Using the Quality Improvement Process to

Implement VA/DoD Guidelines

SUBSTANCE USE DISORDERSSUBSTANCE USE DISORDERS

Why Care About Guidelines?

• Practice lags behind published Practice lags behind published evidence regarding what worksevidence regarding what works

• Unacceptable variation in practiceUnacceptable variation in practice• Examples:Examples:– Smoking cessation in addiction Smoking cessation in addiction

treatmenttreatment– Pharmacotherapy of alcohol Pharmacotherapy of alcohol

dependencedependence– Treatment of opioid dependenceTreatment of opioid dependence

Why Care About Guidelines?

• This means that:This means that:

– Where you are treated will Where you are treated will determine the quality of treatment determine the quality of treatment you receiveyou receive

– Our patients are not receiving up-Our patients are not receiving up-to-date treatmentto-date treatment

– The outcomes achieved are less The outcomes achieved are less than is possiblethan is possible

How would you feel if …

• you got a radical mastectomy when you got a radical mastectomy when a lumpectomy would give the same a lumpectomy would give the same result?result?

• your doctor failed to prescribe a your doctor failed to prescribe a medication that could prevent medication that could prevent relapse of your heart disease?relapse of your heart disease?

How would you feel if…• you knew that your provider didn’t even

know about new treatments?

• your provider knew that multiple studies showed that a new treatment was safe and effective, but said, “I don’t believe in it”?

What if it meant that you died 10 years earlier than you would have otherwise?

What if you would have received that treatment if you had been in another VISN?

Why Don’t We Implement Evidence Based Practices?

• Lack of timeLack of time

• Lack of knowledge and skillsLack of knowledge and skills

• Lack of belief in the evidenceLack of belief in the evidence

• TraditionTradition

• Lack of institutional supportLack of institutional support

• Pharmacy barriersPharmacy barriers

Why Don’t We Implement Evidence Based Practices?

• Peers do not support changePeers do not support change

• Patient preferencePatient preference

• System makes it hard to changeSystem makes it hard to change

• No incentive to changeNo incentive to change

• Hard to do aloneHard to do alone

Examples in VHA

0102030405060708090

100

Smokingcessation

RelapsePrevention

Naltrexone

Evidence

Recommend

Implemented

OpportunitiesOpportunities

43%

31%

39%

Opioid Agonist Therapy

• Methadone, LAAM, buprenorphine Methadone, LAAM, buprenorphine treatment for opioid dependencetreatment for opioid dependence

• Very strong evidence baseVery strong evidence base

• Highly cost effective Highly cost effective (Barnett et al, 2000)(Barnett et al, 2000)

• Yet…Yet…

Opioid Agonist Therapy

• Only about ¼ of veterans with a Only about ¼ of veterans with a diagnosis of opioid dependence diagnosis of opioid dependence received opioid agonist therapy in 1999received opioid agonist therapy in 1999

• 6/22 (27%) of networks have 6/22 (27%) of networks have nono OAT OAT

• This includes 8 of the 25 largest metro This includes 8 of the 25 largest metro areas in the country (32%).areas in the country (32%).

The QI Process: A Possible Solution?

• All VA health care facilities use QIAll VA health care facilities use QI

– Staff are familiar with itStaff are familiar with it

– Hospital infrastructure to support itHospital infrastructure to support it

– JCAHO Accreditation requires itJCAHO Accreditation requires it

The QI Process: A Possible Solution?

• Structured process to:Structured process to:

– Identify areas needing improvementIdentify areas needing improvement

– Develop strategies for changeDevelop strategies for change

– Measure resultsMeasure results

– Interpret outcome and reviseInterpret outcome and revise

The QI Process: A Possible Solution?

• Usually used to improve clinical Usually used to improve clinical operationsoperations

• Examples:Examples:

– Improve efficiency of intake processImprove efficiency of intake process

– Improve program retentionImprove program retention

– Decrease error ratesDecrease error rates

The QI Process: A Possible Solution?

• Involves a team of cliniciansInvolves a team of clinicians

• Change from the ground upChange from the ground up

• Based in realityBased in reality

• Incorporates patient preferencesIncorporates patient preferences

Applying QI to Guideline Implementation

• Identify areas where:Identify areas where:

– A good evidence base exists A good evidence base exists defining effective therapydefining effective therapy

– There appears to be variation There appears to be variation across staff members in applicationacross staff members in application

– It is likely that current practice is at It is likely that current practice is at substantial variance from evidence-substantial variance from evidence-based practicesbased practices

Applying QI to Guideline Implementation

• Single practice or treatment focusSingle practice or treatment focus

• Clearly definedClearly defined

• MeasurableMeasurable

• Linked to outcomesLinked to outcomes

• ImportantImportant

Applying QI to Guideline Implementation

• Maximize chance of success byMaximize chance of success by

– Choosing treatment over which Choosing treatment over which you have more control you have more control

– Choosing treatment that has a Choosing treatment that has a greater consensusgreater consensus

The PDSA Model of QI

Plan

Act Study

Do

PDSA is a common form of QI. PDSA is a common form of QI.

PDSA means:PDSA means:

PDSA is a common form of QI. PDSA is a common form of QI.

PDSA means:PDSA means:

Plan

• During theDuring the Plan Plan phase, staff examine phase, staff examine evidence and decide what areas of evidence and decide what areas of the program to address. the program to address.

• The The Plan Plan phase ends with a decision phase ends with a decision to collect data about your current to collect data about your current practices.practices.

Plan: Example

• Dr. James Olson, the program Dr. James Olson, the program coordinator, convenes a team to coordinator, convenes a team to implement guidelines.implement guidelines.

• The group examines the VA/DOD The group examines the VA/DOD SUD guideline to identify practices SUD guideline to identify practices with a strong evidence base.with a strong evidence base.

Plan: Example

• They decide to focus on naltrexone They decide to focus on naltrexone treatment for alcohol dependence treatment for alcohol dependence because:because:

– Very strong evidence baseVery strong evidence base

– Meta-analysis showed consistent Meta-analysis showed consistent effecteffect

– Very low rate of implementation in Very low rate of implementation in programprogram

Plan: Example

• The group discusses possible The group discusses possible reasons for the low implementation reasons for the low implementation rate:rate:

– Lack of belief in effectivenessLack of belief in effectiveness

– ExpenseExpense

– Poor compliancePoor compliance

Plan: Example

– Lack of experience using Lack of experience using pharmacotherapy to treat alcohol pharmacotherapy to treat alcohol dependencedependence

– Low demand by patientsLow demand by patients

– Poor compliancePoor compliance

Do

• Once program staff agree to examine Once program staff agree to examine current practices, they enter the current practices, they enter the DoDo phase.phase.

• Baseline data are collected on current Baseline data are collected on current practices in the clinic.practices in the clinic.

• The purpose is to compare clinic and The purpose is to compare clinic and evidence-based practices.evidence-based practices.

Do: Example

• They examine their records for the They examine their records for the past 6 months, and find that 5% of past 6 months, and find that 5% of their patients with alcohol their patients with alcohol dependence receive naltrexone.dependence receive naltrexone.

• They also find that physicians and They also find that physicians and counselors vary considerably in counselors vary considerably in their use of naltrexone.their use of naltrexone.

Study

• The The StudyStudy phase begins with phase begins with analysis of the baseline data. analysis of the baseline data.

• Program staff identify aspects of Program staff identify aspects of practice they wish to bring closer to practice they wish to bring closer to evidence-based practices.evidence-based practices.

• Based on the data, staff set a goal Based on the data, staff set a goal for change.for change.

Study: Example

• The group sets a goal that 80% of The group sets a goal that 80% of appropriate patients receive a appropriate patients receive a recommendation for naltrexone.recommendation for naltrexone.

Act

• Once a goal is defined, programs Once a goal is defined, programs enter the enter the ActAct phase in which they phase in which they plan and implement a strategy for plan and implement a strategy for change.change.

• Measurement of practices continues Measurement of practices continues while change is implemented.while change is implemented.

• At the end of the At the end of the Act Act phase, the data phase, the data are compared to baseline.are compared to baseline.

Act: Example

• The QI group develops strategies to The QI group develops strategies to address perceived barriers.address perceived barriers.

• For example, they address the lack of For example, they address the lack of belief in effectiveness, lack of belief in effectiveness, lack of familiarity, and lack of experience familiarity, and lack of experience through education.through education.

• The develop a protocol to identify, The develop a protocol to identify, assess, and treat appropriate patients.assess, and treat appropriate patients.

Plan

• Programs re-enter the Programs re-enter the Plan Plan phase to phase to determine if their original change has determine if their original change has been effective and plan for a new been effective and plan for a new PDSA cyclePDSA cycle

• PDSA Cycles should be:PDSA Cycles should be:

– MultipleMultiple

– RepeatedRepeated

– Short (3 months)Short (3 months)

Plan: Example

• After 3 months, the group examines the After 3 months, the group examines the success of the initiative:success of the initiative:

– 46% of appropriate patients received a 46% of appropriate patients received a recommendation for naltrexone, and recommendation for naltrexone, and 38% filled a prescription for it.38% filled a prescription for it.

– Staff are much more knowledgeable.Staff are much more knowledgeable.

Plan

• If the original goal has not been met: If the original goal has not been met:

– Examine barriers to changeExamine barriers to change

– Develop additional strategiesDevelop additional strategies

– Begin a new PDSA cycleBegin a new PDSA cycle

Plan: Example

• The result, while a big improvement, The result, while a big improvement, fell short of the goalfell short of the goal

• Barriers identified include:Barriers identified include:

– Poor patient compliancePoor patient compliance

– Some staff members still telling Some staff members still telling patients not to take naltrexonepatients not to take naltrexone

– Delays in the protocol due to long Delays in the protocol due to long appt waits for physicianappt waits for physician

Plan: Example

• The group decides to:The group decides to:

– Develop patient education Develop patient education resources regarding naltrexone.resources regarding naltrexone.

– Initiate one-to-one sessions with Initiate one-to-one sessions with staff members to determine basis staff members to determine basis for resistance.for resistance.

– Physician agrees to see pts Physician agrees to see pts immediately for naltrexone immediately for naltrexone prescription.prescription.

Plan

• If the original goal has been met:If the original goal has been met:

– Congratulations!Congratulations!

– Review data pertaining to other Review data pertaining to other practices practices

– Select a new goalSelect a new goal

– Begin a new PDSA cycleBegin a new PDSA cycle

Plan: Example

• After another two PDSA cycles, 72% After another two PDSA cycles, 72% of appropriate patients received a of appropriate patients received a prescription for naltrexone.prescription for naltrexone.

• The group began to identify other The group began to identify other areas for the next group of PDSA areas for the next group of PDSA cycles.cycles.

That’s why it’s called

That’s why it’s called continuous

continuous

quality im

provement.

quality im

provement.

That’s why it’s called

That’s why it’s called continuous

continuous

quality im

provement.

quality im

provement.