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Each additional 1% reduction in LDL-c reduces MCE (IHD death and nonfatal MI) risk by 1.7% (1). Heart Protection Study: RCT with Simvastatin decreased mortality in a broad range of patients and reduced MI and stroke by one-third (2). Simvastatin Survival Study Group. Lipoprotein changes and reduction in the incidence of major coronary heart disease events in the Scandinavian Simvastatin Survival Study (4S). Circ 97:1453-1460; 1998. 2. http://www.ctsu.ox.ac.uk/~hps/ Z`PZ0 " Z2#0 " Z2omContext: Round 1aEight VA medical centers in a single VISN VISN 20, Northwest Network Wide variation in size Small, non-tertiary to large, tertiary, teaching Wide variation in number of IHD patients 400 to 4000 per site Wide variation in number of primary care providers 12 to 200*21)3 *21)3   GVHA Is Divided Into 21 VISNssnFacilitation: Round 1bInvolvement in team selection Trained team members Kick off meetings Offered menu of options for methods of intervening Case management including pharmacist-led lipid clinics (3) Point of care paper-based reminders (2) Audit/feedback + patient education (1) Complex, multi-faceted interventions (2) Teams selected their preferred method Monthly follow up by project manager Quarterly data extraction and reports Monitoring proportion of IHD patients with current LDL measurement, on treatment, and those at goal3ZZ3ZZqZdZ33qd  x%Mean LDL for IHD Patients on Statins wMean LDL values by VAMCuHContext: Round 1cVery difficult to measure  success Clear that some interventions had fallen apart without accomplishing much Clear that some interventions were continuing Unclear what dose there had been of any intervention Massive secular trend Conducted qualitative follow up study ~6 months after intervention phase ended Interviewed  key players involved in intervention in each facility (54)\$ZZ&ZrZ$&r Summary of Facilitators Overall Evidence Wide acceptance of evidence-based finding High level of enthusiasm for delivering care based on evidence Context General support from front line clinicians and managers Facilitation High level of interest from active, respected clinicians  ZiZZ8Z Z:Z i8 :  Summary of Barriers Overall @Evidence Some disagreement about goal statements based on available evidence Context Perceived lack of resources Time, energy, space Relatively low priority for quality improvement  We re doing well on the EPRP reports Facilitation Insufficient planning for active, engaged facilitation  ZDZZZZ0Z'Z Z8Z D0  ' 8b9www.va.gov/resdev www.hsrd.research.va.gov/research/queri:}:"Publications: Newsletters (QUERI Quarterly, other HSR&D) QUERI Fact Sheets Project, publication databases Links to QUERI center websites Grant solicitations, new initiativesfZ=0ZcZ  c& Site A Lipid Clinic Intervention{Lipid Clinic opened October 15, 1999 Pharmacist-run clinic based on provider referral Hours were 10-11am and 12-3pm Fridays'*Process Variables and Outcomes for Site A++(+Site B Combined Audit/Feedback InterventionAudit/Feedback: Providers were e-mailed a list of IHD patients ranked by LDL-c level excluding patients without LDL measurement 98 providers in all firms were sent e-mails Pharmacist Case Management: Pharm D Resident identified high-risk patients and intervened with providers and their patients in one clinic. PharmD only intervened with 5 patients during the time of the intervention. Z))Process Variables and Outcomes for Site B*!Barriers and Facilitators: Site BPrevention is given a low priority in this facility (lack of time) Lack of communication between services No central leadership Good fit between skills and experience and implementers Buy-in was considered  very good Management was considered supportive ZI+Site C Combined Audit/Feedback InterventionAudit/Feedback Providers were e-mailed a list of IHD patients ranked by LDL-c level; Patient Education IHD patients were sent a letter stating the importance of maintaining a LDL-c cholesterol below 100 mg/dL, a brochure, and two pages of resourcesLGGJ)Process and Outcome Variables for Site CK!Barriers and Facilitators: Site C20 minute appointment not enough time to address prevention Reluctance by some providers to turn over care to allied health providers Roles were poorly defined Staff time to address patient lists Quality of data in first patient list compromised buy-in from provider staff .ZZ Chief of Ambulatory care provided strong leadership Kickoff meeting and working meeting were good team building opportunities Compilation of data and expertise of IRM staff+Site D Multiple Interventions Ten proposed interventions, two successful Cardiology Clinic I: Paper POC Reminder: Initiated by Cardiology Coordinator. Continues today Home Site: Computerized Order template adds fasting lipid panels to cardiac cath and cardiology admissions. Continues today,*Process Variables and Outcomes for Site D -!Barriers and Facilitators: Site DToo many interventions proposed Team: no planning/no protocol, no communication, poorly defined roles Limited resources: lack of time of intervention staff Lacked buy-in from nursing staff and managementZ Easy to integrate satellite cardiology clinic intervention into already existing job functions Good working relationships in satellite cardiology clinicL!Site E Lipid Clinic Intervention Approved in April 1999 by the PT&N Committee Pharmacist-run clinic based on provider referral Initially daily clinics M-F 1:30 - 3:30 pm PharmacoManagement Clinic started in Jan 2000. M)Process Variables and Outcomes for Site EN!Barriers and Facilitators: Site ELack of buy-in from providers Lack of resources: space, time, personnel Patients live far away Team had problem with data from LMMS team  wHaving intervention come from outside source (administrative buy-in) Fellow colleagues who referred patients to clinic /Site F Multiple Interventions6ER orders for IHD patients were changed to add lipid profile & LFTs; Start Simvastatin, review ASA, ACE inhibitor, B-blocker use; repeat LFTs & lipids in 6 weeks Admission orders for ICU/ACU changed to include LFTs and statins w/6 week f/u Target education program for nursing staff Pharmacist-run Lipid Clinic770(Process and Outcome Variables for Site F1!Barriers and Facilitators: Site FOrdering labs and meds can be difficult There are overwhelming demands on providers Need for a centralized leader w/expertise of guidelines Team communication suffered during implementation Strong time and resource limitationsZ KTeam process good during planning Management support from Chief of Medicine2'Site G Paper POC Reminder Intervention Paper POC Reminder A sheet was placed in front of the patient s chart at the time of the appointment. The sheet contained lab information, pharmacy information and text lines for a provider response to the reminder.3*Process and Outcome Variables for Site G 4!Barriers and Facilitators: Site GAppointment times too short to accomplish preventive care No opinion leader No follow-up to promote physician response Lack of intervention team time to promote intervention VA providers are more conscientious about meeting guidelines than private sector providers Multidisciplinary team Buy-in was good because of evidence basis of intervention 51Site H Electronic Clinical Reminder Intervention "When interventionists returned from Seattle kickoff meeting they presented the electronic clinical reminder to providers during a staff meeting and an e-mail In August 1999 the IHD-PCE reminder was turned on for providers One of the interventionists received patient data in early Jan 2000.##6'Process and outcome variables in Site HOContext: Round 2New VISN VISN 19, Rocky Mountain Network Single intervention Electronic IHD Lipid Reminders Eastern half of VISN received intervention Western half did not Effort to control for secular trend v 4@$ 4@$PVHA Is Divided Into 21 VISNsQIHD Lipid Clinical RemindersDevelopment of two national IHD reminders Notifies clinicians if lipid panel due or  ed LDL Provides relevant lab & pharmacy data Links directly to lab & lipid lowering med orders and progress notes ***qR SCurrent StatusEvaluation of reminder still in progress Preliminary results of provider survey available Suggest that non-intervention sites did not receive intervention With one exception intervention sites did receive intervention Providers in intervention sites are using the reminders>ZZZZgN/K k$l&m'FRS]^7`8a9b:c;d<e=fThUiVjF;  0` ̙33` ` ff3333f` 333MMM` f` f` 3>?" dd@ |?" dd@   " @ ` n?" dd@   @@``PR    @ ` ` p>> 7x76(    6< P  T Click to edit Master title style! !  0(   RClick to edit Master text styles Second level Third level Fourth level Fifth level!     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̙33$ a 0L0 @ (    c $P<$D 0    0 BA a?H a$ 0 B  6D ,$D 0  6м ,$D 0 yIAudit/Feedback intervention starts May 2000 and continues until Jan 2001 JJ B  6D ,$D 0  6x¶  y ,$D 0 ^.Pharmacist case management intervention starts//   6Pƶ @I ,$D 0 \,Pharmacist case management intervention ends-- ^B   6DP  RB   s *D ppH  0޽h ? ̙33NF___PPT10&.+-D' = @B D' = @BA?%,( < +O%,( < +D' =%(%(D#' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*D{' =%(D#' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*D{' =%(D#' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*D{' =%(D#' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*++0+0 ++0+0 ++0+0 ++0+0 +  0L0 xp`(  x  c $P     c $ <$ 0    c $$p <$ 0  H  0޽h ? ̙334  0L0 \(  x  c $P     c $<$ 0  H  0޽h ? ̙33F0 i 0L0 W O  (    c $ _P<$D 0    0 BA |?H |$D 0   6p m,$D 0 GKickoff Meeting on site    6u z,$D 0 qAProviders were sent an e-mail informing them of the interventionsBB B  s *DP @ @ p,$D 0B  s *D` ` ` ,$D 0B  s *D0 ,$D  0   s *,{0 : P ,$D 0 Q!632 letters were sent to patients""    0  ,$D  0 @ 2      6  I ,$D  0 rBProviders were sent a list of IHD patients with rank order of LDLCC ^B   6DP p^B   6D W H  0޽h ? ̙33&w&___PPT10W&.+XD%' = @B D$' = @BA?%,( < +O%,( < +D' =%(%(D#' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*D{' =%(D#' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*D{' =%(D#' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*D{' =%(D#' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<* %(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<* D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<* Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*D{' =%(D#' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<* %(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<* D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<* ++0+0 ++0+0 ++0+0 ++0+ 0 ++0+ 0 +  0L0 xp(  x  c $TP     c $U <$ 0    c $Vp <$ 0  H  0޽h ? ̙334  0L0 p\(  x  c $DP     c $F<$ 0  H  0޽h ? ̙33> b 0L0 M E   (    c $TP<$D 0    0 BA b?H b$  0   0T,$D  0 ?Kickoff Meeting   6 P ,$D 0 l<In-service at primary care staff meeting at satellite clinic==   6!@ L ,$D 0 vFPaper POC reminder in cardiology clinic at Satellite Cardiology ClinicGG B  6D` ` ,$D  0B  6D @,$D 0B   6D   ,$D 0'   6%  ,$D  0 ]Fasting lipid panel added to order template in CPRS (cardiology admissions and cath patients)^^ B   6DP @@ ,$D  0   6,+@ Z ,$D  0 k;CCU informational In-service for nursing staff in Home Site<< B   6D@@@` ,$D 0H  0޽h ? ̙33&44___PPT103.+7QD2' 8= @B DA2' = @BA?%,( < +O%,( < +D' =%(%(D#' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*D{' =%(D#' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<* %(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<* D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<* D{' =%(D#' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<* %(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<* D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<* D{' =%(D#' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<* %(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<* D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<* D{' =%(D#' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<* %(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<* D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<* Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*D{' =%(D#' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<* %(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<* D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<* +P+0+0 ++0+0 ++0+0 ++0+0 ++0+ 0 ++0+ 0 + c 0L0 xp(  x  c $0P     c $8 <$ 0    c $$ p <$ 0  H  0޽h ? ̙334  0L0 \(  x  c $HP     c $H<$ 0  H  0޽h ? ̙33J h 0L0 s k  (    c $P<$D 0    0 BA {?H {$  0   6̲ `y,$D 0 CLipid Clinic Starts B  6D P ,$D  0  6p0 ,$D 0 VKickoff Meeting In Seattle   B  6D @,$D 0  6ؼ @  ,$D 0 i9CME Meeting: with national expert and LMMS Research Staff:: B   6DP p ,$D 0   6°` ,$D  0 O*Clinical pharmacist leaves VA*  B   6DP P ,$D  0   6ư0  ,$D  0 X(PharmD starts PharmacoManagement Clinic )) B   6D ,$D  0X  s *˰p *,$D 0 J PharmD receives permission to call patients on Seattle Data list*C@   s *Ѱ ,$D  0 @J" RB  s *D H  0޽h ? ̙33==___PPT10t=.+}q<D;' = @B DG;' = @BA?%,( < +O%,( < +D' =%(%(D#' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*D{' =%(D#' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*D{' =%(D#' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<* %(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<* D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<* D{' =%(D#' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<* %(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<* D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<* D{' =%(D#' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<* %(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<* D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<* Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<* %(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<* D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<* D{' =%(D#' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<* %(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<* D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<* D{' =%(D#' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*D{' =%(D#' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*++0+0 ++0+0 ++0+0 ++0+0 ++0+ 0 ++0+ 0 ++0+0 ++0+0 +  0L0 xp(  x  c $DP     c $D <$ 0    c $p <$ 0  H  0޽h ? ̙334  0L0 \(  x  c $P     c $<$ 0  H  0޽h ? ̙33xC d 0L0   A (    c $aP<$D 0    0 BA c?H c$ 0 B  6D @,$D  0#  6c ,$D  0 YAddition to computerized order templates to include fasting lipid profile and SimvastatinZZ B  6D  ,$D 0  s *hiP3,$D 0 JKickoff meeting in Seattle   Bmp ,$D  0 W'Nursing/Pharmacy/MD Staff IHD Education(( B  @ 6DPp ,$D 0B   6DP p ,$D 0B   6D ` P ,$D 0B   6D` P ,$D  0   6+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*D{' =%(D#' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<* %(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<* D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<* Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<* %(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<* D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<* Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<* %(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<* D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<* Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<* %(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<* D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<* D{' =%(D#' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*D{' =%(D#' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*D{' =%(D#' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<* %(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<* D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<* ++0+0 ++0+0 ++0+0 ++0+0 ++0+ 0 +  0L0 xp(  x  c $NP     c $O <$ 0    c $Rp <$ 0  H  0޽h ? ̙334  0L0 \(  x  c $lEP     c $ G<$ 0  H  0޽h ? ̙33f> e 0L0    ` (    c $P<$D 0    0 BA d?H d$D  0 B  6D  ,$D  0  6`G,$D 0 JKickoff Meeting in Seattle B  6D ,$D 0  s *| ,$D 0 Z*Intervention is presented to Medical Staff++   s * ` @,$D  0 m=QA manager distributed a copy of the LMMS report to providers>> B   6D  ,$D  0B   6D 0 0 0,$D 0   6L%G ,$D 0 Z*The Paper POC reminder intervention starts++ B   6D 0 ,$D  0   6L* ` 6 ,$D  0 CIntervention ends H  0޽h ? ̙33&44___PPT103.+N/D2' 8= @B DA2' = @BA?%,( < +O%,( < +D' =%(%(D#' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*D{' =%(D#' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*D{' =%(D#' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<* %(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<* D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<* D{' =%(D#' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<* %(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<* D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<* Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<* %(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<* D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<* D{' =%(D#' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<* %(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<* D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<* D{' =%(D#' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<* %(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<* D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<* +P+0+0 ++0+0 ++0+0 ++0+0 ++0+ 0 ++0+ 0 +E   0L0 04(    c $QP<$D 0  Q   c $Q <$D 0 Q   c $Qp <$D 0 Q H  0޽h ? ̙331)___PPT10 .+ȇD' Q= @B Dd' = @BA?%,( < +O%,( < +D' =%(%(D#' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*+8+0+0 +  0L0 @(    c $PQP<$D 0  Q   c $ Q<$D 0 Q H  0޽h ? ̙331)___PPT10 .+8BD' Q= @B Dd' = @BA?%,( < +O%,( < +D' =%(%(D#' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*+8+0+0 +3 f 0L0 4,P (    c $QP<$D 0  Q  0 BA e?H e$D  0 QB  s *D ,$D  0  6QG,$D 0 JKickoff Meeting in Seattle B  s *D@ ,$D 0  6hQGP ,$D 0 SIntervention team presents study and intervention to provider staff @ Staff MeetingTT B  s *D  ,$D 0   60Qp P ,$D 0 OIHD-PCE Reminders are turned on  B   s *D0  ,$D  0   s *Q  ,$D  0 V&Patient list is sent by Seattle team'' H  0޽h ? ̙33**___PPT10*.+]D)' Q= @B DH)' = @BA?%,( < +O%,( < +D' =%(%(D#' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*D{' =%(D#' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*D{' =%(D#' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<*%(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<*D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<*D{' =%(D#' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<* %(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<* D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<* Dn' =%(D' =%(D' =4@BBBB%(D' =1:Bvisible*o3>+#.<* %(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<* D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<* D{' =%(D#' =%(D' =A@BBBB0B%(D' =1:Bvisible*o3>+#.<* %(D' =+4 8?dCB0-#ppt_w/2BCB#ppt_xB*Y3>B ppt_x<* D' =+4 8?\CB#ppt_yBCB#ppt_yB*Y3>B ppt_y<* ++0+0 ++0+0 ++0+0 ++0+ 0 ++0+ 0 +  0  0(  x  c $0QP  Q x  c $Q Q H  0޽h ? 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MMM̙f4 j 0L0 0\(  x  c $QP  Q   c $Q<$ 0 Q H  0޽h ? ffD3f  0L0 \TP$(  $ $0 <A }?mH }$ 0 QH $ 0޽h ? MMM̙f  0 `(0(  (x ( c $ܖQP  Q x ( c $Q Q H ( 0޽h ?  0 |p$(  $R $ 3     $ C  @   " H $ 0޽h ? ̙33$7 0 0t(  ^ S     # lT__ 6   " H  0޽h ? ̙33$9 0 t(  ^ S     # l__ 6   " H  0޽h ? ̙33$: 0 t(  ^ S     # l__ 6   " H  0޽h ? ̙33V 0 @ (  X C     S $ @   " H  0޽h ? ̙33b 0 D,(  D^ DS     Dc $* @   " H D 0޽h ? a(f 0 `<(  X  C      S  @   > H  0޽h ? ̙33 0 p`,(  `^ ` S     ` c $5 @   " H ` 0޽h ? ̙33 0 h,(  h^ h S     h c $X; @   " H h 0޽h ? ̙33- 0  }(  ^  S      c $@ @   s_Kickoff meeting June 1999 Cardiologists presentation September 1999 Lipid Clinic October 1999H  0޽h ? ̙33 0 PL(  ^  S      c $H @   BPharmacist case mngt intervention starts January 2000 Audit/Feedback intervention starts May 2000 and continues until Jan 2001 (add data pt) Pharmacist case management intervention ends June 2000 >7W 7 H  0޽h ? ̙33N 0 (  ^  S      c $T @   ZKickoff Meeting June 1999 In-service at primary care staff meeting at AL July 1999 Paper POC reminder in cardiology clinic at American Lake Clinic September 1999 Fasting lipid panel added to order template in CPRS (cardiology admissions and cath patients) September 1999 CCU informational In-service for nursing staff in Seattle November 1999@ [H  0޽h ? ̙33 0 VN(  ^  S    H  c $e @   I added the ones that I included for the interventions that worked at AL and the ones that didn t work in Seattle. I did not state in previous slide what did not work but what actually ended up being successful. H  0޽h ? ̙33V 0 (  ^  S      c $l @   Kickoff meeting in Seattle June 1999 Nursing/Pharmacy/MD Staff IHD Education July 1999 Nursing/Pharmacy/MD Staff IHD Education August 1999 Addition to computerized order templates to include fasting lipid profile and Simvastatin September 1999 Nursing/Pharmacy/MD Staff IHD Education February 2000 Nursing/Pharmacy/MD Staff IHD Education April 2000 Nursing/Pharmacy/MD Staff IHD Education May 2000 Pharmacist-run Lipid Clinic opens in October 2000  2 4 j 6 3 1 2 H  0޽h ? ̙33 0  Q(  ^  S      c $ @   GKickoff Meeting in Seattle June 1999 Intervention is presented to Medical Staff July 1999 The Paper POC reminder intervention starts November 1999 QA manager distributed a copy of the LMMS report to providers February 2000 Intervention ends April 2000 * H  0޽h ? ̙33 0 H@`(  ^  S    :  c $ @   Kickoff Mtg June 1999 Intervention Team presentation July 1999 IHD-PCE Reminders turned on September 1999 Patient List sent from Seattle January 2000H  0޽h ? ̙33 0 ,(  ^  S      c $\ @   "zLipid Clinic Starts April 1999 Kickoff Meeting In Seattle June 1999 CME Meeting: with Dr. Feingold and LMMS Research Staff August 1999 *Clinical pharmacist leaves VA* December 1999 PharmD starts PharmacoManagement Clinic January 2000 J PharmD receives permission to call patients on Seattle Data list June 2000 X> &D e@ ,1GH  0޽h ? ̙33# 0  s(   ^   S       c $ @   i#Kickoff Meeting in Portland October 1999 Providers were sent an e-mail informing them of the interventions February 2000 Providers were sent a list of IHD patients with rank order of LDL March 2000 632 letters were sent to patients April 2000 632 letters were sent to patients June 2000 *  $H   0޽h ? ̙33 0 @ J(   ^   S !      c $̼ @   @  H   0޽h ? a((xZ xUյ^k$&!d6B00 3aY$! dFa)"XD`erE li)*<ĊkaM9IW]EwW¹BL彨wX.7 G| A@U U_o>4)i,"rQO(dW=ܰ׋+n3'. 42)F, )t=׻@oR/XKh2l@k귦OR2@>M^16N\^uU9k_(={u푟]4n¸i;wQP[4"lbOZɨ'e8qB 6CӺwաO#Gg헛=*h|Ʌ#iyjVx9ڸYtCmkal7ouw^lFF]6ʹPkP1v'+=޲sRT1a)~woSI7Z=s|kqS ;W\eyy!DI,~oOD]tx|eNnۿ9$=|\n+jq\C@+'S*/tЉK;/^@ ̦<}/w|;es*MvTηnqG;SUӋ e)d`%eÔhS9C% 7>τ1Hp{ƃ9Ky=Ov2ɮ9܁gk~ūy??ͫa=Bq>ﲹ\$4d1ɲ5d3ͦ|9ͷ1Cf#n.o>WgWˇQ {lc(UQo~EF.Ûe2ErϒnYKU^+aSK~NnW';])2? 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B2  'Quality Enhancement Research Initiative.-՜.+,0     S On-screen ShowVA-R&Dx\1 ;Times New RomanArial Book Antiqua Courier New WingdingsMonotype SortsDefault DesignMicrosoft Clip GalleryMicrosoft Graph 2000 ChartMicrosoft Word DocumentMultiple Methods of Implementing Evidence Based Best Practices: Examples from QUERI Health Services Research & Development Service Department of Veterans Affairs Overview"VHA Is a Large, Integrated SystemBenefits PackageVHA Is Divided Into 21 VISNsThe QUERI Mission9Eight QUERI Groups Focused on Specific Health ConditionsThe Six-step QUERI ProcessSlide 9eExamples focus on lipid management for secondary prevention in patients with ischemic heart disease EvidenceContext: Round 1aVHA Is Divided Into 21 VISNs Slide 14Facilitation: Round 1b&Mean LDL for IHD Patients on Statins Mean LDL values by VAMC Slide 18Context: Round 1c!Summary of Facilitators Overall Summary of Barriers Overall :www.va.gov/resdev www.hsrd.research.va.gov/research/queri!Site A Lipid Clinic Intervention+Process Variables and Outcomes for Site A,Site B Combined Audit/Feedback Intervention*Process Variables and Outcomes for Site B"Barriers and Facilitators: Site B,Site C Combined Audit/Feedback Intervention*Process and Outcome Variables for Site C"Barriers and Facilitators: Site CSite D Multiple Interventions +Process Variables and Outcomes for Site D "Barriers and Facilitators: Site D"Site E Lipid Clinic Intervention *Process Variables and Outcomes for Site E"Barriers and Facilitators: Site ESite F Multiple Interventions)Process and Outcome Variables for Site F"Barriers and Facilitators: Site F(Site G Paper POC Reminder Intervention +Process and Outcome Variables for Site G "Barriers and Facilitators: Site G2Site H Electronic Clinical Reminder Intervention (Process and outcome variables in Site HContext: Round 2VHA Is Divided Into 21 VISNsIHD Lipid Clinical Reminders Slide 48Current Status  Fonts UsedDesign TemplateEmbedded OLE Servers Slide Titles1 _q0cmmillercmmiller  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`bcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+,-.0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ\]^_`abdefghijuRoot EntrydO)PicturesCurrent UsercSummaryInformation(/WPowerPoint Document(aDocumentSummaryInformation8[