Improvement Science – Future Directions Carolyn M. Clancy, MD Assistant Deputy Undersecretary for Health, Quality, Safety and Value Veterans Administration

Improvement Science – Future Directions

Carolyn M. Clancy, MD

Assistant Deputy Undersecretary for Health, Quality, Safety and Value

Veterans Administration

December 9, 2013

Health Care as an Enterprise

“Health care … is a moral enterprise and a scientific enterprise, but not fundamentally a commercial one. We are not selling a product. We don’t have a consumer who understands everything and makes rational choices – and I include myself here.”

Health Affairs – Volume 20, Number 1 (January/February 2001)Health Affairs – Volume 20, Number 1 (January/February 2001)

Avedis DonabedianAvedis Donabedian

VETERANS HEALTH ADMINISTRATION

Health System Transformation: Current and Future


21st Century Health Care• Patients play a larger role, including

involvement in making decisions about the future of health care

• Innovative, adaptable and very scalable systems have the potential to become national solutions

• Health IT makes it possible for doctors to know how patients are doing over time – and for patients to engage in new ways – and at their convenience!


Diagnosing the Problem is One Big Step . . .

“The fundamental problem with the quality of American medicine is that we’ve failed to view delivery of health care as a science. … That’s a mistake, a huge mistake.” Peter Pronovost, M.D., PhD, Johns

Hopkins Hospital


Maintaining the Status Quo is Not an Option

• Evidence is being produced at an extremely rapid rate, but its incorporation into clinical practice is happening much more slowly

• Transparency efforts don’t offer enough usable data for decisions regarding a specific disease and selection of a treatment option

We face an underperforming health We face an underperforming health care system and untenable cost care system and untenable cost forecastsforecasts

Too often, the patient is an Too often, the patient is an afterthoughtafterthought


Understanding a Changing Landscape

• Health care reform, including payment, reform has already begun– How is evidence integrated into the

new environment?– How has the nature of evidence

changed?– How do these changes affect

providers, payers and patients?

• How do we ensure that these changes are beneficial?

CHANGE AHEAD


Do Something

“Do something. If it works, do more of it. If it doesn’t, do something else.”

Franklin Delano Roosevelt

Quality Improvement Works:HeQureQu’s Proof

• Large ambulatory care collaborative• Focus on practice coaching • Results for diabetes:

– Getting recommended tests improved 9 percentage points

– Outcomes (diabetes in control) improved 5 points

– Hospitalization rates fell 8.4% for target hospitals

• Results for hypertension:– Outcomes improved 2 points– Hospitalization rates fell 10.4% for target

hospitals


'The Checklist Manifesto' by Atul Gawande


Quality Is Improving Slowly

• Nearly 60 percent of health care quality measures tracked showed improvement

• However, the median rate of change was 2.5 percent per year

AHRQ 2011 National Healthcare Quality and Disparities Reports AHRQ 2011 National Healthcare Quality and Disparities Reports


Few Disparities in Quality of Care Are Getting Smaller

• Few disparities in quality showed significant improvement.

• The number of disparities that were getting smaller exceeded the number that were getting larger

AHRQ 2011 National Healthcare Quality and Disparities Reports AHRQ 2011 National Healthcare Quality and Disparities Reports


Article: A Young Veteran’s First Encounter with VA Health Care By: Tom Aiello

Link to Article: http://www.huffingtonpost.com/tom-aiello/veteran-healthcare_b_4070634.html

“Out of Sight. Out of Mind.”

“If You're Going to Go To Hell, You Still Need To Go Through Your Primary Care Physician”

“In Case of Emergency”

“God Helps Those Who Help Themselves”

“Golden Rule: Prepare to Wait”


Closing the Quality Gap: Revisiting the State of the Science

• Series of reports summarizing the evidence on quality improvement strategies for chronic conditions and other priorities:– Bundled Payment– Health Disparities– Patient-Centered Medical

Home– Public Reporting– Medication Adherence

http://www.ahrq.gov/clinic/tp/gapbundtp.htmhttp://www.ahrq.gov/clinic/tp/gapbundtp.htm


• Information• Incentives• Infrastructure

How Do We Do All of This?


Closing the Gap: System Interventions

• Disability: Clear information gaps• Disparities, HAI and Adherence: how organizations

can implement changes, which are effective• Palliative Care• PCMH: changes in infrastructure


Improving Quality: Consumer / Patient / Caregiver Perspective

PCMH: small + effects on patient experience

Disparities: research gaps Adherence: decreased out of

pocket costs** HAI: little evidence re pt role Palliative Care: little known


Improving Quality: Clinician / Provider Perspective

• PCMH: Small + effects on staff experience; NO information on unanticipated consequences (common theme)**

• Disparities: research gaps• Public Reporting

• Modest evidence that providers increase QI efforts• Adherence: varies by condition• Disability: NO clear consensus across disciplines re.

definition of “success”• HAI: effective interventions – many stuck at scale up and

spread• Palliative Care: NOT effective re coordination, continuity,

transitions


What We Need Now

• Rapid cycle mechanisms for evaluation and learning – and support for learning communities

• New partnerships between researchers and decision makers

• Proximal metrics of success• Scalable technical assistance – and connectivity

across multiple initiatives (public and private)• Practical strategy for patient engagement


VA’s QERI: Types of Implementation Studies

• Understand behaviors across multiple groups (providers, organizations, consumers) influencing implementation

• Focus on the “how” and “why” effective treatments are used, based on guiding framework

• Testing implementation strategies, e.g., systematic processes, resources and activities used to integration into usual settings (Hybrid Designs)


Hybrid Effectiveness / Implementation Designs in QERI

• Address limits of step-wise research (efficacy effectiveness translation)

• Promote external validity• Blend effectiveness, implementation studies,

i.e., for rapid partner-driven research (Curran et al, Medical Care, 2012)


Hybrid Effectiveness / Implementation Designs in QERI

• Type 1: test clinical intervention (patient; health outcomes)

• Type 2: test both clinical and implementation strategies (Providers, clinics; process measures)

• Type 3: test implementation strategy (providers, clinics; uptake)


Hybrid Effectiveness/Implementation Designs

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QUERI Hybrid Type II DesignImplementing Effective, Collaborative Care for

Schizophrenia (EQUIP; MNT 03-213)

• Weight and employment intervention sessions for patients

• System-level implementation intervention of care model and implementation strategy (EBQI)

• Group sessions delivered by existing providers• Primary outcomes: patient-level weight and

employment24


QUERI Hybrid Type III DesignBlended Facilitation to Enhance PCMH Program

Implementation (SDP 08-316)

• Primary Care-Mental Health Integration (PC-MHI) model • Regional implementation of VA mandate to provide

integrated mental health in primary care settings – Existing providers – Co-located care model: care management and

outcomes• External and Internal Facilitators worked with providers

to promote uptake of integrated care components

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QUERI Hybrid Type III DesignIntervention for Stroke Improvement using Redesign

Engineering (SDP 09-158, INSPIRE)

QUERI Facilitators•Established relationships with site stroke teams anticipating a long term relationship •Provided referrals to other VA sites and stroke personnel•Coaching changed over time from helping teams identify what needed to be done, to overcoming barriers, to providing encouragement of their QI efforts

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VERC Systems Engineers •Taught teams how to use System Redesign tools•Assisted teams with applying those tools (PDSA cycles, spreadsheets) to their QI efforts in follow up calls/visits•Provided encouragement •Preferred to see site data as an indicator of their QI activity


QERI: Types of Studies• Partnered rapid response projects (RRP’s)

• QERI Service-directed projects (SDPs)

• Partnered evaluation centers


Rapid Response Projects (RRPs)

• QUERI's principal mechanism to study process of implementing new treatments in VA– Center-focused RRPs: endorsement from QUERI Center and falls

within Center’s content area/priority goal– Partnered RRPs: Central Office or VISN-level health system

partner endorsement • One-year, $100,000 maximum:

– Feasibility/refinement of implementation strategy– Assessment of barriers/facilitators to implementation– Follow-ups to larger implementation efforts- further spread– Observational studies of partner-initiated program rollouts

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Continuum of Partnered Research:Partner Engaged vs. Partner Directed

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• Investigator-initiated projects• Service-directed research• CREATEs• QUERI projects: SDPs, RRPs• QUERI Evaluation Centers• Operations Funded work

• e.g. PACT Demo Labs• e.g., MHO evaluation

centers

DirectionInnovative

Partnered

Funding Locus HSRD

Clinical Partners


A Key to Culture Change:A Learning Health System (LHS)

“ … one in which progress in science, informatics, and care culture align to generate new knowledge as an ongoing, natural by-product of the care experience, and seamlessly refine and deliver best practices for continuous improvement in health and health care.”

Institute of MedicineInstitute of Medicine


Keystone: Maintaining Improvement Practices

• Example of building improvement into the research– Partnership with grants from AHRQ and various

commitments from Blue Cross Blue Shield of Michigan, the Michigan Hospital Association, Johns Hopkins University and others

– Stakeholders, end users and others are able to use the data to monitor progress

– Innovative methods of dissemination and communication

– An ongoing effort to learn and improve


What Needs to Change?

• Academic Incentives• The way and with whom we do our

work and report results (e.g., partners may get most value from initial aspects of study, don’t want to be constrained by journal timelines)

• Incorporating quality improvement, innovation, communication, etc.

• Training Programs

Health Services Research

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What IS the New Model?

• That remains to be determined, although overall things to consider include:– Stakeholders are engaged more and more when the

strategic decisions are being made– Making evidence available earlier and during different

intervals of a project– Thinking of publication as one step in the continuing

process to get results into the hands of those who need it rather than the end of the research cycle

– Testing multiple conclusions in the field rather than waiting until there is a ‘right’ answer


A Decent Meal,Or a New Model of Care?

• The challenge: – Serving millions of people– Delivering a range of services– Keeping costs reasonable– Attaining a consistently high level of

quality

• Can care be mechanized? Should it be?• Are there models we can use?

Gawande A. Big Med: Restaurant chains have managed to combine quality control, cost control, and innovation. Can health care? New Yorker. August 13, 2012


Where to From Here?

• Do more to ensure that new treatments and research knowledge reach patients and are implemented correctly

• Improve quality by improving access• Expand the boundaries of basic science to include

other “basic sciences” (e.g., epidemiology, psychology, communication, social marketing and economics)

• More focus on research and delivery of existing treatments

Woolf, S. Woolf, S. The Meaning of Translational Research and Why It MattersThe Meaning of Translational Research and Why It Matters , JAMA January 2009, JAMA January 2009


How Will We Know We’re On Track?

• The quality enterprise adds value to clinical practice

• Care includes focus on missed opportunities and dropped balls: transitions; handoffs; anticipating errors

• Physicians say, “we” rather than “I”• Patient activation and engagement is

welcomed and encouraged• “Best doctors” are evaluated in terms

of care for individual patients and leadership in health of population

What I Have Heard Here Today

04/19/23 37


Traveling Fast or Traveling to Get Somewhere?

If you want to travel fast, you travel alone. If you want to go far, travel with others.

African ProverbAfrican Proverb

Your Thoughts, Comments, Questions

04/19/23 39

Documents

Improvement Science – Future Directions Carolyn M. Clancy, MD Assistant Deputy Undersecretary for Health, Quality, Safety and Value Veterans Administration