Diffusion of Excellence Initiative Overview

Better Health PartnershipFall Learning Collaborative Summit

September 30, 2016

Shereef Elnahal, MD, MBA

Office of the Under Secretary for Health

Veterans Health Administration

Shereef.Elnahal@va.gov

Conflicts of Interest

• None

Table of Contents

• Diffusion of Excellence Overview

• Process: How we Identify and Spread Best Practices

• Leveraging the Model to Provide Top-Notch Cancer Care to Veterans

• Discussion

3

Diffusion of Excellence Overview

4

Background

The Veterans Health Administration (VHA) is the largest

integrated health care delivery system in the United States,

with over:

• 1,700 sites of care

• 300,000 employees

• 8.76 million Veterans served each year

5

While VHA is a leader in the delivery of high quality health care, it has lacked

consistency in the application of best practices

We sought to develop a method to effectively identify, diffuse, and sustain

best practices in this heterogeneous system

Objective

6

Identify

and scale

innovations

across VHA,

while:

Empowering employees

to promote innovation sharing and drive a supportive culture of continuous improvement

Institutionalizing processes and mechanisms

for systematically diffusing and implementing promising practices throughout the system

Minimizing negative variation, and standardizing

practices by diffusing innovative and industry recognized best practices across the system

Everett Rogers: Rural Sociology

7

1. Innovation

2. Adopters

3. Communication Channels

4. Time

5. Social Systems

Model for Disseminating Best Practices

Find the ChampionsLocal champions, or ‘early

adopters,’ served as sharks in a

‘shark tank’ style event. Those

selected as implementers

identified local champions to lead.

Replicate

Establish Consistency

& StandardizeLeverage national program office

leader support to select those ready

for national rollout and support

standard development and scaling.

Sustain and improveEstablish a robust operations

center for managing and tracking

outcomes, in parallel with

implementation.

Identify Promising PracticesSolicited practices nationally and engaged

staff at all levels, including projects from the

VA Innovators Network and Communities of

Practice, to evaluate them using a rigorous

set of criteria.

Adapt and ReplicateLeverage Diffusion Council governance structure to

engage field staff and leaders during initial replication

to support issue resolution; Use advanced technology

tools and project management resources to track and

monitor progress.

Process

Governance

Technology

8

Enabling success by leveraging three organizing

principles

9

Process

• Consistent framework

for evaluation, adaptation, and reapplication of practices

Governance

• Vertical accountability

to agency priorities

• Engagement of senior leadership and staff

Technology

• Rapid and transparent flow of information

across regions and boundaries

Replication & Diffusion

Multi-level governance structure provides leadership support,

drives accountability and enables diffusion to occur at multiple levels

Identification

• Diffusion Council oversees semi-annual national Shark Tank

• Regional leaders (medical center directors) invest in those they want to implement

• Communities of practices elicit best practices

• Regional leaders host their own events to identify practices for local dissemination, and national consideration

• Mentorship from prior year cohort of best practice fellows

• Governance Board of senior executives provide resourcing and immediate issue resolution as needed

• Project management support provided to facility innovators and implementers

10

Diffusion of Excellence Org Structure

• Responsible for allocating resources

11

Continuous operational support

Each team is responsible for implementing 2-4 Promising

Practices

Responsible for achieving objectives

Responsible for allocating resources

Governance Board

10 Members, w/ USH as Chair

Diffusion Council

Co Chairs: Shereef Elnahal, Patrick Littlefield

Access

Action Team

-Team Lead

-Gold Status Fellows

-Implementing Facility Fellows +

Stakeholders

Employee

Engagement

Action Team

-Team Lead

-Gold Status Fellows

-Implementing Facility Fellows +

Stakeholders

Care Coordination

Action Team

-Team Lead

-Gold Status Fellows

-Implementing Facility Fellows +

Stakeholders

Quality & Safety

Action Team

-Team Lead

-Gold Status Fellows

-Implementing Facility Fellows +

Stakeholders

Executive Sponsor: David Shulkin, Under Secretary for Health

Driver: Shereef Elnahal

Support: Veterans Engineering Resource Center (VERC), VA Center for Innovation (VACI)

Contractor Support: ERPi/Atlas Research

Diffusion Framework: How we

Identify and Spread Best Practices

12

Driving success through process

Facilitated adaptation and implementation

Use of human centered design and LEAN frameworks

Peer-to-peer learning between designers and adapters

Project management and technical support

Processes in place to provide resourcing when needed

13

Process

Accelerating and sustaining adoption and uptake

with technology tools

Pulse platform promotes conversation and sharing

about promising practices

Virtual VA “Shark Tank” style event enabled virtual

engagement in unique opportunity to ‘pitch’ promising practices

Diffusion Hub provides robust project

management and tracking tools to manage replication and implementation of best practices, all based on LEAN principles and frameworks

14

Integrated Operations Platform:

VA Diffusion of Excellence Hub

The VA Diffusion of

Excellence Hub is

utilized by two

initiatives to identify

and diffuse best

practices across the

enterprise

The VA Diffusion of

Excellence Hub is

utilized by two

initiatives to identify

and diffuse best

practices across the

enterprise

Diffusion across the

enterprise is

measured through

the Diffusion Meter

Diffusion across the

enterprise is

measured through

the Diffusion Meter

15

Using these processes, VHA is implementing 300

ongoing replications at over 70 facilities.

As of August 29, 201616

Questions/Comments

17

Appendix

18

Leveraging the Model to Scale Best

Practices in Multidisciplinary Cancer Care

19

Meeting Veterans Where They Are

• There are 5.3 million rural and highly rural Veterans in the U.S., with three

million enrolled in the VA health care system

– 57 percent of rural Veterans are enrolled in the VA health care system -

significantly higher than the 36 percent enrollment rate of urban Veterans

• Rural Veterans tend to be older, and can be medically more complex:

Specific challenges for rural Veterans include:

– Higher poverty rates

– Greater geographic and distance barriers (to VA and non-VA facilities)

– Limited broadband internet access

• Rural cancer patients can have poor access to comprehensive oncology

resources

20

Given these factors, VA has developed innovative solutions to

provide outstanding cancer care to rural Veterans.

Given these factors, VA has developed innovative solutions to

provide outstanding cancer care to rural Veterans.

Gold Status Practice: Virtual Liver Cancer Tumor Board

Overview

Challenge

Limited availability of specialty multidisciplinary clinical staff in individual VA Medical Centers to address abnormal liver imaging in high-risk individuals

This issue results in unnecessary biopsies, delayed diagnoses of liver cancer and delayed referrals for loco-regional treatments, resection, or transplant

Solution

Virtual Liver Cancer Tumor Boards, supported by telehealth and web-based technology, allow for pooling of staff across facilities to provide more timely care to liver cancer patients

Results

Standardized imaging improved accuracy and quality of images captured

Reduced liver biopsy rate from current rate of 18% to the national standard of less than 10%

Decreased time from liver cancer diagnosis to treatment from current average of 75 days to 30 days or less

Improved communication and coordination of care between Medical Centers

21

Originating Facility

Corporal Michael J. Crescenz VA Medical Center (Philadelphia, PA)

Setting

•Urban/Rural Mix; VISN 4 covers a smaller geographic area

•Hub & Spoke facilities less than 150 miles apart

Model: Hub & Spoke

•Hub: Philadelphia VAMC

•Spokes: Allentown, Lebanon, Pittsburgh, Wilkes-Barre

Supporting Technology

•Computerized Patient Record System (CPRS)

•Microsoft Access

•Microsoft SharePoint

•Polycom Telehealth Bridge

•Regional shuttle between facilities

Implementing Facility

G.V. (Sonny) Montgomery VA Medical Center (Jackson, MS)

Setting

•Urban/Rural Mix; VISN 16 covers a wide geographic area

•Hub & Spoke facilities 250+ miles apart

Model: Hub & Spoke

•Hub: Little Rock VAMC

•Spoke: Jackson VAMC

Supporting Technology

•Computerized Patient Record System (CPRS)

•Microsoft Access

•Microsoft SharePoint

•Polycom Telehealth Bridge

Implementation steps

•Standardized liver imaging protocols

•Developed telehealth service agreement including required personnel, primary and secondary stop codes for interventional radiology

•Completed resource request for Liver Cancer Coordinator

•Researching options for transportation

22

Gold Status Practice: Virtual Liver Cancer Tumor Board

Adaptation and Implementation

National Deployment Plan (1 of 3)

23

Pre-Diffusion

of Excellence

Post-Diffusion

of Excellence

National Deployment Plan (2 of 3)A

sse

ss C

urr

en

t S

tate

Determine how virtual tumor boards are used across the agency

•VHA Cancer Care

Survey open July 29 –

August 25, 2016;

Included 4-part

question on tumor

board use. See survey

questions on slide 22.

SM

E R

ev

iew

Assemble SMEs to review models and methods used for virtual tumor boards and recommend options for broader use

Pla

n D

eve

lop

me

nt

Develop plan based on selected option

De

plo

ym

en

t

National Deployment

24

National Deployment Plan (3 of 3)

25

Virtual Tumor Board

26As of August 29, 2016