• T M Damush, E J Miech, N A Rattray, B Homoya, Lauren S Penney, A Cheatham, S Baird, J Myers, C Austin, L J Myers, A J Perkins, Y Zhang, B Giacherio, M Kumar, L D Murphy, J J Sico, and D M Bravata.
• Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRIS-M) Quality Enhancement Research Initiative (QUERI), Indianapolis, IN, USA. Teresa.Damush@va.gov.
• J Gen Intern Med. 2021 Feb 1; 36 (2): 322-332.

BackgroundThe Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurologic Symptoms (PREVENT) program was designed to address systemic barriers to providing timely guideline-concordant care for patients with transient ischemic attack (TIA).ObjectiveWe evaluated an implementation bundle used to promote local adaptation and adoption of a multi-component, complex quality improvement (QI) intervention to improve the quality of TIA care Bravata et al. (BMC Neurology 19:294, 2019).DesignA stepped-wedge implementation trial with six geographically diverse sites.ParticipantsThe six facility QI teams were multi-disciplinary, clinical staff.InterventionsPREVENT employed a bundle of key implementation strategies: team activation; external facilitation; and a community of practice. This strategy bundle had direct ties to four constructs from the Consolidated Framework for Implementation Research (CFIR): Champions, Reflecting & Evaluating, Planning, and Goals & Feedback.Main MeasuresUsing a mixed-methods approach guided by the CFIR and data matrix analyses, we evaluated the degree to which implementation success and clinical improvement were associated with implementation strategies. The primary outcomes were the number of completed implementation activities, the level of team organization and > 15 points improvement in the Without Fail Rate (WFR) over 1 year.Key ResultsFacility QI teams actively engaged in the implementation strategies with high utilization. Facilities with the greatest implementation success were those with central champions whose teams engaged in planning and goal setting, and regularly reflected upon their quality data and evaluated their progress against their QI plan. The strong presence of effective champions acted as a pre-condition for the strong presence of Reflecting & Evaluating, Goals & Feedback, and Planning (rather than the other way around), helping to explain how champions at the +2 level influenced ongoing implementation.ConclusionsThe CFIR-guided bundle of implementation strategies facilitated the local implementation of the PREVENT QI program and was associated with clinical improvement in the national VA healthcare system.Trial Registrationclinicaltrials.gov: NCT02769338.

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