One important factor influencing the successful implementation of system-wide change is initial readiness. Readiness is defined as the degree to which those involved are individually and collectively primed, motivated, and technically capable of executing the change. We present a conceptual framework that highlights three broad areas to be considered if health-care professionals are to comprehensively evaluate readiness that includes psychological factors (i.e., characteristics of those being asked to change), structural factors (i.e., circumstances under which the change is occurring) as well as the level of analysis (i.e., individual and organizational levels). We also describe more specific dimensions within each of these broad categories that have both empirical and theoretical support, presenting several valid and reliable survey instruments that measure key dimensions of readiness quantitatively.

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The study assessed sustainability of the Family Care Map, a family-centered approach to providing care for Veterans with polytrauma-related injuries, in four Department of Veterans Affairs Polytrauma Rehabilitation Centers. We applied a mixed-methods approach. Staff surveys used standardized measures of sustainability, commitment to change, information, and participation during implementation. Qualitative inquiry assessed Family Care Map implementation and facilitators and barriers to sustainability. Staff sustainability perceptions had a significant positive correlation with affective commitment to change, participation, and information received about the change process. Family Care Map integration into standard practices and use of its concepts with patients and families related to staff perceptions about sustainability. The degree of use and integration of the Family Care Map in traumatic brain injury/polytrauma care varied among the Polytrauma Rehabilitation Centers. Some successful sustainability strategies included integration into daily workflow and organizational culture. Examples of sustainability barriers included staff awareness and use and outdated information. Some practices, such as measuring and documenting the use of the Family Care Map in treatment plans, may not routinely occur. The focus on family-centered care will require further evaluation of organization-, staff-, and innovation-level attributes that influence sustainability of changes designed to improve family-centered care.

BackgroundThe U.S. Department of Veterans Affairs (VA) implemented the Polytrauma System of Care to meet the health care needs of military and veterans with multiple injuries returning from combat operations in Afghanistan and Iraq. Studies are needed to systematically assess barriers to use of comprehensive and exclusive VA healthcare services from the perspective of veterans with polytrauma and with other complex health outcomes following their service in Afghanistan and Iraq. These perspectives can inform policy with regard to the optimal delivery of care to returning veterans.MethodsWe studied combat veterans (n = 359) from two polytrauma rehabilitation centers using structured clinical interviews and qualitative open-ended questions, augmented with data collected from electronic health records. Our outcomes included several measures of exclusive utilization of VA care with our primary exposure as reported access barriers to care.ResultsNearly two thirds of the veterans reported one or more barriers to their exclusive use of VA healthcare services. These barriers predicted differences in exclusive use of VA healthcare services. Experiencing any barriers doubled the returnees’ odds of not using VA exclusively, the geographic distance to VA barrier resulted in a 7 fold increase in the returnees odds of not using VA, and reporting a wait time barrier doubled the returnee’s odds of not using VA. There were no striking differences in access barriers for veterans with polytrauma compared to other returning veterans, suggesting the barriers may be uniform barriers that predict differences in using the VA exclusively for health care.ConclusionsThis study provides an initial description of utilization of VA polytrauma rehabilitation and other medical care for veteran returnees from all military services who were involved in combat operations in Afghanistan or Iraq. Our findings indicate that these veterans reported important stigmatization and barriers to receiving services exclusively from the VA, including mutable health delivery system factors.

Abstract-Although research shows that caring for a family member with chronic disease or disability can cause significant distress for caregivers, it also shows that families that function well and adequately support patients can improve the quality of life and health outcomes for their ill or disabled family member. Currently, little knowledge exists about how families function and cope after a loved one has sustained polytrauma, the multiple traumatic injuries that often include traumatic brain injury (TBI). We summarize the polytrauma and TBI research about family needs during rehabilitation and recovery, describe current efforts to improve family-centered care, and detail approaches for understanding family resilience and the longterm consequences of injuries on families. We conclude with recommendations for future research in inpatient and outpatient settings where evidence has been limited for families of patients with TBI and is nonexistent for families of patients with polytrauma. Understanding many of these issues will help to better inform families of policies for benefits and resources and help researchers and clinicians plan for appropriate interventions.

BACKGROUND:The Department of Veterans Affairs (VA) provides rehabilitation for veterans with moderate to severe war injuries through four regional Polytrauma Rehabilitation Centers (PRCs). To standardize and improve care provided to these veterans′ family members, health services researchers partnered with program leaders and rehabilitation specialists to implement a family care quality improvement collaborative. OBJECTIVE:To describe practice changes associated with the Family Care Collaborative′s intervention. DESIGN:Cross-site, mixed-method evaluation.PARTICIPANTS: Rehabilitation interdisciplinary team members (n=226) working at the four participating sites. INTERVENTIONS:The collaborative developed and implemented in a 6-month pilot a web-based tool to standardize and promote family-centered care.OUTCOMES: Provider survey of family care, satisfaction with family care, and perceived competence in working with families; specific practice changes at each site; provider and facilitator perceptions of the collaborative work; and a validated measure to predict likelihood of success of the selected intervention. MAIN RESULTS:Family-centered practices and satisfaction improved at sites with lower baseline scores (P<0.05) and was equivalent across sites after the pilot. Providers initiated specific family-centered practices that often began at one site and spread to the others through the collaborative. Sites standardized family education and collaboration. Providers believed that the collaborative produced a "culture change" from patient-centered to family-centered care and viewed program leadership and health services researchers' involvement as crucial for success. Scores on the measure to predict successful implementation of the intervention beyond the pilot were promising. CONCLUSIONS:Collaboratives that bring together clinicians, program leaders, and researchers may be useful for fostering complex change involving interdisciplinary teams.

Background Implementation researchers recognize the influential role of organizational factors and, thus, seek to assess these factors using quantitative measurement instruments. However, researchers are hindered by instruments that measure similar constructs but rely on different nomenclature and/or definitions. The Consolidated Framework for Implementation Research (CFIR) provides a taxonomy of constructs derived from prior frameworks and empirical studies of implementation-related constructs. The CFIR includes constructs based on the original Promoting Action on Research Implementation in Health Services (PARiHS) framework which highlights the key roles of strength of evidence for a specific evidence-based intervention (EBI), favorability of organizational context for change, and capacities to facilitate implementation of the EBI. Although the CFIR is among the most frequently used implementation frameworks, it does not include quantitative measures. The Organizational Resource and Context Assessment (ORCA) is a quantitative measurement instrument that was developed based on PARiHS, assessing its three domains. Factors within these three domains are conceptually similar to constructs in the CFIR but do not match directly. The aim of this work was to map ORCA survey items to CFIR constructs to enable direct comparisons and syntheses of findings across studies using the CFIR and/or ORCA. Methods Two distinct, independent research teams, each used rigorous constant comparative techniques with deliberation and consensus to map individual items from the ORCA to the five domains and 39 constructs of CFIR. Results ORCA items were mapped primarily to three of five CFIR domains: Inner Setting, Process, and Intervention Characteristics. The two research teams agreed on 88% of mappings at the higher domain level; at the lower construct level, their mappings aligned for 62.2% of the ORCA items. Conclusions Mapping results reveal that the ORCA focuses measurement prominently on Inner Setting, Process, and Intervention Characteristics. This mapping guide can help improve consistency in measurement and reporting, enabling more efficient comparison and synthesis of findings that use either the ORCA instrument or the CFIR framework. The guide helps advance implementation science utilizing mixed methods by providing CFIR users with quantitative measures for selected constructs and enables ORCA users to map their findings to CFIR constructs.