Northwestern Health Sciences University (NWHSU)

1. EVIDENCE BASED HEALTH CARE and BEST PRACTICES at Northwestern Health Sciences UniversityGert Bronfort DC, PhD; Michele Maiers, DC, MPH; Roni Evans DC, MS

2. Northwestern Health Sciences University (NWHSU) • Six clinics in Twin Cities area • Conservative health care services, including • chiropractic • acupuncture/ Oriental medicine • massage therapy • healing touch • naturopathy • Teaching clinics for upper term students

3. Best Practices at NWHSU:Precipitating Events • Council on Chiropractic Guidelines and Practice Parameters • MN State Legislative Initiative • NWHSU • Mission • Guiding principles and values • Strategic goals

4. Our Mission To advance and promote natural approaches to health through education, research, clinical services and community involvement Best Practices affect our ability to fulfill our mission • Education: providing students with the tools they need to be effective and competitive providers • Research: accurately documenting clinical practice • Clinical Services: optimizing patient care • Community Involvement: providing consistent message of our standards of care and our effectiveness

5. Several advantages for our providers: • Easier access to research pertinent to their practice • An opportunity to evaluate themselves before others do • The ability to change and improve their systems of care • Provide standardized documentation of effectiveness

6. Several advantages to our stake-holders: • Evaluation system based on accurate analysis of clinical outcomes • Internal assessment • Patients can see progress over time • Provides the ability for standardized documentation of the effectiveness of our providers’ interventions • Standards of care = consistent public message about chiropractic

7. Best Practices Pilot Project Specific Aims: To optimize the quality of diagnosis and therapeutic management of patients through: • application of evidence-based health care • within the context of a quality assurance system …in the NWHSU clinic system

8. Implementation: Effective Transfer Strategies • Educational outreach visits • trained personnel visit providers in their practice settings - information / support   • Interactive educational sessions • health care providers participating in interactive, problem-based learning sessions (adult learning principles) • Decision support and reminder systems • automated or manual prompts to perform clinical tasks • Multifaceted interventions • any combination of audit & feedback, reminders, local consensus processes, or marketing Bero et al (1998); Davis et al (1995); Freemantle et al (1998)

9. Outline of Pilot Project • Assessment of Clinical Environment • Development of Quality Assurance System • Implementation • Evaluation of Pilot Project

10. Assess Clinic Environment • Choose pilot sites and providers • Identify representative clinicians to serve on project team • Survey current practice behaviors • Case vignettes (exam, imaging, treatment) • Record keeping • Use of guidelines, outcome measures

11. Interactive Workshop I • Teach the concepts of Best Practices and Quality Assurance • Outline/ timeline for pilot project • Present and discuss of results of practice behavior survey • Identify facilitating factors for implementation • Identify barriers against implementation

12. Development of QA System • Select clinical indicators • structure, process, outcome (Kristensen 2001) • Select standards for clinical indicators • Research evidence • Consensus by participants • Develop specific elements • Integrate access to information within QA system • Finalize content of QA database • Develop data collection protocols • Develop test electronic patient record system • Develop centrally located database for all clinics

13. Quality Database • Electronic Patient Record • Standardized documentation • Prompts to ensure complete data collection • Link to resources • Centralized database • Collection of quality indicators • Compare actual outcomes to standards • Access for clinicians, researchers, administrators

14. Interactive Workshop II • Select quality indicators and standards • Participant driven (rank consensus) • Minimal set of data to be included in QA database • Introduce EPR • Electronic access to best practices documents • Updated internet web-sites • hyper-links to additional information, reference materials, guidelines • “Bedside” with use of tablet PCs, etc. • Problem solve perceived barriers

15. Implementation • Identify implementation strategies • Minimize staff, provider and patient burden • Maximize efficiency • Train clinicians to use Best Practices and QA system • Case study vignettes • Data collection processes • On-site visits

16. Implementation: How would this look in practice? Initial Presentation • Patient presents to NWHSU Clinic • Completes intake forms • Standardized questions, entered into data collection system for QA purposes • Clinician performs history, exam, treatment • Clinician has access to best practice information • may inform choices of exam procedures, imaging, treatment • Exam, treatment decisionsentered into data collection system for QA purposes

17. Implementation:How would this look in practice? Follow-up visits • Patient returns to clinic for next appointment(s) • Completes follow-up questionnaire, entered into data collection system for QA purposes • Clinician manages case as usual • Subsequent exam, treatment decisionsentered into data collection system for QA purposes • Established benchmarks and Best Practice recommendations help clinician make decisions for subsequent treatment plan, care • Questionnaire mailed to patient • Sent back to clinic, entered into data collection system

18. Evaluation of Pilot Project • Compliance assessment • Best practices utilization • Results of 3 months follow up of care • Assess clinicians’ experiences • Determine overall feasibility • Report to NWHSU Office of Institutional Effectiveness

19. Results: Assessment of Clinical Environment • Who: 12 clinicians • Where: 2 multidisciplinary NWHSU clinics • What: Each clinician follows 5 consecutive LBP patients for 3 months • How: Outcomes tracked in centralized database with quality indicators

20. Results: Develop Quality Assurance Selection of Quality Indicators • Timely collection of quality indicator data • Diagnostic classifications • Patient/ clinic records • Patient education • Patient knowledge • Pain severity • Disability • Global improvement • Patient satisfaction • Quality of life/ general health status

21. Global improvement (DC or ET for LBP) Results: Develop Quality Assurance Selection of Standards

22. Satisfaction (DC and ET for LBP) Results: Develop Quality Assurance Selection of Standards

23. Next Steps • Select measurement tools for quality indicators • Established instruments • Consensus • Agree to standards for quality indicators • Research literature • Consensus standards • Choose and implement EPR

24. Perceived Barriers • Appropriate allocation of resources • Financial • Administrative • Multi-disciplinary setting • Access to literature • EPR and classification system • Burden (staff, providers, patients) • Minimal set of quality indicators • Benefits outweigh burden

25. Educational Impact • Evidence based curriculum translates to clinical experience • Expose students in controlled environment to: • Electronic patient records • Standardized data collection • Pragmatic use of research literature • Develop habits for evidence based practice