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www.pspbc.ca
Shared System of Care COPD HF Prototype Session 4
February 28, 2013
Wireless: Westin-Meeting
Wireless Code: bcma2013
Session Opening
Dr. Gordon Hoag
www.pspbc.ca
Brian Deakin
The Good The Bad The Ugly
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5
COPD Heart Failure Ischemic Heart Disease Diabetes Renal Problems Hypertension Barretts Esophagus Sleep Apnea Former Smoker Reformed Alcoholic
My Health
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How Many Health Professionals Share My Care?
2007
UncoordinatedSporadicLoosely Structured
2012
CoordinatedContinuousComprehensive & proactive
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Then
As I saw fit
Loosely structured
Sporadic
Incomplete
Easy
Comparing My Care … Then and Now
Now
Shared Coordinated
Continuous
Comprehensive
Complex
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My care has really developed over the past few years
COORDINATED
› I know where things are leading to
COMPREHENSIVE
› I know that someone is going to look after my heart, and that someone is going to check my lungs
CONTINUOUS
› I don’t need to chase the health professionals because they are following up with me on a regular basis.
My experience with COPD & HF
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“A growing number of sub-specialties and … physician teams … have contributed to care that is comprehensive… often disjointed, especially for the most complex patient populations.” https://www.bcma.org/files/SharedCare_Backgrounder.pdf
This IS my Experience NOW !
Shared Care initiatives foster mutual trust, respect, and knowledge of each physician’s expertise, skills, and responsibilities…
It’s not just mutual trust between physicians, it’s mutual trust between them and the PATIENT!
This WAS my Experience THEN
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NowCommunicationEducationResourcesActive interest
› in my life
› in my health
My Self Management…
Then Invincible Self-Denial Smoked Drank Medications? Huh?
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I have taken charge of my health Group medical visits I learned how to communicate I ask questions, and I record answers My GP and I have mutual trust & respect for each other. That has absolutely has an impact on my experience
with specialists
What Has Happened?
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Shared Care
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Predictive Modelling and PROOF - Ella Young, Dr. Bruce McManus and Janet McManus Steveston
Updated HF and Co-morbid materials - Drs. Sean Virani and Mark FitzGeraldBridgeport
Partners in Care - Aman Hundal, Clay Barber Lulu Island
Brief Action Planning - Connie DavisGulf of Georgia
Break Out Sessions – Part 1
Break
Break Out Sessions – Part 2
Creating Shared Care in a Northern Health Practice
Shared Care – Heart Failure
Prototyping in Maple RidgeJuly – December 2012
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Dr. Ken Burns – Family Physician Champion
Dr. Winston Tsui – Cardiologist
Carol Galte – Nurse Practitioner, Co-Lead Regional Health Failure Strategy, Fraser Health
Marleen Ouellette – Clinical Nurse Specialist, Heart Function Clinic, Fraser Health
Patti Scott – Practice Automation Coach, PITO
Dr. Christopher Rauscher – PSP Specialist Lead, Fraser Health
Kathy Riyazi/Jennifer Montgomery – PSP Project Coordinator, Fraser Health
Our Team
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Focus on clinical pearls
Build the Network
Connect with resources
Our Goals
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2 team meetings to plan learning sessions
2-2 hour learning sessions
Optional Practice/Support visits
What We Did
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Clinical Review
Case Studies
Registry Building
Boardwalk Activity
Content of Learning Sessions
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Patient Self Management
› Local Community Resources
› Heart Failure Zones
› Smoking Cessation
Content of the Learning Sessions
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Registry building
Smoking Cessation
Case Finding
Resource Access
Support Visits
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Shared Care COPD Module to begin in April
The Future
Lunch
Idea BONANZA!
Christina Southey
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Pa, I think these folks have some ideas in ‘em.
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If you were 10 times bolder,
what would you test to improve
shared care for HF/COPD in
your community.
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Write 1 idea on the cue card provided.
Do not put your name on it
1 cue card for each person. Each person must write one idea.
Step 1
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Walk around the space trading cards
with everyone you pass
Step 2
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When asked to stop,
read the idea on the cue card you hold
and rate it from 1-5, on the back of the card.
1 = This idea is not for me5 = I love this idea and want to try it!
Step 3
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Repeat 4 more times
Step 4
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After 5 rounds tally up the numbers
on the back of the 5th cue card.
Give a score out of 25.
Step 5
www.pspbc.ca
Planning for Sustainabilityaka Holding the Gains
Connie Davis
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Define sustainability
Describe what ‘sustainability actions’ to take during testing and implementation
Create a sustainability plan
Objectives
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What is Sustainability?
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› The ability to be maintained at a certain rate or level.
› The ability to be upheld.- Oxford English Dictionary
› Maintaining the process - National Health Service Modernization Agency, 2002
What is Sustainability?
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The challenge is not starting, but continuing after the initial enthusiasm is goneOvretveit, 2003
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What are we trying toaccomplish?
How will we know that achange is an improvement?
What change can we make thatwill result in improvement?
Model for Improvement
Act Plan
Study Do
Langley et al,The Improvement Guide, 2009
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Testing: Trying and adapting existing knowledge on a small scale. Learning what works in your system.
Implementing: Making a change a part of the day-to-day operation of the system in your pilot population. Holding the gains.
Spreading: adapting change to areas or populations other than your pilot populations
Testing vs Implementation vs Spread
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Spreading to other locations/processes
Developing a change
Implementing a change (HTG)
Testing a change
Act Plan
Study Do
Theory and Prediction
Test under a variety of conditions
Make part of routine operations
Robert Lloyd
The Sequence for Improvement and Spread
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Improvement
Hold Gains
Spread
Improvement Hold Gains Spread
BETTER
Design Spread
Langley GJ, Nolan KM, Nolan TW, Norman CL, Provost LP. San Francisco: Jossey-Bass; 2009
Creating a New System
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Purposefully test the changes under a wide range of conditions (robust design)
› Regular staff/temp, experienced/ inexperienced staff
Foolproof the new process/procedure
› Look for ways to use constraints, affordances, reminders, differentiation
Use technology where appropriate
› Look for opportunities to use computers/EMR, bar coding ,etc.
Think about reliability and change concepts related to reliability
During Testing— Before We Even Implement!
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When an improvement was implemented Are the gains still there?
› If yes, what was done to make that happen?
› If no, why weren’t they sustained? What got in the way?
Think of a Time
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Use multiple PDSA cycles to implement the change
› Testing is not de-facto implementation!
Collect data over time when conditions are expected to change
› Continue use of run chart
Redesign support processes for new process
› Training, getting forms, etc.
Address the social aspects of change
› WIFM, appreciation, publicity, resistance
During Implementation
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Collect Data Over Time When Conditions are Expected to Change
Unreconciled Meds
0
10
20
30
40
50
60
70
Perc
ent
Baseline
Testing
SuccessfulTesting
Begin implementation on pilot unit
Evidence of improvement during implementation
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ACT
STUDY DO
PLAN
- What changes are to be made?
- Next cycle?
- Objective
- Questions and predictions
- Plan to answer the questions (who, what, where, when)
- Complete the analysis of the data
- Compare data to predictions
- Summarize what was learned
- Carry out the plan
- Collect the data
- Begin analysis of the data
Source: Improvement Guide, Pg 185
Implementation Cycle
Measurements required:New measurements defined. Comments: Measurement procedures defined. Comments:
Measurement responsibilities defined. Comments: Measurement review scheduled with responsibilities. Comments:
Analysis of data responsibility assigned. Comments:
Impact on training:Training procedure defined for implementation. Comments: Training resources allocated. Comments: Training schedule complete. Comments: New employee training procedure complete. Comments:
Documentation of change:Materials/forms defined. Comments: Procedure defined. Comments: Equipment defined. Comments: Change request procedure. Comments: Changes in job descriptions or role statements. Comments:
••••••8
••••••7
••••••6
••••••5
••••••4
••••••3
••••••2
••••••1
•Predicted Acceptance
•High/Med/Low
•Change in Standard?•Yes/No
•Number of People Affected
•Process or Product Owner
•Processes or Products Affected
Processes or Products affected by the change:
••••8
••••7
••••6
••••5
••••4
••••3
••••2
••••1
•Predicted Level after Change
•Current Level of Performance
•Measure
Predicted impact of change on key measures:
Implementation dates: From to .
Description of change:
Measurements required:New measurements defined. Comments: Measurement procedures defined. Comments:
Measurement responsibilities defined. Comments: Measurement review scheduled with responsibilities. Comments:
Analysis of data responsibility assigned. Comments:
Impact on training:Training procedure defined for implementation. Comments: Training resources allocated. Comments: Training schedule complete. Comments: New employee training procedure complete. Comments:
Documentation of change:Materials/forms defined. Comments: Procedure defined. Comments: Equipment defined. Comments: Change request procedure. Comments: Changes in job descriptions or role statements. Comments:
••••••8
••••••7
••••••6
••••••5
••••••4
••••••3
••••••2
••••••1
•Predicted Acceptance
•High/Med/Low
•Change in Standard?•Yes/No
•Number of People Affected
•Process or Product Owner
•Processes or Products Affected
Processes or Products affected by the change:
••••8
••••7
••••6
••••5
••••4
••••3
••••2
••••1
•Predicted Level after Change
•Current Level of Performance
•Measure
Predicted impact of change on key measures:
Implementation dates: From to .
Description of change:
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1. Clarify what you are sustaining
2. Engage leaders
3. Involve and support front-line staff
4. Communicate the benefits of the improved process
5. Ensure the change is ready to be implemented and sustained
6. Embed the improved process in your electronic and human processes.
7. Build ongoing measurement
Key Factors for Holding the Gains
Health Quality Ontario
What are You Sustaining?
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Identify clinical champion
Champion has time to participate
Business leader supports improvement (if applicable)
Leaders have skills and knowledge about the change
Leaders have
› removed barriers
› can state the benefits
› provide required resources (especially time)
Leadership for Sustainability
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Information about purpose and significance
Participate in identifying issues with change
Are involved in developing solutions
Right people are involved
Communication process clear
Skills enhancement is addressed
Involving Front Line Staff
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WIIFM for each group identified
Data is tracked real-time and shared
Stories, updates and visual display of data routinely shared
Information on benefits
Communication Strategy
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The change is an improvement
It has been widely tested
No further testing needed (at this time)
Targets have been achieved
Readiness to Implement
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Necessary supplies, facilities, forms etc. are available
Staff have been trained and job descriptions updated
Policies and procedures updated
New process is now standard
The new process is monitored and ongoing adaptation planned
Required electronic or paper based changes have been made
Embed the Improved Process
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Skills and culture of measurement
Measures set defined
Staff assigned to measurement
Regular reporting established
Communication plan established
Plan for responding to data
Celebrate accomplishments!
Measurement Strategy
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Still in the planning process: consider how you can integrate these concepts into your design and testing?
In the early testing stages: can some of these concepts be integrated or added to what you're doing?
Close to being implemented: what might you need to address before you consider moving to 'sustain'?
Changes implemented: what might you need to go back and address before you move on?
Sustainability at Every Stage
Evaluation Introduction
Marcus J. Hollander, PhD
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Hollander Analytical Services Ltd. has been contracted to conduct the evaluation of the PSP program.
There are two aspects to the evaluation: a Train-the-Trainer evaluation and our evaluation of the Learning Modules once they are rolled out.
In terms of the Train-the-Trainer or Prototyping evaluation, a report of findings is produced quite quickly and is used as input to plan future activities. Thus, the information provided is actually used to improve future planning.
Evaluation Overview
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The Learning Module evaluations have shown very positive results and have been instrumental in giving both a national and international profile to the PSP.
The most recent publication of the Learning Module Evaluation is:
› MacCarthy, D., Kallstrom, L., Kadlec, H., & Hollander, M.J. (2012). Improving primary care in British Columbia, Canada: Evaluation of a peer-to-peer continuing education program for family physicians. BMC Medical Education, 12, 110.
You will be asked to complete the prototyping evaluation in the breakout groups. Please hand them in to the breakout group leader who will give them to us.
Evaluation Overview (cont’d)
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The evaluation survey may appear to be long but it is broken into sections so not everyone will be asked to complete the full survey.
We would like to thank you in advance for your cooperation in completing the survey forms.
Evaluation Overview (cont’d)
Next Steps
Fraser HealthLulu Island
Interior HealthBridgeport
Northern HealthGulf of Georgia
Vancouver CoastalSteveston A
VIHASteveston B
Report Out
