Kaiser Permanente RESEARCH Toward a Learning Healthcare Delivery
Kaiser Permanente RESEARCH Toward a Learning Healthcare Delivery System: Leveraging Implementation, Improvement and Delivery System Science to Improve Performance November 11, 2015 Brian S. Mittman, PhD Dept of Research and Evaluation, Kaiser Permanente Southern California US Dept of Veterans Affairs Quality Enhancement Research Initiative (QUERI) UCLA CTSI Implementation and Improvement Science Initiative Defining a Learning Healthcare System 1. Outcomes and performance goals 2. Features and performance processes Institute of Medicines
Crossing the Quality Chasm (2001) Safe: avoiding injuries Effective: services based on scientific knowledge; avoiding underuse and overuse Patient-centered: responsive to individual patient preferences, needs, and values
Timely: reducing waits and delays Efficient: avoiding waste [value, affordability] Equitable: across gender, ethnicity, geography, SES Commonwealth Funds Framework for a High Performance Health System (2006) Quality and Safety the right health care, avoiding underuse, overuse and misuse safe, reliable
coordinated patient-centered: timely, excellent service, active and informed patients Access to Care universal participation financial protection, established benefits, affordable equitable Commonwealth Funds Framework for a High Performance Health System (2006) Efficient, High Value Care efficient
right time, right setting ongoing evaluation of new technologies; defined processes for introduction, surveillance, reevaluation System Capacity to Improve investment in innovation and research information infrastructure effective educational system rapid response to threats and disasters
culture of improvement balance between autonomy and accountability Summary of desired features 1. 2. 3. 4. 5. 6. 7. Safe and reliable High-quality, effective, evidence-based Patient-centered, excellent service Timely, accessible Efficient, cost-effective, high-value
Equitable System is technologically advanced, research- and improvement-oriented, balancing autonomy and accountability Learning Healthcare Delivery System features Explicit performance, improvement, learning goals Comprehensive performance monitoring against goals Explicit care management plans, policies, practices
Active environmental scanning Explicit policies and processes for locating, vetting, evaluating, refining, scaling/spreading external innovations for internal innovation, experimentation Supportive leadership, culture, training, resources (staff, expertise, space, equipment, funds, etc.), rewards, etc. Achieving learning and improvement: Role of improvement, implementation, delivery sciences? 1. Reliable evidence-based strategies (interventions) for delivering, improving care (FDA-approved, formulary-listed) 2. Strategies for working to improve care (e.g., PDSA/rapidcycle improvement); analytical approaches and tools for monitoring and guiding improvement 3. Insights into barriers to change, requirements or conditions for improvement (environment, organization, team, indl) 4. Insights into the behavior of delivery systems and organizations, teams, clinicians and staff
What is implementation science? 1. Clinical research produces new evidence, innovation 2. Initial efforts to promote implementation 3. Measurement of rates of implementation and implementation (quality) gaps 4. Research to develop and evaluate implementation programs* to increase adoption * quality improvement programs, practice change programs (interventions) Health benefits of research Basic Science ?
Clinical Research ? Improved Health Processes, Outcomes The Clinical Research Crisis AAMC Clinical Research Summit: Clinical Research: A National Call to Action (Nov 1999) IoM Clinical Research Roundtable (2000-2004) UK Cooksey Report (2006), other US and non-US reports Translational research
Basic Science Type 1 Translation Clinical Research Type 2 Translation Improved Health Processes, Outcomes Translational research Type 2
Translation Type 1 Translation Basic Science Pre-Clinical/ Translational Research Clinical Research Implementation Research Improved Health
Processes, Outcomes Implementation research Basic Science Pre-Clinical/ Translational Research Clinical Research Implementation Research
Improved Health Processes, Outcomes Implementation science definition Implementation research is the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and, hence, to improve the quality and effectiveness of health services. It includes the study of influences on healthcare professional and organizational behavior. Eccles and Mittman, 2006 Implementation science aims 1. Develop reliable strategies for improving healthrelated processes and outcomes; facilitate widespread adoption of these strategies 2. Produce insights and generalizable knowledge
regarding implementation processes, barriers, facilitators, strategies 3. Develop, test and refine implementation theories and hypotheses; methods and measures Clinical research vs. implementation research Study type Study feature Aim: evaluate a / an Clinical research Implementation research clinical
Typical outcomes symptoms, health outcomes, patient behavior Typical unit of analysis, randomization patient US, international resources NIH Conference on the Science of Dissemination and Implementation (2007 2015 )
NIH grant funding, review committee, training programs Journals: Implementation Science, Translational Behavioral Medicine, special issues of general and specialty journals, new SIRC journal in development NIH CTSAs (selected), PBRNs, ACTION, VA QUERI Patient-Centered Outcomes Research Institute (PCORI), AAMC Research on Care Community (ROCC)
Knowledge Translation Canada, Kings College London Centre for Implementation Science, etc. Local resources Health Sciences: Community Health, Health Behavior Health Services, Management GIM, Family/Prev Medicine, Subspec Nursing, Dentistry, Psychology, Social Work, OT, PT, other allied
Main Campus: Psychology, Sociology, Anthropology, Political Science, Economics Management, Education, Public Policy Practice-focused research: Emerging models VA QUERI Academic Health System / School of Medicine 3I Institutes (Improvement, Implementation, Innovation)
Integrated delivery system (Health Care Systems Research Network) embedded/partnership research: KPSC Care Improvement Research Team AcademyHealth Delivery System Science fellowship Key features: joint governance, internal funding, negotiated scope, goals, standards (timeline, rigor)
The Quality Chasm Institute of Medicine (1999, 2001) Quality report cards (US, international) Emergence and evolution of research interest 50+ years of research to identify causes and develop solutions to slow, uneven adoption of effective practices Changing physician behavior (1970s/80s: CME, reminders, incentives) Quality improvement, patient safety (1980s, 1990s, etc.)
Implementation science (2000s to present) Findings, insights, recommendations are rich and valuable, yet difficult to apply VA, Kaiser and other systems have improved, but significant quality and performance gaps remain The Tower of Babel problem Knowledge translation
Translational research Research utilization, knowledge utilization Knowledge-to-action, knowledge transfer & exchange Technology transfer Dissemination research Quality improvement research T-1, T-2, T-3, T-4 Etc. Achieving learning and improvement: Contributions from improvement science (QI research) vs. implementation science (1) QI often focuses on the here and now immediate, local improvement needs via rapid-cycle, iterative improvement
IS often attempts to develop, deploy and rigorously evaluate a fixed implementation strategy across multiple sites, emphasizing theory, contextual factors, (sometimes) mediators, moderators, mechanisms IS aims to develop generalizable knowledge Achieving learning and improvement: Contributions from QI vs. implementation science (2) QI is pragmatic, improvement-oriented (often at the cost of limited confidence in interpretation and attribution and useful knowledge); IS is scientific, research/knowledge-oriented (often at the cost of improvement outcomes and useful
knowledge) Neither has made much headway in achieving either goal Achieving learning and improvement: Contributions from QI vs. implementation science (3) QI often ignores contextual factors, fundamental insights into organizational/professional behavior, cross-site differences and implications for improvement success IS usually ignores heterogeneity and dominance of context over intervention main effects, and too often mediators, moderators, mechanisms
Neither has made much headway in achieving either goal Achieving learning and improvement: Contributions from QI vs. implementation science (4) QI offers tools for persisting until improvement is achieved, driven by a desire to solve an identified quality problem IS offers theories, designs, methods, conceptual clarity for building from effectiveness/innovation work to implementation, to reap the benefits of innovation and research discovery and development Achieving learning and improvement: Contributions
from QI research and implementation science Despite some overlap, QI research and implementation science are largely complementary, and each could (should) learn and benefit from the other Necessary conditions for practice change: insights from QI and implementation research 1. Valid, legitimate (accepted) evidence 2. Evidence of deviations 3. External expectations, interest (monitoring), pressure 4. Supportive professional norms 5. Etiology of practices, deviations 6. Information, evidence, education
7. Feasible methods/systems Necessary conditions for practice change 1. Valid, legitimate (accepted) evidence 2. Evidence of deviations 3. External expectations, interest (monitoring), pressure 4. Supportive professional norms 5. Etiology of practices, deviations 6. Information, evidence, education 7. Feasible methods/systems Implementation and QI in local settings factors contributing to success Exceptional (non-routine, unsustainable, nonscalable) resources and support from central project team:
site-by-site, individualized technical assistance funding for new staff, services recruitment, hiring, training, supervision, support for new staff Hawthorne effect (enhanced attention from monitoring, evaluation, external/internal interest) Challenges to planned scale-up and spread
Lack of exceptional resources coupled with: 1. Features of innovations 2. Features of target adopters 3. Features of the environment 4. Features of innovation champions 5. Features of scale-up/spread strategies ______________ Source: WHO and ExpandNet, Practical Guidance for Scaling Up Health Innovations, 2009. http://expandnet.net/PDFs/WHO_ExpandNet_Practical_Guide_published.pdf Barriers to progress? Critiques and commentaries on the state of the science in implementation science often cite: Lack of rigor; limited internal validity; too few RCTs Limited external validity; too many RCTs (or too many flawed RCTs); use of black box evaluation approaches
Lack of theory; lack of appropriate theory Too many theories; lack of guidance in using theory Implementation and improvement problems and phenomena are extraordinarily complex (simple vs. complex vs. wicked problems) An alternative (re-stated) hypothesis Implementation and improvement science study phenomena characterized by: Heterogeneity and variability of program (intervention) content across time and place Heterogeneity of program implementation across time and place Significant and variable contextual influences (leadership, culture, experience/capacity, staff/budget sufficiency) Strong mediator effects (indirect impacts) and attenuation of effects
Weak main effects (other than for robust programs) Studying complex social interventions: What is our goal? Two very different questions 1. Does it work? Is it effective? Should it be approved? Included in the formulary? Should I use it? 2. How, why, when and where does it work? How should I use it? How do I make it work? For many or most implementation strategies, Q1 is meaningless Developing insights and guidance for implementation and improvement
How do I choose an appropriate implementation or improvement strategy given my context? How do I implement (deploy) the strategy to increase effectiveness? How do I adapt and customize the strategy to increase effectiveness (initially and over time)? How do I modify (manage) the organization or setting to increase effectiveness (initially and over time)?
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