Diffusion of Excellence Accelerating the Implementation of Best - PowerPoint PPT Presentation

1 Diffusion of Excellence Accelerating the Implementation of Best Practices in America’s Largest Integrated Healthcare Delivery System Shereef Elnahal, MD, MBA Assistant Deputy Under Secretary for Health for Quality, Safety, and Value Department of Veterans Affairs

VA Diabetic Teleretinal 2 Screening Program: A Scaled VA Best Practice #VADiffusion

VA National Diabetic Teleretinal 3 Imaging Project • Implementation of teleretinal imaging for diabetic eye disease since 2006 within primary care clinics (70%) and eye clinics (30%) • image acquisition and reading centers, linked by computerized patient records (CPRS), Imaging archive (VistA Display), imaging tools (TeleReader) • National Training Center for teleretinal imagers and readers, dedicated implementation team and imaging support #VADiffusion

4 Level of Agreement Between Live Examination and Tele-retinal Imaging 268 patients examined by TRI and retina specialist • Exact agreement 72% • Within one DR level 89% • Appropriate referral 92% • Other referable eye findings 25% • Patients with no DR or mild DR 67% Cavallerano AA, et al. Retina 2003; 23: 215 – 223. #VADiffusion

From: Effect of a Teleretinal Screening Program on Eye Care Use and Resources 5 #VADiffusion JAMA Ophthalmol. 2014;132(9):1045-1051. doi:10.1001/jamaophthalmol.2014.1051

6 Teleretinal Telehealth Growth 2006-2014 Teleretinal Encounters from FY06- FY2014 = 1,544,274* * FY06 – FY14 *Extrapolated to Q4 2014 = 1,165,274 * to Q4 2014 #VADiffusion

Diabetic Retinal Eye Exams 7 100 90 80 70 60 VA Performance 50 Goal 40 30 20 10 0 FY00 FY02 FY04 FY06-3rdQt FY08-3rdQt FY10-3rdQt FY12-3rdQt FY14-3rdQt FY16-3rdQt 7

8 Length of Time Required to Diffuse Teleretinal Diabetic Eye Exams: 10 YEARS 8 #VADiffusion

9 Diffusion of Excellence Initiative: Shortening the Time to Consistency 9

Background 10 The Veterans Health Administration (VHA) is America’s largest integrated health care delivery system, with over: • 1,700 sites of care • 300,000 employees • 8.76 million Veterans served each year While VHA is a leader in the delivery of high quality health care , it has lacked consistency in the application of best practices We sought to develop a method to effectively identify , diffuse , and sustain best practices in this heterogeneous system 10

Diffusion of Excellence Objectives 11 Identify and Empowering employees scale to promote innovation sharing and drive a supportive innovations culture of continuous improvement across VHA, while: Institutionalizing processes and mechanisms for systematically diffusing and implementing promising practices throughout the system Minimizing negative variation, and standardizing practices by diffusing innovative and industry recognized best practices across the system 11

How long does it take for randomized evidence to 12 change clinical practice widely? 17 YEARS

Enabling success by leveraging three organizing 13 principles • Rapid and transparent flow of information across regions and boundaries Technology Governance • Vertical accountability to agency priorities Process • Engagement of senior leadership and staff • Consistent framework for evaluation, adaptation, and reapplication of practices 13

Model for Disseminating Best Practices 14 Identify Promising Sustain and Improve Practices Establish a robust operations center for managing and tracking Solicit practices nationally and outcomes, in parallel with engage staff at all levels, implementation. including projects from the VA Innovators Network and Communities of Practice, to evaluate them using a rigorous Establish Consistency & set of criteria. Standardize Leverage national program office leader support to select those ready for national rollout and support standard development and scaling. Find the Champions Local champions, or ‘early adopters,’ serve as sharks in a Adapt and Replicate ‘shark tank’ style event. Those Leverage Diffusion Council governance selected as implementers structure to engage field staff and leaders identify local champions to during initial replication to support issue Replicate lead. resolution; Use advanced technology tools and project management resources to track and monitor progress. 14

Identify Promising Practices 15 13

Find the Champions 16 435 Practices Submitted 14 Gold Status Practices

Adapt and Replicate 17 Diffusion of FY17 Gold Status Practices Across VHA

Establish Consistency and Standardize 18 Driving success through process Facilitated adaptation and implementation Use of human centered design and LEAN frameworks Peer-to-peer learning between designers and adapters Project management and technical support Processes in place to provide resourcing when needed 18

Sustain and Improve 19 Accelerating and sustaining adoption and uptake with technology tools Pulse platform promotes conversation and sharing about promising practices Virtual VA “Shark Tank” style event enabled virtual engagement in unique opportunity to ‘pitch’ promising practices Diffusion Hub provides robust project management and tracking tools to manage replication and implementation of best practices, all based on LEAN principles and frameworks 19

Results 20 Launched in October 2015, VHA is implementing 390 adaptations of Gold Status practices at 100 facilities • Diffusion meter tracks number of ongoing implementations including practices in planning, in progress, and in completion • Case study examples of implementation success • eScreening • Planning for Future Medical Decisions via Group Visits • Increasing Access to Primary Care with Pharmacists 20

Results 21 National Deployment - Planning Update Access Data Dashboard to Improve Clinic Management National deployment planned; no roadblocks Increasing Access to Primary Care with Pharmacists National deployment planned but facing Improving Same-Day Access Using RNCM Chair Visits roadblocks eScreening National deployment determination requires additional analysis Regional Liver Cancer Tumor Board Unit Tracking Board Care Access WAKE Score for Recovery from Anesthesia Coordination Employee Quality and Flu Self-Reporting Desktop Icon Engagement Safety Planning for Future Medical Decisions via Group Visits 21

Implementation Measures and Outcomes 22 Initiative Title Outcome Statement Initiative Metric Institutionalize a culture within VA medical centers that encourages Total # of Best Practice Diffusion of Excellence sharing & adoption of best practices throughout the system to drive Replications (ongoing or towards a high reliability organization completed) Sub-Initiative Title Description Stage Sub-Initiative Metric Facilitate Bi-Annual Under Facilitate two Under Secretary for Health Shark Secretary for Health Shark Tanks in FY17 to share, vet, and pledge to adopt best Implement # of Shark Tanks Held practices Tanks Ensure VISNs and VAMCs elevate promising # of VISNs and VAMCs which Launch Diffusion Program practices and implement best practices in their Implement have Adopted and Shared organizations Best Practices Facilitate the implementation of the identified best # of Gold Status Best Implement FY17 Gold Status practices from the FY17 Shark Tanks with the Plan Practices Successfully Best Practices partner VAMCs Implemented Achieve National Scale in Achieve national scale (implementation projects in # of FY16 Gold Status Select FY16 USH Gold Status every medical center) in at least 3 out of the 8 FY16 Implement Practices Implemented VHA- USH Gold Status Best Practices with scale potential wide Best Practices

Findings 23 VA Innovation Engine – empowering and enabling those who know VA best to make it better • Encourages employee engagement through different pathways of innovation • VA Innovators Network feeds best practices into Diffusion of Excellence • Creates a culture of innovation and dissemination of excellence • Promotes collaboration through peer-to-peer sharing

Implications for Dissemination and Implementation 24 Research • Early evidence that Diffusion of Excellence is an engaging solution that can scale best practices across VA’s healthcare system • The Quality Enhancement Research Initiative (QUERI) is using Implementation research in their evaluation of Diffusion of Excellence • Mixed-methods approach (qualitative and quantitative analysis) • Explore the decision making process • Consolidated framework for implementation research (CFIR) • Theory of organizational readiness for change (ORC)

Rate of VA Diffusion under Diffusion of Excellence: 25 1-2 Years for National Standardization (Best Practice: Veteran direct scheduling into audiology and optometry)

Proving the Rogers Model 26 26

Questions/Comments 27 Please contact Dr. Shereef Elnahal (Shereef.Elnahal@va.gov) with any questions or concerns