Fostering Transformational Change in an Integrated System: The Case of HIV Testing Steven M. Asch MD MPH VA GLAHS/UCLA/RAND

Examples of Broad Systemic Reforms for Quality

In the Early 1990s, a Prominent Health Care Provider Was at a Crossroads Its failings were widely publicized in the news media and popular movies Studies showed serious access, quality and satisfaction problems Some argued that this health organization needed new management

Its failings were widely publicized in the news media and popular movies

Studies showed serious access, quality and satisfaction problems

Some argued that this health organization needed new management

But Within 10 Years, Its Quality Greatly Improved The organization’s quality of care was found “significantly better” than that of Medicare on 11 out of 12 measures (Jha 2003) It provided better care than commercial insurers to diabetes patients on 7 out of 7 measures (Kerr 2004)

The organization’s quality of care was found “significantly better” than that of Medicare on 11 out of 12 measures (Jha 2003)

It provided better care than commercial insurers to diabetes patients on 7 out of 7 measures (Kerr 2004)

The VA Implemented Important Reforms Expansion of primary care Researcher-administrator partnership Electronic medical records system Tracks patients Alerts clinicians of needed care

Expansion of primary care

Researcher-administrator partnership

Electronic medical records system

Tracks patients

Alerts clinicians of needed care

The VA Implemented Important Reforms Performance tracking of key indicators especially chronic and preventive care Managers held accountable Able to allocate resources across integrated system Big investment

Performance tracking of key indicators especially chronic and preventive care

Managers held accountable

Able to allocate resources across integrated system

Big investment

2.3 2.9 Chronic conditions per patient 12 cities 26 facilities Sites 59 992 Random sample National 62 597 Administrative data VA Age Number of patients Source

Overall, VA Patients Were More Likely to Receive Recommended Care VA National Sample Asch Annals Int Med 2004

National Sample Adjusted Overall Quality by Income (52-54) (54-56) (56-58)

The VA Scored Higher Across the Spectrum of Health Care Diagnosis Follow-Up Screening Treatment

The VA Outpaced the National Sample on Chronic and Preventive Care

The VA Scored Higher on Care that It Measured VA-Targeted Performance Measures Measures Unrelated to VA Targets

VA Also Scored Higher in Areas Related to Measured Processes VA-Targeted Performance Measures Measures Unrelated to VA Targets Related Performance Measures

Performance Measurement Chain Reaction Influenza Vaccination Pneumonia Vaccination Tetanus Vaccination Checking Hearing Targeted Process Related Processes

Lessons from Integrated VA Model Health information technology is important and easier for integrated systems, but it’s not enough Performance measurement, QI, and accountability are also critical Integration of service delivery and financing allows for strategic resource allocation Organizational determinants of quality are just as important as individual determinants

Health information technology is important and easier for integrated systems, but it’s not enough

Performance measurement, QI, and accountability are also critical

Integration of service delivery and financing allows for strategic resource allocation

Organizational determinants of quality are just as important as individual determinants

HIV/Hepatitis QUERI VA as a QI laboratory Teams HSR researchers and national QI managers Translation project to improve HIV testing rates merged several streams of organizational change: Systemic redesign Clinical reminders Provider activation

VA as a QI laboratory

Teams HSR researchers and national QI managers

Translation project to improve HIV testing rates merged several streams of organizational change:

Systemic redesign

Clinical reminders

Provider activation

We Had to Make a Case to VA Managers HIV easier/cheaper to treat if detected early (~<$25,000/QALY) VA has high prevalence of HIV (~2%) VA performance falls short (~20%) Therefore we should improve screening and testing rates

HIV easier/cheaper to treat if detected early (~<$25,000/QALY)

VA has high prevalence of HIV (~2%)

VA performance falls short (~20%)

Therefore we should improve screening and testing rates

They Asked Us a Question “ You’ve given us a strong rationale for long-term benefits of earlier identification, but what is the short term impact of increasing screening and an acute influx of HIV patients on the system?” or “ Where is it coming out of my budget when?”

“ You’ve given us a strong rationale for long-term benefits of earlier identification, but what is the short term impact of increasing screening and an acute influx of HIV patients on the system?”

or

“ Where is it coming out of my budget when?”

Business Case Modeling Data-driven models for making managerial or technical decisions Valuable tool for program managers although underused in public sector

Data-driven models for making managerial or technical decisions

Valuable tool for program managers although underused in public sector

Excerpt of Modeling Process

Quarter on Quarter Increases in Overall Costs Increasing HIV screening rates from…

Barriers to HIV Testing Organizational Cumbersome written informed consent & pre-test counseling Provider time constraints, especially post-test Provider behaviors Incomplete recognition of HIV risk factors Belief that only trained counselors can do HIV counseling

Organizational

Cumbersome written informed consent & pre-test counseling

Provider time constraints, especially post-test

Provider behaviors

Incomplete recognition of HIV risk factors

Belief that only trained counselors can do HIV counseling

System Redesign Streamlined counseling Telephonic notification of negative tests Removed restrictions on who could order tests Audit-feedback: clinic level progress reports

Streamlined counseling

Telephonic notification of negative tests

Removed restrictions on who could order tests

Audit-feedback: clinic level progress reports

Provider Activation Leverage group dynamics Academic detailing Social marketing Opinion leaders

Leverage group dynamics

Academic detailing

Social marketing

Opinion leaders

Implementation and Evaluation Plan Prospective, controlled quasi-experimental implementation in southern CA and NV Primary endpoints Rate of evaluation for HIV Rate of HIV testing in at-risk patients

Prospective, controlled quasi-experimental implementation in southern CA and NV

Primary endpoints

Rate of evaluation for HIV

Rate of HIV testing in at-risk patients

HIV Testing & Evaluation Rates One Year Post Intervention Site A Site B Site C Site D Site E Primary care clinics

Conclusion Integrated systems have many of the elements for transformational change. Integrated systems can serve as a laboratory for more focused QI programs How these elements can be transferred to more distributed systemd remains an area for future research.

Integrated systems have many of the elements for transformational change.

Integrated systems can serve as a laboratory for more focused QI programs

How these elements can be transferred to more distributed systemd remains an area for future research.