Improving safety and quality through evidence-based de-implementation of ineffective diagnostics and therapeutics.

 描述(由申请人提供)： 项目背景：根据国际移民组织的说法，高质量的护理是安全、有效和以患者为中心的。像Choose Wise这样的计划，一个取消实施低价值实践的计划，可以提供一个同时提高质量和价值的有效信息。然而，尽管明智的选择确定了取消执行的目标，但它并没有说明什么战略可能有助于实现这一目标。虽然人们对有效的执行战略知之甚少，但对有效的非执行战略却知之甚少。这一点很重要，因为主动取消实施可能会带来与实施不同的动态和意外后果。退伍军人管理局药房福利管理和专科护理服务办公室的业务合作伙伴帮助确定了一套应该取消实施的初步常见临床做法并确定了优先顺序。项目目标：我们的总体目标是通过与专科护理和药房福利管理办公室的合作伙伴合作，取消实施低价值做法，与退伍军人和退伍军人管理局在卓越蓝图中概述的多种战略保持一致，改善退伍军人和退伍军人管理局的医疗保健提供、安全和价值。我们提出了一系列实验和准实验质量改进项目，比较了替代去实施策略的有效性：基于不断变化的临床医生信息和知识的策略，以及基于为有害做法提供工具和替代品的策略。我们的具体目标是：目标1.与关键的运营领导合作，识别无效、禁忌或对患者价值低的诊断和治疗方法并确定其优先顺序，并制定与运营战略和政策相协调的非实施战略。目的2.测试非实施战略的有效性，以减少无效、禁忌或低价值的诊断和治疗。目的3.通过评估(A)临床医生对关于无效做法的证据的感知、(B)临床医生的专业效能和(C)诊所的组织背景对去实施的影响，发展去实施的科学和分类学。目标4.评估非执行战略对预算的影响，以便为传播提供信息。项目方法：我们将测试跨越多个专科和患者群体的四种临床实践的去实施策略，包括治疗和诊断实践。在每个项目中，我们将单独和结合测试非执行战略的效力，并将评估部署非执行战略对预算的影响。在我们成功和长期的QUERI/专业护理办公室评估中心的结构基础上，我们将纳入混合方法形成性评估，以评估障碍和促进者，并确定非实施战略的潜在意外后果。我们将评估在采用去实施策略参与的临床医生对针对无效实践的经验证据的看法、临床医生减少无效实践的意图以及专业无效(工作相关倦怠的一个组成部分)的前后的变化。我们还将评估组织背景的关键组成部分，如领导人和工作人员的变革文化。我们将评估组织背景，将其作为跨临床环境和实践变化的去实施战略有效性的调节因素。通过这样做，我们将通过开发、测试和细化去实现的概念模型，为去实现的科学和分类学做出贡献。

 DESCRIPTION (provided by applicant): Project Background: According to IOM, high quality care is safe, effective and patient centered. Initiatives such as Choosing Wisely, a program to de-implement low value practices, can provide an effective message to simultaneously improve quality and value. However, while Choosing Wisely identifies targets for de-implementation, it does not speak to what strategies may help achieve this goal. While much is known about effective implementation strategies, little is known about effective de-implementation strategies. This is important because active de- implementation likely entails different dynamics, and unintended consequences, than implementation. VA operational partners in Pharmacy Benefits Management and Office of Specialty Care Services have helped identify and prioritize an initial set of common clinical practices that should be de-implemented. Project Objectives: Our overall goal is to improve healthcare delivery, safety and value for Veterans and VHA, consistent with multiple strategies outlined in the VA Blueprint for Excellence, by working with our partners in the Office of Specialty Care and Pharmacy Benefits Management to de-implement low value practices. We propose a series of experimental and quasi-experimental quality-improvement projects that compare the effectiveness of alternative de-implementation strategies: strategies based on changing clinician information and knowledge, and strategies based on providing tools and substitutes to the harmful practices. Our specific aims are to: Aim 1. Work with key operational leaders to identify and prioritize diagnostics and therapeutics that are ineffective, contraindicated, or of low value to patients, and develop de-implementation strategies that work in concert with operational strategies and policies. Aim 2. Test the effectiveness of de-implementation strategies to reduce ineffective, contraindicated or low value diagnostics and therapeutics. Aim 3. Develop the science and taxonomy of de-implementation by assessing the impact on de- implementation from (a) clinicians' perception of the evidence about ineffective practices, (b) clinicians' professional efficacy, and (c) clinics' organizational context. Aim 4. Assess the budget impact of de-implementation strategies in order to inform dissemination. Project Methods: We will test de-implementation strategies for four clinical practices spanning multiple specialties and patient populations, including both therapeutic and diagnostic practices. In each project, we will test the effectiveness of de-implementation strategies alone and in combination, and will assess the budget impact of fielding de- implementation strategies. Built on the structure of our successful and longstanding QUERI/Office of Specialty Care Evaluation Center, we will incorporate a mixed-methods formative evaluation to assess barriers and facilitators, and identify potential unintended consequences of the de-implementation strategies. We will assess changes, before and after employing de-implementation strategies in participating clinicians' perceptions of the empirical evidence against the ineffective practice; clinicians' intent to reduce the ineffective practice; and professional inefficacy (a component of work-related burnout). We will also assess key components of organizational context, such as culture of change among leaders and staff. We will assess organizational context as a moderator of de-implementation strategy effectiveness across clinical settings and practice changes. By doing this we will contribute to the science and taxonomy of de-implementation by developing, testing and refining a conceptual model of de-implementation.