Maria Danila, MD (Monika M. Safford, MD) February 12, 2015 Building the Infrastructure to Enhance QI Research in the Health System Maria Danila, MD (Monika M. Safford, MD) February 12, 2015

Disclosures Dr. Safford receives salary support from Amgen, Inc. for investigator-initiated research. She also consults for diaDexus, a manufacturer of blood lipid assays.

Outline Needs Assessment Strategic Planning/Opportunity Example of a First Project Lessons Learned and Next Steps

Needs Assessment - Background AAMC Learning Health System award Support of CEO of Health System Support of Dean, School of Medicine Support of Chair, Department of Medicine Proposal to use CME as a strategy to bridge two camps CME to engage? Performance Improvement CME Engage QI leaders (non-researchers): challenge = physician engagement Engage researchers: challenge = misaligned priorities Research priority not necessarily = Health System priority UAB received an AAMC Learning Health System award for 2014 with the support of the CEO of our health system, the Dean of the school of medicine, and the Chair of the department of medicine. We proposed to use CME as a strategy to bridge the gap between health system quality leaders, and a vibrant but very separate health services research community at UAB. A relatively new form of CME, called “Performance Improvement CME”, focuses primarily on QI and provides education in that context. This type of CME is intended to support health system QI efforts. The idea was to engage QI leaders in the health system and offer CME as an engagement tool for physicians, who may not be highly enthusiastic about yet another QI intervention. Similarly, health services researchers have focus areas, and these are not necessarily the priority of the health system, which is focused on its bottom line and quality indicators like in-hospital mortality and improving the quality of documentation. Dr. Safford is both the Assistant Dean for CME and the Co-Director of the Center for Outcomes and Effectiveness Research and Education at UAB, therefore well-positioned to bridge the gap between the health system and health services research camps.

Needs Assessment Nominal group of leaders in QI in Health System, health services research What are the biggest challenges to conducting QI research in the UAB Health System? Which are the most difficult to overcome? We started our project by conducting a nominal group of leaders of QI in the Health system, and leading health services researchers. Briefly, a nominal group is a structured group process, where the group responds to a question and generates a list of answers in round robin fashion. The generated list of responses is then ranked by the participants. In this case the questions we asked were…

Needs Assessment -- Results Collaboration No forum for regular communication and coordination of efforts Differences in culture Lack of common language/understanding Lack of instruction on research methods How to align investigator interests and health system priorities What should be the scientific home for QI research The results were probably not surprising to people who are attempting this at their institutions. A major category of items related to collaboration. Participants cited that we had no forum for regular communication and coordination of efforts. They also cited the differences in culture between scientists and operations people, with different languages and understanding.

Needs Assessment -- Results System-related Absence of coordinated analysis and interpretation of data Budget for high quality QI projects not available Communication of QI research being a priority and expectation by leadership Lack of reliable centralized repository of institutional QI efforts Turn over with trainees Results that make UAB look bad – ability to publish System-related barriers included access to data and data analysts, as well as money to conduct this type of research. Attendees also questioned whether QI research was really a priority of the Health System leadership.

Needs Assessment -- Results Data-related Lack of confidence in data veracity Lack of coordinated data Clinical data may not be research grade Contamination due to multiple ongoing programs Time-related Academic approach takes too long Time availability IRB Operational time requirements Some data-related barriers included lack of confidence in data because operational data elements were not validated and challenges related to designing a rigorous study when there were so many QI efforts ongoing simultaneously. There were also concerns that researchers are too slow for operations, and that time was a major barrier. Operations people were also concerned about IRB’s, which further slow things down.

Needs Assessment -- Results Biggest barriers: Aligning investigator and health system priorities Lack of coordinated data No forum for communication/coordination Funds for high quality QI research Communication of QI research as a priority by leadership When the group ranked the biggest challenges, the top vote getter was aligning investigator and health system priorities, followed by lack of coordinated data, the lack of a forum for communication between researchers and health system QI staff, lack of funding, and communication that QI research was a priority by health system leaders.

Strategic Planning Met with each supporter (CEO, Dean, Chair) Obtain insights, recommendations We then went back to our supporters, namely the CEO of the health system, the Dean and the Chair, to brief them on these results and get their input about the way forward. Interestingly, whereas the Dean and Chair were very supportive of QI research, the CEO confirmed that QI research was in fact not a priority when the health system had just experienced its first year in the red in the history of the health system.

Strategic Planning/Opportunity Met with each supporter (CEO, Dean, Chair) Obtain insights, recommendations Request for partnership from Medscape Aligning investigator and health system priorities Lack of coordinated data No forum for communication/coordination Funds for high quality QI research Communication of QI research as a priority by leadership During this strategic planning phase, an opportunity arose unexpectedly to partner with Medscape. As you know, Medscape is a very large presence in CME, with over 60 million viewers per month. A partnership with Medscape did not necessarily address each of the top barriers identified by our team, but it did address the funding issue. Medscape is very successful at getting funding for education from pharma, and many of these opportunities are focused on QI.

Example Project Improving the utilization of tPA in acute ischemic stroke at UAB Genentech grant for QI CME to Medscape, UAB as subcontractor UAB applying for Stroke Center certification – well-aligned Proposal: Needs assessment with nominal groups of stakeholders ED RNs, ED MDs, Neurologists, Neuroradiologists Educational programs QI program informed by nominal groups Baseline and f/u data Our first partnership project got off the ground quickly. It is a Genentech funded project on “Improving the utilization of tPA in acute ischemic stroke at UAB”. The project was well aligned with Health System priorities because we are applying for Stroke Center certification from the Joint Commission and AHA. The project proposed to conduct a needs assessment of ED nurses and physicians, and Neurologists, and Neuroradiologists, to learn their perspectives on barriers to tPA administration. An educational program would present the evidence in support of tPA utilization. A QI intervention would be developed to address the barriers identified in the needs assessment and designed to improve tPA utilization on ideal candidates. The design of the evaluation was a pre/post interrupted time series.

Example Project – Lessons Learned Partnership takes time! Medscape is a large organization CME team playing leading role UAB clinicians not used to CME in this role (2) QI CME projects: templated Not well suited to innovation required for research (3) Educational content concurrent with needs assessment (not after) Required reconfiguring educational content Needs assessment: ED MD community controversy about use of tPA Planned education: all Neurologists Modification: add ED MD as peer model The project is in process, and we have completed the needs assessments and presentations of the results to the various stakeholder groups last month. We designed the QI intervention, which is now in place, and we will evaluate results on the number of patients who receive tPA before and after the intervention. We have certainly learned a lot from this experience. First, we again learned that partnership takes a lot of time. In this case, Medscape is a large organization and understanding who does what at a distance is challenging. Although the physician champion was instrumental, we learned that our CME team needs to play a big role in project management for the success of the project. This is mission aligned, since we are interested in building relationships with various clinical departments to support QI efforts, but does take a substantial amount of time. Perhaps the most surprising lesson was how templated these types of grants tend to be. Medscape has a successful formula that is not QI research. They create educational programs around the topic, and focus less on the actual QI intervention, even uncoupling the education from the QI intervention. In this case, we learned that the ED physician community includes many who are skeptical about the use of tPA, expressing concerns about the validity of the data and possible conflicts of interest on the part of people engaged in developing the guidelines. These views led us to conclude that the original plans for the education component, which included only expert Neurologists, should be modified to also include a leading ED physician to better engage physicians in that community. The educational content was already well underway when this came to light, and there was some scrambling to accommodate the changes. The literature is consistent on the lack of efficacy of education alone in changing behaviors or processes of care, yet that is at the crux of a lot of these projects. There is a real opportunity to use these pharma funds for programs that marry innovative research projects with physician education.

Next Steps Medscape #2 Improving the quality of care in chronic lymphocytic leukemia Medscape #3 Rheumatoid arthritis Several proposal submitted (time) Analyst to obtain data from health system (rapid turn around) Refine model Opportunity identified  Find champion  Data scan  Go/no go 48 hours We have obtained funding for two additional projects over the last 6 months, reflecting the very fast pace of this field. One of the highest priorities for us is to fund a part-time analyst with the health system’s data team so that we can pull the required data to make go/no go decisions. Our partner identifies a potential opportunity, and we have committed to giving the go/no go within 48 hours.

Summary: Using CME as a strategy to propel QI research Work in progress – stay tuned Pro’s: Funding source - $250,000+ per year Funding specifically for QI Con’s: Lots of time Rapid turn around – announcement to due date ~30 days Health services researchers: learning curve Highly focused opportunities (aligning researcher priorities?) In summary, our project to use CME as a strategy to propel QI research is still very much a work in progress. The pro’s include the fact that there is clearly a funding source for what could be QI research, with substantial funds that could serve to support excellent pilot data. The funding is specifically targeted at improving quality. However, this is by no means easy money. The timeline for these projects is very tight, usually 30 days. The type of grant is also very different from research grants, thus there is a learning curve for researchers. Without an experienced QI CME grant getter, this could be a large challenge. Last, the opportunities are highly focused, creating challenges to aligning the topic with researcher priorities. We are continuing to explore how this new partnership can move forward the QI research agenda at UAB.

Thanks to Ronan O’Beirne, PhD, Director UAB CME Will Ferniany, PhD, CEO, UAB Health System Selwyn Vickers, MD, Dean, UAB School of Medicine Seth Landefeld, MD, Chair, UAB Department of Medicine