The protocol-guided rapid evaluation of veterans experiencing new transient neurological symptoms (PREVENT) quality improvement program: rationale and methods

Bravata, Dawn M.; Myers, Laura J.; Homoya, Barbara J.; Miech, Edward J.; Rattray, Nicholas A.; Perkins, Anthony J.; Zhang, Y.; Ferguson, Jared; Myers, Jennifer; Cheatham, Ariel J.; Murphy, Lauren; Giacherio, B; Kumar, Meetesh; Cheng, Eric M.; Levine, Deborah A.; Sico, Jason J.; Ward, Michael J.; Damush, Teresa M.

doi:10.1186/s12883-019-1517-x

Cited by 23 publications

(57 citation statements)

References 43 publications

(58 reference statements)

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“…The site recruitment methods have been described. 15 The VA hospitals were rank ordered in terms of quality of TIA care 12 ; invitations to participate were sent beginning with facilities with the lowest performance and the highest TIA annual patient volume. Recruitment continued until 6 facilities agreed to participate.…”

Section: Methodsmentioning

confidence: 99%

“…The PREVENT intervention targeted clinical teams (not patients) and consisted of the following 5 components: clinical programs (including clinical pathways with educational materials and documentation tools), data feedback, professional education, electronic health record tools, and QI support (including a virtual collaborative). 15 Active implementation of the PREVENT intervention involved a full-day kickoff during which the facility team explored their site-specific quality of care data to identify processes of care with the largest gaps in quality for the greatest number of patients. Using systems redesign approaches, facility team members brainstormed about barriers to providing the highest quality of care, identified solutions to address barriers, ranked solutions in terms of potential benefits and effort, and developed a site-specific action plan.…”

Section: Methodsmentioning

confidence: 99%

“… 14 The objective of the Protocol-Guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) trial was to evaluate a multicomponent QI intervention to improve the quality of TIA care. 15 The PREVENT intervention was designed to align with the learning health care system model. 13 , 15 …”

Section: Introductionmentioning

confidence: 99%

“… 15 The PREVENT intervention was designed to align with the learning health care system model. 13 , 15 …”

Section: Introductionmentioning

confidence: 99%

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Assessment of the Protocol-Guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) Program for Improving Quality of Care for Transient Ischemic Attack

et al. 2020

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Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

“… 15 The PREVENT intervention was designed to align with the learning health care system model. 13 , 15 …”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Assessment of the Protocol-Guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) Program for Improving Quality of Care for Transient Ischemic Attack

et al. 2020

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“…The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) was a stepped-wedge trial to improve the quality of TIA care (NCT02769338). (22) The implementation trial and its methodology was previously published. To summarize brie y, two VA facilities participated in each of three waves (n=6); each facility had a one-year active implementation period.…”

mentioning

confidence: 99%

Multi-tiered External Facilitation: The Role of Feedback Loops and Tailored Interventions in Supporting Change in a Stepped-Wedge Implementation Trial

Penney

Damush

Rattray

et al. 2020

Preprint

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Background Facilitation is a complex, relational implementation strategy that guides change processes. Facilitators engage in multiple activities and tailor efforts to local contexts. The contextual factors that prompt facilitators to tailor activities have not been well-described. Methods We conducted a mixed methods evaluation of a trial to improve the quality of transient ischemic attack care. Six sites in the Veterans Health Administration received external facilitation (EF) before and during a 1-year active implementation period. We examined how EF was employed, perceived, and activated. Data analysis included prospective logs of facilitator correspondence with sites (160 site-directed episodes), stakeholder interviews (n=78), and collaborative call debriefs (n=22). Logs were descriptively analyzed across facilitators, sites, time periods, and activity types. Interview transcripts were coded for content related to EF and themes were identified. Debriefs were reviewed to identify instances of and utilization of EF during site critical junctures. Results Multi-tiered EF was supported by two groups (site-facing quality improvement [QI] facilitators and the implementation support team) that were connected by feedback loops. Each site received an average of 24 episodes of site-directed EF; most of the EF was delivered by the QI nurse. For each site, site-directed EF frequently involved networking (45%), preparation and planning (44%), process monitoring (44%), and/or education (36%). EF less commonly involved audit and feedback (20%), brainstorming solutions (16%), and/or stakeholder engagement (5%). However, site-directed EF varied widely across sites and time periods in terms of these facilitation types. Site participants recognized the responsiveness of the QI nurse, and valued her problem-solving, feedback, and accountability support. External facilitators used monitoring and dialogue to intervene by facilitating redirection during challenging periods of uncertainty about project direction and feasibility for sites. External facilitators, in collaboration with the implementation support team, successfully used strategies tailored to diverse local contexts, including networking, providing data, and brainstorming solutions. Conclusions Multi-tiered facilitation capitalizing on feedback loops allowed for tailored, site-directed facilitation that aligned with the types of supports that local participants valued. Critical juncture cases illustrate the complexity of EF and the need to often try multiple strategies in combination to facilitate implementation progress.

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A Learning Health Care System–Based Approach for Improving Quality of Care Among Patients With Transient Ischemic Attack

Vahidy

2020

JAMA Netw Open

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Transient ischemic attack (TIA) is a harbinger of recurrent stroke and poor cardiovascular outcomes.Early evaluation and targeted management substantially reduce the risk of subsequent adverse events. 1,2 Furthermore, specialized clinic-based care is associated with higher adherence to evidence-based secondary stroke prevention strategies and improved outcomes. 3 Bravata et al 4 provide the findings from the Protocol-Guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) quality improvement (QI) program.They highlight that the PREVENT program was conceived on the principles of a learning health care system (LHS). The multicomponent PREVENT intervention comprised the following 5 domains: development and sharing of clinical protocols across participating sites, provision of a data-driven web-based interactive and customizable dashboard (the PREVENT hub), professional education for health care providers, electronic health record (EHR) tools, and ongoing QI support, including a virtual collaborative platform. 5 The results of the intervention were primarily measured by monitoring adherence to the following 7 guideline-recommended processes of care for patients with TIA: anticoagulation for atrial fibrillation, antithrombotic use, brain imaging, carotid artery imaging, high-or moderate-potency statin therapy, hypertension control, and neurological consultation. The prespecified primary outcome was a without-fail rate, defined as the proportion of participants with TIA who received all of the individually indicated processes of care. Of note, this outcome measure does not provide partial credit toward achieving some of the applicable processes of care. Therefore, a secondary consolidated measure of care was also included that described the proportion of care that patients received for which they are eligible. The program was implemented across 6 Veterans Affairs (VA) hospitals as a cluster design, and the investigators compared outcomes between the 6 participating sites and 36 matched nonparticipating VA hospitals.The PREVENT intervention was conducted in 3 phases; however, the sites were not randomly assigned to the intervention, which would have been the case in a classic step-wedge trial (SWT) design. 6 The SWT is a design that is gaining traction in health services research in which the intent is to establish the effectiveness of implementation strategies for evidence-based interventions at a cluster or group level. Although the design provides logistical advantages (eg, a phased rollout across sites or clusters), it does not compromise scientific rigor and, if correctly implemented, provides causal estimates. Evaluation of QI interventions warrants a rigor similar to that of randomized clinical trials (RCTs), and PREVENT's rationale and setting were suitable for an SWT design. The design limitations are further compounded by a selective nature of the 6 VA hospitals where the program was implemented. Although the logistical, behavioral, political, and administrative challenge...

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The protocol-guided rapid evaluation of veterans experiencing new transient neurological symptoms (PREVENT) quality improvement program: rationale and methods

Cited by 23 publications

References 43 publications

Assessment of the Protocol-Guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) Program for Improving Quality of Care for Transient Ischemic Attack

Assessment of the Protocol-Guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) Program for Improving Quality of Care for Transient Ischemic Attack

Multi-tiered External Facilitation: The Role of Feedback Loops and Tailored Interventions in Supporting Change in a Stepped-Wedge Implementation Trial

A Learning Health Care System–Based Approach for Improving Quality of Care Among Patients With Transient Ischemic Attack

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