Playing Nice in the Sandbox: Lessons on Roles, Interdisciplinary Collaboration, and Leadership from a VA National Improvement Intervention (F405D)

Abstract

1.Apply organizational role theory in examining health care system initiative for goals of care conversations.2.Identify strategies that can increase health care system adoption of goals of care initiatives. The Department of Veterans Affairs (VA) implemented the Life-Sustaining Treatment Decisions Initiative (LSTDI) nationally in 2017. This policy encourages universal goals of care conversations (GoCCs) regarding life-sustaining treatments among veterans with serious illnesses. A key component is expanding clinician roles, including nurses and social workers, in GoCCs. To evaluate the impact of organizational structure on clinician role expansion in the LSTDI. We undertook secondary analyses of LSTDI implementation evaluation interviews to understand site experiences with expanded clinician roles. Interviews purposively sampled interdisciplinary providers from 12 diverse national VA sites. Organizational role theory informed our coding framework. Using an iterative, constant comparative, dual coding process, we summarize major themes. 1) Organizational culture change is needed to expand clinician roles in GoCCs. Most sites described the acceptance of expanded roles required a “culture shift” within the organization. Sites that defined GoCCs as “everyone’s job” increased adoption of the LSTDI. 2) Supportive executive leadership and diverse middle management are key in clinician role expansion. A diverse advisory council, including front-line staff, helped clinicians take GOCCs as a “role-specific versus person-specific” task. 3) Diverse education champions, trainers, and materials increased clinician readiness for role expansion, by enhancing a “provider’s initiative and comfort in having that kind of a conversation”. 4) Clarity in roles across disciplines improved acceptance of role expansion. Leadership support for interdisciplinary team structure increased uptake of the initiative. 5) Role expansion increased clinician task burden. Clinicians felt “overwhelmed, it was just one more thing on their plate”. Leadership acknowledgment alleviated this burden through dedicated clinician time to the initiative. Organizational role theory provided insights on LSTDI implementation and informs specific preparatory strategies to foster expanded clinician roles and improve system-wide adoption of GoCCs.