Explaining site-level fidelity within a national initiative to implement a VA patient safety guidebook: the...

Implementation fidelity-the degree to which an intervention is executed as intended-is critical for evaluating healthcare interventions' success. Contextual determinants such as organizational culture, communication, and leadership influence how interventions unfold at the site level. The Veterans Health Administration (VA) developed the Patient Safety Events in Community Care: Reporting, Investigation, and Improvement Guidebook to improve standardization of patient safety reporting across VA-delivered and VA-purchased care. While the Guidebook aims to enhance reporting fidelity, little is known about which local contextual factors influence its implementation success across diverse VA sites. This study examined the contextual determinants associated with site-level variation in Guidebook implementation fidelity.

We conducted a cross-sectional, mixed-methods evaluation of 18 geographically diverse VA Medical Centers. Data were collected from 32 interviews with 45 key personnel involved in Guidebook implementation. Using the 2009 Consolidated Framework for Implementation Research (CFIR), 12 constructs were rated at each site. Fidelity was assessed across three safety processes (reporting, investigation, and improvement) on a three-point scale. We used Coincidence Analysis, a configurational comparative method, to identify combinations of CFIR constructs (difference-makers) that consistently distinguished higher- from lower-fidelity sites.

Guidebook fidelity varied across sites (range = 0.23 to 1.59). We identified three key CFIR constructs associated with higher fidelity: Networks & Communications, Relative Priority, and Leadership Engagement. Of these, Networks & Communications was both a necessary and sufficient condition for higher fidelity, serving as a precondition for high levels of Leadership Engagement. Sites that rated highly in Relative Priority were more likely to fully implement Guidebook processes. These constructs fostered strong collaboration, timely information exchange, and internal alignment on the importance of patient safety reporting.

Effective communication networks and perceived priority of the intervention were central to high-fidelity implementation of the VA's safety reporting Guidebook. These findings highlight critical levers for improving implementation fidelity in complex healthcare systems. Targeted strategies that strengthen communication and emphasize the value of safety interventions may enhance implementation success, offering valuable insights for patient safety efforts both within and beyond the VA.