Development of a Conceptual Model for Surgical Quality Improvement Collaboratives

Development of a Conceptual Model for Surgical Quality Improvement Collaboratives Michael W. Wandling, MD; Christina A. Minami, MD; Julie K. Johnson, MSPH PhD; Kevin O Leary, MD MS; Cynthia Barnard, MBA MSJS CPHQ; Allison R. Dahlke, MPH; Paula R. Farrell, RN BSN; Anthony D. Yang, MD FACS; Amy Halverson, MD; Steve Reinhart; Jane L. Holl, MD MPH; Karl Y. Bilimoria, MD MS FACS

Disclosures None

Key Features of QI Collaboratives Bring together QI teams from multiple sites Focus on common QI problem(s) Facilitate interaction and sharing of lessons and experiences Provide participants with periodic expert instruction in performance improvement

History of QI Collaboratives Mid-1980s: first QI collaboratives in health care Northern New England Cardiovascular Disease Group US Veterans Affairs National Surgical Quality Improvement Program Vermont Oxford Network 1990s: IHI developed the Breakthrough Series Designed to help organizations improve quality through collaboration and expert guidance Numerous quality collaborativeshave developed since this time, particularly in surgery. Surgical Care and Outcomes Assessment Program (SCOAP) Tennessee Surgical Quality Collaborative (TSQC) Michigan Surgical Quality Collaborative (MSQC)

Are QI CollaborativesSuccessful? Shown to improve quality and decrease cost Mechanisms of success remain unclear Sustainability is often an issue

Current Problems The systematic evaluation of QI collaboratives has been limited Little data exists regarding the optimal design of effective QI collaboratives

Conceptual Models A conceptual framework that provides visual representation of the overarching structure of the components and relationships of a system/process. Actual or theoretical relationships/interactions Provide structure and organization to complex systems/processes Particularly important for communication and systematic evaluation (ie impact of QI intervention)

Objective To design a conceptual model for surgical QI that: 1) Facilitates the development/implementation of surgical QI collaboratives 2) Guides the evaluation of their ability to improve quality 3) Maximizes their impact by promoting iterative improvement

Creating a Conceptual Model In 2014, we convened a multi-disciplinary, multiinstitutional team of 12 health services researchers Reviewed literature Expanded and adapted key components of existing models for QI iethe Model for Understanding Success in Quality (MUSIQ), a model of institutional healthcare QI Formed preliminary conceptual model Iteratively revised until consensus regarding final model was achieved

Conceptual Model

How do we improve quality? DMAIC Define Measure Analyze Improve Control PDSA Plan Do Study Act FADE Focus Analyze Develop Execute/Evaluate

Key Structural Domains of QI

Hospital Sub-Domains Hospital Leadership Support Hospital Board Hospital Administrators QI Support and Capacity Infrastructure/Resources Financial QI Characteristics MD Compensation Model Organization QI Maturity QI Culture

Surgical QI Team Sub-Domains Surgical QI Team Team Dynamic Decision-Making Process Norms/Power Structure Skill Sets Team Attributes Leadership Skills Team Experience Team Composition Key Stakeholders Diversity

Peri-Operative Microsystem Sub-Domains Peri-Operative Microsystem QI Environment Staff Capability Staff Motivation QI Culture Pre-Op, Intra-Op, Post-Op Workforce Engagement Staff Leaders Nursing Managers Ancillary Staff Managers Physicians

Framework for Surgical QI Hospital Surgical QI Team Peri-Operative Microsystems Hospital QI Leadership Board of Directors Chief of Surgery Surgeon Champion QI Support & Capacity Data Infrastructure Resource Availability Workforce QI Focus Surgical QI Team Dynamic Decision-Making Process Team Norms Team QI Skill Microsystem QI Environment Motivation to Change Capability to Change SYSTEM & PROCESS CHANGES OUTCOME IMPROVEMENTS Hospital QI Characteristics Surgical QI Team Attributes Surgical QI Team Composition Microsystem QI Culture QI Maturity Physician Compensation Model MD Involvement QI Experience Past Collaboration Team Leadership Team Diversity Surgical Culture QI Culture Employee Engagement Hospital QI Culture Microsystem Leadership Surgical Culture QI Culture Microsystem Staff Leaders

Quality Collaborative Support Collaborative Support Hospital Surgical QI Team Peri-Operative Microsystems Hospital QI Leadership Board of Directors Chief of Surgery Surgeon Champion QI Support & Capacity Data Infrastructure Resource Availability Workforce QI Focus Surgical QI Team Dynamic Decision-Making Process Team Norms Team QI Skill Microsystem QI Environment Motivation to Change Capability to Change SYSTEM & PROCESS CHANGES OUTCOME IMPROVEMENTS Hospital QI Characteristics Surgical QI Team Attributes Surgical QI Team Composition Microsystem QI Culture QI Maturity Physician Compensation Model MD Involvement QI Experience Past Collaboration Team Leadership Team Diversity Surgical Culture QI Culture Employee Engagement Hospital QI Culture Microsystem Leadership Surgical Culture QI Culture Microsystem Staff Leaders Surgical QI Framework

Illinois State Quality Improvement Collaborative (ISQIC)

ISQIC: Hospital-Level Support Leadership Support Board Engagement Program, Administrator Toolkit, Coordinating Center Infrastructural Support NSQIP Participation, Performance Reports Financial Support Pilot Grants, Stipend/Performance Bonus Institutional QI Support Hospital Collaboration, Hospital- Specific QI Projects

ISQIC: Surgical QI Team Support Team Leadership Surgeon Mentor, Project Management Training Team Skills QI/PI Curriculum, QI Toolkit Team Experience Surgical QI Case Studies, Statewide QI Projects, Hospital-Specific QI Projects Team Composition Surgeon Champion, SCR, PI Coach Team Dynamic Surgeon Champion SCR Meetings Miscellaneous Team Support Hospital Collaboration (webinars, conferences), Coordinating Center

ISQIC: Peri-Operative Microsystem Support QI Environment Site Visits QI Culture Site Visits, Best Practice Guidelines Microsystem Leadership Surgeon-Level Risk-Adjusted Comparative Data, Site Visit and Audit, Performance Feedback

Benefits of Conceptual Model Facilitated the development of ISQIC Provides platform for generating and testing hypotheses Provides structure for implementing and evaluating QI interventions Serves as overarching framework for ISQIC and promotes iterative improvements of collaborative

Conclusion This conceptual model for surgical quality improvement may be a useful tool for other new or established surgical QI collaboratives.

Acknowledgments Christina Minami, MD Karl Bilimoria, MD MS Julie Johnson, MSPH PhD Jane Holl, MD MPH ISQIC Team ISQIC Hospitals Blue Cross Blue Shield of Illinois

Thank You

Quality Collaborative Support Collaborative Support Hospital Surgical QI Team Peri-Operative Microsystems Hospital QI Leadership Board of Directors Chief of Surgery Surgeon Champion QI Support & Capacity Data Infrastructure Resource Availability Workforce QI Focus Surgical QI Team Dynamic Decision-Making Process Team Norms Team QI Skill Microsystem QI Environment Motivation to Change Capability to Change SYSTEM & PROCESS CHANGES OUTCOME IMPROVEMENTS Hospital QI Characteristics Surgical QI Team Attributes Surgical QI Team Composition Microsystem QI Culture QI Maturity Physician Compensation Model MD Involvement QI Experience Past Collaboration Team Leadership Team Diversity Surgical Culture QI Culture Employee Engagement Hospital QI Culture Microsystem Leadership Surgical Culture QI Culture Microsystem Staff Leaders Surgical QI Framework

Future Directions Validate the relationships between the components of the conceptual model. Identify collaborative interventions that improve clinical outcomes. Develop additional interventions for each domain and evaluate their efficacy.

Limitations Not all relationships between components of the model have been validated Based on previous publications and expert opinion Factors not related to QI interventions may influence clinical outcomes External forces (ie policy)