Measuring QI Intervention Implementation: Helping the Blind Men See? EQUIP (Evidence-Based Practice in Schizophrenia ) QUERI National Meeting Working Group December 12, 2008

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 EBQI Provider/patient education Quality manager QI Informatics support Performance feedback Leadership support “infrastructure” “priority-setting” Evidence base: TMAP EQUIP-1

Context Matters: Design for It EQUIP – 4 VISNs: intervention and control site in each VISN – sites chosen collaboratively based on interest – Each VISN asked to select evidence-based care targets for intervention: all selected Wellness & Supported Employment – Availability & quality of these care targets vary across sites – Structure of care for patients with schizophrenia varies across sites – Formative evaluation methods utilized to understand variable implementation

Formative evaluation=assessment process designed to identify potential and actual influences on the progress and effectiveness of implementation efforts Data collection occurs before, during, and after implementation Need to be able to answer questions about context, adaptations, and responses to change What is Formative Evaluation?

Developmental evaluation Implementation-focused evaluation (process evaluation) Progress-focused evaluation Interpretive evaluation Four Stages of Formative Evaluation

Simpson Transfer Model

Developmental Field notes Documents (minutes, etc.) ORC & Burnout Inventory Key stakeholder interviews Implementation- Focused Field notes Quality Coordinator logs Documents Key stakeholder interviews Progress-Focused QI tools Interpretive Field notes Key stakeholder interviews ORC & Burnout Inventory Stages of FE (STM) & EQUIP FE Measures Post- Implementation (STM: Practice) Pre- Implementation (STM: Exposure & Adoption) Implementation (STM: Implementation)

Multiple Data Sources: Measuring Implementation EQUIPExamples Semi-structured interviews: leaders, clinicians, mgrs participation, level of implementation Organizational site surveys: admin. & staff clinic structure, processes, change Field journals group-level dynamics, implementation details Administrative data visits, Rxs Patient surveys PAS Activity logs Time spent on aspects of study

Multiple Data Sources: Strengths and Challenges StrengthsChallenges Semi-structured interviews: leaders, clinicians, mgrs rich data, diverse perspectives expensive, time- consuming Organizational site surveys: Admin & staff site profiles, faster, easier to analyze limited discovery, key informant view Field journalsdetailed contextual data variation between observers Administrative datareadily available, historical value not QII-specific, local coding differences Patient surveysvalidate experience, exposure, outcomes expensive, highly sensitive to sample Activity logsclinical implementation, dose of effort/time global measure—no detailed dose info.

Organizational Readiness for Change (ORC): Staff and Administrator versions Maslach Burnout Inventory On-line measure Pre- and post-implementation EQUIP Organizational Climate Measures

Using scales related to: – Motivation for change (program needs, training needs, pressures for change) – Staff attributes (growth, adaptability) – Organizational climate (mission, cohesion, autonomy, communication, change) Purpose is descriptive & to assess change in readiness from pre- to post-implementation Organizational Readiness for Change

Conducted pre-, mid-, and post-implementation Versions for providers, administrators, and VISN leaders Covered in consent Face-to-face recorded interviews Professionally transcribed Analyzed after each round EQUIP Semi-Structured Interviews

Primary method of capturing data from observant participation “If you didn’t write it down in your field notes, then it didn’t happen.” (at least in terms of data analysis) 3 kinds of notes – Records of events observed and information given – Records of prolonged activities – Chronological daily diary EQUIP Participant Observation: Field Journal

Submitted monthly by RN Quality Coordinator What % of time was spent on each aspect of clinical intervention Will be able to look across sites to see variation in time spent on clinical activities; can see if this relates qualitatively to implementation at each site EQUIP Quality Coordinator Logs

Critical Measures of Implementation Integrity of innovation – Fidelity to planned implementation strategy – Dose of intervention delivery, when variability is possible – Requires clear operational definitions of intervention components Exposure to innovation – Degree to which intervention is experienced by targeted users – Dose of exposure, when variability is possible – Requires clear operational defs for measuring intervention exposure Intensity of implementation – E.g, implementation or intensity scores for multifaceted interventions – Eg, ‘goal attainment scaling’ when strategy allows local adaptation or choice of alternative interventions across sites

Triangulation Critical to collect information about implementation from multiple sources – Be prepared for disagreement – Perspectives and opportunities for observation differ for managers, providers vs. patients Recognize differences between “exposed” sample and practice population – Does the “enrolled” group represent the practice? – Did the intervention penetrate among all providers?

Telling the story of variable implementation Examine range of data sources as a team – Throughout course of data collection – Discuss which data sources answer which questions Examine which data sources are complementary – Which data sources should be triangulated? – What questions are raised or what answers are provided?

Telling the story of variable implementation Use qualitative data analysis software to facilitate mixed methods analysis – Multiple data sources – Multiple grouping options (e.g., by site, by stakeholder, by data collection time points) – Team-based analysis – Ongoing, iterative analysis informing implementation efforts

Software Support: ATLAS.ti

Telling the story of variable implementation Audience considerations – Throughout course of data collection – Which data sources answer which questions, for whom – Issue of providing feedback to sites Product considerations – Which data sources should be triangulated? – What questions are raised or what answers are provided? – How much and what should go into which products?