Improvement Science – Future Directions

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 don’t have a consumer who understands everything and makes rational choices – and I include myself here.” AvedisDonabedian Health Affairs – Volume 20, Number 1 (January/February 2001)

3. Health System Transformation: Current and Future

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 we’ve failed to view delivery of health care as a science. … That’s 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 don’t 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? CHANGE AHEAD

8. Do Something “Do something. If it works, do more of it. If it doesn’t, do something else.” Franklin Delano Roosevelt

9. Quality Improvement Works:HeQureQu’s 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 Veteran’s 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. VA’s 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 DesignImplementing 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 DesignBlended 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 DesignIntervention 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 (RRP’s) • 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 Center’s 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 Direction Innovative Partnered • 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 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, don’t want to be constrained by journal timelines) • Incorporating quality improvement, innovation, communication, etc. • Training Programs Health Services Research ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ?

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 We’re 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