Organizational characteristics of high- and low-performing anticoagulation clinics in the Veterans Health Administration

Health Serv Res. 2012 Aug;47(4):1541-60. doi: 10.1111/j.1475-6773.2011.01377.x. Epub 2012 Feb 2.


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.

Publication types

  • Comparative Study
  • Multicenter Study
  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Anticoagulants / administration & dosage*
  • Documentation
  • Efficiency, Organizational
  • Evidence-Based Medicine
  • Health Services Research
  • Hospitals, Veterans / standards*
  • Humans
  • Interviews as Topic
  • Medical Staff, Hospital / standards
  • Organizational Innovation
  • Patient Care Team / organization & administration
  • Qualitative Research
  • Quality of Health Care*
  • United States
  • Veterans Health*


  • Anticoagulants