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Experiences of agency for healthcare research and quality-funded projects that implemented practices for safer patient care.

Article Excerpt
BACKGROUND

In 2002, the U.S. Congress gave the Agency for Healthcare Research and Quality (AHRQ) the mandate to lead federal patient safety improvement activities. In response, AHRQ formulated a strategy with an explicit commitment to improving quality and safety in health care through a combination of scientific research and promotion of improvement (AHRQ 2003). In September 2002, AHRQ contracted with RAND to serve as its Patient Safety Evaluation Center and perform a longitudinal, formative evaluation of its patient safety initiative (Farley et al. 2008; Farley and Battles 2008, in this issue).

This paper reports the results of one component of this broader evaluation-assessment of the experiences and lessons learned from AHRQ-funded projects that focused on the implementation of patient safety practices. Within our process evaluation, these projects were assessed as contributing to the Development of Effective Practices and Tools component of the system framework (see Farley and Battles 2008, in this issue).

Our goal was to inform future related work by AHRQ other policy makers, and health care providers by synthesizing lessons learned from the experiences of these projects, assessing how their experiences varied, and identifying factors associated with successful implementation. To our knowledge, this is one of the first reported evaluations of patient safety implementation projects. This paper also describes the data collection methods used and how we adjusted those methods in response to changes in data needs during the course of our evaluation. Future evaluations of patient safety implementation projects might learn from our choice of tools and data collection processes.

The Implementation Projects Addressed

We addressed three groups of projects in this evaluation component, as shown below (see Sorbero et al. 2008, in this issue, for details on the sets of funded projects).

Original Grants. In fiscal years (FY) 2000 and 2001, AHRQ funded 81 patient safety projects in seven project groups. Of these 81 projects, we identified 39 that implemented at least one patient safety intervention. These 39 projects were included in the evaluation of implementation experiences reported here. (We refer to these projects here as the "Original Grants.")

Challenge Implementation Grants. AHRQ awarded 13 Challenge Grants in FY 2003, seven of which were funded to implement and evaluate proven patient safety practices in a variety of health care institutions and health care systems. (1) These seven Challenge Implementation Grant projects were included in this portion of our evaluation.

Partnerships in Implementing Patient Safety (PIPS) Grants. In FY 2005, AHRQ awarded 17 PIPS grants to assist health care institutions in implementing safe practices. One of the unique grant requirements was the development of "toolkits" that would assist others in any future implementation of the practices being tested. All of these grants were included in this portion of our evaluation.

METHODS

Our evaluation was formative--not only because we created a feedback loop to AHRQ to share lessons learned after evaluating each group of grantees-but also in the sense that we modified and refined our methods as we learned from our early assessments of grantees' experiences. The methodological changes enabled us to collect richer and more precisely defined data, allowing improved comparisons across project groups. The Original and Challenge grants were awarded early in the patient safety initiative. Therefore, we could collect data from them at two points in time to capture their early implementation experiences as well as their later assessments regarding project success and sustainability. Because the PIPS grants were awarded close to the end of the 4-year term of the evaluation, we could only gather data from them once, in the second year of their projects.

For the Original grants and Challenge grants, we collected qualitative data in the first year of the projects to characterize their early experiences. Specifically, we conducted telephone interviews using semi-structured protocols to collect data from the Original grants in 2003. In 2004, we also used semi-structured protocols during site visits to the Challenge grant project locations, allowing us to gain richer insights into the dynamics of the implementation process and related issues. Site visits were financially feasible for this project group because of the small number of seven projects; it was not feasible for the larger group of 39 Original projects. This is the first of two major differences in methods used, in this case a difference across groups.

We returned to the Original (in 2006) and Challenge (in 2005) grant projects in the last year of the evaluation soon after most of them had completed their work to obtain their retrospective views on their implementation experiences. In this second round of interviews, which were done by telephone, we collected both qualitative data and quantifiable data that allowed us to make more systematic comparisons across groups than was possible with only qualitative data. The development and use of the questions to collect quantifiable data is the other major methodological modification, in this case a difference in the type of data collected.

For the PIPS grants, we collected data only once using telephone interviews conducted in the second year of the projects (2006). We used a semistructured interview protocol similar to that used for the second data collection for the Original and Challenge grants to obtain both qualitative and quantifiable data on their implementation experiences.

In all interviews except those conducted during the Challenge grant site visits we interviewed the project Principal Investigators (PIs). At the site visits, we obtained data from PIs as well as other project staff; institutional leadership; end users (physicians, nurses, and pharmacists); and other stakeholders. All data collection was done in accordance with the human subjects requirements of RAND's Institutional Review Board (IRB).

Telephone Interviews on Early Implementation Experiences

The protocols used for the interviews on early experiences of the three project groups covered many of the same topics, focusing on what was working well and where they...

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