Organizational characteristics of high- and low-performing anticoagulation clinics in the veterans health administration

Adam J. Rose*, Beth Ann Petrakis, Patricia Callahan, Scott Mambourg, Dimple Patel, Elaine M. Hylek, Barbara G. Bokhour

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

35 Scopus citations


Objective Anticoagulation clinics (ACCs) can improve anticoagulation control and prevent adverse events. However, ACCs vary widely in their performance on anticoagulation control. Our objective was to compare the organization and management of top-performing with that of bottom-performing ACCs. Data Sources/Study Setting Three high outlier and three low outlier ACCs in the Veterans Health Administration (VA). Study Design Site visits with qualitative data collection and analysis. Data Collection/Extraction Methods We conducted semi-structured interviews with ACC staff regarding work flow, staffing, organization, and quality assurance efforts. We also observed ACC operations and collected documents, such as the clinic protocol. We used grounded thematic analysis to examine site-level factors associated with high and low outlier status. Principal Findings High outlier sites were characterized by (1) adequate (pharmacist) staffing and effective use of (nonpharmacist) support personnel; (2) innovation to standardize clinical practice around evidence-based guidelines; (3) the presence of a quality champion for the ACC; (4) higher staff qualifications; (5) a climate of ongoing group learning; and (6) internal efforts to measure performance. Although high outliers had all of these features, no low outlier had more than two of them. Conclusions The top-performing ACCs in the VA system shared six relatively recognizable characteristics. Efforts to improve performance should focus on these domains.

Original languageAmerican English
Pages (from-to)1541-1560
Number of pages20
JournalHealth Services Research
Issue number4
StatePublished - Aug 2012
Externally publishedYes


  • Qualitative research
  • anticoagulants
  • organization and administration
  • pharmacists
  • quality of health care


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