MIDAS: Maintaining Implementation through Dynamic Adaptations

MIDAS QUERI的首要目标是减少循证实践实施中的可变性 （EBP）针对后期采用者。如果数据表明即使在治疗后仍存在护理差距，则该中心被视为后期采用者。 国家执行工作已作出努力，以增加电子商务程序的使用。我们将帮助实现VHA 现代化计划的目标是成为一个高可靠性组织（HRO），致力于零伤害。所有三 我们的EBP的重点是减少潜在的有害药物的做法，并取代他们更多的 适当的治疗。我们建议的MIDAS QUERI将侧重于维护（又名维持）更改 旨在改善护理，特别是已经推出有针对性的实施工作的做法 全国范围内。我们的实施方法旨在让一线的临床医生和团队参与到 在忙碌的临床中识别和实施可行的增量变更的动态过程 设置.我们的方法将导致临床过程和三个EBP的适应。 MIDAS QUERI的实施核心将加强我们的合作伙伴先前的国家实施工作 与两个额外的战略，以促进持续使用的EBP：学习。开火法过程 （LEAP）质量改进（QI）培训计划和增强的学术细节（eAD）。LEAP， 最近作为“实施中心”的一部分得到资助， 更改并包含在VHA的在线市场中。我们将进行随机对照试验 （cRCT）来严格比较这些单独和组合递送的策略。呢我们一起来 三个EBP的持续努力，所有这些都是我们业务合作伙伴的优先事项： 项目1：优化质子泵抑制剂的使用，以尽量减少医源性损伤，包括上消化道出血。 这包括两个分项目：1a）处理生产者价格指数使用不足问题; 1b）处理生产者价格指数过度使用问题。我们 这些项目的运营合作伙伴分别是VISN 10和药房福利管理（PBM）。 项目2：更安全地使用直接口服抗凝剂（DOAC），以减少可预防的急诊室就诊。我们 国家运营合作伙伴是PBM，我们的VISN合作伙伴是VISN 15。 项目3：增加使用认知行为疗法（CBTI）而不是药物疗法 睡眠辅助作为失眠症的一线治疗。我们的业务合作伙伴是心理健康办公室 自杀预防（OMHSP） 我们将招募12个后期采用网站的基础上，每个项目的指标证明不充分的实施 在参与国家实施方案后，我们的具体目标是： 具体目标1：通过在后期采用VHA设施中增加三种EBP的采用来改善临床护理。 对护理的影响将通过接受指南一致性治疗的合格患者的百分比来衡量 药物和剂量（项目1和2），以及接受指南一致性治疗的合格患者百分比 治疗（项目3）。这些临床结果预计将减少艾德就诊（项目1和2）， 高风险药物的老年患者（项目3）和急性医院利用率（项目1、2和3）。 具体目标2：比较三种实施战略的有效性：LEAP与eAD， LEAP+eAD。我们将在每个项目内进行随机对照试验（cRCT）， 我们还将在每个实施战略中跨项目组合联合收割机数据， 战略布局结果将与目标1相同。 具体目标3：让临床团队参与动态的、渐进的适应性调整，以维持EBP的使用。中的两 接受LEAP的三个cRCT手臂，我们将收集以下指标：1）前线团队在多大程度上 持续的QI活动; 2）团队成员之间的倦怠; 3）衡量团队的能力， 改变;和4）联邦最佳工作场所的措施。

MIDAS QUERI’s overarching goal is to reduce the variability in implementation of evidence-based practices (EBPs) by targeting late adopters. A center is considered a late adopter if data indicate gaps in care even after national implementation efforts have been made to increase use of an EBP. We will help achieve VHA’s Modernization Plan goal to become a High Reliability Organization (HRO), committed to zero harms. All three of our EBPs focus on reducing potentially harmful medication practices and substituting them with more appropriate therapy. Our proposed MIDAS QUERI will focus on Maintaining (aka sustaining) changes designed to improve care, specifically practices that have had targeted Implementation efforts rolled out nationally. Our implementation approaches are designed to engage clinicians and teams at the frontline in a Dynamic process of identifying and implementing incremental changes that are feasible within busy clinical settings. Our approach will lead to Adaptations of clinical processes and the three EBPs. The MIDAS QUERI’s Implementation Core will augment our partners’ prior national implementation efforts with two additional strategies for promoting sustained use of the EBPs: the Learn. Engage. Act. Process. (LEAP) quality improvement (QI) training program and enhanced Academic Detailing (eAD). LEAP, which was recently funded as part of an “Implementation Hub,” is already recognized as a valuable strategy for practice change and is included in VHA’s Online Marketplace. We will conduct cluster randomized controlled trials (cRCTs) to rigorously compare these strategies delivered alone and in combination. We will focus our sustainment efforts across three EBPs, all of which are priorities of our operational partners: Project 1: Optimizing use of proton pump inhibitors to minimize iatrogenic injury, including upper GI bleeding. This includes two sub-projects: 1a) addressing underuse of PPIs; and 1b) addressing overuse of PPIs. Our operations partners in these projects are VISN 10 and Pharmacy Benefits Management (PBM), respectively. Project 2: Safer Use of Direct Oral Anticoagulants (DOACs) to reduce preventable emergency room visits. Our national operations partner is PBM and our VISN partner is VISN 15. Project 3: Increasing use of Cognitive Behavioral Therapy for Insomnia (CBTI) rather than pharmacologic sleep aids as a first-line treatment of insomnia disorder. Our operations partner is the Office of Mental Health and Suicide Prevention (OMHSP). We will recruit 12 late adopter sites per project based on metrics demonstrating inadequate implementation of the EBP following participation in a national implementation program. Our specific aims are: Specific Aim 1: To improve clinical care by increasing adoption of three EBPs in late-adopting VHA facilities. Impact on care will be measured by the percentage of eligible patients receiving guideline-concordant medications and dosages (Projects 1 and 2), and percentage of eligible patients receiving guideline concordant therapy (Project 3). These clinical outcomes are expected to reduce ED visits (Projects 1 and 2), percentage of elderly patients on high risk medications (Project 3), and acute hospital utilization rates (Projects 1, 2, and 3). Specific Aim 2: To compare the effectiveness of three implementation strategies: LEAP versus eAD, versus LEAP+eAD. We will conduct cluster randomized controlled trials (cRCTs) within each project to compare strategies; we will also combine data across projects within each implementation strategy to compare strategies. Outcomes will be the same as those for Aim 1. Specific Aim 3: To engage clinical teams in dynamic, incremental adaptations to sustain EBP use. In two of the three cRCT arms that receive LEAP, we will collect measures of: 1) the extent to which frontline teams are continuing QI activities; 2) burnout among team members; 3) a measure of teams’ ability to make and sustain change; and 4) the Federal Best Places to Work measure.