From July 2017 to December 2018, 17 interprofessional healthcare teams were enrolled to participate in an 18-month QI Collaborative. Participating teams made significant progress implementing evidence-based changes to clinic workflow and care processes with a focus on initiation and retention of OAT to improve outcomes for their patients with OUD. Changes to improve access to care included identifying clients lost to care, improving intake forms and adding reminder or follow-up calls for appointments. As a result, there was a significant increase in the number of individuals retained in OAT at the three-month mark from three out of ten to seven out of ten. Results from this study provide evidence to support the implementation QI and process improvement to improve retention on OAT for people living with OUD.
Improvements in care were captured in monthly reports containing process and outcome indicators and qualitative descriptions of change. Reporting rates were variable among teams with a median reporting rate of 42 and 35% for qualitative and quantitative reports, respectively. By reporting monthly on their progress, teams were able to determine if the changes they were implementing in practice, were indeed resulting in an improvement. Although reporting rates were variable among teams, this is consistent with other similar initiatives , and may reflect the reality that not all teams are able to establish a system of measurement to inform their quality improvement initiatives.
As part of the preparation phase for the BOOST Collaborative, the core team sought to address known issues with data quality in participating teams’ EMRs. It has been shown that data quality can significantly influence the accuracy of quality indicators ; therefore, we aimed to improve the fidelity of clinical data as it was entered into the EMR. EMR forms have been found to improve the likelihood of patients receiving evidence-based care and the accuracy of both clinical and administrative data . This is also in line with the CCM, which highlights the importance of decision support and information systems in the proactive care of patients with chronic conditions .
Monthly reports were used by the core team to assign a monthly Collaborative Assessment Score , a characterization of team progress throughout the Collaborative process. Overall, teams showed improved progress throughout the Collaborative, with the majority of teams (59%) showing modest or some improvement. The relatively modest rates of improvement between teams may be explained by the challenges outlined above regarding data extraction and indicator reporting. Without demonstration of measurable improvement, teams cannot progress to a score greater than 2.5 (changes tested), limiting their ability to demonstrate improvements. Assessment scores do not fully capture the complexity of changes made and, when combined with quality indicator outcomes, can provide further information about team success and what may predict success for a participating team.
The BOOST Collaborative designed a QI initiative including a suite of OUD intervention strategies based on the HIV cascade of care . This process requires taking a system-level view and systematically identifying gaps in care for people living with OUD from screening to diagnosis to follow-up. Further, it involves meaningfully including the client and family voice to characterize gaps in care and address this complex issue. The evidence clearly shows that people living with OUD have better health outcomes when engaged in care and retained in treatment, such as OAT [3, 4]. Retention in OAT is often suboptimal for a number of different reasons, including barriers to induction and titration, limited drop-in or clinic hours, and reactive patient recall systems. This initiative supported teams to more accurately identify and characterize patients with OUD (i.e., age, treatment stage, engagement in care and retention), and target interventions and changes based on that information to improve care and outcomes.
Limitations and implications
Unlike other similar QI initiatives, where healthcare teams go through an application process and pay to participate [12,13,14], Vancouver BOOST participants were selected by health authority leadership. This may have influenced team’s receptiveness and readiness to participate in this initiative. Without an application process, there was a high variability of leadership support and commitment to quality improvement processes among teams. This may have impacted the ability of teams to engage fully in this work, particularly if time and resources were not consistently available to participants. Strong leadership commitment and financially accountable teams may have improved participants engagement in this initiative.
Although teams were provided with access to in-practice coaching and support to extract data from their EMRs, some teams had ongoing challenges with measurement and reporting and the workload it placed on staff. Qualitative data reporting rates ranged from 15 to 85% and quantitative data reporting rates ranged from 0 to 77%. The differences in reporting rates may be partially explained by variable technical skills and comfort with EMR data and functionalities. Further to this, there were ongoing and, in some cases, significant challenges with EMR data quality, which created barriers to extracting useful quality indicator data, resulting in low reporting rates for some teams. A parallel commitment from service providers, vendors or internal information technology teams to support data fidelity may have improved this element of the Collaborative.
Baseline QI knowledge and uptake of QI resources was also highly variable among teams. Some teams had participated in previous QI Collaboratives and were very familiar with QI methodology and resources, whereas others had no knowledge at all. A considerable amount of time was dedicated up front to establishing a common understanding of QI among teams. Ongoing and ad-hoc training for new staff may have improved engagement from participating teams.
Other factors that may have influenced the success of implementation and team participation included a provincial system-wide primary care redesign initiative occurring in parallel with the BOOST Collaborative. This resulted in program reorganizations and restructuring, in addition to clinic moves. This was disrupting for many of the teams as staff and caseloads were redistributed.
Finally, implementing a QI Collaborative was very challenging in the midst of a public health emergency and substantial patient mortality. For participating teams from low-barrier clinics with no set appointment times, there were challenges related to protecting time for meetings and sourcing backfill staff to attend support activities given unpredictable and fluctuating demands. This initiative offers some encouraging results for improving care for people living with OUD; however, additional research is needed to determine the sustainability of these improvements beyond the end of the Collaborative.