OCD & Anxiety Lecture SeriesRegister today on Ethos

All dates: 9:00 am – 12:15 pm

Sessions I & II - Friday, March 26, 2021Session I: Core Concepts in Diagnosing and Treating Obsessive Compulsive Disorder with Cognitive Behavioral Therapy - Jon Hershfield, MFT

Session II: Medication Protocols for Obsessive Compulsive Disorder, New Research, and Differential Diagnosis - Robert Hudak, MD

Sessions III & IV - Friday, April 23, 2021

Session III: Treating Pediatric Obsessive Compulsive - Aureen Pinto Wagner, PhDSession IV: Working With Families and Treatment Refusal - C. Alec Pollard, PhD

Sessions V & VI - Friday, May 21, 2021Session V: Inhibitory Learning Theory in Exposure-based Treatment of Obsessive Compulsive Disorder - Jonathan Abramowitz, PhDSession VI: Disgust and Not Just Right Experiences in Obsessive Compulsive Disorder - Dean McKay, PhD

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Disclosure Statements

Sheppard Pratt holds the standard that its continuing medical education programs should be free of commercial bias and conflict of interest. In accord with Sheppard Pratt's Disclosure Policy, as well as standards of the Accreditation Council for Continuing Medical Education (ACCME) and the American Medical Association (AMA), all planners, reviewers, speakers and persons in control of content have been asked to disclose any relationship he /she (or a partner or spouse) has with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients, during the past 12 months. All planners, reviewers and speakers have also been asked to disclose any payments accepted for this lecture from any entity besides Sheppard Pratt, and if there will be discussion of any products, services or off-label uses of product(s) during this presentation.

Rajeev Krishna, MD, PhD, MBA, reports having no financial interest, arrangement or affiliation with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients, during the past 12 months. He will not discuss any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients in this presentation.

Event Planners/Reviewers Disclosures: The following event planners and/or reviewers are reported as having no financial interest, arrangement or affiliation with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients, during the past 12 months: Todd Peters, MD, Briana Riemer, MD, Ben Borja, MD, Sunil Khushalani, MD, Faith Dickerson, PhD, Carrie Etheridge, LCSW-C, Tom Flis, LCPC, BCBA and Jennifer Tornabene.

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Sheppard Pratt Approval Statements

Physician Statement: Sheppard Pratt is accredited by The Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. Sheppard Pratt takes responsibility for the content, quality, and scientific integrity of this CME activity. Sheppard Pratt designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Nurse Statement: Sheppard Pratt is an approved provider of continuing nursing education by Maryland Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation. Sheppard Pratt takes responsibility for the content, quality, and scientific integrity of this CME activity. This activity is approved for 1.0 contact hours for nurses.

Psychologist Statement: Sheppard Pratt is authorized by the State Board of Examiners of Psychologists as a sponsor of continuing education. Sheppard Pratt takes responsibility for the content, quality, and scientific integrity of this CME activity. Sheppard Pratt designates this educational activity for a maximum of 1.0 contact hours for Psychologists.

Social Worker Statement: Sheppard Pratt is authorized by the Board of Social Work Examiners of Maryland to offer continuing education for Social Workers. Sheppard Pratt takes responsibility for the content, quality, and scientific integrity of this CME activity. This activity is approved for 1.0 contact hours in Category I credits for Social Workers.

Counselor Statement: Sheppard Pratt has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 5098. Programs that do not qualify for NBCC credit are clearly identified. Sheppard Pratt is solely responsible for all aspects of the program. This activity is available for 1.0 NBCC clock hours.

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Learning Objectives

After attending this program, participants will be able to:

1. Recognize key elements of quality improvement research and distinguish from traditional research methodology.

2. Discuss how ethical and monitoring considerations apply to quality improvement work.

3. Identify several key drivers to building a quality improvement program in behavioral health.

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………………..……………………………………………………………………………………………………………………………………..

Quality Improvement in Behavioral Health

Rajeev Krishna, MD, PhD, MBA

Medical Director of Quality Improvement - BH

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Disclosures

No financial conflicts of interest to disclose.

In real life, I walk around, gesture a lot with my hands, and love audience participation.

So please bear with my ongoing transition to zoom!

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Agenda• What is QI?

– Understand how QI fits into the continuum of research.

– Importance of QI in Behavioral Health

• How can we build / expand a QI program?– NCH behavioral health’s process

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What is QI Methodology?

• Analytical framework for implementing and tracking process stability and change. – Robust, valid tools and strategies based on statistical process

control methodology.

– Implementation science

• Multiple approaches (Lean, 6-sigma, etc) with different focus, but same intent and goals– Nationwide Children’s uses the Institute for Healthcare

Improvement (IHI) Model

• Helps ensure a thoughtful approach to achieving a process outcome or change.

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Translating Science into Practice:The 3T’s Road Map

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ImprovedQuality & Value

Basic biomedical science

Clinical efficacyknowledge

Clinical effectivenessknowledge

Key Translational Research Activity (T1): Test what care works

• Clinical Efficacy Research

Key Translational Research Activity (T2): Who benefits from this care

• Outcomes research• Comparative

effectiveness research

• Health services research

Key Translational Research Activity (T3): How to deliver high-quality care reliably and in all settings

• Quality Improvement (QI)

• Implementation reports• Financial studies• Generalization studies• Feasibility studies

T1

T2

T3

Dougherty & Conway, 2008 By Nicole Poellet, DNP, RN; used with permission

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Compared to “Research”Environment in an Enumerative

StudyEnvironment in an Analytic

Study (QI)

Measurement

Conclusion

Sample

Sample

Sample

???

Adapted from: Thomas Bartman, MD; Used with permission

Identify best treatment Deliver best treatment

Generalizable outcome Generalizable process

Control of confounders Normalization of confounders

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Control Chart (Shewhart Chart)

+1SD

+3SD

+2SD

-3SD

-2SD

-1SD

MEAN

+1σ

+3σ

+2σ

-3σ

-2σ

-1σ

MEAN

TIME

LOWER CONTROL LIMIT (LCL)

UPPER CONTROL LIMIT (UCL)

Graphical time-series analysis (quasi-experimental)

By: Thomas Bartman, MD; Used with permission

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Statistical Process Control• Pick out the unnatural variations to identify

process change.– Imagine tracking the temperature of a refrigerator. You want perfection.

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Statistical Process Control

You EXPECT variation

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Statistical Process Control

But THIS “special cause” variation

means something is happening.

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Statistical Process Control• Change process to shift the mean to where you

want it to be.– Change the temperature setting and monitor the response– Set a new “goal mean” and begin implementing changes to achieve it.– Keep implementing interventions until new goal is achieved.

How will we know that a change is an improvement?

Plan

DoStudy

Act

What are we trying to accomplish?

What changes can we make that will result in improvement? (Road Map)

The IHI Improvement Model

AIM

Run & Control Chart

Key Drivers & Interventions

The Process Steps to Get There

By Thomas Bartman MD, Used with permission

The Process

• Make a goal• Defines measures for progress and markers for completion.

• Make a team• Key providers, support staff, operation staff, and leadership.

• Make a plan• Research, Brainstorming, surveys, affinity diagrams, fishbone diagrams, etc.

• Develop Key Drivers and Interventions

• Make a change: begin “Plan-Do-Study-Act” (PDSA) Cycles• Implement the plan

• Review the results

• Make a new plan

• Repeat...

Example Key Driver Diagram

Plan-Do-Study-Act (PDSA) Cycles

All PatientsAll Clinics

All ProvidersFull System

Early Appointments

New PatientsPilot Clinic

Pilot ProvidersPilot System

Standard Scheduling

All ProvidersPilot Clinic

Pre-visit Phone Reminders (for early arrival)

Advanced Appointment

Letter

Full System

Early Appointments

New PatientsAll Clinics

All PatientsPilot Clinic

All PatientsAll Clinics

Infrastructure Change Scope Change Scheduling Change

Infrastructure

Scope

Scheduling

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Why should I use QI?• Most of a health system’s daily

activity is some form of continuous QI.

• Part of the job in any supervisory or administrative role.

• The “Scientific Method” of process management / improvement.

• Increasingly part of working in health care as an “equal player”.

• Measuring change

• Demonstrating performanceThis Photo by Unknown Author is licensed under CC BY-SA

QI is Research• Formal Process

• Scientifically rigorous

• Different type of outcome

• Ethical• Monitoring through institutional administrative structure

• IRB exempt (but doesn’t hurt to ask)

• Publishable• Growing number of scientific publications accepting QI articles

• SQUIRE guidelines: http://squire-statement.org/

• IHI “QI Friendly” Journals• http://www.ihi.org/education/IHIOpenSchool/resources/Pages/WhereToSubmitYourWritingQ

IFriendlyPeerReviewedJournals.aspx

• Many others have or are developing a “QI Section”.

(AKA: Bust the myths!)

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QI is EffectiveMeasure Impact

Antipsychotic medication monitoring compliance 48% to 85%(4 years)

Use of standard outcome measures in psychiatry 90%(3 years)

Patient who no-show or late cancel to psychiatry appointments

16% to 7%(1 year)

Patients with significant depression treated to remission

35% increase(2 year)

Reduce seclusions and restraints on inpatient unit 60% reduction(3 years)

Shameless plug for measurement based care!

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Building a QI Program

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"From Projects to Culture"• QI was:

– A few top-level projects, creating a lot of “extra work”.

– "That thing you remember for the TJC reviewer"

• QI needed to be: – The method we use to do our everyday work

– Owned by everyone --> Culture

• “I’m really frustrated by …”

• “Why don’t you propose QI project?”

This sounds like a QI project...!!

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From Projects to Culture

• Scene setting:– Large institutional investment in QI

– Hospital level QI training program

• Make a goal– Increase "QI Effectiveness" in Behavioral Health.

• Increased use of methodology

• Increased number of projects

• Increased engagement in QI activities

• Make a team: – Identify a “Project Lead” Established position of QI Medical Director

– Create a team Formed QI Steering Committee

– Support QI service line coordinator provided by hospital QI program.

• Make a plan– Build ownership at all levels

– Build internal management capability (build QI into normal service line operations)

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QI Effectiveness in Behavioral Health

Develop and sustainQI effectiveness inBehavioralHealth: (metricsUnder development)

Key DriversInterventions

Aim

Data Infrastructure

Resources

Communication

Education

To develop and sustain culture quality improvement in all NCH Behavioral Health

staff to achieve the highest level of patient care

1. Create a priority list for QI projects2. Identify Meaningful Metrics to measure QI

effectiveness3. Setup monthly meetings and quarterly report

outs to hospital leadership.

Administrative Infrastructure /

Steering Committee

Culture

1. Create and maintain Dashboards or Share point sites

2. Develop ways to communicate QI efforts to service line regularly

1. Develop plan to support ‘mini’ QI projects2. Incorporate QI in appraisals3. Identify and communicate other sources of QI

training and education

1. Create additional DB resources2. Acquire software and provide training to

facilitate use of data

Organize QI poster symposium

Proactively secure QIE spots and participants

Implement QI Methodology training

Add QI module to BH new employee orientation

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2016 2017 2018 2019 2020

BH QI Initiative• Medical Director Position• Steering Committee

Communication / Infrastructure • Lunch and Learn• Group Meetings• QI intro seminar• “QI Corner”

Culture• QI Symposium• Publication /

recognition

Education• MTP Program• QIE Strategy

“Sustain”• BHP Opening• Pandemic

Data Infrastructure

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Infrastructure:Creating Alignment of Efforts

• Danger of expanding “ownership”– Poorly organized projects consuming

resources with little systemic benefit

– QI Infrastructure creates a second administrative system

– Not every project can change high level practice

• Need to put guardrails around QI activity

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InfrastructureProjects that lay groundwork for process/outcome measures

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ProcessProjects to improve processes in patient care

OutcomeProjects to improve clinical outcomes

Creating Alignment of Efforts

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Outcome Based Care

30 Day Readmissions

Access Safety

Creating Alignment of Efforts

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Outcome Based Care

30 Day Readmissions

Access Safety

Infr

astr

uct

ure

P

roce

ssO

utc

om

e

Creating Alignment of Efforts

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Outcome Based Care

30 Day Readmissions

Access Safety

• Computerized assessments(new patients, return visits)

• Collection of PHQ9Depression ratings

• Depression Outcomes• Zero Suicide

• Fact Sheet documentation

• Discharge folder• PFK Care Coord• Follow-up

attendance• Family education

• Connect trial

• Cadence optimization• Centralized scheduling

• Just-in-time• CDC monitoring• N-psych access

• T5A Seclusionsand Restraints

Ou

tco

me

• Antipsychotic medication safety

• Combative patients (ASD)

• CASE approach compliance

• Referral Triage process• Treatment Linkage• PPP Stepping stones

• Long Acting Inj. Antipsychotic med safety

Infr

astr

uct

ure

P

roce

ss

Creating Alignment of Efforts

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QI Culture

• Create word-of-mouth recognition of QI– Culture change is a bottom-up process

– Ownership and empowerment are necessary elements

• Create motivation to use QI– Generate interest, then teach methodology

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Behavioral Health QI Poster Symposium

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2016 -2020 BH-QI HighlightsHighlights #

BH-QI projects published in journals 7

BH-QI papers accepted /in print 3

BH-QI papers in progress 1

Podium presentations: CHA, APNA, NNPRFTC

External poster presentations: OHA, APNA, AACAP

BH symposium poster presentations: 60+ posters

BH-QI training pilot: 4 cohorts in progress

BH-QI awarded 2019 Dr. John Shultz Quality award

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Conclusion

• What is QI?– QI is about process and change management

– Creates structure for making sensible changes and achieving outcomes.

– Approachable and useful, but also a formal and rigorous process

– Part of the continuum of translational research

• How do you build a QI program?– Build structure and culture

– Create ownership and empowerment

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