QUERI Project Example
This example is meant to illustrate how quality improvement methods may help in an implementation project. This example is loosely based on an actual set of projects conducted by Matthew B. Goetz, MD and colleagues. See Goetz et al. "A system-wide intervention to improve HIV testing in the Veterans Health Administration." Journal of General Internal Medicine 23.8 (2008): 1200-1207 and Goetz et al. "Central Implementation Strategies Outperform Local Ones in Improving HIV Testing in Veterans Healthcare Administration Facilities." Journal of General Internal Medicine 28.10 (2013): 1311-1317. The example has been adapted to illustrate the various methods.
1. Proposal: A Multi-VISN Implementation of a Program to Improve HIV Screening and Testing
Screening for HIV infection offers significant clinical benefits and is cost-effective. However, historically, at many VA facilities such screening was not consistent, even though HIV identification and treatment provides substantial clinical benefits to the population receiving the screening. Screening results in more timely medications, immunizations, and prophylactic treatments that reduce mortality, prevent hospitalizations and turn HIV into a chronic disease, avoiding the high cost of treatment and the mortality of more advanced cases. Screening appears to improve patients' outcomes, particularly quality of life after treatment. However, at one point in time such screening was not deployed commensurate with the benefits and was not well understood at many VA provider locations. The facilities that were currently using the screening procedures differed in terms of how it was deployed. There are multiple ways in which HIV testing can be encouraged, results audited, providers reminded and the program organized.
An initial limited program was successfully implemented resulting in a significant increase in testing rates and as well as an improvement in outcomes. Based on this success, the researchers proposed to extend this program to more sites and VISNs with eventual goal of a national roll-out.
Let's now imagine that we are the researchers preparing the proposal. The proposed research project must answer pressing questions as to how best to deploy limited resources for this program with the best design in order to achieve the desired results. Thus, proposed objectives are to:
- Evaluate alternative refined versions of the intervention to be done at multiple sites. This will utilize of a study in which implementations will be done at a randomized set of sites to apply differing designs of the program. It will allow the researchers to determine the effectiveness of alternative designs for applying local resources.
- Identify situational variations as well as systematically neglected populations and identify strategies to reduce these issues. Particular attention will be paid to the needs of veterans who are at highest risk. The project plans to design clinical testing and reminders.
- Further evaluate implementation costs, generalizing the business case model developed for the prior deployment so that the full rollout of the program can be justified based on its economics.
- Identify organizational requisites (e.g., staffing, infrastructure and training) for the success of this intervention.
Accomplishment of these objectives is expected to provide a strong foundation for the roll out this intervention to the entire VA. Thus, at the end of the proposed project, which is based on current knowledge and some preliminary data, the researchers expect to know if their proposed screening plans are effective and how best to change provider behavior appropriately and sufficiently. The researchers hope to extend a pilot intervention, improve upon it and to extend it to a wide set of providers.
What QI methods should be included in such a proposal?
2. Selecting the right QI methods
Certain of the QI improvement methods presented in this handbook will strengthen the proposal in significant ways. Success requires selecting the most relevant methods and having the necessary training and experience in their use. The proposal will be enhanced by having staff with relevant QI expertise as part of the team and in a meaningful role.
First, the researchers must understand the environment they hope to impact and that there are proven QI methods to improve upon that understanding. Researchers are expert practitioners in their particular clinical field but they must understand the specific sequence of work processes they plan to impact and constraints on making sustained changes. There may be an organizational culture that will delay or reduce the effectiveness of the proposed intervention, there may be unanticipated costs and there could be many factors not experienced in the researchers' earlier studies. Cost is always a constraint and efficient use of resources requires an efficient design as well as a measurement of outcomes and resulting costs.
Before making a significant change it is important to understand the existing processes and opportunities for improvement. The following methods are particularly applicable for the above proposal:
- Understanding existing processes - A good way to understand current screening processes is documentation through mapping the process and reviewing the map with the staff (See Process Mapping, Section 36). It may be useful to compare a map of the processes at the initial study site versus a map at other sites doing similar screening to identify relevant differences. To the extent certain individuals will need to change practices, the development of a responsibility matrix would be helpful (See Responsibilities Matrix, Section 40). That would indicate which types of individuals must be included and where duplication should be avoided. Also the receptivity of the local organization to the new practices could be considered. A Maturity Model (See Section 26) is one way to do that as assuring proper goals are understood as well as a plan to communicate new objectives (See Hoshin Kanri Section 19).
- Planning change to assure success - Implementing change, in order to be effective, should follow a proven technique such as PDSA (see Section 33). This will mean the change process is designed so as to adopt new practices in a manner to assure a high likelihood of being sustained. Since a variety of professional specialties are involved, a Kaizen like team will be useful (See Section 22). Clinical researchers may be familiar with what is to be done in implementing a change, such as new testing and patient education, but there are ways to increase the likelihood of complete and permanent change. Early implementations may not be as efficient as they could be. A value stream map (See Section 53) based on process maps done earlier in the project can be used to identify waste and opportunities for improvement. The Kaizen team that created the Value Stream Map can use it to identify desirable practical changes. Setting clear goals is also important (See SMART Goals Section 45) so that participants know what is intended and so that leadership can know if it is being achieved.
- Implementation - Often implementation of changes such as new testing and clinical reminders can best be done in an incremental way (See PDSA in Section 33). Consistent implementation is necessary for good quality and maximum effectiveness. That means that it will be very important to document the Standard Work description (See Section 47). By having Standard Work prepared, an ongoing use of the preferred practices is assured. If data is available, a control chart (See Section 9) can be used to verify the outcomes are as desired and to communicate progress to all concerned (See the A-3 form Section 1).
- Evaluation of results and sustaining change - Sustaining a consistent practice may benefit from checklists (See Section 7) and designing work processes so that they must be done one certain way (See Poka Yoke Section 35) and to use visual controls (See Section 54) where possible. The business case will require determination of cost effectiveness (See Section 10) and statistical comparisons to assure support of the change. Cost is always as constraint and determining an economic effectiveness measure for the results of the project is reasonable to expect.