Dissemination of a Care Collaboration Project
A 4-step protocol, outlined by Tomioka and colleagues, was chosen to guide dissemination activities and allow for evaluation of the degree of fidelity to the project model on replication.14 The steps begin with identifying the components of the program and advance through determining implementation and evaluating the degree of fidelity at the new site. Described here is the application of step 1 of the protocol. The second component is under way, and all remaining steps will be reported in a future article.
Methods
Through a series of focused discussions, the core project team delineated the specific project components. Each team member independently assigned an Adaptation Traffic Light designation to each component. Red light changes were those elements that cannot be altered without negatively impacting fidelity to the project model. Yellow light changes can be undertaken with caution, as they could potentially result in substantial deviations from the original project model. Finally, green light changes can be made without negative impact on the program.14 The team reconvened, discussed rationales for the assignments, reevaluated the values assigned, and reached an agreement about the light designation for each component. In cases where an agreement could not be reached through discussion, the team reexamined the component and made changes to the definition where warranted. For example, a concept that had been defined too broadly was broken down further until an agreement was reached regarding categorization of the resultant parts.
Results and Discussion
The project components, how they were implemented, and the Adaptation Traffic Light designations are presented in Table 1. This exercise brought clarity and focus to how the core project team viewed the implementation activities.
Red Lights
Several staff roles and project components were identified that were considered essential to success. First on this list was the role of the leader-champion. To have full impact, the leader-champion must be in a position of authority. For this project, the role of leader-champion was filled by the VISN 1 Primary Care Service Line director. The leader-champion actively facilitated weekly meetings, acted as a project ambassador to VA leadership, and expressed an even-tempered, supportive, problem-solving perspective with the various medical center project leads.
Because this project is implemented across a wide geographic area, local champions at each VAMC were deemed a red-light component. Having motivated people “on the ground” who are invested in the project’s goals is essential for success. For optimal outcomes, local champion involvement must be a choice and not an additional assigned responsibility. Maintaining a stable project team is ideal. In the instances where VAMC teams lost members, the core project team would actively assist in finding new members and orienting new members to the project.
An experienced project manager was also thought to be a red-light element for successful implementation. The project manager must maintain project focus, momentum, and trajectory while identifying opportunities for improvement and expansion.
This project could not be successfully implemented without dedicated administrative support and therefore could not be replicated without administrative assistance. Administrative support for this project was provided by 2 individuals. One individual maintained the weekly meeting schedule, arranged in-person team meetings, produced and circulated meeting minutes, and maintained a calendar of presentations. The second individual provided logistic support to ensure that project funds, equipment, and materials were accessible to each local medical center team as needed.
Community attendees were also a red-light component. On project initiation, the study team intended physicians and midlevel PCPs to be the target audience. However, many physicians were unable to attend due to time constraints. Instead, nurses and other office staff attended—only 13% of the attendees identified themselves as physicians or midlevel providers. As a result, the large project team decided to shift the initial focus from targeting providers to a the broader complement of HCPs. Work began to develop a more in-depth presentation, which would be of interest to nurses, case managers, social workers, administrators, and other medical office personnel.
Presentation content must be consistent across the sites and was, therefore, a red-light element. It is vitally important that the core message being delivered is unified. A small number of slides in the presentation were edited locally to include information specific to the individual medical center (clinic locations, addresses, telephone numbers, and local processes), but the majority of slides had identical content and formatting. The slide set is available on request.
Yellow Lights
Three project components were thought to have yellow-light flexibility and could, when changed with caution, allow for dissemination with fidelity to the project model. The printed materials distributed at presentations included booklets, trifold brochures, information sheets, and other resources seen as useful by each medical center team. Any printed materials could be distributed as long as they were VHA vetted and approved.
