This was originally published on SpringerOpen blog.

Women are the fastest growing group of veterans, which has made women’s healthcare in the Veterans Health Administration (VA) increasingly central. One particular area of attention has been primary care, which in critical ways is different from primary care for male veterans, who have always been the majority of VA users.

Notably, women veterans are younger (median age, 50) than male veterans (median age, 65), and women need gender-specific services. Further, the experience of military sexual trauma is more common among women veterans than men, which heightens the importance of delivering care in a manner that is sensitive to the prevalent trauma histories.

Women veterans also rely more on community-based health providers for some of their care, so it can be challenging to coordinate healthcare across different systems. Because of these and other unique features of women veterans’ needs, reorganizing primary care to accommodate women and tailoring care to ensure their access to needed services is paramount to reducing delayed and missed care. It’s also critical for preventing women from discontinuing a course of treatment or leaving VA care altogether.

Engaging stakeholders

Women are the fastest growing group of veterans, which has made women’s healthcare in the Veterans Health Administration (VA) increasingly central

Given that change is notoriously difficult, the process of improving quality of primary care for women veterans requires meaningful and continual engagement of stakeholders. Stakeholders include leaders from many different levels (national, regional, local) as well as providers, staff, and patients.

There are many quality improvement approaches that entail engaging stakeholders. For our study published in the September 2017 issue of Translational Behavioral Medicine, we selected one approach called evidence-based quality improvement (EBQI) because it has a strong track record of facilitating organizational change. EBQI is characterized by partnerships between researchers and clinicians; engagement of different stakeholders in group decision-making; the use of data to guide the change process; and support from researchers (for example, to help obtain necessary data). What’s critical to EBQI is getting stakeholders on the same page about what needs to be changed and how to change it; this usually involves a priority-setting process.

In our effort to improve the quality of primary care for women veterans, our research team trained women’s health providers and staff across eight VA sites in EBQI and supported them through both the selection of specific targets for change and the process of trying to make change happen.

Because women’s health primary care is typically a small segment of general primary care, we knew that it would be important to request the participation of stakeholders at all levels of the organization in order for local women’s health teams to have the resources and support to improve quality. Fortunately, leaders demonstrated a high level of interest in supporting this effort; they gathered in person and spent time looking at information about their respective sites and developing roadmaps for quality improvement based on that information.

After this initial buy-in and planning, it was important to keep momentum going. Our research team met with each site’s EBQI team regularly. We also conducted interviews with stakeholders from all of the sites and regions (a total of 87 participants), to learn about the processes they were using to improve quality.

Improving quality

We learned about three key challenges to quality improvement: lack of coordination and communication across services, changes in staffing and roles, and lack of time

We found that higher-level leaders were typically aware of multiple committees and efforts focused on organizational change, usually guided by the rich data sources available in the VA system. These high-level, more formal efforts were generally focused on the big picture of the organization and patients at a population level.

We also learned about informal quality improvement efforts that were happening locally within clinics (for example, within women’s health primary care clinics). These were important contexts for us to understand in order to support sites with EBQI, driven by this question: What local circumstances, structures, and priorities might impede or facilitate quality improvement in women’s health?

We learned about three key challenges to quality improvement: lack of coordination and communication across services, changes in staffing and roles, and lack of time, which seemed to contribute to lack of commitment to quality improvement. This information helped gear our research team’s support of local women’s health EBQI teams, as well as ensured that these teams’ efforts and successes were heard by higher levels of leadership.

The process of continually engaging stakeholders across multiple organizational levels is complicated and dynamic, yet we know it is critical to quality improvement work. By emphasizing group priority-setting and decision-making as well as data-informed support, EBQI smooths the pathways to making changes that can improve quality of care—in this case, for a growing subpopulation of women veteran patients that has distinct care needs and circumstances.