Regenstrief Conference Doebbeling

10th Biennial Regenstrief Conference Overview

Brad Doebbeling

VA Center of Excellence on Implementing Evidence-based Practice

IU Center for Health Services & Outcomes Research, Regenstrief Institute, Inc.

IU School of Medicine

October 2-4, 2007

• The U.S. is a world leader in the advancement of medical science and technology, defining the cutting edge in most areas of clinical training, research and practice.

• This tremendous progress by focusing resources on research in the physical and life sciences and developing devices and equipment.

• However, our lack of systems for the delivery of healthcare limit the realization of achievements made possible by these advances.

Healthcare “System” Chasm

“Between the healthcare we have and the care we could have lies not just a gap but a chasm”.

How Hazardous Is Health Care?

1

10

100

1,000

10,000

100,000

1 10 100 1,000 10,000 100,000 1,000,000 10,000,000

Number of encounters for each fatality

To

tal lives lo

st

per

year

REGULATEDDANGEROUS(>1/1000)

ULTRA-SAFE(<1/100K)

HealthCare

Mountain Climbing

Bungee Jumping

Driving

Chemical Manufacturing

Chartered Flights

Scheduled Airlines

European Railroads

Nuclear Power

Source: Berwick, D.M.

RAND Study: Quality of Health Care Often Not Optimal

• We provide appropriate health care only 55% of the time

Percentage of timePercentage of time

Alcohol dependenceAlcohol dependenceHip fractureHip fracturePeptic ulcerPeptic ulcer

DiabetesDiabetesLow back painLow back painPrenatal carePrenatal careBreast cancerBreast cancer

CataractsCataracts

11%11%23%23%

33%33%45%45%

69%69%73%73%76%76%79%79%

E. McGlynn, S. Asch, J. Adams, et al., The Quality of Health Care Delivered E. McGlynn, S. Asch, J. Adams, et al., The Quality of Health Care Delivered to Adults in the United States, to Adults in the United States, N Engl J MedN Engl J Med, 2003, 2003

New and Unprecedented Challenges

• Greater demands in performance and accountability

• New drugs and technologies • Deteriorating nurse, pharmacist and

physician morale • Limited access, under- and non-insured• Inequitable patterns of utilization

unsustainable cost increases

Challenges

• Delays between research and implementation

• New products often poorly evaluated before hitting the market

• Overuse, underuse, misuse, duplication, system failures, unnecessary repetition

• Poor communication and inefficiency

Challenges

• Implementation of research suboptimal• Major gaps in the quality and reliability of

healthcare persist • Inequitable patterns of utilization, poor

safety and unsustainable cost increases • Estimated 98,000 Americans die and more

than 1 million patients injured annually receiving health care in the US due to system failures

Systems Transformation

Healthcare Systems• “consists of interacting, interrelated, or

interdependent elements that form a complex whole.”

• Comprised of multiple levels, including the patient, provider or care team, organization, and the political and economic environment.

• This set of interacting elements (e.g., clinics, units, people) behaves differently than individuals acting alone.

Ryan J. in IOM/NAE Report, 2005.

System Transformation

• A series of multidimensional changes to the context/culture, structure, and processes of a health care organization, designed to radically, consistently, and reliably improve the delivery of care

Challenges to System Transformation

• Adopting a systems view

• Coordinating complicated changes across multiple system levels

• Meeting data requirements for systems engineering approaches

• Building relationships between healthcare professionals and engineering professionals

• Available resources

Systems Transformation

• Three concepts central to system transformation – Integration

-training, aligning reinforcements with new behaviors, or assigning responsibilities

– Sustainability-maintaining gains in safety and quality as well as maintaining support for change

– Spread-requires supportive infrastructure for sharing successful redesign experiences

Wang et al. Redesigning health systems for quality: lessons from emerging perspectives. Jnt Comm J Qual Safety 2007

Systems Engineering

Institute of Medicine (IOM) and National Academy of Engineering (NAE) Report

• Systems engineering tools and a system perspective should be applied to redesign healthcare delivery in order to reduce waste and provide more efficient care.

• Partnerships between systems engineers and providers.

Reid PP, Compton D, et al. Building a better delivery system: A new engineering/health care partnership, Natl. Acad. Press, 2005.

System Engineering

• Systems engineering involves the design, implementation, and control of a complex system.

• Goal: to produce a system that meets the needs of all users or participants within the constraints that govern the system’s operation.

Challenges to applying system engineering to healthcare

• Organizational and Managerial Obstacles – rigid division of labor. This

compartmentalization does not optimally support the application of tools that transcend and span functional areas.

• Educational Barriers – few healthcare providers trained to think

analytically and systematically about how healthcare delivery systems can and should function.

Reid PP, Compton D, et al. Building a better delivery system: A new engineering/health care partnership, Natl. Acad. Press, 2005.

Challenges

• Lack of training• Systems engineering approaches often

have major data requirements• Collection, storage, processing, and

retrieval of this data require sophisticated and expensive integrated information systems

• Need for building effective partnerships

Promoting System Redesign

• Involve top- and middle-level leaders

• Align and integrate improvement efforts with organizational goals

• Involve champions, teams, and staff in leading redesign efforts

• Establish and maintain infrastructure, processes, and performance feedback that supports continuous improvement

Wang et al. Redesigning health systems for quality: lessons from emerging perspectives. Jnt Comm J Qual Safety 2007

Systems Redesign

• Change must be perceived as beneficial to the individual and organization

• Change must be perceived as compatible with existing systems, practices, values, beliefs, and current needs

• Frequent data monitoring and feedback to adopters helps reinforce changes and sustainability

Implementation Science

Conceptual Frameworks

• Research efforts not directly related to healthcare can be used in system transformation– complex responsive systems theory– organizational change theory– sociotechnical theory – knowledge management, utilization– implementation research

An IHI Framework for Spread

• Prepare for the spread

• Identify an aim for the spread

• Develop a plan for spread

• Execute and refine the plan

Informatics Implementation Challenges• Most settings don’t assess provider or patient

needs

• Implementation often does not utilize research findings about human cognition, HCI or organizational ergonomics

• Need for adoption of information systems, clinical decision support to consistently improve care.

• Great need to use data to inform decisions.

• Value of visualization, modeling, simulation.

Doebbeling et al. Priorities and Strategies for Implementation of an Integrated Informatics and Communications Technology System for Evidence-based Practices. J. Gen. Intern. Med. 21:S98-S105, 2006

Toward Evidence-Based Quality Improvement

• Most comparisons reporting dichotomous process data (87%) observed improvements in care, suggesting that dissemination and implementation of guidelines can promote compliance.

• Reminders potentially effective intervention and likely to result in moderate improvements in process.

• Educational materials and audit and feedback result in modest effects.

• Multifaceted interventions did not appear to be more effective than single interventions.

• The effects of multifaceted interventions did not appear to increase with the number of component interventions.

Grimshaw et al J GIM 2006; 21:S14–20.

Strategies for Promoting Organizational and Practice Change by Advancing Implementation Research

Rubenstein & Pugh J GIM 2006; 21:S58–64.

• Implementation researchers focus on understanding and influencing the process of uptake of scientific findings by applying and developing theories on provider & organizational behavior, and on how to improve performance.

• This science’s ultimate goal is to improve the health of the public through equitable, efficient application of rigorously evaluated scientific knowledge.

Strategies for Promoting Organizational and Practice Change by Advancing Implementation Research


• “Take account” of implementation science• Maximize learning from past & current

implementation initiatives• Reduce duplication & promote progression of

evidence into practice• Incorporate implementation science into CPGs• Applying existing implementation science• Necessary partners in initiatives to increase

implementation

“Taking account” of implementation science


• literature needed--summaries of how to carry out implementation research--systematic reviews of empirical studies of implementation (identify types of interventions known to have impact, expected magnitude);--reviews of theoretical constructs important for setting the stage;--literature on methodologic issues relevant to implementation science (thorny issues!).

Reduce duplication & promote progression of evidence into practice


• Active efforts to foster strategic progression of studies from clinical science toward full implementation.

• Studies should progress along a continuum spanning clinical guidelines or best practices, measurement of quality and quality variations, tests of QII effectiveness, tests of QII spread, and policy development.

• Studies of QIIs should progress from higher researcher control to lower researcher control.

• Studies of QIIs should progress from local studies to regional studies to national studies.

• Studies move from a focus on effectiveness to a focus on quality impacts, and from a focus on individuals enrolled to populations.

Applying existing implementation science


• Use existing IS to develop policies and information dissemination methods that promote adoption of research findings in routine care.

• Required to document all information and tools necessary for understanding how the product was developed, applied, and evaluated.

• Guideline concordant treatment and management strategies can be thought of as products that may or may not diffuse effectively (Greenhalgh et al).

Paradox


• The shifting baseline of context and the multiplicity of confounding variables must be ‘‘controlled for’’ to make research objective.

• Context and ‘‘confounders’’ lie at the very heart of the diffusion, dissemination, and implementation of complex innovations.

• They are not extraneous to the study; they are an integral part of it (Greenhalgh et al)

Research Agenda

Necessary partners in initiatives to increase implementation


• Research funders• Health care funders• Health care providers• Health care provider educational institutions• Quality improvement and healthcare

accreditation organizations• Journals & publications• Professional societies• Community partners

The Road to Healthcare Systems Transformation

• Incorporating many different disciplines, (e.g., engineering, psychology, education, sociology, informatics, computer science, pharmacy, nursing and management).

• Time is ripe for a convergence of these diverse perspectives.

• Multidisciplinary teams can bring these perspectives together, creating synergy and applying diverse perspectives and tools to changing healthcare systems.

Maximize learning from past & current implementation initiatives


• Assessing past successes and failures

• Cross-cutting analyses that generate or test hypotheses about implementation across studies within these initiatives can provide new information beyond the results of individual studies.--VA QUERI, System Redesign programs--AHRQ’s Translating Research Into Practice & ACTION collaboratives, Practice Based Research Networks, etc--CDC Translating Research Into Action for Diabetes (TRIAD)--Robert Wood Johnson Foundation’s ‘‘Pursuing Perfection’’ initiative--Institute for Healthcare Improvements Protecting 5M Lives from Harm, Breakthrough Collaborative

“Business Case” for Spread

• Developing return on investment models helps build the “business case”.

• Crucial for gaining leadership support for redesign activities.

• Need for readily approachable methods.

Future Research Agenda

• Implementation literature review doesn’t provide a single implementation strategy or a group of strategies guaranteed to be effective in all contexts

• Iterative testing of implementation strategies allows continual improvement in implementation programs and widens their application to a variety of settings

Future Research Agenda

• New models of collaboration, sharing.

• Carefully planned measurement and methods for testing.

• New research designs.

• Novel methodology development.

• Strategies for dissemination, systematization & spread.

• Marketing research & solutions to public & policy makers.