20,000 Days Campaign StoryboardLearning Session 3, 11-12 March 2013

Better Breathing Programme Collaborative

Clinical Leads: Sarah Candy & Fiona Horwood

Team: Jen Mepham, Charulata Kulkarni, Prof Harry Rea, Fiona Smyth, Samuel Menia, Barbara Lambert, Meg Goodman, Rose Ikimau, Michelle Mills, Ta-Mera Rolland, Richard Small, Sarah Mooney

Project Manager: Alison HowittImprovement Advisor: Prem KumarDecision Support: Penny Wilkings

Aim

• The aim of this project is to keep more people with chronic respiratory disease well in the community by increasing the number of participants enrolled into Better Breathing (community based pulmonary rehabilitation) from 60 to 250 per year.

This will result in;

a reduction of unplanned admissions, increased exercise tolerance and improved health related quality of life.

Driver Diagram

- Include Collaborative Driver Diagram

Change Packages

2O Drivers(Theory of change)

Change Ideas Tested

(describe process)

Evidence of Improvement

Access & Community

Community Location and Venue

Transport options

Attendance & Feedback

Access & Community

Patient Engagement

GP support and involvement

Supporting attendance for Maori and Pacific patients

Attendance & Feedback

Identifying patients

Referrals

Assessments

Waiting List, drop outs & starting programme

Change Packages

2oDrivers(Theory of change)

Change Ideas Tested

(describe process)

Evidence of Improvement

Programme Programme Content

Sessions and format

Equipment

Speakers

Clinical outcome assessments

Based on current research, modifications based on testing, user feedback.

Combined Programme

Healthy Hearts – Heart Failure Patients

Initial set up phase.

Most Successful PDSA Cycles?

- Include PDSA Tree diagram

Most Successful PDSA?

Act Plan

Study Do

• Additional pulmonary rehabilitation programme into the community

• Otara• Pukekohe

• Programmes need to be design to suit the community they serve and each community is different.

• Having the flexibility to provide programmes tailored to the patient demographics is essential for best outcomes

• Identify & secure venues• Supply equipment• Design programme• Engage Community• Identify patients• Arrange staffing &

speakers• Start programme

• Continue to refine and measure the programmes.

• Offer as a Franchise model with flexibility to suit patient demographice

Measures Summary

• Outcome Measures– The number of patients enrolled in each community Better

Breathing programme– The number of unplanned hospital admissions

• Process Measures– The number of referrals to Better Breathing– The number of participants who start Better Breathing – The number of participants completing the programme– The change in distance walked on 6 minute walk test– The change in health related quality of life questionnaire

scores

Implementation

Implementation Areas

Changes to Support Implementation

PDSA cycles

Standardisation Developing Process Map

Programme Guidelines

Developed Otara, To some extent tested in Pukekohe

Documentation Plan to create a franchise “options” document giving examples as case studies

Training Developing training materials Testing on new staff

Measurement Produce and monitor guideline measures, covering clinical outcomes, patient drop out and completions targets.

Resourcing Information on ideal venue, staffing and equipment in Franchise document.

Adapted from “The Improvement Guide. A Practical Approach to Enhancing Organizational Performance” Gerald Langley et al., 2009, p180.

Highlights and Lowlights

Highlights- Accessibility – patients report they are now able to attend a

programme- Patients feel safe and supported in a familiar environment

which is in the heart of their community- As a whole, the pulmonary rehabilitation service is able to offer

an increased number places on the programme (240 – 450)- Increased profile of pulmonary rehabilitation in South Auckland

Lowlights- Recruitment of staff - Practise nurse involvement in Otara- Pukekohe site size and availability

Achievements to date

Moving Pulmonary Rehabilitation to the community

Venues, equipment, programme, speakers, referrals, assessments, staff, speakers, advertising, patient information, cultural support

Starting the Better Breathing Programme in Otara (running for 7 months)

Starting the Better Breathing Programme in Pukekohe. (4 intakes)

Testing and refining everything while we are doing it.

Learning from the patients and the community

Co-ordinating all the various groups, departments, stakeholders and people.

Thank you to everybody that has been involved

20,000 Days Campaign StoryboardLearning Session 3, 11-12 March 2013

Better BreathingClinical Pathway

Clinical Leads: Fiona Horwood, Richard Hulme

Team: Katie Coulter, Nicola Corna, Diana Hart, Sue Beaumont-Orr, Michelle Mills, Ta-Mera Rolland, Richard Small

Project Manager: Alison HowittImprovement Advisor: Prem KumarDecision Support: Tanesha Patel

Aim

• The overall aim of the Better Breathing Collaborative is to work together with the Counties Manukau Community to help people with breathing problems to manage their condition well in the community.

• This will be accomplished by •Providing community based pulmonary rehabilitation, for 250 in Otara and Pukekohe.

• Introducing a COPD care bundle for patients with a primary diagnosis of COPD patients in Middlemore Hospital.

• Increasing the numbers of COPD patients, identified in primary care and by piloting the introduction of an “early diagnosis primary care bundle.”

Driver Diagram

- Include Collaborative Driver Diagram

Primary Care Change Packages

2o Drivers(Theory of change)

Change Ideas Tested Describe Process

Early Diagnosis

Primary Care Bundle The receptionist gives a CAT survey to a patient who is 40y+, is a smoker or ex-smoker & doesn’t have known asthma. The CAT survey has been incorporated into a decision support tool in the GP Patient Management System. GP act on the information provided by the patient

Clinical Pathway

Primary Care COPD Pathway CME

Roll out CME course developed by Clinical Pathway Group and ProCare. Focus on spirometry and WOF.

Primary and Secondary Change Ideas to be tested

2o Drivers(Theory of change)

Change Ideas

(describe process)

Evidence

Secondary care bundle has been developed and tested, using the “pink” form

Further evidence is required

Winter warrant of fitness for target patients

Options for spirometry in the community• Practices/Shared Group of Practices

• Locality Hub

• Alongside Better Breathing Programme

• Huff and Puff Bus

Most Successful PDSA Cycles?

Based on UK developed

Care BundleTested Resp

Ward

Order changed Y/N added

Tested Resp Ward

Further info added for non Resp wards

Tested on Gen Ward

Referral Check box, sign & date

added Tested Resp &

Gen Ward

Re-think and Simplify

Tested Resp Ward

One box removed, not

enough patients to test

Tested Resp Ward & Gen

Ward

Testing continues and we’ve

learn’t a lot

Measures Summary

- Measures related to Aim- Graphs of key measures

- Which of your run charts would you give to senior leadership to use?

- Include Collaborative Dashboard

Measures Summary

Outcome Measure • Unplanned admissions to Middlemore Hospital• Length of Stay in Middlemore• Readmission rate

Process Measures • Numbers of patients identified with COPD in primary care. • Numbers of patients receiving all or parts of early diagnosis primary

care bundle. • Numbers of patients offered, attending and completing community

based pulmonary. • Numbers of patients receiving discharge care bundle.• COPD patients by localities

Highlights and Lowlights- Highlights

- Working across primary and secondary care.

- Forming, what has become the COPD Team to work on the secondary care bundle.

- Having the opportunity to review best practices, adapting and testing them for our patients and community.

- Partnering with Auckland & Waitemata DHB’s for the COPD primary care pathway.

- Sharing ideas and learning’s with Northland DHB and Canterbury

- Lowlights

- The challenges of testing when there are no patients.

- Finding a meeting time that everybody can attend.