Beyond Big Data Chair ir & Moderator: Laura Damschroder, VA A - - PowerPoint PPT Presentation

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Beyond Big Data Chair ir & Moderator: Laura Damschroder, VA A - - PowerPoint PPT Presentation

Implementation Science as Catalyst for Transforming Health Systems to Learning Organizations: Beyond Big Data Chair ir & Moderator: Laura Damschroder, VA A Center for or Cli linical Man anagement Res esearch, An Ann Arb Arbor MI


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Implementation Science as Catalyst for Transforming Health Systems to Learning Organizations:

Beyond Big Data

Chair ir & Moderator:

Laura Damschroder, VA

A Center for

  • r Cli

linical Man anagement Res esearch, An Ann Arb Arbor MI

Panel l Members:

  • Bla

lake Henderson, , VA

A Dif Diffusi sion of

  • f Ex

Exce cellence Ini nitiative, Was ashi hington DC DC

  • George Ja

Jackson, , VA

A Center of

  • f Inn

nnovation to Ac Accelerate Disc Discovery and and Prac actice Transformation, , Du Durham NC

  • Sarah Cutrona,

, VA

A Center for

  • r Hea

ealthcare Organization and and Implementation Res esearch (C (CHOIR), , Bedford/Boston MA

  • Lucy Savi

vitz, , Kai

aiser Perm ermanente Nort

  • rthwest Center for
  • r Hea

ealth Rese esearch, Port

  • rtland OR
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The views expressed in this presentation are our own and do not reflect the POCition or policy of any entities with which we are affiliated

Acknowledgements

Spreading Healthcare Access, Activities, Research and Knowledge (SHAARK): VA QUERI Grant PEC-17-002 Innovators Network – Population Factors, Organizational Capacity, Workflow and Resources (INPOWR): VA QUERI Grant PEC-18-015

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Learning Health System Foundations

  • Continuous knowledge building
  • Improvement at all levels of the system
  • Agile implementation of effective innovations

Patients get higher quality, safer, efficient care Data is necessary to achieve these ideals… …but much more is needed beyond big data

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“Without concerted attention to evidence-based implementation strategies, learning health systems risk developing massive, expensive rePOCitories of information without adequate strategies to actually utilize such data for system change…the assumption that comprehensive, elegant, real-time datasets will, in and of themselves, lead to practice change is at best an optimistic aspiration and at worst, a massively expensive error”

Bauer MS, Damschroder L, Hagedorn H, Smith J, Kilbourne AM. An introduction to implementation science for the non-

  • specialist. BMC psychology. 2015 Dec;3(1):32.

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Guise JM, Savitz LA, Friedman CP. Mind the Gap: Putting Evidence into Practice in the Era of Learning Health Systems. Journal of general internal medicine. 2018 Dec 1;33(12):2237-9.

Image Attribution: Ben Davis from the Noun Project

How do we get from here to there? How do we get from here to there? How do we get from here to there?

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Agenda

  • Introductions & Setting the stage (10 minutes)
  • 1st Round:
  • 5-minute “Story Bites” from each panel member (20 minutes)
  • Audience Discussion (10 minutes)
  • 2nd Round
  • 5-minute “Story Bites” from each panel member (20 minutes)
  • Audience Discussion (10 minutes)
  • Endnotes: Pulling it all together (10 minutes)
  • Q&A (10 minutes)

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Blake Henderson

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VHA Diffusion of Excellence Mission

To Change and Save Veteran Lives by transforming VHA into the nationally recognized leader in the discovery and spread of emerging evidence-based health care practices in the United States.

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VHA Shark Tank Competition

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Phase Gate Model of Innovation

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Phase-Gate Model

  • f Innovation

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National Implementations

AT LEAST 116 FACILITIES FULLY IMPLEMENTED 39 FACILITIES FULLY IMPLEMENTED OR IN PROGRESS

VHA Rapid Naloxone Initiative

Expanding rapid access at VA to naloxone at VA facilities via Police, AED cabinets, and educating at-risk patients

Project HAPPEN

Hospital Acquired Pneumonia Prevention through Engaging Nurses to complete oral care

IMPACT IMPACT

Clinical Societal Operational Clinical Societal Operational Financial

  • Makes life-saving naloxone more readily available in the event of an
  • pioid overdose on VA grounds (2 min or less response time)
  • Has led to at least 132 Veteran lives saved, with likely many more

reversals unreported

  • Saves Veteran lives and improves patient safety
  • Addresses the national opioid epidemic that disproportionately affects

Veterans

  • Trains VA Police officers and other basic life support (BLS)-trained staff

to recognize opioid overdoses and administer naloxone

  • 116 facilities have their VA Police forces carrying naloxone (68%

increase in adoption since September 2018)

  • 56 VA facilities have select AED cabinets that contain naloxone (107%

increase in adoption since September 2018)

  • Since its inception, 202 cases of NV-HAP have been prevented, and an

estimated 36 lives have been saved as of April 2019

  • Potential for hundreds of Veterans lives saved when diffused nationally
  • Reduces Veterans’ hospital stays, while reducing the risk of

readmission

  • Risk of non-ventilator associated hospital-acquired pneumonia

decreased by 90% at pilot site

  • $8.09M in estimated cost avoidance across 8 facilities as of April 2019
  • Potential for >$100M cost avoidance when diffused nationally

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Diffusion Marketplace

Enable practice discovery and sharing Facilitate informed “buying”

SEARCH IMPLEMENT

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Sarah Cutrona

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What is the VHA In Innovators Network?

Innovation Specialists (at 37 Sites Nationwide)

  • VA Employees selected for leadership and expertise
  • FTE dedicated toward training VA staff at their site

Spark-Seed-Spread (S-S-S) Investment Program

FY19 Portfolio: 90 projects across 36 facilities & 17 VISNs/regions

  • Funding for frontline VA employees to develop innovative projects.
  • >$10 million invested in over 300 S-S-S projects
  • Projects include clinical, administrative, educational, and health

information technology initiatives.

Participants in Spark-Seed-Spread Investee Bootcamp Nationwide distribution of FY19 Spark-Seed-Spread Investments Innovation Specialists with Innovators Network Team DO NOT SHARE WITHOUT PERMISSION POC: LAURA.DAMSCHRODER@VA.GOV

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In Innovators Network: A Complex Learning Health System

Diverse set of

  • Innovation Sites (VA Medical Centers)
  • Innovation Specialists & Project Leads (varied professional backgrounds)
  • Projects (Clinical, administrative, educational, health IT)
  • Project Stages of Implementation Completion
  • Pre-implementation; Implementation; Spread

QUERI Partnered Evaluation (‘INPOWR’) conducting ongoing evaluation

Is there a unifying theme that can inform evaluation & ongoing improvement?

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Local sites and local challenges can be unique

(“You’ve seen one VA, you’ve seen one VA”)

Attribution (CC BY-SA 3.0) Created by Wolfgang Beyer with the program Ultra Fractal 3. - Own work; accessed 5/19/2019 Wikipedia https://commons.wikimedia.org/w/index.php?curid=322029

Learning Health Systems sup suppo port t Inn Innova vation tion at multiple t multiple le levels els

What we learn at the grassroots/micro level …

  • Identify problems
  • Develop local solutions
  • Find local problem-solvers/champions

…Can (and should!) be applied at macro levels (medical center, nationwide)

  • Expected barriers & POCsible facilitators
  • Power of networks to improve access to expertise
  • Centralization to avoid duplications of effort

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Veterans and their families Learning Health Systems suppor support t Inn Innova vation tion at multiple le t multiple levels els

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Frontline Employees Veterans and their families Learning Health Systems suppor support t Inn Innova vation tion at multiple le t multiple levels els

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Sites (VA Medical Centers) Frontline Employees Veterans and their families Learning Health Systems suppor support t Inn Innova vation tion at multiple le t multiple levels els

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Nation (VHA) Sites (VA Medical Centers) Frontline Employees Veterans and their families Learning Health Systems suppor support t Inn Innova vation tion at multiple le t multiple levels els

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Sites (VA Medical Centers) Frontline Employees Veterans and their families Network Level (Nationwide):

  • Funds Locally Developed Projects with Varied Scope (Spark-Seed-Spread)
  • Centralized support (contracting, data collection)
  • Centralized Training & Resources for Innovation Specialists & Investees

Nation (VHA) INNOVATORS NETWORK

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  • Local Champion w/ dedicated FTE (Innovation Specialist) supports:
  • Local Programming/Training
  • Local Projects (Spark-Seed-Spread)

Sites (VA Medical Centers) Frontline Employees Veterans and their families Network Level (Nationwide):

  • Grant Funding program (Spark-Seed-Spread investments)
  • Centralized support (contracting, data collection)
  • Centralized Training & Resources for Innovation Specialists & Investees

Nation (VHA) INNOVATORS NETWORK Network Level (Nationwide):

  • Funds Locally Developed Projects with Varied Scope (Spark-Seed-Spread)
  • Centralized support (contracting, data collection)
  • Centralized Training & Resources for Innovation Specialists & Investees

Nation (VHA) INNOVATORS NETWORK

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  • Identify Problems & proPOCe solutions based on work

with Veterans

  • Lead Projects (Spark-Seed-Spread) & Engage in training
  • Local Champion w/ dedicated FTE (Innovation Specialist) supports:
  • Local Programming/Training
  • Local Projects (Spark-Seed-Spread)

Sites (VA Medical Centers) Frontline Employees Veterans and their families Network Level (Nationwide):

  • Grant Funding program (Spark-Seed-Spread investments)
  • Centralized support (contracting, data collection)
  • Centralized Training & Resources for Innovation Specialists & Investees

Nation (VHA) INNOVATORS NETWORK Network Level (Nationwide):

  • Funds Locally Developed Projects with Varied Scope (Spark-Seed-Spread)
  • Centralized support (contracting, data collection)
  • Centralized Training & Resources for Innovation Specialists & Investees

Nation (VHA) INNOVATORS NETWORK

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  • Identify Problems & proPOCe solutions based on work

with Veterans

  • Lead Projects (Spark-Seed-Spread) & Engage in training
  • Local Champion w/ dedicated FTE (Innovation Specialist) supports:
  • Local Programming/Training
  • Local Projects (Spark-Seed-Spread)

Sites (VA Medical Centers) Frontline Employees Veterans and their families Network Level (Nationwide):

  • Grant Funding program (Spark-Seed-Spread investments)
  • Centralized support (contracting, data collection)
  • Centralized Training & Resources for Innovation Specialists & Investees

Nation (VHA) INNOVATORS NETWORK Network Level (Nationwide):

  • Funds Locally Developed Projects with Varied Scope (Spark-Seed-Spread)
  • Centralized support (contracting, data collection)
  • Centralized Training & Resources for Innovation Specialists & Investees

Nation (VHA) INNOVATORS NETWORK Veterans and their families

  • Projects co-designed by

Veterans (Human-centered Design)

Photo: Ricardo Brazziell / Austin American- Statesman; Credit:Associated Press Greg Saulmon / The Republican

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Attribution (CC BY-SA 3.0) Created by Wolfgang Beyer with the program Ultra Fractal 3. - Own work; accessed 5/19/2019 Wikipedia https://commons.wikimedia.org/w/index.php?curid=322029

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George Jackson

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Implementation Science

Research evidence Implementation strategies Theory/framework-based methods Often a longer view

Implementation Practice

Innovations with varying traditional “evidence” Improvement orientation Rapid development, testing & diffusion

Implementation Science Meets Implementation Practice

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  • Setting and aligning overall organizational goals
  • Reducing system-level barriers to implementation
  • Providing initial implementation support and resources
  • Packaging and endorsing new promising practices
  • Having “evidence” that a promising practice has “worked” in similar clinical settings
  • Linking organization-wide goals with local facility needs and objectives
  • Identifying promising practices
  • Identifying opportunities to improve clinical and administrative processes
  • Empowering front-line staff

Is Is th the Le Learning Health System Top Down or Bottom Up?

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Ecosystem-QUERI-Research Partnership

Evaluation of Diffusion of Excellence & Innovators Network as Programs Assisting with the Use of Results in Strategic Planning and Programing Evaluation of the Impact of Specific Programs Selected for National Diffusion Providing Metrics on Individual Practices Integration of Implementation Science and Practice Diffusion Basecamp, QUERI Implementation Hubs, Review of Practices Collaboration Between Office of Research & Development and Innovation Ecosystem to Implement Research and Study Innovations Diffusion of Excellence & Innovators Network Serving Veterans

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QUERI Partnered Evaluations: Program-Level

  • VA Diffusion of Excellence Initiative

➢Aims to identify and spread promising

administrative and clinical practices across the VA.

  • Evaluation Aims

➢Patterns of participation, engagment and

diffusion?

➢How do leaders decide what to adopt? ➢What leads to successful replication?

  • VA Innovators Network

➢Aims to develop an infrastructure with

trained innovation specialists who work with front-line staff developing Innovative technology and care processes.

  • Evaluation Aims

➢What do sites expect from the network? ➢Can facilities build innovation infrastructure? ➢What is the impact of specific innovations?

Spreading Healthcare Access, Activities, Research and Knowledge (SHAARK) Innovators Network – Population Factors, Organizational Capacity, Workflow and Resources (INPOWR)

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QUERI I Part rtnered Evaluations: :

Gold Status Practices Designated for National Diffusion

  • Deep dive into the specifics of 3 of the 5 Gold Status Practices

designated for national diffusion

  • Focus on the process of how to quantify and otherwise describe the

impact of individual projects

  • SHAARK will work with project-level evaluation to look for synergies

aimed at describing similarities and differences in the diffusion process that can inform the program

Project HAPPEN: Hospital Acquired Pneumonia Prevention by Engaging Nurses to provide oral care Novel FLOW 3 System: Provides accurate and reliable real-time data for process control and reporting of prosthetic consults Tele-Wound: Increasing wound care access for rural veterans through telehealth

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Connecting Implementation Science and Practice:

Diffusion Basecamp and Implementation Strategy Learning Hubs

Diffusion of Excellence Base Camp

  • Brings together DoE Gold Status and Implementing Fellows

to plan for facilitated implementation within the context of implementation science principles QUERI Implementation Strategy Hubs

  • Led by QUERI investigators
  • Train providers in specific implementation strategies
  • Strategies range from training, toolkit development, to

engaging opinion leaders, mentoring champions

  • QUERI Learning Hub Sites use evidence-based

implementation strategies coordinated by Center for Evaluation & Implementation Resources

EBQI IF A&F D4DI

VA Quality Scholars

LEAP

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Lucy Savitz

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What is a learning health system?

If you’ve seen one learning health system, you’ve seen one learning health system.

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Learning at Scale

Implementation Science as a Catalyst for Transforming Health Systems to Learning Organizations: Beyond Big Data

June 2, 2019

Lucy A. Savitz, PhD, MBA Kaiser Permanente Northwest Center for Health Research

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Key Building Blo locks & Anticipated Challenges in in Wid idespread Im Implementation of f the LHS

  • 1. Capacity building & resource allocation
  • 2. Creating a culture with realistic expectations
  • 3. Shared agendas & priorities
  • 4. Perceived ownership—data asset vs. knowledge
  • 5. Aligning time frames

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HEALTH CARE SYSTEMS RESEARCH NETWORK

Group Health Research Institute Group Health Cooperative Seattle, WA Center for Health Research - Kaiser Permanente NW Portland, OR Division of Research Kaiser Permanente Northern California Oakland, CA PAMF Research Institute - Palo Alto Medical Foundation Palo Alto, CA Department of Research & Evaluation Kaiser Permanente Southern California Pasadena, CA Institute for Health Research Kaiser Permanente Colorado Denver, CO Division of Research Baylor Scott & White Temple, TX Center for Research and Evaluation - Kaiser Permanente Georgia Atlanta, GA Geisinger Research Geisinger Health System Danville, PA Harvard Pilgrim Health Care Institute, Dept.

  • f Population

Medicine Harvard Medical School Boston, MA Meyers Primary Care Institute, UMass Medical School - Fallon Community Health Plan; Reliant Medical Group Worcester, MA Center for Health Services Research; Public Health Sciences - Henry Ford Health System Detroit, MI Marshfield Clinic Research Institute Marshfield Clinic Marshfield, WI Essentia Institute of Rural Health - Essentia Health Duluth, MN Institute for Research and Innovation Catholic Health Initiatives Englewood, CO Mid-Atlantic Permanente Research Institute - Kaiser Permanente Mid-Atlantic States Rockville, MD HealthPartners Institute HealthPartners – Minneapolis, MN Center for Health Research Hawai’i Kaiser Permanente Hawai’i Honolulu, HI Institute for Health Services Research Maccabi Health Care Services Tel Aviv Israel

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High Value Healthcare Collaborative

The High Value Healthcare Collaborative (HVHC) was founded in October of 2009. We are a provider learning network committed to improving health care value through data and collaboration. To accomplish this, we: (1) Measure, innovate, test, and continuously improve value-based care; (2) Rapidly disseminate and facilitate adoption of proven high value care models across HVHC members and beyond; and (3) Advocate for policy and payment models that support sustainable high value healthcare. DO NOT SHARE WITHOUT PERMISSION

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Generalized Framework for Accelerated Dissemination & Implementation – The Sepsis Story

Collaborative External Influences Evidence EXTERNAL TO ORGANIZATION INTERNAL TO ORGANIZATION Shared Learning Organizational Conduits

Multi-level Adoption Decision

Linking Agents Implement Tools & Resources Outcomes

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Need for a Healthcare System that Learns

We require a sustainable system

  • That gets the right care to the right person at the right time

and then

  • Captures the results for making improvements

and

  • Knowing what works.

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Guise JM, Savitz LA, Friedman CP. Mind the Gap: Putting Evidence into Practice in the Era of Learning Health Systems. Journal of general internal medicine. 2018 Dec 1;33(12):2237-9.

Image Attribution: Ben Davis from the Noun Project

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Open Reflections

  • Multi-level structures and processes to support innovation and spread
  • Insert fun
  • Fractal models
  • The role of trusting relationships
  • Across levels into the frontline
  • Building the knowledge-base
  • Internal & External

This Photo by Unknown Author is licensed under CC BY-SA

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Sarah Cutrona

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Nation VHA INNOVATORS NETWORK

Photo: Ricardo Brazziell / Austin American- Statesman; Credit:Associated Press Greg Saulmon / The Republican

Sites (VA Medical Centers) Frontline Employees Veterans and their families Development & Implementation of Data Collection Tools In-person and Virtual observations

  • f iNET events & calls

Qualitative Interviews with Diverse Stakeholders Network Analysis to understand connections & growth

Understanding Inn Innova vation tion at mu t multiple ltiple le levels ls QUERI QUERI INPO INPOWR WR ME METHODOL THODOLOG OGY

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In-person and Virtual observations

  • f iNET events & calls

Development & Implementation of Data Collection Tools Network Analysis to understand connections & growth

Understanding Inn Innova vation tion at mu t multiple ltiple le levels ls QUERI QUERI INPO INPOWR WR ME METHODOL THODOLOG OGY

Qualitative Interviews with Diverse Stakeholders

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Spark-Seed-Spread Projects: Who will your project serve?

48 *Categories of Target Populations are not mutually exclusive

QUERI INPOWR team helped develop & implement data collection tools

Photo: Ricardo Brazziell / Austin American- Statesman; Credit:Associated Press Greg Saulmon / The Republican

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Spark-Seed-Spread Projects: In what areas will project show measurable success?

49

  • Veteran Experience and/or Veterans Satisfaction (46)
  • Veteran-Centered Care/Veteran Wellness (42)
  • Improvement in Clinical Outcome (31)
  • Access to Care (28)
  • VA costs (22)
  • Patient Safety (15)
  • Quality of Care through Employee Education (15)
  • Efficiency of Care Administration (14)
  • Timeliness of Care (13)

QUERI INPOWR team helped develop & implement data collection tools

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Training Underway: Local, , Regional & National

Teaching Specific Content and Skills

  • Human Centered Design (HCD)
  • Three Box Solution
  • Innovators Network 101
  • Specific Tech. Skills (Computer Skills 10 Minute Tech)

Strengthening Innovation Infrastructure

  • Pitch Training
  • Pitching Sessions (Local Shark Tanks)
  • Local Accelerators to prep for future rounds of Spark-

Seed-Spread and Shark Tank Applications

Highlighting Spark-Seed-Spread Investments beyond initial investment period

  • Innovation Showcase (for a specific innovation)

Locally Spreading the Word

  • New Employee Orientation
  • CBOC Presentations
  • Staff Meetings
  • Facility Leadership Presentations
  • Facility Town Halls + Lunch & Learn

Celebrating Innovation on a Larger Scale

  • Hackathons
  • Innovation Showcases
  • Innovation Roadshows

Outside the VA: Connecting with Community Partners

  • Community Innovation Meetings + Partnerships
  • University Collaborations
  • National Recognition

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In Their Voice Suggestions, Questions & Reflections from In Innovatio ion Sp Specialists November 2018 National Training, Boston MA

“It’s really hard. But then we come to these meetings and you’re ready to go again.” “We need a place to find solutions” “I’m terrified because it’s literally me. I’m looking for succession planning [to keep work sustainable]” “You’ve succeeded when you aren’t needed” “How do we get Executive leadership to get over their fear

  • f failure?”

“Our mission is to build a culture” “To be connectors” “A lot of what we’re doing with heavy manpower can be done lighter, but we need help connecting teams, help triaging ideas.” “No one would have known what we’re doing [to adopt our idea] without this program”

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  • Qualitative Interviews suggest:
  • Larger, stronger networks are a key outcome of participation
  • Breaking down silos through network-building was emphasized
  • Evaluation Goal: Capture Network-building quantitatively and visually
  • Data collection on network connections at Boot Camp 2019 to track:
  • Connections made and sustained
  • Geographic and interprofessional reach of connections
  • Impact on local facility networks
  • Types of activities that generate and sustain networks

Capturing network growth and utility as an outcome of participation

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Visualization of network connections made

  • n Day 1 of 2019 Boot Camp,
  • verlaid on map of the US

Capturing network growth and utility as an outcome of participation

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POCsible questions for discussion

Thinking about Learning Health Systems (LHS) that you are familiar with, in what ways do lessons learned at the grassroots/micro level apply at the macro level? Are there systems in place to promote this type of information flow? In your LHS, are there local challenges that lend themselves to centralized solutions and if so, how does your LHS engage with this type of situation.

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Blake Henderson

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VIO IONE: An In Innovative Medication Deprescribing Tool

VA Gold Status Fellow Team

  • Dr. Sara Battar, Chief of Geriatrics and Extended Care, Central Arkansas Veterans Healthcare System
  • Dr. Kimberly Dickerson, Academic Detail Pharmacist, Central Arkansas Veterans Healthcare System

Tim Cmelik, Chief of Pharmacy, Central Arkansas Veterans Healthcare System

  • Dr. Christopher Sedgwick, Pharmacy Analytics Program Manager, VISN 15 Heartland Network
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The Solution

To improve patient safety, comfort, and medication compliance, a team from Central Arkansas VHS developed and evolved a simple, flexible methodology to help providers work with their patients to avoid undue polypharmacy What makes VIONE different?

Common sense and user friendly Enables shared decision making Focuses on high-risk patients Automated reporting infrastructure Adaptable to various provider types Agnostic to drug class (holistic approach)

Vital, life-saving medications Important, for quality of life Optional, no major difference Not indicated/treatment

complete

Every medication has a

diagnosis/indication of use

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VIONE’S IMPACT

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The VISION

Diffusion of Excellence is POCitioning VIONE as a leading solution to systematically address polypharmacy and enables VA facilities across the enterprise to move towards high reliability by June 2023, the VIONE network will:

Impact 550,000+ total Veterans Generate $275 million+ in annualized cost savings Discontinue 800,000+ unnecessary medications

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George Jackson

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How do we encourage meaningful engagement? Goal: Help DoE determine how to encourage meaningful engagement with DoE, practices, and tools. How do leaders choose practices? Goal: Help DoE develop tools to enhance the decision process. What influences implementation success? Goal: Help DoE select practices and facilitate implementation. What factors influence spread of practices? Goal: Help DoE measure and develop strategies for spread.

Clear and frequently communicated roles & expectations are essential for success Based on Consolidated Framework for Implementation Research (CFIR); Weiner Theory of Organizational Readiness for Change; and Rogers Diffusion of Innovations Mixed methods evaluation: Quantitative facility & practice data; qualitative methods; surveys

Evaluation of Diffusion of Excellence Program

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Summary of Some Major Findings To Date

Participation Goals

  • Addressing opportunities to improve processes observed at the front line [Gold Status Fellows]
  • Impacting facility metrics [mentioned more by facility leaders]
  • Sharing and implementing ideas
  • Seeking to drive culture of innovation and employee engagement

Decision to Adopt/Implement

  • Often passion projects for Gold Statius Fellows
  • Facility leaders tend to look less at detailed implementation process – Consider big picture
  • Alignment with strategic priorities, stakeholder buy-in, potential competitive advantage, and

resources

  • Innovation evidence-base and viability; likely impact (e.g., official performance measures)

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Summary of Some Major Findings To Date

Success Rates

  • Intensive six-month facilitated implementation
  • ~Half of Implementing Facilities were successful
  • ~Half of Implementing Facilities were unsuccessful or had partial success

Facilitators

  • Extensive external facilitation helped teams “power” to implementation success
  • Facilities with infrastructure, staff, and resources already in place prior to implementation were more likely

to succeed

Barriers

  • Facilities with inadequate implementation readiness (infrastructure, staff, resources) were not as successful
  • Single most important “kiss of death”
  • Too often, Sharks do not “deliver” on their bids

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SLIDE 66

Summary of Some Major Findings To Date

Spread/ Replication

  • Replication has varied widely for practices
  • More spread with significant national support and/or relatively discreet of clear actions

Infrastructure

  • As the program evolves, there is a need to clarify the roles of different groups and individuals involved in

Diffusion of Excellence

  • What to expect
  • Providing information to participants
  • Encouraging involvement of multiple levels within the organization

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SLIDE 67

Spread of Gold Status Practices to Individual VA Medical Centers

Challenges with Tracking Practice Implementation

  • Linking specific practices to

facilities vs. type of similar practices

  • What does it mean to

“implement” a practice?

  • Measuring interest in a practice
  • Encouraging facilities to record

that they are implementing practices

Graph shows top 20 practices by implementation projects; one project counted per facility

947 facility projects to implement Gold Status Practices

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SLIDE 68

Diffusion Marketplace: Linking and Tracking Promising Practices

  • Set to fully launch in fall 2019
  • Allows VA staff to search for practices to

solve specific problems

  • Will provide an opportunity to monitor

interest in practices (e.g., downloads of information)

  • Will include opportunity for facilities to

indicate the degree to which they have implemented a practice

➢ Especially important for practices that have been designated for national diffusion

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SLIDE 69

Lucy Savitz

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SLIDE 70

Engaging & Accelerating Knowledge to Insight

Implementation Science as a Catalyst for Transforming Health Systems to Learning Organizations Beyond Big

June 2, 2019

Lucy A. Savitz, PhD, MBA Kaiser Permanente Northwest Center for Health Research

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SLIDE 71

KPNW CHR Learning Health System Program Stru ructure

Operational Interaction Committee Horizon Scanning Healthcare Improvement Program Clinical Interface SAC Prioritizing/ Resourcing R r

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SLIDE 72

Guise JM, Savitz LA, Friedman CP. Mind the Gap: Putting Evidence into Practice in the Era of Learning Health Systems. Journal of general internal medicine. 2018 Dec 1;33(12):2237-9.

Mind the Gap

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SLIDE 73

Assembling the needed data from various sources to examine local practices Literature monitoring in target clinical areas of importance for new comparative effectiveness evidence Data analytics Data visualization for business value

EQuIP, An Evidence-based Quality Improvement Process: Improving the Speed to Insight

Comparative Effectiveness Studies Systematic Reviews Other Filtered Scientific Evidence EHR Data Clinical Databases Digital Data Claims Data Geospatial Data Patient-Reported Outcome Measures Traditional Descriptive Statistics Traditional QI Tools Root Cause Analysis Pareto Chart SPC Charts Process Map Advanced Analytics Geospatial Analysis

Specify improvement opportunities in the context of business value.

Insight-Rich Illustrations Value-Rich Findings Annotated Charts Actionable Targets Measurable Impact

Combine different tools to draw insight from your data Horizon scanning: structured approach that provides a systematic process for exploring data Build a robust dataset by combining relevant data sources

Provide parameters for guiding data

  • exploration. Use prior available

knowledge to define the scope and to add specificity to the data exploration. Set the data exploration goals and build a logic model to describe the inputs and the outputs. Extract only the data relevant for the data exploration. Spend time cleaning, merging, defining, and validating the data. This should be a combined effort of the data scientist and business or clinical expert. Try to fit the logic model with the data. Identify patterns, anomalies, and

  • pportunities. Seek to answer the

following questions: Who?, When?, Where?, What?, How?, and Why? Begin with broad descriptions and then focus on areas of value, such as unwarranted variation or worse than expected clinical outcomes. Risk adjust and use benchmarks for meaningful comparisons. Clearly represent key points, tell a story with your data. Help stakeholders interpret your results, explain what they mean. Present data only if it can lead to: safer care, better care, reduced costs, less waste, less unnecessary care, or innovation.

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SLIDE 74

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SLIDE 75

Results

  • Our evidence-based approach was tested on one of Kaiser’s target

clinical areas of importance, interventional cardiology.

  • Three potential improvement opportunities were identified:
  • network leakage;
  • avoidable hospital days; and
  • preventable 30-day hospital readmissions.
  • Preliminary estimates suggest that our work could lead to

approximately $1 million in savings and up to 250 avoided hospital days while improving the quality and safety of care to our members.

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SLIDE 76
  • 1. How can LHSs use published evidence to improve care?
  • 2. How can LHSs use and inform evidence in dynamic

evidentiary areas (e.g., QI, patient safety)?

  • 3. What can we do to close the evidence-to-practice gap?

Some Questions for the Learning Health System (LHS) in Action

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SLIDE 77

Evidence needed to in inform, creating knowledge that im impacts care.

Knowledge – the range of one’s information or understanding

  • 1. Addressing the need to know – real-world data & evidence

syntheses→ obstacles

  • 2. Understanding the quality/constraints of the underlying data →

shared learning

  • 3. Reporting embedded research results→ providing a home

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SLIDE 78

New, AcademyHealth Jo Journal

Newly added section: Insights in analyzing health data.

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SLIDE 79

The Inaugural Special Issue for Implementation and Quality Improvement Sciences: A New JGIM Area of Emphasis Types of articles can include those that: ▪ test improvement interventions being spread beyond a single ward or clinic ▪ assess the quality or utility of tools or toolkits ▪ advance the utility of systematic review ▪ assess the validity or reliability of new relevant methods ▪ provide high level synthesis, perspectives or wisdom on major, innovative improvement efforts. Papers due September 3, 2019

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SLIDE 80

balance scale by tracy tam from the Noun Project

Internal Learning Cycle External Evidence

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SLIDE 81

balance scale by tracy tam from the Noun Project

➢ Goal: High value care ➢ System affiliated: Embedded researcher ➢ Stance: Internal to the system ➢ Involved in strategic planning: Goal-setting ➢ Evolutionary, adaptive design ➢ No/little IRB oversight ➢ Rapid feedback of findings ➢ Roll-out before “evidence” is built ➢ A priori aim development ➢ Goal: Published evidence ➢ Academic affiliation ➢ Stance: External to the system ➢ No involvement in system strategic planning; goal-setting ➢ Burden of research under IRB

  • versight

➢ Slower feedback of findings ➢ Build evidence → Disseminate & Implement

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SLIDE 82

Open Reflections

This Photo by Unknown Author is licensed under CC BY-SA

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SLIDE 83

Laura Damschroder

by ahmad from the Noun Project DO NOT SHARE WITHOUT PERMISSION

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SLIDE 84

EBPs → Shark Tank Alignment

  • Agendas & Priorities
  • Time frames
  • Expectations

Published Research

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SLIDE 85

This is where the ACTION is Grassroots/frontline: ID problems → develop/match solutions National structures to build learning networks Encourage innovation Innovation’s role in “learning” Centralized support → local champions → Frontline leads → human-centered design Phase Gate Model (Discovery to National Diffusion Online Marketplace: Informed Buying Shark Tank Innovators Network, Spark-Seed-Share investment Evaluation/Research: rapid feedback Tension between top-down (EBPs; mandates) and bottom-up empowerment Shared Learning TRUSTED networks: System to frontline Skills Training

This is where the ACTION is

✓ Structured multi-level processes to ignite Discovery to National Diffusion ✓ Online Marketplace/Knowledge RePOCitory ✓ Serious Fun: Shark Tank ✓ Spark-Seed-Share investments ✓ Fractal structures ✓ Skills Training ✓ Tension between top-down (EBPs; mandates) and bottom-up ✓ TRUSTED networks: System to frontline

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SLIDE 86

Impact from innovations ID and develop metrics

  • Research & System
  • Qual & Quant

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SLIDE 87

Knowledge that matters

  • Multiple constituencies

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SLIDE 88

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slide-89
SLIDE 89

Additional Acknowledgements

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SLIDE 90

The views expressed in this presentation are our own and do not reflect the POCition or policy of any entities with which we are affiliated

Spreading Healthcare Access, Activities, Research and Knowledge (SHAARK): VA QUERI Grant PEC-17-002 Innovators Network – Population Factors, Organizational Capacity, Workflow and Resources (INPOWR): VA QUERI Grant PEC-18-015

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SLIDE 91

SHAARK Evaluation Team

Durham VA HSR&D Center of Innovation George Jackson (evaluation corresponding PI) Hayden Bosworth Eugene Oddone Heather King Maren Olsen Jennifer Lindquist Brandolyn White Ann Arbor VA HSR&D Center of Innovation Laura Damschroder (evaluation PI) Julie Lowery Caitlin Reardon Andrea Nevedal Bedford/Boston VA HSR&D Center of Innovation Sarah Cutrona (evaluation PI) Thomas Houston (initial PI) Kathryn DeLaughter Timothy Hogan Allen Gifford Lindsay White Elizabeth (Liz) Orvek Stephanie Shimada

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SLIDE 92

INPOWR Evaluation Team

Bedford/Boston, MA Corresponding PI: Sarah Cutrona Co-Investigators: Timothy Hogan; Allen Gifford; Barbara Lerner Project Manager: Elizabeth Orvek; Lindsay White Durham, NC Multi- PI: George Jackson Co-Investigators: Heather King; Maren Olsen; Jennifer Lindquist Project Manager: Brandolyn White Palo Alto, CA Multi- PI: Anita Vashi Co-Investigators: Nell Marshall; Steven Asch, Wei Yu Project Manager: Tracy Urech Portland, OR Multi-PI: Anais Tuepker Co-Investigators: Steven Dobscha MD; Samuel Edwards, MD; Jessica Wyse, Summer Newell Project Manager: Lauren Sawyer Also: Ann Arbor Co-Investigator: Laura Damschroder, MS, MPH

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SLIDE 93

VHA Innovation Ecosystem and QUERI

VHA Innovation Ecosystem

  • Ryan Vega

Director, VHA Innovation Ecosystem

  • Kristopher (Kit) Teague

Director of Operations, VHA Innovation Ecosystem

  • Blake Henderson

Director, VHA Diffusion of Excellence

  • Allison Amrhein

Director of Operations, VHA Innovators Network

  • Brynn Cole

Director of Programming, VHA Innovators Network

  • Devin Harrison

Diffusion Specialist

  • Carl McCoy

Diffusion Specialist

  • Brian Stevenson

Diffusion Specialist

VA Quality Enhancement Research Initiative (QUERI)

  • Amy Kilbourne

Director

  • Melissa Braganza

Program Manager

  • Faith Booker

Program Specialist

Center for Implementation and Evaluation Research

  • Nicholas Bowersox

Director

  • David Goodrich

Implementation Scientist

  • Christine Kowalski

Implementation Resource Specialist

  • Veronica Williams

Program Manager

Atlas Research & Agile Six Applications

  • Provide operational support for the Innovation Ecosystem
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SLIDE 94
  • Lisa Weiss
  • Andreas Taenzer
  • Jose Benuzillo
  • Jason Scott
  • Members of the KPNW CHR Learning Health System Program

Members of the High Value Healthcare Collaborative

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SLIDE 95

Gold Status Practice-Level QUERI Partnered Evaluations

  • Project HAPPEN: Hospital Acquired Pneumonia Prevention by Engaging Nurses to provide
  • ral care

➢ Gold Status Facility Fellow / practice originator: Shannon Munro, Salem VA Medical Center ➢ Evaluation principle investigators Mike Ho, VA Eastern Colorado Health Care System

  • Novel FLOW 3 System: Provides accurate and reliable real-time data for process control and

reporting of prosthetic consults

➢ Gold Status Facility Fellow / practice originator: Jeff Heckman, VA Puget Sound Health Care System ➢ Evaluation principle investigators: Mike Ho & Chelsea Leonard, VA Eastern Colorado Health Care System

  • Tele-Wound: Increasing wound care access for rural veterans through telehealth

➢ Gold Status Facility Fellow / practice originator: Mona Baharestani, Mountain Home VA Medical Center ➢ Evaluation principle investigators: Fran Weaver & Bella Etingen, Hines VA Hospital