Quality improvement in primary care:

What is it? Does it work?

A review of the evidence & sharing our experience

Liz Muggah, Sharon JohnstonEric Wooltorton

Disclosure

The following presentation is free from bias and the presenters are not affiliated with any for-profit organizations or parties. The presenters do not have any conflict of interests to disclose and are not affiliated with any commercial entities or organizations that serve to profit from this presentation.

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Faculty/Presenter Disclosure

•Relationships with commercial interests: None

•Disclosure of Commercial Support: N/A

•Mitigating Potential Bias: N/A

From PAPS & PALLIATIVE CARE

To MAPS & METRICS

OutlineWhat is QI (brief primer in 1 slide)

Quality Improvement in 3 parts

1. YOU: How can I create and encourage change as a physician?

2. DATA and MEASUREMENT: What do I measure to know if there is a change?

3. CHANGE IDEA: What changes should I make?

Quality Improvement: a very brief overview

• Quality Assurance – object is the measurement of performance, usually against pre defined standards or benchmarks ‐

• Discovery Research – object is to discover new knowledge through blinded tests and control of biases

• Quality Improvement – object is to improve quality of care by making changes OR

to take what we know from EBM and try it out in the “real” world

PAPS & PALLIATIVE CARE

Reflect Consider a change you have made or

would like to make in your clinic

1. You: How can I create and encourage change?Barriers to change for doctors

• Goals of patient care at odds with system view of care

• Goals for system change take time & are seen as less important than immediate patient needs

• Inbuilt sense of autonomy, “lone healer”, less comfortable with hierarchy

• Accepting of “technical” change less so of “adaptive” change

• Clinical perspective leads to critical thinking (look for negative) and need for certainty

Enablers of change for physicians

• ensure QI goals are about improving patient care (or medical education)

• demonstrate realistic sense of urgency for system change, give compensation

• nurture trust in team, allow autonomy in local “microsystem”

• create and articulate a shared vision

• reliable and clear data required to encourage action

Hussey, R et al. (2013) NHS Improving Healthcare White Papers. Doctors: leaders of change

Technical vs Adaptive Change – QI is a bit of both

TECHNICAL CHANGE• Uses knowledge you have

• Implemented by “authority”

• Simple

ADAPTIVE CHANGE• Learn new ways of doing, experiment

• Implemented by the people with the problem

• Complex, takes time, can be stressful

1. You: How can I create and encourage change?Consider the barriers and enablers that we just presented.

How do these relate to the changes you have made or want to make in your clinic?

2. DATA and MEASUREMENT: What do I measure? Measuring and reporting on performance or ”Audit and Feedback” can (when done right) improve provider behaviour

AUDIT data should be: •Valid and context specific (local input)•Based on recent performance •Repeated cycles of data•Focus on areas of low performance (ie: worst performance improved the most)

Ivers, N et al Cochrane Review of A and F 2012

2. DATA and MEASUREMENT: What do I do with the data?

FEEDBACK should be:•From a trusted source (ie: senior colleague vs regulatory body)•Delivered regularly (more than once per year) •Written and verbal•Seeking to decrease a behaviour (stop prescribing) rather than increase a behaviour (start counselling)•Include benchmarks (compare to top 10% vs the mean)•Clear goals and action plan

2. DATA and MEASUREMENT: What do I measure? Intermountain: Case Study

•Non-profit healthcare system in Utah

•22 hospitals and 185 ambulatory clinics

• Internationally recognized leader in Quality Improvement

2. DATA and MEASUREMENT: What do I measure?Intermountain: Case Study

• Two independent pathways for measurement: “change” vs “accountability” •Autonomy and local control encouraged (microsystem)•Rigorous Data•Data analyst and statistician attached to every unit•Granular data, but MDs recognized it was messy

•Benchmarking with clear expectations

2. DATA and MEASUREMENT: What do I measure?Consider the evidence about data and measurement that we just presented.

How do these relate to the changes you have made or want to make in your clinic?

3. INTERVENTIONS: What changes should you make? • The bad news…

• Low “quality” of QI research

• Effects sizes vary enormously

•Not clear what component of interventions works

3. INTERVENTIONS: What changes should I make? The good news…

• Almost any intervention works

• Starting with poor quality areas gives biggest gains

•Multifaceted interventions are better

• Team based interventions better for chronic disease

• Interventions implemented as part of broader plan for improvement were more effective

Van cleave et al (2012) Acad Pediatrics, ARHQ (2013) Closing the Quality Gap: Critical Reviews

SQUIRE guidelines for QI research

3. INTERVENTIONS: What changes should I make?

Consider the evidence about interventions that we just presented.

How do these relate to the changes you have made or want to make in your clinic?

From PAPS and PALLIATIVE CARE toMAPS & METRICS

Resources• HQO:Primary Care QI tools and best practiceshttp://www.hqontario.ca/quality-improvement/primary-care

• US Veteran’s Affairs QUERI initiative http://www.queri.research.va.gov/default.cfm

• AHRQ: Closing the quality gap - Critical Reviews

• Intermountain Healthcare: http://intermountainhealthcare.org/qualityandresearch/institute/clinicalmanagement/Pages/home.aspx