Presentation on theme: "Ed Wagner, MD, MPH MacColl Institute for Healthcare Innovation"— Presentation transcript:
1 What will it Take to Improve Care for Chronic Illness for the Population? Ed Wagner, MD, MPHMacColl Institute for Healthcare InnovationCenter for Health StudiesGroup Health CooperativeImproving Chronic Illness CareA national program of the Robert Wood Johnson Foundation
2 Step 1: Find the causes of inadequate care. IOM Quality Chasm Report: “The current care systems cannot do the job.”“Trying harder will not work.”“Changing care systems will.”
3 What Patients with Chronic Illnesses Need A “continuous healing relationship” with a care team and practice system organized to meet their needs for:Effective Treatment (clinical, behavioral, supportive),Information and support for their self-management,Systematic follow-up and assessment tailored to clinical severity,More intensive management during high risk periods, andCoordination of care across settings and professionals
4 What’s Responsible for the Quality Chasm? A system oriented to acute disease that isn’t working for patients with long-term care needs or the professionals caring for them
5 Step 2: Select a strategy Three Options: 1 Step 2: Select a strategy Three Options: 1. Assume that competition and computers will improve care 2. Direct to patient disease management 3. Improve medical care by changing care systems
6 Why is it critical that we change care systems? The human and financial costs of chronic disease are heavily determined by the level and duration of disease controlWithout high quality medical care, disease control measures like HbA1c, BP, LDL tend to plateau or slowly worsen over timeIt is difficult (maybe impossible) to deal with the many attitudinal, behavioral and pharmacologic issues associated with poor control in currently designed care systems.
7 Why?1. Some patients simply fall between the cracks and many practices have neither the data nor mechanisms to find them.2. If care consists largely of patient-initiated visits for new problems, there usually isn’t time to optimize:Patient understanding and involvementMedication adherenceSelf-management competenceThe drug regimen3. Many patients with less than optimal control need more intensive management and follow-up than practices usually provide
8 What kind of changes to practice systems improve care? better use of non-physician team members,planned encounters,modern self-management supportCare management for high riskLinks to effective community resourcesguidelines integrated into careenhancements to information systems (registries)
9 Clinical Information Systems Self- Management Support Chronic Care ModelCommunityHealth SystemResources and PoliciesHealth Care OrganizationClinical Information SystemsSelf- Management SupportDelivery SystemDesignDecisionSupportPrepared,ProactivePractice TeamInformed,ActivatedPatientProductiveInteractionsOur premise is that good outcomes at the bottom of the model (clinical, satisfaction, cost and function) result from productive interactions. To have productive interactions, the system needs to have developed four areas at the level of the practice (shown in the middle): self-management support (how we help patients live with their conditions), delivery system design (who’s on the health care team and in what ways we interact with patients), decision support (what is the best care and how do we make it happen every time) and clinical information systems (how do we capture and use critical information for clinical care). These four aspects of care reside in a health care system, and some aspects of the greater organization influence clinical care. The health system itself exists in a larger community. Resources and policies in the community also influence the kind of care that can be delivered. It is not accidental that self-management support is on the edge between the health system and the community. Some programs that support patients exist in the community. It is also not accidental that it is on the same side of the model as the patient. It is the most visible part of care to the patient, followed by the delivery system design. They know what kind of appointments they get, and who they see. They may be unaware of the guidelines that describe best care (but we should work to change that) and they may be totally unaware of how we keep information to provide that care. We’ll talk about each in detail in the following slides.Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. A survey of leading chronic disease management programs: Are they consistent with the literature? Managed Care Quarterly. 1999;7(3):56-66.Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA 2002 Oct 16; 288(15):Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A., Improving chronic illness care: translating evidence into action. Health Aff (Millwood) Nov-Dec;20(6):64-78.Improved Outcomes
10 Current status of Chronic Care Model National measurement and pay for performance programs – NCQAState initiatives – California, Vermont, Pennsylvania, North Carolina, etc.New models of Primary Care AAFP – combines CCM, medical home, and pay for coordination and performanceACP – “advanced medical home” has same three ingredients
12 Organizing the Evidence Randomized controlled trials (RCTs) of interventions to improve chronic careStudies of the relationship between organizational characteristics and quality improvementEvaluations of the use of the CCM in Quality ImprovementRCTs of CCM-based interventionsCost-effectiveness studiesThe following slides discuss each of these types of evidence in turn.
13 1: Randomized Controlled Trials of Interventions to Improve Chronic Care Most reviews are disease specific.Reviews and meta-analyses tend to focus on individual components rather than combined effects.Diabetes reviews played an important role in CCM development.
14 1: Randomized trials of system change interventions: Diabetes Cochrane Collaborative Review and JAMA Re-reviewAbout 40 studies, mostly randomized trialsInterventions classified as decision support, delivery system design, information systems, or self-management support19 of 20 studies that included a self-management component improved care.All five studies with interventions in all four domains had positive impacts on patients. Renders et al, Diabetes Care, 2001; 24:1821Bodenheimer, Wagner, Grumbach, JAMA 2002; 288:1910Let’s look at some of the evidence that initially led the IOM Committee to conclude that it was the system, and not individuals, that was the issue.This review was focused on intervention studies (about 85% were RCTs) that tried to improve the primary care of persons with diabetes. Interventions were fairly diverse, but fell into four broad categories:Interventions directed at provider behavior change, to increase the likelihood they would do evidence-based care.Interventions directed at patients to make them more knowledgeable about their condition, more skillful in managing their health, and more confident in their ability to take care of their illness.Interventions directed at the design of the practice: Changes to the way the practice team is configured, such as an added team member, or new responsibilities taken on by existing members. Changes to the way visits were organized and structured, such as use of planned visits and groups visits. Case management.Enhancements to clinical information systems. Development of systems that provided automated reminders, performance feedback to practice, and the like.The interventions as a group tended to improve care. But, there was no magic bullet; no single intervention seemed to make the major difference. As the number of intervention categories increased in the program tested, the more effective the program seemed to be.The Bodenheimer et al re-analysis found five studies that included interventions in all four categories. All five studies had a major positive effect on both process and outcome measures, suggesting that it is comprehensive system change that makes the difference. One apparently necessary but not sufficient intervention was self-management support, as summarized in the last two bullets.
15 1: RCTs of interventions to improve chronic care results “Complex,” “integrated care,” programs show positive effects on quality of careConsistently powerful elements include: team care, case management, self-management supportSTUDY SPECIFICSA review of systematic reviews demonstrates that integrated care programs generally have positive outcomes. The most commonly used components of integrated care programs include: self-management support, patient education, case management, multidisciplinary patient care team, and clinical feedback/reminders/education. Authors caution that inconsistent definitions of interventions and outcomes are prevalent throughout the literature and, if ignored, can lead to inappropriate conclusions about the effectiveness of programs in meta-analyses.1One of two reviews of depression treatment in primary care finds that complex interventions using clinician education, enhanced nurse case management, and greater integration between primary and specialty care are effective in improving patient outcomes. Less complex interventions like provider education alone are less likely to be effective.2Badamgarav and colleagues conducted systematic evaluation of disease management. Lack of a clear definition of “disease management” makes interpreting the findings difficult, but in general they found an improvement in patient satisfaction, adequacy of prescribed treatment, and other quality of care markers. They also found increases in costs associated with hospitalization and treatment costs among the intervention groups as compared to controls.3A review of quality improvement strategies in hypertension finds that interventions that include team care are associated with the greatest improvement in blood pressure outcomes. Here, team care is defined as the “assignment of some responsibilities to a health professional other than the patient's physician.” Other strategies that proved effective include patient education and self-management support.4Glasgow and colleagues published a literature review and expert recommendations for future research around diabetes care as part of the Health Care Delivery Work Group. They find that the continued focus on acute illness, rather than proactive chronic care management, is the cause for poor-quality diabetes care processes and outcomes. They cite articles showing that self-management support, improved patient-provider communication, and collaborative goal setting are linked to improved behavioral, biological, and quality of life outcomes. They also cite that a population focus, inclusion of clinician prompts and reminders, and a quality clinical information systems that supports disease registries are helpful tools to improve care.5A second systematic review of diabetes shows that multifaceted interventions that “facilitate structured and regular review of patients were effective in improving the process of care.” Renders et al finds that studies rarely assess outcomes. Like the studies above, they find that clinician education with performance feedback and use of care teams seemed to improve care.6A recent Cochrane review of diabetes care finds that in 58 papers with 66 comparisons, quality improvement initiatives that used team changes and those that use case management with the ability to influence physicians’ prescribing patterns showed the largest difference in post intervention HbA1c scores.7Ouwens M, Wollersheim H, Hermens R, Hulscher M, Grol R. Integrated care programmes for chronically ill patients: a review of systematic reviews. Int J Qual Health Care 2005; 17(2):141-6.Gilbody S, Whitty P, Grimshaw J, Thomas R. Educational and organizational interventions to improve the management of depression in primary care: a systematic review. JAMA 2003; 289(23):Badamgarav E, Weingarten SR, Henning JM et al. Effectiveness of disease management programs in depression: a systematic review. Am J Psychiatry 2003; 160(12):Walsh JM, McDonald KM, Shojania KG et al. Quality improvement strategies for hypertension management: a systematic review. Med Care 2006; 44(7):Glasgow RE, Hiss RG, Anderson RM et al. Report of the health care delivery work group: behavioral research related to the establishment of a chronic disease model for diabetes care. Diabetes Care 2001; 24(1):Renders CM, Valk GD, Griffin SJ, Wagner EH, Eijk Van JT, Assendelft WJ. Interventions to improve the management of diabetes in primary care, outpatient, and community settings: a systematic review. Diabetes Care 2001; 24(10):Shojania KG, Ranji SR, McDonald KM et al. Effects of quality improvement strategies for type 2 diabetes on glycemic control: a meta-regression analysis. JAMA 2006; 296(4):
16 1: An Example of a Meta-analysis of interventions to improve chronic illness Includes 112 studies, most RCTs (27 asthma, 21 CHF, 33 depression, 31 diabetes)Interventions that contained one or more CCM elements improved clinical outcomes (RR ) and processes of care (RR )No superfluous elementDidn’t study interactive effectsWhat impact does the CCM and its components have on patients? This is a meta-analysis of chronic care model-like interventions in asthma, congestive heart failure, depression, and diabetes done by the RAND Team.Across these four conditions, meta-analytically they found a 30-60% improvement in the process of care associated with CCM-like interventions, and a 10-15% improvement in clinical outcomes, across all of these studies, suggesting that they really do have a measurable effect on patients.Tsai AC, Morton SC, Mangione CM, Keeler EB. A meta-analysis of interventions to improve care for chronic illnesses. Am J Manag Care Aug; 11(8): PMID:Tsai AC, Morton SC, Mangione CM, Keeler EB. Am J Manag Care Aug;11(8):
17 2: Studies of the Relationship between Organizational Characteristics and Quality Studies by CMS, NCQA and others have shown strong correlations between practice consistency with the CCM and diabetes performance indicators.STUDY SPECIFICSThere is a significant relationship between a practice’s primary care orientation and its implementation of the CCM. Specifically, medical groups (as opposed to IPAs) that accept risk for hospitalization costs, use health promotion programs, have an electronic standardized problem list, and are required to report patient process and outcome measures appear to use more chronic care management practices.1Flemming et al. studied 134 managed Medicare organizations and collected diabetes quality measures (HbA1c, LDL, microalbuminuria and eye exams). They assessed 32 care elements based on the CCM and compared top and bottom quartiles on quality (e.g., HbA1c > 9.5–20% vs. 50%). Top quartile more likely to employ CCM elements, especially: computerized reminders, practitioner involvement on QI teams, guidelines supported by academic detailing, formal self-management programs, a registry.2Staff participation in practice decisions and optimization of the clinical care team to include non-physician staff can improve the delivery of preventive services. In addition, improved clinical systems such as reminders and patient registries are associated with improved delivery of preventive services.3Overall, physician organizations have not adopted as many components of the diabetes care management index as we would expect. 47% use one or fewer care management processes. A number of factors were associated with increased use of care management processes: Reporting data to external organizations; receiving income, recognition, or better contracts for quality; improved IT infrastructure; ownership by HMO or hospital system; receiving capitated payments; and large size.41. Schmittdiel JA, Shortell SM, Rundall TG, Bodenheimer T, Selby JV. Effect of primary health care orientation on chronic care management. Ann Fam Med 2006; 4(2):2. Fleming B, Silver A, Ocepek-Welikson K, Keller D. The relationship between organizational systems and clinical quality in diabetes care. Am J Manag Care 2004; 10(12): Hung DY, Rundall TG, Crabtree BF, Tallia AF, Cohen DJ, Halpin HA. Influence of primary care practice and provider attributes on preventive service delivery. Am J Prev Med 2006; 30(5):4. Li R, Simon J, Bodenheimer T et al. Organizational factors affecting the adoption of diabetes care management processes in physician organizations. Diabetes Care 2004; 27(10):
18 3: Evaluations of the Use of CCM in Quality Improvement Largest concentration of literatureIncludes RAND Evaluation of ICICWide variety in quality and type of evaluation designsMajority of studies focus on diabetesRAND Evaluation of the Improving Chronic Illness Care was a multimillion dollar evaluation effort sponsored by the Robert Wood Johnson Foundation. Because of the size and robustness of that evaluation, those findings are highlighted separately in the next few slides.
19 3: RAND Evaluation of Chronic Care Collaboratives Two major evaluation questions: 1. Can busy practices implement the CCM? 2. If so, would their patients benefit?Studied 51 organizations in four different collaboratives, 2132 BTS patients, 1837 controls with asthma , CHF, diabetesControls generally from other practices in organizationData included patient and staff surveys, medical record reviewsSee for details.
20 3: RAND Findings Implementation of the CCM Organizations made average of 48 changes in 5.8/6 CCM areasOne year later, over 75% of sites had sustained changes, and a similar number had spread to new sites or new conditions.STUDY SPECIFICSOver four-fifths of the organizations implemented some interventions in all six CCM elements. However, there were differences: since many elements of the CCM depend on having a registry of patient, sites worked most intensely on improving information support (24% of all their efforts, on average) and least intensely on developing community linkages (8% of their efforts).1Pearson ML, et al. Assessing the implementation of the chronic care model in quality improvement collaboratives. Health Serv Res Aug; 40(4):
21 3: RAND Findings (2) Patient Impacts Diabetes pilot patients had significantly reduced CVD risk (pilot > control), resulting in a reduced risk of one cardiovascular disease event for every 48 patients exposed.CHF pilot patients more knowledgeable and more often on recommended therapy, had 35% fewer hospital days and fewer ER visitsAsthma and diabetes pilot patients more likely to receive appropriate therapyAsthma pilot patients had better QOLSTUDY SPECIFICSThe 10-year risk of cardiovascular disease was determined using a modification of the U.K. Prospective Diabetes Study risk engine. The baseline 10-year risk was 31% for both cases and controls. At the end of the period, the intervention group had a 2.1% greater reduction in predicted risk.1Participation in the collaborative for Heart Failure was associated with fewer emergency department visits.2 The RAND team also utilized medical record review to measure performance on 23 predefined quality indicators for sites participating in the heart failure collaborative. Patients from collaborative sites showed greater improvement than control sites for 11 of the 21 indicators, including use of lipid lowering and angiotensin converting enzyme inhibition therapy. When all indicators were combined into a single overall process score, participating sites improved more than controls (17% versus 1%, P _ ). The improvement was greatest for measures of education and counseling (24% versus _1%, P _ ).3The overall process of pediatric asthma care improved significantly in the intervention group but remained unchanged in the control group (change in process score +13% vs 0%; P < .0001). Patients in the intervention group were more likely than patients in the control group to monitor their peak flows (70% vs 43%; P < .0001) and to have a written action plan (41% vs 22%; P = .001). Patients in the intervention group had better general health-related quality of life (scale score 80 vs 77; P = .05) and asthma-specific quality of life related to treatment problems (scale score 89 vs 85; P < .05).4The RAND study of adult asthma care had a smaller study population and found process of asthma care improved significantly, as did patient satisfaction with communication, but outcomes were not significantly different from controls.51. Vargas R, et al. Can a Chronic Care Model Collaborative Reduce Heart Disease Risk in Patients with Diabetes? JGIM, Pre-published online at: Accessed January 29, 2007Baker DW, Asch SM, Keesey JW, Brown JA, Chan KS, Joyce G, Keeler EB. Differences in education, knowledge, self-management activities, and health outcomes for patients with heart failure cared for under the chronic disease model: the improving chronic illness care evaluation. J Card Fail Aug; 11(6): PMID:Asch SM, Baker DW, Keesey JW, Broder M, Schonlau M, Rosen M, Wallace PL, Keeler EB. Does the collaborative model improve care for chronic heart failure? Med Care Jul; 43(7):Mangione-Smith R, et al. Measuring the effectiveness of a collaborative for quality improvement in pediatric asthma care: does implementing the chronic care model improve processes and outcomes of care? Ambul Pediatr Mar-Apr; 5(2):75-82.Schonlau M, et al. Evaluation of a quality improvement collaborative in asthma care: does it improve processes and outcomes of care? Ann Fam Med May-Jun; 3(3):200-8.
22 3: Non-RAND Evaluations of CCM Implementation In general, those studies with greater fidelity to the CCM showed greater improvements.All but one showed improvement on some process measures.Most showed improvement on outcomes and empowerment measures, as well.Recent evaluation shows cost-effectiveness of collaborative participation-- $33,000/QALYSTUDY SPECIFICSUsed disease registry, diabetes nurse case managers, and group visits to improve diabetes outcomes in rural, minority populations in Eastern North Carolina. Pre-post findings indicated an increase in patients with self-management goals who received lipid panel, used aspirin and received a foot exam.1Pre-post examination of Midwestern CHCs’ participation in the Diabetes Health Disparities Collaborative showed increased process measures, like rates of HbA1c measurement, eye examination referral, foot examination and lipid assessment. Mean value of HbA1c also decreased. Survey respondents felt the effort was worth it and successful. Practices struggled in: needing more time, developing a patient registry, staff turnover, more support by senior management.2Teams implementing CCM as part of the Diabetes BTS collaborative improved their self-management support capabilities, as measured both by self report and objective data. Among heart failure collaboratives, daily self-monitoring of weight by patients improved significantly (19% to 93%) and teams provided education significantly more often to patients.3Harwell and colleagues supported primary care practices with performance feedback. Practices then did a variety of additional system changes. This cross-sectional study found improvements in some processes – foot examinations, microalbumin testing, dilated retinal examination – but not others like HbA1c testing or LDL-C testing.4Multiple North Carolina residency practices participated in the BTS collaboratives and implemented strategies across all elements of the CCM. Practices evaluated themselves at base-line and after using the ACIC. Study found that key measures of diabetes care were improved in two-thirds of practices.5Practices in Wisconsin and Minnesota that implemented planned care and DEMS found that planned care plus use of a disease registry improved care across all 12 performance measures. Planned care alone or in conjunction with DEMS improved metabolic outcomes. DEMS alone improved process measures, but not metabolic outcomes.6Implementation of the CCM in a rural Pennsylvania practice resulted in significant improvement in adherence to ADA guidelines including 2 HbA1c tests per year, lipid profile, urinalysis, eye exam, and foot exam performed. Mean HbA1c also declined significantly, as did mean HDLc levels. Improvement in three empowerment measures was seen, though it wasn’t significant.7Among a highly transient, uninsured population, significant improvements in diabetes outcomes including decreased LDL, HbA1c, and Arterial Pressure were observed. 8Case studies from North Carolina show that participation in the CCM collaborative resulted in improved HbA1c values for diabetics. Factors contributing to success included senior leadership support, physician champions, and multidisciplinary teams. Staff turnover was a barrier.9A Washington state initiative to conduct state-level collaboratives around diabetes care resulted in some improvement in process and outcome measures in most of the 47 participating teams. Absolute improvement was higher for process measures than for outcome measures. 10One study used the CCM framework to improve the delivery of diabetes self-management training. They found the framework useful in terms of improving the number of DSMT programs offered, enhancing reimbursement to cover costs, and lowering patients HbA1c –ostensibly by offering more patients self-management support. 11The implementation of the Chronic Care Model produced different results when used at two different primary care practices in London. One site showed significant improvements in identification and case management of depression; the other did not. Tangible barriers like a primative information technology system, lack of experience with chronic disease management, and the inability to find common meeting time proved serious barriers to the implementation of the project in the second site. Other, intangible barriers which mediated the impact of the CCM at the second site included a lack of staff ownership, participation, and buy-in as well as lack of external support for the elements of the project. 12Sites participating in the Breakthrough Series Collaborative for HIV/AIDS did not show improvement on process or outcome measures when compared to other clinics that did not participate in the BTS collaborative. The proportion of patients with a suppressed viral load decreased in the intervention group, compared to the control group, but the decrease was not significant. 13Bray P, Roupe M, Young S, Harrell J, Cummings DM, Whetstone LM. Feasibility and effectiveness of system redesign for diabetes care management in rural areas: the eastern North Carolina experience. Diabetes Educ 2005; 31(5):712-8.Chin MH, Cook S, Drum ML et al. Improving Diabetes Care in Midwest Community Health Centers With the Health Disparities Collaborative. Diabetes Care 2004; 27(1):2-8.Glasgow RE, Funnell MM, Bonomi AE, Davis C, Beckham V, Wagner EH. Self-management aspects of the improving chronic illness care breakthrough series: implementation with diabetes and heart failure teams. Ann Behav Med 2002; 24(2):80-7.Harwell TS, McDowall JM, Gohdes D, Helgerson SD. Measuring and improving preventive care for patients with diabetes in primary health centers. Am J Med Qual 2002; 17(5):Landis SE, Schwarz M, Curran DR. North Carolina family medicine residency programs' diabetes learning collaborative. Fam Med 2006; 38(3):190-5.Montori VM, Dinneen SF, Gorman CA et al. The impact of planned care and a diabetes electronic management system on community-based diabetes care: the Mayo Health System Diabetes Translation Project. Diabetes Care 2002; 25(11):Siminerio LM, Piatt G, Zgibor JC. Implementing the chronic care model for improvements in diabetes care and education in a rural primary care practice. Diabetes Educ 2005; 31(2):Stroebel RJ, Gloor B, Freytag S et al. Adapting the chronic care model to treat chronic illness at a free medical clinic. J Health Care Poor Underserved 2005; 16(2):Wang A, Wolf M, Carlyle R, Wilkerson J, Porterfield D, Reaves J. The North Carolina experience with the diabetes health disparities collaboratives. Jt Comm J Qual Saf 2004; 30(7):Daniel DM, Norman J, Davis C et al. A state-level application of the chronic illness breakthrough series: results from two collaboratives on diabetes in Washington State. Jt Comm J Qual Saf 2004; 30(2):69-79.Siminerio LM, Piatt GA, Emerson S et al. Deploying the chronic care model to implement and sustain diabetes self-management training programs. Diabetes Educ 2006; 32(2):Scott J, Thorne A, Horn P. Quality improvement report: Effect of a multifaceted approach to detecting and managing depression in primary care. BMJ 2002; 325(7370):951-4.Landon BE, Wilson IB, McInnes K et al. Effects of a quality improvement collaborative on the outcome of care of patients with HIV infection: the EQHIV study. Ann Intern Med 2004; 140(11):
23 4: Randomized Controlled Trials (RCT) of CCM-based Interventions 6 RCTs covering asthma, diabetes, bipolar disorder, comorbid depression and oncology, and multiple conditions5 in the US – disease specific, 1 in Australia – multiple diseasesPractice-level randomizationAll showed positive effects on process, and all but one on outcomesThese trials all tested multi-component interventions based on the CCM in primary care.
25 Lessons learned in chronic illness care improvement Chronic care collaboratives have demonstrated that practices can make these changes and improve careMostly reaching early adoptersPractice redesign is very difficult in the absence of a larger, supportive “system”, especially for smaller practicesHow to help isolated small practices where 80% of Americans receive their care?How do the VA, Kaiser achieve high quality?
26 But, the VA and Kaiser are organizations with leaders, money, fairly clear business goals, and staff who share those goals. Is there anything analogous in the community?
27 Organizational factors supportive of high quality chronic care*: Strategic values and leadership that support long term investment in managing chronic diseasesInvestment in information technology systems and other infrastructure to support chronic careUse of performance measures and financial incentives to shape clinical behaviorActive programs of Quality Improvement based on explicit models*King’s Fund Study
28 What’s needed to improve chronic illness care for the population? Commitment and LeadershipMeasurement (and incentives)Infrastructure supportActive program of practice change
29 Step 4—Build a regional healthcare “system” But, who might do it, and what would they do?
30 A Framework for Regional Quality Improvement Data sources were a literature review, interviews with leaders of major coalitions directed at quality, and lessons learned in helping launch the PSHAThe goal is to provide a visual summary of what leading coalitions were doing—I.e. not an evidence-based model