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.

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.

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.