Implementing a Statewide Learning Collaborative to Support Clinical Quality Improvement

Maryland Learning Collaborative: Recipe for Public Health

Overview

Health departments can support clinical quality improvement by teaming up with a partner organization with inroads to health care systems to implement a statewide learning collaborative with clinical care practices for improving patient care and outcomes. Using findings from an evaluation conducted by CDC, this Recipe for Public Health outlines programmatic “ingredients” for implementing a statewide learning collaborative with health systems to support clinical quality improvement activities and provides key considerations for replicating this approach. The Recipe for Public Health provides information for public health practitioners who are interested in learning more about a public health approach to supporting clinical quality improvement by leveraging public health and health systems partnerships.

Recipe cards.

Key Ingredients

Every state and local health department is different and implements strategies under different circumstances. As in many recipes, the “ingredients” mentioned here are suggestions and may need to be modified or combined in different ways, depending on the setting and target population.

Example

The Maryland Department of Health and Mental Hygiene’s Center for Chronic Disease Prevention and Control (CCDPC) established a mutually beneficial relationship with the Maryland Learning Collaborative (MLC). The MLC was a bridge to primary care practices in the state involved in quality improvement and care transformation. The CCDPC could provide evidence-based resources and technical assistance to improve population health outcomes. In addition, the MLC leadership team was seeking a partner and funding to further sustain its efforts. The two entities formed a memorandum of agreement and scope of work of the activities to be carried out by the MLC and those to be carried out by the CCDPC.

The first ingredient for implementing a statewide collaborative with health systems is to find a partner who can access the health care sector and may already have some of the infrastructure in place to implement a learning collaborative.

How to Implement

  • Seek out state-level partners with goals and objectives that align or who serve as a bridge to a health care setting.
    • An example of a shared goal may be to improve population health through the health care setting by focusing on chronic disease and clinical care transformation.
  • Establish an agreement or formal relationship between the collaborators, detailing a scope of work for each partner.

Example

The MLC was led by a medical doctor and housed at an academic medical center, which provided additional clinical support to the MLC and participating practices. The MLC also had practice coaches who were trained in quality improvement strategies for primary care and provided on-site technical assistance to adopt and sustain practice transformation concepts. The MLC was an ideal partner for the CCDPC, since it already had the infrastructure and expertise to conduct a primary care learning collaborative.

A health department can establish the components needed for a learning collaborative by securing the infrastructure, leadership, process, and participants.

How to Implement

  • Create a forum for health systems or primary care practices to convene.
  • Identify clinical primary care content-area experts to lead and facilitate the collaborative.
  • Lead health systems or primary care practices through a data-driven and systematic quality improvement process, focusing on chronic disease risk factors.

Example

The MLC focused on facilitating primary care practices’ adoption of PCMH principles and team-based care with the ultimate goal of improving quality of care and health outcomes among patients across the state. Likewise, the CCDPC supported a team-based care approach as an evidence-based health system intervention to improve hypertension control. The MLC required participating practices to hire and use practice care managers embedded in the clinical team. It delivered a train-the-trainer model to practice care managers, who then trained medical assistants to improve blood pressure measurement, screening, and management.

To further strengthen your foundation for success, ensure all health systems participating in the learning collaborative have some basic capabilities in place that will support the implementation of quality improvement activities.

How to Implement

  • Leverage evidence-based models such as team-based care to ensure the participating health systems or primary care practices have a common foundation before engaging in cardiovascular disease–focused quality improvement activities.
    • For example, support health systems in achieving nationally accredited National Committee for Quality Assurance patient-centered medical home (PCMH) recognition.
  • Build a training infrastructure that uses clinical support staff who are part of the clinical team.

Example

The MLC optimized use of health information technology by partnering with the Maryland state health information exchange to facilitate the receipt and interpretation of data and to develop vendor-specific EHR user groups for support. The MLC partnered with the Maryland Health Care Commission (housed within the state health department) to select and report key quality measures. The individual and aggregate data reports drove the MLC hypertension quality improvement activities. The data reports allowed health systems and practices to compare current clinical process with established standards and guidelines.

One essential ingredient to guide the quality improvement process is the collection of data for key quality measures. It is important to assess electronic health record (EHR) capabilities of the participating health systems and to develop easily digestible data reports that can facilitate understanding of areas of strength and areas for improvement.

How to Implement

  • Establish a process or system that allows participating practices to collect and report required data from their EHRs to a data steward or data warehouse.
    • It is important that each participating health system or primary care practice can adequately use EHRs and create connections with other health information technology state partners that can provide additional EHR support and training. The collaborative may provide learning opportunities and technical assistance to build a practice’s capacity for data use.
  • Share practices’ data reports on key process and outcome measures at the learning collaborative forum in order to identify areas of strength and areas for improvement.
  • Use findings from the data reports to prioritize and to guide the quality improvement strategies and activities delivered through the learning collaborative.

Example

The CCDPC and the MLC conducted the following cardiovascular disease and hypertension-focused activities:

  1. Trained care managers on team-based care approaches to help patients manage their high blood pressure
  2. Disseminated evidenced-based guidelines for managing high blood pressure
  3. Promoted use of the American Medical Group Association’s Measure Up/Pressure Down campaign for effectively managing and treating high blood pressure
  4. Assessed team-based care among MLC practices, using the Agency for Healthcare Research and Quality’s (AHRQ) Teamwork Perceptions Questionnaire
  5. Collected additional data points on specific quality measures for blood pressure and overall chronic disease self-management (National Quality Foundation [NQF] measures 0018External, 0028External, 0059External, and 0575External)
  6. Offered collaborative interactive trainings focused on quality improvement strategies targeting blood pressure control (NQF measure 0018External)

Through the learning collaborative, facilitate trainings and quality improvement activities that focus on improving the identification and diagnosis of hypertension, follow-up care and treatment, and achieving blood pressure control.

How to Implement

  • Deliver a series of trainings and data-driven quality improvement activities with the participating health systems and primary care practices in the learning collaborative to improve chronic disease outcomes, specifically cardiovascular disease and hypertension.
  • Support these efforts from the public health sector by providing the evidence-based guidelines and other helpful resources.
Measuring spoons.

If you encounter implementation challenges, keep in mind the following troubleshooting tips (derived from the Maryland example):

  • Engage a wide range of partners. Various partnerships with a wide range of organizations across the state, spanning public, private, and academic sectors, can help carry out key program steps. Partners provided the MLC with valuable expertise and perspective, facilitating achievement of program goals. The statewide health information exchange (HIE) was a strategic partnership that facilitated primary care practices’ ability to use HIE data to inform quality improvement activities. In addition, local HIEs can play a critical role in helping practices fully apply health information technology to drive improvement.
  • Use data collected (e.g., quality measures, program monitoring data) to refine how the collaborative is implemented with participants. Use various data sources to continually refine program implementation of the learning collaborative. By continually examining the performance of practices on quality measures, coupled with feedback on how learning sessions were being implemented, the MLC was able to provide activities that supported primary practices’ ability to conduct continuous quality improvement.
  • Use national clinical measures. Using nationally recognized clinical quality measures (e.g., NQF measures) can help facilitate data reporting across practices and minimize the amount of data required of each participating practice. Clinical practices that have limited capacity with information technology (e.g., technical expertise and/or staff time and resources) may have greater difficulties in reporting timely data on quality measures.
  • Recognize differences in practice characteristics. For example, smaller practices (e.g., one or two primary care providers) may be more adept at making changes to practice protocols to improve how hypertensive patients are identified and managed. Primary care practices that are part of larger health systems often have to go through hierarchies before a process-oriented change can be made, and that may delay quality improvement activities.
  • Consider patient characteristics. Patient characteristics can affect implementation of quality improvement strategies for hypertension management. For example, considering socioeconomic and cultural factors is important to making specific recommendations about blood pressure self-management.