10 th  Biennial Regenstrief Conference Overview Brad Doebbeling VA Center of Excellence on Implementing Evidence-based Pra...
<ul><li>The U.S. is a world leader in the advancement of medical science and technology, defining the cutting edge in most...
Healthcare “System” Chasm <ul><li>“ Between the healthcare we have and the care we could have lies not just a gap but a ch...
How Hazardous Is Health Care? Source: Berwick, D.M.
RAND Study:  Quality of Health Care Often Not Optimal <ul><li>We provide appropriate health care only 55% of the time </li...
New and Unprecedented Challenges <ul><li>Greater demands in performance and accountability  </li></ul><ul><li>New drugs an...
Challenges  <ul><li>Delays between research and implementation </li></ul><ul><li>New products often poorly evaluated befor...
Challenges <ul><li>Implementation of research suboptimal </li></ul><ul><li>Major gaps in the quality and reliability of he...
Systems Transformation
Healthcare Systems <ul><li>“consists of interacting, interrelated, or interdependent elements that form a complex whole.” ...
System Transformation <ul><li>A series of multidimensional changes to the context/culture, structure, and processes of a h...
Challenges to System Transformation <ul><li>Adopting a systems view  </li></ul><ul><li>Coordinating complicated changes ac...
Systems Transformation <ul><li>Three concepts central to system transformation  </li></ul><ul><ul><li>Integration  -traini...
Systems Engineering
Institute of Medicine (IOM) and National Academy of Engineering (NAE) Report <ul><li>Systems engineering tools and a syste...
System Engineering <ul><li>Systems engineering involves the design, implementation, and control of a complex system.  </li...
Challenges to applying system engineering to healthcare  <ul><li>Organizational and Managerial Obstacles  </li></ul><ul><u...
Challenges <ul><li>Lack of training </li></ul><ul><li>Systems engineering approaches often have major data requirements </...
Promoting System Redesign <ul><li>Involve top- and middle-level leaders </li></ul><ul><li>Align and integrate improvement ...
Systems Redesign <ul><li>Change must be perceived as beneficial to the individual and organization </li></ul><ul><li>Chang...
Implementation Science
Conceptual Frameworks <ul><li>Research efforts not directly related to healthcare can be used in system transformation </l...
An IHI Framework for Spread <ul><li>Prepare for the spread  </li></ul><ul><li>Identify an aim for the spread  </li></ul><u...
Informatics Implementation Challenges <ul><li>Most settings don’t assess provider or patient needs </li></ul><ul><li>Imple...
Toward Evidence-Based Quality Improvement <ul><li>Most comparisons reporting dichotomous process data (87%)  observed impr...
Strategies for Promoting Organizational and Practice Change by Advancing Implementation Research <ul><li>Implementation re...
Strategies for Promoting Organizational and Practice Change by Advancing Implementation Research <ul><li>“ Take account” o...
“ Taking account” of implementation science <ul><li>literature needed --summaries of how to carry out implementation resea...
Reduce duplication & promote progression of evidence into practice <ul><li>Active efforts to foster strategic progression ...
Applying existing implementation science <ul><li>Use existing IS to develop policies and information dissemination methods...
Paradox <ul><li>The shifting baseline of context and the multiplicity of confounding variables must be ‘‘controlled for’’ ...
Research Agenda
Necessary partners in initiatives to increase implementation <ul><li>Research funders </li></ul><ul><li>Health care funder...
The Road to Healthcare Systems Transformation <ul><li>Incorporating many different disciplines, (e.g., engineering, psycho...
Maximize learning from past & current implementation initiatives <ul><li>Assessing past successes and failures </li></ul><...
“Business Case” for Spread <ul><li>Developing return on investment models helps build the “business case”.  </li></ul><ul>...
Future Research Agenda <ul><li>Implementation literature review doesn’t provide a single implementation strategy or a grou...
Future Research Agenda <ul><li>New models of collaboration, sharing. </li></ul><ul><li>Carefully planned measurement and m...
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Regenstrief Conference Doebbeling

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Brad's opening presentation for the 10th Biennial Regenstreif Conference

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  • Regenstrief Conference Doebbeling

    1. 1. 10 th Biennial Regenstrief Conference Overview Brad Doebbeling VA Center of Excellence on Implementing Evidence-based Practice IU Center for Health Services & Outcomes Research, Regenstrief Institute, Inc. IU School of Medicine October 2-4, 2007
    2. 2. <ul><li>The U.S. is a world leader in the advancement of medical science and technology, defining the cutting edge in most areas of clinical training, research and practice. </li></ul><ul><li>This tremendous progress by focusing resources on research in the physical and life sciences and developing devices and equipment. </li></ul><ul><li>However, our lack of systems for the delivery of healthcare limit the realization of achievements made possible by these advances. </li></ul>
    3. 3. Healthcare “System” Chasm <ul><li>“ Between the healthcare we have and the care we could have lies not just a gap but a chasm”. </li></ul>
    4. 4. How Hazardous Is Health Care? Source: Berwick, D.M.
    5. 5. RAND Study: Quality of Health Care Often Not Optimal <ul><li>We provide appropriate health care only 55% of the time </li></ul>Percentage of time E. McGlynn, S. Asch, J. Adams, et al., The Quality of Health Care Delivered to Adults in the United States, N Engl J Med , 2003 Alcohol dependence Hip fracture Peptic ulcer Diabetes Low back pain Prenatal care Breast cancer Cataracts 11% 23% 33% 45% 69% 73% 76% 79%
    6. 6. New and Unprecedented Challenges <ul><li>Greater demands in performance and accountability </li></ul><ul><li>New drugs and technologies </li></ul><ul><li>Deteriorating nurse, pharmacist and physician morale </li></ul><ul><li>Limited access, under- and non-insured </li></ul><ul><li>Inequitable patterns of utilization unsustainable cost increases </li></ul>
    7. 7. Challenges <ul><li>Delays between research and implementation </li></ul><ul><li>New products often poorly evaluated before hitting the market </li></ul><ul><li>Overuse, underuse, misuse, duplication, system failures, unnecessary repetition </li></ul><ul><li>Poor communication and inefficiency </li></ul>
    8. 8. Challenges <ul><li>Implementation of research suboptimal </li></ul><ul><li>Major gaps in the quality and reliability of healthcare persist </li></ul><ul><li>Inequitable patterns of utilization, poor safety and unsustainable cost increases </li></ul><ul><li>Estimated 98,000 Americans die and more than 1 million patients injured annually receiving health care in the US due to system failures </li></ul>
    9. 9. Systems Transformation
    10. 10. Healthcare Systems <ul><li>“consists of interacting, interrelated, or interdependent elements that form a complex whole.” </li></ul><ul><li>Comprised of multiple levels, including the patient, provider or care team, organization, and the political and economic environment. </li></ul><ul><li>This set of interacting elements (e.g., clinics, units, people) behaves differently than individuals acting alone. </li></ul>Ryan J. in IOM/NAE Report, 2005.
    11. 11. System Transformation <ul><li>A series of multidimensional changes to the context/culture, structure, and processes of a health care organization, designed to radically, consistently, and reliably improve the delivery of care </li></ul>
    12. 12. Challenges to System Transformation <ul><li>Adopting a systems view </li></ul><ul><li>Coordinating complicated changes across multiple system levels </li></ul><ul><li>Meeting data requirements for systems engineering approaches </li></ul><ul><li>Building relationships between healthcare professionals and engineering professionals </li></ul><ul><li>Available resources </li></ul>
    13. 13. Systems Transformation <ul><li>Three concepts central to system transformation </li></ul><ul><ul><li>Integration -training, aligning reinforcements with new behaviors, or assigning responsibilities </li></ul></ul><ul><ul><li>Sustainability -maintaining gains in safety and quality as well as maintaining support for change </li></ul></ul><ul><ul><li>Spread -requires supportive infrastructure for sharing successful redesign experiences </li></ul></ul>Wang et al. Redesigning health systems for quality: lessons from emerging perspectives. Jnt Comm J Qual Safety 2007
    14. 14. Systems Engineering
    15. 15. Institute of Medicine (IOM) and National Academy of Engineering (NAE) Report <ul><li>Systems engineering tools and a system perspective should be applied to redesign healthcare delivery in order to reduce waste and provide more efficient care. </li></ul><ul><li>Partnerships between systems engineers and providers. </li></ul>Reid PP, Compton D, et al. Building a better delivery system: A new engineering/health care partnership, Natl. Acad. Press, 2005.
    16. 16. System Engineering <ul><li>Systems engineering involves the design, implementation, and control of a complex system. </li></ul><ul><li>Goal: to produce a system that meets the needs of all users or participants within the constraints that govern the system’s operation. </li></ul>
    17. 17. Challenges to applying system engineering to healthcare <ul><li>Organizational and Managerial Obstacles </li></ul><ul><ul><li>rigid division of labor. This compartmentalization does not optimally support the application of tools that transcend and span functional areas. </li></ul></ul><ul><li>Educational Barriers </li></ul><ul><ul><li>few healthcare providers trained to think analytically and systematically about how healthcare delivery systems can and should function. </li></ul></ul>Reid PP, Compton D, et al. Building a better delivery system: A new engineering/health care partnership, Natl. Acad. Press, 2005.
    18. 18. Challenges <ul><li>Lack of training </li></ul><ul><li>Systems engineering approaches often have major data requirements </li></ul><ul><li>Collection, storage, processing, and retrieval of this data require sophisticated and expensive integrated information systems </li></ul><ul><li>Need for building effective partnerships </li></ul>
    19. 19. Promoting System Redesign <ul><li>Involve top- and middle-level leaders </li></ul><ul><li>Align and integrate improvement efforts with organizational goals </li></ul><ul><li>Involve champions, teams, and staff in leading redesign efforts </li></ul><ul><li>Establish and maintain infrastructure, processes, and performance feedback that supports continuous improvement </li></ul>Wang et al. Redesigning health systems for quality: lessons from emerging perspectives. Jnt Comm J Qual Safety 2007
    20. 20. Systems Redesign <ul><li>Change must be perceived as beneficial to the individual and organization </li></ul><ul><li>Change must be perceived as compatible with existing systems, practices, values, beliefs, and current needs </li></ul><ul><li>Frequent data monitoring and feedback to adopters helps reinforce changes and sustainability </li></ul>
    21. 21. Implementation Science
    22. 22. Conceptual Frameworks <ul><li>Research efforts not directly related to healthcare can be used in system transformation </li></ul><ul><ul><li>complex responsive systems theory </li></ul></ul><ul><ul><li>organizational change theory </li></ul></ul><ul><ul><li>sociotechnical theory </li></ul></ul><ul><ul><li>knowledge management, utilization </li></ul></ul><ul><ul><li>implementation research </li></ul></ul>
    23. 23. An IHI Framework for Spread <ul><li>Prepare for the spread </li></ul><ul><li>Identify an aim for the spread </li></ul><ul><li>Develop a plan for spread </li></ul><ul><li>Execute and refine the plan </li></ul>
    24. 24. Informatics Implementation Challenges <ul><li>Most settings don’t assess provider or patient needs </li></ul><ul><li>Implementation often does not utilize research findings about human cognition, HCI or organizational ergonomics </li></ul><ul><li>Need for adoption of information systems, clinical decision support to consistently improve care. </li></ul><ul><li>Great need to use data to inform decisions. </li></ul><ul><li>Value of visualization, modeling, simulation. </li></ul>Doebbeling et al. Priorities and Strategies for Implementation of an Integrated Informatics and Communications Technology System for Evidence-based Practices. J. Gen. Intern. Med. 21:S98-S105, 2006
    25. 25. Toward Evidence-Based Quality Improvement <ul><li>Most comparisons reporting dichotomous process data (87%) observed improvements in care, suggesting that dissemination and implementation of guidelines can promote compliance. </li></ul><ul><li>Reminders potentially effective intervention and likely to result in moderate improvements in process. </li></ul><ul><li>Educational materials and audit and feedback result in modest effects. </li></ul><ul><li>Multifaceted interventions did not appear to be more effective than single interventions. </li></ul><ul><li>The effects of multifaceted interventions did not appear to increase with the number of component interventions. </li></ul>Grimshaw et al J GIM 2006; 21:S14–20.
    26. 26. Strategies for Promoting Organizational and Practice Change by Advancing Implementation Research <ul><li>Implementation researchers focus on understanding and influencing the process of uptake of scientific findings by applying and developing theories on provider & organizational behavior, and on how to improve performance. </li></ul><ul><li>This science’s ultimate goal is to improve the health of the public through equitable, efficient application of rigorously evaluated scientific knowledge. </li></ul>Rubenstein & Pugh J GIM 2006; 21:S58–64.
    27. 27. Strategies for Promoting Organizational and Practice Change by Advancing Implementation Research <ul><li>“ Take account” of implementation science </li></ul><ul><li>Maximize learning from past & current implementation initiatives </li></ul><ul><li>Reduce duplication & promote progression of evidence into practice </li></ul><ul><li>Incorporate implementation science into CPGs </li></ul><ul><li>Applying existing implementation science </li></ul><ul><li>Necessary partners in initiatives to increase implementation </li></ul>Rubenstein & Pugh J GIM 2006; 21:S58–64.
    28. 28. “ Taking account” of implementation science <ul><li>literature needed --summaries of how to carry out implementation research --systematic reviews of empirical studies of implementation (identify types of interventions known to have impact, expected magnitude); --reviews of theoretical constructs important for setting the stage; --literature on methodologic issues relevant to implementation science (thorny issues!). </li></ul>Rubenstein & Pugh J GIM 2006; 21:S58–64.
    29. 29. Reduce duplication & promote progression of evidence into practice <ul><li>Active efforts to foster strategic progression of studies from clinical science toward full implementation. </li></ul><ul><li>Studies should progress along a continuum spanning clinical guidelines or best practices, measurement of quality and quality variations, tests of QII effectiveness, tests of QII spread, and policy development. </li></ul><ul><li>Studies of QIIs should progress from higher researcher control to lower researcher control. </li></ul><ul><li>Studies of QIIs should progress from local studies to regional studies to national studies. </li></ul><ul><li>Studies move from a focus on effectiveness to a focus on quality impacts, and from a focus on individuals enrolled to populations. </li></ul>Rubenstein & Pugh J GIM 2006; 21:S58–64.
    30. 30. Applying existing implementation science <ul><li>Use existing IS to develop policies and information dissemination methods that promote adoption of research findings in routine care. </li></ul><ul><li>Required to document all information and tools necessary for understanding how the product was developed, applied, and evaluated. </li></ul><ul><li>Guideline concordant treatment and management strategies can be thought of as products that may or may not diffuse effectively (Greenhalgh et al). </li></ul>Rubenstein & Pugh J GIM 2006; 21:S58–64.
    31. 31. Paradox <ul><li>The shifting baseline of context and the multiplicity of confounding variables must be ‘‘controlled for’’ to make research objective. </li></ul><ul><li>Context and ‘‘confounders’’ lie at the very heart of the diffusion, dissemination, and implementation of complex innovations. </li></ul><ul><li>They are not extraneous to the study; they are an integral part of it (Greenhalgh et al) </li></ul>Rubenstein & Pugh J GIM 2006; 21:S58–64.
    32. 32. Research Agenda
    33. 33. Necessary partners in initiatives to increase implementation <ul><li>Research funders </li></ul><ul><li>Health care funders </li></ul><ul><li>Health care providers </li></ul><ul><li>Health care provider educational institutions </li></ul><ul><li>Quality improvement and healthcare accreditation organizations </li></ul><ul><li>Journals & publications </li></ul><ul><li>Professional societies </li></ul><ul><li>Community partners </li></ul>Rubenstein & Pugh J GIM 2006; 21:S58–64.
    34. 34. The Road to Healthcare Systems Transformation <ul><li>Incorporating many different disciplines, (e.g., engineering, psychology, education, sociology, informatics, computer science, pharmacy, nursing and management). </li></ul><ul><li>Time is ripe for a convergence of these diverse perspectives. </li></ul><ul><li>Multidisciplinary teams can bring these perspectives together, creating synergy and applying diverse perspectives and tools to changing healthcare systems. </li></ul>
    35. 35. Maximize learning from past & current implementation initiatives <ul><li>Assessing past successes and failures </li></ul><ul><li>Cross-cutting analyses that generate or test hypotheses about implementation across studies within these initiatives can provide new information beyond the results of individual studies. --VA QUERI, System Redesign programs --AHRQ’s Translating Research Into Practice & ACTION collaboratives, Practice Based Research Networks, etc --CDC Translating Research Into Action for Diabetes (TRIAD) --Robert Wood Johnson Foundation’s ‘‘Pursuing Perfection’’ initiative --Institute for Healthcare Improvements Protecting 5M Lives from Harm, Breakthrough Collaborative </li></ul>Rubenstein & Pugh J GIM 2006; 21:S58–64.
    36. 36. “Business Case” for Spread <ul><li>Developing return on investment models helps build the “business case”. </li></ul><ul><li>Crucial for gaining leadership support for redesign activities. </li></ul><ul><li>Need for readily approachable methods. </li></ul>
    37. 37. Future Research Agenda <ul><li>Implementation literature review doesn’t provide a single implementation strategy or a group of strategies guaranteed to be effective in all contexts </li></ul><ul><li>Iterative testing of implementation strategies allows continual improvement in implementation programs and widens their application to a variety of settings </li></ul>
    38. 38. Future Research Agenda <ul><li>New models of collaboration, sharing. </li></ul><ul><li>Carefully planned measurement and methods for testing. </li></ul><ul><li>New research designs. </li></ul><ul><li>Novel methodology development. </li></ul><ul><li>Strategies for dissemination, systematization & spread. </li></ul><ul><li>Marketing research & solutions to public & policy makers. </li></ul>

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