Presenting developments in Quality Improvement science and promoting the involvement of psychologists

1. PSYCHOLOGISTS &
QUALITY IMPROVEMENT
HEALTH PSYCHOLOGY FELLOWS SEMINAR
LOUIS STOKES CLEVELANDVETERANS ADMINISTRATION MEDICAL CENTER
9/25/2018
NANCY MERBITZ, PHD

2. QUESTIONS
• Do you believe that you gain knowledge during your work with patients and healthcare
systems that is not captured in research publications you’ve encountered so far?
• Do questions arise in your practice that are rarely if ever explored in publications?
• How often do you encounter “systems issues” that seem to impede clinical care?
• Have you wondered about making a contribution to the knowledge base of psychology in
healthcare settings, but perceive great barriers to accessing the necessary resources?

3. QUALITY IMPROVEMENT (QI) SCIENCE:
• is a flexible systems-based approach for improving the quality of health care delivery
within daily clinical practice.
• One widely used QI framework for developing, implementing and testing changes in
clinical practice is the Model for Improvement (Moen, Nolan, & Provost, 1999).
• A cornerstone of this model is the use of Plan-Do-Study-Act (PDSA) cycles. PDSAs are
rapid, sequential, and cumulative learning cycles that provide valuable outcome data
within the on-going work of care teams.

4. OUTLINE OF PDSA CYCLES IN QI …
• A change idea is identified in the ‘Plan’ phase.
• The actual implementation and measurement of the idea occurs in the ‘Do’ phase.
• Review of the measurement data occurs in the ‘Study’ phase, and
• next steps (whether to adopt, adapt, or abandon) are decided in the ‘Act’ phase, with
subsequent PDSA cycles utilizing the data to improve the intervention.
• Thus, QI methodology is a means of increasing the delivery of evidence-based care to patients
by developing interventions that are guided by on-going collection of relevant data.
• QI methodology has been utilized to improve care for a wide variety of medical situations.

5. THE STEPS IN THE PDSA CYCLE ARE:
• Step 1: Plan—Plan the test or observation, including a plan for collecting data
• Step 2: Do—Try out the test on a small scale
• Step 3: Study—Set aside time to analyze the data and study the results
• Step 4:Act—Refine the change, based on what was learned from the test

6. THIS GRAPH TELLS THE STORY OF A NURSING
QI PROJECT TO REDUCE PRESSURE ULCERS
• How convincing is this story about efforts at one hospital to increase
screenings for pressure ulcer risk?
• Note where “phase changes” are identified (events or changes in process).
• Although the number of patients involved was large, what is the actual
“sample size” for this intervention? Should this be considered as an
example of single subject design?

10. EXAMPLE OF ATEST OF CHANGE
(PLAN-DO-STUDY-ACT CYCLE):VERY SMALL
FIRST CYCLE
• Test a change quickly on a small scale, see how it works, and refine the change as necessary before
implementing it on a broader scale.The following example shows how a team could start with a small-
scale test.
• Diabetes intervention: follow up visits for more education on blood sugar management
• Plan: Ask each patient if he or she would like more information on how to manage his or her blood
sugar.
• Do: Dr. J. asked patients with diabetes in Tuesday clinic.
• Study: 3 of 5 patients were interested; Dr. J. was pleased at the positive response.
• Act: Dr. J. will continue with the next five patients and set up an additional visit for those who say yes.

11. QUALITY IMPROVEMENT AND PROGRAM EVALUATION:
COMPETENCIES FOR PSYCHOLOGISTS IN PRIMARY CARE
• “This competency area in the Science cluster requires competence in research and program evaluation
applied specifically to the PC [Primary Care] setting.“ (McDaniels et al., 2014)
• “Distinct competencies include
• functioning as leaders on interdisciplinary research projects,
• evaluating clinical programs,
• fully participating in quality improvement assessments.”

12. QUALITY IMPROVEMENT AND PROGRAM EVALUATION:
COMPETENCIES FOR PSYCHOLOGISTS IN PRIMARY CARE
• “Evaluating the effectiveness of screening or prevention programs used in the PC setting is a behavioral
example of the essential component of applying research skills to evaluate practice, interventions, and
programs.”
• The psychologist “works with clinical leadership and the team to design, implement, and evaluate
quality improvement initiatives that impact how care is routinely delivered”

13. QI / IMPROVEMENT SCIENCE: SUBVERSIVE?
UPENDING THE TRADITIONAL ORDER?
• The new field of improvement science is emerging as a place of coming together by
demonstrating the potential understanding of “the universal” that can be drawn from
intense understanding of “the particular” in practice.
• (Hawe, P. Interventions to Improve Health. Annu. Rev. Public Health 2015. 36:307–23)

14. REGARDING THE EVIDENCE BASE FOR OUR CLINICAL
PRACTICE:
• “Don’t assume that science lives up at one end of the spectrum, while application and
impact live on the other.
• Recognize the primary knowledge that is generated in practice contexts, which holds its
own integrity and foundations, and is in no way a sole derivative of bench, laboratory, or
even descriptive population sciences.”
• “The occupational division between researchers and practitioners
• relegates practitioners to the distal end of the knowledge pipeline, to be seen only as end
users of knowledge and not as creators.
• A lopsided evidence base on complex interventions potentially and unjustifiably ensues.”

15. HEALTHCARE SETTINGS AND INTERVENTIONS
ARE COMPLEX. QI METHODS ARE WELL-SUITED.
• Complexity—resulting from interactions among many component parts—is a property
of both the intervention and the context (or system) into which it is placed.
• New metaphors and terminology are needed to capture the recognition that knowledge
generation comes from the hands of practitioners/implementers as much as it comes from
those usually playing the role of intervention researcher.
• Researchers in clinical settings are documenting health improvement gains made as a
consequence of complex systems thinking. Improvement science in clinical settings has
much to offer researchers ... (Hawe, P. Annu. Rev. Public Health 2015. 36:307–23)

16. • “The greater the difficulty in defining precisely what exactly are the active ingredients of
an intervention and how they relate to each other, the greater the likelihood that you are
dealing with a complex intervention.”

17. START SMALL & EXPLORE SOME DATA:
THE STORY OF A MAN WITH HYPONATREMIA (LOW SODIUM)
& HOW IT AFFECTED HIS PARTICIPATION IN REHAB
• Participation was roughly defined at minutes of therapy per day.
• To stay in inpatient rehabilitation (acute) the patient must
participate in 3 hours/day (180 minutes) on average.
• As his sodium level dropped, this fellow became more tired &
had more trouble moving and learning as his sodium dropped.
• Returned to acceptable minutes/day as hyponatremia resolved.

18. 115
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2-Feb 9-Feb 16-Feb 23-Feb 2-Mar 9-Mar 16-Mar 23-Mar 30-Mar 6-Apr 13-Apr
Sodium
Lab
Values
Trend in Sodium LabValues
Na

19. 27-Jan 6-Feb 16-Feb 26-Feb 8-Mar 18-Mar 28-Mar 7-Apr 17-Apr
0
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2-Feb 9-Feb 16-Feb 23-Feb 2-Mar 9-Mar 16-Mar 23-Mar 30-Mar 6-Apr 13-Apr
Therapy
Minutes
Sodium
Lab
Values
Calendar Days (Sundays numbered)
TherapyTime and Sodium LabValuesTrendingTogether
Na total time

20. BEHAVIOR IS THE OUTCOME METRIC OF
HEALTHCARE.
• Sodium levels provided vital information to medical providers about the need for and the
results of their intervention.
• ButTHE POINT of intervening was to enable the patient to continue behaving, learning,
and benefitting from rehabilitation (i.e. to continue being alive and “doing stuff”).
• Without information about both together, some team members added to the burden of
this patient’s experience through misattributions. NEVER underestimate the importance
of your role in educating teams and shaping interventions.

21. SELECTED READINGS
• Berwick, D. & Nolan,T. (1998) Developing andTesting Changes in Delivery of Care. Ann Intern Med.
1998;128:651-656. Also available at http://www.acponline.org.
• PDSA worksheet download from http://www.ihi.org/knowledge/Pages/Tools/PlanDoStudyActWorksheet.aspx
• Speroff,T., O’Connor, G. (2004) Study Designs for PDSA Quality Improvement Research. Q Manage Health
CareVol. 13, No. 1, pp. 17–32
• Goldberg, S. B., Babins-Wagner, R., Rousmaniere,T., Berzins, S., Hoyt,W.T.,Whipple, J. L., ... & Wampold, B. E.
(2016). Creating a climate for therapist improvement:A case study of an agency focused on outcomes and
deliberate practice. Psychotherapy, 53(3), 367.
• Reese, R. J., Duncan, B. L., Bohanske, R.T., Owen, J. J., & Minami,T. (2014). Benchmarking outcomes in a public
behavioral health setting: Feedback as a quality improvement strategy. Journal of consulting and clinical psychology,
82(4), 731.

22. SELECTED READINGS
• Ernst, M. M.,Wooldridge, J. L., Conway, E., Dressman, K.,Weiland, J.,Tucker, K., & Seid, M. (2009). Using
quality improvement science to implement a multidisciplinary behavioral intervention targeting pediatric
inpatient airway clearance. Journal of pediatric psychology, 35(1), 14-24.
• Hart,T. (2009).Treatment definition in complex rehabilitation interventions. Neuropsychological rehabilitation,
19(6), 824-840.
• Callahan, C. D., & Barisa, M.T. (2005). Statistical process control and rehabilitation outcome:The single-
subject design reconsidered. Rehabilitation Psychology, 50(1), 24.
• Hart,T., & Bagiella, E. (2012). Design and implementation of clinical trials in rehabilitation research. Archives
of physical medicine and rehabilitation, 93(8), S117-S126.
• Berwick, D. M. (2016). Era 3 for medicine and health care. Jama, 315(13), 1329-1330.

23. SELECTED READINGS
• Girdler, S. J., Glezos, C. D., Link,T. M., & Sharan,A. (2016).The Science of Quality Improvement. JBJS reviews,
4(8).
• Ogrinc, G., Davies, L., Goodman, D., Batalden, P., Davidoff, F., & Stevens, D. (2015). SQUIRE 2.0 (Standards
for QUality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus
process. The Journal of Continuing Education in Nursing, 46(11), 501-507.
• Tate, R. L., Perdices, M., Rosenkoetter, U., Shadish,W.,Vohra, S., Barlow, D. H., ... & Sampson, M. (2016).The
single-case reporting guideline In BEhavioural interventions (SCRIBE) 2016 statement. Evidence-based
communication assessment and intervention, 10(1), 44-58.
• Taylor, M. J., McNicholas, C., Nicolay, C., Darzi,A., Bell, D., & Reed, J. E. (2013). Systematic review of the
application of the plan–do–study–act method to improve quality in healthcare. BMJ Qual Saf, bmjqs-2013.