1. Evidence-Based Quality Improvement (EBQI) Amy N. Cohen, PhD Desert Pacific Mental Illness Research Education and Clinical Center (MIRECC)

2. Outline of Talk Description of EBQI Building a local QI team EBQI methods and tools Example: EQUIP study

3. The Quality Problem Routine practice fails to make use of research evidence and effective practices – particularly prevalent in mental health and substance abuse – prevailing quality is poor to moderate Quality improvement seeks to close this gap between research and practice

4. Total Quality Management (TQM) & Continuous Quality Improvement (CQI) Structured organizational process for involving personnel in planning and executing a continuous flow of improvements to provide quality health care Goal is to implement evidence-based practices However, strategies for changing organization and provider behavior are typically based on intuition and anecdote, NOT evidence Shojania KG, Grimshaw JM: Evidence-based quality improvement: the state of the science. Health Affairs. 2005; 24: 138-50.

5. Evidence-Based Quality Improvement (EBQI) “Strategies for implementing evidence-based medicine require an evidence base of their own.” (Shojania & Grimshaw 2005) In other words, QI strategies used to support implementation need to be evidence-based.

6. QI Assumptions Improvement possible Process complex Teamwork essential Data required Blame removed

7. Steps to QI Clear mission and goals Establish Team Problem Identification Quality Improvement Cycle

8. Clear Mission and Goals Mission: What evidence-based care practice is to be implemented or improved Goals: short-term and long-term We want to improve X (amount) by X (date)

9. Team Establishment Sponsorship Composition Facilitation Meeting time Duration Training Rewards

10. Team Formation Small number Complementary skills Committed to common purpose Performance goals Mutually accountable

11. Problem Identification Baseline data Brainstorm causes Specify focus Recognize complex Secure support and involvement

12. PDSA Cycle for Learning and Improvement

13. Repeated Use of the Cycle Hunches Theories Ideas Changes That Result in Improvement AP SD A P S D AP SD D S P A DATA

14. QI Data Tools 1. Process Maps 2. Cause & Effect diagrams (Fishbone) 3. Check sheets (Tabulations) 4. Histograms (Distributions) 5. Scatter diagrams (Regression) 6. Pareto charts 7. Control charts Used in PDSA cycles for data collection & analysis

15. Process Map Most flow charts are made up of five main types of symbols: Walk through the steps and document. Reality versus Ideal

16. Cause and Effect Diagram (Fishbone) Brainstorming stage

17. Cause and Effect Diagram (Fishbone) Organizing data

18. Check Sheets

19. Process Redesign (Act) Explore redesign ideas – Automate steps – Insert technology, if applicable – Benchmark – Apply new management practices Map new process & information flows Consider organizational context – Stakeholder interests – Obtain input

20. QI Essentials Good management Training Team work Measurement of performance Time Faith

21. Effective Teams Have Supportive sponsor Orientation Sensible structure Clear mission and roles Staff support Access to information Shared expectations Useful tools and techniques

22. EBQI Example in VA: The EQUIP Experience

23. 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)

24. EQUIP: Effective Schizophrenia Care 4 VISNs: intervention and control site in each VISN Each VISN asked to select 2 evidence-based care targets for collaborative care model intervention – All selected Wellness & Supported Employment – Availability, quality, and utilization of these care targets vary across sites Evidence-based strategies were used to support implementation

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

26. Development of EQUIP QI teams To foster a quality improvement (QI) environment in the intervention sites, we developed local QI teams Site leadership identified team facilitators Local Recovery Coordinators (LRCs) were identified as the most suitable for the role – Trained each at WLA VA over 2 days

27. Team-building at the sites In pre-implementation interviews, key stakeholders asked if they would be interested in being part of a QI team At sites A, B, & C, LRCs invited individuals to initial meetings (non-mandatory attendance) At site D, LRC was brought into existing clinic team and all members of team constituted her QI team (mandatory attendance) Teams met weekly or biweekly

28. Identification of quality problems Teams engaged in their own version of the Deep Dive – 3 sites generated lists of possible problems to address – 1 site had specific guidance from administrative presence on the team Teams determined priorities based on group consensus

29. Quality problems by site Site A: non-recovery-oriented mental health treatment plans Site B: lack of transitional housing (too big of a problem for small team), lack of recovery services in community Site C: high rate of walk-in patients, low attendance at wellness groups Site D: poor collaboration/coordination between mental health inpatient ward and outpatient clinic

30. Attempted solutions to quality problems Site A: worked on replacing existing treatment plan with new recovery-oriented plan; faced extensive resistance Site B: implemented recovery/wellness groups in homeless shelter that serves mostly vets Site C: assessed reasons for walk-ins and educated patients about medication refills; created flyers about wellness groups & tracked # attending Site D: gathered data about communication problems, created welcome packet for new residents on inpatient ward

31. Support from EQUIP research team Monthly calls with LRCs Gaining support from local administration Helped at each PDSA step, as needed – Reasonable goal – Causes/possible solutions to try – Measurement – Adopt, adapt, abandon

32. Sustainability Teams are continuing to work together on quality problems in Sites B, C, and D – One of the most sustainable aspects of EQUIP – Team-building and QI processes were valuable for staff morale Team and project at Site A have been abandoned due to high resistance and LRC changing position

33. Conclusions Providing special training for facilitators promoted investment in the QI endeavor Support from local administration for QI teams is critical Having sites see quality gap is motivation for endeavor/ provides value After some initial resistance, most staff found the QI endeavor to be positive, rewarding, and morale-building

34. Web Sites Healthcare Change Focus Cmwf.org Rwj.org Chcf.org Ihi.org Improvingchronicillnesscare.org improvehealthcarenow.com http://www1.va.gov/hsrd/QUERI/ Healthtransformation.net