Implementing the MOVE! Weight-Management Program in the Veterans Health Administration, 2007-2010: A Qualitative Study

Bryan J. Weiner, PhD; Lindsey Haynes-Maslow, MHA; Leila C. Kahwati, MD, MPH; Linda S. Kinsinger, MD, MPH; Marci K. Campbell, PhD

Suggested citation for this article: Weiner BJ, Haynes-Maslow L, Kahwati LC, Kinsinger LS, Campbell MK. Implementing the MOVE! weight-management program in the Veterans Health Administration, 2007-2010: a qualitative study. Prev Chronic Dis 2012;9:110127. DOI: http://dx.doi.org/10.5888/pcd9.110127.

PEER REVIEWED

Abstract

Introduction

One-third of US veterans receiving care at Veterans Health
Administration (VHA) medical facilities are obese and, therefore, at higher risk
for developing multiple chronic diseases. To address this problem, the VHA
designed and nationally disseminated an evidence-based weight-management program
(MOVE!). The objective of this study was to examine the organizational factors
that aided or inhibited the implementation of MOVE! in 10 VHA medical
facilities.

Methods

Using a multiple, holistic case study design, we conducted 68 interviews with
medical center program coordinators, physicians formally appointed as program
champions, managers directly responsible for overseeing the program, clinicians
from the program’s multidisciplinary team, and primary care physicians
identified by program coordinators as local opinion leaders. Qualitative data
analysis involved coding, memorandum writing, and construction of data displays.

Results

Organizational readiness for change and having an innovation champion were most consistently
the 2 factors associated with MOVE! implementation. Other organizational factors,
such as management support and resource availability, were barriers to
implementation or exerted mixed effects on implementation. Barriers did not
prevent facilities from implementing MOVE! However, they were obstacles that had
to be overcome, worked around, or accepted as limits on the program’s scope or
scale.

Conclusion

Policy-directed implementation of clinical weight-management
programs in health care facilities is challenging, especially when no new
resources are available. Instituting powerful, mutually reinforcing
organizational policies and practices may be necessary for consistent, high-quality
implementation.

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Introduction

In 2006, the Veterans Health Administration (VHA) issued a policy directing
implementation of an evidence-based weight-management program to help reduce
obesity rates among veterans receiving care from VHA (1). Created by VHA’s
National Center for Health Promotion and Disease Prevention (NCP) on the basis
of guidelines from the National Institutes of Health (2,3) and other literature,
the MOVE! weight-management program uses a
population-based clinical approach to disease in which all patients seen in VHA
medical facilities are systematically screened for obesity and offered
evidence-based tiered treatment options tailored to their needs and preferences.
In order of increasing intensity, treatment options include self-management
support, individual counseling or group sessions, clinically supervised
weight-management medications, and, in some facilities, brief residential
treatment or bariatric surgery. Delivered by a multidisciplinary team
encompassing primary care, dietetics, behavioral health, and physical activity,
MOVE! is a comprehensive approach to weight loss and maintenance that promotes
behavior change, healthy nutrition, physical activity, and psychological
well-being. MOVE! addresses an urgent need: 35% of VHA primary care enrollees —
representing 90% of all of VHA patients — are estimated to be obese (4,5) and,
therefore, at higher risk for chronic diseases such as hypertension,
cardiovascular disease, stroke, and osteoarthritis (6).

NCP took several steps in designing and disseminating MOVE! to ensure rapid
adoption and implementation (7). First, it developed an easy-to-use toolkit that
contained patient handouts, promotional brochures, clinical references,
curriculum modules, online staff training, implementation checklists,
administrative manuals, and marketing materials. Second, it tested the program
for feasibility in 17 VHA medical facilities and revised program content and
materials on the basis of staff and patient feedback. Third, NCP secured
endorsements for the program from influential internal stakeholders, culminating
in the issuance of a VHA policy in March 2006 requiring all facilities to
implement MOVE! or an equivalent multidisciplinary weight-management program.
Fourth, NCP held 2 national training conferences and biweekly teleconferences
with program coordinators in the 21 regional VHA networks. Finally, VHA policy
required facilities to complete an annual report on their weight-management
services and prepare to be held accountable for their obesity screening rates as
part of VHA’s performance measurement system.

By 2009, nearly all (98.7%) of the 155 medical centers in VHA reported
having MOVE! programs in place (7). A VHA evaluation conducted in 2010 showed
that, overall, the program has had a modestly positive effect on weight change
at 6 months (8). However, facilities varied in the speed with which they
implemented the program and the level of program activity they achieved 12 to 36
months after the issuance of the policy. Given the national scope of the
program’s dissemination within a single health care system, the MOVE! program
offers a unique opportunity to examine the local organizational factors that
aided or hindered program implementation among multiple facilities. The
objective of this study was to examine the organizational facilitators and
barriers of MOVE! implementation in 10 VHA medical facilities.

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Methods

Conceptual framework

We used an organizational model of innovation implementation to guide the
study (9-11). The model posits that the effective implementation of an
innovation (ie, consistent, high-quality delivery of MOVE!) is a function of the
organization’s readiness for change; level of management support for the
innovation; amount of resources available for implementation; presence of an
innovation champion; extent to which the innovation fits local task demands,
such as work processes and patient preferences (“innovation-task fit”); and
extent to which intended implementers of the innovation, such as physicians,
nurses, and allied health professionals, perceive that innovation implementation
fosters the fulfillment of their values (“innovation-values fit”).

Study design and sample

We used a multiple, holistic case study design; the VHA medical facility
was the unit of analysis (12). Case study methods are well suited for
studying implementation processes, which tend to be fluid, nonlinear, and
context-sensitive (13-15). We invited 126 VHA facilities with at least 30 active
MOVE! participants in 2006 to participate in our study. Of the 14 facilities
that accepted our invitation, we purposefully selected 10 to reflect diversity
in geographic region, organizational size, and organizational complexity
(Table
1). National program officials assured us that the range of MOVE! program
activity among participating facilities, as indicated by growth in the number of
new program participants and level of program activity (eg, number of program
participants receiving individual face-to-face or telephone counseling or group
education), reflected the wide range of MOVE! program activity among VHA facilities.

This study was reviewed for human subjects protection and approved by all
participating VHA facility institutional review boards and by the review boards
of the 2 coordinating centers.

Data collection

From 2007 through 2010, a researcher (B.J.W.) with 15 years of experience
conducting qualitative research, interviewed 68 MOVE! representatives. He asked
each VHA facility to identify the MOVE! coordinator, the program’s physician
champion (formally appointed), the facility manager directly responsible for
overseeing the program, an opinion leader in primary care, and 3 or 4 members of
the program’s multidisciplinary team (Table 2). Of the 74
people contacted,
5 did not respond to recruitment e-mails, and
1 could not be reached because she was on maternity leave. The interviewer had
no previous relationship with interview participants. He used semistructured
interview guides informed by the study’s conceptual framework to gather
information about the program’s staffing, structure, and operations and
facilitators and barriers of program implementation (Appendix). The 30- to
60-minute telephone interviews were recorded with permission from the
participants and transcribed verbatim.

Data analysis

Analysis proceeded in 3 steps. First, we used Atlas.ti version 5.0
qualitative data analysis software (Scientific Software Development GmbH,
Berlin, Germany) to code the data. Using a codebook informed by the conceptual
framework, 2 investigators independently coded the transcripts, compared their
coding, and reconciled coding discrepancies through discussion until consensus
was reached. Second, we conducted a within-case analysis of facilitators and
barriers for each facility. We generated reports of all text segments for each
code and wrote memoranda in which we assessed the degree to which the construct
emerged in the data (its “strength”), identified themes in the coded data for
the construct, and assessed the degree to which the construct positively or
negatively affected implementation (its “valence”). We then created a checklist
matrix to visually display the construct valences and support the identification
of patterns within medical facilities (16). Finally, we developed a conceptually
clustered matrix to enable a between-case
analysis of facilitators and barriers by construct (16). Two investigators
independently conducted the within- and between-case analyses, compared results,
discussed findings, reconciled discrepancies, and produced a final conceptually
ordered matrix.

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Results

All 10 VHA medical facilities encountered facilitators and barriers as they
implemented MOVE! (Table 3). Although some facilities
reported more barriers
than others, no facility had barrier-free implementation.
Among the 10 facilities, the organization’s readiness for change and the
presence of an innovation champion most consistently served as facilitators of
MOVE! implementation. Other organizational factors, such as resource
availability and innovation-values fit, either acted as barriers to
implementation or exerted mixed effects (Table 4) on implementation. None of the
barriers observed prevented any of the 10 facilities in this study from
implementing MOVE! However, interview participants cited the barriers as
obstacles to be overcome, worked around, or accepted as limits on the program’s
scope or scale.

All facilities either had an existing weight-management program or
had participated in the pilot phase of MOVE! before issuance of VHA policy.
Moreover, all facilities knew that the VHA central office would soon hold them
accountable for their obesity screening rates (a key factor leading to increased
demand for MOVE! treatment). However, preexisting weight-management programs at
3 facilities provided limited preparation for MOVE! because they focused
primarily on healthful eating and offered only group education. In 1 facility,
previous programs were perceived as failures, which undermined organizational
readiness.
Even with pilot-phase experience, 2 facilities struggled to offer the full range
of tiered treatment options of MOVE!. Delaying accountability for obesity
screening gave facilities time to implement MOVE!; the delay, however, had the
unintended effect of reducing the sense of urgency during the interim period,
leading to slower MOVE! implementation than interview participants at 2
facilities had desired. Finally, obesity screening rates were added to an
already long list of performance indicators at 2 facilities, which may have
diluted the motivational effect of such accountability.

Interview participants often, but not always, characterized the facility’s
senior managers (eg, facility director, chief of staff, facility chief nurse,
and chief administrative officer) as supportive of MOVE!. In 2 facilities,
senior managers allocated resources for hiring staff or purchasing materials
during the pilot phase or immediately after the national launch. However, in 4
other facilities, senior management support did not translate into resource
allocation until facilities became accountable for their obesity screening
rates. Moreover, the support of service-line chiefs for MOVE! was highly
variable, ranging from enthusiasm to passive acceptance to skepticism.
(Service-line chiefs are the formal leaders of clinical service lines [eg, primary care service-line chief]; they
report to senior managers.) Service-line chief support varied as
a function of where the MOVE! program was based administratively. In 2
facilities where MOVE! was based in nutrition service, for example, support from
the primary care service-line chief was sometimes tepid. In 3 facilities,
interview participants attributed variable service-line chief support as a
barrier to creating and sustaining a multidisciplinary team approach to MOVE!
program delivery.

In several facilities, interview participants cited limited resource
availability as a significant barrier to MOVE! implementation. Three facilities
praised the toolkit that NCP developed for MOVE! implementation and delivery.
The national program launch, however, provided no additional funding for
facilities to implement MOVE!. With no additional funding, 5 facilities launched
MOVE! by assigning existing clinical staff the additional duty to implement and
deliver MOVE!. When facilities became accountable for their obesity screening
rates, facility managers at 2 facilities proved more receptive to requests to
hire full-time staff for MOVE!. In all 10 facilities, however, MOVE! relied
heavily on the staff who were personally committed to supporting and delivering
the program in addition to performing their other clinical or administrative
duties. Four facilities coped with limited staffing resources by involving
psychiatric residents, psychology interns, and nutrition students from nearby
universities. Interview participants generally reported that MOVE! is understaffed
in their facility and that the understaffing limits the number of veterans
served, the range of tiered treatment options, and the multidisciplinary
approach. In 5 facilities, for example, interview participants reported little
or no staff support in physical activity disciplines (eg, recreational therapy,
physical therapy, occupational therapy). Five others reported shortages in
behavioral health disciplines (eg, psychology, social work).

VHA policy required all facilities to assign a physician champion for
MOVE! In most facilities, interview participants reported that the physician
champion was actively engaged in MOVE! and served as a respected ambassador for
the program among primary care physicians and an influential advocate for
additional resources. In 2 facilities, however, the physician champion was
described as uninvolved in MOVE! or passive as a spokesperson for the program.
In these facilities, interview participants sometimes identified the MOVE!
coordinator or another MOVE! staff member as an innovation champion. These
people, however, did not have the position, prestige, or influence of the
physician champion.

Primary care physicians are expected to
screen patients for obesity, counsel them about the health risks and
consequences of obesity, and refer them to MOVE! if they seem interested or
ready. Interview participants at 7 facilities noted that primary care physicians
strongly believe in the value of prevention and perceive weight management as
necessary for reducing illness among their patients and to VHA as a health care system. As a comprehensive, multidisciplinary
weight-management program that offers tiered treatment options tailored to
patient needs and interests, the MOVE! program fits the values of many primary care physicians. However, interview
participants at 4 facilities noted that some primary care physicians doubt the
program’s efficacy to produce and sustain enough weight loss to make a
noticeable impact on patients’ health. This skepticism, plus the urgency of
patients’ more pressing medical issues, led to less support from some
physicians.

All 10 facilities attempted to tailor MOVE! to better fit their
organization’s capacity to implement it. These modifications included adding or
removing clinical reminders for obesity screening, tailoring procedures for
enrolling patients, and offering various levels of the MOVE! program at a
facility. Eight facilities noted that primary care nurses and physicians felt
that tasks associated with MOVE!, such as the clinical reminder to screen for
obesity or attending multidisciplinary meetings, were time consuming and
burdensome to already heavy workloads. Two facilities decided to remove the
clinical reminder altogether.

Enrolling patients in MOVE! was challenging for some facilities. One facility
reported patient reluctance to participate in a weight-loss program.
Additionally, 4 facilities had difficulty motivating patients to
practice behavior changes, such as exercising and eating healthfully, outside of
the MOVE! classroom. Implementation of the most basic treatment option —
self-management supported by frequent telephone contact — varied among
facilities. Four facilities discontinued this level because they had difficulty
reaching people by telephone and it was time consuming for staff and volunteers
to make calls. One facility could make initial telephone calls but noted that
staff availability limited the number of follow-up calls.
Another found this level was more convenient for patients living farther away.

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Discussion

Organizational facilitators and barriers played a salient role in the
implementation of MOVE! — the only nationally implemented, evidence-based
weight-management program that focuses on reducing obesity rates among US
veterans receiving care at VHA facilities. Of the 6 organizational factors
examined in this study, organizational readiness for change and innovation
champions were the most consistent facilitators of MOVE! implementation.
Management support, resource availability, innovation-values fit, and
innovation-task fit either acted as barriers to implementation or exerted mixed
effects on implementation.

Our findings contribute to a limited body of research on the organizational
context of innovation implementation in health care settings (17,18). A study
with similar findings (19) observed that resource limitations posed a
substantial barrier to the implementation of quality improvement and patient
safety interventions in infection prevention. Our results suggest that
organizational accountability through explicit performance measurement can
prompt health care organization leaders to allocate scarce resources to support
program implementation and spur program staff to find creative solutions to
resource constraints. Several studies indicate that informal, emergent
innovation champions play a role in innovation implementation (9,20-24). Our
results suggest that formally appointed innovation champions can also aid
implementation by helping secure resources, overcome obstacles, and encourage
innovation.

This study had several limitations. Case study research emphasizes depth over
breadth and insight over generality (12,15). Ten cases do not provide a strong
basis for statistically generalizing study results to all VHA facilities.
Although national program officials (L.C.K. and L.S.K.) report many VHA
facilities encountered the same or similar organizational facilitators and
barriers as those identified in this study, a national survey of randomly
sampled VHA facilities would be needed to document the frequency and
distribution of facilitators and barriers. As is true of all research, case
study research involves an irreducible element of expert judgment. We used
time-honored case study research methods, but we cannot discount the
possibility that investigator bias in interpretation influenced our results.

We suggest 2 directions for future research. First, the theory and practice
of the multilayered complexities of management support need to be understood.
Senior management support is often cited as necessary for innovation
implementation (14,25-29), but our study shows that support from middle managers
(eg, service-line chiefs) and even direct supervisors can also aid or hinder
implementation. Second, innovation champions are often conceptualized as
people who, driven by passion and enthusiasm, not formal designation, step
outside of their organizationally prescribed roles to advocate for innovations
(9,20-24). Our study shows, however, that formally designated innovation
champions promoted implementation in many facilities; informal champions
surfaced only when formally designated champions left a gap to be filled. The
emergence of informal champions, rather than being lauded, should perhaps be
considered a sign that the organization’s formal roles, structures, and policies
are not aligned with its goals for program implementation. This conjecture could
be empirically investigated.

We also learned 2 practical lessons that may help other health care or public
health systems to implement new programs amid competing
organizational priorities and a lack of new resources. First, organizational
leaders directing implementation of new programs must put into place powerful,
mutually reinforcing policies and practices that make implementation expected,
supported, and rewarded. Such policies and practices include setting measurable
goals for implementation, instituting a realistic schedule for meeting those
goals, monitoring progress against goals, recognizing those who meet goals, and
holding accountable those who do not. These policies and practices must be
clearly and consistently communicated, and they must command the attention of
those charged with implementation. Second, the policies and practices must
cascade throughout the multiple levels of organizational hierarchy to form an
aligned, interlocking implementation strategy. Otherwise, an implementation gap
arises between top management and the front line of service provision to
veterans.

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Acknowledgments

This research was supported by grant no. R01CA124400 from the National Cancer
Institute.

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Author Information

Corresponding Author: Bryan J. Weiner, PhD, Department of Health Policy and
Management, CB 7411, Gillings School of Global Public Health, University of
North Carolina at Chapel Hill, Chapel Hill, NC 27599-7411. Telephone: 919-966-7375. E-mail:
bryan_weiner@unc.edu.

Author Affiliations: Lindsey Haynes-Maslow, Marci K. Campbell, University of
North Carolina at Chapel Hill, Chapel Hill, North Carolina; Leila C. Kahwati,
Linda S. Kinsinger, Veterans Health Administration, Durham, North Carolina.

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References

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Tables

Table 1. Veterans Health Administration (VHA) Medical Centers Included in
Qualitative Study on Implementation of the MOVE! Weight-Management Program,
United States, 2007-2010

^a Data were obtained for fiscal year 2006 from the VHA Service
Support Center Unique Patient Data Cube (unpublished data).

^b The VHA categorizes VHA Medical Centers according
to a defined complexity model for the purposes of performing program and
organization analyses, making decisions on organizational structure, and setting
senior executive pay levels. The model uses data on patient population served
(including numbers served and patient risk as measured by the diagnostic cost
group), clinical services complexity (eg, intensive care units, specialized
clinical programs), and the scope of the graduate medical education and research
enterprise of the facility. Facilities are categorized into 1 of 5 complexity
levels: IA (most complex), IB, IC, 2, or 3 (least complex).

^c Data were obtained for fiscal year 2006 from the VHA Service
Support Center MOVE! Visits Data Cube (unpublished data).

^d Visits include group, individual, and telephone communication.
Visits are identified through the use of a unique administrative code required
by VHA policy.

Table 2. Number of Interview Participants, by Veterans Health Administration
(VHA) Facility and Organizational Role, Qualitative Study on Implementation of
the MOVE! Weight-Management Program, United States, 2007-2010

^a The coordinator is the clinical staff person responsible for
program coordination, communication, and reporting. The physician champion is
responsible for facilitating program implementation and overseeing the clinical
aspects. The facility manager is the administrator directly responsible for
overseeing the program; facility managers had different titles in different VHA
facilities (eg, associate chief of staff for ambulatory care, primary care
service line manager, nutrition/food service chief). Multidisciplinary team
members are clinical staff from the 4 core disciplines involved in program
delivery: dietetics, primary care, physical activity, and behavioral health. The
opinion leader is a primary care physician who is not directly involved in the
program but is considered influential in primary care.

^b Physician was on maternity leave; we were unable to reach her.

^c Participant did not respond to recruitment
e-mail.

^d Two interview participants did not respond to
recruitment e-mail.

Table 3. Organizational Factors Associated With Implementation of MOVE!
Weight-Management Program, United States, 2007-2010

Abbreviations: + indicates factor was present and favorable for
implementation; −, factor was absent or unfavorable for implementation; +/−,
factor was present but mixed (favorable and unfavorable) for implementation.

^a Refers to the extent to which
expected implementers and users of an innovation are psychologically and
behaviorally prepared to make the necessary changes in organizational policies and
practices.

^b Refers to managers’ shared resolve to pursue
courses of action that promote the successful implementation of the innovation.

^c Refers to the accessibility of financial,
material, or human assets that can be used to support initial and ongoing
innovation use.

^d Refers to a charismatic person who
supports the innovation, thus overcoming the indifference or resistance that a
new idea often provokes in an organization.

^e Refers to the extent to which targeted
employees perceive that innovation use will fulfill their values.

^f Refers to the extent to which the innovation is
compatible with task demands, work processes, and organizational capabilities.

Table 4. Facilitators and Barriers to Implementing MOVE! in Veterans Health
Administration (VHA) Medical Facilities, United States, 2007-2010

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Appendix. Interview Guide for Qualitative Study on Implementation of
the MOVE! Weight-management Program, Veterans Health Administration, United
States, 2007-2010

Organizational readiness for change refers to the extent to which
targeted organizational members (especially the implementers and intended users)
are psychologically and behaviorally prepared to make the changes in
organizational policies and practices that are necessary to put the innovation
into practice and to support innovation use.

Management support refers to facility or
VISN managers’ shared resolve
to pursue courses of action that promote the successful implementation of the
innovation. Although titles vary, management includes facility director,
facility chief of staff, facility chief nurse, facility chief administrative
officer, facility service line chiefs, VISN network director, VISN chief medical
officer, and VISN clinical leads. Although some MOVE! coordinators wear
“management hats,” the coordinator role is not considered a management position.

Resource availability refers to the accessibility of financial,
material, or human assets that can be used to support initial and ongoing
innovation use.

Implementation policies and practices refer to the plans, practices,
structures, and strategies that an organization employs to put the innovation
into place to support innovation use.

Innovation-task fit refers to the extent to which the innovation is
compatible with task demands, work processes, and organizational capabilities.

Implementation climate refers to organizational members’ shared
perceptions of implementation policies and practices in terms of their meaning
and significance for innovation use.

Innovation-values fit refers to the extent to which targeted employees
perceive that innovation use will foster the fulfillment of their values. Values
are concepts or beliefs that a) pertain to desirable end-states or behaviors, b)
transcend specific situations, and c) guide the selection and evaluation of
behavior and events.

Innovation champion refers to a charismatic individual who throws
his/her weight behind the innovation, thus, overcoming the indifference or
resistance that a new idea often provokes in an organization.

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