Certificate Program in Practice-Based Research Methods
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1 Certificate Program in Practice-Based Research Methods UTILIZING QUALITY IMPROVEMENT FOR PBRN RESEARCH Session 7 - January 12, 2017 Chester H. Fox MD, FAAFP, FNKF Professor of Family Medicine Jacobs School of Medicine and Biomedical Sciences University at Buffalo, The State University of New York Mary A. Dolansky, RN, PhD, FAAN Associate Professor Frances Payne Bolton School of Nursing Case Western Reserve University
2 Utilizing QI for PBRN Research: Chet Fox MD Mary Dolansky RN, PhD
3 CONCEPTUAL MODEL THE CHRONIC CARE MODEL
4 PRINCIPLES OF PRAGMATIC CLINICAL TRIALS IMPROVING CARE IN THE REAL WORLD CLINICALLY RELEVANT ALTERNATIVES DIVERSE STUDY POPULATION HETEROGENEOUS PRACTICE SETTINGS DATA COLLECTED ON A BROAD RANGE OF OUTCOMES Tunis SR, Stryer DB, Clancy CM. Practical clinical trials: increasing the value of clinical research for decision making in clinical and health policy. JAMA. Sep ;290(12):
5 Why This Kind of Study Is needed? PEOPLE GET ONLY 50% OF EVIDENCE- BASED PREVENTIVE AND CHRONIC DISEASE CARE IT TAKES 7.9 HOURS/PATIENT/YEAR TO COMPLETE PREVENTIVE SCREENINGS IT TAKES 3.6 HOURS/DAY FOR STABLE PATIENTS AND 10.6 HOURS/DAY FOR COMPLEX PATIENTS TO DO CHRONIC DISEASE MANAGEMENT IT TAKES 17 YEARS FROM EVIDENCE IN THE LITERATURE TO BECOME ROUTINE CARE McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. New England Journal of Medicine. 2003;348(26): Yarnall KS, Pollak KI, Ostbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention? Am J Public Health. 2003;93(4): Ostbye T, Yarnall KS, Krause KM, et al. Is there time for management of patients with chronic diseases in primary care? Annals of Family Medicine. 2005;3(3): Balas EA, Boren SA. Managing clinical knowledge for health care improvement. Yearbook of medical informatics. 2000;2000:65-70.
6 PRINCIPLES OF QUALITY IMPROVEMENT The Model for Improvement
7 METHODS THAT WORK PRACTICE FACILITATION ACADEMIC DETAILING/ MENTORING AUDIT AND FEEDBACK COLLABORATIVE LEARNING
8 PRACTICE FACILIATION DEVELOPS LONG-TERM RELATIONSHIP WITH PRACTICE WORKS INTEGRALLY WITH PRACTICE TO SET UP EFFICIENT SYSTEMS FOR QI AND POPULATION MANAGEMENT WORKS WITH AND TRAINS STAFF IN EFFECTIVE TEAM MEETINGS HELPS SET UP EFFICIENT WORK FLOWS TO INTEGRATE INTO ROUTINE CARE HELPS PREPARE NECESSARY DATA AND REPORTS SO PEOPLE CAN KNOW HOW THEY ARE DOING CROSS POLLINATE IDEAS THAT WORK
9 Academic Detailing/Mentoring Academic Detailing Experienced MD Champions educate practice champions Academic mentoring On-going relationship and support of practice champions Purpose: Clinician buy-in To support efficiency instead of the dreaded One More Thing
10 Audit and Feedback Two Forms Pre-post change over time Benchmarking compared to other practice sites or clinicians 30% 25% % BP Not at Goal 20% 15% 10% 5% Average: 0% Clinic ID
11 Collaborative Learning Video In-person Webinar Small group Large group Mixed; Practice managers, staff and clinicians Specialized: just staff; just clinicians etc
12 Key Elements of Success Goals: Clear, easily measurable and feasible Not too many Resources: Time and personnel to do the project Data at the point of care and population reports Clinician Champions Site coordinator for local accountability Shared learning abilities
13 Develop the One page value proposition using the 5R approach PCORI grant as example Requirements Resources Roles Responsibilities Respect Practices must have ½ time behavioral health specialist who can see Medicare and fill out integration forms $150,000 per practice site over 5 years PCP, BH specialist, facilitator Complete web based training and give all necessary research data This is attitudinal and underlies the project
14 Decision support plan
15 Point of Care Decision Support example
16 TRANSLATE CKD Overview of a Pragmatic Clinical Trial Comparative Effectiveness Trial Computer Decision Support alone vs. Computer Decision Support + Virtual Facilitation
17 TRANSLATE CKD Study Point of Care Decision Support
18 Versus Facilitated Decision Support TRANSLATE Target Reminder Administrative Buy- In Network Information System Site Coordinator Local Clinician Champion Audit and Feedback Team Approach Education
19 Study Outcome Measures Treatment Goal Measurement Recommendation Control blood pressure 130 Means of last three systolic BP; will be based on last one or two if fewer than three available Control HbA1C <7.0 Last HbA1c; Control LDL <100 Mean of last two LDL; last LDL if only one is available Use ACE/ARB Refer to Nephrologist (GFR < 30) Eliminate smoking Eliminate NSAID/Cox-2 use Documentation in EHR/pharmacy of prescription; yes/no for each time period Referral documented, if applicable Yes/no for each time period Yes/no for each time period
20 Preliminary Results 35 Practices 10 States 21,105 patients Data available for 3 years Pre- post in intervention practices improves: Dx of CKD: 34%-44% Use of ACE/ARB: 46%- 51% Referral to Nephrology for CKD stage 4: 29%-34%
21 Dissemination of Results 6 peer reviewed publications 20 national presentations TRANSLATE scoring framework used as a model of practice transformation for CMS 685 million dollar transforming clinical practice initiative
22 Qualitative Methods Surveys (conducted at baseline) Physician Interviews Analysis of all communications between facilitators and practice ( s, phone calls, meeting notes, etc.) TRANSLATE rubric scoring Site visits** **Planned in original design, but not conducted
23 Baseline Physician Interview Themes
24 Quality Improvement: Operations & Research Mary A. Dolansky, PhD, RN, FAAN Associate Professor VA Quality Scholar Senior Fellow Director of the QSEN Institute Director of Interprofessional Integration VA Center of Excellence in Primary Care
25 Objective: Differentiate between Quality Improvement and Improvement Science
26 What is Quality? IOM s Six Aims for Improvement
27 Quality IOM s Six Aims for Improvement 1. Safe: Care in healthcare facilities should be as safe as at home *3 rd leading cause of death 2. Effective: Care should be science based and evidence based 3. Efficient: Care and service should be cost effective
28 IOM s Six Aims for Improvement (cont.) 4. Timely: No waits or delays should occur in receiving care 5. Patient centered: System of care revolves around patient- appropriate 6. Equitable: Disparities in care should be eradicated- Geographic
29 What is QI? The combined and unceasing efforts of everyone- health care professionals, patients and their families, researchers, payers, planners, educators to make changes that will lead to better patient outcomes, better system performance and better professional development. Batalden & Davidoff 2007
30 History 1. Origins in manufacturing 1980 s Deeming, Shewhart, Donabedian HMO Group conference on Total Quality Management 3. Emphasis on links between improvement, change & learning 4. 1st projects: breast cancer & asthma Mammography Quality Standard, 1992 Breast Cancer Surveillance Consortium Luce, J., Bindman, A., Lee, P. (1994). Brief history of quality improvement in the US.
31 What is QI Systematic - data guided activity Dynamic intervention Designed to bring immediate improvement to a local context
32 The Model for Improvement Identifying an area for improvement Proposing specific changes Testing the changes Evaluating the success of the changes Multiple pilot studies Other models: Six Sigma Lean Juran Nolan and Nolan, 2000
33 QI Dimensions Philosophy- Culture- Learning Organization Practical problem solving (tool)- An evidenced based management style (local level) An application of a theory-driven science of system change (science- Implementation science) Lynn, J, et al. (2007). The Ethics of Using Quality Improvement Methods In Health Care. Annals of Internal Medicine, 146,
34 QI Dimensions Philosophy- Culture- Learning Organization Practical problem solving (tool)- An evidenced based management style (local level) An application of a theory-driven science of system change (science) Lynn, J, et al. (2007). The Ethics of Using Quality Improvement Methods In Health Care. Annals of Internal Medicine, 146,
35 QI Philosophy Personal level Organizational level Culture Learning Organization
36 QI Dimensions Philosophy- Culture- Learning Organization Practical problem solving (tool)- An evidenced based management style (local level) An application of a theory-driven science of system change (science) Lynn, J, et al. (2007). The Ethics of Using Quality Improvement Methods In Health Care. Annals of Internal Medicine, 146,
37 QI: Theory of Profound Knowledge 1) Knowledge of a system 2) Knowledge of variation 3) Knowledge of psychology Change management 4) Theory of knowledge ---PDSA Batalden & Stoltz, 1993 & Batalden & Davidoff, 2003
38 Knowledge of a system
39 Knowledge of Variation Knowledge of Variation
40 Psychology of Change Change Innovation Education Reminder- Cue to action Champion model Audit and feedback Collaborative
41 Theory of Knowledge
42 Using Sequential PDSA Cycles to Build Knowledge
43
44 Product: Story Board
45 Publication Squire Guidelines
46
47 QI Dimensions Philosophy- Culture- Learning Organization Practical problem solving (tool)- An evidenced based management style (local level) An application of a theory-driven science of system change (science) Lynn, J, et al. (2007). The Ethics of Using Quality Improvement Methods In Health Care. Annals of Internal Medicine, 146,
48 2010 Improvement Science A field of research focused on healthcare improvement. The primary goal of this scientific field is to determine which improvement strategies work as we strive to assure effective and safe patient care.
49 Improvement Knowledge Batalden & Stoltz, 1993 & Batalden & Davidoff, ) Knowledge of a system 2) Knowledge of variation 3) Knowledge of psychology Change management 4) Theory of knowledge PDSA
50 Knowledge of a System Theoretical Domains Framework Cane, O Connor, & Michie (2012) SCIENCE
51 Systems Thinking Scale inking Scale SCIENCE
52 Knowledge of Variation SCIENCE
53 Knowledge of Psychology/Change Management Implementation Interventions Education Reminder- Cue to action Champion model Audit and feedback Collaborative SCIENCE
54 Effectiveness of Knowledge of Psychology/Change management Interventions (Bero et al., 1998, Grimshaw et al., 2001) Little or no effect Educational materials Didactic educational meetings
55 Sometimes Effective Audit and feedback Local opinion leaders Local consensus processes Patient mediated interventions
56 Generally Effective Educational outreach visits Reminders Interactive educational meetings Multifaceted interventions including two or more of: Audit and feedback Reminders Local consensus processes Social marketing
57 Theory of Knowledge SCIENCE
58 Other Uses in Science Qualitative QI RCT
59
60
61 CEP, Ottawa Health Research Institute / University of Ottawa
62
63 Topic for Discussion
64 organizations IHI.org
65 organizations
66 Summary What is Quality What is QI Philosophy, Local application, Science
67 Questions
68 The End
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