1. VA HSR&D SDP 09-158 Teresa Damush, PhD Heather Woodward-Hagg, MS Marianne Matthias, PhD Virginia Daggett, DNS, MSN Joseph Ross, MD, MHS Zhangsheng Yu, PhD Xinli Li, PHD, MS Systems Engineering and Implementation Partnership: The INSPIRE Stroke Project

2. How the partnership began… Chose improving stroke care as one element of their VISN-wide focus for FY08 VISN 11OQP Stroke QUERI Conducted national measurement of inpatient stroke care in FY07-09 Worked with OQP to develop and measure stroke care, used these data to pilot a Systems Redesign-based collaborative in VISN 11 FY08-09, launch multi-site INSPIRE in FY10

3. OQP Stroke Special Project: National stroke performance data benchmarking Goals:  Measure in-hospital stroke care quality within the VA system using both Joint Commission and VA specific in-patient care performance measures  Provide VA medical centers their data for inpatient stroke care quality  Assemble toolkit of existing programs, templates, and strategies to improve stroke care  Assess stroke risk factor management at 6 months and one-year post-discharge for veterans in the cohort with VA outpatient care

4. FY 2006FY 2007FY 2008FY 2009 Quality indicators defined Data collection tool developed Abstractor (n=90) training Data collection tool pilot testing Data collection completed Scoring algorithms completed Final national data reported Field review and correction of facility level data Toolkit completed Stroke QUERI and OQP collaboration established Stroke network established Multidisciplinary team assembled

5. OQP Stroke Special Project: Main Results Process of Care Denominator Eligible Proportion of Eligible Patients with Performance Measure Present (%) Antithrombotic at discharge351496.4 Antithrombotic by HD2352395.6 Smoking cessation counseling126894.9 Pressure ulcer assessment378991.8 Early ambulation300986.1 Rehab consultation/FIM279686.0 Lipid management300982.1 Fall risk assessment367379.3 DVT prophylaxis101878.2 Anticoagulation for afib40975.3 NIHSS documented364027.7 Dysphagia screen before po359123.4 Stroke education252418.1 Thrombolysis (tPA) given2278.4

6. VISN 11 Pilot: Introducing Systems Engineering Methods in a Stroke Collaborative VISN11 leadership  Dr. Pamela Reeves, CMO; Ann Herm, Clinical Program Manager; Mary Sherrill, Systems Redesign lead 7 VAMC interdisciplinary teams of front line staff involved in stroke care Stroke QUERI Center investigators and research coordinators System Redesign/OSE Expertise – VISN 11 SR staff, Heather Woodward-Hagg/Indy COE

7. VISN 11 Pilot: Methods Identification of stroke care improvement teams at all 7 VISN 11 facilities in 2008 Facility survey about stroke systems of care Pre-collaborative work:  Baseline data collection  Choice of 2 performance indicators: dysphagia screening before oral intake and discharge on lipid-lowering medication  OSE methods training (conference call and video)  Inpatient stroke flow map and “Voice of the customer” interviews Collaborative:  Shared baseline data (chart review)—dysphagia screening, d/c on lipid lowering medication, developed standard admission order template  Paired didactic and team break-out sessions: More flow mapping, impact/effort assessments, PDSA cycles, future state process maps/action plans  Shared plans with group after each team session

8. Collaborative Didactic and team break-out sessions

9. VISN 11 Pilot: Methods Post-collaborative work:  Systems Redesign “coaches” assigned to each team  6 biweekly coach-team calls and monthly group calls  Monthly data review and aggregate data input on Sharepoint site for 12 months Analysis:  Pre-collaborative data on indicators from OQP compared to post- collaborative data  Follow-up interviews with each team to assess how changes were made, barriers to and facilitators of change, spread of methods Developed training materials subsequently used in other VA collaboratives

10. VISN 11 Pilot: Results Dysphagia results Cholesterol results

11. INSPIRE SDP: Intervention for Stroke Performance Improvement using Redesign Engineering Study aims:  1. To evaluate the effect of public reporting on organizational change to improve stroke care quality in VA  2. To conduct a formative developmental evaluation in 14 of the largest volume VAMCs to understand organizational barriers and facilitators to the delivery of high-quality stroke care  3. To test a Systems Redesign/OSE-based intervention vs. performance feedback alone in improving 2 stroke indicators  Stratify randomization by baseline performance  Work on two indicators; plan for DVT prophylaxis and dysphagia screening before oral intake but will be based on baseline data collection and site input

12. Year 1Year 2Year 3 IRB R&D Union Aim 1 and Aim 2 interviews 1 Aim 3 pre- work Site inter- views 2 Site inter- views 1 Baseline chart reviews Intervention Primary outcome chart reviews Analysis Q1 Jan 10 Q2Q3Q4Q1Q2Q3Q4Q1Q2Q3Q4 INSPIRE timeline 1 In-person site interviews 2 Telephone site interviews

13. INSPIRE Interview and baseline phase (Aims 1 and 2) Interviews arranged by site PI, 2 interviewers to each site 2 different interviews  Receipt of and response to the OQP Stroke Special Project data: who received it, who else saw it, what action(s) resulted, how can the field best use/receive this type of data?  Current state of stroke systems of care from front-line providers: structure and personnel involved, any ongoing improvement teams or activities, assessment of the overall level of care provided, what is working well, what could be improved? Interviews recorded, transcribed, analyzed Baseline stroke performance data collected via central chart review for CY2009

14. INSPIRE Intervention Phase (Aim 3) Sites randomized to intervention vs. control, stratified by baseline performance  All sites with at least 50 stroke admissions annually Intervention sites: In-person collaborative with OSE/SR training, followed by 6 months of coaching through rapid tests of change; monthly performance data feedback Control sites: quarterly performance data feedback Data collection for 12 months post-intervention Analyses:  Primary: improvement in individual and composite performance indicators  Secondary: temporal pace of change in performance, sustainability of change, qualitative assessments of local context and relationship to changes observed

15. INSPIRE status 11 sites on board; active recruitment of 3 others  Bay Pine, Birmingham, Chicago (Jesse Brown), Cleveland, Durham, Houston, Loma Linda, Miami, Oklahoma City, Tennessee Valley, Tucson Site interviews underway VistaWeb access pending; plan for baseline data collection via chart abstractions July-November In-person collaborative January 2011 Planned SDP September: RE-INSPIRE: Rich-context evaluation of INSPIRE; Edward Miech, PI

16. Questions? Quality Improvement Systems Engineering Implementation Research