Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA.
Department of Internal Medicine, Division of General Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.
Implement Sci. 2018 Jul 9;13(1):93. doi: 10.1186/s13012-018-0787-9.
Organizational culture and climate are considered key factors in implementation efforts but have not been examined as moderators of implementation strategy comparative effectiveness. We investigated organizational culture and climate as moderators of comparative effectiveness of two sequences of implementation strategies (Immediate vs. Delayed Enhanced Replicating Effective Programs [REP]) combining Standard REP and REP enhanced with facilitation on implementation of an outreach program for Veterans with serious mental illness lost to care at Veterans Health Administration (VA) facilities nationwide.
This study is a secondary analysis of the cluster-randomized Re-Engage implementation trial that assigned 3075 patients at 89 VA facilities to either the Immediate or Delayed Enhanced REP sequences. We hypothesized that sites with stronger entrepreneurial culture, task, or relational climate would benefit more from Enhanced REP than Standard REP. Veteran- and site-level data from the Re-Engage trial were combined with site-aggregated measures of entrepreneurial culture and task and relational climate from the 2012 VA All Employee Survey. Longitudinal mixed-effects logistic models examined whether the comparative effectiveness of the Immediate vs. Delayed Enhanced REP sequences were moderated by culture or climate measures at 6 and 12 months post-randomization. Three Veteran-level outcomes related to the engagement with the VA system were assessed: updated documentation, attempted contact by coordinator, and completed contact.
For updated documentation and attempted contact, Veterans at sites with higher entrepreneurial culture and task climate scores benefitted more from Enhanced REP compared to Standard REP than Veterans at sites with lower scores. Few culture or climate moderation effects were detected for the comparative effectiveness of the full sequences of implementation strategies.
Implementation strategy effectiveness is highly intertwined with contextual factors, and implementation practitioners may use knowledge of contextual moderation to tailor strategy deployment. We found that facilitation strategies provided with Enhanced REP were more effective at improving uptake of a mental health outreach program at sites with stronger entrepreneurial culture and task climate; Veterans at sites with lower levels of these measures saw more similar improvement under Standard and Enhanced REP. Within resource-constrained systems, practitioners may choose to target more intensive implementation strategies to sites that will most benefit from them.
ISRCTN: ISRCTN21059161 . Date registered: April 11, 2013.
组织文化和氛围被认为是实施工作的关键因素，但尚未作为实施策略比较有效性的调节因素进行检验。我们研究了组织文化和氛围作为两种实施策略序列（立即与延迟增强复制有效项目[REP]）的比较有效性的调节因素，这两种策略序列将标准 REP 与通过促进为全国退伍军人健康管理局（VA）设施中失去护理的严重精神疾病退伍军人提供外展计划的 REP 相结合。
这项研究是对再参与实施试验的二次分析，该试验将 89 个 VA 设施的 3075 名患者随机分配到立即或延迟增强 REP 序列。我们假设具有更强创业文化、任务或关系氛围的站点将从增强 REP 中比标准 REP 中获益更多。从再参与试验中合并了退伍军人和站点层面的数据，并结合了 2012 年 VA 全体员工调查中站点汇总的创业文化和任务和关系氛围指标。纵向混合效应逻辑模型检验了在随机分组后 6 和 12 个月时，文化或气候测量是否调节了立即与延迟增强 REP 序列的比较有效性。评估了三个与退伍军人与 VA 系统互动相关的退伍军人层面结果：更新文档、协调员尝试联系和完成联系。
对于更新文档和尝试联系，与创业文化和任务气候得分较高的站点相比，具有较高得分的站点的退伍军人从增强 REP 中获益更多，而不是标准 REP。对于实施策略的完整序列的比较有效性，很少有文化或气候调节作用被发现。
实施策略的有效性与背景因素高度交织在一起，实施从业者可能会利用背景调节知识来调整策略部署。我们发现，在创业文化和任务氛围较强的站点中，增强 REP 提供的促进策略在改善心理健康外展计划的采用方面更为有效；在这些措施得分较低的站点中，标准和增强 REP 下的改善更为相似。在资源有限的系统中，从业者可能会选择将更密集的实施策略针对最能从中受益的站点。
ISRCTN：ISRCTN84214321。注册日期：2013 年 4 月 11 日。
