aligning measurement-based qi with evidence-based practice implementation richard hermann, md, ms...
TRANSCRIPT
Aligning Aligning
Measurement-Based QI with Measurement-Based QI with
Evidence-Based Practice ImplementationEvidence-Based Practice Implementation
Richard Hermann, MD, MS
Associate Professor of Medicine and PsychiatryTufts University School of Medicine
Center for Quality Assessment & Improvement in Mental Healthat Tufts-New England Medical Center
www.cqaimh.org
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OverviewOverview
How does evidence-based practice implementation (EBPI) relate to measurement-based quality improvement (MBQI)?– different paradigms
– similarities and differences
Potential for convergence & synergy What obstacles need to be addressed? Current research study on QI
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Evidence-Based PracticesEvidence-Based Practices
EBP Rating
ACT / ICM AEvidence-based Psychotherapies AFamily Psychoeducation ASupported Employment AIntegrated Dual Diagnosis Treatment AMedication Management AMulti-Systemic Therapy A
A = RCTs B = less rigorous studies C = consensus or opinion
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EBP Implementation: a Top-Down ModelEBP Implementation: a Top-Down Model
Research: Controlled trial of clinical intervention↓
Development: Codification of EBP by experts↓
Commercialization: Packaging: tools, scales, materials↓
Diffusion: Social marketing, training, support↓
Adoption: Local provider organizations↓
Consequences: Change to practice & outcomes
Rogers, Diffusion of Innovations, 2003
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Measurement-Based QIMeasurement-Based QI
A “bottom-up” model– Activities conducted by local provider organizations– Influenced by external groups
MBQI is in wide use: – 90-98% of hospitals report formal programs
MBQI is costly: – estimated cost ~$200,000 per hospital per year
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Principles of Measurement-Based QIPrinciples of Measurement-Based QI
Quality as problems in “processes”
Measurement & analysis
Broad participation
Inductive reasoning
Trial and error
Intervene Measure Plan Diagnose
Aim
Model for Measurement-based QIModel for Measurement-based QI
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Commonalities between MBQI and EBPICommonalities between MBQI and EBPI
Both address important problems—some overlap
Both employ measurement – MBQI: rates of EBP use, appropriateness– EBPI: fidelity to evidence-based model
Both start with an understanding of underlying processes– MBQI: determined locally, informed externally– EBPI: studied externally, expanded locally
Both involve systematic intervention to change practice– MBQI: determined locally, informed by research & experience– EBPI: developed by experts, customized to local circumstances
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Potential for MBQI to Enhance Potential for MBQI to Enhance Evidence-Based Practice ImplementationEvidence-Based Practice Implementation
Promotes local organizational development– system perspective– team work– analytic skills– experience implementing change
Increases awareness of gapsPrompts investigationMotivates exploration of available interventions
→ Potential for uptake of EBPs
Integrating MBQI with EBPI Requires Integrating MBQI with EBPI Requires Alignment Across Healthcare SystemAlignment Across Healthcare System
Environment
(eg, payers, accreditors)
Local Organization
(eg, hospital)
Micro-system
(eg, hospital inpatient unit)
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Conditions for Successful AlignmentConditions for Successful Alignment
1. Local organizations need to select QI objectives that address gaps between actual & evidence-based practice
2. External organizations mandating measures also need to emphasize measures of EBPs
3. Microsystems within local organizations need to execute these QI activities effectively
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1. Do Quality Measures Used for Local MBQI 1. Do Quality Measures Used for Local MBQI Address Evidence-Based Practices? Address Evidence-Based Practices?
Reviewed measures developed for mental health QI
308 measures identified & evaluated:– 9% supported by RCTs– 30% supported by less rigorous evidence– 61% not supported by evidence
Evidence-based measures less likely to be adopted
Pilot study of QI objectives adopted by MA hospitals:< 10% of hospital objectives address EBPs
National Inventory of Mental Health Quality Measures (www.cqaimh.org)
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2. Do Mandated Quality Measures Address 2. Do Mandated Quality Measures Address Evidence-based Processes of Care?Evidence-based Processes of Care?
Measures established by:– Accreditor requirements – Government reporting requirements– Benchmarking collaboratives
Results increasingly linked to:– Pay for performance incentives – Public disclosure– Employer purchasing decisions
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2. Do Mandated Quality Measures Address 2. Do Mandated Quality Measures Address Evidence-based Processes of Care?Evidence-based Processes of Care?
Illustrative Measures RatingRestraint / seclusion rates CElopement rate CInjury rate CNumber of medications CReadmission rate CMedication errors BAntipsychotic dose AAntidepressant Adherence AA = RCTs B = less rigorous studies C = consensus or opinion
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Evidence-Based PracticesEvidence-Based Practices
EBP Rating
ACT / ICM AEvidence-based Psychotherapies AFamily Psychoeducation ASupported Employment AIntegrated Dual Diagnosis Treatment AMedication Management AMulti-Systemic Therapy A
A = RCTs B = less rigorous studies C = consensus or opinion
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Meaningful
stakeholder needs
clinically important
evidence-based
valid
comprehensible
Feasible
precisely specified
data available
affordable
accurate
reliable
case mix adjustment
pt. confidentiality
Actionable
quality problem
under user’s control
interpretable
results
norms
benchmarks
standards
Domains of Process (prevention, detection, access, assessment, treatment, continuity, coordination,
safety/errors)
Clinical Population (diagnostic groups, comorbidities, prevalence, morbidity)
Vulnerable Groups (children, elderly, racial/ethnic minorities)
Modalities (medication, psychotherapy, other somatic, other psychosocial)
Clinical Setting (inpatient, ambulatory, residential, partial, emergency service)
Purpose of Measurement (internal QI, external QI, consumer selection, purchasing, research)
Level of Health Care System (population, plan, delivery system, facility, provider, patient)
Attributes Informing Quality-Measure Selection
Represent Mental Health System Broadly
Maximize Measure Attributes
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Evidence-Based Objectives for Inpatient QI: SchizophreniaEvidence-Based Objectives for Inpatient QI: Schizophrenia
↑ use of antipsychotic drugs w/in recommended dose range
↓ use of multiple antipsychotics without adequate rationale
↑ % receiving adequate drug trials for refractory sx
↑ assessment/detection for EPS, akathisia or TD; ↑ rate of evidence-based treatment
↑ enrolled/referred to ACT among inpatients at high risk for relapse
↑ family members provided/referred to psychoeducation
↑ fidelity of inpatient psychoeducation program.
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Evidence-Based Objectives for Inpatient QI: DepressionEvidence-Based Objectives for Inpatient QI: Depression
↑ use of antidepressant drugs w/in recommended dosage range
↑ assessment/detection of psychosis among depressed inpatients; ↑ use of adequate pharmacotherapy or ECT for psychotic depression
↓ use of anticholinergic antidepressants among depressed elderly inpatients
↑ % of inpatients w/ major depression referred to OP clinicians providing evidence-based psychotherapy
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Other Evidence-Based Objectives for Inpatient QIOther Evidence-Based Objectives for Inpatient QI
↑ assessment & detection of medical conditions
↑ % receiving appropriate inpatient medical care, outpatient referral & communication between IP & OP clinicians
↑ assessment/detection of SUD; ↑ % receiving inpatient treatment & OP referral
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3. Do Local Healthcare Organizations 3. Do Local Healthcare Organizations Execute QI Activities Effectively?Execute QI Activities Effectively?
Effectiveness in controlled trialsShortell (1998) reviewed 55 studies finding “pockets of
improvement” rather than evidence of widespread change
Effectiveness of routine QINot well studiedCase reports of successful initiativesAnecdotal evidence suggests much of local QI is ineffective
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Macro Model of Organizational Predictors of QIMacro Model of Organizational Predictors of QI
Environment
Culture
Organizational Factors
Technical
Hospital QI Implementation
QI Outcomes
Stategic
Structure
Shortell, 1995
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Predictors of QI ImplementationPredictors of QI Implementation
Cultural: beliefs, values & behaviors relative to QI+ organizational culture emphasizing teamwork & innovation+ commitment of senior managers & physicians
Structural: individual & group responsibilities+ Decentralized decision-making+ Longer experience + Greater number of teams & projects
Strategic: approach to QI+ “prospector” approach
Technical: resources + presence of organization-wide information systems
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NIMH-funded study of 32 hospitals in MA & CA What are inpatient psychiatry units trying to improve?
– effectiveness -- patient-centered care– access -- safety– equity -- efficiency
To what extent do these objectives address EBPs?– Facilitators & barriers to adoption
To what extent do hospitals achieve measurable change? Hypothesis
– Fit between organization & predict QI effectiveness
Study of MBQI in Inpatient Psychiatric UnitsStudy of MBQI in Inpatient Psychiatric Units
Micro Model of Organizational Predictors of QIMicro Model of Organizational Predictors of QI
Environment
Culture
Organizational Factors
Resources
Selected Aims
& Measures
QI Progress
Diagnose
Measure Plan
Intervene
QI Outcomes
Leadership
Structure
Hermann, 2005
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CultureCulture
Inpatient clinicians’ knowledge & beliefs about evidence basis for QI objective
Inpatient clinicians’ beliefs about the value of the QI objective to their patients’ care & outcomes
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StructureStructure
Course of QI objective as tracer of organizational structure:– serial reports of results disseminated to inpatient clinicians?– are interventions attempted?– reports of progress (or barriers) to appropriate committees?– participation / coordination among necessary departments?
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LeadershipLeadership
Selecting objectives that are priority of hospital
leaders?
Responsive to external pressures?
Leaders actively involved or monitoring progress?
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ResourcesResources
Availability of resources for achieving QI objective– training – tools– time – support (eg, data collection & analysis)
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ConclusionConclusion
Greater progress toward implementing EBPs may be achieved by aligning organizations’ QI activities with EBP goals
Components of alignment:– Provider organizations need to select evidence-based QI objectives – External groups need to reinforce emphasis on EBPs– Local MBQI needs to be more effective
Ongoing research aimed at:– understanding barriers to adopting evidence-based QI objectives– understanding organizational factors influencing QI progress– developing interventions to improve effectiveness of local QI