1. Lynne S. Nemeth, PhD, RN Medical University of South Carolina

2. PPRNet Research Team Ruth G. Jenkins, PhD Paul J. Nietert, PhD Andrea M. Wessell, PharmD Heather Liszka Rose, MD, MS Loraine F. Roylance, MA Steven M. Ornstein, MD

3. Objectives Provide context for evaluating QI research interventions within a practice-based research network (PPRNet) Describe evaluation of a broad QI intervention in 99 primary care practices (A-TRIP) Extend a conceptual framework to identify potential practice interventions to be tested (MS-TRIP)

4. Take home message Learning about how quality improvement interventions are implemented can inform study design Future QI interventions might be more feasible and effective if we collect information about what is most commonly adopted within intervention sites

5. PPRNet is… … a practice-based learning and research organization designed to improve health care in its member practices and elsewhere in the United States.

6. PPRNet QI Research TRIP II: RCT, 20 CVD indicators, 20 practices (2001- 02) A-TRIP: Demonstration project of >80 indicators focused on primary care in 99 practices (2002-06) AA-TRIP: RCT sub-project of A-TRIP focusing on ETOH screening and brief intervention (2004-07) C-TRIP: RCT to investigate CRC screening in 30 practices (2006-10) MS-TRIP: Demonstration project in 22 practices developing a set of medication safety indicators in ambulatory care practice (2007-2010)

7. Context for PPRNet QI Theoretically informed process using three models: Improvement Model (Feifer & Ornstein, 2004; Joint Commission Journal of Quality and Safety) Intervention Model (Feifer et al, 2006; Evaluation and the Health Professions) Social influence, marketing Readiness for change Organizational learning, adult learning Complexity Practice Development Model (Nemeth et al, 2008; Implementation Science)

8. Nemeth, Feifer, Stuart and Ornstein Implementation Science 2008: 3:3

9. QI Activities Practice Reports (quarterly) Show practices performance over time Comparison to Other PPRNet practices PPRNet ABC (90 th percentile) (Wessell et al, American Journal of Medical Quality, 2008) National benchmarks (if available) Practice activation, evaluation and feedback: site visits and network meetings

10. Data Sources Focus group style interviews on site and at network meetings Site visit observation of key attributes related to improvement model Follow up phone or email contacts with practice liaisons Practice level surveys on specific topics Performance data extracted from the EMR

11. PPRNet TRIP Quality Improvement Model Key Elements Prioritize Performance Involve All Staff Redesign Delivery System Activate the Patient Use EMR Tools © PPRNet, 2003 * Jt Comm J Qual & Safety, August 2004, 30(8):432-441.

12. PPRNet-TRIP QI Model Practices have used the model to organize plans for improvement in the practice We catalogued QI activities related to site visits A compendium of strategies was developed (35) In the ATRIP final survey, adoption of these strategies was rated by practices Each of the following strategies (18) listed was rated by a nurse and physician as =>3 1-5 scale (1= never used, 5 =always used).

13. Prioritize Performance Involve staff to determine approaches to improvement (4.34) Focus improvement efforts on ~3 items/quarter (3.93)

14. Redesign Delivery Systems Limit prescription phone refills for medications when visits are overdue (4.30) Nursing staff alert providers about clinical parameters not at goal. (4.26) Incorporate schedules at least three months in advance so the next follow-up can be scheduled at the current visit (3.94) Use electronic systems to remind patients of services needed (3.94)

15. Redesign Delivery System Review office processes to decrease redundancy (3.85) Nursing staff reviews medications with patients (3.71) Schedule chronic disease labs before visit (3.68) Reschedule chronically ill/health maintenance patients that no show (3.65) Help patients to acquire medications via prescription assistance programs (3.64)

16. Activate the Patient Reinforce protocols for prevention/disease management with consistent staff messages (3.45) Distribute prevention/disease management goals in a handout (3.23)

17. Use EMR Tools Use EMR templates to guide nursing staff with patient screening (3.99) Use flow sheets, lab tables and/or health maintenance to remind practice of services needed (3.97)

18. Use EMR Tools Use visit note templates to guide process of care (3.97) Improve documentation of relevant A-TRIP diagnoses and measures (3.59) Update activity status for deceased or inactive patients (3.51)

19. Top Ten Strategies Involve staff to determine approaches to improvement (4.34) Limit phone refills when pt visits are overdue (4.3) Nsg staff alert clinicians re: clinical parameters not at goal (4.26) Use EMR templates to guide nsg staff pt screening (3.99) Use flow sheets, lab tables or health maintenance to remind practice of services needed (3.97) Use visit note templates (3.96) Incorporate schedules at least 3 months ahead (3.94) Use electronic systems to remind pts of services needed (3.93) Focus improvement on limited # of items per quarter (3.93) Review office processes to decrease redundancy (3.84) (Nemeth et al, 2007 Journal of Nursing Care Quality)

20. A Culture of Safety the biggest challenge in moving towards a safer health system is changing the culture from one of blaming individuals for errors to one in which errors are treated not as personal failures but as opportunities to improve the system and prevent harm Institute of Medicine, 2001

21. MS-TRIP Indicator Categories Avoidance of Inappropriate Therapy Inappropriate Dosing (weight, age, renal function) Drug-Drug Interactions Drug-Disease State Interactions Adverse Drug Event Prevention

22. Avoidance of Inappropriate Therapy Prioritize Performance, Redesign Delivery System Develop a practice wide approach for managing viral URI and evaluating medications in the elderly Activate the Patient: Review ineffectiveness of antibiotics for colds in advance; reinforce with office posters Provide elderly patients with a list of meds that should be avoided Use EMR Tools: Avoid inappropriate or rarely appropriate meds in the elderly, attending to warnings in prescription writer Review and evaluate patients for medications that should be avoided during chronic care or wellness visits

23. Inappropriate Medication Dosing (age, weight, and/or renal function) Prioritize Performance, Involve all Staff: Clinical staff review lab data prior to visit in chronic care patients; flag out of range lab values for provider to act upon Develop a consistent process to call pt back re: lab data Redesign the Delivery System: Assure weight is consistently measured at each visit Obtain labs in advance to adjust dosing as needed Use EMR Tools: Use dose advisor in prescription writer; act upon warnings when prompted Apply disease and medication specific templates in health maintenance tables

24. Drug-Drug Interactions Prioritize Performance: Record all medications patient is taking Involve all Staff: Educate staff calling in refills on high risk medications on the interactions within indicators Redesign the System/Use EMR tools: When entering/reviewing medications heed all drug interaction warnings (click MORE for ALL warnings) Activate the Patient: Have patients always bring list of all medications

25. Drug-Disease State Interactions Activate the Patient: Provide specific warning to patients about interactions related to their specific therapy as appropriate Redesign Delivery System /Use EMR Tools: Apply disease and medication specific HM templates as indicated Assure problem lists are accurate to activate disease state interactions Identify (using query tools) and contact patients with specific disease and medications that interact

26. Adverse Drug Event Prevention Involve all Staff/Redesign the System: Ensure lab f/u ordered, monitored appropriately Clinical staff prompt providers re: out of range results Develop an anticoagulation monitoring system Activate the Patient: Advise patient of specific f/u for medication regimens Provide a patient handout on medication safety Use EMR Tools: Use Health Maintenance medication templates and act upon the specific reminders

27. Implications Adapt QI interventions to suit local context, yet ensure consideration of specific strategies Measurement involves comprehensive qualitative data collection and survey methods to identify effective approaches, but maximize survey response as needed Evaluate high and low performers in the context of what has or has not been changed in practice