Aligning Aligning Measurement-Based QI with Measurement-Based QI with Evidence-Based Practice Evidence-Based Practice Implementation 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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Aligning Aligning Measurement-Based QI with Measurement-Based QI with
Evidence-Based Practice ImplementationEvidence-Based Practice Implementation
Richard Hermann, MD, MS
Associate Professor of Medicine and PsychiatryTufts University School of Medicine
Center for Quality Assessment & Improvement in Mental Healthat Tufts-New England Medical Center
www.cqaimh.org
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OverviewOverview
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
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 QIPrinciples of Measurement-Based QI
Quality as problems in “processes”
Measurement & analysis
Broad participation
Inductive reasoning
Trial and error
Intervene Measure Plan Diagnose
Aim
Model for Measurement-based QIModel for Measurement-based QI
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Commonalities between MBQI and EBPICommonalities between MBQI and EBPI
Both address important problems—some 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 Potential for MBQI to Enhance Evidence-Based Practice ImplementationEvidence-Based Practice Implementation
Promotes local organizational development– system perspective– team work– analytic skills– experience implementing change
Increases awareness of gapsPrompts investigationMotivates exploration of available interventions
→ Potential for uptake of EBPs
Integrating MBQI with EBPI Requires Integrating MBQI with EBPI Requires Alignment Across Healthcare SystemAlignment Across Healthcare System
Environment
(eg, payers, accreditors)
Local Organization (eg, hospital)
Micro-system (eg, hospital inpatient unit)
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Conditions for Successful AlignmentConditions 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 1. Do Quality Measures Used for Local MBQI Address Evidence-Based Practices? 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:< 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 2. Do Mandated Quality Measures Address Evidence-based Processes of Care?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 2. Do Mandated Quality Measures Address Evidence-based Processes of Care?Evidence-based Processes of Care?
Illustrative Measures RatingRestraint / seclusion rates CElopement rate CInjury rate CNumber of medications CReadmission rate CMedication errors BAntipsychotic dose AAntidepressant Adherence AA = RCTs B = less rigorous studies C = consensus or opinion
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
Study of MBQI in Inpatient Psychiatric UnitsStudy of MBQI in Inpatient Psychiatric Units
Micro Model of Organizational Predictors of QIMicro Model of Organizational Predictors of QI
Environment
Culture
Organizational Factors
Resources
Selected Aims
& Measures
QI Progress Diagnose
Measure Plan
Intervene
QI Outcomes
Leadership
Structure
Hermann, 2005
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CultureCulture
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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StructureStructure
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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LeadershipLeadership
Selecting objectives that are priority of hospital
leaders?
Responsive to external pressures?
Leaders actively involved or monitoring progress?
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ResourcesResources
Availability of resources for achieving QI objective– training – tools– time – support (eg, data collection & analysis)
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ConclusionConclusion
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