The Department of Veterans Affairs, Veterans Health Administration, a national public sector health care system in the US consisting of 162 hospitals and more than 850 community and facility-based clinics, developed and implemented, in partnership with the Institute for Healthcare Improvement (IHI), a change model to improve access resulting in significant decreases in waiting times despite a 23 percent increase in demand for health care services and an increase in supply of only 2.3 percent.

IHI designed and VA implemented a major system re-organization and a model to spread Advanced Clinic Access (ACA) throughout the VA. Each element of the model has been developed and continues to be refined and reinforced. The spread model included the elements and activities described below. 

Organizational Infrastructure:
Leadership commitment and support; a staging plan or strategy to reach all new sites; technical support to ensure that providers have the knowledge and tools they need to make the change; a measurement system that monitors progress and provides feedback to providers about progress; and a knowledge management system to document information, progress, issues, and questions as they arise

• Established a national leadership team
• Established a national ACA Steering Committee, chaired by a VISN Director (a high-ranking VHA official)
• Included goals to improve access in Network Directors’ 2000 and 2003 Performance Measures and Monitors for six clinic areas: primary care, audiology, eye care, orthopedics, urology, and cardiology
• Established policies to support measurement, reporting and accountability
• Updated software to improve database utilization
• Conducted training in interpretation and use of the national databases and national waiting times reports
• Appointed ACA points of contact in each VISN 
• Established Work Groups to focus on measurement, ACA implementation in academic settings, and communication
• Established a National Referral Template task force to review best examples of referral templates and post on the intranet
• Established Steering Committee Liaisons for each of the six focus clinic areas and mental health
• Conducted regular briefings with Under Secretary for Health and Deputy Under Secretary for Health
• Conducted a briefing with the Secretary and Deputy Secretary of the Department of Veterans Affairs
• Developed VISN spread plans to meet the access goals
• Established a National VHA ACA website that contains:
  • Resource documents
  • Referral templates
  • Transcripts of conference calls
  • National and VISN-level waiting time reports
  • PowerPoint files and other resources for teaching

Information about Advanced Clinic Access:

• Produced a 45-minute video featuring Dr. Mark Murray, MD, MPA, on Advanced Clinic Access to teach the principles and strategies for implementation of ACA
• Produced a 10-minute video "The Time Has Come" featuring testimonials from providers who had implemented ACA to make the case for and to spread awareness about ACA
• Compiled core ACA information about changes needed to implement ACA into a document entitled Advanced Clinic Access

Communication:
To spread awareness, technical information, and identify key messengers

• Developed a national poster to promote ACA 
• Built a national marketing campaign featuring the national poster
• Utilized Public Affairs Officers at both the VISN- and facility level to launch the national marketing campaign
• Utilized public affairs expertise to develop the Advanced Clinic Access Communications Reference Guide
• Held weekly conference calls with VHA executive leaders
• Held twice-monthly conference calls featuring brief presentations on the improvements in access achieved through ACA implementation
• Published articles about ACA in internal VHA publications
• Established email groups for each of the focus clinic areas

The Social System (The Unit of Spread):
Those who are adopting the new system, communities of practice, listeners and connectors, and motivators and incentives

• Identified and trained National Access Coaches as well as coaches at the facility level
• Added new national and local coaches
• Established regular conference calls with the VISN and facility point of contacts

Better Ideas

• Include making the case and the description 
• Include both stories and data
• Gather the core content in one place so it can be communicated in many different ways
• Leadership support is essential

Communication

• Balance communication of awareness and technical knowledge
• Because people are at different stages of change, awareness, and technical knowledge, communication is continuous 
• The strength of the message is the key to awareness 
• Peer-to-peer communication is needed to spread technical knowledge
• Context is important, i.e., receptivity of receivers (noise, adverse motivators, etc.)

Social System

• Identifying opinion leaders is only the first step 
• Communicating explicit knowledge is not enough
• Use relationships in the social system to spread tacit knowledge
• The need for improvement is not obvious to everyone 

Infrastructure

• Use the natural structure within the organization to lead the effort
• For large systems, a staging plan is a key first step in developing a spread strategy
• Don’t expect that your technical experts can effectively communicate the information 
• Knowledge management is not just the creation of a website
• Measurement can lead to system changes
• Measurement can lead to compliance; behavior change takes longer

The model for large system change has been in place for approximately two years. Significant improvement in access continues to occur despite ever-increasing demand for services. Continued implementation of the model will focus on strengthening and maintaining each element of the model.

The model introduced by IHI to guide the spread of the Advanced Clinic Access Initiative is also being applied within other health care organizations around the country in a number of different areas including patient safety, critical care, patient flow in the acute care setting, workforce development, and all aspects of office practices and outpatient settings. There is growing evidence that the model contains the key components needed to spread any innovation or new process within any organization.

Renee L. Parlier, RN, MPA
Director, Veterans Health Administration Advanced
Clinic Access Initiative
Department of Veterans Affairs (10NC)
5445 Minnehaha Avenue
Building 9, 2nd Floor
Minneapolis, MN 55417 

[Storyboard presentation at IHI's National Forum, December 2003]