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Engaging multilevel stakeholders in an implementation trial of evidence-based quality improvement in VA women’s health primary care


The Veterans Health Administration (VHA) has undertaken primary care transformation based on patient-centered medical home (PCMH) tenets. VHA PCMH models are designed for the predominantly male Veteran population, and require tailoring to meet women Veterans’ needs. We used evidence-based quality improvement (EBQI), a stakeholder-driven implementation strategy, in a cluster randomized controlled trial across 12 sites (eight EBQI, four control) that are members of a Practice-Based Research Network. EBQI involves engaging multilevel, inter-professional leaders and staff as stakeholders in reviewing evidence and setting QI priorities. The goal of this analysis was to examine processes of engaging stakeholders in early implementation of EBQI to tailor VHA’s medical home for women. Four inter-professional regional stakeholder planning meetings were conducted; these meetings engaged stakeholders by providing regional data about gender disparities in Veterans’ care experiences. Subsequent to each meeting, qualitative interviews were conducted with 87 key stakeholders (leaders and staff). Stakeholders were asked to describe QI efforts and the use of data to change aspects of care, including women’s health care. Interview transcripts were summarized and coded using a hybrid deductive/inductive analytic approach. The presentation of regional-level data about gender disparities resulted in heightened awareness and stakeholder buy-in and decision-making related to women’s health-focused QI. Interviews revealed that stakeholders were familiar with QI, with regional and facility leaders aware of inter-disciplinary committees and efforts to foster organizational change, including PCMH transformation. These efforts did not typically focus on women’s health, though some informal efforts had been undertaken. Barriers to engaging in QI included lack of communication across clinical service lines, fluidity in staffing, and lack of protected time. Inter-professional, multilevel stakeholders need to be engaged in implementation early, with data and discussion that convey the importance and relevance of a new initiative. Stakeholder perspectives on institutional norms (e.g., gender norms) and readiness for population-specific QI are useful drivers of clinical initiatives designed to transform care for clinical subpopulations.

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We would like to thank Dr. Susan Frayne for her WH-PBRN leadership and Ms. Diane Carney for her management of the WH-PBRN; Ms. Selene Mak for data analysis support; Dr. Amy Cohen for editorial input; and Ms. Kristina Oishi and Ms. Anneka Oishi for logistics support. We would also like to thank Ms. Angela Cohen for her overall management of the Women’s Health CREATE, and our Executive Steering Committee members and Women Veteran Council members for their valuable contributions to this project.

Author information



Corresponding author

Correspondence to Alison B. Hamilton PhD, MPH.

Ethics declarations

Study funding sources

Support for this research was provided by VA HSR&D Service, Veterans Health Administration through the CREATE initiative (CRE 12-026) and the VA HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy (CIN 13-417). Development and implementation of the EBQI intervention is being supported through annual Memoranda of Understanding with funding from VA Women’s Health Services (WHS) in the Office of Patient Care Services, Veterans Health Administration. Dr. Yano’s effort was funded by a VA HSR&D Senior Research Career Scientist Award (Project #RCS 05-195).

Conflicts of interest

The authors declare that they have no conflicts of interest.

Reporting and control of data

The findings reported have not been previously published and the manuscript is not being simultaneously submitted elsewhere. The data has not been previously reported. The authors have full control of all primary data and agree to allow the journal to review their data if requested. The views expressed within this study are solely those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the U.S. Government.

Ethics approval and consent to participate

This study protocol has been approved by the VA Greater Los Angeles Healthcare System IRB-B Subcommittee (IRB Chair, Paul Shekelle, MD, PhD) (approval number 2013-040589). Individual study components, including key stakeholder interviews, were reviewed and approved by IRB-B as serial project modifications to an umbrella IRB application under the study title. For each study component, we obtained IRB approval for waivers of documentation of consent for all data collections. Consent was provided verbally and recorded in the case of interviews. The VA Central IRB (Washington DC) also determined that the participating VA medical centers (n = 12) were not engaged in research and that the intervention (or implementation strategy, evidence-based quality improvement [EBQI]) was QI. Documentation of IRB approval (and in VA settings, Research and Development Committee approval as well) and Central IRB determination of non-research for the implementation strategy are available on request. The UCLA Institutional Review Board also reviewed and approved the key stakeholder interview component. No individual person’s data in any form are or will be included in this or subsequent manuscripts. Only aggregated data will be reported. For key stakeholder data, non-attributed or identifiable quotes may be reported in addition to thematic summaries.

Statement on welfare of animals

No animals are or will be involved in this study protocol. Similarly, use of animal or human data or tissue is not applicable to this study protocol.

Helsinki statement

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Additional information


Research: Researchers interested in engaging organizational stakeholders in implementation and improvement efforts could consider tailoring data reports to subpopulations of interest and using that data to educate, raise awareness, and promote buy-in. Researchers could also make efforts to align new initiatives with institutional norms and existing practices.

Practice: Practitioners interested in engaging in implementation and improvement efforts could, with institutional support, (1) seek out local researchers who are conducting studies on topics of interest to learn about opportunities for involvement, (2) seek out inter-disciplinary improvement initiatives to become involved in them or use them as a model for new initiatives, or (3) identify relevant training opportunities that might create linkages to individuals who are conducting interesting projects.

Policy: Policymakers interested in engaging in implementation and improvement efforts could identify ways to obtain data—analyzed and available in approachable ways—that would support decision-making around care targets that may warrant policy changes or innovations, and they could also partner with researchers to guide the design of studies that would generate policy-relevant results.

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Hamilton, A.B., Brunner, J., Cain, C. et al. Engaging multilevel stakeholders in an implementation trial of evidence-based quality improvement in VA women’s health primary care. Behav. Med. Pract. Policy Res. 7, 478–485 (2017).

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  • Stakeholder engagement
  • Implementation
  • Evidence-based quality improvement
  • women’s health
  • Primary care
  • Veterans health administration