Establishing a Research-Operations-Clinical Collaborative

1. Establishing a Research-Operations-Clinical Collaborative Polytrauma Rehabilitation Centers’ Family Care Collaborative: a Case Study National QUERI Meeting December 11, 2008 Phoenix, AZ Presenters: Carmen Hall, RN, PhD, Implementation Research Coordinator, PT/BRI QUERI Barbara Sigford, MD, PhD, VHA PM&R National Director Sharon Benedict, PhD, Rehabilitation Psychologist, RICVAMC

2. Objectives • Describe the: • general context in which a research-operations-clinical collaborative might be useful. • roles and responsibilities of the research, operations and clinical members. • Explore challenges presented: • by clinical service and context; • to traditional research approaches. • Describe how implementation can be supported with a research-operations-clinical collaborative.

3. Background • 2005---Polytrauma Rehabilitation Centers • 2006 • OIG report • Experiences of staff and families • QI information • Research

4. Phase 1: Project Start Family Care Advisory Group • 1 - 2 representative / PRC • PM&R leadership • QUERI Reviewed and discussed • Research findings • Good experiences/ staff and family • Literature • Interviews with experts

5. Roles • Operations • Leadership • Legitimacy • Resources • Clinical • Rehabilitation expertise • Knowledge of patient care unit and experiences • QUERI • Facilitation • Resources

6. Phase 2: Problem Exploration… • Aims and objectives identified • Decrease variation in practice • Decrease staff stress • Increase family satisfaction with information • Increase staff satisfaction with resources and materials • Increase staff efficacy working with families of polytrauma patients

7. … Problem Exploration • Review data and information to date • Review CARF rehabilitation guidelines • Consult with external experts • Possible solutions identified • Stakeholder critique, feedback & input April 2007-- Web-based intervention selected May -- Meeting with expert panel May – July ---local teams developing ideas for solution

8. Phase 3: Development of Intervention • Web-based Family Care Map • Structure • Content • Web-page • Stakeholder feedback • Plan for evaluation • Adaptation • Improvement

9. Family Care Map Home Page

10. Web Shot of FCM • Steps1-6

19. Context • Stress • Constant change • Highly scrutinized • Able, committed team • Support from all levels • Interest and expectations across the organization • Stressed families • Not many families

20. Phase 4: Solution Implementation and Testing • Develop implementation plan • National Pilot • Continuous evaluation • Local adaptation of plan

21. Phase 6: Sustained Implementation • National Roll Out • Central Office • Program Management • Ongoing evaluation • Practice and Policy

22. Phase 5: Evaluation • Successes • Modify & adapt for unit clinical populations • Expand access across system of care • Expand & adapt application for other populations

23. Strengths • Synergy • Engagement and involvement • Multiple levels of leadership involved & aware • Consistency in project leadership / culture • Empower local change leader • Principles of a learning organization---diversity • Standardize yet accommodate local functional variation • Share resources --- Funding, staff, systems and materials

24. Challenges… • Time to do the work • PRC team changes • External pressure • Defining role of QUERI as change facilitator • Conflict with non-VA facilitators • Achieving consensus • Varied experience with QI methods and workshop format

25. … Challenges ---continued • Team very “patient-centered” • Teams from different sites had limited experience working together • Limited support staff available to clinicians • Small number of family “consumers” = small n and large burden • Multiple IRBs • Consent families • HIPAA

26. Key Success Factors… • High priority problem • Trust • Clear, timely communication • Follow through • Clear expectations • Co-commitment • Mutual respect

27. …Key Success Factors • Shared / mutual learning • Change leaders leadership training • Joint problem solving and intervention design • Flexibility- adaptability • Sufficient resources--- Funding, staff, time, systems • Guided by a model for organizational change

28. Four Phases of Organizational Change 1. Project Start Successful Limited Change 4. Solution Implementation & Testing 2. Problem Exploration SolutionPlan Modify / adapt ? 3. Solution Development

29. Family Care Collaborative Process Phase 1 Phase 2 • Family Care Advisory Group Formed • Supplementary data and info • Good & bad experiences • Literature search • PI / QI / CQI info Aims and goals Review data to date Consult with external experts Possible solutions Research findings CARF Guidelines Problems identified Supplementary analyses Phase 3 Solution identified Solution development & Iterative Stakeholder feedback Adaptation & improvement Develop implementation plan Phase 6: NationalRoll Out Phase 4 Phase 5 Pilot evaluation • National Pilot • Continuous evaluation • Local adaptation of plan as needed • Modify & adapt • for unit clinical populations • expand access across system of care • & to other populations

30. Phases of Family Care Change Initiative 1. Project Start Successful Limited Change Supplementary analyses 4. Solution Implementation & Testing 2. Problem Exploration National Roll-out SolutionPlan Modify / adapt ? 3. Solution Development Adapting or improving proposal Supplementary analyses

31. Summary • Identified urgent need based on convergence of evidence about status quo • Undeveloped evidence base… • Creating foundation for practice-based evidence • Polytrauma rehab experts within our system • Experts on FCC outside VA • Accelerated working together in a young system • Partnership

32. Acknowledgements • Members of VA Polytrauma Rehabilitation Centers’ Family Care Map Collaborative • Family members who shared their time to offer their input while participating in the rehabilitation of a loved one in one of the Polytrauma Rehabilitation Center • Maureen Reilly and the Family-Centered Care Map teams of the Vermont Oxford Network project • Phil Kibort, MD, CMO & Julie Morath, RN, MS, COO (Children's Hospitals and Clinics of Minnesota) • Steve Bergeson, MD, Allina Hospitals and Clinics • Carol Levine, United Hospital Fund of NY • Sue Aumer, PhD, CCDOR---FCM web-developer

33. References • Institute for Healthcare Improvement. The Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvement.2003. Institute for Healthcare Improvement. Boston, MA. • Implementation Framework: Organizational Change Manager (OCM) (Gustafson & Steudel, 1998-2008) • Ovretveit J, Bate P, Cleary P, Cretin S, Gustafson D et al. Quality collaboratives: lessons from research. Qual Saf Health care. 2002; 11;345-351. www.hsrd.minneapolis.med.va.gov/FCM