Implementing a Systems-Level Change Model to Increase Capacity of One VA Spinal Cord Injury Center

Monday, 30 October 2017: 2:45 PM

Christine M. Nicholas, DNP
Consultant, San Antonio, TX, USA
Seth D. Chandler, DO
Spinal Cord Injury Center, South Texas Veterans Health Care System, San Antonio, TX, USA
Nancy Cuevas-Soto, DNP
Nursing Education, South Texas Veterans Health Care System, San Antonio, TX, USA
Frank Puga, PhD
School of Nursing, University of Texas Health Science Center San Antonio, San Antonio, TX, USA

PURPOSE: Access to healthcare is a national problem, with approximately 18% of U.S. adults experiencing barriers to services meeting their healthcare needs (Kullgren, McLaughlin, Mitra, & Armstrong, 2012). This gap is especially evident in persons with physical disabilities. The purpose of this project was to increase capacity of Home Care and Telehealth Extended Care Services in a Veterans Health Administration (VHA) Spinal Cord Injury and Disorders Center (SCIC) using an evidence-based Systems-Level Change Model.

METHODS: Healthcare is a complex adaptive system with interdependent, non-linear components. The complexity of healthcare has implications for system implementation of evidence based interventions and quality improvement due to the multiple system levels influencing process and clinical outcomes. Thus this project focused on developing and implementing a model to better understand the relationship between interacting agents within a system. The Systems-Level Change Model is comprised of four different models/frameworks, each addressing a different aspect of assessment and understanding, as well as guiding selection of interventions and recommendations. The Consolidated Framework for Implementation Research (CFIR) guided assessment of the organizational culture and context (Breimaier, Halfens, & Lohrmann, 2015; Breimaier, Heckemann, Halfens, & Lohrmann, 2015; Damschroder et al., 2009; Damschroder et al., 2015; Garg et al., 2016; Hung, Gray, Martinez, Schmittdiel, & Harrison, 2016). Donabedian’s Conceptual Model for healthcare quality provided a structure for identifying and assessing the SCIC processes (Donabedian, 1980; Gardner, Gardner, & O'Connell, 2014). Assessment of organizational behavior and selection of interventions was guided by application of The Behaviour Change Wheel (S. Michie, van Stralen, & West, 2011; Susan Michie & West, 2013). Finally, the Multimethod Assessment Process/Reflective Adaptive Process (MAP/RAP), which is grounded in complexity science, was used to facilitate data collection, analysis and reflection (Khan, Boustani, & Lasiter, 2015; Stroebel et al., 2005; Waxmonsky et al., 2011). MAP/RAP incorporates both qualitative and quantitative data collection and analysis (MAP), in addition to thoughtful reflection of the data to move an organization from mechanistic thinking to adaptive learning (RAP). Qualitative and quantitative data were collected through formal and informal stakeholder interviews, surveys, process mapping and time logs.

RESULTS: Results from the evaluation revealed a hierarchical and internally-focused culture, leadership lacking access to information and data that would help improve management of operations, programs, and inefficient processes. Stakeholder interviews revealed incongruent interpretation of directives among SCIC personnel, inefficient processes, duplication of work, and ineffective use of professional resources. A patient needs assessment revealed a widely geographically-dispersed patient population with varied program awareness, and high interest rates in the Extended Care services.

CONCLUSIONS: Using a Systems-Level Change Model provided a holistic view of the SCIC and resulted in: 1) an immediate 41.6% increase in the number of patients seen by the extended care services, 2) an immediate change in management interaction with staff, 3) the development of a Program Management Plan to measure and monitor program and patient outcomes, to set baseline data in preparation for future iterative improvement intervention implementations and, 4) verbal and non-verbal indications of improved staff morale.

IMPLICATIONS: Implications for nursing and administration include 1) further use of this Systems-Level Change Model by the quality improvement community and researchers to test its efficacy in evidence-based improvement implementations and, 2) dissemination of implementation results achieved with use of the Systems-Level Change Model so others may benefit from valuable experiences.