va hsr&d sdp 09-158 teresa damush, phd heather woodward-hagg, ms marianne matthias, phd virginia...
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VA HSR&D SDP 09-158
Teresa Damush, PhDHeather Woodward-Hagg, MS
Marianne Matthias, PhDVirginia Daggett, DNS, MSN
Joseph Ross, MD, MHSZhangsheng Yu, PhD
Xinli Li, PHD, MS
Systems Engineering and Implementation Partnership:The INSPIRE Stroke Project
How the partnership began…
Chose improving stroke care as one element of their
VISN-wide focus for FY08
VISN 11
OQP
Stroke QUERI
Conducted national measurement of inpatient
stroke care in FY07-09
Worked with OQP to develop and measure stroke care, used these data to pilot a Systems Redesign-based collaborative in VISN 11 FY08-09, launch multi-site INSPIRE in FY10
OQP Stroke Special Project: National stroke performance data benchmarking
Goals: Measure in-hospital stroke care quality within the VA system
using both Joint Commission and VA specific in-patient care performance measures
Provide VA medical centers their data for inpatient stroke care quality
Assemble toolkit of existing programs, templates, and strategies to improve stroke care
Assess stroke risk factor management at 6 months and one-year post-discharge for veterans in the cohort with VA outpatient care
FY 2006 FY 2007 FY 2008 FY 2009
Quality indicators defined
Data collection tool developed Abstractor (n=90)
training
Data collection tool pilot testing
Data collection completed
Scoring algorithms completed
Final national data reported
Field review and correction of facility level data
Toolkit completed
Stroke QUERI and OQP collaboration established
Stroke network established
Multidisciplinary team assembled
OQP Stroke Special Project: Main Results
Process of CareDenominator
EligibleProportion of Eligible Patients with Performance Measure Present (%)
Antithrombotic at discharge 3514 96.4Antithrombotic by HD2 3523 95.6Smoking cessation counseling 1268 94.9Pressure ulcer assessment 3789 91.8Early ambulation 3009 86.1Rehab consultation/FIM 2796 86.0Lipid management 3009 82.1Fall risk assessment 3673 79.3DVT prophylaxis 1018 78.2Anticoagulation for afib 409 75.3NIHSS documented 3640 27.7Dysphagia screen before po 3591 23.4Stroke education 2524 18.1Thrombolysis (tPA) given 227 8.4
VISN 11 Pilot: Introducing Systems Engineering Methods in a Stroke
Collaborative
VISN11 leadership Dr. Pamela Reeves, CMO; Ann Herm, Clinical Program
Manager; Mary Sherrill, Systems Redesign lead
7 VAMC interdisciplinary teams of front line staff involved in stroke care
Stroke QUERI Center investigators and research coordinators
System Redesign/OSE Expertise – VISN 11 SR staff, Heather Woodward-Hagg/Indy COE
VISN 11 Pilot: Methods
Identification of stroke care improvement teams at all 7 VISN 11 facilities in 2008
Facility survey about stroke systems of carePre-collaborative work:
Baseline data collection Choice of 2 performance indicators: dysphagia screening
before oral intake and discharge on lipid-lowering medication OSE methods training (conference call and video) Inpatient stroke flow map and “Voice of the customer”
interviewsCollaborative:
Shared baseline data (chart review)—dysphagia screening, d/c on lipid lowering medication, developed standard admission order template
Paired didactic and team break-out sessions: More flow mapping, impact/effort assessments, PDSA cycles, future state process maps/action plans
Shared plans with group after each team session
Collaborative
Didactic and team break-out sessions
VISN 11 Pilot: Methods
Post-collaborative work: Systems Redesign “coaches” assigned to each team 6 biweekly coach-team calls and monthly group calls Monthly data review and aggregate data input on Sharepoint
site for 12 months
Analysis: Pre-collaborative data on indicators from OQP compared to
post-collaborative data Follow-up interviews with each team to assess how changes
were made, barriers to and facilitators of change, spread of methods
Developed training materials subsequently used in other VA collaboratives
VISN 11 Pilot: Results
Dysphagia results Cholesterol results
INSPIRE SDP: Intervention for Stroke Performance Improvement using Redesign
Engineering
Study aims: 1. To evaluate the effect of public reporting on
organizational change to improve stroke care quality in VA
2. To conduct a formative developmental evaluation in 14 of the largest volume VAMCs to understand organizational barriers and facilitators to the delivery of high-quality stroke care
3. To test a Systems Redesign/OSE-based intervention vs. performance feedback alone in improving 2 stroke indicators Stratify randomization by baseline performance Work on two indicators; plan for DVT prophylaxis and
dysphagia screening before oral intake but will be based on baseline data collection and site input
Year 1 Year 2 Year 3
IRB
R&D
Union
Aim 1 and
Aim 2
interviews1
Aim 3
pre-
work
Site
inter-
views2
Site
inter-
views1
Baseline chart
reviews
Intervention Primary outcome chart
reviews
Analysis
Q1
Jan 10
Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
INSPIRE timeline
1In-person site interviews2Telephone site interviews
INSPIRE Interview and baseline phase (Aims 1 and 2)
Interviews arranged by site PI, 2 interviewers to each site
2 different interviews Receipt of and response to the OQP Stroke Special Project
data: who received it, who else saw it, what action(s) resulted, how can the field best use/receive this type of data?
Current state of stroke systems of care from front-line providers: structure and personnel involved, any ongoing improvement teams or activities, assessment of the overall level of care provided, what is working well, what could be improved?
Interviews recorded, transcribed, analyzedBaseline stroke performance data collected via
central chart review for CY2009
INSPIRE Intervention Phase (Aim 3)
Sites randomized to intervention vs. control, stratified by baseline performance All sites with at least 50 stroke admissions annually
Intervention sites: In-person collaborative with OSE/SR training, followed by 6 months of coaching through rapid tests of change; monthly performance data feedback
Control sites: quarterly performance data feedback
Data collection for 12 months post-interventionAnalyses:
Primary: improvement in individual and composite performance indicators
Secondary: temporal pace of change in performance, sustainability of change, qualitative assessments of local context and relationship to changes observed
INSPIRE status
11 sites on board; active recruitment of 3 others Bay Pine, Birmingham, Chicago (Jesse Brown), Cleveland,
Durham, Houston, Loma Linda, Miami, Oklahoma City, Tennessee Valley, Tucson
Site interviews underwayVistaWeb access pending; plan for baseline data
collection via chart abstractions July-NovemberIn-person collaborative January 2011Planned SDP September: RE-INSPIRE: Rich-
context evaluation of INSPIRE; Edward Miech, PI
Questions?
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