VA HSR&D SDP 09-158

Teresa Damush, PhDHeather Woodward-Hagg, MS

Marianne Matthias, PhDVirginia Daggett, DNS, MSN

Joseph Ross, MD, MHSZhangsheng Yu, PhD

Xinli Li, PHD, MS

Systems Engineering and Implementation Partnership:The INSPIRE Stroke Project

How the partnership began…

Chose improving stroke care as one element of their

VISN-wide focus for FY08

VISN 11

OQP

Stroke QUERI

Conducted national measurement of inpatient

stroke care in FY07-09

Worked with OQP to develop and measure stroke care, used these data to pilot a Systems Redesign-based collaborative in VISN 11 FY08-09, launch multi-site INSPIRE in FY10

OQP Stroke Special Project: National stroke performance data benchmarking

Goals: Measure in-hospital stroke care quality within the VA system

using both Joint Commission and VA specific in-patient care performance measures

Provide VA medical centers their data for inpatient stroke care quality

Assemble toolkit of existing programs, templates, and strategies to improve stroke care

Assess stroke risk factor management at 6 months and one-year post-discharge for veterans in the cohort with VA outpatient care

FY 2006 FY 2007 FY 2008 FY 2009

Quality indicators defined

Data collection tool developed Abstractor (n=90)

training

Data collection tool pilot testing

Data collection completed

Scoring algorithms completed

Final national data reported

Field review and correction of facility level data

Toolkit completed

Stroke QUERI and OQP collaboration established

Stroke network established

Multidisciplinary team assembled

OQP Stroke Special Project: Main Results

Process of CareDenominator

EligibleProportion of Eligible Patients with Performance Measure Present (%)

Antithrombotic at discharge 3514 96.4Antithrombotic by HD2 3523 95.6Smoking cessation counseling 1268 94.9Pressure ulcer assessment 3789 91.8Early ambulation 3009 86.1Rehab consultation/FIM 2796 86.0Lipid management 3009 82.1Fall risk assessment 3673 79.3DVT prophylaxis 1018 78.2Anticoagulation for afib 409 75.3NIHSS documented 3640 27.7Dysphagia screen before po 3591 23.4Stroke education 2524 18.1Thrombolysis (tPA) given 227 8.4

VISN 11 Pilot: Introducing Systems Engineering Methods in a Stroke

Collaborative

VISN11 leadership Dr. Pamela Reeves, CMO; Ann Herm, Clinical Program

Manager; Mary Sherrill, Systems Redesign lead

7 VAMC interdisciplinary teams of front line staff involved in stroke care

Stroke QUERI Center investigators and research coordinators

System Redesign/OSE Expertise – VISN 11 SR staff, Heather Woodward-Hagg/Indy COE

VISN 11 Pilot: Methods

Identification of stroke care improvement teams at all 7 VISN 11 facilities in 2008

Facility survey about stroke systems of carePre-collaborative work:

Baseline data collection Choice of 2 performance indicators: dysphagia screening

before oral intake and discharge on lipid-lowering medication OSE methods training (conference call and video) Inpatient stroke flow map and “Voice of the customer”

interviewsCollaborative:

Shared baseline data (chart review)—dysphagia screening, d/c on lipid lowering medication, developed standard admission order template

Paired didactic and team break-out sessions: More flow mapping, impact/effort assessments, PDSA cycles, future state process maps/action plans

Shared plans with group after each team session

Collaborative

Didactic and team break-out sessions

VISN 11 Pilot: Methods

Post-collaborative work: Systems Redesign “coaches” assigned to each team 6 biweekly coach-team calls and monthly group calls Monthly data review and aggregate data input on Sharepoint

site for 12 months

Analysis: Pre-collaborative data on indicators from OQP compared to

post-collaborative data Follow-up interviews with each team to assess how changes

were made, barriers to and facilitators of change, spread of methods

Developed training materials subsequently used in other VA collaboratives

VISN 11 Pilot: Results

Dysphagia results Cholesterol results

INSPIRE SDP: Intervention for Stroke Performance Improvement using Redesign

Engineering

Study aims: 1. To evaluate the effect of public reporting on

organizational change to improve stroke care quality in VA

2. To conduct a formative developmental evaluation in 14 of the largest volume VAMCs to understand organizational barriers and facilitators to the delivery of high-quality stroke care

3. To test a Systems Redesign/OSE-based intervention vs. performance feedback alone in improving 2 stroke indicators Stratify randomization by baseline performance Work on two indicators; plan for DVT prophylaxis and

dysphagia screening before oral intake but will be based on baseline data collection and site input

Year 1 Year 2 Year 3

IRB

R&D

Union

Aim 1 and

Aim 2

interviews1

Aim 3

pre-

work

Site

inter-

views2

Site

inter-

views1

Baseline chart

reviews

Intervention Primary outcome chart

reviews

Analysis

Q1

Jan 10

Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

INSPIRE timeline

1In-person site interviews2Telephone site interviews

INSPIRE Interview and baseline phase (Aims 1 and 2)

Interviews arranged by site PI, 2 interviewers to each site

2 different interviews Receipt of and response to the OQP Stroke Special Project

data: who received it, who else saw it, what action(s) resulted, how can the field best use/receive this type of data?

Current state of stroke systems of care from front-line providers: structure and personnel involved, any ongoing improvement teams or activities, assessment of the overall level of care provided, what is working well, what could be improved?

Interviews recorded, transcribed, analyzedBaseline stroke performance data collected via

central chart review for CY2009

INSPIRE Intervention Phase (Aim 3)

Sites randomized to intervention vs. control, stratified by baseline performance All sites with at least 50 stroke admissions annually

Intervention sites: In-person collaborative with OSE/SR training, followed by 6 months of coaching through rapid tests of change; monthly performance data feedback

Control sites: quarterly performance data feedback

Data collection for 12 months post-interventionAnalyses:

Primary: improvement in individual and composite performance indicators

Secondary: temporal pace of change in performance, sustainability of change, qualitative assessments of local context and relationship to changes observed

INSPIRE status

11 sites on board; active recruitment of 3 others Bay Pine, Birmingham, Chicago (Jesse Brown), Cleveland,

Durham, Houston, Loma Linda, Miami, Oklahoma City, Tennessee Valley, Tucson

Site interviews underwayVistaWeb access pending; plan for baseline data

collection via chart abstractions July-NovemberIn-person collaborative January 2011Planned SDP September: RE-INSPIRE: Rich-

context evaluation of INSPIRE; Edward Miech, PI

Questions?