Upload
nguyenxuyen
View
216
Download
0
Embed Size (px)
Citation preview
1
Quality Improvement in Primary Health Care
Southeast LHIN Primary Health Care ForumKingston, 8 Nov 2007
Dr. Ben Chan, MD MPH MPACEO, Ontario Health Quality Council
2
What is Quality?
“Quality health care means doing the right thing at the right time in the right way for the right person and having the best results possible.”
3
Attributes of Quality & High Performing Health System
• Effective• Efficient• Equitable• Accessible• Safe• Patient-centred
• Focused on population health
• Integrated• Appropriately
resourced
4
What’s Wrong with Quality?
5
Effectiveness: The Evidence Gap
• How long does it typically take for clinical evidence to enter mainstream clinical practice in primary care?
6
Effectiveness: The Evidence Gap
The lag between publication of landmark clinical trials and application in practice (to 50% use) is unnecessarily long, in the range of about 15 to 20 years.
Balas and Boren, 2000
7
Landmark Trials and Current Rate of Use
20%1993Diabetic foot care17%1986Fecal occult blood test65%1984Cholesterol screening70.4%1982Mammography61.9%1982Beta blockers after MI38.4%1981Diabetic eye exam35.6%1977Pneumococcal vaccination20%1971Thrombolytic therapy55%1968Flu vaccinationCurrent UseLandmark TrialClinical Procedure
Balas, Boren 2000
8
Why?
9
Why Isn’t Best Evidence Taken Up?• Not knowing the gap from optimal
– “I think I’m doing a good job…”• Time, skills needed to redesign care• Mechanism for spreading good ideas
10
Examples of Upcoming Measures for Quality in Primary Care
OHQC 2008 Report
• Diabetes patients:– % A1C <7– A1C ordered 2x / yr– % BP < 130/80– Foot exam done– Eye exam done– On ACEI
• CHF patients:– On ACEI– On b-blocker
11
Examples of Upcoming Measures for Quality in Primary Care
OHQC 2008 Report
• CAD patients– On b-blocker– On ACEI– On statin– BP < 140/90
• Access (under consideration)– Ease of getting
apptmt with family physician
12
So We’ve Found Problems with Quality – Now What??
13
Hypothetical Case• Study announced today that in Eastern
Ontario patients in diabetes are not managed well. Less than half of these patients have their blood sugar (A1c), blood pressure and cholesterol within recommended targets.
• How would you respond to this?
14
15
learn as you gosmall tests, not (necessarily) small changes
16
Aim Statements for QI Projects
• What are we trying to accomplish?
– “Improve diabetes care for our patients.”
17
Aim Statements for QI Projects
• What are we trying to accomplish?
– Improve diabetes care for our regular patients in the Bay St, May St. and Gray St. clinics. Increase the % of these patients hitting their targets for BP, cholesterol & AIC to 75%. Do this by December 2008.
18
Measures:How Will We Know a Change is
an Improvement? • Mainline measures
– A1C, BP, chol• Consider balancing measures
– Unintended consequences• Consider related process measures
19
What Changes Can We Make That Can Result in Improvement?
• “Let’s implement an electronic medical record!”
20
What Changes Can We Make That Can Result in Improvement?• Avoid jumping immediately to the
perceived panacea solution• Consider best practice examples for
implementation from elsewhere• Conduct careful analysis of system, root
causes, cause & effect, process maps before implementing changes
21
Example – Ishikawa Diagrams
Why is A1C poorly
controlled?
Consider people, policies, procedures, equipment
22
ImplementationExample: Pt Self-Mgt
• We’re going to create a committee. In the next four months they’re going to research pt self mgt tools. We’re going to carefully select a package of materials. Then we’re going to have extensive in-service sessions to train all the staff on how to use the materials.
23
Alternative Approach from QI Science
• Implementing Change: PDSA cycles• Plan, Do, Study, Act• Testing predictions • Learning from small tests of change• Rapid cycle improvement
24
What should a PDSA look like?
Write It down!
ObjectiveWhat do you want to learn/try?
PlanWho, what, where, when?MeasurementPredict outcome as a group
DoJust do it!
StudyWhat worked? What didn’t? Predict correctly?
ActNext steps
25
Multiple PDSA Cycle Ramps
A PS D
A PS D
A PS D
D SP A
Coordination w/ DM educators
Pt self-mgt
A PS D
A PS D
A PS D
D SP A
A PS D
A PS D
A PS D
D SP A
Standing orders, checklists
Try different ways of implementing change concept
26
Case Study Revisited• Describe some PDSA cycles for some
different ideas for improving pt self-management:
PLAN:DO:STUDY:ACT:
27
ImplementationExample: Pt Self-Mgt
• OK, we’re going to try test out some different ways of implementing patient self-management over the next few months. We’ll show a nifty bar chart of how our results for A1C & cholesterol improved before an after.
28
Try Annotated Run Charts% of patients who have set >= 1 written pt mgt goal in past 6 months
23 24 21 23
31
10
34
46 47 50
0
10
20
30
40
50
April
May
June Ju
lyAug
ust
Sept
Oct
Nov
Dec Jan
Time Period
Perc
ent
new doctor
Test new tool
New tool w Group sessions
29
Building a QI Team
30
Building a QI Team• Select representatives of key parts of
process• Identify champions, leaders, resistors• Keep size manageable (~10)• Secure resources for their time• Build in conflict management skills
31
Commitment Mapping
32
Case Study RevisitedYou’ve created the QI team. It includes nurses, admin staff, a couple of docs, a local pharmacist, diabetes educator / nutritionist, and a patient representative. Two months into your work, the team’s momentum is stalling. Attendance at QI meetings is dwindling. People say they will try a PDSA cycle but don’t get around to it in time for the subsequent meeting. Everyone complains that their plate is too full with their other duties.
33
Getting Support for QI• What are competing initiatives?• For employees of organizations: how does
your initiative align with organization’s core strategies, priorities?
• What resources do I need to ask for?• What can I promise to deliver in quality? • Is there a business case for QI initiative?• Especially for independent practitioners –
who can I turn to for support?
34
An improvement methodthat relies on thespread and adaptation of existing
knowledge to multiple settingsto accomplish a common aim.
Brings together multiple QI teams at different sites with practitioners from various disciplines, to share knowledge about what improvement ideas work & how they are implemented.
What is a Collaborative?
35
Learning Collaboratives
Support
SPREAD
LW0
LW1
LW2
LW3
Pre- work
Select Topic Participants Reference Panel
Identify Change Concepts
36
SK CDM Collaborative• Focus on CAD, Diabetes, &
Access
• Two waves deployed (Nov 05, Nov 06)
• Enrolment to date:– 28% of all family physicians in Sask
– All RHAs in province
– Mix of FFS, non-FFS
37
SK Collaborative Topics• Why CAD and DM together?
– Major contributor to burden of illness– Many common measures
• BP control, lipids, smoking, weight
• Why add improving access?– Improving access frees time for better chronic
disease mgt– “triple combo” used successfully in UK’s
Collaboratives
38
Common Aims & Measures• Developed from Reference Panel of local,
international experts• Key Aims:
– 75% of diabetes pts with A1C <7.0%– 75% of pts with HDL/Tchol < 4.0– 75% of pts with BP < 130/80
• Approx. equiv. to ↓ sub-optimal care by 1 / 2
39
Learning Workshops
40
Storyboards – Sharing Learnings
41
Storyboards – Sharing Learnings
42
Regional Improvement Teams
43
Regional Improvement Teams• Interdisciplinary mix• Examine ways to improve coordination,
communication of care within regions• Heavy mentorship, support from
“Collaborative Facilitators” positioned in each region
44
45
Web-Based CDM Toolkit
46
Web-Based Patient Registry
47
CDM Web-based Patient Registry
48
CDM Toolkit - Flowsheets
49
Change Concepts & Ideas
50
51
Wagner’s Chronic Disease Model
52
53
54
KEY MEASURE% of Diabetes Patients with a BP ≤ 130/80
among Wave 1 Practices, Baseline vs Month 9 (Nov 2006)
51.5
75.0%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
3 8 23 32 15 18 30 21 31 29 35 11 26 16 1 4 13 2 22 10 27 6 9 24 14 17 20 33 25 34 19 28 7 5
Practices
Monthly Average Baseline Goal
The absence of a practice's bar is due to lack of a baseline value or small counts (i.e., < 6)
55
Sask. CDM CollaborativePreliminary Improvements in Diabetes Care
56
Sask. CDM CollaborativePreliminary Improvements in CAD Care
57
Dr. Vickie HolmesSaskatoon Medical Associates
58
Participant Quotes• “Improved communication between regional
improvement team members. Better coordination of patient care.”
• “Identifying all chronic care patients within our practice and providing them with better health care.”
59
Participant Quotes• “Beginning to speak as a team about the
importance of chronic disease care and adherence to Canadian best practice guidelines.”
• “This experience gave our area a chance to look at our clients and see where they were. It gave us an opportunity to network with many people across the province and realized we are all striving for the best.”
60
Key Messages• Huge opportunities to improve quality in
primary care & chronic disease mgt / prevention
• Quality improvement science & tools essential for change
• Need highly coordinated strategy, campaign to spread change
• Teams need support, training to make it happen
61
Next Steps• OHQC has dual legislated mandate to:
– Report on quality of care– Support quality improvement
• Third report on quality due May 2008• Moving to expanding QI support role• Strong interest in primary care & chronic
disease prevention/management• Examine opportunities, plans to work
together over next year