Evidence-Based Quality Improvement(EBQI)

Amy N. Cohen, PhDDesert 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

PDSA Cycle for Learning and Improvement

PlanAct

DoStudy

- Objective- Questions and predictions (Why?)- Plan to carry out the cycle(who, what, where, when)

- Carry out the plan- Document problems and unexpected observations- Begin analysis of the data

- Complete the analysis of the data - Compare data to predictions - Summarize what was learned

- What changes are to be made?

- Next cycle?

Repeated Use of the Cycle

Hunches Theories

Ideas

Changes That Result

in Improveme

nt

A P

S D

APS

D

A P

S DD S

P ADATA

QI Data Tools

1. Process Maps2. Cause & Effect diagrams (Fishbone)3. Check sheets (Tabulations)4. Histograms (Distributions)5. Scatter diagrams (Regression)6. Pareto charts7. 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

Cause and Effect Diagram (Fishbone) Brainstorming stage

Cause and Effect Diagram (Fishbone)Organizing data

Policies Place

4 P’s

People Procedure

Check Sheets

Process Redesign (Act)

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

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

EBQI Example in VA:The EQUIP Experience

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

EBQI

Provider/patient education

Quality manager

QI Informatics support

Performance feedback

Leadership support

“infrastructure”“priority-setting”

Evidence base: • TMAP• EQUIP-1

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