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Elwy AR, Maguire EM, Gallagher TH, Asch SM, Durfee JM, Martinello RA, Bokhour BG, Gifford AL, Taylor TJ, Wagner TH. Risk Communication After Health Care Exposures: An Experimental Vignette Survey With Patients. MDM Policy Pract 2021; 6:23814683211045659. [PMID: 34553068 PMCID: PMC8451260 DOI: 10.1177/23814683211045659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 08/24/2021] [Indexed: 11/19/2022] Open
Abstract
Purpose. We investigated how health care systems should communicate with patients about possible exposures to blood-borne pathogens that may have occurred during their care. Our goal was to determine how best to communicate uncertain risk information in a way that would minimize harm to patients, maintain their trust, and encourage patients to seek follow-up treatment. Methods. Participants (N = 1103) were randomized to receive one of six vignette surveys; 997 (98.4%) responded. All vignettes described the same event, but differed by risk level and recommendations (lower risk v. higher risk) and by communication mode (telephone, letter, social media). We measured participants’ perceived risk of blood-borne infection, trust in the health care system, and shared decision making about next clinical steps. Open-ended questions were analyzed using grounded thematic analysis. Results. When the vignette requested patients to undergo testing and practice certain health behaviors (higher risk), participants’ likelihood of seeking follow-up testing for blood-borne pathogens and their understanding of health issues increased. Perceived trust was unaffected by risk level or communication processes. Qualitative data indicated a desire for telephone communication from providers known to the patient. Limitations. It is not clear whether higher risk language or objective risk levels in vignettes motivated patients’ behavioral intentions. Conclusion. Using higher risk language when disclosing large-scale adverse events increased participants’ willingness to seek follow-up care. Implications. Health care organizations’ disclosures should focus on the next steps to take after health care exposures. This communication should involve helping patients to understand their personal health issues better, make them feel that they know which steps to take following the receipt of this information, and encouraging them to seek follow-up infectious disease testing in order to better take care of themselves.
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Affiliation(s)
- A Rani Elwy
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts
| | - Elizabeth M Maguire
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts
| | - Thomas H Gallagher
- Division of General Internal Medicine, University of Washington, Seattle, Washington
| | - Steven M Asch
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, California
| | - Janet M Durfee
- Department of Veterans Affairs, Veterans Health Administration, Office of Patient Care Services, Washington, DC
| | - Richard A Martinello
- Yale-New Haven Hospital Departments of Medicine (Infectious Diseases) and Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| | - Barbara G Bokhour
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts
| | - Allen L Gifford
- Center for Healthcare Organization and Implementation Research, VA Boston Health Care System, Jamaica Plain, Massachusetts
| | - Thomas J Taylor
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, California
| | - Todd H Wagner
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, California
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Elwy AR, Maguire EM, McCullough M, George J, Bokhour BG, Durfee JM, Martinello RA, Wagner TH, Asch SM, Gifford AL, Gallagher TH, Walker Y, Sharpe VA, Geppert C, Holodniy M, West G. From implementation to sustainment: A large-scale adverse event disclosure support program generated through embedded research in the Veterans Health Administration. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2021; 8 Suppl 1:100496. [PMID: 34175102 DOI: 10.1016/j.hjdsi.2020.100496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 10/25/2020] [Accepted: 11/03/2020] [Indexed: 10/21/2022]
Abstract
In 2008, the Veterans Health Administration published a groundbreaking policy on disclosing large-scale adverse events to patients in order to promote transparent communication in cases where harm may not be obvious or even certain. Without embedded research, the evidence on whether or not implementation of this policy was generating more harm than good among Veteran patients was unknown. Through an embedded research-operations partnership, we conducted four research projects that led to the development of an evidence-based large-scale disclosure toolkit and disclosure support program, and its implementation across VA healthcare. Guided by the Consolidated Framework for Implementation Research, we identified specific activities corresponding to planning, engaging, executing, reflecting and evaluating phases in the process of implementation. These activities included planning with operational leaders to establish a shared research agenda; engaging with stakeholders to discuss early results, establishing buy-in of our efforts and receiving feedback; joining existing operational teams to execute the toolkit implementation; partnering with clinical operations to evaluate the toolkit during real-time disclosures; and redesigning the toolkit to meet stakeholders' needs. Critical lessons learned for implementation success included a need for stakeholder collaboration and engagement, an organizational culture involving a strong belief in evidence, a willingness to embed researchers in clinical operation activities, allowing for testing and evaluation of innovative practices, and researchers open to constructive feedback. At the conclusion of the research, VA operations worked with the researchers to continue to support efforts to spread, scale-up and sustain toolkit use across the VA healthcare system, with the final goal to establish long-term sustainability.
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Affiliation(s)
- A Rani Elwy
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, 01730, USA; Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, RI, 02912, USA; Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, 02118, USA.
| | - Elizabeth M Maguire
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, 01730, USA
| | - Megan McCullough
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, 01730, USA
| | - Judy George
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Jamaica Plain, MA, 02130, USA
| | - Barbara G Bokhour
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, 01730, USA; Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, 01605, USA
| | - Janet M Durfee
- Department of Veterans Affairs, Veterans Health Administration, Office of Patient Care Services, Washington, DC, USA
| | - Richard A Martinello
- Departments of Medicine (Infectious Diseases) and Pediatrics, Yale University School of Medicine, New Haven, CT, 06510, USA; Yale New Haven Hospital and Yale New Haven Health, Quality and Safety, New Haven, CT, 06510, USA
| | - Todd H Wagner
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, 94025, USA; Department of Surgery, Stanford University Medical School, Palo Alto, CA, 94305, USA
| | - Steven M Asch
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, 94025, USA; Department of Primary Care and Population Health, Stanford University School of Medicine, Palo Alto, CA, 94305, USA
| | - Allen L Gifford
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Jamaica Plain, MA, 02130, USA; Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, 02118, USA
| | - Thomas H Gallagher
- Division of General Internal Medicine, University of Washington, Seattle, WA, 98104, USA
| | - Yuri Walker
- Department of Veterans Affairs, Veterans Health Administration, Office of Quality and Safety, Risk Management Service, Washington, DC. 20420, USA
| | - Virginia A Sharpe
- Department of Veterans Affairs, Veterans Health Administration, National Center for Ethics in Healthcare, Office of Ethics Policy, Washington, DC. 20420, USA
| | - Cynthia Geppert
- Department of Veterans Affairs, Veterans Health Administration, National Center for Ethics in Healthcare, Office of Ethics Policy, Washington, DC. 20420, USA
| | - Mark Holodniy
- Public Health Surveillance & Research Program and Public Health Reference Laboratory, VA Palo Alto Health Care System, Palo Alto, CA, 94304, USA; Department of Medicine (Infectious Diseases), Stanford University School of Medicine, Palo Alto, CA, 94305, USA
| | - Gavin West
- VA Salt Lake City Health Care System, Salt Lake, UT, 84148, USA
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How hospitals select their patient safety priorities: An exploratory study of four Veterans Health Administration hospitals. Health Care Manage Rev 2019; 45:E56-E67. [PMID: 31498164 DOI: 10.1097/hmr.0000000000000260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hospitals face ongoing pressure to reduce patient safety events. However, given resource constraints, hospitals must prioritize their safety improvements. There is limited literature on how hospitals select their safety priorities. PURPOSE The aim of this research was to describe and compare the approaches used by Veterans Health Administration (VA) hospitals to select their safety priorities. METHODOLOGY Semistructured telephone interviews with key informants (n = 16) were used to collect data on safety priorities in four VA hospitals from May to December 2016. We conducted a directed content analysis of the interview notes using an organizational learning perspective. We coded for descriptive data on the approaches (e.g., set of cues, circumstances, and activities) used to select safety priorities, a priori organizational learning capabilities (learning processes, learning environment, and learning-oriented leadership), and emergent domains. For cross-site comparisons, we examined the coded data for patterns. RESULTS All hospitals used multiple approaches to select their safety priorities; these approaches used varied across hospitals. Although no single approach was reported as particularly influential, all hospitals used approaches that addressed system level or national requirements (i.e., externally required activities). Additional approaches used by hospitals (e.g., responding to staff concerns of patient safety issues, conducting a multidisciplinary team investigation) were less connected to externally required activities and demonstrated organizational learning capabilities in learning processes (e.g., performance monitoring), learning environment (e.g., staff's psychological safety), and learning-oriented leadership (e.g., establishing a nonpunitive culture). PRACTICE IMPLICATIONS Leaders should examine the approaches used to select safety priorities and the role of organizational learning in these selection approaches. Exclusively relying on approaches focused on externally required activities may fail to identify safety priorities that are locally relevant but not established as significant at the system or national levels. Organizational learning may promote hospitals' use of varied approaches to guide their selection of safety priorities and thereby benefit hospital safety improvement efforts.
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Maguire EM, Bokhour BG, Wagner TH, Asch SM, Gifford AL, Gallagher TH, Durfee JM, Martinello RA, Elwy AR. Evaluating the implementation of a national disclosure policy for large-scale adverse events in an integrated health care system: identification of gaps and successes. BMC Health Serv Res 2016; 16:648. [PMID: 27835983 PMCID: PMC5106838 DOI: 10.1186/s12913-016-1903-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Accepted: 11/04/2016] [Indexed: 11/24/2022] Open
Abstract
Background Many healthcare organizations have developed disclosure policies for large-scale adverse events, including the Veterans Health Administration (VA). This study evaluated VA’s national large-scale disclosure policy and identifies gaps and successes in its implementation. Methods Semi-structured qualitative interviews were conducted with leaders, hospital employees, and patients at nine sites to elicit their perceptions of recent large-scale adverse events notifications and the national disclosure policy. Data were coded using the constructs of the Consolidated Framework for Implementation Research (CFIR). Results We conducted 97 interviews. Insights included how to handle the communication of large-scale disclosures through multiple levels of a large healthcare organization and manage ongoing communications about the event with employees. Of the 5 CFIR constructs and 26 sub-constructs assessed, seven were prominent in interviews. Leaders and employees specifically mentioned key problem areas involving 1) networks and communications during disclosure, 2) organizational culture, 3) engagement of external change agents during disclosure, and 4) a need for reflecting on and evaluating the policy implementation and disclosure itself. Patients shared 5) preferences for personal outreach by phone in place of the current use of certified letters. All interviewees discussed 6) issues with execution and 7) costs of the disclosure. Conclusions CFIR analysis reveals key problem areas that need to be addresses during disclosure, including: timely communication patterns throughout the organization, establishing a supportive culture prior to implementation, using patient-approved, effective communications strategies during disclosures; providing follow-up support for employees and patients, and sharing lessons learned. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1903-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Elizabeth M Maguire
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA. .,Center for Healthcare Organization and Implementation Research, 200 Springs Road (Mailstop152), Bedford, 01730, MA, USA.
| | - Barbara G Bokhour
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA.,Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - Todd H Wagner
- Health Economics Resource Center, VA Palo Alto Healthcare System, Menlo Park, CA, USA.,Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, USA.,Stanford University School of Medicine, Palo Alto, CA, USA
| | - Steven M Asch
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Menlo Park, CA, USA.,Stanford University School of Medicine, Palo Alto, CA, USA
| | - Allen L Gifford
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA.,Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | | | - Janet M Durfee
- Patient Care Services, Veterans Health Administration, Department of Veterans Affairs, Washington, DC, USA
| | | | - A Rani Elwy
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA.,Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 150 S. Huntington Ave, Jamaica Plain, MA, USA
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