THE STATE OF QUALITY IMPROVEMENT AND IMPLEMENTATION RESEARCH

EXPERT VIEWS

WORKSHOP SUMMARY

Samantha Chao, Rapporteur

Forum on the Science of Health Care Quality Improvement and Implementation

Board on Health Care Services

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.
www.nap.edu



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The State of Quality Improvement and Implementation Research: Expert Views, Workshop Summary THE STATE OF QUALITY IMPROVEMENT AND IMPLEMENTATION RESEARCH EXPERT VIEWS WORKSHOP SUMMARY Samantha Chao, Rapporteur Forum on the Science of Health Care Quality Improvement and Implementation Board on Health Care Services INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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The State of Quality Improvement and Implementation Research: Expert Views, Workshop Summary THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. This project was supported by Award No. 691-D68159 between the National Academy of Sciences and the Department of Veterans Affairs and a grant from the Robert Wood Johnson Foundation. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number-13 978-0-309-11071-6 International Standard Book Number-10 0-309-11071-8 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2007 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Institute of Medicine (IOM). 2007. The state of quality improvement and implementation research: Expert views. Workshop summary. Washington, DC: The National Academies Press.

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The State of Quality Improvement and Implementation Research: Expert Views, Workshop Summary “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Advising the Nation. Improving Health.

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The State of Quality Improvement and Implementation Research: Expert Views, Workshop Summary THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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The State of Quality Improvement and Implementation Research: Expert Views, Workshop Summary PLANNING COMMITTEE FOR THE WORKSHOP ON THE CONDUCT OF HEALTH CARE QUALITY IMPROVEMENT AND IMPLEMENTATION RESEARCH THOMAS F. BOAT, Chair, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH CAROLYN M. CLANCY, Director, Agency for Healthcare Research and Quality, Rockville, MD DENISE DOUGHERTY, Senior Advisor, Child Health and Quality Improvement, Agency for Healthcare Research and Quality, Rockville, MD JEREMY GRIMSHAW, Director, Clinical Epidemiology Program, Ottawa Health Research Institute, Ontario, Canada BRIAN S. MITTMAN, Co-Editor-in-Chief, Implementation Science and VA Greater Los Angeles Healthcare System, Sepulveda, CA PAUL H. O’NEILL, Former U.S. Secretary of the Treasury, Pittsburgh, PA

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The State of Quality Improvement and Implementation Research: Expert Views, Workshop Summary FORUM ON THE SCIENCE OF HEALTH CARE QUALITY IMPROVEMENT AND IMPLEMENTATION THOMAS F. BOAT (Co-Chair), Chair, Department of Pediatrics, University of Cincinnati College of Medicine, OH PAUL H. O’NEILL (Co-Chair), Former U.S. Secretary of the Treasury, Pittsburgh, PA PAUL B. BATALDEN, Director, Health Care Improvement Leadership Development, Dartmouth Medical School, Hanover, NH IGNATIUS BAU, Program Director, The California Endowment, San Francisco, CA JAY E. BERKELHAMER, Senior Vice President of Medical Affairs, Children’s Healthcare of Atlanta, GA MARSHALL H. CHIN, Associate Professor of Medicine and Co-Director, General Internal Medicine Research, University of Chicago, IL CAROLYN M. CLANCY,* Director, Agency for Healthcare Research and Quality, Rockville, MD CATHERINE D. DEANGELIS, Editor-in-Chief, Journal of the American Medical Association Scientific Publications and Multimedia Applications, Chicago, IL JULIE L. GERBERDING,* Director, Centers for Disease Control and Prevention, Atlanta, GA JEREMY GRIMSHAW, Director, Clinical Epidemiology Program, Ottawa Health Research Institute, Ontario, Canada JEROME H. GROSSMAN, Senior Fellow, John F. Kennedy School of Government, Harvard University, Cambridge, MA JUDITH GUERON, Scholar in Residence, Manpower Demonstration Research Corporation, New York ANDREA KABCENELL, Executive Director for Pursuing Perfection, Institute for Healthcare Improvement, Cambridge, MA RICHARD KAHN, Chief Scientific and Medical Officer, American Diabetes Association, Alexandria, VA RAYNARD S. KINGTON,* Deputy Director, Office of the Director, National Institutes of Health, Bethesda, MD JOEL KUPERSMITH,* Chief Research and Development Officer, Veterans Health Administration, Washington, DC LAURA C. LEVITON, Senior Program Officer, The Robert Wood Johnson Foundation, Princeton, NJ BRIAN S. MITTMAN, Co-Editor-in-Chief, Implementation Science and VA Greater Los Angeles Healthcare System, Sepulveda, CA * Denotes Ex-Officio Members

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The State of Quality Improvement and Implementation Research: Expert Views, Workshop Summary LESLIE NORWALK,* Acting Administrator, Centers for Medicare and Medicaid Services, Washington, DC STEPHEN M. SHORTELL, Blue Cross of California Distinguished Professor of Health Policy and Management, University of California, Berkeley MARITA G. TITLER, Director, Institute for Translational Practice, University of Iowa City Health Care System and University of Iowa, Department of Nursing Services and Patient Care, Iowa City IOM Forum Staff SAMANTHA CHAO, Forum Director MICHELLE BAZEMORE, Senior Program Assistant MICHELE ORZA, Acting Board Director, Board on Health Care Services

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The State of Quality Improvement and Implementation Research: Expert Views, Workshop Summary Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: IGNATIUS BAU, The California Endowment, San Francisco, CA DENISE M. CARDO, Centers for Disease Control and Prevention, Atlanta, GA RICHARD KAHN, American Diabetes Association, Alexandria, VA JOHN OVRETVEIT, Medical Management Centre, The Karolinska Institutet, Stockholm and Bergen University, Norway Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the final draft of the report before its release. The review of this report was overseen by coordinator JACK C. EBELER, of Ebeler Consulting. Appointed by the Institute of Medicine, he was responsible for

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The State of Quality Improvement and Implementation Research: Expert Views, Workshop Summary making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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The State of Quality Improvement and Implementation Research: Expert Views, Workshop Summary Contents     INTRODUCTION   1 1   PERSISTENT PROBLEMS WITH QUALITY   3      Value Proposition,   3      Patient Perspective,   4 2   SPREAD IN HEALTH CARE   5 3   STATE OF THE SCIENCE OF QUALITY IMPROVEMENT RESEARCH   8      Evidence-Based Practice Center,   9      Cochrane EPOC,   11      Multiple Research Methods,   13      Veterans Administration,   14      Practice-Based Research Networks,   16      Patient Safety,   18      Open Discussion,   21 4   PRIORITIES FOR CHANGE   25      Intervention-Level Priorities,   25      Organizational-Level Priorities,   26      Opportunities for Change,   27

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The State of Quality Improvement and Implementation Research: Expert Views, Workshop Summary 5   SPREAD AND IMPLEMENTATION OF RESEARCH FINDINGS   29      Health Plan Perspective,   29      Perspectives from Other Disciplines,   34 6   BREAKOUT GROUPS   41      Spread and Implementation of Research Findings,   41      Research,   43 7   STRATEGIC OPPORTUNITIES   44      Ethics,   44      Research Training,   45      Publication,   47      Funding,   50 8   OPPORTUNITIES FOR CHANGE   53      The Problem,   53      Research Approaches,   54      People,   54      Putting It Together,   54      Changing the System,   56 9   GENERAL REACTIONS   57      Information Capacity,   57      Training,   57      Bridging Theory and Practice,   58      Systems Change,   58     REFERENCES   60     APPENDIXES     A   Workshop Agenda   61 B   Workshop Participants   64 C   Submitted Responses   67