title: Strengthening organizations to implement evidence-based clinical practices.
abstract: OBJECTIVE
  Despite recognition that implementation of evidence-based clinical practices (EBPs) usually depends on the structure and processes of the larger health care organizational context, the dynamics of implementation are not well understood. This project's aim was to deepen that understanding by implementing and evaluating an organizational model hypothesized to strengthen the ability of health care organizations to facilitate EBPs. CONCEPTUAL MODEL: The model posits that implementation of EBPs will be enhanced through the presence of three interacting components: active leadership commitment to quality, robust clinical process redesign incorporating EBPs into routine operations, and use of management structures and processes to support and align redesign.
  
  
  METHODS
  In a mixed-methods longitudinal comparative case study design, seven medical centers in one network in the Department of Veterans Affairs participated in an intervention to implement the organizational model over 3 years. The network was selected randomly from three interested in using the model. The target EBP was hand-hygiene compliance. Measures included ratings of implementation fidelity, observed hand-hygiene compliance, and factors affecting model implementation drawn from interviews.
  
  
  RESULTS
  Analyses support the hypothesis that greater fidelity to the organizational model was associated with higher compliance with hand-hygiene guidelines. High-fidelity sites showed larger effect sizes for improvement in hand-hygiene compliance than lower-fidelity sites. Adherence to the organizational model was in turn affected by factors in three categories: urgency to improve, organizational environment, and improvement climate.
  
  
  CONCLUSIONS
  Implementation of EBPs, particularly those that cut across multiple processes of care, is a complex process with many possibilities for failure. The results provide the basis for a refined understanding of relationships among components of the organizational model and factors in the organizational context affecting them. This understanding suggests practical lessons for future implementation efforts and contributes to theoretical understanding of the dynamics of the implementation of EBPs.
authors.affiliation: Center for Organization, Leadership and Management Research, Department of Veterans Affairs, Boston, MA, USA. carol.vandeusenlukas@va.gov
authors.forename: Carol
authors.initials: C
authors.lastname: VanDeusen Lukas
authors.forename: Ryann L
authors.initials: RL
authors.lastname: Engle
authors.forename: Sally K
authors.initials: SK
authors.lastname: Holmes
authors.forename: Victoria A
authors.initials: VA
authors.lastname: Parker
authors.forename: Robert A
authors.initials: RA
authors.lastname: Petzel
authors.forename: Marjorie
authors.initials: M
authors.lastname: Nealon Seibert
authors.forename: Michael
authors.initials: M
authors.lastname: Shwartz
authors.forename: Jennifer L
authors.initials: JL
authors.lastname: Sullivan
mesh_terms: D055317:Evidence-Based Practice / Q000458:organization & administration*; D019983:Guideline Adherence; D006235:Hand Disinfection / Q000592:standards; D006284:Health Plan Implementation; D006787:Hospitals, Veterans; D008137:Longitudinal Studies; D017146:Models, Organizational; D019982:Organizational Case Studies; D014481:United States; D014493:United States Department of Veterans Affairs