Aligning measurement based qi with evidence based practice implementation
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Aligning Measurement-Based QI with Evidence-Based Practice Implementation. Richard Hermann, MD, MS Associate Professor of Medicine and Psychiatry Tufts University School of Medicine Center for Quality Assessment & Improvement in Mental Health at Tufts-New England Medical Center

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Aligning measurement based qi with evidence based practice implementation l.jpg

Aligning Measurement-Based QI with Evidence-Based Practice Implementation

Richard Hermann, MD, MS

Associate Professor of Medicine and Psychiatry

Tufts University School of Medicine

Center for Quality Assessment & Improvement in Mental Health

at Tufts-New England Medical Center

www.cqaimh.org


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Overview

  • How does evidence-based practice implementation (EBPI) relate to measurement-based quality improvement (MBQI)?

    • different paradigms

    • similarities and differences

  • Potential for convergence & synergy

  • What obstacles need to be addressed?

  • Current research study on QI


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Evidence-Based Practices

EBPRating

ACT / ICM A

Evidence-based Psychotherapies A

Family Psychoeducation A

Supported Employment A

Integrated Dual Diagnosis Treatment A

Medication Management A

Multi-Systemic Therapy A

A = RCTs B = less rigorous studies C = consensus or opinion


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EBP Implementation: a Top-Down Model

Research: Controlled trial of clinical intervention

Development: Codification of EBP by experts

Commercialization: Packaging: tools, scales, materials

Diffusion: Social marketing, training, support

Adoption: Local provider organizations

Consequences: Change to practice & outcomes

Rogers, Diffusion of Innovations, 2003


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Measurement-Based QI

  • A “bottom-up” model

    • Activities conducted by local provider organizations

    • Influenced by external groups

  • MBQI is in wide use:

    • 90-98% of hospitals report formal programs

  • MBQI is costly:

    • estimated cost ~$200,000 per hospital per year


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Principles of Measurement-Based QI

  • Quality as problems in “processes”

  • Measurement & analysis

  • Broad participation

  • Inductive reasoning

  • Trial and error



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Commonalities between MBQI and EBPI

  • Both address important problems—some overlap

  • Both employ measurement

    • MBQI: rates of EBP use, appropriateness

    • EBPI: fidelity to evidence-based model

  • Both start with an understanding of underlying processes

    • MBQI: determined locally, informed externally

    • EBPI: studied externally, expanded locally

  • Both involve systematic intervention to change practice

    • MBQI: determined locally, informed by research & experience

    • EBPI: developed by experts, customized to local circumstances


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Potential for MBQI to Enhance Evidence-Based Practice Implementation

  • Promotes local organizational development

    • system perspective

    • team work

    • analytic skills

    • experience implementing change

  • Increases awareness of gaps

  • Prompts investigation

  • Motivates exploration of available interventions

    → Potential for uptake of EBPs



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Conditions for Successful Alignment Healthcare System

  • Local organizations need to select QI objectives that address gaps between actual & evidence-based practice

  • External organizations mandating measures also need to emphasize measures of EBPs

  • Microsystems within local organizations need to execute these QI activities effectively


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1. Do Quality Measures Used for Local MBQI Healthcare System Address Evidence-Based Practices?

  • Reviewed measures developed for mental health QI

  • 308 measures identified & evaluated:

    • 9% supported by RCTs

    • 30% supported by less rigorous evidence

    • 61% not supported by evidence

  • Evidence-based measures less likely to be adopted

  • Pilot study of QI objectives adopted by MA hospitals:

    < 10% of hospital objectives address EBPs

    National Inventory of Mental Health Quality Measures (www.cqaimh.org)


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2. Do Mandated Quality Measures Address Evidence-based Processes of Care?

  • Measures established by:

    • Accreditor requirements

    • Government reporting requirements

    • Benchmarking collaboratives

  • Results increasingly linked to:

    • Pay for performance incentives

    • Public disclosure

    • Employer purchasing decisions


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2. Do Mandated Quality Measures Address Evidence-based Processes of Care?

Illustrative MeasuresRating

Restraint / seclusion rates C

Elopement rate C

Injury rate C

Number of medications C

Readmission rate C

Medication errors B

Antipsychotic dose A

Antidepressant Adherence A

A = RCTs B = less rigorous studies C = consensus or opinion


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Evidence-Based Practices Processes of Care?

EBPRating

ACT / ICM A

Evidence-based Psychotherapies A

Family Psychoeducation A

Supported Employment A

Integrated Dual Diagnosis Treatment A

Medication Management A

Multi-Systemic Therapy A

A = RCTs B = less rigorous studies C = consensus or opinion


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Attributes Informing Quality-Measure Selection Processes of Care?

Maximize Measure

Attributes

Represent Mental Health System Broadly


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Evidence-Based Objectives for Inpatient QI: Schizophrenia Processes of Care?

  • ↑ use of antipsychotic drugs w/in recommended dose range

  • ↓ use of multiple antipsychotics without adequate rationale

  • ↑ % receiving adequate drug trials for refractory sx

  • ↑ assessment/detection for EPS, akathisia or TD; ↑ rate of evidence-based treatment

  • ↑ enrolled/referred to ACT among inpatients at high risk for relapse

  • ↑ family members provided/referred to psychoeducation

  • ↑ fidelity of inpatient psychoeducation program.


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Evidence-Based Objectives for Inpatient QI: Depression Processes of Care?

  • ↑ use of antidepressant drugs w/in recommended dosage range

  • ↑ assessment/detection of psychosis among depressed inpatients; ↑ use of adequate pharmacotherapy or ECT for psychotic depression

  • ↓ use of anticholinergic antidepressants among depressed elderly inpatients

  • ↑ % of inpatients w/ major depression referred to OP clinicians providing evidence-based psychotherapy


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Other Evidence-Based Objectives for Inpatient QI Processes of Care?

  • ↑ assessment & detection of medical conditions

  • ↑ % receiving appropriate inpatient medical care, outpatient referral & communication between IP & OP clinicians

  • ↑ assessment/detection of SUD; ↑ % receiving inpatient treatment & OP referral


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Effectiveness in controlled trials Processes of Care?

Shortell (1998) reviewed 55 studies finding “pockets of improvement” rather than evidence of widespread change

Effectiveness of routine QI

Not well studied

Case reports of successful initiatives

Anecdotal evidence suggests much of local QI is ineffective

3. Do Local Healthcare Organizations Execute QI Activities Effectively?


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Macro Model of Organizational Predictors of QI Processes of Care?

Shortell, 1995


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Predictors of QI Implementation Processes of Care?

Cultural: beliefs, values & behaviors relative to QI

+ organizational culture emphasizing teamwork & innovation

+ commitment of senior managers & physicians

Structural: individual & group responsibilities

+ Decentralized decision-making

+ Longer experience

+ Greater number of teams & projects

Strategic: approach to QI

+ “prospector” approach

Technical: resources

+ presence of organization-wide information systems


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Study of MBQI in Inpatient Psychiatric Units Processes of Care?

  • NIMH-funded study of 32 hospitals in MA & CA

  • What are inpatient psychiatry units trying to improve?

    • effectiveness -- patient-centered care

    • access -- safety

    • equity -- efficiency

  • To what extent do these objectives address EBPs?

    • Facilitators & barriers to adoption

  • To what extent do hospitals achieve measurable change?

  • Hypothesis

    • Fit between organization & predict QI effectiveness


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Micro Model of Organizational Predictors of QI Processes of Care?

Hermann, 2005


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Culture Processes of Care?

  • Inpatient clinicians’ knowledge & beliefs about evidence basis for QI objective

  • Inpatient clinicians’ beliefs about the value of the QI objective to their patients’ care & outcomes


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Structure Processes of Care?

Course of QI objective as tracer of organizational structure:

  • serial reports of results disseminated to inpatient clinicians?

  • are interventions attempted?

  • reports of progress (or barriers) to appropriate committees?

  • participation / coordination among necessary departments?


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Leadership Processes of Care?

  • Selecting objectives that are priority of hospital leaders?

  • Responsive to external pressures?

  • Leaders actively involved or monitoring progress?


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Resources Processes of Care?

Availability of resources for achieving QI objective

  • training

  • tools

  • time

  • support (eg, data collection & analysis)


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Conclusion Processes of Care?

  • Greater progress toward implementing EBPs may be achieved by aligning organizations’ QI activities with EBP goals

  • Components of alignment:

    • Provider organizations need to select evidence-based QI objectives

    • External groups need to reinforce emphasis on EBPs

    • Local MBQI needs to be more effective

  • Ongoing research aimed at:

    • understanding barriers to adopting evidence-based QI objectives

    • understanding organizational factors influencing QI progress

    • developing interventions to improve effectiveness of local QI


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