How leaders make decisions about implementing health interventions in the Veterans Health Administration

BACKGROUND: Many effective health interventions remain unimplemented, delaying patient benefits. This is true even within integrated health care systems such as the U.S. Veterans Health Administration (VHA). Little is known about how leaders decide to adopt new interventions. PURPOSE: This study explored organizational leaders' thought choices to implement or forego new health interventions within VHA. METHODOLOGY: We conducted semi-structured interviews with 13 organizational leaders across local, regional, and national levels. Data were analyzed with content analysis and aligned to the Consolidated Framework for Implementation Research. RESULTS: VHA leaders' thought processes differed if health interventions were mandated versus discretionary. Participants described two implementation processes for successful change: top-down, usually featuring policy mandates, and bottom-up, driven by clinician-generated interest. Facilitators included intervention fit, alignment with performance measures, and effectiveness evidence. Barriers comprised upfront staffing and training costs and organizational challenges such as leadership turnover and resource limitations. CONCLUSIONS: Before implementing, organizational leaders wanted an intervention to have a positive impact on patients and considered budget impact and/or cost-effectiveness as a second priority. This decision-making process was balanced by circumstances for costly interventions addressing imminent needs, for example, pandemic ills and suicide risk. PRACTICE IMPLICATIONS: VHA organizational leaders believed successful implementation required top-down directives and bottom-up clinician engagement, but approached the process differently depending on whether implementation was mandated or discretionary. Implementation, systems redesign, or quality improvement personnel might ease practice change by noting mandated versus discretionary context and addressing leaders' needs explicitly. Organizational leaders wanted multiple types of information about intervention effectiveness, fit to context for nonresearch audiences.