Mapping quality improvement: a comparative study of healthcare systemsUK Harkness / Health Foundation Fellow: Robbie Foy
Mentors: Brian Mittman & Lisa Rubenstein
VA/UCLA/RAND Center for the Study of Healthcare Provider Behavior
Harkness Fellowship Final Reporting Seminar, Orlando 2007
Center for the Study of Healthcare Provider Behavior Quality
Enhancement Research Initiative
What’s the problem?
• Much past, present and future activity to address quality gaps in healthcare in US and UK, e.g.– Clinical guidelines– Performance indicators– Incentives for change
• Significant challenges remain• Lack of coordination or incomplete reach of
quality improvement (QI) efforts across all levels of healthcare systems
A multi-level framework for quality improvement
Larger system/ environment
Organisation
Team/ microsystem
Individual
Ferlie & Shortell. Milbank Q 2001;79:281-315
Study objectives
1. Further elaborate a multi-level framework for QI
2. Document type and intensity of QI efforts among selected US (and UK healthcare) organisations
3. Explore similarities and differences in QI activities
Study sites
Department of Veterans Affairs
HealthPartners of Minnesota
Key relations Federal government and Central Office set priorities
VISN latitude on how to address given priorities
‘The Enterprise’
Intentional ‘blurred boundaries’ between Health Plan, Medical Group and ICSI
QI partner QUERI ICSI
Strategies Mental Health Strategy & TIDES: Translating Initiatives for Depression into Effective Solutions
DIAMOND: Depression Improvement Across Minnesota, Offering a New Direction
Change Current roll out of depression care model
Planned introduction of depression care model
Data collection and analysis
• Literature review and discussions to inform development of model
• Semi-structured interviews
• Framework analysis
• Iterative revision of multi-level framework
Interview participants
Veterans Affairs
HealthPartners
Over-arching leadership 2 3
Mainly QI / research 4 4
Mainly primary care 3 1
Mainly mental health 4 2
Total interviews 13 10
Data collection and analysis
• Literature review and discussions to inform development of model
• Semi-structured interviews
• Framework analysis
• Iterative revision of multi-level framework
Preliminary findings
The multi-level matrix
Core features or tasks Actual or planned for each level?
Larger system
Organisation Team Individual
Strategic alignment and integrated improvement into routine organizational activities
? ? ? ?
Involving key stakeholders and leaders ? ? ? ?
Priority setting ? ? ? ?
Identifying best practice recommendations ? ? ? ?
Identifying factors that help or hinder QI ? ? ? ?
Developing people and roles for effective and efficient team function
? ? ? ?
Developing technical support and procedures for coordinated care
? ? ? ?
Shaping organisational culture ? ? ? ?
Monitoring and evaluating quality ? ? ? ?
The multi-level matrix: VA
Core features or tasks Actual or planned?
Larger system
Organisation Team Individual
Strategic alignment and integrated improvement into routine organizational activities
Involving key stakeholders and leaders
Priority setting
Identifying best practice recommendations
Identifying factors that help or hinder QI
Developing people and roles for effective and efficient team function
Developing technical support and procedures for coordinated care
Shaping organisational culture
Monitoring and evaluating quality
The multi-level matrix: HealthPartners
Core features or tasks Actual or planned?
Larger system
Organisation Team Individual
Strategic alignment and integrated improvement into routine organizational activities
Involving key stakeholders and leaders
Priority setting
Identifying best practice recommendations
Identifying factors that help or hinder QI
Developing people and roles for effective and efficient team function
Developing technical support and procedures for coordinated care
Shaping organisational culture
Monitoring and evaluating quality
The multi-level matrix
Core features or tasks Actual or planned?
Larger system
Organisation Team Individual
Strategic alignment and integrated improvement into routine organizational activities
? ? ? ?
Involving key stakeholders and leaders ? ? ? ?
Priority setting ? ? ? ?
Identifying best practice recommendations ? ? ? ?
Identifying factors that help or hinder QI ? ? ? ?
Developing people and roles for effective and efficient team function
? ? ? ?
Developing technical support and procedures for coordinated care
? ? ? ?
Shaping organisational culture ? ? ? ?
Monitoring and evaluating quality ? ? ? ?
Strategic alignment and integration of improvement into routine organizational activities
Fairly ‘simple’ for the VA…
“[Strategy] starts with the development of a quality indicator which would normally have its origin in Central Office… makes recommendations about what quality metrics get into my performance contract. And what gets into my performance contract trickles down into everyone else’s performance contract.”
Senior manager, VA4
But multiplicity of initiatives…
“One of the primary barriers... Ideally there would be some way of prioritizing quality improvement initiatives so that they fit together, sometimes instead of that they’re competitive.”
Quality improvement researcher, VA6
Strategic alignment and integration of improvement into routine organizational activities
Complex for HealthPartners…
“It is time to challenge assumptions about payment systems – to align incentives and ensuring that costs of care are reimbursed. Both need to happen together. If only incentives are used, care will still be substandard if the infrastructure is not present.”
Quality improvement leader, HP1
And need for “quantum leap” redesign …
“… efforts like CQI can achieve limited change but substantial change depends upon reforming infrastructure and enhancing governance, culture and leadership.”
Quality improvement leader, HP8
Developing technical support and procedures for coordinated care
EMR firmly embedded within the VA but…
“There are a vast number of clinical reminders that exist currently so simply finding the time in a busy appointment to address all of the reminders and the patient’s complaints and any other health care or preventive care is challenging.”
Primary care physician leader, VA5
Developing technical support and procedures for coordinated care
Within HealthPartners, EMR available in half of medical groups
Plans for redesign and widespread implementation of systemised care
“… establish systems and change environments so that it is easier to do the right thing than the wrong thing.”
QI researcher Medical Group, HP3
Shaping organisational culture
• Strong mission to support (‘deserving’) veterans• Variable emphasis on ‘professionalism’• Use of performance data for positive reinforcement – and
‘humiliation’ by comparison
“I think that when leadership feels that they are personally affected by quality outcomes, you know their bonuses are affected, their ratings are affected, their embarrassment factor is affected because their facility isn’t doing well.”
Senior manager, VA4
Shaping organisational culture
• Strong drivers around meeting members’ needs and being competitive
• Potentially greater emphasis on developing leadership capacity• Efforts to transmit norms
“Standardisation is challenging to the physician culture... The Medical Group has been trying to change culture from one where anything goes towards establishing norms in semi-legal contractual way.”
QI researcher, Medical Group HP3
Conclusion one: elaborating the multi-level framework
• Multi-level QI efforts– Larger system, organisation, team, individual
• Range of core features or tasks suggested from literature
– E.g. involving stakeholders, priority setting
Conclusion two: documenting QI efforts
• Strong research-practice partnerships in two sites
• Concerted efforts to improve depression care– Demonstrate range of QI activities– Suggest nine core features and tasks that contribute
to ‘multi-level matrix’
• Potential of matrix as a tool for mapping out and identifying gaps in other QI strategies
Conclusion three: comparing QI efforts
• VA depression strategy emergent from existing structures and processes
• HealthPartners strategy needs multi-level planning and whole system redesign
• Differences in complexity and focus of approaches
Policy implications: Nothing as practical as a good theory?
The benefits of QI efforts may not be fully realised if there is over-reliance on one approach and such efforts are not coordinated across levels of the healthcare system
Need for further attention to multi-level framework in planning and policy
Common sense is very uncommonHorace Greeley
Policy insights: Caveat emptor
Further research needs
• Validation?
• Population?
• Acceleration?
• Cost equation?
Common sense is what tells us the Earth is flat and the Sun goes around it
Anon