Healthcare researchers develop new evidence-based practices and tools to improve clinical care and patient safety. However, only a fraction of these practices and tools are implemented in clinical settings.1 While multiple factors contribute to the research to practice gap, slow or improper diffusion of information is a known barrier to rapid adoption of evidence-based practices.1 Diffusion is the passive and natural spread of information to a broad audience, such as through word of mouth.2 Large healthcare organizations, such as the Veterans Health Administration (VA), use person to person diffusion of information with some benefit. An alternative to diffusion is dissemination, defined as planned efforts to spread practices through targeted, direct delivery of information to a particular audience, such as healthcare providers or patients.1 While no single diffusion or dissemination strategy is effective for every situation, diffusion has been shown to be less effective than dissemination when the aim is to consistently and rapidly spread best practices to improve patient care.1
Dissemination strategies selected and crafted to reach a specific audience can positively impact the adoption of best practices.3,4 Marketing theory offers a valuable framework to select dissemination strategies for large healthcare organizations. Marketing is the management process responsible for identifying, anticipating, and satisfying customer requirements profitably.5 Social marketing applies marketing principles to societal objectives, such as improving the health and welfare of individuals and society, rather than corporate ones.6 Social marketing is an active process that induces behavior change through deliberate influence and persuasion by leaders, compared to more passive marketing approaches that aim to influence behavior change by bringing awareness to a topic.5 In healthcare, social marketing theory offers a strategy to focus on influencing voluntary, socially beneficial behaviors and harnessing those behaviors to enact social change.6 The social marketing approach provides dissemination guidance, including identification of the four Ps of marketing, product, price, place, and promotion, the target audience and objective setting, and the creation, testing, and circulation of materials.6
The four Ps of marketing can inform decision making around dissemination of evidence-based practices in healthcare.6 Product refers to the practice, process or innovation being disseminated. The product should be designed for and by end-users who know their local context, be they an individual provider, a clinical team, a community, or an organization. Price refers to the cost in time and money to end-users for adopting and implementing the product. Price is a driving factor in implementation of evidence-based practices for human and financial resources are limited in healthcare settings. Place is how a target audience receives and accesses product information. The ideal is for audiences to invest minimal effort to retrieve product information. This is achieved when the product is pushed to end users through established and frequently visited communication forums (e.g. publications, meetings). Promotion considers the different methods of communication. These range from low touch methods such as social media, radio and television, and internet messages which subliminally promote products through low involvement processing.7 High touch methods include distribution of branded promotional materials such as pens, folders, and toolkit binders or academic detailing, which allows face-to-face interaction and discussion.8 Identification and optimization of the four Ps can inform healthcare dissemination plans and may increase the uptake of evidence-based strategies.6
This paper details the dissemination strategy for The Relational Coordination in the Veterans Health Administration (RC in VA) program, a national project designed to educate and motivate VA research and operational staff to study and implement relational coordination9 within their programs of research or areas of operation. The VA Health Services Research & Development (HSR&D) program funded the RC in VA as a one-year pilot with hopes of understanding the impact of team communication and relationships on organizational performance. Given the size and geographic dispersion of VA healthcare facilities, the RC in VA program prioritized bringing together VA researchers and operational leaders to establish processes to study relational coordination across settings, conditions, and populations. The goals of the RC in VA program were to develop knowledge and understanding of relational coordination that results in implementation projects that positively impact patient and provider health and safety. The work supports current VA priorities including a focus on patient centered care, learning healthcare systems and high reliability organizing.10,11,12
Relational coordination is an empirically supported theory of organizational performance that proposes interdependent work is most effectively coordinated by workers with each other, their customers, and their leaders.13 Relational coordination drives performance outcomes including quality, efficiency, client satisfaction, worker well-being and engagement.14 In healthcare, relational coordination is a salient component of delivering an effective, reliable, highly coordinated experience of care as well as a key aspect of patient centered care and high reliability organizing.15 The state of relational coordination within teams is captured using the Relational Coordination Survey (RC Survey), a validated measure of coordination and team performance. The RC Survey assesses the quality of communication and relationships among roles and can be used for research or to support organizational change.16
In line with social marketing theory described above, dissemination of the RC in VA program involved multi-component strategies. This was important given, the unique needs of individual VA research and operational teams, the institutional structure of the VA, and the fact that relational coordination is novel and a less well understood approach to study team relationships and communication. Once the objectives for the RC in VA program were identified, the question remained as to optimal dissemination products, price, placement and promotion techniques. To determine best practices for dissemination, we considered many factors, including the available resources within the VA, the ideal target audience, and the variable involvement of VA researchers and operational staff in team focused assessment and improvement.
This paper describes dissemination of the RC in VA program, including the successful dissemination efforts that led to adoption of relational coordination into currently funded VA research and operational projects. We also present the dissemination strategies that failed to garner lasting engagement. The value of understanding dissemination of the RC in VA program is not exclusive to this project. Rather this paper highlights the useful lessons and strategies that may be applied to the broad dissemination of a theoretically driven team communication and relationship theory and assessment tool through a large healthcare organization.