Best Practices: Supporting Clinicians in the Development of Best Practice Innovations in Education

In recent years, the Department of Veterans Affairs (VA) has emphasized the implementation of evidence-based practices. Because programs that emphasize these practices often seem to operate in a top-down, one-size-fits-all manner, frontline clinicians may feel as though their specific needs and concerns are not addressed (1) and that their own clinical experience and expertise are not valued (2). Clinicians may have their own ideas about best-practice innovations but few resources with which to develop and evaluate them.

To encourage clinicians' contributions to clinical practice, the South Central Mental Illness Research, Education, and Clinical Center (MIRECC), a virtual research and education center funded by the VA, developed a program to tap into the creativity and expertise of experienced clinicians and enlist them to identify clinical educational needs, propose solutions, and test their products. This clinical educators program encourages clinicians in the South Central VA Health Care Network to develop and evaluate educational materials that can be used in everyday clinical settings. The program emphasizes the creation of tools that promote best clinical practices (for example, treatment adherence, patient-centered treatment, and family involvement) that are exportable to other clinical sites. This column describes the guidelines and rationale of the program, the application process, the review process for funding, some of the products produced, and dissemination and use of products within the South Central VA Health Care Network.

Background

The South Central VA Health Care Network includes ten VA medical centers and 1,312 mental health clinicians in Louisiana, Oklahoma, and Arkansas and parts of Texas, Mississippi, Missouri, Alabama, and Florida (3). Mental health care in the network is coordinated by the manager of the mental health product line in consultation with mental health administrative leaders at each VA medical center. The MIRECC's collaborative relationship with the manager of the mental health product line and the administrative leaders facilitates access to clinicians at individual facilities. The MIRECC aims to promote research on mental disorders, support best practices in care, and educate various stakeholders about mental illness and its treatment.

The program

The clinical educators program, which began in 1999, supports clinicians in the development of innovative educational products and in the enhancement of current educational materials and programs, especially those that target underserved or hard-to-reach populations or their families, to improve health care delivery. The program defines educational products as materials developed to improve patient care that are intended for use by providers, patients, or patients' families.

Criteria for evaluating applications included the likelihood of a project's success (for example, achievable goals, clear procedures, available local resources, and appropriateness of requested resources), its expected benefit to the target audience (for example, significance of the potential outcome), the exportability of the final product, and the appropriateness of the plan for the target audience (for example, attention to reading level and ethnic and cultural factors). An application form listing these criteria and a description of the program was sent out in a Request for Applications, which required the applicant to describe the proposed educational materials, outline an evaluation strategy, identify a target audience, project a timeline, and submit a budget up to $5,000. The program was announced to clinicians through e-mail notices and direct announcements from clinical leaders at the ten VA medical centers.

Applications were reviewed by members of the MIRECC education committee, a working group of clinicians and administrators. Content experts were added to the committee when necessary. Reviewers scored each application on a scale of 1 to 10 on each of the four criteria listed above and rated the clinical priority of the project—that is, the project's relevance to pressing clinical needs in the South Central VA Health Care Network—as high, medium, or low. Funding decisions were based on high mean review scores and level of priority, although lower-scoring proposals with high priority ratings were funded if the proposal came from a small facility. Projects from smaller hospitals were given preference because they have fewer resources.

Applicants received feedback about the review, including the reasons for not funding the project and suggestions for improving the application. The awards were announced in the monthly electronic MIRECC newsletter that is sent to all mental health providers in the network. Individual facilities often gave special recognition to awardees.

Products

Fifty-one projects have been funded at eight of the ten VA medical centers, representing 72 percent of all applications. The average award was $2,725. Of the 51 funded projects, 23 (45 percent) proposed to develop original educational materials for a specific patient population (for example, veterans with a diagnosis of posttraumatic stress disorder [PSTD]). Seventeen other projects (33 percent) proposed to repackage existing educational materials or information into convenient, portable formats (for example, workbooks, compact discs, and audiotapes). Eleven projects (22 percent) fell into other categories, from an assessment of provider competencies to educational interventions to improve medication compliance.

Because typical applicants were busy full-time clinicians, projects often required 14 to 18 months to complete; a few projects spanned two years. Twenty-three of the 51 projects have been completed. Twelve have produced high-quality exportable educational products, ten of which have been disseminated throughout the South Central VA Health Care Network and to clinical programs in all 21 of the other networks in the VA. These 12 products and others can be found at www.va.gov/scmirecc. The following is a description of three exemplary products.

Support and Family Education (SAFE) manual

This manual was created to involve family members in the treatment of veterans with severe mental illnesses, consistent with the VA's emphasis on best practices for these disorders. The curriculum includes instructions for conducting caregiver workshops, handouts, information about community resources, and tips for scheduling and publicizing groups. Information about the causes and treatments of severe psychiatric disorders (for example, schizophrenia, bipolar disorder, and major depression) is provided. The manual describes 18 sessions that focus on how families are affected by mental illness and that address such topics as improving communication, setting limits, anger management, and self-care. Such sessions should be co-led by two nonphysician-mental health professionals, with a psychiatrist attending a portion of each session to answer questions about medications.

Helping Dementia Caregivers CD-ROM

This interactive Windows-based program demonstrates effective behavioral and stress management skills to caregivers of individuals with dementia. Users choose which topics to access by way of pop-up boxes and pull-down menus. The program presents basic, easy-to-read information about dementia and features three instructive video clips of actors who portray interactions between an individual with dementia and a family caregiver. These vignettes demonstrate an ineffective response to someone with dementia, an effective behavioral management response, and an effective stress-preventive response. A second version of the program teaches behavioral management responses to nursing assistants in extended care facilities.

PTSD: Families Matter videotape

This videotape was the winner of an Award of Distinction for exceeding industry standards in quality and excellence, which was bestowed by the Communicator Awards, an international organization of communications professionals. This 29-minute educational video was designed to promote communication between veterans with combat-related PTSD and their family members. The video describes the symptoms of PTSD and addresses the ways in which PTSD affects the family by showing a realistic portrayal of a veteran with PTSD and his spouse at home. Information about treatment resources at the VA and the Veterans Readjustment Counseling Services Centers ("Vet Centers") is included.

Dissemination and utility of products

The South Central MIRECC maintains a library of products from the clinical educators program. The product list is published biannually in the electronic MIRECC newsletter and maintained on the Web site (www.va.gov/scmirecc).

To assess the extent to which products from the clinical educators program are used in South Central VA Health Care Network treatment programs, we surveyed clinicians to whom products had been sent and asked whether the product was currently being used. At least one product was being used at each of the network's ten medical centers, and seven of the facilities used five or more products on a routine basis. The PTSD: Families Matter videotape, the SAFE manual, and an anger management group workbook were the most frequently requested and used products. Because our initial focus was on engaging clinicians in the best-practices process, the popularity and use of these products surpassed expectations. It may be that clinicians in this network are eager to adopt tools developed by fellow clinicians because the developers have similar practices and patient populations (1) or because the developers are viewed as local experts or opinion leaders (4,5).

Alterations in the program

Over time the program has provided support to applicants in developing their proposals, and proposals have been held to higher standards. In the first year, the MIRECC funded as many projects as possible largely to engage clinicians in the program. In subsequent years, funding decisions have emphasized innovation and exportability, and applicants are now asked to propose a simple evaluation of their materials. Access to a MIRECC methodologist and evaluation expert is provided. Examples of basic evaluation strategies are included in the application. In addition, a revise-and-resubmit procedure, wherein the review committee suggests changes to applications that are weak or vague, has strengthened the quality of funded projects.

Although the number of applications has decreased over time, the number of clinicians submitting applications has increased with each year. Rather than working alone, more clinicians are collaborating on projects. The fifth year of the program marked the first multisite proposals.

Conclusions

With a modest budget, the clinical educators program has supported experienced frontline clinicians in the development of innovative best practices tools that are now being tested and used in clinical settings. The program has engaged clinicians as agents of change, supported the production of valuable educational materials, and become a vehicle to introduce clinicians to basic principles of evaluation. It has allowed a number of clinicians to receive acknowledgment for their creative contributions, promoted collaboration across the network, and encouraged the view among clinicians that they can actively contribute to the promotion of best practices.

The authors are affiliated with the Department of Veterans Affairs South Central Mental Illness Research, Education, and Clinical Center (MIRECC) in New Orleans and in Little Rock, Arkansas. Dr. Kauth is also with the department of psychiatry and neurology at Tulane School of Medicine in New Orleans. Dr. Sullivan and Dr. Henderson are also with the department of psychiatry at the University of Arkansas for Medical Sciences in Little Rock. Send correspondence to Dr. Kauth at South Central MIRECC (COS6-6), Department of Veterans Affairs Medical Center, 1601 Perdido Street, New Orleans, Louisiana 70112 (e-mail, [email protected]). William M. Glazer, M.D., is editor of this column.