Doctors Role in Quality Improvement - Research Proposal Example

Doctors Role in Quality Improvement Introduction Recent large-scale surveys of U.S. hospitals have found high rates of utilization of continuous quality improvement (CQI) in health care. Although hospitals are experiencing more pressure than ever to implement quality improvement practices—from accreditation organizations, a competitive marketplace, and quality-conscious health care purchasers and consumers—enthusiasm for CQI may be on the decline (Shortell, Levin, O'Brien, & Hughes, 1995). One barrier to successful implementation and survival of CQI is physician reluctance to adopt new work practices (Shortell et al., 1995). Physicians often view CQI as a threat to professional autonomy (McLaughlin & Kaluzny, 1990) and are skeptical that a management technique can improve patient outcomes. Structural barriers, including inadequate training (Shortell et al., 1995), longstanding social norms (Mittman, Tonesk, & Jacobson, 1992), and the fact that many physicians are independent providers (Chan & Ho, 1997), can also impede physician involvement in CQI and other changes in health care. Changing Physician Behavior Physician involvement in CQI becomes critical as quality improvement initiatives turn from administrative functions (e.g., streamlining outpatient registration) to clinical functions (e.g., increasing adherence to clinical practice guidelines). Unfortunately, traditional approaches to physician behavior change are unlikely to increase physician involvement in CQI. A meta-analysis of 102 studies examining the efficacy of continuing medical education strategies found that our most heavily used interventions, educational materials and conferences, tend to have little impact on physician behavior or patient outcomes in health care (Davis, Thomson, Oxman, & Haynes, 1995). There is growing recognition that the success of interventions may depend in part on individual readiness to change (Armstrong, Reyburn, & Jones, 1996; Cantillon & Jones, 1999; Davis et al., 1995). The transtheoretical model (TTM, also known as the stage model), one of the leading approaches to health behavior change, offers a promising approach to behavior change among health care professionals. The model systematically integrates the following four theoretical concepts central to change: • Stages of change: Readiness to take action • Processes of change: Ten cognitive, affective, and behavioral activities that facilitate change • Decisional balance: Pros and cons of changing • Self-efficacy: Confidence to make and sustain changes in difficult situations The TTM understands change as progress, over time, through a series of stages: precontemplation, contemplation, preparation, action, and maintenance. Nearly 20 years of research on a variety of health behaviors have identified processes of change that work best in each stage to facilitate progress. This research can serve as a foundation on which to build stage-matched interventions to increase participation in CQI and other changes in professional practices. In this article, we provide an overview of the TTM and how it can guide the development of stage-matched interventions to increase physician readiness to participate in CQI. In addition, we describe the development of TTM measures designed to assess the extent to which hospitals are engaging in activities that can facilitate individual providers' movement through the stages of change for CQI. The Transtheoretical Model of Change In the past 20 years, the TTM has been shown to be robust in its ability to explain and facilitate change across a broad range of health behaviors, including smoking cessation (J. O. Prochaska, DiClemente, Velicer, & Rossi, 1993), exercise adoption (Marcus et al., 1998), dietary change (Greene et al., 1999), and mammography screening (Rakowski et al., 1998). More recently, the model has been applied to professional practices, including collaborative service delivery among university employees (Levesque, Prochaska, & Prochaska, 1999), time-limited therapy among mental health workers (J. M. Prochaska, 2000), and patient cancer screening and counseling among physicians (Main, Cohen, & DiClemente, 1995). Stage of Change Stage of change, the central organizing construct of the model, represents the temporal and motivational dimensions of the change process. Longitudinal studies of change have found that people move through a series of five stages when modifying behavior on their own or with the help of formal intervention (DiClemente & Prochaska, 1982; J. O. Prochaska & DiClemente, 1983). In the first stage of change, the precontemplation stage, individuals deny they have a problem and thus are resistant to change, are unaware of the negative consequences of their behavior, believe the consequences are insignificant, or have given up the thought of changing because they are demoralized. They are not intending to take action in the next 6 months. Individuals in the contemplation stage are likely to recognize more of the pros or benefits of changing. However, they continue to overestimate the cons or costs of changing and, therefore, experience ambivalence. They are seriously considering taking action within the next 6 months. Individuals in the preparation stage have decided to take action in the next 30 days and have already begun to take small steps toward that goal. Individuals in the action stage are overtly engaged in modifying their problem behaviors or acquiring new, healthy behaviors. Individuals in the maintenance stage have been able to sustain action for at least 6 months and are actively striving to prevent relapse. For most people, the change process is not linear, but spiral, with several relapses to earlier stages before they attain permanent behavior change (J. O. Prochaska & DiClemente, 1983, 1986). The stage construct has received empirical support across studies of behavior change in several areas, including smoking cessation (DiClemente et al., 1991), alcohol abuse (DiClemente & Hughes, 1990), psychological distress (J. O. Prochaska, Rossi, & Wilcox, 1991), and safe sex practices (J. O. Prochaska, Redding, Harlow, Rossi, & Velicer, 1994). For example, smokers in the preparation stage are twice as likely to be abstinent at 1 month posttreatment than contemplators, who in turn are twice as likely to be abstinent than precontemplators. The pattern continues at 6 months posttreatment (DiClemente et al., 1991). Research comparing stage distributions across a range of behaviors and populations found that about 40% of pre-action individuals are in precontemplation, 40% in contemplation, and only 20% in preparation (Laforge, Velicer, Richmond, & Owen, 1999; Velicer et al., 1995). If only 20% of physicians are prepared to take action, it should come as no surprise that many CQI initiatives fail. Individuals in precontemplation and contemplation are likely to see change as imposed and can become resistant and defensive if forced to take action before they are ready. Processes of Change In a comparative analysis of 24 major systems of psychotherapy and behavior change, J. O. Prochaska (1984) distilled a set of 10 fundamental processes by which people change. The set was refined following further theoretical analyses (J. O. Prochaska & DiClemente, 1984) and empirical studies (J. O. Prochaska & DiClemente, 1985, 1986). These processes also describe the basic patterns of activity that change agents try to encourage or elicit to help individuals change problem behaviors, affects, cognitions, or interpersonal relationships. The 10 processes applied to CQI are defined in Table 1. The first five processes are experientially oriented, and the latter five are behaviorally oriented (see J. O. Prochaska, Velicer, DiClemente, & Fava, 1988). Research on a variety of health behaviors has identified processes of change that are used in each stage to facilitate change. For example, the data show that individuals in the precontemplation stage use consciousness raising, dramatic relief, and environmental reevaluation; individuals in contemplation use self-reevaluation; individuals in preparation use self-liberation; and individuals in action and maintenance use reinforcement management, counterconditioning, helping relationships, and stimulus control to make and sustain changes (DiClemente et al., 1991; J. O. Prochaska, DiClemente, & Norcross, 1992). Stage-Matched Versus Action-Oriented Interventions Research has shown that stage-matched interventions can have a far greater impact than action-oriented, one-size-fits-all programs. First, stage-matched interventions can allow all individuals to participate in the change process, even if they are not prepared to take action. Second, stage-matched interventions can increase the likelihood that individuals will take action. Stage-matched interventions for smokers more than double the smoking cessation rates of the best traditional interventions available (J. O. Prochaska et al., 1993). Stage-matched interventions have outperformed one-size-fits-all interventions for exercise acquisition (Marcus et al.,1998), dietary behavior (Campbell et al., 1994), mammography screening (Rakowski et al., 1998), and other health behaviors in population-based studies. These findings have important implications for CQI initiatives in health care. Interventions should be individualized and matched to physicians' readiness to change to reduce resistance, reduce stress, and reduce the time needed to implement the change by accelerating movement toward the action stage. In most TTM research, stage-matched interventions are delivered directly to individuals by means of counselors, computer-based expert systems, or manuals or other tailored communications (e.g., Velicer, Prochaska, Fava, Laforge, & Rossi, 1999). However, we recognize that organizations can become powerful change agents in the workplace by creating more optimal conditions for change. If a majority of physicians are in the precontemplation stage, health care organizations can facilitate early-stage processes like consciousness raising (e.g., by communicating about the change through memos, newsletters) and dramatic relief (e.g., by telling stories about the consequences of failure) to help physicians progress to the contemplation stage. If a majority of physicians are already in the action stage, organizations can facilitate stimulus control (e.g., by providing resources to support the change) and helping relationships (e.g., by providing trouble-shooters) to help physicians make and sustain the changes. Physicians who are asked to change without adequate information, inspiration, resources, or assistance are more likely to become apathetic, resistant, or frustrated. In a pilot study, Levesque et al. (1999) demonstrated how the TTM might be used to assess organizational readiness for integrated service delivery and guide the development of a stage-matched change management program. The purpose of the present study is to develop psychometrically sound and externally valid measures of organizational-level stages and processes of change for CQI. J. M. Prochaska (2000) developed similar measures assessing community mental health clinics' readiness for time-limited therapy. Organizational-level TTM measures for CQI can provide an index of health care organization change-management activities designed to facilitate individual movement through the stages of change for CQI. The measures can be used to assess differences between organizations or within organizations over time. However, the development and administration of individual-level measures of stages of change and other TTM constructs will be necessary to understand the needs of physicians within a given organization and to guide the development of a TTM-based stage-matched program for individuals. Quality Improvement in the Veteran's Health Administration This study will apply the TTM to the Veteran's Health Administration (VHA) CQI program. In an effort to adapt to the rising costs of health care and meet internal and external pressures to improve quality, the VHA implemented a nationwide program of quality improvement (Barbour, Malby, Lussier, Thomale, & Lerner, 1996; Young, Charns, & Barbour, 1997). The change initiative relied on three deployment strategies: (a) the reorganization of service providers throughout the country into 22 Veterans' Integrated Service Networks (VISNs) that are based on geographical service areas; (b) the measurement and tracking of specific outcome and performance measures, including customer satisfaction, in all 22 VISNs; and (c) the provision of training in quality improvement to all staff. To address challenges related to improvement methodology, the Department of Veterans Affairs (VA) has collaborated with the Institute of Healthcare Improvement (IHI), a nonprofit corporation that assists health care organizations in implementing rapid, large-scale improvements using the breakthrough series model (e.g., Nolan, Schall, Berwick, & Roessner, 1996). The IHI breakthrough series provides organizations with a model for improvement applied to specific clinical problem areas. This is accomplish by convening several collaborative interdisciplinary teams together from a variety of institutions for a series of three 2-day learning sessions spread over a several month period. The first large-scale collaborative effort between the VA and IHI will be on the topic of reducing delays and waiting times for health care. All VA facilities will be required to send teams of at least three individuals to work on the breakthrough series topic. The TTM measures under development will be administered to participants in the first IHI learning session. Methodology Development of an Operational Definition of CQI The first step in the application of the TTM to CQI in health care is to identify and define the concrete behavioral targets for the change. Drawing from the literature on CQI, including Joint Commission on Accreditation of Healthcare Organizations (JCAHO) documents (e.g., JCAHO, 1991), we will develop an operational definition of CQI. Identifying and defining the behavior change targets in concrete terms helps change leaders to clarify the goals of the change initiative and then to communicate them to the rest of the organization. On the recommendation of experts on CQI in the VA, we will use the term clinical process improvement instead of continuous quality improvement throughout the assessment to increase the likelihood that informants would attend to the definition instead of relying on preconceived, local notions of what is meant by CQI. Also, experts asked that our measures assess organizational readiness to facilitate CQI involvement among all health care providers or clinicians in the VA hospitals, not only physicians. 1 Below is the definition of clinical process improvement used in the assessment: • Successful clinical process improvement requires that health care providers: • Gather data regularly • Use technology more effectively • Participate in cross-functional teams • Involve customers in decision making • Change work processes in response to new knowledge The terms CQI and clinical process improvement will be used interchangeably in the rest of this article. Development of TTM Measures Stages of change A staging algorithm—or set of decision rules—will be developed to assess organizational readiness to facilitate clinician involvement in CQI. The algorithm will begin with the operational definition of clinical process improvement, to ask, “In your opinion, has your VA hospital done what it can to facilitate clinician involvement in process improvement?” Organizations will be classified into stages on the basis of on the following rules: • Precontemplation: Does not intend to facilitate clinician involvement in the next 6 months • Contemplation: Intends to facilitate involvement in the next 6 months • Preparation: Intends to facilitate involvement in the next 30 days • Action: Has been facilitating involvement but for less than 6 months • Maintenance: Has been facilitating involvement for 6 months or longer Similar decision rules will be used and validated for a wide range of health behaviors (e.g., DiClemente et al., 1991; J. O. Prochaska, Velicer, et al., 1994) and work practices (e.g., Levesque et al., 1999; Pro-Change Behavior Systems, Inc., 2000) among individuals. Processes of Change The sequential system for scale development described by Jackson (1970, 1971) and Comrey (1988) will be used to guide development of the organizational-level processes of change measure. At the outset, conceptual definitions of the 10 processes of change and an additional dimension entitled “rules and policies” guided item generation for the new organizational-level processes of change measure for CQI. Literature on CQI implementation and change management will be reviewed to identify change management activities representing each of the processes. Conceptual definitions of each of the organizational processes are provided in Table 2. Once again, note that organizational-level processes are design to encourage use of individual-level processes (Table 1) among clinicians. A total of approximately 70 processes of change items will be generated, with six to seven items representing each of the 11 process categories. To assess content validity, four experts on the TTM from Pro-Change sorted items into 11 categories on the basis of the conceptual definitions of the stage dimensions. Items that will be sorted into different categories by the experts will be dropped or rewritten. A final list of 57 items will be selected for administration on the basis of clarity of expression, lack of redundancy with other items, and the degree to which they represented the 11 processes as conceptually defined. Five to seven items represented each of the process dimensions. The instructions for the organizational-level processes of change measure read as follows: Organizations engage in a variety of activities that can help clinicians get involved in clinical process improvement. Please indicate whether or not you observed your VA hospital engage in each of the following activities in the LAST THREE MONTHS. For each activity you did observe, rate how effective you think it was in getting clinicians involved in process improvement. Informants circled “yes” or “no” to indicate whether or not they had observed each activity and indicated their assessment of effectiveness on a 5-point scale ranging from 1 (not at all effective) to 5 (extremely effective). Given the large number of missing responses on the latter scale, only responses to the former were considered in analyses below. Participants Study participants will be VA administrators and clinical and support staff who will attend the first learning session in the IHI breakthrough series “Reducing Delays and Waiting Times Throughout the Healthcare System” (Nolan et al., 1996) in July 1999. The TTM assessment will be introduced and distributed to 560 attendees in a large group meeting on the first day of the session. Procedure The TTM organizational stages and processes of change measures will be administered as part of a 150-item paper-and-pencil survey that will take approximately 30 min to complete. For the organizational-level TTM measures, informants will be asked to report on their own VA hospital. The survey will include questions to assess professional role and position within the VA and to identify the informant's VA hospital and VISN. Measure Development Stages of Change Health care organizations will be classified into stages of change for CQI on the basis of the staging algorithm outlined above. Organizational Processes Of Change The 57 organizational-level processes of change items will be arranged in random order in the survey. Using components analysis extended program (Velicer, Fava, Zwick, & Harrop, 1988), principal-component analysis (PCA) with varimax rotation will be performed on the 57 × 57 matrix of organizational process interitem correlations to examine the measure's dimensionality as the first step in its refinement. The minimum average partial procedure (Velicer, 1976) and a parallel analysis approximation procedure (Horn, 1965) will be used to determine how many components to retain. These two decision rules are among the most accurate available (Zwick & Velicer, 1986). Component interpretability, component loadings, and coefficient alphas including and excluding particular items will determine the final number of components to retain and their composition. Scale scores for each of the organizational process of change components will be calculated by taking the unweighted sum of the final items comprising the components. 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