Hats off to the CFHA research and evaluation committee for developing a research and evaluation track for the 2015 CFHA Conference in Portland, Oregon. The session track consists of five workshops, the first two of which this blog post will review.
Jodi Polaha, J.D. Smith, et al
Unlocking Implementation in Primary healthcare: The Family Check Up as an example
Session 1, presented by Jodi Polaha, J.D. Smith, and colleagues, “Unlocking Implementation in Primary healthcare: The Family Check Up as an example” provided excellent information for attendees on some crucial concepts in implementation science, using an illustrative case of implementing the Family Check Up in a primary care setting.
Implementation science, defined by the NIH, is the use of strategies to adopt and integrate evidence-based health interventions and change practice patterns within specific settings. Research on implementation addresses the level to which health interventions can fit within real-world public health and clinical service systems.
This level of investigation is particularly crucial in our field, where we believe that integrated, family and patient-focused care matters, yet need to understand the barriers and facilitators of making and sustaining these actual changes in practice settings and take them to scale.
The EPIS model describes four phases in the implementation process:
This group used the Family check up intervention, an evidence based model of family assessment and intervention, in a primary care setting to work with obese children and their families. J.D. Smith and his colleagues’ work have published using the model in other settings as well. To identify families for the intervention, they used the PSC-17 (Pediatric Symptom Checklist) as a screener.
While discussing the process outcomes of implementation, Jodi Polaha notes that these can reinforce behavior change at the system or team level. So, as the processes become established and more successful “on the ground” it feeds back to the ‘actors’, i.e. clinicians and staff, suggesting that the implementation efforts are ‘working.’ Thinking about this as system-level feedback for positive change represents an important parallel process to what patients, clients, and families may experience!
Jodi, who reflects that she is now a facile iMovie maker (as evidenced by the fantastic marketing video for the research track!), showed a video of physician and behavioral health consultants reflecting on the positive experiences of adopting the Family Check-Up using the PSC-17. Involving the whole team is key; providers are happy with the process and the intervention.
Stay tuned for more learning about implementation science and its role in evaluating collaborative and integrative healthcare settings!
Joe Grasso, Andrew Pomerantz
An Interactive, Case-Based introduction to quality improvement in Integrated care
The second session on Friday, “An Interactive, Case-Based introduction to quality improvement in Integrated care” presented by Joe Grasso, PhD and Andrew Pomerantz, MD provided an excellent overview of the Quality Improvement process and a solid rationale for why this method is important to make change in integrated care practices.
For anyone who needs to learn or teach about Quality Improvement, check the definition and other resources in the Health Resources and Services Administration (HRSA) toolbox here.
Joe reminded us that QI is not research, mainly because it has a different purpose. Focused on local level questions and answers, the goal of QI is not to create generalizable knowledge, but to ask small questions and test small changes in series to result in sustained improvement in a system. Given that systems vary, seeking generalizability is not the point. Likewise, sampling is done within the defined local system, and the processes are the key element being studied.
The process of change can be modeled on key elements of LEAN concepts that arose largely in manufacturing engineering. These are the 5S--Sort, straighten, shine/scrub standardize, sustain. “Just like your kitchen” according to Andy Pomerantz! If only my kitchen could attain this bar! Plan, Do, Study, Act, or PDSA cycles focus on small, iterative tests of change around a carefully constructed objective.
To begin the PDSA process, the team must agree on one goal to start, and this should be in the “SMART goal” format: Specific, measurable, attainable, relevant, and time-based. Joe and Andy provided a structured small group activity for practice on this seemingly simple activity. The work in my small group demonstrated the difficulty of developing a SMART goal: we had lots of discussion about screening, identifying, referring, prescribing for depression. What were the important elements? Who should do what? Was the PHQ-9 the right tool? And on went the conversation. Eventually, the group achieved a SMART goal: in patients who screen 11 or more by the PHQ-9, the clinic would see an increase in the # of referrals by the primary care clinicians to the behavioral health clinicians by 15% in 3 months.
Large group reflection on this process revealed that other groups found this difficulty too. Joe pointed out that this realization mirrors life, and is one of the strengths of the short cycle test of change: PDSA cycles can identify other concerns or problems needing attention.
"Where are we going to find the time to do QI??" This question is heard across systems as we are called to improve our systems, maintain our physicians board certification, and reach PCMH or other national level certification. Joe Grasso says that stakeholder and administrator buy-in helps!
Both of these sessions “knocked it out of the park” in introducing conference attendees to important methods for evaluating and improving our work. I look forward to more sessions in this well-crafted track!
Colleen Fogarty MD, MSc, is the Director of the Faculty Development Fellowship and Assistant Residency Director at the University of Rochester/Highland Hospital Department of Family Medicine.