How Active Resisters and Organizational Constipators Affect Health Care–Acquired Infection Prevention Efforts

The Joint Commission Journal on Quality and Patient Safety Infection Prevention and Control

How Active Resisters and Organizational Constipators Affect Health Care–Acquired Infection Prevention Efforts Sanjay Saint, M.D., M.P.H.; Christine P. Kowalski, M.P.H.; Jane Banaszak-Holl, Ph.D.; Jane Forman, Sc.D., M.H.S.; Laura Damschroder, M.S., M.P.H.; Sarah L. Krein, Ph.D., R.N.

H

ealth care–associated infection (HAI) is a common and costly patient safety problem.1–4 The Centers for Disease Control and Prevention (CDC) estimates that HAI leads to approximately 99,000 deaths per year in hospitals in the United States and an annual attributable cost of $6.7 billion.5,6 Given the potential for prevention, the Centers for Medicare & Medicaid Services (CMS) will no longer reimburse hospitals for the extra cost of caring for patients who develop certain infections during hospitalization, such as infection due to either urinary or vascular catheter use.7 Catheter-associated urinary tract infection (CAUTI), central venous catheter–related bloodstream infection (CRBSI), and ventilator-associated pneumonia (VAP) are the most common device-associated infections. Given the clinical and economic consequences of HAI, various evidence-based guidelines and recommendations are available to hospitals and clinicians.8–16 Yet, the existence and subsequent dissemination of evidencebased recommendations are insufficient to ensure that current hospital practice reflect scientific evidence.17–20 The study reported in this article was part of a national, multicenter, sequential study,21 in which the first phase was a quantitative survey to identify what hospitals are doing to prevent device-related infections in hospitalized patients.21–23 In May 2005 we sent a survey to the lead infection control professional (ICP) at more than 700 hospitals across the United States, including all Veterans Affairs (VA) medical centers and a stratified random sample of non–VA general medical and surgical hospitals with > 50 beds and with intensive care beds. This survey, with a response rate of 72%, provided the basis for the selection of hospitals for the second and third phases of the study in which we sought to understand why hospitals are using or not using certain practices by rigorously collecting and analyzing detailed qualitative data. This included characterizing the role of hospital personnel in HAI–prevention activities, which is the focus of this article. Specifically, we sought to understand why some hospitals appeared to be actively engaged in and committed to prevent-

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Article-at-a-Glance Background: As of October 2008, hospitals in the United States no longer receive Medicare reimbursement for certain types of health care–associated infection (HAI), thereby heightening the need for effective prevention efforts. The mere existence of evidence-based practices, however, does not always result in the use of such practices because of the complexities inherent in translating evidence into practice. A qualitative study was conducted to determine the barriers to implementing evidence-based practices to prevent HAI, with a specific focus on the role played by hospital personnel. Methods: In-depth phone and in-person interviews were conducted between October 2006 and September 2007 with 86 participants (31 physicians) including chief executive officers, chiefs of staff, hospital epidemiologists, infection control professionals, intensive care unit directors, nurse managers, and frontline physicians and nurses, in 14 hospitals. Findings: Active resistance to evidence-based practice change was pervasive. Successful efforts to overcome active resisters included benchmarking infection rates, identifying effective champions, and participating in collaborative efforts. Organizational constipators—mid- to high-level executives who act as insidious barriers to change—also increased the difficulty in implementing change. Recognizing the presence of constipators is often the first step in addressing the problem but can be followed with including the organizational constipator early in group discussions to improve communication and obtain buy-in, working around the individual, and terminating the constipator’s employment. Discussion: Two types of personnel—active resistors and organizational constipators—impeded HAI prevention activities, and several approaches were used to overcome those barriers. Hospital administrators and patient safety leaders can use the findings to more successfully structure activities that prevent HAI in their hospitals.

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The Joint Commission Journal on Quality and Patient Safety ing HAIs whereas others appeared more lackadaisical in their approach. We theorized a priori that one possible reason for this variability involved hospital personnel. Several popular business-oriented books have long identified “people” as a key part of every organization. For example, the management book “Good to Great”—itself a product of empiric research in the performance of for-profit companies—advised that organizations should “get the right people on the bus” and “in the right seats.”24(p. 41) We were curious whether this concept would also apply to hospital personnel and HAI prevention.

Methods STUDY DESIGN AND SAMPLE In Phase 2 of the project, we conducted telephone interviews with staff from 14 hospitals. To select these hospitals, we used purposeful sampling, the goal of which is to sample cases for indepth analysis that can best help the investigator understand the central problem under study, rather than representative sampling, which enables generalizations from study samples to populations.25 Therefore, we intentionally included a diverse set of hospitals that, on the basis of their responses to the survey, used or did not use various practices to prevent HAI. Because we were also interested in looking at different types of hospitals, we stratified by size (< 250 beds versus > 250 beds) and made sure that we included both VA and non–VA hospitals and academic and non-academic medical centers. For the third and final phase of the project, we augmented the phone-interview data by visiting 6 of the 14 hospitals for detailed in-person interviews with key staff. We purposefully sampled these hospitals for their usefulness in elaborating themes that were emerging from our ongoing data analysis. Institutional review board (IRB) approval was obtained from the VA Ann Arbor Healthcare System as well as the local IRBs for each of the hospitals that we visited.

DATA COLLECTION During Phase 2, we conducted 38 semistructured phone interviews with participants at 14 hospitals (2–4 at each hospital). Interviews were conducted between July 2005 and May 2006, lasted 30–92 minutes (mean, 60 minutes), and were audiorecorded and transcribed verbatim by an experienced medical transcriptionist. At least two team members conducted each interview, and five of the six co-authors were interviewers [all but J.B.-H.] The first interviewee at each hospital was an ICP. Thereafter, we used a snowball sampling technique, asking the ICP to recommend other potential informants, including specific staff 240

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who were integrally involved in adopting or implementing at least one key infection prevention practice. We also interviewed other staff who we thought would provide valuable information, such as the hospital epidemiologist. We used an interview guide, developed with input from all team members, to ask interviewees which practices, if any, their organization used to prevent HAI. We then asked them to discuss, in detail, the process that led their organization to use those practices (Table 1, page 241) or to explain why they did not use certain practices. The interview also included general questions on relevant organizational characteristics. In Phase 3, we conducted another 48 interviews (mostly in person) in conjunction with site visits to 6 hospitals between October 2006 and September 2007. The site visits were intended to fill in gaps from the phone interview data and to test our interpretations of, or further explore issues identified in, the phone interviews. We observed the hospitals’ environments and obtained perspectives from additional staff, including senior executives, mid-level managers, and frontline clinicians. Interviews were tailored to each site and each interviewee.

ANALYTIC APPROACH Analysis, conducted using rigorous qualitative procedures,26,27 included all the phone and site-visit interviews in Phases 2 and 3 of the study. We conducted data analysis concurrently with data collection. Interviewers produced interview summaries after each interview, and the team met monthly to identify and discuss emerging themes. In addition, to examine the data systematically, we developed a qualitative code book. An initial set of codes was established on the basis of our study’s conceptual model,21 and these codes were then refined and supplemented with categories derived from the interview transcripts. Two team members coded each transcript independently and then discussed and reached consensus on all discrepancies.28 The interview transcripts, along with their coding, were then entered into NVivo software (QSR International, Cambridge, Massachusetts) to facilitate the analysis.29 Coding represented an early stage of the analysis process that allowed us to view the data by topic—such as particular HAI–prevention practice or provider type—and that facilitated higher-level interpretation. For this study, four of the team members prepared extensive summary reports, including one focusing specifically on hospital personnel, for each site using all transcripts from Phases 2 and 3. The team members then met to question, discuss, and document interpretations and findings.

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The Joint Commission Journal on Quality and Patient Safety Table 1. Main Semistructured Interview Questions Can you please describe the process this hospital went through in deciding to adopt/not adopt this practice?* How did this hospital identify the need for the practice?† What kind of information did this hospital have on the practice? Who were the important people who helped this hospital decide to use this practice? What factors did decision makers consider? What problems did this hospital run into getting this practice adopted? Is this hospital experiencing any implementation problems? If so, what? What are the major barriers that prevented your hospital from implementing practices for reducing health care–associated infections? What are the facilitators? What were the major facilitators for your hospital in implementing practices for reducing health care–associated infections? If I could fix one barrier here that makes it more difficult for your organization to implement key practices for preventing health care–associated infections, what would you have me fix? If someone wants to adopt a new infection control practice what committees do they go through? How does being part of a large health care system affect the adoption and implementation of infection control practices? What are the benefits? The barriers? Who are the main people who need to be on board for change to occur? Have collaboratives‡ had a role in the adoption or implementation of infection control practices at this hospital? How has nursing been involved in infection control? What is your perception of how senior management is involved in the adoption and implementation of infection control practices? * Asked for each practice of interest for all telephone interviewees in Phase 2 of the study and asked of interviewees when relevant during the site visits (Phase 3). † The questions in the Practice section were asked for each practice (for example, maximum sterile barrier precautions) that the interviewee provided. ‡ A collaborative was defined as some type of joint effort to reduce health care infections such as Keystone, the 100,000 Lives Campaign, or the Pittsburgh Regional Health Initiative.

Findings Characteristics of the 14 hospitals included in the study are provided in Table 2 (above). We interviewed participants in a wide range of roles at their respective hospitals, as listed in Table 3 (page 242). Table 4 (page 244) lists the main themes that describe the role of hospital personnel in HAI–prevention activities. Each theme is discussed in more detail below with illustrative quotations.

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Table 2. Characteristics of the 14 Hospitals That Gave Phone Interviews and the 6 That Hosted Site Visits* Site Characteristics Location Northeast Midwest South West Hospital type VA Non–VA Bed size Fewer than 50 hospital beds 50–250 hospital beds 251 or more hospital beds Academic affiliation Yes No Participated in a collaborative Yes No

Phone Interview (n)

Site Visit (n)

2 5 3 4

0 3 0 3

7 7

3 3

1 5 8

0 1 5

12 2

6 0

5 9

4 2

* VA, Department of Veterans Affairs.

ACTIVE RESISTERS The presence of “active resisters”—hospital personnel who vigorously and openly opposed various changes in practice— increased the difficulty of implementing new methods to prevent infection. Each of the 14 sites encountered some form of active resistance. The first type of active resistance was the almost universal difficulty of integrating new practices with ingrained habits that result from both previous clinical training and day-to-day work flow. The lead ICP at one hospital explained, “resistance . . . came from the attendings, the older groups of physicians who were used to using [a previous type of skin disinfection prior to central venous catheter insertion] forever.” She attributed opposition to a new skin disinfecting agent to the fact that “it’s just not how they were trained.” When asked to list the major barriers in implementing evidence-based infection prevention practices, a hospital epidemiologist pointedly said, “entrenched culture.” A second type of active resistance that we encountered was competing authorities on whether to implement new practices. For example, when a respected supervisor or mentor of a clinician (nurse or physician) dismisses a new practice or instructs the clinician to ignore the practice, then a recommendation by an outside authority (for example, CDC) was likely to be disregarded. One infectious diseases chief believed that attending

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The Joint Commission Journal on Quality and Patient Safety Table 3. Interviewee Characteristics* Interviewee Characteristics

Phone Interviews (n = 38)

Site Visits (n = 48)

Infection control professional

15

6

Physician hospital epidemiologist or chief of infectious diseases

5

5

ICU nurse manager

5

4

ICU chief or other critical care physician

2

7

Chair or vice chair of medicine

2

5

IV nurse clinician

2

1

Clinical nurse specialist or nurse practitioner

3

0

Quality manager or medical director of quality

1

5

Chief of staff

0

4

Chief nurse or nurse executive

0

3

Chief of general internal medicine or GIM physician

0

3

Hospital director, deputy director, or CEO

0

3

Other (respiratory therapy supervisor, risk manager, ED nurse)

3

2

* IV, intravenous; GIM, general internal medicine; CEO, chief executive officer; ED, emergency department.

physicians were responsible for some of the noncompliance with using maximum sterile barriers during central venous catheter insertion: It’s like the attending in the operating room dictates the practice even though the residents know what they’re supposed to do. . . if that’s a good practice [that is, evidencebased], everything’s fine. If it’s not as good a practice, then you tend to have some problems.

The hospitals used different strategies with varying levels of success to overcome active resistance. Collecting data and then providing feedback was successfully used in some of the hospitals. As the director of an ICU stated: Data seems to be the best motivation for physicians… [they] compare rates to national rates… it is sort of an incentive because once the rates are up there, everyone looks to the director and he or she will have to react to those.

Surgeons and anesthesiologists were often mentioned as key examples of active resisters, at least involving the use of maximum sterile barriers and chlorhexidine gluconate site disinfection to prevent CRBSI. For example, one ICP explained, “Anesthesia does present a huge problem for us in our hospital . . . [by] not following some of the prevention procedures that we’ve outlined.” A VA–based general internist stated, “Getting the surgeons to adopt things in general is problematic . . . they’re like baseball players, they’ve got superstitions . . . in their minds if it’s working, why should we change it.” We also found that nurses could actively resist change, at least at some sites. A hospital epidemiologist from a large private hospital explained the active resistance that he experienced when promoting the early removal of indwelling urinary catheters:

We were curious why local rates were necessary when the literature exists to show the evidence behind various practices to prevent CRBSI. The lead ICP at a large private hospital explained:

Let’s say someone has a Foley in, you know, is incontinent and the nurse is not interested in removing it because it’s going to be more work. She’s going to try everything not to remove that Foley.

First we had a little resistance from the physicians that a nurse was standing there doing the check off . . . then when [the medical ICU director] started graphing it and showing them . . . this is how many of you wore your masks, this is

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Even with all the research that goes into guidelines. . . there’s still a lot of opinions out there in the hospital that “well, I don’t really believe that, that won’t work here because I know my patient population.”

For changes involving physician behavior, monitoring by nurses coupled with feedback on rates of compliance was another important strategy. It was most effective, however, when a key physician was providing visible support and enforcement of the monitoring and practice change. As a lead ICP from a VA hospital explained:

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The Joint Commission Journal on Quality and Patient Safety how many wore your gowns . . . and then they started seeing what we were doing and it went much better.

Similarly, the ICP at a large private hospital stated: Initially. . . there were certain physicians that didn’t think they needed to follow the practices but having strong physician support [from] the medical director of critical care [helped] . . . if there was any issue, [the nurses] were told to call the medical director directly or the ICU physician on call.

Another strategy to overcome active resistance is for a key physician leader to clearly make compliance mandatory. As one nurse explained: When we started implementing these new standards, we found that there was still a core group [of surgical residents] that really didn’t want to get on board so what we did, is the intensivists had just spoken with the chief of surgery and that was pretty much resolved shortly after that.

In contrast, a senior intensivist at another hospital that was still experiencing active resistance from local surgeons characterized the chief of surgery as “a terrible administrator . . . He doesn’t discipline [the other surgeons on the service].” We also learned that overcoming active resistance to change often requires selecting an appropriate champion who can “speak the language” of the staff they are trying to sway. A chief of staff had the following advice about how to ensure that other surgeons used evidence-based practices to prevent infection: Surgeons are very tribal so if you, what you need to do, is you have something that you think is a best practice at your hospital . . . you need to get . . . either the chair of surgery or some reasonable surgeon . . . If you come in and you’re an internist . . . into a group of surgeons . . . the first thing we’re going to do is we’re going to say, “Look, you’re not one of us” . . . the way to get buy-in from surgeons is you got to have a surgeon on your team.

For some hospitals, overcoming active resistance required participating in a collaborative effort aimed at preventing HAI, such as Michigan’s Keystone project or the Institute for Healthcare Improvement’s 5 Million Lives Campaign. As the lead ICP from a VA stated: “[Before joining a collaborative]…it was a one man band . . . now we’ve got support.” In addition to providing external validation to certain practices, collaboratives also promoted strategies to encourage compliance. For example, several hospitals began packaging together all the required components to promote maximum sterile barriers

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during central venous catheterization either in a single kit or on a single cart that made it easier to find the key elements (such as the large sterile drape used to cover the patient). As one ICP stated, “We package it for them now . . . the only reason we do it is . . . we want to see this work.” Packaging the necessary components appeared to make it more difficult for resisters not to comply with a new practice. In summary, clinicians who actively impede the use of recommended practices to prevent HAI were present in all the hospitals we evaluated. Overcoming these active resisters required a concerted effort, including providing data and feedback, engaging well-respected champions, participating in a collaborative to promote buy-in, and identifying innovative strategies to make compliance the easiest course of action.

ORGANIZATIONAL CONSTIPATORS Another type of hospital employee that we discovered were individuals whom we refer to as organizational constipators. Although we use the term constipator in a “tongue and cheek” way, it does clinically and aptly describe the phenomenon that we have observed. These individuals tended to be mid- to highlevel executives who prevented or delayed certain actions without active resistance, thereby acting as insidious barriers to change by increasing the work required to implement evidencebased practices. For example, at one hospital a chief nurse interfered with the implementation of an evidence-based collaborative to reduce infections. The hospital’s lead quality manager told us that even after the hospital’s director had agreed to participate in a quality improvement collaborative she was reprimanded by the chief nurse for her involvement: When [the chief nurse] found out I went to the first day [of two-day training], I was told I wasn’t allowed to go to the second day . . . no one else could understand why . . . there was a control issue.

Similarly, at another hospital where the chief nurse was also considered a constipator, a physician leader explained: The nursing chief is very powerful and does not always see eye to eye with what’s going on in the clinical services . . . there have been some battles waged over the years . . . a lot of times, the disagreement persists and there’s no resolution.

Organizational constipation did not appear to be confined to nurses. We heard about a chief of staff from one of his physician colleagues who appeared to be an insidious barrier: There’s sort of the passive side of the problem . . . somebody

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The Joint Commission Journal on Quality and Patient Safety who will nod their head and say, “Well let me think about it.” We’ve got a chief of staff who . . . takes that approach and you just lose energy and you keep bringing it up and then you can’t remember whether they’ve acted on it or not and you have to go back to your e-mail and dig up an old message and send it to him again and say, “Did you ever make a decision on this?” So yeah, I think that certainly is a barrier.

Once identified, hospitals have attempted various approaches to address the presence of organizational constipators, including working around that individual. For example, a quality manager described how, “basically if I keep off the radar, I can do what I need to do, so that’s what I did.” A potentially more effective strategy, as described by a hospital director was as follows: Well I think if you have a systematic way of addressing major issues through an executive board . . . essentially we’ve brought a particular person who’s known for . . . having strong opinions into these discussions and so we are able to vet them.

The director explained the hazards of working around these individuals:

Table 4. Major Unifying and Recurrent Themes Indicative of the Role of Hospital Personnel in Health Care–Associated Infection Prevention Efforts 1. Active resistance to a change in practice is pervasive, whether by attending physicians, resident physicians, or nurses. Successful efforts to overcome active resistance included the following: a. Data feedback comparing local infection rates to national rates b. Data feedback comparing rates of compliance with the practices to rates of others in the same area c. Effective championing by an engaged and respected change agent that can speak the language of the staff they are guiding (e.g., a surgeon to motivate other surgeons) d. Participation in collaborative efforts that generally align hospital leadership and clinicians in the goal of reducing health care–associated infection 2. Organizational constipators—mid- to high-level executives who act as insidious barriers to change—present added challenges to change in practice. Once leadership recognizes the problem and the negative effect on other staff, various techniques were used to overcome this barrier: a. Include the organizational constipator early in group discussions in order to improve communication and obtain buy-in. b. Work around the individual, realizing that this is likely a shorter-term solution. c. Terminate the constipator’s employment.

I think so often organizations take that person and keep them out because they’re going to block maybe something that you wanted and we put them over here instead of bringing them into the fold and . . . I’ve seen that in a couple of specific situations where it’s been so helpful to have that person there and have the dialogue and in a couple of instances, you know, they changed their mind or turned into a supporter of it.

Another strategy used was to fire the constipator. As the chief of medicine from a private hospital explained: The tough approach is what we’ve done here and that is, they’re gone. We get somebody else in that position who will embrace what we philosophically agree we should do.

In systems such as the VA, in which stringent policies for hiring and firing preclude relatively quick dismissal of constipators, however, hospitals simply had to wait for a “turnover opportunity,” such as retirement, before finding someone new. Besides impeding evidence-based practice, organizational constipators can have other detrimental effects on the organization, including undermining staff morale and professional relationships. For example, as an ICP described:

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d. Take advantage of turnover opportunities when the constipator leaves the organization by hiring a person who has a very high likelihood of being effective.

We have a real problem with one individual that has sort of a higher-up job and he . . . is not functioning at his proper level and he affects all of us so . . . that’s really been a huge problem and I think that they’re just not going to do anything about it . . . he needs to do certain things . . . and he just doesn’t do them. So we end up feeling very frustrated in having to do it for him because it’s something that makes us look bad.

At another hospital, where the former chief nurse was described as a constipator, the new chief nurse explained: I came and the communication and relationships between nursing and the other services, especially medicine and surgery, were broken . . . the relationship between the person who held this office before and the chief of staff was nonexistent. So there’s a lot of bridge building to do again.

In summary, organizational constipators presented a significant barrier to the use of evidence-based practices in four of the six sites we visited. Organizations dealt with these constipators

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The Joint Commission Journal on Quality and Patient Safety with varying degrees of success through several means including working around the individual, including the constipators earlier in the process, actively terminating employment, and waiting for the individual to retire.

Discussion Active resisters and organizational constipators appear to be significant personnel-related impediments to translating research into practice. Active resistance to change in practice was a universal problem for our study sites. However, the energy with which this issue was tackled and the types of people involved in the effort dictated whether the issue persisted. To overcome active resistance sites used several strategies, including identifying champions, providing data and feedback to frontline clinicians, and redesigning some processes (for example, insertion of central venous catheterization using new kits that contain all the necessary materials), to enhance compliance. Our findings suggest that, although certainly not easy, active resistance can be overcome using various strategies (Table 4). The problem posed by organizational constipators appeared more challenging, possibly because the issue is more insidious in nature and often is not explicitly tackled. The presence of such constipators appeared to have a pervasively negative effect on staff at many different levels. The concept of a constipator was not hypothesized before we began collecting data; the issue, however, was brought to our attention by frontline clinicians (nurses and physicians), mid-level managers, and executive leaders from multiple organizations, presumably once they perceived that speaking with us could be an outlet for their frustrations. Our findings fit with other studies of implementation that have identified multiple factors that can lead individuals to resist adopting beneficial changes in clinical practice.30,31 For example, Ferlie et al.31 discuss how professionals may resist change similarly to the way that the organizational constipators in our study do. In general, however, the implementation literature focuses more on picking champions in health care organizations30 rather than those who are barriers to change and ways to overcome resistance to new ideas. Individuals may doubt the value of changing their clinical practice; in our study, interviewees mentioned competing authorities, which included leaders or prior training experiences not supportive of practice change. In addition, individuals fear disruption of existing habits, perhaps because they personally resist changing routines or perhaps because they rely on habits or routines to minimize the time spent on those activities. Clinicians likely face competing priorities when choosing to

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invest in new practices and must therefore be provided incentives to make clinical practice change a priority. This supports recent calls for changes in organizational culture to promote adoption of new quality practices.32,33 Constipators, on the other hand, appear to undercut changes desired both in health care and in their provider organization, and in this case, appear to be putting either their own or local interests before the organization’s and the patient’s. Organizational studies have long documented cases of individual resistance to new practices, but usually at the blue-collar level (for example, the slowing or actual destruction of organizational property in industrial assembly lines34) and rarely among managers or professionals. Consequently, our findings indicate that even among managers and professionals, sometimes additional incentives or strategies will be needed to ensure support for practice change. Our qualitative study has several limitations. Although qualitative methodology is appropriate for exploring why hospitals are behaving in certain ways, it does not allow us to provide precise estimates of effect size and statistical significance, as is common with quantitative evaluation. Second, although the sample of 14 hospitals, 6 of which we evaluated in depth through site visits, is relatively large for a qualitative evaluation, the findings cannot be extrapolated to the approximately 6,000 hospitals in the United States. Third, our use of snowball sampling may have excluded dissenting or alternative points of view. Another limitation of our study is the entanglement of behaviors and personality types. Although we believe we were primarily observing behaviors, it is likely that we were observing to some extent a combination of the two. It is quite possible that specific behaviors are more likely to be found in individuals with certain personality traits. However, we did not apply psychological testing to our study participants, and thus we have no way of disentangling the two. Finally, the study was undertaken as part of a larger study designed to address a broader question. Further work focusing specifically on resistance or obstructive behavior would likely yield further insights. Our findings, hopefully, will provide a starting point for local discussion of hospital-specific barriers and facilitators to bolster infection prevention efforts. Ideally, hospital administrators and patient safety leaders will use the results of our study to more successfully structure activities that prevent HAI in their hospitals. J This project was supported by the Department of Veterans Affairs, Health Services Research and Development Services (SAF 04-031), and the Ann Arbor VAMC/ University of Michigan Patient Safety Enhancement Program. Dr. Saint is supported by an Advanced Career Development Award from the Health Services Research & Development Program of the Department of Veterans Affairs. The views

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The Joint Commission Journal on Quality and Patient Safety expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. Preliminary results from this study were presented at the Society for Healthcare Epidemiology of America national meeting, April 15, 2007, Baltimore, and at the 2nd Annual National Institutes of Health Conference on the Science of Dissemination and Implementation: Building Research Capacity to Bridge the Gap from Science to Service, January 29, 2009, Bethesda, Maryland.

Sanjay Saint, M.D., M.P.H., is a Research Investigator, Department of Veterans Affairs (VA) Ann Arbor HSR&D Center of Excellence, VA Ann Arbor Healthcare System (VAAAHS), Ann Arbor, Michigan; and Professor of Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor. Christine P. Kowalski, M.P.H., is a Research Specialist, VA Ann Arbor HSR&D Center of Excellence, VAAAHS. Jane Banaszak-Holl, Ph.D., is an Associate Professor of Health Management & Policy, Department of Health Policy and Management, University of Michigan School of Public Health, Ann Arbor; and Research Associate Professor, Institute of Gerontology, University of Michigan. Jane Forman, Sc.D., M.H.S., is a Research Investigator, VA Ann Arbor HSR&D Center of Excellence, VAAAHS. Laura Damschroder, M.S., M.P.H., is a Research Investigator, VA Ann Arbor HSR&D Center of Excellence, VAAAHS. Sarah L. Krein, Ph.D., R.N., is a Research Investigator, VA Ann Arbor HSR&D Center of Excellence, VAAAHS; and Research Assistant Professor, Department of Internal Medicine, University of Michigan Medical School. Please address reprint requests to Sanjay Saint, M.D., M.P.H., [email protected].

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Volume 35 Number 5

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