Tracking VA's chiropractic program: Implementation timelines and variations across selected facilities

Background/Introduction: In 2004, VA began providing on-site chiropractic care at select facilities. By January 2010, 38 VA sites were delivering chiropractic services. VA Chiropractic Services collaborated with VA QUERI Center for Implementation Practice and Research Support (CIPRS), with funding from the Samueli Institute, to study the initial planning and implementation of the VA chiropractic program.

Data/Methods: Seven sites were sampled for variation (e.g., urban/rural, small/medium/large facilities, early/mid/late program adopters, collaboration with academic affiliates, etc.). An observational comparative case study approach was employed to collect qualitative and quantitative data via semi-structured interviews with key stakeholders (facility leaders, clinicians, clinic staff, patients, academic affiliates, and other external stakeholders), archival data (e.g., policy and procedure documents), and facility operations data (e.g., number of clinic patients and visits). Interview transcripts (n=118) were subjected to thematic and content analysis using NVivo software (QSR International); Adobe Acrobat (Adobe Systems, Inc), MSWord and MSExcel (Microsoft Corp) software were used for data management and for manual coding of archival source documents (n=75). The study was approved by IRBs at VA Greater Los Angeles Healthcare System, VA Connecticut Healthcare System, Western IRB and US Army Medical Research and Materiel Command.

Analysis/Results: Study findings will be presented describing considerable variability in characteristics of the planning and implementation of the VA chiropractic services program across the 7 facilities. Facilities varied greatly by: implementation timeline (reaching key milestones in program roll-out and establishing benchmarks for monitoring/improving quality), academic affiliate involvement (in either program planning or establishing clinical rotations), continuity of service delivery, and overall access for Veterans. Findings and conclusions will be presented using the Donabedian Structure-Process-Outcome model as a general orienting framework, highlighting variations in Intra-Clinic Structures and Processes (within each clinic), and Inter-Clinic Structures and Processes (between each chiropractic and other VA clinics and providers at each facility).

Discussion: This exploratory descriptive study corroborates prior research and observations of considerable variations in organizational structures, processes and outcomes across the VA healthcare system. During this session, we will also discuss and invite input from session participants regarding (1) other important parameters that may contribute to the pronounced variability we observed in program characteristics, such as external contextual factors (e.g., market environment or catchment area) and internal context (e.g., institutional culture), and (2) study implications for other health systems and initiatives to introduce new clinical services.