Delivery System Science to Improve Performance November 11 2015 Brian S Mittman PhD Dept of Research and Evaluation Kaiser Permanente Southern California US Dept of Veterans Affairs Quality Enhancement Research Initiative QUERI ID: 908243
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Slide1
Toward a Learning Healthcare Delivery System: Leveraging Implementation, Improvement and
Delivery System Science to Improve Performance
November 11, 2015Brian S. Mittman, PhDDept of Research and Evaluation, Kaiser Permanente Southern CaliforniaUS Dept of Veterans Affairs Quality Enhancement Research Initiative (QUERI)UCLA CTSI Implementation and Improvement Science Initiative
Kaiser Permanente
Research
Slide2Defining a Learning Healthcare System
Outcomes
and performance
goals
Features and
performance
processes
Slide3Institute of Medicine’sCrossing the Quality Chasm (2001)
Safe
: avoiding injuries
Effective: services based on scientific knowledge; avoiding underuse and overuse
Patient-centered: responsive to individual patient preferences, needs, and values
Timely: reducing waits and delays
Efficient: avoiding waste [value, affordability]
Equitable: across gender, ethnicity, geography, SES
Slide4Commonwealth Fund’s Frameworkfor a High Performance Health System (2006)
Quality
and Safety
the right health care, avoiding underuse, overuse and misuse
safe, reliable
coordinated
patient-centered: timely, excellent service, active and informed patients
Access to Care
universal participation
financial protection, established benefits, affordable
equitable
Slide5Commonwealth Fund’s Frameworkfor a High Performance Health System (2006)
Efficient, High Value Care
efficient
right time, right setting
ongoing evaluation of new technologies; defined processes for introduction, surveillance, reevaluation
System Capacity to Improve
investment in innovation and research
information infrastructure
effective educational system
rapid response to threats and disasters
culture of improvement
balance between autonomy and accountability
Slide6Summary of desired features
Safe
and reliable
High-quality, effective, evidence-based
Patient-centered, excellent service
Timely, accessible
Efficient, cost-effective, high-value
Equitable
System is technologically advanced, research- and improvement-oriented, balancing autonomy and accountability
Slide7Learning Healthcare Delivery System features
Explicit
performance
, improvement,
learning
goals
Comprehensive performance monitoring against goals
Explicit care management plans, policies, practices
Active environmental scanningExplicit policies and processes for locating, vetting, evaluating, refining, scaling/spreading external innovations
“ “ “ for internal innovation, experimentation
Supportive leadership, culture, training, resources (staff, expertise, space, equipment, funds, etc.), rewards, etc
.
Slide8Achieving learning and improvement: Role of improvement, implementation, delivery sciences?
Reliable evidence-based strategies
(
interventions) for delivering, improving care (
FDA-approved
,
formulary-listed)
Strategies
for working to improve care (e.g., PDSA/rapid-cycle improvement); analytical approaches and tools for monitoring and guiding improvementInsights into barriers to change, requirements or conditions for improvement (environment, organization, team, ind’l)
Insights
into the behavior of delivery systems and organizations, teams,
clinicians and staff
Slide9What is implementation science?
Clinical research produces new evidence, innovation
Initial efforts to promote implementation
Measurement of rates of implementation – and implementation (quality) gaps
Research to develop and evaluate
implementation programs*
to increase adoption
* quality improvement programs, practice change programs (interventions)
Slide10Health benefits of research
Improved Health Processes, Outcomes
Basic
Science
Clinical
Research
?
?
Slide11The
Clinical Research Crisis
AAMC Clinical Research Summit:
Clinical Research:
A National Call to Action
(Nov 1999)
IoM Clinical Research Roundtable
(2000-2004)
UK
Cooksey Report
(2006), other US and non-US reports
Slide12Translational research
Improved Health Processes, Outcomes
Basic
Science
Clinical
Research
Type 1
Translation
Type
2
Translation
Slide13Translational research
Basic
Science
Pre-Clinical/ Translational Research
Type 2
Translation
Implementation
Research
Clinical Research
Type 1
Translation
Improved Health Processes, Outcomes
Slide14Implementation research
Basic
Science
Pre-Clinical/ Translational Research
Implementation
Research
Clinical Research
Improved Health Processes, Outcomes
Slide15Implementation science definition
Implementation research is the scientific study of
methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and, hence, to improve the quality and effectiveness of
health services. It includes the study of influences on healthcare
professional and organizational behavior.
Eccles and Mittman, 2006
Slide16Implementation science aims
Develop reliable strategies for improving health-related processes and outcomes; facilitate widespread adoption of these strategies
Produce insights and
generalizable knowledge regarding implementation processes, barriers,
facilitators
,
strategies
Develop, test and refine implementation theories and hypotheses; methods and measures
Slide17Clinical research
vs. implementation research
Study typeStudy feature
Clinical
research
Implementation research
Aim: evaluate a / an …
clinical intervention
implementation strategy
Typical intervention
drug, procedure, therapy
clinician, organizational practice change
Typical outcomes
symptoms,
health outcomes,
patient behavior
adoption, adherence, fidelity
Typical unit of analysis, randomization
patient
clinician, team, facility
Slide18US, international resources
NIH Conference on the Science of Dissemination and Implementation (2007 — 2015
)NIH grant funding, review committee, training programsJournals: Implementation Science, Translational Behavioral Medicine, special issues of general and specialty journals, new SIRC journal in developmentNIH CTSAs (selected), PBRNs, ACTION,
VA QUERIPatient-Centered Outcomes Research Institute (PCORI), AAMC Research on Care Community (ROCC)
Knowledge Translation Canada,
Kings College London Centre for Implementation Science, etc.
Slide19Local resources
Community Health, Health BehaviorHealth Services, Management
GIM, Family/Prev Medicine, SubspecNursing, Dentistry, Psychology, Social Work, OT, PT, other allied Psychology, Sociology, Anthropology, Political Science, EconomicsManagement, Education, Public Policy
Health Sciences:
Main Campus:
Slide20Practice-focused research:Emerging models
VA QUERI
Academic Health System / School of Medicine “3I Institutes” (Improvement, Implementation, Innovation) Integrated delivery system (Health Care Systems Research Network) embedded/partnership research:KPSC Care Improvement Research TeamAcademyHealth
Delivery System Science fellowshipKey features: joint governance, internal funding, negotiated scope, goals, standards (timeline, rigor)
Slide21The “Quality Chasm”
Institute of Medicine (1999, 2001)
Quality “report cards” (US, international)
Slide22Emergence and evolution of research interest
50+ years of research to identify causes and develop solutions to slow, uneven adoption of effective practices
Changing physician behavior (1970s/80s: CME, reminders, incentives)
Quality improvement, patient safety (1980s, 1990s, etc.)
Implementation science (2000s to present)
Findings, insights, recommendations are rich and valuable, yet difficult to apply
VA, Kaiser and other systems have improved, but significant quality and performance gaps remain
Slide23The Tower of Babel problem
Knowledge translation
Translational research
Research utilization, knowledge utilization
Knowledge-to-action, knowledge
transfer &
exchange
Technology transfer
Dissemination research
Quality improvement research
T-1, T-2, T-3, T-4
Etc.
Slide24Achieving learning and improvement: Contributions from improvement science
(QI research) vs. implementation science (1)
QI often focuses on the “here and now” – immediate, local improvement needs via rapid-cycle, iterative improvementIS often attempts to develop, deploy and rigorously evaluate a fixed implementation strategy across multiple sites, emphasizing theory, contextual factors, (sometimes) mediators, moderators, mechanisms
IS aims to develop generalizable knowledge
Slide25Achieving learning and improvement:
Contributions from QI vs. implementation science (2)
QI is pragmatic, improvement-oriented (often at the cost of limited confidence in interpretation and attribution and useful knowledge);IS is scientific, research/knowledge-oriented (often at the cost of improvement outcomes and useful knowledge)
Neither has made much headway in achieving either goal
Slide26QI often ignores contextual factors, fundamental insights into organizational/professional behavior, cross-site differences and implications for improvement success
IS usually ignores heterogeneity and dominance of context over intervention main effects, and – too often – mediators, moderators, mechanisms
Neither has made much headway in achieving either goalAchieving learning and improvement:Contributions from QI vs. implementation science (3)
Slide27Achieving learning and improvement:Contributions from QI vs. implementation science
(4)
QI offers tools for persisting until improvement is achieved, driven by a desire to solve an identified quality problemIS offers theories, designs, methods, conceptual clarity for building from effectiveness/innovation work to implementation, to reap the benefits of innovation and research discovery and development
Slide28Achieving learning and improvement: Contributions from QI research and
implementation science
Despite some overlap, QI research and implementation science are largely complementary, and each could (should) learn and benefit from the other
Slide29Necessary conditions for practice change: insights from QI and implementation research
Valid, legitimate (accepted) evidence
Evidence of deviationsExternal expectations, interest (monitoring), pressureSupportive professional normsEtiology of practices, deviations
Information, evidence, educationFeasible methods/systems
Slide30Necessary conditions for practice change
Valid, legitimate (accepted) evidence
Evidence of deviationsExternal expectations, interest (monitoring), pressureSupportive professional normsEtiology of practices, deviations
Information, evidence, education
Feasible methods/systems
Slide31Implementation and QI in local
settingsfactors contributing to success
Exceptional (non-routine, unsustainable, non-scalable) resources and support from central project team:site-by-site, individualized technical assistancefunding for new staff, servicesrecruitment, hiring, training, supervision, support for new staffHawthorne effect (enhanced attention from monitoring, evaluation, external/internal interest)
Slide32Challenges to planned scale-up
and spread
Lack of exceptional resources coupled with:Features of innovationsFeatures of target adoptersFeatures of the environmentFeatures of innovation champions
Features of scale-up/spread strategies______________
Source: WHO and
ExpandNet
,
Practical Guidance for Scaling Up Health Innovations,
2009. http://expandnet.net/PDFs/WHO_ExpandNet_Practical_Guide_published.pdf
Slide33Barriers to progress?
Critiques and commentaries on the “state of the science” in implementation science often cite:
Lack
of rigor; limited internal validity; too
few
RCTs
Limited external validity; too
many
RCTs (or too many
flawed
RCTs); use of “black box” evaluation approaches
Lack of theory; lack of appropriate theory
Too many theories; lack of guidance in using theory
Implementation and improvement problems and
phenomena are extraordinarily complex (simple vs. complex vs. wicked problems)
Slide34An alternative (re-stated) hypothesis
Implementation and improvement science study phenomena
characterized
by:
Heterogeneity and variability
of program (intervention)
content
across time and place
Heterogeneity of program
implementation
across time and place
Significant and variable contextual
influences (leadership, culture, experience/capacity, staff/budget sufficiency
)
Strong
mediator effects (indirect impacts
) and attenuation of effects
Weak main effects (other than for robust programs)
Slide35Studying complex social interventions:
What is our goal?Two very different
questions1. Does it work? Is it “effective”?Should it be approved? Included in the formulary?Should I use it? 2. How
, why, when and where does it work?How
should I use it
?
How do I
make
it work?For many or most implementation strategies, Q1 is meaningless
Slide36Developing
insights and guidance for implementation and improvement
How do I choose an appropriate implementation or improvement strategy given my context?How do I implement (deploy) the strategy to increase effectiveness?How do I adapt and customize the strategy to increase effectiveness (initially and over time)?How do I modify (manage) the organization or setting to increase effectiveness (initially and over time)?How, why, when and where does it work?