Delfini
Evidence-based Value Model for Clinical Quality Improvement =
Net Gain + (Net Loss)
Unite
and apply together evidence, QI and value
Consider
the plusses and minuses of —
— Health Care Outcomes +
—
Patient Perspective +
— Satisfaction +
— Savings/Cost +
— Other Considerations +
|
| Efficiency
and Effectiveness
The
classic approach frequently omits much in the area of effectiveness. |
Much
of the industrial model of QI deals with efficiencies in delivering
health care. While CQI steps can be effective in implementing change,
the classic approach frequently omits much in the area of effectiveness.
This has been a major obstacle in getting
many clinicians engaged in QI work or accepting of change –
and if your docs won’t go along with you, you’re in
major trouble.
We
think of QI projects as falling into several categories which can
be ranked from strongest to weakest:
1.
Explicit, Evidence-based Improvements
The distinguishing feature is that these projects are developed
from a synthesis of the available medical literature,
which has been systematically and rigorously
evaluated, and includes an analysis of all anticipated
outcomes. |
2.
Evidence-based Improvements
These QI projects contain some elements from #1 above. And be
forewarned! The "evidence" label gets liberally
tossed around these days, without proper understanding of the
systematic rigor required! Much touting the label, "evidence-based,"
really is not! |
|
3.
Consensus, Benchmarks, Variations
These 3 types are described below:
- Consensus
These projects are developed by consensus of experts.
- Benchmarks
These projects use data from other sources or groups. Some
targets may be associated with evidence of improved outcomes.
- Variations
These projects are usually based on intermediate markers,
but may be based on outcomes.
|
Before
you decide to change practice, you need to evaluate interventions
for appropriateness. And appropriateness has a
number of components!
We
evaluate appropriateness by following a set of steps in
a specific order. The first thing to do is an evaluation
for effectiveness and benefit. If an intervention is effective the
next step is to perform a cost analysis. The last step is to “triangulate”
other areas such as coverage, politics, etc., using the best data
you have. This requires judgment.
|
| Predictability
of Outcomes
Predictability
is a critically important concept in learning the best model for
achieving QI. |
If
you are going to implement change, you need to be as sure as you can
that the change will result in improved care. Typically variations
in practice are not sufficient to establish
a baseline for quality improvement. What is required to better understand
optimal practice is a “round-up” of medical evidence which
has been subjected to rigorous critical appraisal and synthesis. |
| Quality
Medical Evidence
We
have effective training methods and tools to make this easy
for staff. |
A
centerpiece of our QI framework is critical appraisal of
the medical literature, which we use to inform all our
steps, from seeking the right thing to do, to doing the right thing
right. We approach quality improvement first by asking what valid
and useful evidence is currently available in the literature to
assist leaders, clinicians and patients improve outcomes.
|
| Impacts
of Change &
Economic Analysis
We
teach a simple method that is straightforward,
clear and easy to apply. |
Before
you make change, it is important to predict what’s going to
happen. Before implementing a QI initiative, the team should project
the impact of change. This can range from an analysis of
economic impacts as well as more subjective outcomes. All too often,
this ends up being a neglected step or one that is made impossibly
difficult and mysterious by those with “black box” approaches.
|
| Implementation
& Measurement
Strong
evidence of clinical improvement
facilitates implementation because people understand what to expect.
Even
when there is little or no published evidence,
QI teams become more confident about decisions when
they know what is (and what isn’t) in the medical literature.
Contact
us... |
We
have considerable experience in the area of implementation
and measurement – we can tell you what the
evidence says on these topics, and we can share our vast experience
(successes and failures) to help your staff prepare to make change.
We have a set of implementation tools and measurement tips that
are easy to understand and can jump start implementation planning.
You
also need information aids and decision-support
for your staff and your patients. We have considerable skills in
creating highly useful tools. We can provide people with clear advice
and strategies for content and presentation along with dissemination
tips.
We
have developed simple, effective methods and the tools
to successfully “do” quality clinical improvements,
based on the "value" equation — quality, cost and
satisfaction.
- Teaching
leaders & staff in your organization the value of
evidence in determining appropriateness
- Successful,
functional committees and work
groups — structures, processes, tools and tips
- Selecting
good projects for success
- Searching
for the best evidence regarding efficacy and
effectiveness
- Critically
appraising the evidence for validity (people get great
results using our simplified approach —
with no sacrifice of rigor!)
-
Assessing benefits
-
Performing economic analysis — again, we
promote a simplified approach
-
Assessing non-economic impacts of practice change
- Summarizing
assessments
- Handling
other considerations — trials, tribulations, politics
and triangulations
- Preparing
for measuring change
- Developing
information and decision-aid tools
- Successful
implementation and maintenance
strategies
|