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Investigating (unwarranted) clinical variation in the inpatient setting
Chronic Heart Failure / Chronic Obstructive Pulmonary Disease
Lea Kirkwood
Program Manager,Centre for Healthcare Redesign
Agency for Clinical Innovation
LEADING BETTER VALUE CARE
1
Quality Improvement Collaboration - QuIC
February Webinar
A QuIC update: Next Steps After Audit
FROM AUDIT OR SELF – ASSESSMENT TO IMPLEMENTATION
Audit Cycle
Image Downloaded from: https://www.rcpath.org/profession/clinical-effectiveness/quality-improvement/clinical-audit.html
Baseline
• Audit can include a snapshot assessment of:
– The structure of care—for example, resources such as the presence of a dedicated High Risk Foot Clinic
– The process of care —e.g , investigations, treatment against guidelines, discharge
– The outcome of care—for example, readmission, complications, clinical symptom improvement.
• Prioritising – Where do we start?
Next Step in the QI process
• Understanding the impact and the cause
– WHY?
• Clinical Care
– Symptom / Sign Diagnostic Solution Test Implement Sustain
• QI
– Baseline Diagnostic Solution Test Implement Sustain
Diagnostic Tools that can be used
• Asking – individuals, focus groups, all stakeholder groups
involved e.g. why don’t we set targets and adjust O2 therapy? Why don’t we weigh patients?
• Collect data – may need to drill a bit deeper
– What is our referral rate to Pulmonary Rehab? Is there a difference in readmission for those that complete?
– What is our LOS variation by dept / clincian?
Diagnostic Tools that can be used
• Process or Journey map – how does it currently work, and where are the holes? – e.g. Discharge processes, referral to Pulmonary rehab, referral for
smoking cessation
• Patient and carer interviews / surveys – what’s working, what isn’t,
what’s important? – E.g. Pulmonary rehab, discharge information, self-management
• Tag – along, observation
– Patient reported outcomes process
• What else have people used?
Collating the Information
• Themes - What does the information collected point to as the main issues? – Do you need to drill down more – to
the root causes?
• Tools
– Fishbone, why / because (up to 5 times)
• Prioritise
– If we address which issues – will we have the biggest impact on the problem, and have we got the biggest chance of success in solving?
Issues Prioritisation
High Impact on patient / objective
Ability to Influence
Low
High
Low
Low Priority
Medium Priority
Medium Priority
High Priority
Issues to be taken to the solutions phase
Issues to consider / potential quick wins
Issues to consider / special project?
Issues to discard in a first instance
Solutions
• What exists? – in our organisation / in other services / literature
• What ideas do staff have? (individuals / group brainstorming)
• Theme, Prioritise – impact and ease of implementation (cost, time, size of change)
– Quick wins (fast and high impact) and longer term solutions
Solution Selection – Is it a good idea?
• Does it address the problem?
• Is it good for patients, staff, organisation?
• Can we do it?
• Should we do it?
• Can we Test it…..
Don’t wait until it’s perfect – Plan, Do, Study, Act
Service Centre – prototype for feedbackS centre
Concept testing and feedback
email address
website
Making Change Happen Implementation
Why do we use Guidelines? • We know about them • We believe they are useful – locally • They are easy to use • We have the competence to do it • We have the equipment to do it • Guidelines are flexible, allow autonomy • Guidelines come from good evidence and
experience • Leaders use them and check • We see results
Building Readiness for Change
Predicting the impact of change
CHANGE FACILITATION MONITORING AND REPORTING
Visible and Active
• Mentor
• Coach
• Observer
• Leader
• Connector
• Reporter
• Creator
Feedback Loops keep Implementation Moving
• Think frequency and workload
– What can you measure?
– Where will you report?
– How will you track resulting actions?
More Information • Contacts
– Local – include: • Quality managers, • CPI trainers, • Redesign leaders https://www.aci.health.nsw.gov.au/make-it-happen/centre-for-healthcare-
redesign/redesign-leaders
– Statewide: • ACI – CHR [email protected] • Quic Network manager at ACI • Implementation Support – [email protected]
• Training Available – AIM courses
• (for implementation) https://www.aci.health.nsw.gov.au/make-it-happen/centre-for-healthcare-redesign/accelerating-implementation-methodology-aim
– CPI courses (locally) – Redesign on Gem elearning
• Register at: https://gem.workstar.com.au/public/?action=login