# Presentation: 502874

## A Multimethod Tailored QII for Sustainable Practice Change

- Mary C. Ruhe, B.S., R.N.
- Kurt C. Stange, MD, PhD
- Research Association of Practices (RAP)
- & Case Western Reserve University

**Notes:**
A line of inquiry in collaborating PBRNs that seeks first to understand practice {using a multimethod assessment process (MAP),
 then to use that understanding to improve practice.

## PBRN Collaboration in a Line of Inquiry

- Primary care setting
- Practice as the focus of change
- Patient care and practice enhancement the goal

**Notes:**
Fertile ground is established for initiating a QII through collaboration in a PBRN and following an ongoing line of inquiry

## Slide 3

**Notes:**
This line of inquiry has been funded by the AHRQ, NCI, NHLBI, and RWJF, and goes form observation to intervention and back again.

## Competing Demands Theory

**Many worthwhile services compete for time on the agenda of primary care patient visits.**
**When primary care clinicians are not doing one activity under scrutiny (e.g. preventive services), they may be doing something else that is more compelling.**
** **Jaén CR, Stange KC, Nutting PA.  The competing demands of primary care: A model for the delivery of clinical preventive services.  J Fam Pract.  1994; 38:166-171.
-  Stange KC, Fedirko T, Zyzanski SJ,  Jaén CR.  How do family physicians prioritize  delivery of multiple preventive services?  J Fam Pract.  1994; 38:231-237.

**Notes:**
We began this work to try to understand practice from the viewpoint of competing demands theory, which states...

## Transdisciplinary, multimethod approaches

- Stange KC, Zyzanski SJ.  Integrating qualitative and quantitative research methods.  *Fam Med*, 1989; 21:448-451.
- Stange KC, Miller WL, Crabtree BF, O’Connor PJ, Zyzanski SJ.  Multimethod research: Approaches for integrating qualitative and quantitative methods.  *J Gen Intern Med*.  1994; 9:278-282.
- Crabtree BF, Miller WL, Addison RB, Gilchrist VJ, Kuzel A.  *Exploring Collaborative Research in Primary Care*.  Thousand Oaks, California: Sage Publications, 1994.
- Crabtree BF, Miller WL.  *Doing Qualitative Research.  2nd Ed*. Thousand Oaks, California: Sage Publications, 1999.
- Crabtree BF, Miller WL, Stange KC.  Understanding practice from the ground up.  *J Fam Pract*, 2001; 50:881-887.

**Notes:**
Our approach was guided by integrating quantitative and qualitative methods.

## Multimethod Research 

-   **Quantitative methods**
- Counting descriptions
- Testing *a priori* hypotheses
- Seek to isolate phenomenon from context
-   **Qualitative methods**
- Rich descriptions
- Discovery; testing evolving hypotheses
- Seek to understand meaning and context
-  **Integrated use**
- Qualitative, then quantitative
- Quantitative, then qualitative
- Simultaneous

**Notes:**
Quantitative methods are good for counting and testing hypotheses for things that you already know how to measure.
Qualitative methods are good for understanding meaning and context.
Together, they provide complementary views, and make for efficient research that is grounded in the wisdom of the participants.

## Understanding  before, during and after Intervening

**Notes:**
Our approach is based on the premise that understanding practice is on ongoing process essential to successful intervention.

## STEP-UP

- Group RCT in 77 practices
- Individualized intervention based on multimethod assessment process (MAP)
- Control group gets (refined) delayed intervention with pre/post evaluation
- Goodwin MA, Zyzanski SJ, Zronek S, et al.  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.
- Kottke TE, Solberg LI.  STEP(ing)-UP to deliver clinical preventive services.  *Am J Prev Med*.  2001; 21:20-28.

**Notes:**
STEP-UP, the Study to enhance prevention by understanding practice was a group randomized clinical trial of a practice-tailored approach to improving prevention.

## MAP

**Observation**
**Practice operations**
**Patient visits**
**Key informant interviews**
**Practice genograms***
**Focus on understanding practices’**
**Key stakeholders and motivation**
**Current approach to preventive service delivery**
**Capacity to change and levers for change**
- *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.

**Notes:**
The practice assessment includes observation and interviews and a focus on understanding the unique characteristics of the practice

## Practice Genogram

- A tool for gathering data on and depicting the structure and relationships of primary care practices
- Enhances understanding of practices as complex adaptive systems
- Can help identify levers for change
- 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.

**Notes:**
Creating a practice genogram is helpful in understanding the structures and relationships in a practice 

## Slide 11

**Notes:**
Here is a practice with one physician and one NP

## Slide 12

**Notes:**
Here is the same practice 11 months later (lots of change)

## Practice-Tailored Intervention

- Multimethod practice assessment
- Practice meeting
- Facilitation of implementation
- Continued feedback

**Notes:**
Our project went in with a list of tools and approaches designed to facilitate the delivery of preventive services. 
The exact fit, use and often the design of tools or approaches for a practice stemmed from information and understanding gained through the multi-method assessment process. 
Information was shared with the practice at a practice meeting and follow-up interactions with the faciliitator were available to help the practice implement a change. 
Ongoing feedback on delivery rates was also given to the practices.

## Global Preventive Service Delivery

**Global Preventive Service Delivery**

- Mean % eligible services up to date

**Notes:**
This slide show the change in PSD in the control (White - No further data) and intervention groups

Yellow is intervention group, which increased its PSD from patients being up to date on 31% of services for which they were eligible to 43%.

Normally rates decay back toward baseline( show with pointer). We think ours did not because wt was an individualized intervention based on practice assessment.

## Global Preventive Service Delivery

- 0

- 2

- 4

- 6

- 8

- 10

- 0.9

- 1.0

- 1.1

- 1.2

- 1.3

- 1.4

- 1.5

- 1.6

- 1.7

- 1.8

- 1.9

**Rate Ratio - 12 months to baseline**

**Number of practices**

**Global Preventive Service Delivery**

**Notes:**
This table shows the variability of intervention uptake.
It shows the rate ratio of PSD rates at 12 months compared to baseline.  
{A ratio of 1 = no change, < 1 means getting worse, >1=better)
1 practice dropped slightly
1 practice stayed the same
Most practices were between 10 and 60% increase, and a few made even larger changes

##     Health Behavior Counseling

**   **

**    ****Health Behavior Counseling**

- 0

- 1

- 2

- 3

- 4

- 5

- 6

- 7

- 8

- 9

- 0.75

- 1.00

- 1.25

- 1.50

- 1.75

- 2.00

- 2.25

- 2.50

- 2.75

- 3.00

- 3.25

- 3.50

- 3.75

**Rate Ratio - 12 months to baseline**

**Number of practices**

**Notes:**
The differing effects are even more remarkable for health behavior counseling, which was the main focus of the intervention.
2 practices got worse.
4 stayed the same.
Most made between a 25 and 100% improvement.
One tripled their rates, and one almost quadrupled their health behavior counseling rates.

## Implications

- A tailored quality improvement intervention has variable, but sustained effectiveness, even in a changing health care environment
- Greater individualization of intervention approaches is needed, based on greater understanding of practice variation

**Notes:**
From this quality improvement intervention we concluded that... (read slide)

This led to the ULTRA study, which is being conducted in the NJ and PA PBRN’s.  ULTRA is using a MAP assessment and a Reflective Adaptive Process (RAP) to help practices improve their communication, processes and their chronic disease management.

It also led to EPOCHS, which is being conducted in RAP:

## STEP-2

- Greater individualization
- Evaluation and reflection on         (general and prevention specific)
- Values
- Structures
- Processes
- Outcomes

**Notes:**
From this quality improvement intervention we concluded that... (read slide)

This led to the ULTRA study, which is being conducted in the NJ and PA PBRN’s.  ULTRA is using a MAP assessment and a Reflective Adaptive Process (RAP) to help practices improve their communication, processes and their chronic disease management.

It also led to EPOCHS, which is being conducted in RAP:

## EPOCHSEnhancing Practice Outcomes through Communities and Healthcare Systems

- RCT of 30 primary practices in 3 systems
- Engagement of resources from
- Practice
- Healthcare system
- Community organizations
- Tailored Appreciate Inquiry intervention
- Multimethod process assessment
- Funded by a grant (5R01 CA60862) from the National Cancer Institute

**Notes:**
Our current study, (EPOCHS), Enhancing Practice Outcomes through Communities and Healthcare Systems adds an Appreciative inquiry process component to heighten the engagement of practices and involves the resources of healthcare systems and the communities to better meet the needs of the practice and patients.

## Understanding (and working with) Practices as Complex Adaptive Systems

**Notes:**
Our work has led us to think of practices as complex adaptive systems, and to expand our research team to include complexity scientists.

## Facilitating Practice Change

- The edge of chaos
- Innovators (live on the edge)
- Outside forces move toward the edge
- QI intervention moves toward the edge
- Change is difficult to predict
- Tailor facilitation to malleable moments
- Motivated change agents
- Work with the already motivated
- Increase motivation by
- Linking to values or other needs
- Peer comparison feedback
- Once motivated, address instrumental needs
- 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.

**Notes:**
In working with practices, we identified several principles that are useful in helping practices to change...

## Primary Care Practices are Complex Adaptive Systems

- Complex behavior emerges from relationships among agents
- Simple rules
- Recurrent patterns
- Co-evolution
- Dependence on initial conditions
- Non-linearity
- Strategies for intervention
- Joining
- Transforming
- Learning
- 	 Miller WL, Crabtree BF, McDaniel RA, Stange KC.  Understanding primary care practice: A complexity model of 	change.  *J Fam Pract*, 1998; 46:369-376.
- 	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.

**Notes:**
These observations are congruent with complexity science approaches to understanding practices as complex adaptive systems...

## Using Complexity Science to Inform a Reflective Practice Improvement Process

- Understanding practices’ vision and mission is useful in guiding change
- Creating time and space for learning & reflection helps organizations to adapt & plan change
- Tension & discomfort are essential & normal during change
- Diverse perspectives foster adaptability & new insights for positive change
- 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.

**Notes:**
The ULTRA study’s reflective adaptation process (RAP) is grounded in the understanding of practices as complex adaptive systems (CAS). 

Using this practice improvement process revealed characteristics common to practice change efforts.

## Implications of a complexity science perspective

- Relationships are critical.
- Sensemaking is more important than decision-making
- Learning is more important than knowing.
- Problems cannot be solved by muscle, but require creativity and improvisation.
- Thinking about the future without prediction is a key to progress

**Notes:**
Using complexity science as a framework for understanding primary care practice lead to these conclusions...

## Conclusions

**Efforts to improve practice should be preceded by efforts to understand practice.**
**Individualizing intervention approaches based on a MAP can lead to sustainable practice improvement.**

**Notes:**
Our line of inquiry shows that ..

## Conclusions

**Continued learning, sensemaking and relationship building is critical to fostering positive co-evolution of practices and systems**

**Notes:**
Our line of inquiry shows that ..