Promising Practices in

Regionalization : Exploring the

barriers and facilitators to moving

knowledge into action

Lisa Clatney –Health Quality Council

Michelina Mancuso – South-East Regional Health Authority

Jennifer Miller –Interior Health

Laura Fletcher – Canadian Health Services Research Foundation

Session Overview

• Brief Introduction

• Panel Presentation

• Question and Answer Period

Promising Practices

A series that highlights healthcare organizations that have

invested their time, energy and resources to improve their ability to use evidence in health services

management or policy.

Issue # 9

How an RHA organized itself to better integrate

evidence into decision-makingSouth-East Regional

Health Authority

Soon to be 2 Regions

Issue # 11

How a B.C. health authority is boosting its

research capacity

Interior Health

Issue # 13

Turning the tide on chronic disease: How a province is using evidence to build quality improvement capacity

Four Questions:

1) Why did your organization want to invest in using

evidence?

2) How was this process implemented?

3) Describe the barriers and the facilitators that you

faced while trying to implement your plan of action.

4) What impact has your new practice had up to now

and how you are monitoring it?

Question one:

Why did your organization want to invest in using

evidence?

Rationale for investing in research use

• ~ 30% - 40% of patients do not receive care aligned with current

scientific knowledge and 20% - 25% of care provided is not

needed or is potentially dangerous (Eccles et al., 2005)

• Within Interior Health:

– Regionalization in 2001, minimal research production/support

– Apparent need and internal desire for evidence-informed

decision making and program planning

• Funding allocation

• Service/Program decisions

Initial Needs Assessment (2006)

* Is Research Working for You?: A Self-Assessment tool and discussion guide for health services management and policy organizations (CHSRF)

0

10

20

30

40

50

IH has skilled staff to do

research

IH staff have enough

time to do research

Per

cen

tag

e o

f R

esp

on

den

ts (

%)

Don't Know

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

IH staff have enough

resources to do research

Initial Needs Assessment (2006)

Don't Know

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

0

10

20

30

40

50

Link research results to

key issues facing DM’s

Per

cen

tag

e o

f R

esp

on

den

ts (

%)

Communicates internally/

ensures info exchanges

* Is Research Working for You?: A Self-Assessment tool and discussion guide for health services management and policy organizations (CHSRF)

Why did your organization want to invest in using evidence?• Decisions made

• The public, the staff and the provincial government often asked why certain

decisions were being made

• Some used research evidence to guide their decisions but evaluation of the

decision was not a priority

• Others implemented decisions based on what worked

• elsewhere and again with little or no evaluation.

Evidence-Based Politically-Charged

2 Camps

Our mandate:

To measure and report on and recommend innovative ways to improve the quality of the province’s health

system.

Our goal is to work with health care providers to ensure

that every patient receives the highest quality of health care possible. That means ensuring that care is timely,

efficient, accessible, patient-centered, safe, effective, and equitable.

Our Mission

To improve the quality of care and the

caring experience in Saskatchewan.

Question two:

How was this process implemented?

Support

SPREAD

LW0 LW1 LW2 LW3

Pre-work

Select Topic Participants

Reference Panel

Identify Change

Concepts

Collaborative Process

Regional Improvement Team

CFPractice Site

Practice Site

PracticeSite

PracticeSite

Practice Site

Practice SiteRHA

Leader

Diabetes

Educator

RehabProgram Community

Pharmacist

Several report options to enhance

decision support

2 waves

71 practices

> 500 providers and staff

> 15,000 pts

Implementation of Research Capacity

Building Initiatives in IH• MSFHR/HSPRSN “research capacity enhancement” grant to all 6 BC health authorities (2005)

• Overall Strategic Goals:

1. Achieve sustainable research capacity within IH

2. Translate & apply research in a timely fashion to address health system priorities

3. Build & enhance healthy partnerships within IH, with other health authorities, research networks and researchers to enable relevant applied research

Implementation of Research Capacity

Building Initiatives in IH

• Research Advisory Committee

• Research Facilitators (2)

– Project Support – proposals, methods, ethics, data

– KTE – workshops & seminar series, literature

syntheses, annual conference

– Collaboration/Liaison – collaboration with networks,

MOH, other HAs, academia

IH Research Capacity Building Initiatives

• Brown Bag Lunch seminar series

• Annual IH Research Conference

• Research Skills Training workshop series

– Workshop “road show”

– Mentorship opportunities

• Literature Syntheses

• Collaboration & Networking

– Rural KTE collaborative research team

How was this process implemented?

• In developing strategic plan for 2005-2009, consultation

with community, staff and key stakeholders wanted to

see the integration of knowledge, research and

innovation into the organization's operations.

• Became 1 of 4 pillars

• Research was happening and being used ad hoc, the

strategic plan saw the opportunity to guide research

and learning towards our priorities and integrate it into

the culture.

• Research services took on an active role in conducting

an environmental scan and interviewing key

stakeholders to discuss what would be needed.

• Results were twofold:

– Re-organization of Research Services

– Establishment of a new information management

working group

Structure

Health Services Planningand QI

Research Services Utilization Patient Safety

External Partners: Universities

Pharmaceutical & Biomedical Industry

Governments/Other Health Authorities

Research AgenciesCommunity Colleges

Health Services Planning & QI

Health Professionals & Their Groups

Researchers & ResearchCo-ordinators

Research Ethics Board

Medical Education

Programs/Services & Committees

Model: SERHA RESEARCH SERVICES

Key Committee for Organizational Perspective Success

TERMS OF REFERENCE

HEALTH SERVICES PLANNING, UTILIZATION,

RESEARCH AND

INFORMATION MANGEMENT COMMITTEE

Purpose

• The mandate is to support enhancement in population

health outcomes and health care services through

knowledge transfer and integration of planning,

utilization, quality improvement, information

management and research.

Functions• To promote and support evidence informed decision-making.

• To identify and prioritize information needs for decision-makers.

• To provide advice and recommendations to the SERHA E-Health Committee on the management of data and information.

• To develop, implement and maintain an integrated information management system to meet the information needs of both internal and external customers, i.e. support Balanced Scorecard activities), i.e. Sharepoint and Balanced Scorecard.

• To promote timely collection, analysis and interpretation of data.

• To support the development of relevant, outcome-oriented and measurable indicators.

• To improve access to and understanding of information.

• To build capacity to support health services research activity.

• To facilitate enhanced monitoring and accountability.

Membership• Vice President Planning & Professional Services, Chair

• Chief Financial Officer

• Chief of Staff or Designate

• Chief Information Officer

• Chief Nursing Officer

• Director,

• Health Records/Admitting/Telecommun./Central Scheduling

• Director, Health Services Planning and Quality Improvement

• Director, Human Resources

• Manager, Clinical Administrative Information

• Manager, Research Services

• Utilization Management Coordinator

• Workload Measurement Coordinator

• Manager, Library Services

• Program Administrative Director

• Community/Facility Representative

• Guests as required

Question three:

Describe the barriers and the facilitators that you

faced while trying to implement your plan of

action.

Describe the barriers and the facilitators that you faced while trying to implement your plan of action.

What Worked:

• Taking the time to identify what the current culture for research is and build the infrastructure based on the staff's needs.

• Identifying those passionate champions in each and every department that could be the vehicle for change.

• Cross-disciplinary teams performing the research or QI projects and committees

• One on one mentoring and group mentoring to build capacity.

• Celebrate successes.

• Messaging on how things have changed. Marketing for buy-in.

Challenges:

• Everyone speaking the same language when you are speaking about indicators versus outcomes

• Quality improvement versus research

• Evidence-based and level of evidence.

• Statistical Software which is easy to manipulate.

• Integrating databases.

• An inventory of data sources.

• Teaching individuals how to interpret evidence and providing assistance. Ie.Journal clubs.

• Messaging on how things changed. Marketing for buy-in.

What´s Worked?• RITs - flexibility

• Collaborative Facilitators

• Incorporation of Expanded CCM

• Breadth and depth of our team

• Alignment with need

• CDM Toolkit

We Keep Learning…

• Toolkit has been phased in over ‘life’ of Wave

1 and Wave 2

• Understanding and using the data

• Incorporation of flexibility into aims and

measures

– Setting 3-month aimsW here you are

W here you’re going

Focus for next 3 months

And Learning…• Don´t feed the paranoia!

– Much more open disclosure

• Much more time on Model for Improvement

• Language and focus around Improved Access

– Clinical Practice Redesign

– Focus on clerical staff

Research Capacity Building Initiatives

in IH ~ What’s Worked?

• Early identification of strengths/gaps within organization

• Enthusiasm from front line and management staff

• Support from key senior leaders

• Strong departmental leadership and vision

• Increasing awareness of need/benefits of using research

• Regional academic health research faculty keen to

collaborate with health region staff

• Strong team with complimentary skill sets

Research Capacity Building Initiatives

in IH ~ What We Keep Learning

• Timelines

• Communication

• Funding/support personnel at the project/program level

• Skill set development

• Priority Setting

• Need for RCB/KTE research to support what we do

• Sparks!

• Language - EVIDENCE

Reference: Pat Martens, Need to Know Team

Question four:

What impact has your new practice had up to now

and how you are monitoring it?

Impact & Monitoring• Diabetes

• Wave 1 (March 2006 to March 2008)

• 30% improvement in percent of patients with diabetes screened for microalbuminuria, used for detection of kidney disease.

• 22% improvement in percent of patients with diabetes prescribed antiplatelet therapy to prevent blood clots.

• 14% improvement in percent of patients with diabetes prescribed a statin drug to help control their blood cholesterol levels. Controlling cholesterol can help prevent stroke and heart attack in people with diabetes.

Impact & Monitoring• CAD

• Wave 2 (March 2007 to March 2008)

• 8% improvement in percent of patients with CAD prescribed antiplatelet therapy to prevent blood clots.

• 8% improvement in percent of patients with CAD prescribed a statin drug to help control their blood cholesterol levels. Controlling cholesterol can help prevent stroke and heart attackin people with diabetes.

• 8% improvement in percent of patients with CAD prescribed an ACE-I/ARB to treat high blood pressure.

The Story Behind the Numbers• “These fantastic learning opportunities have enabled me to be a

much better staff person. Increased my abilities to assist doctors

and nurses in their roles, thereby improving care for our

patients.”

• “Our team’s greatest accomplishment was improved

communication between regional improvement team members.”

• “We developed an effective team within our office that worked

very well together with a coordinated plan where we each knew

our role and the others’ roles, and we became complementary

to each other.”

Research Capacity Building Impact

• Preliminary stages only (next steps = formal evaluation of

RCB initiatives using RDCAP tool, Jo Cooke, UK):

– New emerging teams within the region, between health

authorities and clinician-decision makers

– Links with internationally known researchers

– Positive evaluations for workshops, seminar,

conferences

– Research Capacity Building workshop (Oct 2007)

– Key stakeholder feedback

Research 101 (n=117)

Research 201 (n=116)

Lit Search (n=55)

Stats Part 1 (n=32)

Stats Part 2 (n=29)

Plain Language Writing(n=36)

Unaccept-

able Relevance of material

for your job?

Confidence in applying

material to your job?

Design of the workshop material?

Poor

Adequate

Good

Excellent

Research Capacity Building Impact

• “Interacting with the staff of the research team has

stimulated my thinking in ways that no other individual in

the organization has been able to.”

• “I was approached by a sociological researcher from

Thompson Rivers University who learned of [my project]

from the 2nd Annual Research Day.”

– Note: this project has since received funding

What impact has your new practice had up to now and how you are monitoring it?

• Research services went from 40 research projects with

80% being clinical trials. In three years it went to 148

projects with 35% of the projects looking at health

services research.

Example 1

Suggestion to spend money on an anti-coagulation clinic,

after measuring cohort patient outcomes on how family

physicians were performing on achieving therapeutic

levels, they were at par if not slightly better than

outcomes resulting from an anticoagulation clinic and

therefore resources were redirected.

Example 2

• Examples: Study was performed on LWBS form ER which revealed potential for risk since a high proportion of level 3 (sicker) patients were leaving without being seen. The assumption was to work on reducing those who leave by fast tracking. Although this reduced LWBS rate it did not reduce those at highest risk from a patient safety perspective. This required that we continue to find better solutions.

Example 3

• Study was performed on chest pain patients for a whole year

coming through ER which identified over utilizing hospital

Admissions and under utilizing Cardiac Assessment clinic. This

lead to a meeting with Family Physicians, Internal Medicine

Specialists and Emergency physicians in trying to identify a risk

stratification system for these patients. Senior administrators

and key individuals were also invited to this meeting. It was an

excellent experience.

Open Discussion

Thank You!

Lisa Clatney LClatney@HQC.sk.ca

Michelina Mancuso – Michelina.Mancuso@serha.ca

Jennifer Miller- Jennifer.Miller@interiorhealth.ca

Laura Fletcher – laura.fletcher@chsrf.ca