Initial Evaluation of Breakthrough Series 1999

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 Emmetts comments
• Key research questions and methods challenges
• Disparities

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Emmett Nailed It

• Agree with most of his points

4
Building on Emmetts 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 Emmetts 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

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Building on Emmetts 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/independe
  nce

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Key Research Questions and Methods Challenges

• Summaries of QI Collaboratives
• Wilson et al. Jt Comm J Qual Safety 2003
  2985-93.
• Ovretveit et al. Qual Safety Health Care 2002
  11345- 351.

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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

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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

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Research Challenges 1

• Implementation/managerial vs. quality
  process/outcomes assessment
• Multifactorial interventions
• Isolating effects of indiv. components where to
  invest
• Whats essential
• Going beyond the general e.g. leadership
  support and buy-in
• Do we need new measurement tools for future
  questions

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Research Challenges 2

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

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Research Challenges 3

• Cost Business case and societal perspectives
• Data hard to get
• Limited number of sophisticated models
• Sustainability
• Unintended consequences of QI interventions

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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

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Levels of Interventions

• Policy
• Health care organization
• Health care organization community partnership
• Provider-Patient Interaction

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Other Disparity QI Issues

• Feasibility, replicability, sustainability
• Make explicit societal investment