VA Eastern Colorado Health Care System, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA.
VA Eastern Colorado Health Care System, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA.
J Pain Symptom Manage. 2021 Jul;62(1):125-133.e2. doi: 10.1016/j.jpainsymman.2020.10.034. Epub 2020 Nov 3.
In 2017, Veterans Health Administration (VHA) National Center for Ethics in Health Care began system-wide implementation of the Life-Sustaining Treatment Decisions Initiative (LSTDI). The LSTDI is a national VHA policy and practice to promote conducting goals of care conversations and documenting veterans' preferences for life-sustaining treatments (LSTs).
The aim of this article is to describe facilitators and barriers to early implementation of the LSTDI within one VHA Veterans Integrated Service Network.
From September 2016 to December 2018, we conducted site visits and semistructured phone interviews with implementation coordinators who championed the LSTDI rollout at seven VHA medical centers. We applied the Consolidated Framework for Implementation Research (CFIR) to assess facilitators and barriers to implementing the LSTDI and assigning interview data to specific CFIR constructs and CFIR valence ratings. We simultaneously benchmarked VHA medical centers' implementation progress as outlined by the National Center for Ethics in Health Care implementation guidebook.
We divided sites into three descriptive groups based on implementation progress: successfully implemented (n = 2); moving forward, but delayed (n = 3); and implementation stalled (n = 2). Five CFIR constructs emerged as facilitators or barriers to implementation of the LSTDI: 1) self-efficacy of implementation coordinators; 2) leadership engagement; 3) compatibility with pre-existing workflows; 4) available resources; and 5) overall implementation climate.
Although self-efficacy proved key to overcoming obstacles, degree of perceived workflow compatibility of the LSTDI policy, available resources, and leadership engagement must be adequate for successful implementation within the implementation time line. Without these components, successful implementation was hindered or delayed.
2017 年，退伍军人健康管理局（VHA）国家医疗保健伦理中心开始在全系统实施维持生命治疗决策倡议（LSTDI）。LSTDI 是一项全国性的 VHA 政策和实践，旨在促进进行目标关怀对话，并记录退伍军人对维持生命治疗（LST）的偏好。
本文旨在描述在退伍军人一体化服务网络中的一个 VHA 退伍军人综合服务网络中，早期实施 LSTDI 的促进因素和障碍。
从 2016 年 9 月到 2018 年 12 月，我们对 7 个 VHA 医疗中心倡导 LSTDI 推出的实施协调员进行了现场访问和半结构化电话访谈。我们应用实施研究综合框架（CFIR）评估实施 LSTDI 的促进因素和障碍，并将访谈数据分配给特定的 CFIR 结构和 CFIR 效价评分。同时，我们根据国家医疗保健伦理中心的实施指南，对标 VHA 医疗中心的实施进展。
我们根据实施进展将站点分为三组：成功实施（n=2）；推进中但延迟（n=3）；实施停滞（n=2）。五个 CFIR 结构被认为是实施 LSTDI 的促进因素或障碍：1）实施协调员的自我效能；2）领导力参与；3）与现有工作流程的兼容性；4）可用资源；5）整体实施氛围。
尽管自我效能被证明是克服障碍的关键，但 LSTDI 政策、可用资源和领导力参与的感知工作流程兼容性的程度必须在实施时间表内足够，以实现成功实施。如果没有这些组成部分，实施就会受阻或延迟。
