Evaluating Evidence-Based Quality Improvement of Comprehensive Women's Health Care Implementation in Low-Performing VAs

Gaps in delivery of gender-sensitive comprehensive care have resulted in disparities in quality and patient experience among women seen in VA. VA policy action providing guidance on delivery of comprehensive healthcare services for women Veterans was disseminated nationally in 2010, followed by annual assessments and site visits evaluating local VA efforts. While substantial inroads have been made, policy implementation, even when leveraged by field-based women's health leaders, has not been uniformly successful in achieving delivery of comprehensive care by designated providers in gender-sensitive care environments that ensure women's privacy, dignity and safety, all tenets of the original guidance and the updated directive (2017).

Building on prior effectiveness of an evidence-based quality improvement (EBQI) approach to tailoring VA's medical home model -- Patient Aligned Care Teams (PACT) -- to the needs of women Veterans, VA leaders in women's health adopted EBQI to help low-performing VAs systematically improve services.

The objectives of the resulting Partnered Evaluation Initiative (PEI) funded by VA's Quality Enhancement Research Initiative and VA Office of Women's Health were:

1. To evaluate barriers and facilitators to achieving delivery of comprehensive women's health care in the identified low-performing VAs;
2. To evaluate effectiveness of EBQI in supporting low-performing VA facilities achieve improved organizational features, provider/staff attitudes, quality of care, and patient experiences among women Veteran patients; and,
3. To evaluate contextual factors, local implementation processes, and organizational changes in the participating facilities over time.

Gaps in delivery of gender-sensitive comprehensive care have resulted in disparities in quality and patient experience among women seen in VA. VA policy action providing guidance on delivery of comprehensive healthcare services for women Veterans was disseminated nationally in 2010, followed by annual assessments and site visits evaluating local VA efforts. While substantial inroads have been made, policy implementation, even when leveraged by field-based women's health leaders, has not been uniformly successful in achieving delivery of comprehensive care by designated providers in gender-sensitive care environments that ensure women's privacy, dignity and safety, all tenets of the original guidance and the updated VA directive (2017).

In collaboration with VA Women's Health Services (WHS), VA researchers developed a series of studies to better understand and help improve comprehensive care implementation through the Women Veterans' Healthcare CREATE Initiative. Among these, one focused on testing an evidence-based quality improvement (EBQI) approach to tailoring VA's medical home model -- Patient Aligned Care Teams (PACT) -- to the needs of women Veterans, which has yielded significant local improvements in women Veterans' care. EBQI emphasizes a multilevel partnered approach to building capacity for innovation, implementation and spread of evidence-based practice. With its demonstrated success in the CREATE PACT study and several other EBQI trials, WHS adopted EBQI as a strategy to help low-performing VA facilities systematically improve services.

The objectives of the WHS/QUERI Partnered Evaluation Initiative that this project represents are:

1. To evaluate the barriers and facilitators to achieving delivery of comprehensive women's health care in the identified low-performing VA facilities;
2. To evaluate the effectiveness of EBQI in supporting low-performing VA facilities achieve improved:

   1. Organizational features (e.g., level of comprehensive services available; care coordination arrangements; PACT features implemented; environment of care improvements);
   2. Provider/staff attitudes (e.g., improved gender awareness; women's health knowledge and practice);

   d) Quality of care and patient experiences among women Veteran patients using secondary data; and,
3. To evaluate contextual factors, local implementation processes, and organizational changes in the participating facilities over time.

Results of the evaluation have been used to provide feedback to stakeholders, including women Veterans, at the local, network and national levels, while also being used to continuously refine EBQI implementation processes. The evaluation is also helping inform optimal strategies for ongoing improvements in women Veterans' care in the 21 participating VA facilities, other VA facilities and for other improvement initiatives in this and other national program offices.

Eligibility Criteria:
Inclusion Criteria:

* Unit of randomization: VA healthcare facilities (VA medical center or community-based outpatient clinic)
* Subset of VA healthcare facilities identified as low-performing on the basis of composites of access/wait times, gender disparities in quality, e.g.:

  * depression screening
  * diabetic blood sugar control
* Presence/absence of VA-required structural facets of care, e.g.:

  * designated women's health providers
  * mammography coordinator
  * gynecology access
  * Women Veteran Program Manager (WVPM)
  * 3:1 staffing ratio for PACT teamlets

Key Stakeholder Inclusion Criteria (qualitative interviews):

* Veteran Integrated Service Network (VISN) level leader (Director or Chief Medical Officer)
* VISN level WVPM Lead, VISN level primary care director, VISN level QI/system redesign lead)
* VA facility leader (Director or other member of senior leadership)
* Chief of Staff
* primary care director
* women's health medical director
* WVPM
* local EBQI champion
* other key personnel

Provider/Staff Survey Inclusion Criteria:

* Primary care providers (medical doctor \[MD\], doctor of osteopathy \[DO\], nurse practitioner \[NP\], physician assistant \[PA\]) delivering primary care in general primary care and/or women's health clinics
* PACT teamlet members (registered nurse \[RN\] care managers, licensed vocational nurse/licensed practical nurse \[LVN/LPN\]/health technicians, and clerks)
* larger PACT team members, e.g.:

  * social workers
  * dieticians
  * health coaches
  * integrated mental health

Exclusion Criteria:

* Facility-level exclusion: Facilities not identified in the initial sample of VA facilities (sample not renewed over time).