Improving Quality - Annual Plan Guidance 2020/21Quality improvement should be an integral part of the DHB Annual Plans. Quality improvement is the use of methods and tools to try to continuously improve quality of care delivered and outcome for patients. The Institute of Medicine (IOM) outline six domains of health care quality: safe, effective, patient-centred, timely, efficient and equitable. Quality and cost of health care delivery are closely related and health care systems across the world have improved their performance by working collaboratively with all parts of the system to focus on making the health care delivery effective, efficient and sustainable.

The New Zealand Triple Aim, which provides the platform for improving quality, is based on the Institute for Healthcare Improvement (IHI) Triple Aim framework and encompasses the IOM’s six domains of health care quality. Its primary goal is to: Improve the quality, safety and experience of care; Improve the health and equity for all populations; and Best value for public health system resources. A focus on all three dimensions simultaneously, at a system level, is needed to achieve systematic improvement for delivery of high quality care and better patient and population health outcomes. There are a range of methods and tools available for quality improvement. The Ministry does not endorse any method as long as DHBs have a systematic approach to quality improvement that is used consistently and provides the intelligence and analytics needed for the district alliance to undertake the continuous improvement function.

Improving quality of health care can deliver on all three of the Government commitments:A. Ensure everyone who is able to, is earning, learning, caring or volunteering – actions to improve

health that allows people to participate in the broader educational (including early childhood education) and vocational/employment environment.

B. Support healthier, safer and more connected communities – actions to improve access, population health and personal health, particularly across government agencies to address the social determinants of health (eg justice, education).

C. Ensure everyone has a warm, dry home – actions that particularly improve homes.

Improving quality is at the heart of the work of the Health Quality and Safety Commission (the Commission) through programmes such as Atlas of healthcare variation, Partners in Care programme, Quality and Safety Markers, and building sector capacity and capability for quality improvement and safety.

For the Ministry, the System Level Measures (SLM) programme provides the national framework for system improvement.

This guidance brings together the work of the Commission and the Ministry to provide DHBs and their health system partners a strong impetus for recognising the value of system improvement and shifting resources accordingly to deliver on the key priorities and meet the goals of the Triple Aim.

System Level Measures ProgrammeImplementation of the SLM programme continues in 2020/21. The Guide to Using the System Level Measures Framework for Quality Improvement (SLM guide) should be used for the development of the Improvement Plans.

The SLM Annual Plan guidance complements the SLM guide and provides detailed expectations for 2020/21 Improvement Plans and PHO payment details.

The SLM programme provides the national framework from which to deliver on the Government’s priority of Improving the well-being of New Zealanders and their families. This priority aims to provide equitable access to healthcare, and a healthy and safe home and community environment that ensures New Zealanders can realise their potential. Achieving this goal requires an acknowledgment of the social

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determinants of health, a commitment to achieve equity and the drive to productively work with not only within the health system (hospitals, primary care, community and NGOs) but across government agencies such as education, justice, housing and social development. Collaborative way of working through district alliances, the underpinning enabler for the SLM programme, is an ideal forum to engage all the appropriate parties in discussions based on robust analytics that look at equity, identify service gaps and designing system-wide services that improves the wellbeing of New Zealanders and their families.

SLM programme provides a framework for continuous quality improvement and integration across the health system. Equity gaps for Māori and Pacific populations are evident in all SLMs and in nearly all districts. This programme provides a great opportunity for DHBs and PHOs to work with health system partners in their district to address equity gaps, one of the government priorities. Where equity gaps exist, the district alliances are expected to focus their improvement milestone, quality improvement activities and contributory measures specifically to address these gaps.

Insights from previous Improvement PlansThere are a few areas that generate a lot of discussion during the approval process of the improvement plans. There was a subtle change in the alliance ‘atmosphere’ that came through in these discussions. We are keen to reset the balance to ensure that the core alliance philosophy and principles stay at the forefront. As part of our continuous learning journey for the SLM programme, and particularly as the programme and relationships begin to become embedded as ‘business as usual’ in some districts, we share some of the key messages coming through the SLM Improvement Plan approval process.

With this programme, we are trying to shift behaviours in a complex system that has many parts; each of which is influenced by people that work in the system and people who use the system. Therefore, it is important to acknowledge upfront that development and implementation of the SLM plan is hard work and is dependent on local relationships, trust, connections, and capacity and capability for improvement. These build over time and whilst the improvement plans are annual, there should be a long term view on the philosophy of the SLM programme. It is important to continue to work on building the right environment for system improvement and shift the focus away from providers and professionals to the people who use the system and the entirety of health system rather than just its component parts.

With this shift in focus comes an inevitable emphasis on consulting with consumers and communities in the planning and implementation of service improvement. One of the ways that services can demonstrate partnership is by implementing principles of co-design and seeking advice and input from for example DHB consumer councils. Of necessity this advice should be sought before decisions are made and reflected in the annual plans. Engaging with consumers should take place at all levels of health service delivery: direct level of care, service planning and policy, and governance. It is important that services work in partnership with consumers to co-design solutions to everyday system challenges.

Clinicians need to lead the development of the improvement plan and be enabled by the district alliance to engage with the broader health system. Our observation was that in some of the districts, the improvement plan was developed by the Planning and Funding Units of the DHB and then consulted on with PHOs and other health system partners. We acknowledge that in most districts the Planning and Funding Units (in particular the primary care portfolio managers) are expected to lead this process, and we are very thankful for this resource and the time and effort invested in the process. However, the SLM programme presents an opportunity for a different way of working for all of us, including the Ministry, and we would like this process to continue to have a collaborative and participatory approach which underpins the philosophy of the programme.

It is important to understand how to effectively use improvement science methodology, and the difference between the activities and contributory measures. Choosing the contributory measures first, as some alliances are doing, often means the actions are already current activity that is, in many cases, related to

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PHO payments, or the actions are retro-fitted to the contributory measure. In either case, improvement of the milestone is not the driving focus. The recommended improvement science methodology is to:

o Identify the area of focus for the SLM (define the problem)o Agree the improvement being sought (improvement milestone). An improvement milestone

should be Specific, Measurable, Achievable, Realistic and with a Time set for completion (SMART).

o Identify the quality improvement activities that will achieve the milestone. The activities should be Specific, Measurable, Achievable, Realistic and with a Time set for completion (SMART).

o Select contributory measures that will enable the alliance to monitor local progress against the activities. Balancing measures should also be considered to monitor that the improvement does not disadvantage any group or increase inequities.

Description of activities

These should be short bullet points that clearly describe what frontline action will be undertaken over 12 months to impact the milestone. It should avoid words such as ‘explore, investigate, expand etc’. It should be easy to see the clear deliverable. Analysis of data to define the problem should be part of the plan development and not as an activity as data analysis is unlikely to impact the milestone and is expected to have been done previously to inform development of the improvement plan. Ideally this process should be co-designed with clinicians, consumers, Māori and local communities.

Line of sight between the milestone, activities and contributory measures

The SLM plan is not the place to list all the activities currently being undertaken by the DHB and PHOs in the subject area. The plan should have clear logic to the activities that will be undertaken to achieve the improvement milestone which is based on local population health needs and service configurations. The activities selected should be informed by evidence that implementing them will have the desired effect.

Other strategic documents such as the district annual and strategic plans, and PHO quality plans maybe a useful resource as these include health needs assessment, service configurations and future direction of travel for the district. The SLM plan may provide a useful mechanism to implement some of the activities already identified in these plans.

Keeping the plan realistic and achievable

We would rather the alliances choose a few activities to focus on each year and deliver on these. At the end of the year, the alliance should reflect on whether the activities had an impact on the milestone and if not, why not and what should be done differently the following year (PDSA cycle). Some of the plans have had the same activities for consecutive years and are not clear on whether these have been delivered and had an impact on the milestone. The Ministry will be questioning the inclusion of these actions in the 2020/21 plans.

Current System Level MeasuresAt this stage there are no plans to change the System Level Measures and focus remains on the philosophy of the programme. We will continue with the current six measures:

1. Ambulatory sensitive hospitalisations (ASH) rates for 0 -4 year olds2. total acute hospital bed days per capita3. patient experience of care using the Commission’s national adult hospital and primary care patient

experience surveys 4. amenable mortality rates5. babies living in smokefree homes 6. youth access to and utilisation of youth appropriate health services.

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The Measures Library contains the definitions for all SLMs and contributory measures. SLMs are nationally defined and must be used to set the improvement milestones.

Contributory measures are used to monitor local accountability for the SLM plan. These should clearly identify how the alliance will measure local progress against the quality improvement activities. Contributory measures generally have clearly defined numerator and denominator. Districts may refer to the Measures Library for commonly used contributory measures. However, if the contributory measures available in the library are not suitable, districts may choose to use other measures that will enable them to monitor local progress.

District alliance expectationsDistrict alliances are responsible for leading the implementation of the SLM programme. Ideally each DHB should have one alliance, made up of multiple service level alliances (SLAs) that include perspectives from all partners providing health services in that district and the communities they serve.

District alliances are expected to focus on their district level population when developing improvement plans. Form and function of alliances vary across the country with some being a partnership of the DHB of domicile and its PHOs only. Others have much broader alliance partners that include consumers, ambulance, pharmacy, midwives, Well Child Tamariki Ora providers, public health units etc.

Given the maturity of the SLM programme and with the addition of two new SLMs, the Ministry is expecting the alliance leadership teams to have a broader membership than DHB and PHOs. The Improvement Plan should demonstrate how the alliance has involved their patients and communities, Māori and Pacific health teams, maternity, ambulance, pharmacy, Well Child Tamariki Ora providers and youth health providers (such as Youth One Stop Shops and school-based nurses) in the development and implementation of the SLMs.

DHBs, on behalf of their district alliance, submit the Improvement Plan to the Ministry.

Improvement Plan RequirementsThe SLM Improvement Plan is still part of the DHB Annual Plan, though it should reflect the thinking, participation and decision making of the entire alliance. However, as we also have to meet the contractual requirements for PHO payments, the dates for SLM improvement plan submission, assessment and approval are different than those for the rest of the DHB Annual Plans. The Ministry expects the first draft of the plan to be submitted in April. In order for the 50 percent capacity and capability payment to be made as agreed in the PHO Services Agreement, the final draft of the SLM Improvement Plan has to be submitted to the Ministry by 1 July and approved by the Ministry by 31 July. This allows sufficient time for payments to be calculated, funds drawn down and paid into DHB accounts by 5 September to be paid to PHOs on 15 September.

The Improvement Plan must include:

Improvement milestones that states ‘what’ is to be improved, for which population group and by how much, a number that shows improvement (either for Māori, total population, or a specifically identified population to address equity gaps) for each of the six SLMs.

Brief description of activities to be undertaken by all alliancing partners (primary, secondary and community) to achieve the SLM milestones. Evidence that underpins your rationale and theories for selecting activities should form part of your local project plans. The local project plans are not required to be submitted to the Ministry but should be used by the project teams and the district alliance to understand the theory behind planned activities and is useful for learning from both success and failure and assists replication and spread if successful.

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Contributory measures for each of the six SLMs that is chosen by the district alliance based on local needs, demographics and service configurations that enables the alliance to measure local progress against the SLM activities.

Signatures of all district alliance partners (eg district health boards, primary health organisations, Well Child Tamariki Ora providers, youth one stop shop, ambulance, pharmacy) to demonstrate an integrated and partnership approach to the development and implementation of the improvement plan.

Improvement Plan assessment by the MinistryQuestions and Answers on the Ministry website provide further information on what the Ministry is looking for when assessing and approving the Improvement Plan, in particular questions 6-11.

Past experience has shown that an iterative process starting early with the first draft is useful. This is a complex programme and there is usually a lot of discussion and analysis at the district alliance and working group levels to inform the plan which may not be included in the plan. District alliances are encouraged to share early drafts of their plan with the SLM National Programme Manager and Clinical Lead at the Ministry or involve them in the local discussion. The Ministry may request teleconferences and/or face-to-face visits with district alliances to understand the development of the Improvement Plans.

The Ministry would like to facilitate a collaborative approach with the development and implementation of the SLMs by sharing Improvement Plans and alliances’ stories through the Nationwide Service Framework Library (NSFL) . All the final approved Improvement Plans will be published on the NFSL website.

Quality improvement approachUsing improvement science methodology, the recommended process is:

1. Formation of working groups for each SLM that at the minimum includes clinical, managerial and analytic expertise from across the primary, secondary and community care.

2. Examination of SLM data, both at aggregate and NHI level to understand what is driving local SLM rates to define the problem. This enables the district alliances to: understand the health needs of their population; identify patients and population groups that experience disparity in access to healthcare and health outcomes; and target their activities and investment to provide equitable health care and improve their health outcomes. The SLM guide provides tools and approaches that could be used for this process.

3. Identifying the improvement milestone. If there are equity gaps, the milestone should focus on reducing these gaps.

4. Identifying the activities that are planned to achieve the improvement milestone. These activities should show a clear deliverable, be practical, achievable in one year and targeted to the local population needs. This process should be led by clinicians with input from consumers and local communities.

5. Choosing the contributory measures that will enable the district to monitor local progress. The contributory measures should be measures with defined numerator, denominator and data source that will enable you to report progress on activities to the district alliance. They are not the goals of the activities and are not reported to the Ministry.

6. A final review to ensure a clear line of sight between the improvement milestone, quality improvement activities and the contributory measures.

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SLMs – in detailAmbulatory sensitive hospitalisations (ASH) rates for 0 - 4 year oldsThe top four conditions contributing to the national ASH 0-4 year old rates remain the same: respiratory, dental, skin and gastroenteritis. There are large equity gaps, particularly for Pacific people. The Ministry is providing unencrypted NHI level data for districts, by DHB and PHO. The district alliances are expected to form a working group that brings together clinical, managerial and analytic expertise from across the health system (primary, secondary and community care that includes pharmacy and ambulance) to examine their data, understand the top conditions contributing to ASH rates for 0-4 year olds in their district, identify equity gaps and focus their improvement activity on reducing equity gaps for Māori and Pacific populations. ASH is related to broader social determinants of health such as housing and poverty and therefore the Public Health Units can support this measure through their advocacy and public health policy activities. The improvement milestone can focus on improving an ASH condition for a specific population group.

Resources: Asthma atlas of healthcare variation, presents variations analysis up to end of 2017, including for 0 – 4 age group: www.hqsc.govt.nz/atlas/asthma

The dashboard of health system quality brings together a wide range of measures in one place. Childhood ASH data are presented on the ‘effectiveness’ tab.

Investigating the rates and spatial distribution of childhood ambulatory sensitive hospitalisations in New Zealand: https://ir.canterbury.ac.nz/handle/10092/16898

Total acute hospital bed days per capitaThis is a measure of acute demand and patient flow across the health system. The over 65 years age group are the biggest contributors of bed days and there are equity gaps for Māori and Pacific populations. The Ministry provides unencrypted NHI level data for districts, by DHB and PHO. Similar to ASH, district alliances are expected to form a working group that brings together clinical, managerial and analytic expertise from across the health system (primary, secondary and community care that includes pharmacy, aged residential care and ambulance) to:

examine their data understand the top conditions contributing to bed days in their district identify and understand how each part of the health system in the district contribute to this SLM identify and understand the system enablers and barriers identify equity gaps work with partners from across the health system to determine improvement milestone, activities and

contributory measures.

The improvement activities should focus on improving access to enhanced primary and community care (eg improving primary care’s access to diagnostics and services), and patient flow across the whole health system (before and after the hospital admission – including effective discharge planning), especially for Māori and Pacific populations.

Patient experience of careThis measure uses the Commission’s national adult inpatient and adult primary care patient experience survey tool, data collection and reporting system. The adult inpatient survey has been running since 2014 and the primary care survey has been gradually implemented since 2016. Reports are published on the Health Quality & Safety Commission website .

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Both surveys have been developed and are administered by the Commission. The surveys cover the four key domains of patient experience: communication, co-ordination, partnership, and physical and emotional needs. The surveys provide a nationally consistent approach to the collection and use of patient experience information.

The focus of this SLM is for alliances, DHBs, PHOs and practices to review and understand their survey results; and use the results to improve delivery of quality and coordinated care. A guide From PES to PDSA, published by the Commission, outlines the steps for PHOs and practices to identify quality improvement activities using the patient experience reporting portal.

Improvement milestone and activities for this SLM should focus on:

questions that highlight inequities for Māori, Pacific and other high priority populations. The health service access Atlas provides a useful overview of differences in responses by age group, gender, ethnicity and DHB to seven key questions in the primary care survey.

groups of questions in the domains that highlight an issue eg: access to services, health literacy, medication reconciliation and adherence, flow of information between PHO/practice to specialists or hospitals

low scoring questions from the adult inpatient survey.

The Commission has published two reports investigating the consistently low scoring areas of the adult inpatient survey. Applying behavioural science principles, the Commission worked with Ogilvy and three DHBs to develop ‘nudges’ to respond to the low scoring questions and recommend interventions to improve these results. These reports are available: Raising the bar on the national inpatient experience survey and Phase two: Co-designing nudges.

In addition, three short videos have been produced explaining these projects and the principles behind them. This can be accessed here. The sustainability and spread of these interventions will be followed over time.

The Atlas of Healthcare Variation exploring health service access reports on responses to seven questions in the 2018 primary care patient experience survey. These questions were selected as being key for understanding patient’s experience of accessing and using health services and key areas for improvement. For example, young people are more likely to report a time in the last year when they wanted health care from a GP or nurse but couldn’t get it.

Results from the New Zealand Health Survey could also be used to supplement the information from the patient experience surveys.

Improvement milestones focusing on participation and response rates will not be accepted for this SLM.

The following additional resources relating to the survey can be found on the Health Quality & Safety Commission website :

Videos available in English, te reo Māori, Samoan and Tongan that can be played in practice waiting rooms to inform patients about the survey

Poster for your clinic waiting room to display during survey week (print ready) Flyers promoting the survey available in English, te reo Māori, Samoan and Tongan The survey tool and its development The Privacy Impact Assessment The survey timetable Frequently Asked Questions.

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Amenable mortality rates The Guide to using Amenable Mortality as a System Level Measure has been updated and explains the concept of amenable mortality, how it is measured, and how this measure can be used to improve health system performance and reduce health inequity for Māori and Pacific.

Whilst the equity gap between the Pacific and Māori populations have reduced, the gap between Māori, Pacific and total population remains. District alliances can set a long term milestone for this SLM (eg improvement to be achieved over three or five years) and are expected to focus their improvement milestone, quality improvement activities and contributory measures on reducing the equity gap for amenable mortality rates for Māori and Pacific populations.

Babies living in smokefree homes The amended definition of the measure, effective from 1 Jan 2019 is:

Numerator: number of new babies, up to 56 days of age, with ‘No’ recorded for their WCTO contact question: ‘Is there anyone living in the house who is a tobacco smoker?’ (source: WCTO data set)Denominator: number of registered births by DHB of domicile (source: Ministry of Health NHI register).

Focus of the district alliances should be: broadening the membership of the district alliance or establishing service level alliances for child

health that include WCTO provider and maternity perspectives supporting DHBs to work with their WCTO partners to implement the new data standard so that

there is confidence in the data collected reviewing all the data available to understand smoking prevalence in their population, in particular

for Māori identifying areas of focus for improving accuracy of data collection reducing babies’ exposure to tobacco smoke through collaboration between the services focussed

on child health and smoking cessation, and training and resources for frontline child health workforce (WCTO nurses and lead maternity

carers) so they are confident in assessing household smoking status, offering whānau support to quit smoking and knowing where to refer for cessation support.

The new data standard and the changes to the measure definition will enable district alliances to: improve enrolment in the WCTO service improve engagement for those enrolled to ensure all babies receive their first core check improve the capture of household smoking status improve understanding of smoking prevalence by reviewing data collected by other parts of the

health sector (for example, DHBs, PHOs and maternity), and identify focus areas for smokefree initiatives within infant and child health services and tobacco

programmes.

Resources available are: new data standard (available on the Nationwide Service Framework Library) new measure definition (available on the Measures Library) new DHB rates based on new measure definition (available on the Nationwide Service Framework

Library) intervention logic (available on the Nationwide Service Framework Library) frequently asked questions (available on the Nationwide Service Framework Library).

Youth access to and utilisation of youth appropriate health services This SLM is made up of five domains with corresponding outcomes and national health indicators. Further information is available on the Ministry website.

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The Youth Service Level Alliance Teams should lead the implementation of this measure. This team needs to ensure that there is perspective from all appropriate youth health providers (such as Youth One Stop Shops and school based nurses) and youth from their district to understand the needs of their population and choose the appropriate domain to focus on. The alliance is expected to choose at least one domain and use the corresponding national indicator to set their improvement milestone. For example, if the team decides to focus on ‘alcohol and other drugs’ domain, their milestone will be set using the ‘alcohol related ED presentations’ indicator. There needs to be a clear line of sight between the population need, domain, national indicator, activities and contributory measures.

Quarterly ReportingDHBs are responsible for submitting the quarterly reports on behalf of their district alliance, as part of the regular quarterly reporting process, through the DHB quarterly reporting database. The report should reflect the alliance perspective and not individual provider perspective.

Quarters one, two and three – the alliance reports whether they are on track with the implementation of their Improvement Plan. If the alliance is not on track, the report must include mitigation plans to get back on track. This may include changes to their Improvement Plan (such as changed actions or new timeframes for current activities), in agreement with the Ministry. These reports will be assessed by the Ministry and feedback provided via the DHB quarterly reporting database. DHBs are expected to share this feedback with the appropriate part(s) of their alliance.

Quarter four – performance against the implementation of the Improvement Plan and whether the improvement milestone was achieved by the alliance. If the Improvement Plan was not fully implemented and/or the milestone was not achieved, the report should include clear and reflective thinking from the alliance on how the Improvement Plan was developed and implemented, reasons for not implementing the plan or achieving the milestone and insights from the year that will be used for development and implementation of following year’s plan.

Reporting templates (including examples of mitigation plans and year end reflections) are available on the Nationwide Service Framework Library.

PHO financial incentives for 2020/21The PHO financial incentives, especially for the first and final 25 percent, is expected to be negotiated with PSAAP in the new year. An update will be provided at the conclusion of PSAAP negotiations.

Additional resourcesThe following information can be found on the Nationwide Service Framework Library:

• the Guide to using the System Level Measures Framework • the Guide to using Amenable Mortality as a System Level Measure• System Level Measure Improvement Plans• examples of different alliance approaches to development and implementation of System Level

Measures Improvement Plans• trend data for the System Level Measures.

There is also SLM information including Questions and Answers, and SLM in a nutshell brochure available on the Ministry website. The SLM brochure explains SLMs in plain English and is a useful tool for communicating with clinicians and board members.

Atlas of Healthcare Variation: suggested focus topics

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Gout: www.hqsc.govt.nz/atlas/gout

Diabetes: www.hqsc.govt.nz/atlas/diabetes

Asthma: www.hqsc.govt.nz/atlas/asthma

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