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