is very valuable.

At this point I want to skip and I would like to show a website and where information is posted and what the different things CHF QUERI has been doing which will be helpful. So, here is the CHF QUERI website. With the cursor, here you will get information on the Heart Failure Network. It provides the overview, membership, and then the schedule for all of the meetings that are bimonthly and annual meetings we have had. There are downloadable slides and the name of the presenter at the end. So this is a nice archive and members can go back, especially due to time conflicts and other reasons if they cannot attend a session. They can all go here and then look up these things. We also have recordings, which is very helpful. The last session was our September in-person meeting in Seattle. 

We also have over here the SharePoint site. I had mentioned that CHF QUERI has a SharePoint site for Heart Failure Network members and the focus is to provide a forum for discussion to exchange ideas, to share interesting news and documents, provide comments and feedback, and keep them updated. So, everything we provide access to every new member of the CHF QUERI of the Heart Failure Network member. I do want to say that this SharePoint site has not been very useful. There is minimal traffic and it probably is because the members to access it with any other SharePoint site they have to be logged into the VA Network and then go in there. So, we had hoped that this would be much more active.

We have a catalogue of heart failure programs. These are presentations during the bimonthly sessions and other presentations, which we think are important. There is a nice catalogue here with the name of the contact person with an email address. Members have been contacting these presenters to get more information, which is the purpose of doing this.

The next step, VA hospital to home initiative. This is a funded research project, which has been conducted through the Heart Failure Network and Dr. Paul Heidenreich who will be talking about this in a little while.

Then we have a heart failure toolkit for providers. This is a quality improvement project that we did through the Heart Failure Network and I will just be talking about it. We had heart failure nurse education conference earlier this year. So if one was to click here, you know the slides from this conference and all information you can look at it here. We have got tools. Here is a list of VA heart failure experts who have been identified and offered to help. If I had clicked over here, this is what would have opened up, and here are the names of these experts. So members have been going and approaching them and getting help and discussing. So they do not really have to go through the Heart Failure CHF QUERI leadership. They can contact them directly, which has been very valuable.  

I will talk a little about heart failure toolkit for providers. That is a quality improvement project which we did through the Heart Failure Network using the members and involving them. We developed a comprehensive, evidence based toolkit called a heart failure toolkit for providers and this was funded with CHF QUERI’s core funds. The goal of this toolkit is to provide evidence-based comprehensive tool to VA providers to better manage their heart failure patients.

In terms of how we did it, the Heart Failure Network members were asked to share the existing tools developed by the VA to manage their heart failure patients because we know different facilities have been developing the tools so really did not want to go outside the VA and look for other tools. We reviewed these tools, which were sent by these members, and we also reviewed quality tools being used and recommended by the non-VA heart failure organizations like the American Heart Association’s Get With the Guidelines and the Heart Failure Society of America.

We then formed a multidisciplinary committee of VA clinicians, nurses, pharmacists, and VA patients. One VA patient who is also on our executive committee. This committee then reviewed, screened, and rated these tools. All selected tools were organized into 18 key areas and periodically we review these process tools and add and update these tools. There is opportunity to suggest a tool for any user who is accessing any providers accessing to suggest a tool provide feedback about a downloaded tool or provide comments. Here are the different categories. I will quickly scroll through them and the tools are organized as VA source, non-VA source and it could also be non-VA source Get With the Guidelines, so three possible categories. If you click on any of them it expands. So there is basically the PDFs and sometimes occasionally there may be web links. So these are downloadable tools.

Let me switch back to the slides. So the next few slides I already covered so I will just skip through them. This is about live meetings. This is a SharePoint site. The tools, heart failure nurse conference and heart failure patient tools.

Molly:Anju? Can I ask you to go back up into full screen mode? Thank you.

Dr. Anju Sahay:So here are the tools and then the quality improvement project that I discussed, that was a heart failure provider toolkit with the 18 different categories and downloadable tools. We talked about all of these.

Now I want to talk about the membership in the Heart Failure Network. Since the beginning, July 2006 up until now, we have had 1,110 members and currently there are 910 members. Like I said, the difference is because many of them have left the VA. Some have asked to be removed because they are no longer working with heart failure or their focus has changed or time commitment. So we have been tracking the participation of the members in terms of how many sessions they attended. So, you can see the three boxes; attended zero session in terms of all members and current members; attended one to two sessions, all members and current members; attended three to nine sessions, all current and; attended ten or more sessions and again sessions they joined a live meeting or attended in-person meeting or completed a survey.

This slide shows the different types of members in the Heart Failure Network. We have leadership at the Central Office level. We have facility level leadership. We have VISN level. There are Chiefs of Cardiology, staff physicians, which is a big number of members; similarly nurses are very well  represented. There are pharmacists. We have quality managers. We have others like who are like telehealth coordinators and psychologists, other researchers, and research assistants. So we think it is very well represented.

I will pass the next slides to Dr. Heidenreich for him to present them.

Dr. Paul Heidenreich:Thank you Anju. So I will just discuss briefly a little more description of who is enrolled primarily by facility. Then we will look to see if we have any evidence that the Heart Failure Network has been effective.

Dr. Anju Sahay:Paul, will you be managing the slides? Scrolling through them?

Dr. Paul Heidenreich:I can manage my desktop if that works.

Dr. Anju Sahay:Okay. Molly, could you please give him access.

Molly:Yes.

Dr. Anju Sahay:Thank you.

Dr. Paul Heidenreich:So people should be able to see this now. So this slide is just showing, in the number of members enrolling over the years, it has been, I think there was a little drop-off after it first initiated but we have actually been able to maintain a continued increase, which is I think surprising. I expected a large bolus first and then a sort of a small number but it continues to grow substantially.

In terms of actual participation, so it is one thing for someone to say, yes I would like to be involved and we are looking at people actually attending the teleconferences or the in-person meetings or providing or showing some other active participation. This slide shows that by type of provider we can see that the nurses have been the most active followed by the staff physicians. In fact, if one were to look at it on a per person basis, the nurses would be the most active. Again, many of these are nurses with an interest in heart failure often as part of a Cardiology program or heart failure clinic.

Okay, the participation by facility, if we were to look at the distribution across all of VA facilities and break it down by whether there is a number of participants going. So this sort if you had greater than ten participation episodes that could be ten people participating once or one person participating ten times, we can see that it is almost 40% of the facilities with 20% of facilities not participating at all.

Then we wanted to look at, well why do some facilities have more interest in participation than others and it looks like there is some evidence for academic affiliation as a predictor. Here we see Accreditation for Graduate Medical Education, again being slightly higher, though not significantly in those that have a high level of participation. Because of the Council on Teaching Hospital membership that was significantly higher in those that participated. We also calculated the percent of physicians board certified, this is early in the eight years ago but that was borderline significant again where there seemed to be facilities with more board certified physicians, again more likely to participate. It seemed to be that the more academic facilities were more likely to participate in the Heart Failure Network.

There are also significant differences based on bed size and/or other measures of volume. So here we see that the larger facilities again more likely to participate. Particularly true if that is calculated and determined by the number of heart failure discharges over a two year period. So I think the larger facilities, the ones with more heart failure, and the academic facilities are more likely to participate. Now in some ways this may, especially the bed size, that may indicate total number of resources at the facility and more people involved in quality improvement. It just may be easier for the clinicians to be involved in something like this.

So one question we heard of over the years is well this is a nice Community of Practice for people to share ideas and potentially learn from each other but can you actually show any type of objective evidence that it works. So we have done several things. One is a survey asking providers sort of if they feel it has had an effect and Anju will be discussing that in a second. That was done through both an online survey and then semistructured phone interviews in a smaller number.  

Another thing we have done is a randomized trial and part of this data, some of this data was presented earlier last week when we were discussing the H2H initiative. This was a QUERI funded project with one of the goals being to see if we could show an effect of the Heart Failure Network. For this we split the, we just randomly divided our 122 facilities that had at least 100+ heart failure discharges and put them into two groups; usual care or getting the Heart Failure Network involved in this project. So what this entailed was telling the facilities about the H2H program. For those of you who are not familiar with it, it is run by the Institute of Healthcare Improvement and the American College of Cardiology; so it’s a national program where they get members from hospitals to go enroll their hospital by basically agreeing to several principles: they want to reduce readmission rates and improve the transition of care for patients discharged with heart disease and in our case, heart failure. They are encouraged then, though not required, encouraged to start projects related to medication reconciliation education, getting patients seen back early within one week ideally and then also educating patients on their symptoms and what to do if those occur. 

So the goal is to develop programs in those areas and implement them. Then the national H2H program will test its effectiveness looking at rates and changes of readmission in Medicare. For us, we are going to, one of the options was to look within the VA data on readmission rates but our main goal here was just to see could we actually get hospitals enrolled in this non-VA program by encouraging HF Network members. So the usual care was actually just a discussion of this H2H with the VISN Chief Medical Officers as well as there is a director and Chief of Staff call and it was discussed with all of those directors and Chiefs of Staff. So that was sort of the top-down level. I think that is a typical way of dissemination. The Heart Failure Network was a more bottom-up method of getting people enrolled in H2H.

So we found was it was very successful. The control at six months after trying to engage the Heart Failure Network, we have just under 10% of controlled facilities enrolled and over half of the intervention facilities enrolled where we encouraged the Heart Failure Network. This was done through some email and through several teleconferences. Then following up we had several teleconferences where those facilities that enrolled quickly and started projects discussed what they were doing with the other intervention facilities. But just beyond enrollment we wanted to look at, well, are projects being initiated and that would be sort of the second step. Yes indeed, we did see projects were being initiated here, much more likely, in the blue group, in this here the intervention, versus the red, which is the control on both initiated and planned projects, related to the H2H initiative.

Then we also looked at how we did compared to the rest of the country. After six months, we then tried to enroll all of the facilities. We are currently up to over 60% of all VA facilities enrolled and this compares to, we have a sort of an upper bound probably of just under 30%. I think it is actually probably even closer to 20% when they get the final data for other U.S. so we are at least two if not three times as much have been successful in enrolling VA facilities as compared to the rest of the United States in the program.  

In terms of quality of care, we have four measures followed by the Joint Commission and CMS and publically reported by VA on the hospital compare website. These are all at a very high level and have been for a while. These in process of care measures for inpatient heart failure care they are a measurement of the ejection fraction in everyone. If that is low, then using an ACE inhibitor or angiotensin receptor blocker in patients who can tolerate it, discharge instructions in everyone, and smoking cessation counseling if appropriate. Again, I think at such a high-level no clear differences between groups.

When looking at mortality or readmission we have been unable to show a difference in outcome or mortality between those facilities at a high level of participation and low. These measures apply to the transition of care following a discharge. We obviously need some better measures because most of these patients are not hospitalized so we need some overall admission measures and some overall mortality measures would probably be more appropriate. Even with that, I think it will be hard to see differences in heart outcomes just at the facility level between those participating and not participating. Because, I do not think there is an incredibly strong effect of the network compared to other facilities.

So at this point, I will turn it back over to Anju Sahay to discuss some of the results of the formative evaluation of the Heart Failure Network.

Dr. Anju Sahay:Thank you Paul. We conducted a formative evaluation of the Heart Failure Network because you know both QUERI implementation and science consider it so important and it is important to assess the value of the implementation and to make appropriate refinements in implementation strategy.

Paul had mentioned that we used a phased approach and Phase I of formative evaluation is complete. We used a mixed methods approach. We conducted surveys, web-based surveys, with 115 members and had a 32% response rate and we conducted semistructured phone interviews with 17 members with question specific content analysis. 

Now in the survey one of the questions asked was, which of the following activities have been helpful to you? And it is interesting to see that all activities have been helpful to more than one-third to one-half of the members. So these are the programs presented, learning with barriers and facilitators, talking about and discussing the implementation changes based on the IHS Five Million Lives Campaign; at that time that was the quality improvement project we were conducting through the Heart Failure Network. The network has been providing them opportunities to collaborate with CHF QUERI and other providers and dissemination of QUERI projects. 

We also asked them; overall did participation in the Heart Failure Network sessions influence you in terms of these specific domains? The responses have been very encouraging. Members, four out of five domains, 90% of the members agreed that the participation helped them to understand facilitators and barriers in setting up or running their own heart failure clinical programs. Participation validated their current practice in taking care of their heart failure patients. It provided them with names of contacts from the Heart Failure Network for networking and for problem solving, which is really interesting. Two-thirds of them agreed that participation in the Heart Failure Network has helped them solve implementation-related problems at own facility.

We asked them about the self-influence and the benefit of participation. The results were very interesting. As you see, members who perceived themselves as being very influential, they also have found participation to be very beneficial. So that is good that it really provides and creates a lot of opportunities for development of local champions and opinion leaders to make changes based on the participation in knowledge sharing and learning which is going on through the Heart Failure Network. At the other end, members who do not see themselves as influential, they are finding the participation quite beneficial. So hopefully, there will be some future perspective changes.

This slide is just revisiting the goals of the Heart Failure Network; the five goals. It is linked to this next slide where we asked the members, which goals do you think have been achieved by the Heart Failure Network at least to a moderate extent? This is from the semistructured interviews with providers. Here we see about one-half of them agreed that all five goals of the Heart Failure Network have been achieved at least to a moderate extent.

Regarding the other goals, it is pretty encouraging, especially for sharing evidence-based heart failure programs and updates which is the focus of the QUERI program to make it evidence-based for implementation. Understanding context did not really achieve to the extent we would have liked it to be but learning what barriers and facilitators, establishing collaboration and networking, that has been achieved to a great extent, which is good to know. Because it is a social network and it is an informal network with providers from all levels and not just providers but administrators and quality managers; they all are interacting and kind of sharing information through this forum.

In the interviews we asked, what do you believe are the most significant barriers to the success of the Heart Failure Network in achieving these goals? They said, limited time, short or understaffed, limited resources, communications, and other reasons like limited support from administration.

We also asked them, what do you believe are the most significant facilitators to the success of the Heart Failure Network in achieving these goals? They said, moral support, information and utilization of different forms of media, which have been used to disperse information and other reasons like a person’s own commitment to heart failure specialty care and continuing to hear new ideas in heart failure care.

In the interviews we looked at some interesting goals in terms of the value of the Heart Failure Network perceived by these members. The first one over here is actually from a Nurse Practitioner.  She is one of the VA heart failure experts identified by the Heart Failure Network CHF QUERI and so she said, “I have several people calling me. We are sharing a lot of knowledge so everyone doesn’t have to start at ground zero.” And that is the whole purpose, you know, to share evidence-based programs and then to disseminate information shared from each other’s learning. So that was really good to hear.

A clinician said, and in this facility there was just one member at that point in time, “What I learn and bring out of the program, I usually share with two physician extenders and one other provider.”

Then a nurse, again it was a low participating facility, “These national calls (which are actually the live meetings) are extremely helpful. Like I said, especially to a facility like us where we don’t have the expertise here. We could really be off the mark in our management of what we are doing here to us.”

Then we have a quote from a pharmacist, “So to me it seems like it is a very nice way for the different facilities to share what has worked and what has not worked and to brainstorm and share different ideas so other people listening can take that and also implement those at their site.”

So this was good feedback that we got through the interviews.  

We are planning the next phase for the formative evaluation of the Heart Failure Network. We will again be using mixed methods approach; surveys and interviews. We are finalizing the guides and the survey. We have submitted RRP proposal to get funding for this effort and we will also use CHF QUERI core funds for the formative evaluation of the Heart Failure Network. Like I said, we are using a mixed method and the survey. We will be gathering data from all current Heart Failure Network members, except those who have joined just within the last six months because they may not know so much about the Heart Failure Network to respond to the survey.

At this time, we will also include non Heart Failure Network members to understand the value of such a network and if they know about it even though they are not participating. This subgroup, we will actually create by contacting all the Chiefs of Cardiology and Chiefs of Medicine at all the VA facilities and ask them to provide names of providers who would be interested in joining such a network. Once we get the names, we will check if those providers are already members of the Heart Failure Network and if not, then we will include them in this non Heart Failure Network members. The interviews again, will be with existing network members.

In conclusion, as a Community of Practice, the Heart Failure Network has provided an informal forum to share and exchange ideas and combine tacit and explicit knowledge. A variety of activities have provided opportunities to members to find best fit in their own area of interest and that has been the key thing because some providers are researchers and they are more interested in finding out about QUERI proposals or other sources of funding or doing quality improvement projects versus the other providers who just want to know what is the update about evidence-based care or to learn from other facilities about how they are doing things and how they can work with their limited resources.  So really, it is not one-size fits all. It is what is working for whom and that is really the whole focus for having it and engaging it in so many diverse activities.

The result from formative evaluation will be used to make modifications to improve the value of the Heart Failure Network for participating members and the VA leadership. Then this Community of Practice so also it will be helpful for the growth of similar Communities of Practice within social networks, focusing on other health conditions for veterans.  

I do want to mention that the Stroke QUERI also has a social network for providers who are interested in stroke conditions.

Thank you so much and we would like to take questions or any clarifications that people have.

Molly:Great. Thank you very much. To those attendees that joined us after the top of the hour to submit your questions just go to the go to webinar dashboard on the right hand size of your screen and type your question or comment into that section and press send and we will read it in the order that it is received. At this time, no questions have come in yet. Dr. Mittman, would you like to jump in and ask any?

Dr. Mittman:Sure, I think Paul and Anju, the discussion we have been having I think is one that may be of interest to some others to hear and that is the difference between this network and the Community of Practice; to what extent this is a Community of Practice within a network and then just, I guess, the relationship for correspondence between those different concepts.

Dr. Anju Sahay:Yes. I can take that one. So Communities of Practice they are a type of social network. We just feel that a Community of Practice, the advantage of seeing it more as a Community of Practice and not just a social network is that Communities of Practice are more focused and they have specific domains. So there is a formal of process for exchanging information and on sharing information. They have to go through different stages. So like I said, Community of Practice, according to Wenger they have three fundamental elements. There is a domain of knowledge; in our case it is heart failure and improving heart failure care. A community of people, which are the providers and administrators who are interested in improving the quality of care and learning more about it and sharing and a shared practice, that means different toolkits, we have other resources and so the members have actually been very involved in the development of all of the toolkits in different ways. Toolkits and different resources in different ways but it is really a community of people working together for a specific domain of knowledge. Some of these members would be very much more involved in a particular practice compared to others based on their interests, based on their time, based on their expertise, and their role. So it just makes it more scientific and has a good positive findings of Community of Practice have been very effective especially in the health sector.

Dr. Heidenreich:I would say, as with any probably Community of Practice, there is a spectrum of participants and so I think clearly there are some who are using it and who are involved in it and it is functioning as say Wenger described it. There is a lot of shared practice, discussion, and learning from each other. I think others do just use it as a list or of a way of hearing what is going on with the area but they are not actually making any active contribution.  But, I think that the core of it is I think those principles of the Community of Practice.

Dr. Mittman:Then the other topic I think is of interest are the implications of this approach and your experience for other clinical areas within VA. Is this an activity that is scalable and replicable and if so do you have any suggestions or recommendations for how others might proceed?

Dr. Paul Heidenreich:I will start with that. I definitely think there is opportunity for other areas to do this and I think, in many ways, it is how do the individual providers or staff or others sort of identify themselves and what do they feel is their expertise and interests. Often, that is a disease-specific interest but not always. Someone may feel they are an expert in transition of care or some other thing that would be similar across all areas. So, whatever that area is, I think if one does have or feel that something like this might be useful, I think then the next steps are to find, ideally find the leaders at facilities in the field. We were fortunate in that there already exists a list of say Cardiology Section Chiefs and while not all of those Cardiology Section Chiefs wanted to participate, they could point us in the right direction. So to the extent that such a list exists as a starting point, that is how I would encourage people to proceed.

Molly:Thank you. We do have a question that has come in from the audience. How do Community of Practice differ from shared medical appointment?

Dr. Anju Sahay:Community of Practice is an ongoing interaction among providers for a specific domain of knowledge. So it is long term. It is evolving. It has different stages. Shared medical appointments are where patients come in-group visits and they meet with different providers for that. So there is involvement of patient and provider in shared medical appointments where Community of Practice is more of a sharing of knowledge among providers. Paul, would you like to add anything?

Dr. Paul Heidenreich: It does bring up, I think what Wenger would say is, there are many types of groups where people have an interest and maybe a shared medical appointment is an example where everyone has an interest in diabetes, the patients as well. But, I think the Community of Practice would be limited to those with an expertise in that area who are then going to learn from each other about how to improve or learn about the practice. So it particularly limits itself in this case to the providers.

Molly:Thank you both for those responses. We do not have any more pending questions if either of you would like to give any concluding comments, you can do so now.

Dr. Anju Sahay:We had this Heart Failure Network for over six years now. We have been successful in kind of involving the members in different ways and different activities and we continue to have new members joining the Heart Failure Network, which is really good. For each bimonthly session we send out the emails and at each session we find a few new members who have joined. So basically, how they have heard about it is somebody has forwarded that information to them. So it is just a question of like spread which is just wonderful. From the interviews, also we have learned that it is just not the members who are learning. They are sharing that information with others which is exactly the goal. We know, again through formative evaluation and with other conversations with our Heart Failure Network members some members do participate actively by joining a session but then there are many who actually go to the website and they download the information about the programs or the presentations, or contact the heart failure experts. So it is really nice that there is so much sharing of tacit and explicit knowledge in so many different ways within the environment of this Community of Practice.

Dr. Paul Heidenreich:I will just conclude by saying, we still have I think a lot to learn about how best to use this group and how what we can do to help them get the most out of this. So I think we have made a good start but definitely a lot more to learn.

Molly:Thank you. We do have a couple last questions that have come in. The first one: Can you please show the slide of contact information again? And somebody is wondering how they can gain access to the Community of Practice or become a member.

Dr. Anju Sahay:To become a member you can send an email to Paul or myself and we will invite you to join the Heart Failure Network and definitely look forward to your participation. And here is the slide with our contact information.  

Molly:Excellent. Well thank you both very much for sharing your expertise and thank you to our attendees for joining us today. As you exit today’s presentation please do wait a moment and a feedback survey will upload on your web browser. Please take just a moment to fill out those questions as we want to provide you the sessions most relevant to your work. So thanks again everybody for joining us and have a wonderful day.

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