Using rapid evaluative learning processes to influence primary healthcare practice 1 Learnings from...
-
Upload
abigail-cain -
Category
Documents
-
view
212 -
download
0
Transcript of Using rapid evaluative learning processes to influence primary healthcare practice 1 Learnings from...
![Page 1: Using rapid evaluative learning processes to influence primary healthcare practice 1 Learnings from the Auckland Equipped pilot A Field 2, J Bycroft 1,](https://reader035.fdocuments.us/reader035/viewer/2022070413/5697bfc41a28abf838ca5f7e/html5/thumbnails/1.jpg)
1
Using rapid evaluative learning processes to influence primary healthcare practice
Learnings from the Auckland Equipped pilot
A Field2, J Bycroft1, C Palmer1, K Healey1, M Ghafel1, K Arcus2, L Dale-Gandar2, G Humphrey1
1 Auckland District Health Board2 Synergia Ltd
Paper presented to 2011 Australasian Evaluation Conference, 31 August – 2 September 2011
![Page 2: Using rapid evaluative learning processes to influence primary healthcare practice 1 Learnings from the Auckland Equipped pilot A Field 2, J Bycroft 1,](https://reader035.fdocuments.us/reader035/viewer/2022070413/5697bfc41a28abf838ca5f7e/html5/thumbnails/2.jpg)
Today’s presentation
• The challenge• What is a collaborative?• Equipped – the LTC Collaborative in Auckland• Evaluation findings• Key learnings – in what ways can rapid evaluative learning processes
support improvements in practice?
![Page 3: Using rapid evaluative learning processes to influence primary healthcare practice 1 Learnings from the Auckland Equipped pilot A Field 2, J Bycroft 1,](https://reader035.fdocuments.us/reader035/viewer/2022070413/5697bfc41a28abf838ca5f7e/html5/thumbnails/3.jpg)
Prevalence of long-term conditions
• The NZ Health Survey identified the population diagnosed by a doctor with a health condition expected to last 6 months or more
• Within NZ, LTCs account for 70-86% of all deaths and 70-78% of all health care spending
2 out of 3 adults!
No LTC LTC
66%
Over 1 in 3 children
No LTC
with LTC
36%
![Page 4: Using rapid evaluative learning processes to influence primary healthcare practice 1 Learnings from the Auckland Equipped pilot A Field 2, J Bycroft 1,](https://reader035.fdocuments.us/reader035/viewer/2022070413/5697bfc41a28abf838ca5f7e/html5/thumbnails/4.jpg)
What is a Collaborative?
Developed in 1995, 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
Paul Batalden & Don Berwick, Institute of Healthcare Improvement (IHI)
![Page 5: Using rapid evaluative learning processes to influence primary healthcare practice 1 Learnings from the Auckland Equipped pilot A Field 2, J Bycroft 1,](https://reader035.fdocuments.us/reader035/viewer/2022070413/5697bfc41a28abf838ca5f7e/html5/thumbnails/5.jpg)
Why do a Collaborative?
• Gap between what is known in best practice and what is often delivered (low fidelity)
• Ensuring systematised care for comparable populations• Learn from examples of excellent performance• Disseminate principles of best practice• Valuing insights across professional boundaries• Improve the overall system of care
![Page 6: Using rapid evaluative learning processes to influence primary healthcare practice 1 Learnings from the Auckland Equipped pilot A Field 2, J Bycroft 1,](https://reader035.fdocuments.us/reader035/viewer/2022070413/5697bfc41a28abf838ca5f7e/html5/thumbnails/6.jpg)
Key Features of a Collaborative
• Proven improvement model for rapid & sustainable improvement • Expert Advisory Panel – subject & QI experts• Use of information and measurement to guide improvement work• Clinical leadership and focus on clinical practice• Protected time • Practical support from QI facilitators
Encourages individuals with practices to change
![Page 7: Using rapid evaluative learning processes to influence primary healthcare practice 1 Learnings from the Auckland Equipped pilot A Field 2, J Bycroft 1,](https://reader035.fdocuments.us/reader035/viewer/2022070413/5697bfc41a28abf838ca5f7e/html5/thumbnails/7.jpg)
Outcomes
Typically see improvements in:• Patient care & health outcomes• Safety • Efficiency & effectiveness• Reporting & functionality• Teamwork & staff morale • Systems & processes• Right person for right role• Job satisfaction• Relationships with community, primary and secondary care
Supports culture shift to continuous quality improvement
![Page 8: Using rapid evaluative learning processes to influence primary healthcare practice 1 Learnings from the Auckland Equipped pilot A Field 2, J Bycroft 1,](https://reader035.fdocuments.us/reader035/viewer/2022070413/5697bfc41a28abf838ca5f7e/html5/thumbnails/8.jpg)
Long-Term Conditions Collaborative
1. Can busy practices within ADHB region implement a long term conditions collaborative and adopt QI approaches?
2. If so, would their patients benefit?
![Page 9: Using rapid evaluative learning processes to influence primary healthcare practice 1 Learnings from the Auckland Equipped pilot A Field 2, J Bycroft 1,](https://reader035.fdocuments.us/reader035/viewer/2022070413/5697bfc41a28abf838ca5f7e/html5/thumbnails/9.jpg)
The improvement model
Key topics
Expert Advisory
Panel
Identify change principles/ideas
Participants
Prework
LW 1 EventLW 3LW 2
P
D
S
A
P
D
S
A
P
D
S
A
· What are we trying to accomplish?
· How will we know that a change is an improvement?
· What changes can we make that will result in improvement?
· Plan· Do· Study· Act
Action Period Support(12 month timeframe)
Thinking part
Doing part
![Page 10: Using rapid evaluative learning processes to influence primary healthcare practice 1 Learnings from the Auckland Equipped pilot A Field 2, J Bycroft 1,](https://reader035.fdocuments.us/reader035/viewer/2022070413/5697bfc41a28abf838ca5f7e/html5/thumbnails/10.jpg)
PDSA Cycle(s)
Plan
DoStudy
Act
What, who, when, where, predictions, data collected
Was plan executed? Review and reflect on results
What will you take forward from this cycle?
![Page 11: Using rapid evaluative learning processes to influence primary healthcare practice 1 Learnings from the Auckland Equipped pilot A Field 2, J Bycroft 1,](https://reader035.fdocuments.us/reader035/viewer/2022070413/5697bfc41a28abf838ca5f7e/html5/thumbnails/11.jpg)
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
![Page 12: Using rapid evaluative learning processes to influence primary healthcare practice 1 Learnings from the Auckland Equipped pilot A Field 2, J Bycroft 1,](https://reader035.fdocuments.us/reader035/viewer/2022070413/5697bfc41a28abf838ca5f7e/html5/thumbnails/12.jpg)
PDSA (Do, Study, Act – Cycle 1)
• Do: Plan was completed.• Study: 25 patients were identified as having been prescribed a statin but
were not coded as having CVD. (15 did have CVD, 10 did not) • Act: GPs to correctly code patients with CVD diagnosis where appropriate.
![Page 13: Using rapid evaluative learning processes to influence primary healthcare practice 1 Learnings from the Auckland Equipped pilot A Field 2, J Bycroft 1,](https://reader035.fdocuments.us/reader035/viewer/2022070413/5697bfc41a28abf838ca5f7e/html5/thumbnails/13.jpg)
![Page 14: Using rapid evaluative learning processes to influence primary healthcare practice 1 Learnings from the Auckland Equipped pilot A Field 2, J Bycroft 1,](https://reader035.fdocuments.us/reader035/viewer/2022070413/5697bfc41a28abf838ca5f7e/html5/thumbnails/14.jpg)
The Auckland Approach
• First time Breakthrough Series trialled in New Zealand• Three topic areas
– System redesign, cardiovascular disease/diabetes, self-management support• 15 practices from five Auckland Primary Healthcare Organisations (PHOs)• 3 learning workshops of 1.5 days were offered
– Supported by networking sessions– PHO facilitators– ADHB staff– An expert advisory group – Improvement Foundation, Australia
• Use of population audit tool & monthly feedback (13 practices)• Support from Australian Improvement Foundation
![Page 15: Using rapid evaluative learning processes to influence primary healthcare practice 1 Learnings from the Auckland Equipped pilot A Field 2, J Bycroft 1,](https://reader035.fdocuments.us/reader035/viewer/2022070413/5697bfc41a28abf838ca5f7e/html5/thumbnails/15.jpg)
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
![Page 16: Using rapid evaluative learning processes to influence primary healthcare practice 1 Learnings from the Auckland Equipped pilot A Field 2, J Bycroft 1,](https://reader035.fdocuments.us/reader035/viewer/2022070413/5697bfc41a28abf838ca5f7e/html5/thumbnails/16.jpg)
Evaluation method
• Mid-point survey– November-December 2009– 55 responses (43% of participating practices)
• Qualitative interviews (20) at completion of pilot– Practices– PHOs– ADHB– Australian Improvement Foundation
• Quantitative analysis– Monthly reporting data– Analysis of PACIC (Patient Assessment of Chronic Illness) and ACIC data
![Page 17: Using rapid evaluative learning processes to influence primary healthcare practice 1 Learnings from the Auckland Equipped pilot A Field 2, J Bycroft 1,](https://reader035.fdocuments.us/reader035/viewer/2022070413/5697bfc41a28abf838ca5f7e/html5/thumbnails/17.jpg)
Feedback from practices
• Better coordination and multi-disciplinary teamwork
• Better understanding by practice participants of their populations
• Improved understanding of managing long-term conditions
• Shared learning & peer networking
• 100% retention rate of practices – despite complex challenges of the period
• Value of funding to support involvement
![Page 18: Using rapid evaluative learning processes to influence primary healthcare practice 1 Learnings from the Auckland Equipped pilot A Field 2, J Bycroft 1,](https://reader035.fdocuments.us/reader035/viewer/2022070413/5697bfc41a28abf838ca5f7e/html5/thumbnails/18.jpg)
Catalyst for coordination and teamwork
• Important catalyst for better coordination and multi-disciplinary teamwork• Mid-point survey
– 79% indicated that the Equipped programme had helped them work better as a team
– 66% identified improved communication within their practices – 86% reported increased understanding of the health of their enrolled
population – 83% reported improved understanding of chronic care management.– 90% indicated confidence in using the PDSA cycle
![Page 19: Using rapid evaluative learning processes to influence primary healthcare practice 1 Learnings from the Auckland Equipped pilot A Field 2, J Bycroft 1,](https://reader035.fdocuments.us/reader035/viewer/2022070413/5697bfc41a28abf838ca5f7e/html5/thumbnails/19.jpg)
Changes in practice data
• Analysis– 10 sets of reporting data from 13 participating practices – Comparing first 3 months (mid-2009) of Collaborative with last 3 months (mid-
2010)– Comparing 4 regularly reporting practices with 6 less regular
• Key findings (regularly reporting practices):– 4% increase in the number of patients with CVD on statin/antiplatelet
medication (2.5% decline in less regular reporting practices)– 17% increase in eligible patients with a CVD risk assessment (9%)– Improvement in the management of blood pressure for patients with diabetes
(5% improvement across all practices)– Improvements not evident for HBA1c among diabetes patients and blood
pressure for CVD patients
![Page 20: Using rapid evaluative learning processes to influence primary healthcare practice 1 Learnings from the Auckland Equipped pilot A Field 2, J Bycroft 1,](https://reader035.fdocuments.us/reader035/viewer/2022070413/5697bfc41a28abf838ca5f7e/html5/thumbnails/20.jpg)
Changes in CVD Register over Time
P1 P2 P3 P4 P5 P6 P8 P9 P11 P12 P13 P14 P150
50
100
150
200
250
300
350
400
450
N CVD Apr-09
N CVD Jan-10
![Page 21: Using rapid evaluative learning processes to influence primary healthcare practice 1 Learnings from the Auckland Equipped pilot A Field 2, J Bycroft 1,](https://reader035.fdocuments.us/reader035/viewer/2022070413/5697bfc41a28abf838ca5f7e/html5/thumbnails/21.jpg)
Percentage of eligible practice population with CVD risk assessment
0%5%
10%15%20%25%30%35%40%45%
Other practices RA CVD Collaborative RA CVD
![Page 22: Using rapid evaluative learning processes to influence primary healthcare practice 1 Learnings from the Auckland Equipped pilot A Field 2, J Bycroft 1,](https://reader035.fdocuments.us/reader035/viewer/2022070413/5697bfc41a28abf838ca5f7e/html5/thumbnails/22.jpg)
ACIC data (Assessment of Chronic Illness Care)
• Data from four practices– Significant (p<0.01)
improvement in Delivery System Design
– A moderately significant improvement (p<0.05) in Self-Management and Community Linkages
23
Delive
ry Sy
stem Desi
gn
Self-M
anag
emen
t
Community Lin
kage
s
Integrati
on of CCM
Clinica
l Syst
ems in
fo
Decisio
n support
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
Delivery System Design
Self-ManagementCommunity Linkages
Integration of CCMClinical Systems info
Decision support
ACIC data
Pre Post
![Page 23: Using rapid evaluative learning processes to influence primary healthcare practice 1 Learnings from the Auckland Equipped pilot A Field 2, J Bycroft 1,](https://reader035.fdocuments.us/reader035/viewer/2022070413/5697bfc41a28abf838ca5f7e/html5/thumbnails/23.jpg)
PACIC (Patient Assessment of Chronic Illness Care) data
• Data from four practices– Improvements in
follow-up and coordination (p<0.01)
– Improvements in other areas but not statistically significant
24
Follo
w up/Coord
ination
Five A
's
Delive
ry Sy
st Desi
gn/D
ec Su
pport
Goal Se
tting
Patien
t acti
vation
Problem
Solvi
ng/Contex
tual Counsel
ling
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
Follow up/CoordinationFive A's
Delivery Syst Design/Dec Support
Goal SettingPatient activation
Problem Solving/Contextual Counselling
PACIC data
Pre
Post
![Page 24: Using rapid evaluative learning processes to influence primary healthcare practice 1 Learnings from the Auckland Equipped pilot A Field 2, J Bycroft 1,](https://reader035.fdocuments.us/reader035/viewer/2022070413/5697bfc41a28abf838ca5f7e/html5/thumbnails/24.jpg)
Influences on quality improvement
• Standardised population audit tools and performance measurement– Adopting a population approach, see patterns of management, highlight areas
for change– Timely feedback– Value despite limitations of population audit tool available
• Teamwork– Regular team meetings and cross-practice dialogue– Changing the quality of practice discussions– Greater involvement of nurses in fostering improvements in care
• PDSA cycles– Tool for exploring system of care and incremental improvements
• Protected time from practices • Opportunities to share experience through learning and networking
![Page 25: Using rapid evaluative learning processes to influence primary healthcare practice 1 Learnings from the Auckland Equipped pilot A Field 2, J Bycroft 1,](https://reader035.fdocuments.us/reader035/viewer/2022070413/5697bfc41a28abf838ca5f7e/html5/thumbnails/25.jpg)
Challenges/limitations• PHO facilitation
– Lack of support from PHOs to facilitators role and time needed– Coordinators of data, not leaders of system change– Changes in facilitators and understanding of role
• Competing priorities (e.g. Cornerstone)• Practice level
– Staff changes, time – Variable senior management support
• Compliance views of data processes• DHB level - challenge of working with multiple PHOs• Complex, fragmented environment - 2009
– BSMC, H1N1, Labtests, measles, budget cuts• Limitations of population audit tools
![Page 26: Using rapid evaluative learning processes to influence primary healthcare practice 1 Learnings from the Auckland Equipped pilot A Field 2, J Bycroft 1,](https://reader035.fdocuments.us/reader035/viewer/2022070413/5697bfc41a28abf838ca5f7e/html5/thumbnails/26.jpg)
Key enablers
• Value of rapid learning approach to drive system improvements• Importance of standardised data
– Viewing enrolled populations and supporting planned proactive care– Good data can challenge debate of professional autonomy vs standardisation
• Value of population audit tool– Relevant and timely data reporting– Having tools in place at the start
• Skill and capacity of facilitators• Importance of leadership
– Within practices and peer leadership across practices• Protected time and funding support to practices• Learning and network opportunities
![Page 27: Using rapid evaluative learning processes to influence primary healthcare practice 1 Learnings from the Auckland Equipped pilot A Field 2, J Bycroft 1,](https://reader035.fdocuments.us/reader035/viewer/2022070413/5697bfc41a28abf838ca5f7e/html5/thumbnails/27.jpg)
Acknowledgements
• Expert Advisory Panel • General practice teams• Facilitators & PHOs for joining us on this journey • ADHB• Ministry of Health• Improvement Foundation Australia
Contact: Adrian Field, [email protected] tel +64 21 529 805