Organizational characteristics of high- and low-performing anticoagulation clinics in the Veterans Health Administration.
OBJECTIVE
Anticoagulation clinics (ACCs) can improve anticoagulation control and prevent adverse events. However, ACCs vary widely in their performance on anticoagulation control. Our objective was to compare the organization and management of top-performing with that of bottom-performing ACCs.


METHODS
Three high outlier and three low outlier ACCs in the Veterans Health Administration (VA).


METHODS
Site visits with qualitative data collection and analysis.


METHODS
We conducted semi-structured interviews with ACC staff regarding work flow, staffing, organization, and quality assurance efforts. We also observed ACC operations and collected documents, such as the clinic protocol. We used grounded thematic analysis to examine site-level factors associated with high and low outlier status.


RESULTS
High outlier sites were characterized by (1) adequate (pharmacist) staffing and effective use of (nonpharmacist) support personnel; (2) innovation to standardize clinical practice around evidence-based guidelines; (3) the presence of a quality champion for the ACC; (4) higher staff qualifications; (5) a climate of ongoing group learning; and (6) internal efforts to measure performance. Although high outliers had all of these features, no low outlier had more than two of them.


CONCLUSIONS
The top-performing ACCs in the VA system shared six relatively recognizable characteristics. Efforts to improve performance should focus on these domains.
Center for Health Quality, Outcomes, and Economic Research, Bedford VA Medical Center, Bedford, MA 01730, USA. adamrose@bu.edu
Adam J
AJ
Rose
Beth Ann
BA
Petrakis
Patricia
P
Callahan
Scott
S
Mambourg
Dimple
D
Patel
Elaine M
EM
Hylek
Barbara G
BG
Bokhour
D000925:Anticoagulants / Q000008:administration & dosage*; D004282:Documentation; D017598:Efficiency, Organizational; D019317:Evidence-Based Medicine; D006302:Health Services Research; D006787:Hospitals, Veterans / Q000592:standards*; D006801:Humans; D007407:Interviews as Topic; D008505:Medical Staff, Hospital / Q000592:standards; D009936:Organizational Innovation; D010348:Patient Care Team / Q000458:organization & administration; D036301:Qualitative Research; D011787:Quality of Health Care; D014481:United States; D058014:Veterans Health
D000925:Anticoagulants