Practical PDSAsHow to use a quality framework to improve your integrated care initiative
Nadiya Sunderji, MD MPH FRCPCPriya Vasa, MD MSc CCFPAnn Stewart MD CCFP
St. Michael’s Hospital and University of Toronto, Canada
Session # F1
CFHA 20th Annual ConferenceOctober 18-20, 2018 • Rochester, New York
Faculty DisclosureThe presenters of this session have NOT had any relevant financial relationships during the past 12 months.
Learning ObjectivesAt the conclusion of this session, the participant will be able to:
1. Discuss the role for quality improvement in integrated care, and identify relevant domains and dimensions of quality
2. Apply a quality framework for integrated care to select a specific dimension of quality as a target for improvement in their own setting
3. Develop a potential PDSA cycle to begin the process of integrated care measurement and improvement in their own setting
Outline1. Introductions
2. Brief background – quality framework
3. Identify a target for improvement in your setting*
4. Introduction to the IHI Model for Improvement
5. Example PDSA cycles
6. Develop a potential PDSA cycle for your improvement idea*
7. Take up, Q&A
Background•A "quality chasm" between the research evidence for integrated care and real-world implementation & outcomes.
•We developed a quality framework to evaluate and drive improvements in integrated care.
•QI approaches enable iterative tests of change to improve care delivery in a context-appropriate and sustainable way
What are we trying to achieve?CLIENT CARE OUTCOMESCare achieves good results for clients.
POPULATION-BASED CAREAppropriate care is delivered to the whole population of clients who are, or who should be, served by the primary care team (i.e. services are equitable).
ACCESS AND TIMELINESS OF CAREClients can easily receive care within a reasonable timeframe considering their illness severity, level of risk, and level of function.
CLIENT INCLUSION AND PARTICIPATIONCare is geared toward providing the best possible experience for clients, and achieving outcomes that are important to clients.
VALUE AND EFFICIENCYFrom a system perspective, care delivers good value considering the costs.
What conditions and activities are helping or hindering us?INFRASTRUCTURE, LEADERSHIP AND MANAGEMENTCare is provided under appropriate conditions (e.g. appropriate physical space, having skilled health care providers from different disciplines).
LEVEL OF INTEGRATION BETWEEN MENTAL HEALTH AND PRIMARY CARE SERVICES Services are well coordinated within the collaborative mental health program in primary care, and also between the primary care team and outside mental health specialists.
EVIDENCE-BASED PRACTICESPrograms and treatments are designed and implemented with consideration of the best available research and the local context.
TEAM FUNCTIONINGThe clinical team of primary care and mental health providers work well together.
QUALITY IMPROVEMENTCollaborative Care team and program are continuously working to improve quality.
COLLABORATION FOR PATIENT SAFETYCollaborative Care program is organized to provide the safest possible care.
Your turn*
Thinking about who your program serves, what it’s trying to achieve, and with what resources…
What are the strengths and most important improvement opportunities to your program?
Model for improvement
Institute for Healthcare Improvement (IHI)
Three types of PDSAs• Understand the problem• Develop the intervention• Make a change
PDSA ramp
‘Real life’ PDSA ramp
Ogrinc & Shojania, BMJQS 2018
Example: Implementing measurement-based care for depression in primary care
Specific Aim: By September 2018, 80% of patients with diabetes and known depression (according to their healthcare provider or chart) at the St. Jamestown site of the SMAFHT will have at least one PHQ-9 scale done within the last 12 months.
ExampleOutcome measure:% of St Jamestown patients with diabetes and known depression who have completed PHQ-9 within the past year (EHR search)
ExampleProcess measures
% of St Jamestown patients with diabetes who have a visit with any FHT healthcare provider within the past year (EHR search)
Balance measures:
Staff perceived workload (Qualitative: did the clinic run late more so than it did previously? Did the RN do fewer other activities since adding this process? Quantitative: how many patients seen each day?)
Acceptability of process to patients (qualitative focus group; quantitative survey)
PDSA cycles
Second test of change
First test of change
Process mapFP, RN, clerical
Fishbone12
Interviews w team
Chart audit
EHR search
Understanding the ‘problem’ in its contextDeveloping intervention Testing intervention
PDSA
Cycle Prediction Do Study Act1 Depression is common among
patients with diabetes. It’s also associated with worse diabetes care processes and outcomes.
Electronic health record search of SMAFHT patients x 1 year. Descriptive statistics of depression prevalence. Histograms to compare diabetes care and outcomes for patients with versus without “known depression”.
“Prevalence” of depression 17.9% among patients with diabetes. Mean A1c and BP comparable for patients with diabetes with vs. without depression. Not more likely to be overdue for these measures. More appointments (including with DEP team) but also more no-shows.
Depression is common in diabetes; although there is no difference in diabetes processes and outcomes, there may be room to improve depression management.
2 Depression care in this population does not conform to evidence-based practices and quality standards.
EHR search plus detailed chart audit of subset of patients: a) measurement-based care (e.g. PHQ-9), b) receiving 1+ evidence-based Rx or psychotherapy, c) offered at least one such treatment, d) retention in treatment, and e) time interval to treatment adjustment.
Although 97% of patients saw a FHT clinician in the past year, only 3% had a PHQ-9 done in the past year; only 25% ever had one done.
PHQ-9 rarely used, which is inconsistent with best practice. Qualitatively explore provider perspectives on challenges in care of these patients, and specifically in use of rating scales.
3 Clinicians perceive challenges and improvement opportunities in care of these patients and in use of scales.
Interviewed 12 healthcare providers.
Barriers to using PHQ-9: time, remembering, patient acceptability, language & literacy, concern of what will do if patient is symptomatic. Ideas for using PHQ-9: wait room (paper or tablet), email, embed in standard diabetes form and have RN do at pre-visit, pharmacist via phone during med rec.
Fishbone diagram. Process map. Small tests of change. Collect informal feedback from patients to refine intervention as we begin to use rating scales.
Small data
Your turn again*•What is one next step to explore the ‘problem’ / opportunity?
•Plan & predict•Do (understand problem develop intervention test a change)
•Study (measure)•Act (interpret & plan next steps)
Reflections? Questions?
Thank you!Nadiya Sunderji ([email protected]) Priya Vasa ([email protected]) and Ann Stewart ([email protected])
Co-authors: Abbas Ghavam-Rassoul, MD MHSc CCFP FCFP, Allyson Ion, PhD(c), Gwen Jansz, MD PhD CCFP
St. Michael’s Hospital & University of Toronto
Funding: Ontario Ministry of Health and Long Term Care AFP Innovations Fund; CIHR Strategy for Patient Oriented Research; Health Canada and Mental Health Commission of Canada
Conference ResourcesSlides and handouts shared in advance by our Conference Presenters are available on the CFHA website at http://www.cfha.net/?page=Resources_2018
Slides and handouts are also available on the mobile app.
1. Sunderji N, Ghavam-Rassoul A, Ion A, et al. Driving improvements in the implementation of collaborative mental health care: A quality framework to guide measurement, improvement and research. Toronto, Canada: 2016. Available at https://www.researchgate.net/publication/312539646_Driving_Improvements_in_the_Implementation_of_Collaborative_Mental_Health_Care_A_Quality_Framework_to_Guide_Measurement_Improvement_and_Research
2. Sunderji N, Ion A, Ghavam-Rassoul A, Abate A. Evaluating the Implementation of Integrated Mental Health Care: A Systematic Review to Guide the Development of Quality Measures. Psychiatric Services68(9): 891-898
3. NHS Institute for Innovation and Improvement. The Good Indicators Guide: Understanding How to Use and Choose Indicators. Available at: http://www.apho.org.uk/resource/item.aspx?RID=44584(2008)
4. Leis JA, Shojania KG. A primer on PDSA: executing plan-do-study-act cycles in practice, not just in name. BMJ Qual Saf. 2017 Jul;26(7):572-577. doi: 10.1136/bmjqs-2016-006245
5. Etchells E, Ho M, Shojania KG. Value of small sample sizes in rapid-cycle quality improvement projects. BMJ Qual Saf. 2016 Mar;25(3):202-6. doi: 10.1136/bmjqs-2015-005094
Bibliography
Learning AssessmentA learning assessment is required for CE credit.
A question and answer period will be conducted at the end of this presentation.
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