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US Department of Veterans Affairs (VA) Community Living Centers (CLCs) provide a dynamic array of long- and short-term health and rehabilitative services in a person-centered environment designed to meet the individual needs of veteran residents. The VA Office of Geriatrics and Extended Care (GEC) manages CLCs as part of its commitment to “optimizing the health and well-being of veterans with multiple chronic conditions, life-limiting illness, frailty or disability associated with chronic disease, aging or injury.”1
CLCs are home to veterans who require short stays before going home, as well as those who require longer or permanent domicile. CLCs also are home to several special populations of veterans, including those with spinal cord injury and those who choose palliative or hospice care. CLCs have embraced cultural transformation, creating therapeutic environments that function as real homes, with the kitchen at the center, and daily activities scheduled around the veterans’ preferences. Data about CLC quality are now available to the public, highlighting the important role of support for and continual refinement to quality improvement (QI) processes in the CLC system. 2,3
CONCERT Program
High-functioning teams are critical to achieving improvement in such processes.4 In fiscal year (FY) 2017, GEC launched a national center to engage and support CLC staff in creating high-functioning, relationship-based teams through specific QI practices, thereby aiming to improve veteran experience and quality of care. The center, known as the CLCs’ Ongoing National Center for Enhancing Resources and Training (CONCERT), is based on extensive VA-funded research in CLCs5-7 and builds on existing, evidence-based literature emphasizing the importance of strengths-based learning, collaborative problem solving, and structured observation.8-13 The CONCERT mission is to support CLCs in ongoing QI efforts, providing guidance, training, and resources. This article summarizes the previous research on which CONCERT is based and describes its current activities, which focus on implementing a national team-based quality improvement initiative.
Earlier VA-funded CLC research included a VA Office of Patient Centered Care and Cultural Transformation local innovation project and 2 VA Office of Research and Development-funded research studies. The local innovation project focused on strengthening staff leadership and relational skills in 1 CLC by engaging leaders and staff in collaborative work to reduce stress. The goal was to build high-functioning team skills through shared projects that created positive work experiences and reduced job-related stress while also improving veteran experience and quality of care.14,15 Over the course of a year, 2 national consultants in nursing home quality improvement worked with CLC leadership and staff, including conducting nine 4-day site visits. Using an approach designed to foster development of high-functioning teams, individual CLC neighborhoods (ie, units) developed and implemented neighborhood-initiated, neighborhood-based pilot projects, such as an individualized finger foods dining option for residents with dementia who became distressed when sitting at a table during a meal. Outcomes of these projects included improved staff communication and staff satisfaction, particularly psychological safety.
In the concurrently conducted pilot research study, a research team comprehensively assessed the person-centered care efforts of 3 CLCs prior to their construction of Green House-type (small house) homes. This mixed-methods study included more than 50 qualitative interviews conducted with VA medical center leadership and CLC staff and residents. Researchers also administered online employee surveys and conducted site visits, including more than 60 hours of direct observation of CLC life and team functioning. The local institutional review boards approved all study procedures, and researchers notified local unions.
Analyses highlighted 2 important aspects of person-centered care not captured by then-existing measurement instruments: the type, quality, and number of staff/resident interactions and the type, quality, and level of resident engagement. The team therefore developed a structured, systematic, observation-based instrument to measure these concepts.5 But while researchers found this instrument useful, it was too complex to be used by CLC staff for QI.
LOCK Quality Improvement
A later and larger research study addressed this issue. In the study, researchers worked with CLC staff to convert the complex observation-based research instrument into several structured tools that were easier for CLC staff to use.6 The researchers then incorporated their experience with the prior local innovation project and designed and implemented a QI program, which operationalized an evidence-based bundle of practices to implement the new tools in 6 CLCs. Researchers called the bundle of practices “LOCK”: (1) Learn from the bright spots; (2) Observe; (3) Collaborate in huddles; and (4) Keep it bite-sized.
Learn from the bright spots. Studies on strengths-based learning indicate that recognizing and sharing positive instances of ideal practice helps provide clear direction regarding what needs to be done differently to achieve success. Identifying and learning from outlying instances of successful practice encourages staff to continue those behaviors and gives staff tangible examples of how they may improve.16-19 That is, concentrating on instances where a negative outcome was at risk of occurring but did not occur (ie, a positive outlier or “bright spot”) enables staff to analyze what facilitated the success and design and pilot strategies to replicate it.
Observe. Human factors engineering is built on the principle that integrated approaches for studying work systems can identify areas for improvement.8 Observation is a key tool in this approach. A recent review of 69 studies that used observation to assess clinical performance found it useful in identifying factors affecting quality and safety.9
Collaborate in huddles. A necessary component to overcoming barriers to successful QI is having high-functioning teams effectively coordinate work. In the theory of relational coordination, this is operationalized as high-quality interactions (frequent, timely, and accurate communication) and high-quality relationships (share knowledge, shared goals, and mutual respect).10,11 Improved relational coordination can lead to higher quality of care outcomes and job satisfaction by enabling individuals to manage their tasks with less delay, more rapid and effective responses, fewer errors, and less wasted effort.12
Keep it bite-sized. Regular practice of a new behavior is one of the keys to making that new behavior part of an automatic routine (ie, a habit). To be successfully integrated into staff work routines, QI initiatives must be perceived as congruent with and easily integrated into care goals and workplace practices. Quick, focused, team-building and solution-oriented QI initiatives, therefore, have the greatest chance of success, particularly if staff feel they have little time for participating in new initiatives.13
Researchers designed the 4 LOCK practices to be interrelated and build on one another, creating a bundle to be used together to help facilitate positive change in resident/staff interactions and resident engagement.7 For 6 months, researchers studied the 6 CLCs’ use of the new structured observation tools as part of the LOCK-based QI program. The participating CLCs had such success in improving staff interactions with residents and residents’ engagement in CLC life that GEC, under the CONCERT umbrella, rolled out the LOCK bundle of practices to CLCs nationwide.20
CONCERT’s current activities focus on helping CLCs implement the LOCK bundle nationwide as a relational coordination-based national QI initiative designed to improve quality of care and staff satisfaction. The CONCERT team began this implementation in FY 2017 using a train-the-trainer approach through a staggered veterans integrated service network (VISN) rollout. Each CLC sent 2 leaders to a VISN-wide training program at a host CLC site (the host site was able to have more participants attend). Afterward, the CONCERT team provided individualized phone support to help CLCs implement the program. A VA Pulse (intranet-based social media portal) site hosts all training materials, program videos, an active blog, community discussions, etc.
In FY 2018, the program shifted to a VISN-based support system, with a CONCERT team member assigned to each VISN and VISN-based webinars to facilitate information exchange, collaboration, and group learning. In FY 2018, the CONCERT team also conducted site visits to selected CLCs with strong implementation success records to learn about program facilitators and to disseminate the lessons learned. Spanning FYs 2018 and 2019, the CONCERT team also supports historically low-performing CLCs through a series of rapid-cycle learning intensives based on the Institute for Healthcare Improvement breakthrough collaborative series model for accelerated and sustained QI.21 These incorporate in-person or virtual learning sessions, in which participants learn about and share effective practices, and between-session learning assignments, to facilitate the piloting, implementation, and sustainment of system changes. As part of the CONCERT continuous QI process, the CONCERT team closely monitors the impact of the program and continues to pilot, adapt, and change practices as it learns more about how best to help CLCs improve.
Conclusion
A key CONCERT principle is that health care systems create health care outcomes. The CONCERT team uses the theory of relational coordination to support implementation of the LOCK bundle of practices to help CLCs change their systems to achieve high performance. Through implementation of the LOCK bundle of practices, CLC staff develop, pilot, and spread new systems for communication, teamwork, and collaborative problem solving, as well as developing skills to participate effectively in these systems. CONCERT represents just 1 way VA supports CLCs in their continual journeys toward ever-improved quality of veteran care.
Acknowledgments
The authors thank Barbara Frank and Cathie Brady for their contributions to the development of the CONCERT program.
1. US Department of Veterans Affairs, Geriatrics and Extended Care Services (GEC). https://www.va.gov/GERIATRICS/index.asp. Updated February 25, 2019. Accessed April 9, 2019.
2. US Department of Veterans Affairs. https://www.accesstocare.va.gov/CNH/Statemap. Accessed April 10, 2019.
3. US Department of Veterans Affairs. https://www.va.gov/QUALITYOFCARE/apps/aspire/clcsurvey.aspx/. U
4. Gittell JH, Weinberg D, Pfefferle S, Bishop C. Impact of relational coordination on job satisfaction and quality outcomes: a study of nursing homes. Hum Resour Manag. 2008;18(2):154-170
5. Snow AL, Dodson, ML, Palmer JA, et al. Development of a new systematic observation tool of nursing home resident and staff engagement and relationship. Gerontologist. 2018;58(2):e15-e24.
6. Hartmann CW, Palmer JA, Mills WL, et al. Adaptation of a nursing home culture change research instrument for frontline staff quality improvement use. Psychol Serv. 2017;14(3):337-346.
7. Mills WL, Pimentel CB, Palmer JA, et al. Applying a theory-driven framework to guide quality improvement efforts in nursing homes: the LOCK model. Gerontologist. 2018;58(3):598-605.
8. Caravon P, Hundt AS, Karsh B, et al. Work system design for patient safety: the SEIPS model. Quality & Safety in Health Care. 2006;15(suppl 1), i50-i58.
9. Yanes AF, McElroy LM, Abecassis ZA, Holl J, Woods D, Ladner DP. Observation for assessment of clinician performance: a narrative review. BMJ Qual Saf. 2016;25(1):46-55.
10. Gittell JH. Supervisory span, relational coordination and flight departure performance: a reassessment of postbureaucracy theory. Organ Sci. 2011;12(4):468-483.
11. Gittell JH. New Directions for Relational Coordination Theory. In Spreitzer GM, Cameron KS, eds. The Oxford Handbook of Positive Organizational Scholarship. Oxford University Press: New York; 2012:400-411.
12. Weinberg DB, Lusenhop RW, Gittell JH, Kautz CM. Coordination between formal providers and informal caregivers. Health Care Manage Rev. 2007;32(2):140-149.
13. Phillips J, Hebish LJ, Mann S, Ching JM, Blackmore CC. Engaging frontline leaders and staff in real-time improvement. Jt Comm J Qual Patient Saf. 2016;42(4):170-183.
14. Farrell D, Brady C, Frank B. Meeting the Leadership Challenge in Long-Term Care: What You Do Matters. Health Professions Press: Baltimore, MD; 2011.
15. Brady C, Farrell D, Frank B. A Long-Term Leaders’ Guide to High Performance: Doing Better Together. Health Professions Press: Baltimore, MD; 2018.
16. Bradley EH, Curry LA, Ramanadhan S, Rowe L, Nembhard IM, Krumholz HM. Research in action: using positive deviance to improve quality of health care. Implement Sci. 2009;4:25.
17. Marsh DR, Schroeder DG, Dearden KA, Sternin J, Sternin M. The power of positive deviance. BMJ. 2004; 329(7475):1177-1179.
18. Vogt K, Johnson F, Fraser V, et al. An innovative, strengths-based, peer mentoring approach to professional development for registered dietitians. Can J Diet Pract Res. 2015;76(4):185-189.
19. Beckett P, Field J, Molloy L, Yu N, Holmes D, Pile E. Practice what you preach: developing person-centered culture in inpatient mental health settings through strengths-based, transformational leadership. Issues Ment Health Nurs. 2013;34(8):595-601.
20. Hartmann CW, Mills WL, Pimentel CB, et al. Impact of intervention to improve nursing home resident-staff interactions and engagement. Gerontologist. 2018;58(4):e291-e301.
21. Institute for Healthcare Improvement. The breakthrough series: IHI’s collaborative model for achieving breakthrough improvement. http://www.ihi.org/resources/Pages/IHIWhitePapers/TheBreakthroughSeriesIHIsCollaborativeModelforAchievingBreakthroughImprovement.aspx. Published 2003. Accessed April 9, 2019.
US Department of Veterans Affairs (VA) Community Living Centers (CLCs) provide a dynamic array of long- and short-term health and rehabilitative services in a person-centered environment designed to meet the individual needs of veteran residents. The VA Office of Geriatrics and Extended Care (GEC) manages CLCs as part of its commitment to “optimizing the health and well-being of veterans with multiple chronic conditions, life-limiting illness, frailty or disability associated with chronic disease, aging or injury.”1
CLCs are home to veterans who require short stays before going home, as well as those who require longer or permanent domicile. CLCs also are home to several special populations of veterans, including those with spinal cord injury and those who choose palliative or hospice care. CLCs have embraced cultural transformation, creating therapeutic environments that function as real homes, with the kitchen at the center, and daily activities scheduled around the veterans’ preferences. Data about CLC quality are now available to the public, highlighting the important role of support for and continual refinement to quality improvement (QI) processes in the CLC system. 2,3
CONCERT Program
High-functioning teams are critical to achieving improvement in such processes.4 In fiscal year (FY) 2017, GEC launched a national center to engage and support CLC staff in creating high-functioning, relationship-based teams through specific QI practices, thereby aiming to improve veteran experience and quality of care. The center, known as the CLCs’ Ongoing National Center for Enhancing Resources and Training (CONCERT), is based on extensive VA-funded research in CLCs5-7 and builds on existing, evidence-based literature emphasizing the importance of strengths-based learning, collaborative problem solving, and structured observation.8-13 The CONCERT mission is to support CLCs in ongoing QI efforts, providing guidance, training, and resources. This article summarizes the previous research on which CONCERT is based and describes its current activities, which focus on implementing a national team-based quality improvement initiative.
Earlier VA-funded CLC research included a VA Office of Patient Centered Care and Cultural Transformation local innovation project and 2 VA Office of Research and Development-funded research studies. The local innovation project focused on strengthening staff leadership and relational skills in 1 CLC by engaging leaders and staff in collaborative work to reduce stress. The goal was to build high-functioning team skills through shared projects that created positive work experiences and reduced job-related stress while also improving veteran experience and quality of care.14,15 Over the course of a year, 2 national consultants in nursing home quality improvement worked with CLC leadership and staff, including conducting nine 4-day site visits. Using an approach designed to foster development of high-functioning teams, individual CLC neighborhoods (ie, units) developed and implemented neighborhood-initiated, neighborhood-based pilot projects, such as an individualized finger foods dining option for residents with dementia who became distressed when sitting at a table during a meal. Outcomes of these projects included improved staff communication and staff satisfaction, particularly psychological safety.
In the concurrently conducted pilot research study, a research team comprehensively assessed the person-centered care efforts of 3 CLCs prior to their construction of Green House-type (small house) homes. This mixed-methods study included more than 50 qualitative interviews conducted with VA medical center leadership and CLC staff and residents. Researchers also administered online employee surveys and conducted site visits, including more than 60 hours of direct observation of CLC life and team functioning. The local institutional review boards approved all study procedures, and researchers notified local unions.
Analyses highlighted 2 important aspects of person-centered care not captured by then-existing measurement instruments: the type, quality, and number of staff/resident interactions and the type, quality, and level of resident engagement. The team therefore developed a structured, systematic, observation-based instrument to measure these concepts.5 But while researchers found this instrument useful, it was too complex to be used by CLC staff for QI.
LOCK Quality Improvement
A later and larger research study addressed this issue. In the study, researchers worked with CLC staff to convert the complex observation-based research instrument into several structured tools that were easier for CLC staff to use.6 The researchers then incorporated their experience with the prior local innovation project and designed and implemented a QI program, which operationalized an evidence-based bundle of practices to implement the new tools in 6 CLCs. Researchers called the bundle of practices “LOCK”: (1) Learn from the bright spots; (2) Observe; (3) Collaborate in huddles; and (4) Keep it bite-sized.
Learn from the bright spots. Studies on strengths-based learning indicate that recognizing and sharing positive instances of ideal practice helps provide clear direction regarding what needs to be done differently to achieve success. Identifying and learning from outlying instances of successful practice encourages staff to continue those behaviors and gives staff tangible examples of how they may improve.16-19 That is, concentrating on instances where a negative outcome was at risk of occurring but did not occur (ie, a positive outlier or “bright spot”) enables staff to analyze what facilitated the success and design and pilot strategies to replicate it.
Observe. Human factors engineering is built on the principle that integrated approaches for studying work systems can identify areas for improvement.8 Observation is a key tool in this approach. A recent review of 69 studies that used observation to assess clinical performance found it useful in identifying factors affecting quality and safety.9
Collaborate in huddles. A necessary component to overcoming barriers to successful QI is having high-functioning teams effectively coordinate work. In the theory of relational coordination, this is operationalized as high-quality interactions (frequent, timely, and accurate communication) and high-quality relationships (share knowledge, shared goals, and mutual respect).10,11 Improved relational coordination can lead to higher quality of care outcomes and job satisfaction by enabling individuals to manage their tasks with less delay, more rapid and effective responses, fewer errors, and less wasted effort.12
Keep it bite-sized. Regular practice of a new behavior is one of the keys to making that new behavior part of an automatic routine (ie, a habit). To be successfully integrated into staff work routines, QI initiatives must be perceived as congruent with and easily integrated into care goals and workplace practices. Quick, focused, team-building and solution-oriented QI initiatives, therefore, have the greatest chance of success, particularly if staff feel they have little time for participating in new initiatives.13
Researchers designed the 4 LOCK practices to be interrelated and build on one another, creating a bundle to be used together to help facilitate positive change in resident/staff interactions and resident engagement.7 For 6 months, researchers studied the 6 CLCs’ use of the new structured observation tools as part of the LOCK-based QI program. The participating CLCs had such success in improving staff interactions with residents and residents’ engagement in CLC life that GEC, under the CONCERT umbrella, rolled out the LOCK bundle of practices to CLCs nationwide.20
CONCERT’s current activities focus on helping CLCs implement the LOCK bundle nationwide as a relational coordination-based national QI initiative designed to improve quality of care and staff satisfaction. The CONCERT team began this implementation in FY 2017 using a train-the-trainer approach through a staggered veterans integrated service network (VISN) rollout. Each CLC sent 2 leaders to a VISN-wide training program at a host CLC site (the host site was able to have more participants attend). Afterward, the CONCERT team provided individualized phone support to help CLCs implement the program. A VA Pulse (intranet-based social media portal) site hosts all training materials, program videos, an active blog, community discussions, etc.
In FY 2018, the program shifted to a VISN-based support system, with a CONCERT team member assigned to each VISN and VISN-based webinars to facilitate information exchange, collaboration, and group learning. In FY 2018, the CONCERT team also conducted site visits to selected CLCs with strong implementation success records to learn about program facilitators and to disseminate the lessons learned. Spanning FYs 2018 and 2019, the CONCERT team also supports historically low-performing CLCs through a series of rapid-cycle learning intensives based on the Institute for Healthcare Improvement breakthrough collaborative series model for accelerated and sustained QI.21 These incorporate in-person or virtual learning sessions, in which participants learn about and share effective practices, and between-session learning assignments, to facilitate the piloting, implementation, and sustainment of system changes. As part of the CONCERT continuous QI process, the CONCERT team closely monitors the impact of the program and continues to pilot, adapt, and change practices as it learns more about how best to help CLCs improve.
Conclusion
A key CONCERT principle is that health care systems create health care outcomes. The CONCERT team uses the theory of relational coordination to support implementation of the LOCK bundle of practices to help CLCs change their systems to achieve high performance. Through implementation of the LOCK bundle of practices, CLC staff develop, pilot, and spread new systems for communication, teamwork, and collaborative problem solving, as well as developing skills to participate effectively in these systems. CONCERT represents just 1 way VA supports CLCs in their continual journeys toward ever-improved quality of veteran care.
Acknowledgments
The authors thank Barbara Frank and Cathie Brady for their contributions to the development of the CONCERT program.
US Department of Veterans Affairs (VA) Community Living Centers (CLCs) provide a dynamic array of long- and short-term health and rehabilitative services in a person-centered environment designed to meet the individual needs of veteran residents. The VA Office of Geriatrics and Extended Care (GEC) manages CLCs as part of its commitment to “optimizing the health and well-being of veterans with multiple chronic conditions, life-limiting illness, frailty or disability associated with chronic disease, aging or injury.”1
CLCs are home to veterans who require short stays before going home, as well as those who require longer or permanent domicile. CLCs also are home to several special populations of veterans, including those with spinal cord injury and those who choose palliative or hospice care. CLCs have embraced cultural transformation, creating therapeutic environments that function as real homes, with the kitchen at the center, and daily activities scheduled around the veterans’ preferences. Data about CLC quality are now available to the public, highlighting the important role of support for and continual refinement to quality improvement (QI) processes in the CLC system. 2,3
CONCERT Program
High-functioning teams are critical to achieving improvement in such processes.4 In fiscal year (FY) 2017, GEC launched a national center to engage and support CLC staff in creating high-functioning, relationship-based teams through specific QI practices, thereby aiming to improve veteran experience and quality of care. The center, known as the CLCs’ Ongoing National Center for Enhancing Resources and Training (CONCERT), is based on extensive VA-funded research in CLCs5-7 and builds on existing, evidence-based literature emphasizing the importance of strengths-based learning, collaborative problem solving, and structured observation.8-13 The CONCERT mission is to support CLCs in ongoing QI efforts, providing guidance, training, and resources. This article summarizes the previous research on which CONCERT is based and describes its current activities, which focus on implementing a national team-based quality improvement initiative.
Earlier VA-funded CLC research included a VA Office of Patient Centered Care and Cultural Transformation local innovation project and 2 VA Office of Research and Development-funded research studies. The local innovation project focused on strengthening staff leadership and relational skills in 1 CLC by engaging leaders and staff in collaborative work to reduce stress. The goal was to build high-functioning team skills through shared projects that created positive work experiences and reduced job-related stress while also improving veteran experience and quality of care.14,15 Over the course of a year, 2 national consultants in nursing home quality improvement worked with CLC leadership and staff, including conducting nine 4-day site visits. Using an approach designed to foster development of high-functioning teams, individual CLC neighborhoods (ie, units) developed and implemented neighborhood-initiated, neighborhood-based pilot projects, such as an individualized finger foods dining option for residents with dementia who became distressed when sitting at a table during a meal. Outcomes of these projects included improved staff communication and staff satisfaction, particularly psychological safety.
In the concurrently conducted pilot research study, a research team comprehensively assessed the person-centered care efforts of 3 CLCs prior to their construction of Green House-type (small house) homes. This mixed-methods study included more than 50 qualitative interviews conducted with VA medical center leadership and CLC staff and residents. Researchers also administered online employee surveys and conducted site visits, including more than 60 hours of direct observation of CLC life and team functioning. The local institutional review boards approved all study procedures, and researchers notified local unions.
Analyses highlighted 2 important aspects of person-centered care not captured by then-existing measurement instruments: the type, quality, and number of staff/resident interactions and the type, quality, and level of resident engagement. The team therefore developed a structured, systematic, observation-based instrument to measure these concepts.5 But while researchers found this instrument useful, it was too complex to be used by CLC staff for QI.
LOCK Quality Improvement
A later and larger research study addressed this issue. In the study, researchers worked with CLC staff to convert the complex observation-based research instrument into several structured tools that were easier for CLC staff to use.6 The researchers then incorporated their experience with the prior local innovation project and designed and implemented a QI program, which operationalized an evidence-based bundle of practices to implement the new tools in 6 CLCs. Researchers called the bundle of practices “LOCK”: (1) Learn from the bright spots; (2) Observe; (3) Collaborate in huddles; and (4) Keep it bite-sized.
Learn from the bright spots. Studies on strengths-based learning indicate that recognizing and sharing positive instances of ideal practice helps provide clear direction regarding what needs to be done differently to achieve success. Identifying and learning from outlying instances of successful practice encourages staff to continue those behaviors and gives staff tangible examples of how they may improve.16-19 That is, concentrating on instances where a negative outcome was at risk of occurring but did not occur (ie, a positive outlier or “bright spot”) enables staff to analyze what facilitated the success and design and pilot strategies to replicate it.
Observe. Human factors engineering is built on the principle that integrated approaches for studying work systems can identify areas for improvement.8 Observation is a key tool in this approach. A recent review of 69 studies that used observation to assess clinical performance found it useful in identifying factors affecting quality and safety.9
Collaborate in huddles. A necessary component to overcoming barriers to successful QI is having high-functioning teams effectively coordinate work. In the theory of relational coordination, this is operationalized as high-quality interactions (frequent, timely, and accurate communication) and high-quality relationships (share knowledge, shared goals, and mutual respect).10,11 Improved relational coordination can lead to higher quality of care outcomes and job satisfaction by enabling individuals to manage their tasks with less delay, more rapid and effective responses, fewer errors, and less wasted effort.12
Keep it bite-sized. Regular practice of a new behavior is one of the keys to making that new behavior part of an automatic routine (ie, a habit). To be successfully integrated into staff work routines, QI initiatives must be perceived as congruent with and easily integrated into care goals and workplace practices. Quick, focused, team-building and solution-oriented QI initiatives, therefore, have the greatest chance of success, particularly if staff feel they have little time for participating in new initiatives.13
Researchers designed the 4 LOCK practices to be interrelated and build on one another, creating a bundle to be used together to help facilitate positive change in resident/staff interactions and resident engagement.7 For 6 months, researchers studied the 6 CLCs’ use of the new structured observation tools as part of the LOCK-based QI program. The participating CLCs had such success in improving staff interactions with residents and residents’ engagement in CLC life that GEC, under the CONCERT umbrella, rolled out the LOCK bundle of practices to CLCs nationwide.20
CONCERT’s current activities focus on helping CLCs implement the LOCK bundle nationwide as a relational coordination-based national QI initiative designed to improve quality of care and staff satisfaction. The CONCERT team began this implementation in FY 2017 using a train-the-trainer approach through a staggered veterans integrated service network (VISN) rollout. Each CLC sent 2 leaders to a VISN-wide training program at a host CLC site (the host site was able to have more participants attend). Afterward, the CONCERT team provided individualized phone support to help CLCs implement the program. A VA Pulse (intranet-based social media portal) site hosts all training materials, program videos, an active blog, community discussions, etc.
In FY 2018, the program shifted to a VISN-based support system, with a CONCERT team member assigned to each VISN and VISN-based webinars to facilitate information exchange, collaboration, and group learning. In FY 2018, the CONCERT team also conducted site visits to selected CLCs with strong implementation success records to learn about program facilitators and to disseminate the lessons learned. Spanning FYs 2018 and 2019, the CONCERT team also supports historically low-performing CLCs through a series of rapid-cycle learning intensives based on the Institute for Healthcare Improvement breakthrough collaborative series model for accelerated and sustained QI.21 These incorporate in-person or virtual learning sessions, in which participants learn about and share effective practices, and between-session learning assignments, to facilitate the piloting, implementation, and sustainment of system changes. As part of the CONCERT continuous QI process, the CONCERT team closely monitors the impact of the program and continues to pilot, adapt, and change practices as it learns more about how best to help CLCs improve.
Conclusion
A key CONCERT principle is that health care systems create health care outcomes. The CONCERT team uses the theory of relational coordination to support implementation of the LOCK bundle of practices to help CLCs change their systems to achieve high performance. Through implementation of the LOCK bundle of practices, CLC staff develop, pilot, and spread new systems for communication, teamwork, and collaborative problem solving, as well as developing skills to participate effectively in these systems. CONCERT represents just 1 way VA supports CLCs in their continual journeys toward ever-improved quality of veteran care.
Acknowledgments
The authors thank Barbara Frank and Cathie Brady for their contributions to the development of the CONCERT program.
1. US Department of Veterans Affairs, Geriatrics and Extended Care Services (GEC). https://www.va.gov/GERIATRICS/index.asp. Updated February 25, 2019. Accessed April 9, 2019.
2. US Department of Veterans Affairs. https://www.accesstocare.va.gov/CNH/Statemap. Accessed April 10, 2019.
3. US Department of Veterans Affairs. https://www.va.gov/QUALITYOFCARE/apps/aspire/clcsurvey.aspx/. U
4. Gittell JH, Weinberg D, Pfefferle S, Bishop C. Impact of relational coordination on job satisfaction and quality outcomes: a study of nursing homes. Hum Resour Manag. 2008;18(2):154-170
5. Snow AL, Dodson, ML, Palmer JA, et al. Development of a new systematic observation tool of nursing home resident and staff engagement and relationship. Gerontologist. 2018;58(2):e15-e24.
6. Hartmann CW, Palmer JA, Mills WL, et al. Adaptation of a nursing home culture change research instrument for frontline staff quality improvement use. Psychol Serv. 2017;14(3):337-346.
7. Mills WL, Pimentel CB, Palmer JA, et al. Applying a theory-driven framework to guide quality improvement efforts in nursing homes: the LOCK model. Gerontologist. 2018;58(3):598-605.
8. Caravon P, Hundt AS, Karsh B, et al. Work system design for patient safety: the SEIPS model. Quality & Safety in Health Care. 2006;15(suppl 1), i50-i58.
9. Yanes AF, McElroy LM, Abecassis ZA, Holl J, Woods D, Ladner DP. Observation for assessment of clinician performance: a narrative review. BMJ Qual Saf. 2016;25(1):46-55.
10. Gittell JH. Supervisory span, relational coordination and flight departure performance: a reassessment of postbureaucracy theory. Organ Sci. 2011;12(4):468-483.
11. Gittell JH. New Directions for Relational Coordination Theory. In Spreitzer GM, Cameron KS, eds. The Oxford Handbook of Positive Organizational Scholarship. Oxford University Press: New York; 2012:400-411.
12. Weinberg DB, Lusenhop RW, Gittell JH, Kautz CM. Coordination between formal providers and informal caregivers. Health Care Manage Rev. 2007;32(2):140-149.
13. Phillips J, Hebish LJ, Mann S, Ching JM, Blackmore CC. Engaging frontline leaders and staff in real-time improvement. Jt Comm J Qual Patient Saf. 2016;42(4):170-183.
14. Farrell D, Brady C, Frank B. Meeting the Leadership Challenge in Long-Term Care: What You Do Matters. Health Professions Press: Baltimore, MD; 2011.
15. Brady C, Farrell D, Frank B. A Long-Term Leaders’ Guide to High Performance: Doing Better Together. Health Professions Press: Baltimore, MD; 2018.
16. Bradley EH, Curry LA, Ramanadhan S, Rowe L, Nembhard IM, Krumholz HM. Research in action: using positive deviance to improve quality of health care. Implement Sci. 2009;4:25.
17. Marsh DR, Schroeder DG, Dearden KA, Sternin J, Sternin M. The power of positive deviance. BMJ. 2004; 329(7475):1177-1179.
18. Vogt K, Johnson F, Fraser V, et al. An innovative, strengths-based, peer mentoring approach to professional development for registered dietitians. Can J Diet Pract Res. 2015;76(4):185-189.
19. Beckett P, Field J, Molloy L, Yu N, Holmes D, Pile E. Practice what you preach: developing person-centered culture in inpatient mental health settings through strengths-based, transformational leadership. Issues Ment Health Nurs. 2013;34(8):595-601.
20. Hartmann CW, Mills WL, Pimentel CB, et al. Impact of intervention to improve nursing home resident-staff interactions and engagement. Gerontologist. 2018;58(4):e291-e301.
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