Facility-level factors influencing chronic heart failure care process performance in a national integrated health delivery system

BACKGROUND: Gaps between evidence and practice in the care of patients with chronic heart failure (CHF) in the United States suggest major opportunities for improvement. However, the organizational factors and implementation approaches that influence adherence to national guidelines are poorly understood. OBJECTIVES: The objectives of this study were to explore the degree to which providers in the Veterans Health Administration system adhere to CHF clinical practice guidelines, and to identify facility-level factors influencing adherence. DESIGN: In a national cross-sectional study, facility quality managers were surveyed regarding quality improvement efforts, guideline implementation, and context. These data were linked to organizational structure data and provider adherence data from chart reviews. The unit of analysis was the facility. The data were adjusted for the average number of comorbidities per CHF patient. Multivariate logistic regression models were constructed to model factors affecting adherence to CHF guidelines. SAMPLE: The sample consisted of 143 Veterans Administration Medical Centers with ambulatory care clinics. RESULTS: The quality manager survey included data from 91% of facilities. Facility-level estimates of provider adherence measures were, on average, 85% or more for most measures. In multivariate analyses, facilities with higher levels of adherence were more likely to have: (1) providers who had been given a brief guideline summary, (2) providers receptive to the guidelines, (3) guideline-specific task forces to support implementation, and 4) a well-planned implementation process. CONCLUSIONS: Healthcare organizations should adapt implementation to meet local conditions, including creating guideline-specific task forces, developing a well-planned implementation process, fostering provider buy-in, and providing guideline summaries to providers.