Evidence-Based Quality Improvement (EBQI)

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Evidence-Based Quality Improvement(EBQI)

• Amy N. Cohen, PhD
• Desert Pacific Mental Illness Research Education
  and Clinical Center (MIRECC)

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Outline of Talk

• Description of EBQI
• Building a local QI team
• EBQI methods and tools
• Example EQUIP study

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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

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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.
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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.

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QI Assumptions

• Improvement possible
• Process complex
• Teamwork essential
• Data required
• Blame removed

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Steps to QI

• Clear mission and goals
• Establish Team
• Problem Identification
• Quality Improvement Cycle

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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)

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Team Establishment

• Sponsorship
• Composition
• Facilitation
• Meeting time
• Duration
• Training
• Rewards

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Team Formation

• Small number
• Complementary skills
• Committed to common purpose
• Performance goals
• Mutually accountable

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Problem Identification

• Baseline data
• Brainstorm causes
• Specify focus
• Recognize complex
• Secure support and involvement

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PDSA Cycle for Learning and Improvement
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Repeated Use of the Cycle
Changes That Result in Improvement
DATA
Hunches Theories Ideas
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QI Data Tools

• Process Maps
• Cause Effect diagrams (Fishbone)
• Check sheets (Tabulations)
• Histograms (Distributions)
• Scatter diagrams (Regression)
• Pareto charts
• Control charts
• Used in PDSA cycles for data collection analysis

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Process Map
Most flow charts are made up of five main types
of symbols
Walk through the steps and document. Reality
versus Ideal
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Cause and Effect Diagram (Fishbone)
Brainstorming stage
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Cause and Effect Diagram (Fishbone)Organizing
data
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Check Sheets
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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

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QI Essentials

• Good management
• Training
• Team work
• Measurement of performance
• Time
• Faith

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Effective Teams Have

• Supportive sponsor
• Orientation
• Sensible structure
• Clear mission and roles
• Staff support
• Access to information
• Shared expectations
• Useful tools and techniques

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EBQI Example in VAThe EQUIP Experience
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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)

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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

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EBQI Strategies in EQUIP

• Evidence base
• TMAP
• EQUIP-1

Provider/patient education
Quality manager
EBQI
QI Informatics support
Performance feedback
infrastructure priority-setting
Leadership support
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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

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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

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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

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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

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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

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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

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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

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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

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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