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Table 1 Factors potentially affecting implementation of the fall prevention program in the VA Greater Los Angeles Healthcare System (VAGLAHS) (factors adapted from Durlak and DuPre [16]).

From: Design of a continuous quality improvement program to prevent falls among community-dwelling older adults in an integrated healthcare system

Key factors Status of these factors in fall prevention program
I. Community level factors  
   A. Prevention theory and research There is a well developed research literature on fall prevention. Theory, however, is less well developed.
   B. Politics The political environment has some awareness of falls [29], although in the United States this awareness does not rise to the level of other medical concerns such as cancer and heart disease.
   C. Funding There is some funding available for fall prevention activities from United States government organizations such as the Centers for Disease Control and Prevention as well as philanthropic organizations (e.g., the Archstone Foundation). However, funding for these activities does not parallel the availability of funds for other conditions.
   D. Policy Current policies by governmental organizations provide a small but clear level of support for fall prevention activities [29].
II. Provider characteristics  
   A. Perceived need for innovation Informal interviews with providers (physicians, nurses) in the ambulatory care setting as well as facility leadership suggest the perceived need for innovation at VAGLAHS is moderate to high.
   B. Perceived benefits of innovation Different individuals perceive different benefits from an enhanced fall prevention program. Some perceive the potential to save the facility money in reduced costs from inpatient hospital stays due to injuries. Others perceive the possibility of an improvement in quality of care due to better access to fall prevention services for patients. Yet others note that efficiency might be improved by streamlining the array of fall prevention services already in existence.
   C. Self-efficacy Providers' self-efficacy in preventing falls is unknown. Investigators at VAGLAHS are funded to develop a survey of primary care providers that will assess this issue.
   D. Skill proficiency Providers' skill proficiency in implementing fall prevention activities is unknown. Investigators at VAGLAHS are funded to develop a survey of primary care providers that will assess this issue.
III. Characteristics of the innovation  
   A. Compatibility The fall prevention program being developed is designed to be compatible with existing work processes at VAGLAHS. At least initially, it will not require hiring new individuals, changing existing technology, or reshaping work culture. Instead, it uses an already existing service within the organization in a novel way.
   B. Adaptability The program is fundamentally adaptable. The script that nurses read to patients as part of the telephonic assessment (see Additional File 2) may be modified. The places to which patients may be referred based on the telephonic evaluation may be altered. Multiple provider types (e.g., physicians, nurses, social workers) may place a request for a telephonic fall risk assessment, although in some cases, individuals may need physician or mid-level practitioner approval to place a request.
IV. Factors relevant to the prevention delivery system: organizational capacity  
   A. General organizational factors  
1. Positive work climate The work climate of VAGLAHS relative to other institutions is unclear. Attempts to measure the VA's work climate in a reproducible way are ongoing [30].
2. Organizational norms regarding change VAGLAHS is open to small, incremental changes but probably less open to radical system redesign.
3. Integration of new programming VAGLAHS has adequate organizational slack to integrate a new program on a pilot basis. The ability of VAGLAHS to implement a new program with high workload is doubtful.
4. Shared vision The organization has a shared vision of providing improved services to veterans.
   B. Specific practices and processes  
1. Shared decision-making The interest in shared decision-making at VAGLAHS seems to be high. The two leadership meetings to discuss whether and how the fall prevention program should be developed and implemented were well-attended, including members of senior leadership.
2. Coordination with other agencies Coordination between VAGLAHS and outside agencies that provide fall prevention activities (e.g., community senior centers) is difficult. The VA's electronic health record provides a strong incentive to coordinate activities internally. An exception to this relevant to fall prevention is the use of home care services (including home physical therapy and home safety evaluations), which can be ordered through the VA electronic health record but then may be contracted to a private home health agency, and financed either via a veteran's health insurance benefits or by direct payment from the VA to an outside agency.
3. Communication Communication is facilitated by a common internal e-mail system and phone directory.
4. Formulation of tasks Task formulation was enhanced by the Chief of Staff's chartering a workgroup composed of members from different disciplines relevant to fall prevention (ambulatory care, geriatrics, physical medicine & rehabilitation, nursing, performance improvement, research).
   C. Specific staffing considerations  
1. Leadership The Chief of Staff of VAGLAHS is a geriatrician and therefore has a heightened appreciation of the need for improved quality of care with respect to fall prevention. He is supportive of the intervention.
2. Program champion The first author is acting as program champion. This champion status is protected for 5 years through salary support from a VA Career Development Award whose specific aims include the development and implementation of a fall prevention program at VAGLAHS. The first author's career development is supported by two mentors (PGS and DS) and an advisory committee (including EMY).
3. Managerial/supervisory/administrative support Administrative support for the development of the fall prevention program is limited.
V. Factors related to the prevention support system  
   A. Training The first author has provided continuing medical education about fall prevention to VAGLAHS providers through lectures at various sites within the system. VAGLAHS has a variety of more general training programs that could be harnessed to increase awareness of the importance of fall prevention.
   B. Technical assistance Currently, the first author provides technical assistance to clinicians involved with the project on an ad hoc basis. Developing more formal technical assistance for providers will become necessary if the program advances beyond its pilot phase.
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