Building Health Center Capacity for Research and Quality Development

Framing Discussion and Morning WorkshopThe Difference Between QI and Research and

Applying What We Learned

August 22, 2013Chicago, IL.

Joan PerniceKaren Hacker

Quality in Primary Care

•“The extent to which health services provided to individuals and patient populations improve desired health outcomes. The care should be based on the

strongest clinical evidence and provided in a technically and culturally competent manner with

good communication and shared decision making. “

• As defined by the Institute of Medicine (IOM)

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What is Integrated Quality?Health Center Mission

Strategic Organizational Goals

Quality Improvement Plan

Annual GoalsAnnual Work Plan

Process Improvement EffortsCommunication

Evaluation

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Quality Improvement is Everyone’s Business!

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CHC Board

CEO/Executive Director

CMO/Medical Director

Quality Coordinator

Quality Committee

Department Heads/Directors All StaffChief Operating

Officer

Chief Financial Officer

Dental Director

Director of Behavioral Health

 Linked aims of improvement

Batalden P B , and Davidoff F Qual Saf Health Care 2007;16:2-3

Copyright © BMJ Publishing Group Ltd and the Health Foundation. All rights reserved.

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Quality Improvement Premises

• There are gaps between knowledge and practice• There are large variations in practices• “Best practices” exist all over the world• All improvement requires change, but not all

change leads to improvement• Every system is perfectly designed to achieve the

results it achieves• We can learn a lot more working together than we

can working separately

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Our Focus: How to Enable CHC Culture to be the Best Possible

Performance Improvement

Training

Quality and Process

Improvement Strategies

Patient-Centered

Medical Home Transformation

How do we best leverage the integration of all three forces?

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A Performance Improvement Model

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Effective PI

Program

Leadership Commitmen

t to PIClear Vision

of PI

Rigorous Project

Selection

Measureable Results

Operational Accountabili

ty

Project Managemen

t Skills

Sustainability and

Change Managemen

t

Current Framework

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1. Meeting with Leadership

Team

2. Senior Leadership

Training

3. Essentials of Leadership Excellence

4. PIPD

Coachinga. Define

b. Measure/ Analyze

c. Improve

d. Sustain

e. Report Out

Create the Improvement DNAPerformance Improvement Practitioner Development (PIPD) Program

Define Measure /Analyze Improve Sustain

•Create project charter

•Complete stakeholder analysis

•Communication

•Create & validate process map

•Collect & analyze•Root cause analysis

•Communication

•Brainstorm & select improvements

•Test improvements

•Collect results•Implement improvements

•Communication

•Create sustain plan

•Develop run chart

•Communication

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What is Lean? a set of operational concepts a set of tools used in a

variety of industries – including service & healthcare – to improve business processes

a philosophy that helps drive efficiency through employee empowerment and change at the grass roots

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Jidok

a

Just

-in-T

ime

Standardization

Customer Focus

Continuous Improvement

Create standards for all key processes

Follow standard first, then continuously improve

Go & seeAsk “why” 5 times

Demand root cause action

Don’t accept, make or pass defects

Stop and surface the problem

Standardize

Solve

Cannot recognize defects if standards are not defined

Preventabnormalitiesfrom becoming the standard

The Underlying Principles

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The PDSA Cyclefor Learning and Improvement

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PlanAct

DoStudy

- Objective- Questions and predictions (Why?)- Plan to carry out the cycle(who, what, where, when)

- Carry out the plan- Document problems and unexpected observations- Begin analysis of the data

- Complete the analysis of the data - Compare data to predictions - Summarize what was learned

- What changes are to be made?

- Next cycle?

Lean Concepts for Improving Processes

1. Remove process waste2. Standardize the process3. Implement visual management4. Level load the process5. Improve the process to be “Just in Time”6. Build quality into the process

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Staffing: Acquiring/placing talent

Development: Building competence/capability

Measures: Tracking performance

Rewards: Recognizing/rewarding desired behavior

Communication:

Using information to build and sustain momentum

Organization Design:

Organizing to support the change initiative

IT Systems: Utilizing IT technology to enable changes to be successful and sustained

Resource Allocation:

Adjusting or planning for financial and other resources to support the change project

Factors to Consider

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Key Learning and Future Work Key learning from this work:• Develop process maps of

existing workflows before implementing change

• Communicate need for change, create buy-in, solicit input, engage stakeholders

• Change process: pilot small changes, document new workflows, communicate changes and train staff. Don’t short change the training process – ask the users to help develop training documents.

• Communication about practice redesign should be ongoing and through multiple channels (emails, posters, meetings)

• Develop a plan to ensure follow-through and foster accountability

Plans for future improvements:• Review, revise and document

improved workflows for all visit types using process maps

• Continue to explore ways to standardize workflows by maximizing EMR functionality

• Family Medicine’s lean initiative is part of the health center’s overall practice redesign efforts

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Defining Research

• A systematic investigation, including development, testing and evaluation, designed to develop or contribute to generalizable knowledge.

• Activities that meet this definition may be – funded or unfunded– may be conducted as a component of another program

not usually considered research.

Quality improvement versus research?

Quality Improvement

Classical Research

Primary Goal Local improvement in process or outcome

Generalizable knowledge

Context Embraces context Attempts to eliminate effect of context

Cycle time Rapid tests of change Longer data collection, definitive results

Data analysis More visual, level of certainty implicit

Statistical, explicit

Towards building a learning health care system

• Vision of the IOM Roundtable on Value & Science-Driven Health Care– . …a learning healthcare system designed to

generate and apply the best evidence for the collaborative health care choices of each patient and clinician; to drive the process of discovery as a natural outgrowth of patient care; and to ensure innovation, quality, safety, and value in health care

Institute of Medicine Roundtable on Value & Science-Driven Health Care Charter And VisionStatement. Retrieved August 25th, 2011 from www.iom.edu/~/media/RT%203pgr11_09.ashx

Why engage in research in health centers?

• To provide the best possible care to patients • To facilitate recruitment and retention of primary

care providers• To makes a health center more appealing to medical

school/residency programs• To bring in financial resources to the health center• To facilitate more efficient use of resources

Research in Community Health Centers http://www.aapcho.dreamhosters.com/download/PDF/Fried_ResearchInCHCs.pdf

Unwinding the scientific method:creating new knowledge

• We come to understand things by observing the world in structured ways.

• We develop hypotheses, test them, and (if we’re not ideologically constrained) revise them.

• Sometimes, we intervene and then observe.• We can be fooled by jumping to conclusions: chance,

bias, and confounding.

Bias

Chance

Confounding

Generalizability

Association

Causation

?

?

Threats to what we think we “know”?

Internal Validity

External Validity

Human subjects research

• Research involving human beings in any capacity• Encompasses everything beyond basic science

– translational research (bench to bedside)– clinical trials of preventive and therapeutic strategies– epidemiology, behavioral research, health services and

outcomes research– observational research

• Requires Institutional Review Board Approval (human subjects protection)

Steps in initiating research

• What’s the question?• Does it involve human subjects?• What’s the design?• What are the resources needed?• What is your health center capacity to

conduct?• Who are the partners and what skills do they

bring?

Determining design?

Classical research hierarchy:Case reportsCase seriesCase control studiesCohort studiesNon-randomized intervention trialsRandomized controlled trials

Based only on internal validity! Your best design?…

Ad

van

cin

g R

igo

r

Different designs for different questions

• Ramdomized Trial• Evaluating new treatments

• Cohort Study• Prognosis of patients with specific conditions

• Case-Control Study• Evaluating risk associated with environmental

exposures when outcomes are rare• Cross Sectional Study

• Assessing the accuracy of a diagnostic test• Qualitative Research

• Descriptive and hypothesis generating

Sampling Considerations1. • Comparison Group-is one available?• Bias-how representative is the group of the

group being studied?• Size-are the numbers large enough to assess

outcome of interest?• Is recruitment feasible?

Based only on internal validity! Your best design?…

Types of research at Community Health Centers

• Comparative Effectiveness• Health Services• Community Based Participatory Research

Comparative effectiveness

• Patients to the research community: “What have you done for me lately”… – Focus on direct relevance to shared choices– Comparison to real alternatives– Patient-centered outcomes (PCORI)– Use of both interventional (but more pragmatic) and

observational designs

Health services research

• Study of systems for delivering care, including variation, access to care, quality of care.

• Study of strategies of care (quality) improvement, guideline implementation, and other health policy changes.

• Study of the health system as a whole, including health insurance, managed care, health care workforce.

• Study health at the level of the population.

“ A partnership approach to research that equitably involves community members, organizational representatives, and researchers in all aspects of the research project.”

- Israel, et al., 2001

Community-Based Participatory Research (CBPR)

Infrastructure Needs to Conduct Research

• Research skills– Design– Data collection– Analysis– Dissemination

• Partnerships with Academia• IRB access• Funding