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Research Project Report - University of Tasmania · Research Project Report “Implementing self...
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Research Project Report
“Implementing self management into chronic disease care: Mapping an
organisational and systems approach through the North West Area Health Service,
Tasmania”
Maree Gleeson- University of Tasmania Rural Clinical School
Sharon Griffiths – Department of Health & Human Services Population Health
Background
The NWAHS is incorporating strategies to encourage an organisational and systems
change to the management of chronic disease. By incorporating strategies to
encourage a ‚self management‛ approach to health and disease management the
NWAHS is endeavouring to facilitate the way in which health professionals work to
ensure that the client is at the centre of decision making for their health care. An
important aspect of this process is the role that senior managers play in leading this
change. Their understanding and perceived level of organisational support will play
an important role in executing these changes. The study will utilise the ‚Navigating
self management manual: A practical approach to implementation for Australian
health care agencies‛ (2007 DOHA) document which emphasises the important role
that organisational leaders play in facilitating this shift and outlines the strategies
required to ensure success.
It is anticipated that results from this study will assist in providing feedback to
managers, senior executives of the Service and general staff to illuminate the areas of
change that need to be addressed. It will also provide valuable base line data on
perceived organisational status against which to measure future changes. In turn
this information will allow for reflection on strategies that are important in
contributing to organisation and systems changes in relation to chronic disease self
management.
Aims:
To determine perceptions of senior managers and selected key staff to the
preparedness of the North West Area Health Service (NWAHS) in
implementing a chronic disease self management approach to health care.
To gain an understanding of the perceived enablers and barriers to facilitate
implementing self management into chronic disease care.
To ascertain the views that managers have toward the implementation of the
DHHS Strategic Directions which reflect the principles of chronic disease self
management principles.
To map the processes undertaken by the NWAHS in implementing chronic
disease self management into the organisation.
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Participants
Participants of the research will be selected from the DHHS North West Area Health
Service. These groups include:
Phase 1:
- All managers invited to attend the ‚Embedding Chronic Conditions Self
Management into Systems and Organisations‛ workshop being organised by
DHHS Population Health.
Phase 2:
- Volunteers from the senior management group and key staff at the NWAHS.
The above groups have been chosen because they represent most closely the cohort
of staff that have been deemed to be important in influencing and managing
organisational and systems change in chronic disease self management as purported
by the ‚Navigating self management manual: A practical approach to
implementation for Australian health care agencies‛ (2007 DOHA).
Their view of the organisations preparedness for change and the enablers and
barriers to execute the strategy are important variables to consider for future
development of health services.
Because of the nature of the research there is no control group, however there is a
possibility that the research will be repeated in the future and data from this project
used as baseline to measure change over time.
Brief outline of methodology:
Phase 1: An anonymous survey (developed on SurveyMonkey) was sent to senior
managers and key staff involved in strategic planning of chronic disease care from
the NWAHS. The survey was based on the principles of chronic disease
management as indicated in the ‚Navigating self management manual: A practical
approach to implementation for Australian health care agencies‛ (2007 DOHA).
The first part of the survey consisted of 23 items (Appendix 1) combining questions
answerable on a 5 point Likert scale with an additional ‘not sure’ option and open
ended responses. It explored attitudes towards the variables that impact on
systems and organisational change and how this relates to the NWAHS. The second
part of the survey consists of a 5 item 5 point Likert scale with an additional ‘not
sure’ option and open ended responses. These questions related to the strategic
directions of the Tasmanian Health Plan and how the NWAHS aligned with these
principles.
Phase 2: This involved interviews with 7 managers/key staff who identified their
willingness to partake. The semi structured interviews included 8 key questions
(Appendix 2) to collect qualitative complimentary data.
Phase 3: This related to a mapping exercise of education, training and organisational
activities relevant to facilitating systems change related to chronic disease self
management. This will take place following discussion with NWAHS CEO
regarding Phase 1 and 2 of the research.
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Results - Phase 1
Chart 1: This chart shows that more than half of the participants indicated that the
NWAHS provides leadership investment (at the top level) at least somewhat or quite
well with an average score of 2.6 (or below) out of 5 on the Likert scale
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Chart 2: This chart indicates that more than half of the participants perceived the
NWAHS as taking a system approach somewhat or not at all with an average score
of 2.6 (or below) out of 5 on the Likert scale
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Chart 3: This chart indicates that more than half of the participants perceived the
NWAHS to provide training ‚not at all’ or ‚somewhat‛ with an average score of 2
(or below) out of 5 on the Likert scale
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Chart 4: This chart indicates that most participants perceived the NWAHS as
empowering action through working groups ‚not at all‛ or ‚somewhat‛ with an
average score of 2.7 (or below) out of 5 on the Likert Scale
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Chart 5: This chart indicates that most participants perceived the NWAHS as not
embedding chronic disease self management into strategic service planning with an
average response rate of 2 out of 5 on the Likert scale
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Chart 6: This chart indicates that most participants perceived the NWAHS as not
taking a regional approach to support chronic disease self management with an
average score of 2 (or below) out of 5 on the Likert Scale
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Chart 7: This chart indicates that most participants perceived the NWAHS using an
evidence base ‚somewhat‛ or ‚not at all‛ to support chronic disease self
management with an average score of 2.6 (or below) out of 5 on the Likert Scale
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Chart 8: This chart indicates that most participants perceived the NWAHS as either
not engaging General Practice or not being aware of engaging General Practice to
support chronic disease self management with an average score of 2.3 (or below) out
of 5 on the Likert Scale
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Chart 9: This chart indicates that just over half of the participants that responded
perceived the NWAHS as meeting the strategic objective of supporting individuals,
families and communities to have more control over what matters to them.
Chart 10: This chart indicates that more than half of the participants that responded
perceived that the NWAHS as only ‚somewhat‛ or ‚not at all‛ fulfilling the strategic
objective of promoting health and wellbeing and intervening early when needed
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Chart 11: This chart indicates that most participants that responded perceived that
the NWAHS was fulfilling the strategic objective of developing responsive,
accessible and sustainable services
Chart 12: This chart indicates that just over half of the participants that responded
perceived that the NWAHS was fulfilling the strategic objective of creating
collaborative partnerships to support the development of healthier communities.
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Chart 13: This chart indicates that just over half of the participants that responded
perceived that the NWAHS was fulfilling the strategic objective of shaping our
workforce to be capable of meeting changing needs and future requirements
Results – Phase 2
Themes from CDSM Research
CDSM Framework:
1. Leadership investment (at the top level)
2. Taking a systems approach
3. Invest in training
4. Empowering action through working groups
5. Strategic plans, work plans and position descriptions
6. A regional approach
7. Use an evidence base
8. Engage General Practice
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CDSM
Frame-
work
Themes / Comments Quotes
2, 3, 5 A range of training offered and
undertaken by interested health
professionals in various units and
departments / small pockets. However
with no strategic plan in how to
implement this further (deeper and
wider – in a more integrated way in
care but also across units and for
patients).
‚…but I actually want to start looking at how
[training] works from practical level and I think
once you’ve got that it’s better to see where
you’ve got to go from a leadership perspective
and how you can get people there‛
1, 2 There is strategic intent but no long
term planning for strategic direction,
some of this is due to competing
demands for example the Tasmanian
Health Plan, delivery of clinical
services, health reform, separation of
primary health from acute care
services.
‚….all talks about moving forward for chronic
disease but at this stage, as I said, it’s just tiny
little steps that we see any improvement‛
‚…. From the top down we’ve got to have more
of a drive, you know its like the chronic disease
framework that’s come out and the fact that
we’re just about to go through this
implementation phase of it and yet I don’t feel
like it’s really being drive down from the top‛
‚…the approach is so much *about+ problem
solve, get the person out‛
‚…I think primary health is a much easier setting
where people are going into their homes or you
know there’s longer appointments in the
community setting rather than, you know
eighteen patients a day that we see here, well,
we’ve got to get them out as quickly as possible‛
‚….I guess probably due to the time constraints
for us [acute setting] that was quite
difficult…when we actually go to the clients
house that is probably more of an in depth
assessment to see how we can manage that [their
chronic disease] in conjunction with them and
their families‛
1,2,3,4,5,
6 There needs to be a change in culture
around using language that is
consistent with chronic disease self
management within the area health
services (across disciplines).
‚…I don’t think there’s a collective team
approach… I don’t see doctors, nurses and allied
health professionals talking in a chronic disease
type of way or, but I do see it in pockets‛
‚…I suppose it’s developing that culture, so
having it as a language that we use, we’re
familiar with it, we all understand it and are
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working towards it so that’s really to me
developing leadership in others because we’re
all, I suppose wanting to speak the same
language and move forward in the same way‛
‚…we have not got the doctors on board, and in
terms of if we are going to roll out this strategy
the doctors, if they continue to work in the
medical model, and the same for nursing staff as
well, we’re going to be, banging our heads
against a brick wall‛
1,3,5 Gap between strategic intent and
strategic implementation for example
increasing capacity of managers in
relation to having the skill level to re-
direct their operational plans, position
descriptions and funding. This is
variable.
‚So I think it’s got to be led from the top and it’s
go to be a consistent message right across the
whole service and it’s got to be an ongoing
message that’s driven over and over because
you’re talking about a change in culture‛
‚…I don’t think we are setting jobs up in a
strategic way…you know we’re still setting them
up under a medical model‛
7 People are aware of the importance of
evidence base but it needs to be in the
Tasmanian context. There are variable
opportunities to collect data under the
current system (some can, some can’t)
there is no strategic intent or direction
to collect data or to utilise it.
Documentation of what is being done
with individual clients but there is no
consistent approach to collecting this
information.
‚…one of the things I sort of thought about after
the workshops is that we are not really assessing
or formally wiring down the things…at each
point that they are contacting the hospital for
example, we’re not really assessing or writing
down what we are doing for their chronic
conditions‛
4 Some participants were involved in
working groups and found this very
valuable, those who weren’t thought it
was very necessary as a vehicle to
progress CDSM forward consistently.
‚…I have been part of a fabulous little concept
*working group+ …the self management focus
forum…I thought that this was a really great
concept and I would love to see that continue‛
‚…we *the unit+ all have that same philosophy…
we have regular staff meetings and certainly this
[CDSM] has been a topical issue in our staff
meetings and how we actually go employing
what we’ve learnt on a daily basis… how we
change what we do…you know we talk about
that and how we’re actually going to put the
changes into place‛ 8 There was very little evidence to
support an awareness of general
practice integration.
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Discussion
This project opened the way for discussions with the local health service relating to
the preparedness of the organisation to support health professionals to practice
within a chronic disease self management framework. Health professionals in the
study reported a good understanding of approaches to chronic disease self
management and the importance of how this could facilitate change within the area
health service.
Of particular interest were the identified barriers of implementing a CDSM
framework across all levels of the service. This related mostly to a perception of
competing priorities between service delivery and not having the time to spend with
acute care patients in a more person centred/decision making approach. The culture
of a medical model of care was identified as an impediment to infiltrating all layers
of the health system especially in the area of acute care service. This was translated
in perceptions of the health service having ‚pockets‛ of focused CDSM approaches
to care.
Where these ‚pockets‛ existed it was evident that a number of staff in these areas
had been able to participate in CDSM training (a key focus of the CCP&SM Team
was to provide CDSM training opportunities to health professionals from the period
2007 to 2010). However, whilst a number of training initiatives have been made
available to staff feedback indicated there had not been enough investment made in
training or how the outcomes of training would be translated into practice.
Whilst participants reported evidence of strategic intent from the health service there
was no visible long term plan or direction to implement a CDSM approach.
Recommendations
Complete the Discussion component of this report (Phase 1 and 2 of the
project) following meeting with CEO, NWAHS.
Provide written report (Phase 1 and 2) to the NWAHS Executive.
Disseminate information through appropriate forums.
Phase 3 suggestions:
Upon recommendation from the NWAHS undertake further investigation of
staff perceptions of embedding CDSM into systems / organisation for example
increasing the cohort to include a larger target population or focusing in on a
work unit.
Mapping exercise of education, training and organisational activities that are
relevant to facilitating systems change related to chronic disease self
management.
Focus on the Stanford Chronic Disease Self Management Program: undertake
a further investigation of the perceptions of Stanford Leaders, Managers and
peers in the preparedness of the North West Area Health Service to embed
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the Stanford Chronic Disease Self Management Program as part of Chronic
Disease Management processes.
NWAHS ability to implement the Stanford Program within existing
work practices (with a focus on leadership/organisational capacity)