Lynne S. Nemeth, PhD, RN Medical University of South Carolina.

Lynne S. Nemeth, PhD, RNMedical University of South Carolina

PPRNet Research TeamRuth G. Jenkins, PhDPaul J. Nietert, PhDAndrea M. Wessell, PharmDHeather Liszka Rose, MD, MSLoraine F. Roylance, MASteven M. Ornstein, MD

Objectives Provide context for evaluating QI research

interventions within a practice-based research network (PPRNet)

Describe evaluation of a broad QI intervention in 99 primary care practices (A-TRIP)

Extend a conceptual framework to identify potential practice interventions to be tested (MS-TRIP)

Take home messageLearning about how quality improvement

interventions are implemented can inform study design

Future QI interventions might be more feasible and effective if we collect information about what is most commonly adopted within intervention sites

PPRNet is…

… “a practice-based learning and research organization designed to improve health care in its member practices and elsewhere in the United States.”

PPRNet QI ResearchTRIP II: RCT, 20 CVD indicators, 20 practices

(2001-02)A-TRIP: Demonstration project of >80 indicators

focused on primary care in 99 practices (2002-06)

AA-TRIP: RCT sub-project of A-TRIP focusing on ETOH screening and brief intervention (2004-07)

C-TRIP: RCT to investigate CRC screening in 30 practices (2006-10)

MS-TRIP: Demonstration project in 22 practices developing a set of medication safety indicators in ambulatory care practice (2007-2010)

Context for PPRNet QITheoretically informed process using three

models:Improvement Model (Feifer & Ornstein, 2004; Joint

Commission Journal of Quality and Safety)

Intervention Model (Feifer et al, 2006; Evaluation and the Health Professions)

Social influence, marketing Readiness for change Organizational learning, adult learning Complexity

Practice Development Model (Nemeth et al, 2008; Implementation Science)

Nemeth, Feifer, Stuart and Ornstein Implementation Science 2008: 3:3

QI ActivitiesPractice Reports (quarterly)

Show practice’s performance over timeComparison to

Other PPRNet practicesPPRNet ABC™ (90th percentile) (Wessell et

al, American Journal of Medical Quality, 2008)

National benchmarks (if available)Practice activation, evaluation and

feedback: site visits and network meetings

Data Sources Focus group style interviews on site and at

network meetingsSite visit observation of key attributes related

to improvement modelFollow up phone or email contacts with

practice liaisonsPractice level surveys on specific topicsPerformance data extracted from the EMR

PPRNet TRIP Quality Improvement Model Key Elements

Prioritize Performance

Involve All StaffRedesign Delivery

SystemActivate the PatientUse EMR Tools

© PPRNet, 2003* Jt Comm J Qual & Safety, August 2004, 30(8):432-441.

PPRNet-TRIP QI ModelPractices have used the model to organize

plans for improvement in the practiceWe catalogued QI activities related to site

visitsA compendium of strategies was developed

(35)In the ATRIP final survey, adoption of these

strategies was rated by practicesEach of the following strategies (18) listed was

rated by a nurse and physician as =>3 1-5 scale (1= never used, 5 =always used).

Prioritize PerformanceInvolve staff to

determine approaches to improvement (4.34)

Focus improvement efforts on ~3 items/quarter (3.93)

Redesign Delivery SystemsLimit prescription phone refills for

medications when visits are overdue (4.30)

Nursing staff alert providers about clinical parameters not at goal. (4.26)

Incorporate schedules at least three months in advance so the next follow-up can be scheduled at the current visit (3.94)

Use electronic systems to remind patients of services needed (3.94)

Redesign Delivery SystemReview office processes to decrease

redundancy (3.85)Nursing staff reviews medications with

patients (3.71)Schedule chronic disease labs before

visit (3.68)Reschedule chronically ill/health

maintenance patients that “no show” (3.65)

Help patients to acquire medications via prescription assistance programs (3.64)

Activate the PatientReinforce

protocols for prevention/disease management with consistent staff messages (3.45)

Distribute prevention/disease management goals in a handout (3.23)

Use EMR ToolsUse EMR templates to guide nursing staff with patient screening (3.99)

Use flow sheets, lab tables and/or health maintenance to remind practice of services needed (3.97)

Use EMR ToolsUse visit note templates to guide process of care (3.97)

Improve documentation of relevant A-TRIP diagnoses and measures (3.59)

Update activity status for deceased or inactive patients (3.51)

Top Ten StrategiesInvolve staff to determine approaches to

improvement (4.34)Limit phone refills when pt visits are overdue (4.3)Nsg staff alert clinicians re: clinical parameters not

at goal (4.26)Use EMR templates to guide nsg staff pt screening

(3.99)Use flow sheets, lab tables or health maintenance to

remind practice of services needed (3.97)Use visit note templates (3.96)Incorporate schedules at least 3 months ahead (3.94)Use electronic systems to remind pts of services

needed (3.93)Focus improvement on limited # of items per quarter

(3.93)Review office processes to decrease redundancy

(3.84)

(Nemeth et al, 2007 Journal of Nursing Care Quality)

A Culture of Safety“the biggest challenge in moving towards a

safer health system is changing the culture from one of blaming individuals for errors to one in which errors are treated not as personal failures but as opportunities to improve the system and prevent harm”

Institute of Medicine, 2001

MS-TRIP Indicator CategoriesAvoidance of Inappropriate TherapyInappropriate Dosing

(weight, age, renal function)Drug-Drug InteractionsDrug-Disease State InteractionsAdverse Drug Event Prevention

Avoidance of Inappropriate Therapy

Prioritize Performance, Redesign Delivery SystemDevelop a practice wide approach for managing viral

URI and evaluating medications in the elderlyActivate the Patient:

Review ineffectiveness of antibiotics for colds in advance; reinforce with office posters

Provide elderly patients with a list of meds that should be avoided

Use EMR Tools:Avoid inappropriate or rarely appropriate meds in the

elderly, attending to warnings in prescription writerReview and evaluate patients for medications that

should be avoided during chronic care or wellness visits

Inappropriate Medication Dosing (age, weight, and/or renal function) Prioritize Performance, Involve all Staff:

Clinical staff review lab data prior to visit in chronic care patients; flag out of range lab values for provider to act upon

Develop a consistent process to call pt back re: lab dataRedesign the Delivery System:

Assure weight is consistently measured at each visitObtain labs in advance to adjust dosing as needed

Use EMR Tools:Use dose advisor in prescription writer; act upon

warnings when promptedApply disease and medication specific templates in

health maintenance tables

Drug-Drug InteractionsPrioritize Performance:

Record all medications patient is takingInvolve all Staff:

Educate staff calling in refills on high risk medications on the interactions within indicators

Redesign the System/Use EMR tools:When entering/reviewing medications heed all

drug interaction warnings (click “MORE” for ALL warnings)

Activate the Patient:Have patients always bring list of all medications

Drug-Disease State Interactions

Activate the Patient:Provide specific warning to patients about

interactions related to their specific therapy as appropriate

Redesign Delivery System /Use EMR Tools:Apply disease and medication specific HM templates

as indicatedAssure problem lists are accurate to activate disease

state interactionsIdentify (using query tools) and contact patients

with specific disease and medications that interact

Adverse Drug Event PreventionInvolve all Staff/Redesign the System:

Ensure lab f/u ordered, monitored appropriatelyClinical staff prompt providers re: out of range

resultsDevelop an anticoagulation monitoring system

Activate the Patient:Advise patient of specific f/u for medication

regimensProvide a patient handout on medication safety

Use EMR Tools:Use Health Maintenance medication templates and

act upon the specific reminders

ImplicationsAdapt QI interventions to suit local context,

yet ensure consideration of specific strategiesMeasurement involves comprehensive

qualitative data collection and survey methods to identify effective approaches, but maximize survey response as needed

Evaluate high and low performers in the context of what has or has not been changed in practice