How to make quality improvement science acceptable and successful in primary care

Lessons from 10 years of work in Australia

Andrew Knight

April 2014

ConflictsClinical Advisor to the Improvement FoundationShared funding to attend between IF and role as staff specialist

AcknowledgementsThe Australian Primary Care Collaboratives program is funded by the

Australian Government and conducted by the Improvement FoundationColleagues – Dale Ford and many others who have contributed since 2004.

Plan

1. Explain what we have doneThe problemThe selected solutionWhat happenedLessons

2. Ask you reflect and discussAre there lessons for your health

system?

The Problem

1. Strengthening primary care…but how?2. 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)

Reflection

Does your primary care system resemble ours?

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.

Breakthrough Collaborative Series

7

What we did

Small teams - 18 months3 workshops – aims, evidence, improvement, change principles, measuresActivity periods – PDSA cycles, measures, Monthly reports and cohort comparisonsLocal supportSharing of ideas

What happened

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

What happened

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.

What happened –Hba1c

Mean percentage of patients with an HbA1C ≤ 7% n-743

What happened – HbA1C recorded

Mean percentage of patients on register with HbA1C results recorded

What happened – cholesterol in CHD

Mean percentage of patients with cholesterol at target

What happened – spirometry in COPD

Mean percentage of patients with spirometry recorded

What happened – plans in chronic disease

Mean percentage of patients with care plan recorded

What happened – system change

Data extraction toolData management portalCulture change• knowledge, skills, attititudesSpread• National KPI reporting• Aboriginal medical services

Lessons - transfer

Not for profit• Independence, nimblenessAdjust to local needs…politicsRigour • structured

• sharing of intellectual propertyExpensive

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.

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

Lessons - QICs

What works?Importance of team• In the literature (Ovretveit)• In Australia

• Team principleRight topicLocal support

Lessons - QICs

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

Lessons - QICs

Practice Context

Charlotte Hespe

Reflection

Would it work in your primary care system?•Introduce yourself to some people you don’t know•Share your reactions to our experience

• What would work• What wouldn’t work• What will you try