How to make quality improvement science acceptable and successful in primary care Lessons from 10 years of work in Australia

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How to make quality improvement science
acceptable and successful in primary
careLessons from 10 years of work in Australia

• Andrew Knight

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• Conflicts
• Clinical Advisor to the Improvement Foundation
• Shared funding to attend between IF and role as
  staff specialist
• Acknowledgements
• The Australian Primary Care Collaboratives
  program is funded by the Australian Government
  and conducted by the Improvement Foundation
• Colleagues Dale Ford and many others who have
  contributed since 2004.

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Plan

• Explain what we have done
• The problem
• The selected solution
• What happened
• Lessons
• Ask you reflect and discuss
• Are there lessons for your health system?

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The Problem

• Strengthening primary carebut how?
• General Practice in Australia
• 85 of population per year (March 2013)
• 6.57 visits on average
• 2.44 million encounters per week
• 7035 practices (2011)
• First contact, gatekeeper
• No contract, universal insurance
• Fee for service and some process incentives (10
  income)

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Reflection

• Does your primary care system resemble ours?

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The Solution

• Quality Improvement Collaboratives
• A Breakthrough Series Collaborative is a
  short-term (6 to15 month) learning system that
  brings together a large number of teams from
  hospitals or clinics to seek improvement in a
  focused topic area.
• IHI White Paper.

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Breakthrough Collaborative Series
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What we did

• Small teams - 18 months
• 3 workshops aims, evidence, improvement, change
  principles, measures
• Activity periods PDSA cycles, measures,
• Monthly reports and cohort comparisons
• Local support
• Sharing of ideas

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What happened

• Based on NPDT, Sir John Oldham
• Transferred 2004 and we are still doing it
• Multiple overlapping cohorts - national
• Total services participating 1949 (unique 1230
  approx. 18 of total)
• Diabetes registers 302536
• CHD registers 177740
• COPD registers 41816
• PDSAS 36000

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What happened

• Access, diabetes, CHD
• Prevention
• COPD
• Patient self management
• Diabetes prevention
• Aboriginal health
• E health
• Quality Improvement training
• Chronic Kidney Disease
• Patient safety
• Cancer screening

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What happened

Local workshops 206 health services joined one
of 15 locally based QI Collaboratives delivered
by their support organisation.   Virtual
workshops- 60 health services joined one of four
online QI Collaboratives delivered by
IF.   Medicare Local QIP - 359 health services
joined their Medicare Locals in locally based QI
workshops delivered by their Medicare Local.  
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What happened Hba1c
Mean percentage of patients with an HbA1C 7
n-743
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What happened HbA1C recorded
Mean percentage of patients on register with
HbA1C results recorded
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What happened cholesterol in CHD
Mean percentage of patients with cholesterol at
target
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What happened spirometry in COPD
Mean percentage of patients with spirometry
recorded
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What happened plans in chronic disease
Mean percentage of patients with care plan
recorded
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What happened system change

• Data extraction tool
• Data management portal
• Culture change
• knowledge, skills, attititudes
• Spread
• National KPI reporting
• Aboriginal medical services

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Lessons - transfer

• Not for profit
• Independence, nimbleness
• Adjust to local needspolitics
• Rigour
• structured
• sharing of intellectual property
• Expensive

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Lessons - Evaluation

• Built (budgeted) from the start
• Publish
• Knight AW, Caesar C, Ford D, Coughlin A, Frick C.
  Improving primary care inAustralia through the
  Australian Primary Care Collaboratives Program a
  qualityimprovement report. BMJ Qual Saf. 2012 Jul
  18.
•  
• Knight AW, Ford D, Audehm R, Colagiuri S, Best J.
  The Australian Primary Care Collaboratives
  Program improving diabetes care. BMJ Qual Saf.
  2012 Jun 16.

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Lessons - QICs

• One collaborative
• Short sharp effective
• Achieve improved care
• Provide training in improvement
• TEND to MEAN

• Many collaboratives
• Changed culture
• Increased capacity
• Changed expectations
• SUSTAINABLE CHANGE?

NOT ENOUGH
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Lessons - QICs

• What works?
• Importance of team
• In the literature (Ovretveit)
• In Australia
• Team principle
• Right topic
• Local support

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Lessons - QICs

• Engage with many small organisations
• Known and trusted
• Builds capacity
• Adaptable
• Limited

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Lessons - QICs

• Practice Context
• Charlotte Hespe

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Reflection

• Would it work in your primary care system?
• Introduce yourself to some people you dont know
• Share your reactions to our experience
• What would work
• What wouldnt work
• What will you try