Triangulation On QI for Sustainable Change: STEP-UP Model for Improving Prevention
Mary C. Ruhe BS, RN Kurt Stange MD, PhD Case Western Reserve University
Quality Improvement Goals
Improve prevention in primary care practices Develop methods for building and sustaining improvements Develop practice as a learning organization
Quality Improvement Methods
Theoretical Bases
Complexity theory
Organizational levels involved in QI
PBRN (practice based research network) Individual practice; clinicians and staff
Primary Care Practices as Complex Adaptive Systems
Complex
behavior emerges from relationships among agents
Simple rules, recurrent behavior patterns Co-evolution, with dependence on initial conditions Non-linearity Joining Transforming Learning
Strategies for intervention
Litaker D, Tololo A, Liberatore V, Stange K, Aron, D. Using Complexity Theory to Build Interventions that Improve Health Care Delivery in Primary Care, JGIM, 2006; 21: S2: S30-S34 Stroebel CK, McDaniel RR Jr, Crabtree BF, Miller WL, Nutting PA, Stange KC. Using complexity science to inform a reflective practice improvement process. Jt Comm J Qual Patient Saf, 2005; 31: 438-446 Miller WL, McDaniel RA, Crabtree BF, Stange KC. Practice Jazz: Understanding variation in family practices using complexity science. J Fam Pract, 2001; 50:872-878.
STEP-UP Quality Improvement Model Key Elements
Multimethod assessment of practice (MAP)
Facilitated practice meeting and feedback session Facilitation of implementation Ongoing feedback
Goodwin MA, Zyzanski SJ, Zronek S, Ruhe M, Weyer SM, Konrad N,Esola D, Stange KC. A clinical trial of tailored office systems for preventive service delivery: The Study to Enhance Prevention by Understanding Practice (STEP-UP). Am J Prev. Med 2001; 21:20-28.
Who Provides What for QI
PBRN
Recruitment and ongoing communication (local PBRN) Collaborative learning (across PBRN’s)
Researchers
Practice assessment Facilitate/mentor to meet practice needs Provide or develop intervention tools and approaches
Practices
Choose and/or develop tools and approaches Implement intervention with varied levels of support
STEP-UP Design & Measures
Group randomized clinical trial
Cluster randomization of 77 practices Control group gets (refined) delayed intervention Nested process assessment
Medical record review of prevention activities Q 6 mos to 12 (control) or 24 (exp) Satisfaction & attitude surveys
Patients, clinicians, staff
Qualitative Measures
MAP (multimethod assessment of practice)
Focus on understanding practice Participant observation (3-5 days)
Practice operations Patient visits
Key informant and informal interviews
Practice genograms*
*McIlvain H, Crabtree BF, Medder J, Stange KC, Miller WL, Dodendorf D, Aita V. Using “practice genograms” to understand and describe practice configurations. Fam Med, 1998; 30:490-496.
Wins
Individualizing intervention approaches based on a MAP can lead to practice improvement Sustained for 24 months in experimental group Led to the EPOCHS trial which is using and Appreciative Inquiry to link practices to systems and community
Global Preventive Service Delivery
0.45
Mean % eligible services up to date
0.43 0.41 0.39 0.37 0.35 0.33 0.31 0.29 0.27 0.25 Baseline 6 months 12 months Intervention 18 months Control 24 months
Stange KC, Goodwin MA, Zyzanski SJ, Dietrich AJ. Sustainability of a practice-individualized preventive service delivery intervention Am J Prev. Med 2003; 25: 296-300
Lessons Learned About QI
Uptake is variable across practices Being at the edge of chaos facilitates change
Motivated potential change agents are key
Once motivation exists, address instrumental needs The facilitation approach should be tailored over time
Emergent opportunities Malleable moments
Ruhe MC, Weyer, SM, Zronek S, Wilkinson A, Wilkinson PS, Stange KC. Facilitating practice change: Lessons from the STEP-UP clinical trial. Prev Med. 2005; 40: 729-734.
Complexity Science Informs Practice Improvement
• • •
Understand practices’ vision and mission Create time and space for learning and reflection Tension and discomfort are essential and normal during change
• •
Incorporate diverse perspectives Sustainable change requires supportive leadership
Stroebel CK, McDaniel RR Jr, Crabtree BF, Miller WL, Nutting PA, Stange KC. Using complexity science to inform a reflective practice improvement process. Jt Comm J Qual Patient Saf, 2005; 31: 438-446.
Suggestions for the Future
Address variable uptake by linking with healthcare systems and communities Motivate by focusing on what is meaningful to practice Cycle between action and reflection