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Improvement Science

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Carolyn M. Clancy, MD Assistant Deputy Undersecretary for Health, Quality, Safety and Value Veterans Administration December 9, 2013 A Decent Meal, Or a New Model of ... – PowerPoint PPT presentation

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Title: Improvement Science


1
Improvement Science Future Directions
  • Carolyn M. Clancy, MD
  • Assistant Deputy Undersecretary for Health,
    Quality, Safety and Value
  • Veterans Administration
  • December 9, 2013

2
Health Care as an Enterprise
  • Health care is a moral enterprise and a
    scientific enterprise, but not fundamentally a
    commercial one. We are not selling a product. We
    dont have a consumer who understands everything
    and makes rational choices and I include myself
    here.

Avedis Donabedian
Health Affairs Volume 20, Number 1
(January/February 2001)
3
Health System Transformation Current and Future
Current Future
Variable quality expensive, wasteful Consistently better quality lower cost, more efficient
Pay for volume Pay for quality
Pay for transactions Care-based episodes
Quality assessment based on provider and setting (process) Quality assessment based on patient experience (outcomes)
4
21st Century Health Care
  • Patients play a larger role, including
    involvement in making decisions about the future
    of health care
  • Innovative, adaptable and very scalable systems
    have the potential to become national solutions
  • Health IT makes it possible for doctors to know
    how patients are doing over time and for
    patients to engage in new ways and at their
    convenience!

5
Diagnosing the Problem is One Big Step . . .
  • The fundamental problem with the quality of
    American medicine is that weve failed to view
    delivery of health care as a science. Thats a
    mistake, a huge mistake.
  • Peter Pronovost, M.D., PhD, Johns Hopkins
    Hospital

6
Maintaining the Status Quo is Not an Option
  • Evidence is being produced at an extremely rapid
    rate, but its incorporation into clinical
    practice is happening much more slowly
  • Transparency efforts dont offer enough usable
    data for decisions regarding a specific disease
    and selection of a treatment option
  • We face an underperforming health care system and
    untenable cost forecasts
  • Too often, the patient is an afterthought

7
Understanding a Changing Landscape
  • Health care reform, including payment, reform has
    already begun
  • How is evidence integrated into the new
    environment?
  • How has the nature of evidence changed?
  • How do these changes affect providers, payers and
    patients?
  • How do we ensure that these changes are
    beneficial?

8
Do Something
  • Do something. If it works, do more of it. If it
    doesnt, do something else.
  • Franklin Delano Roosevelt

9
Quality Improvement Works HeQureQus Proof
  • Large ambulatory care collaborative
  • Focus on practice coaching
  • Results for diabetes
  • Getting recommended tests improved 9 percentage
    points
  • Outcomes (diabetes in control) improved 5 points
  • Hospitalization rates fell 8.4 for target
    hospitals
  • Results for hypertension
  • Outcomes improved 2 points
  • Hospitalization rates fell 10.4 for target
    hospitals

10
'The Checklist Manifesto' by Atul Gawande
11
Quality Is Improving Slowly
  • Nearly 60 percent of health care quality measures
    tracked showed improvement
  • However, the median rate of change was 2.5
    percent per year

AHRQ 2011 National Healthcare Quality and
Disparities Reports
12
Few Disparities in Quality of Care Are Getting
Smaller
  • Few disparities in quality showed significant
    improvement.
  • The number of disparities that were getting
    smaller exceeded the number that were getting
    larger

AHRQ 2011 National Healthcare Quality and
Disparities Reports
13
Article A Young Veterans First Encounter with
VA Health Care By Tom Aiello
Out of Sight. Out of Mind.
If You're Going to Go To Hell, You Still Need To
Go Through Your Primary Care Physician
In Case of Emergency
God Helps Those Who Help Themselves
Golden Rule Prepare to Wait
Link to Article http//www.huffingtonpost.com/tom
-aiello/veteran-healthcare_b_4070634.html
14
Closing the Quality Gap Revisiting the State of
the Science
  • Series of reports summarizing the evidence on
    quality improvement strategies for chronic
    conditions and other priorities
  • Bundled Payment
  • Health Disparities
  • Patient-Centered Medical Home
  • Public Reporting
  • Medication Adherence

http//www.ahrq.gov/clinic/tp/gapbundtp.htm
15
How Do We Do All of This?
  • Information
  • Incentives
  • Infrastructure

16
Closing the Gap System Interventions
  • Disability Clear information gaps
  • Disparities, HAI and Adherence how organizations
    can implement changes, which are effective
  • Palliative Care
  • PCMH changes in infrastructure

17
Improving Quality Consumer / Patient / Caregiver
Perspective
  • PCMH small effects on patient experience
  • Disparities research gaps
  • Adherence decreased out of pocket costs
  • HAI little evidence re pt role
  • Palliative Care little known

18
Improving Quality Clinician / Provider
Perspective
  • PCMH Small effects on staff experience NO
    information on unanticipated consequences (common
    theme)
  • Disparities research gaps
  • Public Reporting
  • Modest evidence that providers increase QI
    efforts
  • Adherence varies by condition
  • Disability NO clear consensus across disciplines
    re. definition of success
  • HAI effective interventions many stuck at
    scale up and spread
  • Palliative Care NOT effective re coordination,
    continuity, transitions

19
What We Need Now
  • Rapid cycle mechanisms for evaluation and
    learning and support for learning communities
  • New partnerships between researchers and decision
    makers
  • Proximal metrics of success
  • Scalable technical assistance and connectivity
    across multiple initiatives (public and private)
  • Practical strategy for patient engagement

20
VAs QERI Types of Implementation Studies
  • Understand behaviors across multiple groups
    (providers, organizations, consumers) influencing
    implementation
  • Focus on the how and why effective treatments
    are used, based on guiding framework
  • Testing implementation strategies, e.g.,
    systematic processes, resources and activities
    used to integration into usual settings (Hybrid
    Designs)

21
Hybrid Effectiveness / Implementation Designs in
QERI
  • Address limits of step-wise research (efficacy ?
    effectiveness ? translation)
  • Promote external validity
  • Blend effectiveness, implementation studies,
    i.e., for rapid partner-driven research (Curran
    et al, Medical Care, 2012)

22
Hybrid Effectiveness / Implementation Designs in
QERI
  • Type 1 test clinical intervention (patient
    health outcomes)
  • Type 2 test both clinical and implementation
    strategies (Providers, clinics process measures)
  • Type 3 test implementation strategy (providers,
    clinics uptake)

23
Hybrid Effectiveness/ Implementation Designs
24
QUERI Hybrid Type II Design Implementing
Effective, Collaborative Care for Schizophrenia
(EQUIP MNT 03-213)
  • Weight and employment intervention sessions for
    patients
  • System-level implementation intervention of care
    model and implementation strategy (EBQI)
  • Group sessions delivered by existing providers
  • Primary outcomes patient-level weight and
    employment

25
QUERI Hybrid Type III Design Blended Facilitation
to Enhance PCMH Program Implementation (SDP
08-316)
  • Primary Care-Mental Health Integration (PC-MHI)
    model
  • Regional implementation of VA mandate to provide
    integrated mental health in primary care settings
  • Existing providers
  • Co-located care model care management and
    outcomes
  • External and Internal Facilitators worked with
    providers to promote uptake of integrated care
    components

26
QUERI Hybrid Type III Design Intervention for
Stroke Improvement using Redesign Engineering
(SDP 09-158, INSPIRE)
  • QUERI Facilitators
  • Established relationships with site stroke teams
    anticipating a long term relationship
  • Provided referrals to other VA sites and stroke
    personnel
  • Coaching changed over time from helping teams
    identify what needed to be done, to overcoming
    barriers, to providing encouragement of their QI
    efforts
  • VERC Systems Engineers
  • Taught teams how to use System Redesign tools
  • Assisted teams with applying those tools (PDSA
    cycles, spreadsheets) to their QI efforts in
    follow up calls/visits
  • Provided encouragement
  • Preferred to see site data as an indicator of
    their QI activity

27
QERI Types of Studies
  • Partnered rapid response projects (RRPs)
  • QERI Service-directed projects (SDPs)
  • Partnered evaluation centers

28
Rapid Response Projects (RRPs)
  • QUERI's principal mechanism to study process of
    implementing new treatments in VA
  • Center-focused RRPs endorsement from QUERI
    Center and falls within Centers content
    area/priority goal
  • Partnered RRPs Central Office or VISN-level
    health system partner endorsement
  • One-year, 100,000 maximum
  • Feasibility/refinement of implementation strategy
  • Assessment of barriers/facilitators to
    implementation
  • Follow-ups to larger implementation efforts-
    further spread
  • Observational studies of partner-initiated
    program rollouts

29
Continuum of Partnered Research Partner Engaged
vs. Partner Directed
Funding Locus HSRD
  • Investigator-initiated projects
  • Service-directed research
  • CREATEs
  • QUERI projects SDPs, RRPs
  • QUERI Evaluation Centers
  • Operations Funded work
  • e.g. PACT Demo Labs
  • e.g., MHO evaluation centers

Direction Innovative Partnered
Clinical Partners
30
A Key to Culture Change A Learning Health
System (LHS)
  • one in which progress in science,
    informatics, and care culture align to generate
    new knowledge as an ongoing, natural by-product
    of the care experience, and seamlessly refine and
    deliver best practices for continuous improvement
    in health and health care.

Institute of Medicine
31
Keystone Maintaining Improvement Practices
  • Example of building improvement into the research
  • Partnership with grants from AHRQ and various
    commitments from Blue Cross Blue Shield of
    Michigan, the Michigan Hospital Association,
    Johns Hopkins University and others
  • Stakeholders, end users and others are able to
    use the data to monitor progress
  • Innovative methods of dissemination and
    communication
  • An ongoing effort to learn and improve

32
What Needs to Change?
  • Academic Incentives
  • The way and with whom we do our work and report
    results (e.g., partners may get most value from
    initial aspects of study, dont want to be
    constrained by journal timelines)
  • Incorporating quality improvement, innovation,
    communication, etc.
  • Training Programs

33
What IS the New Model?
  • That remains to be determined, although overall
    things to consider include
  • Stakeholders are engaged more and more when the
    strategic decisions are being made
  • Making evidence available earlier and during
    different intervals of a project
  • Thinking of publication as one step in the
    continuing process to get results into the hands
    of those who need it rather than the end of the
    research cycle
  • Testing multiple conclusions in the field rather
    than waiting until there is a right answer

34
A Decent Meal, Or a New Model of Care?
  • The challenge
  • Serving millions of people
  • Delivering a range of services
  • Keeping costs reasonable
  • Attaining a consistently high level of quality
  • Can care be mechanized? Should it be?
  • Are there models we can use?
  • Gawande A. Big Med Restaurant chains have
    managed to combine quality control, cost control,
    and innovation. Can health care? New Yorker.
    August 13, 2012

35
Where to From Here?
  • Do more to ensure that new treatments and
    research knowledge reach patients and are
    implemented correctly
  • Improve quality by improving access
  • Expand the boundaries of basic science to include
    other basic sciences (e.g., epidemiology,
    psychology, communication, social marketing and
    economics)
  • More focus on research and delivery of existing
    treatments

Woolf, S. The Meaning of Translational Research
and Why It Matters, JAMA January 2009
36
How Will We Know Were On Track?
  • The quality enterprise adds value to clinical
    practice
  • Care includes focus on missed opportunities and
    dropped balls transitions handoffs
    anticipating errors
  • Physicians say, we rather than I
  • Patient activation and engagement is welcomed and
    encouraged
  • Best doctors are evaluated in terms of care for
    individual patients and leadership in health of
    population

37
What I Have Heard Here Today
38
Traveling Fast or Traveling to Get Somewhere?
  • If you want to travel fast, you travel alone. If
    you want to go far, travel with others.

African Proverb
39
Your Thoughts, Comments, Questions
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