Comments on QI Interventions at Multiple Clinical Systems Levels

1. Comments on QI Interventions at Multiple Clinical Systems Levels Marshall H. Chin, MD, MPH Associate Professor of Medicine University of Chicago September 14, 2005

2. Roadmap • Emmett nailed it • Building on Emmett’s comments • Key research questions and methods challenges • Disparities

3. Emmett Nailed It • Agree with most of his points

4. Building on Emmett’s Comments 1 • Before-After with Control Group • Time series – often hard to get mult data points • Patient level cohorts – HIPAA concerns • Control sites often tricky to pick • Self-selection bias – who volunteers to participate in intervention

5. Building on Emmett’s Comments 2 • Population of focus vs. random sample of whole clinic • You may get different results • Biases in population of focus • Problem of who is in the registry - accuracy • Short-term evaluation – popul of focus OK • Whole clinic for ultimate intervention effect and sustainability over time

6. Building on Emmett’s Comments 3 • Multimethods – yes • What actually happened – challenging • Monthly reports – variable utility • Agree that self-reported outcome statistics of limited use • Academic – Funder – Implementer – Agency • Objectivity, fairness • Collaboration yet scientific objectivity/independence

7. Key Research Questions and Methods Challenges • Summaries of QI Collaboratives • Wilson et al. Jt Comm J Qual Safety 2003; 29:85-93. • Ovretveit et al. Qual Safety Health Care 2002; 11:345- 351.

8. Critical Components of QI Collaboratives (Wilson et al.) • Sponsorship – respected organization • Topic – determinant of success • Ideas for improvement – local or external • Participants – open or selective; # for crit mass • Senior leadership support • Preliminary work and learning • Strategies for learning and making improvements

9. Success of a Collaborative Team (Ovretreit et al.) • Work as team • Learn and apply QI methods • Strategic importance to home institution • Culture of home institution • Type and degree of support from management

10. Research Challenges 1 • Implementation/managerial vs. quality process/outcomes assessment • Multifactorial interventions • Isolating effects of indiv. components – where to invest • What’s essential • Going beyond the general: e.g. “leadership support and buy-in” • Do we need new measurement tools for future questions

11. Research Challenges 2 • Stages of Change: Tailor interventions • Structure and autonomy • A QI process vs. specific interventions • Practical: How can we help • Incentives • Assistance

12. Research Challenges 3 • Cost: Business case and societal perspectives • Data hard to get • Limited number of sophisticated models • Sustainability • Unintended consequences of QI interventions

13. RWJF Disparities • RWJF - Debra Perez • Expecting Success – GW – Bruce Siegal • Finding Answers: Disparities Research for ChangeUniv. of Chicago – NORC – Marshall Chin • Leading Change: Disparities Solutions InitiativeHarvard – Joe Betancourt

14. Levels of Interventions • Policy • Health care organization • Health care organization – community partnership • Provider-Patient Interaction

15. Other Disparity QI Issues • Feasibility, replicability, sustainability • $ • Make explicit societal investment