Enhancing Organizational Change and Improvement Prospects: Lessons from an HIV Testing Intervention for Veterans
Sobo, Elisa J., Bowman, Candice, Aarons, Gregory A., Asch, Steven, Gifford, Allen L., Human Organization
Most research on why health care quality improvement implementation succeeds or fails focuses on front-line or providerbased factors. However, background factors related to the structures and processes of projects themselves also pose challenges. Using a focused ethnographic assessment approach, we undertook a case study to characterize particularly challenging background factors in an ongoing implementation effort. We found that the organizational structure of the project under study sustained several key "cultural" differences in stakeholder agendas. Moreover, it fostered the emergence of strategic communication processes that, despite their immediate utility, sometimes undermined progress and threatened long-term relations by distorting information flow in particularly patterned ways. These included a "focus on the local" and "information reconfigurations" or "partiality" that sometimes led to miscommunication or interpretive disjunctions between various stakeholders. Successful cross-organizational communication is in certain ways a crosscultural achievement, and several guidelines were devised to facilitate this. Our experience with other health care systems and with health services research in general suggests that our findings and recommendations are broadly applicable. Because the main barriers identified were generated by complex organizational arrangements, lessons learned may also be transferable to other complex organizational contexts.
Key words: implementation science, quality improvement, organizational culture, health services research and delivery, collaboration, HIV/AIDS
Improving health care is hard. It is hard at the local level and may be even harder in large health care organizations, where various departments or units are concerned with different aspects of quality and safety. The difficulties entailed in cross-organizational communication and collaboration may mean that the diverse aims and agendas of such groups remain in competition. This can, itself, create and maintain missed opportunities for improvement as well as fostering organizational environments in which improvement is much harder-won than need be.
How can we enhance opportunities for productive crossorganizational collaboration? This article presents several strategies to that end, derived from a case study of efforts to increase HIV testing within the United States Veterans Health Administration (VHA). The intervention unwittingly placed various stakeholder groups in competition with one another, undermining cross-organizational communication and creating barriers to full collaboration. Transferable lessons were learned about ways to mitigate such competition, thereby smoothing bumpy relations and enhancing collaboration. Our combined experience suggests that this is a systemic, socioculturally rooted problem inherent in large, complex organizations. Therefore, the strategies we devised to combat it are summarized at the article's end.
Quality Enhancement Research in the VHA
The VHA's Quality Enhancement Research Initiative (QUERI) exists to enhance VHA health care in regard to organizationally-prioritized high-risk and/or highly prevalent diseases or conditions. Work is carried out through nine individual "centers" by affiliated, grant-funded researchers. The centers are physically located at VHA facilities throughout the United States, but report directly to the central office (VHACO). Therefore, while each has a specific disease or condition-related focus, each center's work is intended to cross-cut activities in all 21 of the VHA's regional integrated service networks or VISNs.
Following accepted health services research (HSR) standards described by Donabedian (1966, 1980), in evaluating quality of care, QUERI focuses on structures (provider and organizational characteristics), processes (providers' clinical actions toward patients), and outcomes (health status, economic impact, satisfaction). …