1. Mapping quality improvement: a comparative study of healthcare systems UK Harkness / Health Foundation Fellow: Robbie Foy Mentors: Brian Mittman & Lisa Rubenstein VA/UCLA/RAND Center for the Study of Healthcare Provider Behavior Harkness Fellowship Final Reporting Seminar, Orlando 2007 Center for the Study of Healthcare Provider Behavior Quality Enhancement Research Initiative

2. What’s the problem? Much past, present and future activity to address quality gaps in healthcare in US and UK, e.g. –Clinical guidelines –Performance indicators –Incentives for change Significant challenges remain Lack of coordination or incomplete reach of quality improvement (QI) efforts across all levels of healthcare systems

3. A multi-level framework for quality improvement Larger system/ environment Organisation Team/ microsystem Individual Ferlie & Shortell. Milbank Q 2001;79:281-315

4. Study objectives 1.Further elaborate a multi-level framework for QI 2.Document type and intensity of QI efforts among selected US (and UK healthcare) organisations 3.Explore similarities and differences in QI activities

5. Study sites Department of Veterans Affairs HealthPartners of Minnesota Key relationsFederal government and Central Office set priorities VISN latitude on how to address given priorities ‘The Enterprise’ Intentional ‘blurred boundaries’ between Health Plan, Medical Group and ICSI QI partnerQUERIICSI StrategiesMental Health Strategy & TIDES: Translating Initiatives for Depression into Effective Solutions DIAMOND: Depression Improvement Across Minnesota, Offering a New Direction ChangeCurrent roll out of depression care model Planned introduction of depression care model

6. Data collection and analysis Literature review and discussions to inform development of model Semi-structured interviews Framework analysis Iterative revision of multi-level framework

7. Interview participants Veterans Affairs HealthPartners Over-arching leadership23 Mainly QI / research44 Mainly primary care31 Mainly mental health42 Total interviews1310

8. Data collection and analysis Literature review and discussions to inform development of model Semi-structured interviews Framework analysis Iterative revision of multi-level framework

9. Preliminary findings

10. The multi-level matrix Core features or tasksActual or planned for each level? Larger system OrganisationTeamIndividual Strategic alignment and integrated improvement into routine organizational activities ???? Involving key stakeholders and leaders???? Priority setting???? Identifying best practice recommendations???? Identifying factors that help or hinder QI???? Developing people and roles for effective and efficient team function ???? Developing technical support and procedures for coordinated care ???? Shaping organisational culture???? Monitoring and evaluating quality????

11. The multi-level matrix: VA Core features or tasksActual or planned? Larger system OrganisationTeamIndividual Strategic alignment and integrated improvement into routine organizational activities Involving key stakeholders and leaders Priority setting Identifying best practice recommendations Identifying factors that help or hinder QI Developing people and roles for effective and efficient team function Developing technical support and procedures for coordinated care Shaping organisational culture Monitoring and evaluating quality

12. The multi-level matrix: HealthPartners Core features or tasksActual or planned? Larger system OrganisationTeamIndividual Strategic alignment and integrated improvement into routine organizational activities Involving key stakeholders and leaders Priority setting Identifying best practice recommendations Identifying factors that help or hinder QI Developing people and roles for effective and efficient team function Developing technical support and procedures for coordinated care Shaping organisational culture Monitoring and evaluating quality

13. The multi-level matrix Core features or tasksActual or planned? Larger system OrganisationTeamIndividual Strategic alignment and integrated improvement into routine organizational activities ???? Involving key stakeholders and leaders???? Priority setting???? Identifying best practice recommendations???? Identifying factors that help or hinder QI???? Developing people and roles for effective and efficient team function ???? Developing technical support and procedures for coordinated care ???? Shaping organisational culture???? Monitoring and evaluating quality????

14. Strategic alignment and integration of improvement into routine organizational activities Fairly ‘simple’ for the VA… “[Strategy] starts with the development of a quality indicator which would normally have its origin in Central Office… makes recommendations about what quality metrics get into my performance contract. And what gets into my performance contract trickles down into everyone else’s performance contract.” Senior manager, VA4 But multiplicity of initiatives… “One of the primary barriers... Ideally there would be some way of prioritizing quality improvement initiatives so that they fit together, sometimes instead of that they’re competitive.” Quality improvement researcher, VA6

15. Strategic alignment and integration of improvement into routine organizational activities Complex for HealthPartners… “It is time to challenge assumptions about payment systems – to align incentives and ensuring that costs of care are reimbursed. Both need to happen together. If only incentives are used, care will still be substandard if the infrastructure is not present.” Quality improvement leader, HP1 And need for “quantum leap” redesign … “… efforts like CQI can achieve limited change but substantial change depends upon reforming infrastructure and enhancing governance, culture and leadership.” Quality improvement leader, HP8

16. Developing technical support and procedures for coordinated care EMR firmly embedded within the VA but… “There are a vast number of clinical reminders that exist currently so simply finding the time in a busy appointment to address all of the reminders and the patient’s complaints and any other health care or preventive care is challenging.” Primary care physician leader, VA5

17. Developing technical support and procedures for coordinated care Within HealthPartners, EMR available in half of medical groups Plans for redesign and widespread implementation of systemised care “… establish systems and change environments so that it is easier to do the right thing than the wrong thing.” QI researcher Medical Group, HP3

18. Shaping organisational culture Strong mission to support (‘deserving’) veterans Variable emphasis on ‘professionalism’ Use of performance data for positive reinforcement – and ‘humiliation’ by comparison “I think that when leadership feels that they are personally affected by quality outcomes, you know their bonuses are affected, their ratings are affected, their embarrassment factor is affected because their facility isn’t doing well.” Senior manager, VA4

19. Shaping organisational culture Strong drivers around meeting members’ needs and being competitive Potentially greater emphasis on developing leadership capacity Efforts to transmit norms “Standardisation is challenging to the physician culture... The Medical Group has been trying to change culture from one where anything goes towards establishing norms in semi-legal contractual way.” QI researcher, Medical Group HP3

20. Conclusion one: elaborating the multi- level framework Multi-level QI efforts –Larger system, organisation, team, individual Range of core features or tasks suggested from literature –E.g. involving stakeholders, priority setting

21. Conclusion two: documenting QI efforts Strong research-practice partnerships in two sites Concerted efforts to improve depression care –Demonstrate range of QI activities –Suggest nine core features and tasks that contribute to ‘multi-level matrix’ Potential of matrix as a tool for mapping out and identifying gaps in other QI strategies

22. Conclusion three: comparing QI efforts VA depression strategy emergent from existing structures and processes HealthPartners strategy needs multi-level planning and whole system redesign Differences in complexity and focus of approaches

23. Policy implications: Nothing as practical as a good theory? The benefits of QI efforts may not be fully realised if there is over-reliance on one approach and such efforts are not coordinated across levels of the healthcare system Need for further attention to multi-level framework in planning and policy

25. Common sense is very uncommon Horace Greeley

26. Policy insights: Caveat emptor Further research needs Validation? Population? Acceleration? Cost equation?

27. Common sense is what tells us the Earth is flat and the Sun goes around it Anon