# Presentation: 355307

## Comments and Reactions:Four Evidence-based MH QI projects

- Tim Cuerdon, PhD
- Director of Measurement and Evaluation
- Office of Mental Health Services, VHA
- December 11, 2008

## Background / Context

- Participated in, and evaluated Quality Improvement projects for about 20 years at:
- Program Evaluation and Methodology Division (PEMD) – GAO
- QIO (nee PRO) program at CMS (nee HCFA)
- NIMH
- OQP & OMHS - VHA

## Results

- Fairly typical of most QI efforts
- Some, weak, but disappointing amounts of improvement.
- Improvements tend to be incremental, not tectonic or quantum
- Despite good evidence-based processes and high enthusiasm

## What have we learned?

- Not much
- Shot gun approaches seem to work better than single, rifle shot interventions
- Effective, charismatic champions seem to be associated with most successful QI efforts

## How did we get here?

- “Just do it” mentality
- Moral imperative to deliver the right or best care to all patients has caused a sense of urgency
- “We’re not doing research here”
- We don’t need “analysis paralysis”

## What’s Missing?

- Theory of the Status Quo – why are things the way they are, when everyone knows there’s a better way?
- Identification and appreciation of the forces that cause inertia / resistance to change

## Implicit Theories

- Every QI project reflects an implicit theory, based on the nature of the interventions used.
- But because the theory is left unstated, it usually cannot be directly tested, or compared to a competing theory

## Review of today’s four projects

- Rosenheck and Sernyak Cost-Effectiveness Study
- Typical of many early QI efforts
- Lack of knowledge causes today’s pattern of care
- Spreading the good news will lead to positive change
- Earlier Patient Education literature challenges the utility of information as a change agent

## Review of today’s four projects

- Owen et al Study
- Moves information closer to point of care delivery – reminders / pocket cards.  Makes the information more salient
- Adds performance monitoring and feedback – suggesting that increased self-monitoring and/or competition might induce change
- Team QI vs. Opinion leader – nexus of change “ownership” / motivation

## Review of today’s four projects

- Young et al Study
- Clozapine training
- Family referrals
- Weight / wellness referrals
- Feedback reports
- Evaluation of QI components also incorporated in the design
- Burnout
- Cross-service boundaries identified as barriers

## Review of today’s four projects

- Resnick Study
- Model sites developed
- Other sites come to model to learn by observing
- Fidelity to model site features emphasized
- But not all model sites are exemplery, and some can do, but not teach

## Where do we go from here?

- Make explicit the cause and effect connection between the intervention and the targeted QI outcome
- Use designs that can test out this hypothesized connection
- Include a run out, or post-QI phase to detect Hawthorne effects and delayed onsets

## Where do we go from here?

- Debrief QI participants / collaborators (or “victims”)
- Conduct post-hoc examinations of most and least successful sites.
- Begin to describe and then test the efficacy of the characteristics that make a successful champion / opinion leader

## Invitation

- Implementation of the MH Uniform Services Handbook will generate lots of study opportunities
- Psychotherapy vs. pharmacotherapy
- Delivery of MH services in specialty clinics vs. integrated and primary care clinics
- Delivery of MH services in CBOCs
- Delivery of MH services via Tele-medicine.