Aligning Measurement-Based QI with Evidence-Based Practice Implementation

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Aligning Measurement-Based QI with
Evidence-Based Practice Implementation

• Richard Hermann, MD, MS
• Associate Professor of Medicine and Psychiatry
• Tufts University School of Medicine
• Center for Quality Assessment Improvement in
  Mental Health
• at Tufts-New England Medical Center
• www.cqaimh.org

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Overview

• How does evidence-based practice implementation
  (EBPI) relate to measurement-based quality
  improvement (MBQI)?
• different paradigms
• similarities and differences
• Potential for convergence synergy
• What obstacles need to be addressed?
• Current research study on QI

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Evidence-Based Practices

• EBP Rating
• ACT / ICM A
• Evidence-based Psychotherapies A
• Family Psychoeducation A
• Supported Employment A
• Integrated Dual Diagnosis Treatment A
• Medication Management A
• Multi-Systemic Therapy A
• A RCTs B less rigorous studies C consensus
  or opinion

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EBP Implementation a Top-Down Model

• Research Controlled trial of clinical
  intervention
• ?
• Development Codification of EBP by experts
• ?
• Commercialization Packaging tools, scales,
  materials
• ?
• Diffusion Social marketing, training, support
• ?
• Adoption Local provider organizations
• ?
• Consequences Change to practice outcomes

Rogers, Diffusion of Innovations, 2003
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Measurement-Based QI

• A bottom-up model
• Activities conducted by local provider
  organizations
• Influenced by external groups
• MBQI is in wide use
• 90-98 of hospitals report formal programs
• MBQI is costly
• estimated cost 200,000 per hospital per year

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Principles of Measurement-Based QI

• Quality as problems in processes
• Measurement analysis
• Broad participation
• Inductive reasoning
• Trial and error

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Model for Measurement-based QI
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Commonalities between MBQI and EBPI

• Both address important problemssome overlap
• Both employ measurement
• MBQI rates of EBP use, appropriateness
• EBPI fidelity to evidence-based model
• Both start with an understanding of underlying
  processes
• MBQI determined locally, informed externally
• EBPI studied externally, expanded locally
• Both involve systematic intervention to change
  practice
• MBQI determined locally, informed by research
  experience
• EBPI developed by experts, customized to local
  circumstances

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Potential for MBQI to Enhance Evidence-Based
Practice Implementation

• Promotes local organizational development
• system perspective
• team work
• analytic skills
• experience implementing change
• Increases awareness of gaps
• Prompts investigation
• Motivates exploration of available interventions
• ? Potential for uptake of EBPs

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Integrating MBQI with EBPI Requires Alignment
Across Healthcare System
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Conditions for Successful Alignment

1. Local organizations need to select QI objectives
   that address gaps between actual evidence-based
   practice
2. External organizations mandating measures also
   need to emphasize measures of EBPs
3. Microsystems within local organizations need to
   execute these QI activities effectively

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1. Do Quality Measures Used for Local MBQI
Address Evidence-Based Practices?

• Reviewed measures developed for mental health QI
• 308 measures identified evaluated
• 9 supported by RCTs
• 30 supported by less rigorous evidence
• 61 not supported by evidence
• Evidence-based measures less likely to be adopted
• Pilot study of QI objectives adopted by MA
  hospitals
• lt 10 of hospital objectives address EBPs
• National Inventory of Mental Health Quality
  Measures (www.cqaimh.org)

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2. Do Mandated Quality Measures Address
Evidence-based Processes of Care?

• Measures established by
• Accreditor requirements
• Government reporting requirements
• Benchmarking collaboratives
• Results increasingly linked to
• Pay for performance incentives
• Public disclosure
• Employer purchasing decisions

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2. Do Mandated Quality Measures Address
Evidence-based Processes of Care?

• Illustrative Measures
  Rating
• Restraint / seclusion rates C
• Elopement rate C
• Injury rate C
• Number of medications C
• Readmission rate C
• Medication errors B
• Antipsychotic dose A
• Antidepressant Adherence A

A RCTs B less rigorous studies C consensus
or opinion
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Evidence-Based Practices

• EBP Rating
• ACT / ICM A
• Evidence-based Psychotherapies A
• Family Psychoeducation A
• Supported Employment A
• Integrated Dual Diagnosis Treatment A
• Medication Management A
• Multi-Systemic Therapy A
• A RCTs B less rigorous studies C consensus
  or opinion

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Attributes Informing Quality-Measure Selection
Maximize Measure Attributes
Represent Mental Health System Broadly
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Evidence-Based Objectives for Inpatient QI
Schizophrenia

• ? use of antipsychotic drugs w/in recommended
  dose range
• ? use of multiple antipsychotics without adequate
  rationale
• ? receiving adequate drug trials for refractory
  sx
• ? assessment/detection for EPS, akathisia or TD
  ? rate of evidence-based treatment
• ? enrolled/referred to ACT among inpatients at
  high risk for relapse
• ? family members provided/referred to
  psychoeducation
• ? fidelity of inpatient psychoeducation program.

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Evidence-Based Objectives for Inpatient QI
Depression

• ? use of antidepressant drugs w/in recommended
  dosage range
• ? assessment/detection of psychosis among
  depressed inpatients ? use of adequate
  pharmacotherapy or ECT for psychotic depression
• ? use of anticholinergic antidepressants among
  depressed elderly inpatients
• ? of inpatients w/ major depression referred to
  OP clinicians providing evidence-based
  psychotherapy

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Other Evidence-Based Objectives for Inpatient QI

• ? assessment detection of medical conditions
• ? receiving appropriate inpatient medical care,
  outpatient referral communication between IP
  OP clinicians
• ? assessment/detection of SUD ? receiving
  inpatient treatment OP referral

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3. Do Local Healthcare Organizations Execute QI
Activities Effectively?

• Effectiveness in controlled trials
• Shortell (1998) reviewed 55 studies finding
  pockets of improvement rather than evidence of
  widespread change
• Effectiveness of routine QI
• Not well studied
• Case reports of successful initiatives
• Anecdotal evidence suggests much of local QI is
  ineffective

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Macro Model of Organizational Predictors of QI
Shortell, 1995
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Predictors of QI Implementation

• Cultural beliefs, values behaviors relative to
  QI
• organizational culture emphasizing teamwork
  innovation
• commitment of senior managers physicians
• Structural individual group responsibilities
• Decentralized decision-making
• Longer experience
• Greater number of teams projects
• Strategic approach to QI
• prospector approach
• Technical resources
• presence of organization-wide information
  systems

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Study of MBQI in Inpatient Psychiatric Units

• NIMH-funded study of 32 hospitals in MA CA
• What are inpatient psychiatry units trying to
  improve?
• effectiveness -- patient-centered care
• access -- safety
• equity -- efficiency
• To what extent do these objectives address EBPs?
• Facilitators barriers to adoption
• To what extent do hospitals achieve measurable
  change?
• Hypothesis
• Fit between organization predict QI
  effectiveness

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Micro Model of Organizational Predictors of QI
Hermann, 2005
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Culture

• Inpatient clinicians knowledge beliefs about
  evidence basis for QI objective
• Inpatient clinicians beliefs about the value of
  the QI objective to their patients care
  outcomes

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Structure

• Course of QI objective as tracer of
  organizational structure
• serial reports of results disseminated to
  inpatient clinicians?
• are interventions attempted?
• reports of progress (or barriers) to appropriate
  committees?
• participation / coordination among necessary
  departments?

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Leadership

• Selecting objectives that are priority of
  hospital leaders?
• Responsive to external pressures?
• Leaders actively involved or monitoring progress?

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Resources

• Availability of resources for achieving QI
  objective
• training
• tools
• time
• support (eg, data collection analysis)

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Conclusion

• Greater progress toward implementing EBPs may be
  achieved by aligning organizations QI activities
  with EBP goals
• Components of alignment
• Provider organizations need to select
  evidence-based QI objectives
• External groups need to reinforce emphasis on
  EBPs
• Local MBQI needs to be more effective
• Ongoing research aimed at
• understanding barriers to adopting evidence-based
  QI objectives
• understanding organizational factors influencing
  QI progress
• developing interventions to improve effectiveness
  of local QI