INTERNAL INITIATIVES OR EXTERNAL FEEDBACK: WHAT WILL WORK?

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INTERNAL INITIATIVES OR EXTERNAL FEEDBACK WHAT
WILL WORK?

• Pedro J. Saturno, MD, Dr PH
• Profesor de Salud Pública, Universidad de Murcia
• Visiting Lecturer in Quality Management,
• Harvard School of Public Health

EQuiP Conference, Brussels November 2004
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Every program or initiative to improve quality
has some effect. Everything seems to work A.
Donabedian

• Quality can be measured externally. Internally
  it can be measured and improved
• R.H. Palmer

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• INTERNAL AND EXTERNAL DEFINED
• IMPLEMENTATION RESEARCH WHAT DO WE KNOW?
• STRATEGIES TO IMPROVE QUALITY
• A TAXONOMY
• MODELS AND THEORIES EXPLAINING THE STRATEGIES
• THE ELEMENTS OF MANAGING CHANGE
• THE TYPE AND ROLE OF INCENTIVES
• ADDITIONAL FOOD FOR THOUGHT SOME QUESTIONS
  ARISING FROM HEALTH-SYSTEM-WIDE EMPIRICAL DATA.
• CONCLUSIONS

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1. INTERNAL AND EXTERNAL DEFINED

• THE INITIATIVE TO IMPROVE IS INTERNAL, AND THE
  DOMAINS, TOPICS, INDICATORS AND METHODS FOR QI
  ARE DECIDED BY THE CENTER, TEAM, GROUP OR
  INDIVIDUAL PRACTITIONERS

• INTERNAL FOCUS

• THE INITIATIVE TO IMPROVE IS EXTERNAL, AND THE
  DOMAINS, TOPICS, INDICATORS AND (AT LEAST
  PARTIALLY) METHODS FOR QI ARE DECIDED BY THE
  ADMINISTRATIVE UNITS OR INSTITUTIONS OUTSIDE THE
  CENTER, TEAM OR GROUP.

• EXTERNAL FOCUS

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• INTERNAL AND EXTERNAL DEFINED
• IMPLEMENTATION RESEARCH WHAT DO WE KNOW?
• STRATEGIES TO IMPROVE QUALITY
• A TAXONOMY
• MODELS AND THEORIES EXPLAINING THE STRATEGIES
• THE ELEMENTS OF MANAGING CHANGE
• THE TYPE AND ROLE OF INCENTIVES
• ADDITIONAL FOOD FOR THOUGHT SOME QUESTIONS
  ARISING FROM HEALTH-SYSTEM-WIDE EMPIRICAL DATA.
• CONCLUSIONS

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• II. IMPLEMENTATION RESEARCH. WHAT DO WE KNOW?

• LITTLE !! .
• LITTLE COMPARATIVE INFORMATION ABOUT HE MOST
  EFFECTIVE WAYS TO IMPLEMENT QI.
• MOST EMPIRICAL DATA ARE DESCRIPTIVE
• MOST STUDIES ARE CASE STUDIES

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• . BUT VARIED !!
• EXAMPLES, MODELS AND THEORIES ABOUND

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AND RELATIVELY FOCUSED

• Two main tracks for research
• DIFUSSION OF KNOWLEDGE
• BEHAVIOURAL CHANGE

• Three main and distinct levels for interventions
• FRONT LINE HEALTH PRACTITIONERS (Individuals,
  groups or teams)
• ORGANIZATIONS
• HEALTH CARE SYSTEM

• Three main targets for strategies
• PROVIDERES
• PATIENTS
• SYSTEM (practice environment)

INTERVENTIONS, STRATEGIES AND EXPECTED RESULTS
MAY BE DIFFERENT FOR DIFFERENT LEVELS AND TARGETS
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• INTERNAL AND EXTERNAL DEFINED
• IMPLEMENTATION RESEARCH WHAT DO WE KNOW?
• STRATEGIES TO IMPROVE QUALITY
• A TAXONOMY
• MODELS AND THEORIES EXPLAINING THE STRATEGIES
• THE ELEMENTS OF MANAGING CHANGE
• THE TYPE AND ROLE OF INCENTIVES
• ADDITIONAL FOOD FOR THOUGHT SOME QUESTIONS
  ARISING FROM HEALTH-SYSTEM-WIDE EMPIRICAL DATA.
• CONCLUSIONS

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• III. STRATEGIES TO IMPROVE QUALITY
• A TAXONOMY
• MODELS AND THEORIES EXPLAINING THE STRATEGIES
• THE ELEMENTS OF MANAGING CHANGE

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A TAXONOMY OF QI STRATEGIES
I. TARGETED TO THE ORGANIZATION

• 1.ORGANIZATIONAL CHANGE (e.g. QM programmes, EFQM
  model)
• 2. PROVIDER REMINDER SYSTEMS AND ALIKE

II. TARGETED TO PROVIDERS
3. AUDIT AND FEEDBACK 4. PROVIDER EDUCATION 5.
FACILITATED RELAY OF CLINICAL DATA 6. INCENTIVES
(financial, regulatory or legislative)
III. TARGETED TO PATIENTS

• 7. PATIENT REMINDERS
• 8. PATIENT EDUCATION/EMPOWERMENT
• 9. PROMOTION OF SELF-MANAGEMENT

Adapted from Shojania KG, McDonald KM, Wachter
RM, Owens OK Closing the Quality Gap A Critical
Analysis of Quality Improvement Strategies. Vol.
1. AHRQ, 2004.
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MODELS AND THEORIES FOR QI INTERVENTIONS
I. CONCEPTUAL MODELS OR GRAND THEORIES

• I.1. CLASSICAL THEORIES OF CHANGE
• DIFFUSION OF INNOVATION THEORY

• I.2. PLANNED MODELS OF CHANGE
• PRECEDE-PROCEED
• SOCIAL MARKETING
• BERWICKS SEVEN RULES FOR DISSEMINATION
• OTAWA MODEL FOR HCR USE

II. MID-RANGE THEORIES (DISCIPLINE-SPECIFIC)
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THE DEMOGRAPHY OF CHANGE
SETTLERS
PIONEERS
LAGGARDS
EXPLORERS
STONES
CHANGE BY EVIDENCE (OBSERVED RESULTS)
RATIONAL AND INTELECTUALLY CONVINCED
CHANGE BECAUSE EVERYBODY DOES
CHANGE NEVER QUESTIONED
CHANGE IS NEVER GOOD
Based on E. Rogers Diffusion of Innovations
Theory
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MODELS AND THEORIES FOR QI INTERVENTIONS

• II.1. SOCIAL PSYCHOLOGICAL THEORIES
• SOCIAL INFLUENCE THEORIES
• MOTIVATIONAL THEORIES
• Social cognitive theory
• Theory of planned behaviour
• ACTION THEORIES
• STAGE THEORIES

• II.2. ORGANIZATIONAL THEORIES
• RATIONAL MODELS
• INSTITUTIONAL MODELS

• II.3. OTHER DISCIPLINE-BASED THEORIES
• ADULT LEARNING THEORY
• MARKETING APPROACHES
• ECONOMIC THEORIES (e.g. Quality based purchasing)

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RESULTS INTERNAL QI ACTIVITIES GROUP
1St EVALUATIÓN
2nd EVALUATIÓN
Relativeimprovement
100
70
90.2
p0.04
86.0
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Recording of prescribed treatment
p0.05
72,0
72.5
70
67.6
p0.02
No prescription of Ab/Ah/Ct
52.9
Physical exam
0
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RESULTS FEEDBACK GROUP TRAINING IN QI
Relativeimprovement
1St EVALUATIÓN
2nd EVALUATIÓN
100
97.9
69
p0.03
Recording of prescribed treatment
93.3
50.4
18
p0.04
No prescription of Ab/Ah/Ct
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43.1
Plt0.001
39.7
Physical exam
22.0
0
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RESULTS FEEDBACK S-GROUP WITHOUT TRAINING
1St EVALUATIÓN
2nd EVALUATIÓN
Relativeimprovement
100
93.0
Recording of prescribed treatment
89.9
n.s.
n.s.
42.2
No prescription of Ab/Ah/Ct
36.6
n.s.
n.s.
26.0
Physical exam
17.0
n.s.
n.s.
0
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RESULTS IN THE CONTROL GROUP
1St EVALUATIÓN
2nd EVALUATIÓN
Relativeimprovement
100
Recording of prescribed treatment
n.s.
95.0
94.0
No prescription of Ab/Ah/Ct
74.4
n.s.
70.5
56,0
12
p0.01
Physical exam
40.0
0
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AVERAGE TREATMENT COST ( )
6.07
plt0.01
3.44
7.45
n.s.
7.09
7.49
n.s.
10.11
6.21
n.s.
5.54
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THE ELEMENTS OF MANAGING CHANGE FOR QI

• Intentionally planed and performed
• Defined strategy
• Defined structure for QM
• Comprehensive vision for QM activities
• Resources
• Incentives

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THE ELEMENTS OF MANAGING CHANGE FOR QI

• Intentionally planed and performed
• Defined strategy
• Defined structure for QM
• Comprehensive vision for QM activities
• Resources
• Incentives

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Quality management through the health care system
CHARACTERISTICS AND RESPONSABILITIES
SYSTEM LEVELS FOR QUALITY
Population-based indicators, including all
dimensions of quality and all institutions. Focus
on overall system strategies. Responsibility of
high level managers and political authorities.
Indicators on the quality of the specific
services for the specific population served by
the institution. Focus on optimizing resources
and regulating processes Indicators on the
quality of the organization. Responsibility of
the managers of the institution
Indicators on satisfaction, technical quality and
effectiveness for specific conditions and type of
patients. Focus on clinical quality on a broad
sense. Responsibility mostly of clinical
personnel.
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THE ELEMENTS OF MANAGING CHANGE FOR QI

• Intentionally planed and performed
• Defined strategy
• Defined structure for QM
• Comprehensive vision for QM activities
• Resources
• Incentives

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GROUPS OF ACTIVITIES FOR QUALITY IMPROVEMENT
QUALITY IMPROVEMENT CYCLES
MONITORING
QUALITY PLANNING OR DESIGN
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THE ELEMENTS OF MANAGING CHANGE FOR QI

• Intentionally planed and performed
• Defined strategy
• Defined structure for QM
• Comprehensive vision for QM activities
• Resources
• Incentives

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THE ELEMENTS OF MANAGING CHANGE FOR QI

• Intentionally planed and performed
• Defined strategy
• Defined structure for QM
• Comprehensive vision for QM activities
• Resources
• Incentives

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• INTERNAL AND EXTERNAL DEFINED
• IMPLEMENTATION RESEARCH WHAT DO WE KNOW?
• STRATEGIES TO IMPROVE QUALITY
• A TAXONOMY
• MODELS AND THEORIES EXPLAINING THE STRATEGIES
• THE ELEMENTS OF MANAGING CHANGE
• THE TYPE AND ROLE OF INCENTIVES
• ADDITIONAL FOOD FOR THOUGHT SOME QUESTIONS
  ARISING FROM HEALTH-SYSTEM-WIDE EMPIRICAL DATA.
• CONCLUSIONS

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IV. THE TYPE AND ROLE OF INCENTIVES
unlimited and with permanent effect

• Intrinsic

• Extrinsic

limited and with short time effect

• Financial

mostly extrinsic

• Reputational

mostly intrinsic
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FACTORS THAT MAY INFLUENCE THE EFFECTIVENES OF
FINANCIAL INCENTIVES
1. CHARACTERISTCS OF THE INCENTIVE

• 1.1. FINANCIAL
• ADEQUACY OF RECIPIENT
• POTENTIAL IMPACT ON REVENUE
• COST OF COMPLIANCE

• 1.2. NON FINANCIAL
• ACCEPTABILITY OF GOALS
• ATTAINABILITY OF GOALS
• INTRINSIC MOTIVATION
• PROVIDER PREFERENCES FOR DOMAIN OF GOALS
• APPROACH TO REINFORCEMENT (POSITIVE OR NEGATIVE)

2. CONTEXTUAL FACTORS

• 2.1. PREDISPOSING
• MIX OF OTHER INCENTIVES
• INDIVIDUAL PROVIDER CHARACTERISTICS

• 2.2. ENABLING
• ORGANIZATIONAL/STRUCTURE LEVEL
• PATIENT LEVEL

Adapted from Dudley RA, Frolich A, Robinow itz
DL et al Strategies to support quality-based
Purchasing A review of the Evidence. AHRQ.
Technical Review N.10. 2004
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FACTORS THAT MAY INFLUENCE THE EFFECTIVENES OF
FINANCIAL INCENTIVES
1. CHARACTERISTCS OF THE INCENTIVE

• 1.1. FINANCIAL
• ADEQUALS OF RECIPIENT
• POTENTIAL IMPACT OF REVENUE
• COST OF COMPLIANCE

• 1.2. NON FINANCIAL
• ACCEPTABILITY OF GOALS
• ATTINABILITY OF COALS
• INTRINSIC MOTIVATION
• PROVIDER PREFERENCES FOR DOMAIN OF GOALS
• APPROACH TO REINFORCEMENT (POSITIVE OR NEGATIVE)

2. CONTEXTUAL FACTORS

• 2.1. PREDISPOSING
• MIX OF OTHER INCENTIVES
• INDIVIDUAL PROVIDER CHARACTERISTICS

• 2.2. ENABLING
• ORGANIZATIONAL/STRUCTURE LEVEL
• PATIENT LEVEL

Adapted from Dudley RA, Frolich A, Robinow itz
DL et al Strategies to support quality-based
Purchasing A review of the Evidence. AHRQ.
Technical Review N.10. 2004
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IV. ADDITIONAL FOOD FOR THOUGHT SOME QUESTIONS
ARISING FROM HEALTH-SYSTEM-WIDE PROJECTS AND
EMPIRICAL DATA

• USA Accreditation and quality. Is there a
  relationship?
• UK The new GP contract. Why it will or it will
  not work?
• Commonwealth Comparing data, comparing systems?

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USA Accreditation and quality. Is there a
relationship?
ACCREDITATION external initiative,
reputational/financial incentive

• 96 of hospital beds are accredited by the JCAHO
• (J. Loew, President of JCAHO, ISQua Meeting, Oct.
  2004)

• 50 of compliance with quality indicators
• Assessment of 439 indicators related to 30 health
  problems, in a population sample of 6700 adults.
• Worse scores
• Indicators on patient education a counselling
  (18)
• Alcoholism (10)
• Hip fracture (23)
• Best score senile cataract (78.7)

(MCGlynn et al The Quality of Health Care
Delivered to Adults in the United States. NEJM,
2003)
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UK The new GP contract Why it will or it will
not work?

• External initiative, financial incentive to
  groups.
• Aggregate score (points) based on compliance with
  146 indicators grouped in 7 groups.
• 1 point 75 (to be increased to 120 by
  2005/2006)

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INDICATORS FOR THE NEW GP CONTRACT (UK)
Adapted from UK Department of Health Investing
in General Practice. The New GPS Contract.
London, 2003
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THE SUBGROUP OF CLINICAL INDICATORS
Epilepsy
COPD
CHD
Asthma
CVA
Mental Health
Cáncer
Hypothyroidism
Hypertension
Diabetes
CHD- Coronary Heart Disease COPD- Chronic
Obstructuve Pulmonary Disease CVA
Cerebrovascular Accident (stroke)
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NEW GP CONTRACT INDICATORS ON PATIENT EXPERIENCE
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THE NEW GP CONTRACT

• Domains and areas non covered?
• Indicators non included?
• Weightings?
• Gaming?
• Disadvantaged areas?

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Commonwealth Fund 2004 International Health
Policy Survey
Topics System Views, Access, Doctor-Patient
Communication, Coordination, Emergency Room Care,
Prescription Drugs, Preventive Care, and Chronic
Illness Management Telephone survey of 1,400
adults ages 18 and older in Australia, Canada,
New Zealand, the United States, with an expanded
sample of 3,061 in the United Kingdom (funded by
The Health Foundation)
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GOING WITHOUT NEEDED CARE DUE TO COSTS, TOTAL
AND LOW INCOME
Percent went without care due to cost
75
57
50
44
40
35
34
29
26
25
17
12
9
0
AUS CAN NZ UK US
AUS CAN NZ UK US
Adults with Below
All Adults
Average Incomes
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Out-of-Pocket Medical Costs in the Past Year
Percent
75
57
50
26
25
22
14
12
11
10
7
5
4
0
AUS CAN NZ UK US
AUS CAN NZ UK US
No out-of-pocket cost
More than US 1,000
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• INTERNAL AND EXTERNAL DEFINED
• IMPLEMENTATION RESEARCH WHAT DO WE KNOW?
• STRATEGIES TO IMPROVE QUALITY
• A TAXONOMY
• MODELS AND THEORIES EXPLAINING THE STRATEGIES
• THE ELEMENTS OF MANAGING CHANGE
• THE TYPE AND ROLE OF INCENTIVES
• ADDITIONAL FOOD FOR THOUGHT SOME QUESTIONS
  ARISING FROM HEALTH-SYSTEM-WIDE EMPIRICAL DATA.
• CONCLUSIONS

48
Every program or initiative to improve quality
has some effect. Everything seems to work A.
Donabedian

• Quality can be measured externally. Internally
  it can be measured and improved
• R.H. Palmer

49
VI. CONCLUSIONS

1. Most research and evidence points out the
   importance of internal programs
2. External programs may facilitate internal
   initiatives, though support, supervision,
   provision of comparative data, and appropriate
   incentives.
3. Interventions to QI for specific conditions have
   to be implemented and probably also designed,
   internally, Health System and practice
   environment changes may provide an appropriate
   context for QI.
4. To succeed, an important attention must be given
   to the factors that promote desired behavioral
   changes among front-line clinicians.

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DEAR AUDIENCE, IF YOU OR ANYONE YOU LOVE
UNDERSTANDS THE PRECEDING CONVERSATION YOU
HAVE MY DEEPEST SYMPATHY
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THANK YOU !!

• Pedro J. Saturno

saber_at_um.es http//www.calidadsalud.com