Dr Janine Bycroft, Gayl Humphrey, Dr Celia Palmer, Kate Healey, Dr Mazin Ghafel Auckland DHB, Planning & Funding Team

1. Dr Janine Bycroft, Gayl Humphrey, Dr Celia PALMER, Kate Healey, Dr Mazin Ghafel Auckland DHB, Planning & Funding Team Improving Chronic Care - a NZ experience using a breakthrough series collaborative methodology within primary care

2. Outline of presentation The challenge What is a collaborative? International experience Equipped - the LTC Collaborative in Auckland Lessons and next steps

3. Prevalence of long-term conditions In 2006, NZ Health Survey identified percent of population diagnosed by a doctor with a health condition expected to last 6 months or more

4. What is a Collaborative? A Collaborative is a specific method of quality improvement used to distribute and adapt existing knowledge to multiple groups to achieve a common aim It promotes rapid change, allowing participants to experience the benefits and create results in a short time-frame

5. Origins Paul Batalden, MD - Napkin sketch 1994 Don Berwick, CEO Institute of Healthcare Improvement (IHI) 1996: First Breakthrough Collaborative Caesarean section rates Others include physician prescribing practices, asthma care, low back pain, reducing waiting times

6. Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction and skilful execution; it represents the wise choice of many alternatives. William A Foster

7. Key Features of a Collaborative Proven improvement model for rapid & sustainable improvement Expert Advisory Panel – subject & QI experts Use of information & measurement to guide improvement work Clinical leadership Protected time Practical support from QI facilitators Encourages individuals to change

8. Generic Change Concepts Improve work flow Optimize inventory Change the work environment Focus on product or service Manage variation Enhance the producer/customer relationship Manage time Design systems to avoid mistakes Move towards standardisation & reduce variation Eliminate Waste

9. The process

11. Safety

12. Efficiency & effectiveness

13. Reporting & functionality

14. Teamwork & staff morale

15. Systems & processes

16. Right person for right role

17. Job satisfaction

18. Relationships with community, 1 and 2 care Supports cultural shift to continual quality improvement

21. Long-Term Conditions Collaborative Making it easier to do the right thing

22. Questions Can busy practices within ADHB region implement a long term conditions collaborative and adopt QI approaches? If so, would their patients benefit?

23. The Improvement Model 3 Fundamental Questions (the thinking part) PDSA Cycles (the doing part) What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make thatwill result in improvement? Plan Act Do Study

24. Our three topics and areas of focus System Redesign Optimising Clinical Management of Long-term Conditions: Cardiovascular Disease and Diabetes Self Management Support

25. Measures System Redesign Unmet demand The number of patients who Do Not Attend a scheduled appointment The number of invitations issued for planned CVD or diabetes visits Diabetes and Cardiovascular Disease: The number of the enrolled population with known disease % of enrolled population with CVD prescribed a statin & antiplatelet % of people with CVD or diabetes with BP equal to or less than 130/80 % enrolled eligible population who have had a CVDRA recorded HB A1C levels % of enrolled population < 7.0mmol/l., 7-8, 8 -9, > 9mmol/l Self Management Support % of people with CVD or diabetes who have an annual care plan review

26. PDSA Cycle/s What, who, when, where, predictions, data collected What will you take forward from this cycle? Plan Act Study Do Was plan executed? Review and reflect on results

27. PDSA (Plan – Cycle 1) Plan: What: Run a search of database for patients prescribed a CVD medication who are not coded with a CVD diagnosis. Give GP a copy of the list to confirm diagnosis and code appropriately Who: Kathy When: Friday 21st August Where: At the practice Prediction: That a number of patients not coded will be identified Data to be collected: List of patients to be checked and correctly coded with a diagnosis of CVD

28. PDSA (Do, Study, Act – Cycle 1) Do: Plan was completed. Study: 15 patients were identified as having been prescribed a statin but were not coded as having CVD. Act: GPs to correctly code patients with CVD diagnosis where appropriate.

29. Title of Presentation

31. “Ideas are like rabbits. You get a couple and learn how to handle them and pretty soon you have a dozen.” John Steinbeck

32. Key Components 15 participating practices (most high needs) All 5 PHOs represented 5 PHO facilitators 3 Learning Workshops over 9 months Resources and skills developed and refined over time Population tools used by 13/15 Workbook developed Supported by a website & regular newsletters

33. Changes in CVD Register over Time

36. ACIC & PACIC

38. better coordination and multi-disciplinary teamwork in the participating practices;

39. better understanding by practice participants of their populations improved understanding of managing long-term conditions. Shared learning & peer networking

40. Enablers Full team & stable workforce Dedicated staff time for PDSAs and QI Clinical champions Regular practice team meetings & good internal communications Use of PDSAs Access to population audit tools with immediate feedback Support from Improvement Foundation Australia Strong collaborative/partnership approach between DHB team, facilitators and practices

41. Challenges Practice level Staff changes, time Variable senior management support PHO level Changes in facilitators Added to existing roles Insufficient funding to have dedicated role, unless pooled over all PHOs DHB level Challenge of working with multiple PHOs Complex, fragmented environment - 2009 BSMC, H1N1, Labtests, measles, budget cuts++

42. Lessons Skill and capacity of facilitators – very important Practices slow to engage until data added value Measures must be relevant and timely (changes can be seen monthly, rather than data 6-9 months old) Need population audit tool in place before you start! Preferable to all have same pop audit tool to ensure you are measuring the same thing Practice teams – generally older, IT skills variable Can challenge debate of clinical autonomy vs standardisation with good data

43. Recommendations & Policy Implications Consider practice coach approach Does need to be funded appropriately Opportunity to develop regional approach Link in with LTC Conference – 7-8th April, 2011 Workforce development training Development of a regionally agreed shared care plan National Shared Care Plan Programme Support long-term conditions clinical network

44. Opportunities for improving chronic care Population audit tools Benchmarking Shared decision making – decision aids Standing orders Decision support tools at point of care Pre-visit triage with online or automated telephone diagnostic software Electronic shared care plan – 24/7 access Information therapy

45. Further Information and Presentations on Collaborative Website http://sites.google.com/site/equippedsite/

46. Discussion Photo

47. Acknowledgements Expert Advisory Panel General practice teams Facilitators & PHOs for joining us on this journey ADHB Ministry of Health

48. http://www.microsoft.com/showcase/en/us/details/5c32ceab-40c7-496a-be42-39d4d69fbc12