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Learn about Evidence-Based Quality Improvement (EBQI) methods to bridge the gap between research and practice in healthcare. Discover strategies, steps, and tools for successful quality improvement initiatives. Explore real-world examples and best practices.
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Evidence-Based Quality Improvement(EBQI) Amy N. Cohen, PhD Desert Pacific Mental Illness Research Education and Clinical Center (MIRECC)
Outline of Talk Description of EBQI Building a local QI team EBQI methods and tools Example: EQUIP study
The Quality Problem • Routine practice fails to make use of research evidence and effective practices • particularly prevalent in mental health and substance abuse • prevailing quality is poor to moderate • Quality improvement seeks to close this gap between research and practice
Total Quality Management (TQM) & Continuous Quality Improvement (CQI) • Structured organizational process for involving personnel in planning and executing a continuous flow of improvements to provide quality health care • Goal is to implement evidence-based practices • However, strategies for changing organization and provider behavior are typically based on intuition and anecdote, NOT evidence Shojania KG, Grimshaw JM: Evidence-based quality improvement: the state of the science. Health Affairs. 2005; 24: 138-50.
Evidence-Based Quality Improvement (EBQI) “Strategies for implementing evidence-based medicine require an evidence base of their own.” (Shojania & Grimshaw 2005) In other words, QI strategies used to support implementation need to be evidence-based.
QI Assumptions • Improvement possible • Process complex • Teamwork essential • Data required • Blame removed
Steps to QI • Clear mission and goals • Establish Team • Problem Identification • Quality Improvement Cycle
Clear Mission and Goals Mission: What evidence-based care practice is to be implemented or improved Goals: short-term and long-term We want to improve X (amount) by X (date)
Team Establishment • Sponsorship • Composition • Facilitation • Meeting time • Duration • Training • Rewards
Team Formation • Small number • Complementary skills • Committed to common purpose • Performance goals • Mutually accountable
Problem Identification • Baseline data • Brainstorm causes • Specify focus • Recognize complex • Secure support and involvement
A P S D D S P A A P S D A P S D Repeated Use of the Cycle Changes That Result in Improvement DATA Hunches Theories Ideas
QI Data Tools • Process Maps • Cause & Effect diagrams (Fishbone) • Check sheets (Tabulations) • Histograms (Distributions) • Scatter diagrams (Regression) • Pareto charts • Control charts Used in PDSA cycles for data collection & analysis
Process Map Most flow charts are made up of five main types of symbols: Walk through the steps and document. Reality versus Ideal
Explore redesign ideas Automate steps Insert technology, if applicable Benchmark Apply new management practices Map new process & information flows Consider organizational context Stakeholder interests Obtain input Process Redesign (Act)
QI Essentials • Good management • Training • Team work • Measurement of performance • Time • Faith
Effective Teams Have • Supportive sponsor • Orientation • Sensible structure • Clear mission and roles • Staff support • Access to information • Shared expectations • Useful tools and techniques
QI Intervention Example EQUIP Enhancing QUality of care In Psychosis • evidence-based quality improvement to implement effective care in specialty mental health • Alex Young, MD & Amy Cohen, PhD (Co-PIs)
EQUIP: Effective Schizophrenia Care • 4 VISNs: intervention and control site in each VISN • Each VISN asked to select 2 evidence-based care targets for collaborative care model intervention • All selected Wellness & Supported Employment • Availability, quality, and utilization of these care targets vary across sites • Evidence-based strategies were used to support implementation
EBQI Strategies in EQUIP • Evidence base: • TMAP • EQUIP-1 Provider/patient education Quality manager EBQI QI Informatics support Performance feedback “infrastructure” “priority-setting” Leadership support
Development of EQUIP QI teams • To foster a quality improvement (QI) environment in the intervention sites, we developed local QI teams • Site leadership identified team facilitators • Local Recovery Coordinators (LRCs) were identified as the most suitable for the role • Trained each at WLA VA over 2 days
Team-building at the sites • In pre-implementation interviews, key stakeholders asked if they would be interested in being part of a QI team • At sites A, B, & C, LRCs invited individuals to initial meetings (non-mandatory attendance) • At site D, LRC was brought into existing clinic team and all members of team constituted her QI team (mandatory attendance) • Teams met weekly or biweekly
Identification of quality problems • Teams engaged in their own version of the Deep Dive • 3 sites generated lists of possible problems to address • 1 site had specific guidance from administrative presence on the team • Teams determined priorities based on group consensus
Quality problems by site • Site A: non-recovery-oriented mental health treatment plans • Site B: lack of transitional housing (too big of a problem for small team), lack of recovery services in community • Site C: high rate of walk-in patients, low attendance at wellness groups • Site D: poor collaboration/coordination between mental health inpatient ward and outpatient clinic
Attempted solutions to quality problems • Site A: worked on replacing existing treatment plan with new recovery-oriented plan; faced extensive resistance • Site B: implemented recovery/wellness groups in homeless shelter that serves mostly vets • Site C: assessed reasons for walk-ins and educated patients about medication refills; created flyers about wellness groups & tracked # attending • Site D: gathered data about communication problems, created welcome packet for new residents on inpatient ward
Support from EQUIP research team • Monthly calls with LRCs • Gaining support from local administration • Helped at each PDSA step, as needed • Reasonable goal • Causes/possible solutions to try • Measurement • Adopt, adapt, abandon
Sustainability • Teams are continuing to work together on quality problems in Sites B, C, and D • One of the most sustainable aspects of EQUIP • Team-building and QI processes were valuable for staff morale • Team and project at Site A have been abandoned due to high resistance and LRC changing position
Conclusions • Providing special training for facilitators promoted investment in the QI endeavor • Support from local administration for QI teams is critical • Having sites see quality gap is motivation for endeavor/ provides value • After some initial resistance, most staff found the QI endeavor to be positive, rewarding, and morale-building
Web Sites Healthcare Change Focus • Cmwf.org • Rwj.org • Chcf.org • Ihi.org • Improvingchronicillnesscare.org • improvehealthcarenow.com • http://www1.va.gov/hsrd/QUERI/ • Healthtransformation.net