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Shared System of Care COPD HF Prototype Session 4 February 28, 2013 Wireless: Westin-Meeting Wireless Code: bcma2013 www.pspbc.ca Session Opening Dr. Gordon Hoag Brian Deakin The Good The Bad The Ugly www.pspbc.ca 4 My Health COPD Heart Failure Ischemic Heart Disease Diabetes Renal Problems Hypertension Barretts Esophagus Sleep Apnea Former Smoker Reformed Alcoholic 5 How Many Health Professionals Share My Care? 2007 Uncoordinated Sporadic Loosely Structured 2012 Coordinated Continuous Comprehensive & proactive 6 Comparing My Care … Then and Now Now Then As I saw fit Shared Coordinated Loosely structured Continuous Sporadic Comprehensive Incomplete Complex Easy 7 My experience with COPD & HF 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. 8 This WAS my Experience THEN “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! 9 My Self Management… Now Communication Education Resources Active interest › in my life › in my health Then Invincible Self-Denial Smoked Drank Medications? Huh? 10 What Has Happened? 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 11 Shared Care 12 Break Out Sessions – Part 1 Predictive Modelling and PROOF - Ella Young, Dr. Bruce McManus and Janet McManus Steveston Updated HF and Co-morbid materials - Drs. Sean Virani and Mark FitzGerald Bridgeport Partners in Care - Aman Hundal, Clay Barber Lulu Island Brief Action Planning - Connie Davis Gulf of Georgia 13 Break Break Out Sessions – Part 2 Creating Shared Care in a Northern Health Practice Shared Care – Heart Failure Prototyping in Maple Ridge July – December 2012 Our Team 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 18 Our Goals Focus on clinical pearls Build the Network Connect with resources 19 What We Did 2 team meetings to plan learning sessions 2-2 hour learning sessions Optional Practice/Support visits 20 Content of Learning Sessions Clinical Review Case Studies Registry Building Boardwalk Activity 21 Content of the Learning Sessions Patient Self Management › Local Community Resources › Heart Failure Zones › Smoking Cessation 22 Support Visits Registry building Smoking Cessation Case Finding Resource Access 23 The Future Shared Care COPD Module to begin in April 24 For more information Jennifer Montgomery [email protected] Sophia Tanaka [email protected] 25 Lunch Idea BONANZA! Christina Southey Pa, I think these folks have some ideas in ‘em. 28 If you were 10 times bolder, what would you test to improve shared care for HF/COPD in your community. 29 Step 1 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. 30 Step 2 Walk around the space trading cards with everyone you pass 31 Step 3 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 me 5 = I love this idea and want to try it! 32 Step 4 Repeat 4 more times 33 Step 5 After 5 rounds tally up the numbers on the back of the 5th cue card. Give a score out of 25. 34 Planning for Sustainability aka Holding the Gains Connie Davis www.pspbc.ca Objectives Define sustainability Describe what ‘sustainability actions’ to take during testing and implementation Create a sustainability plan 36 What is Sustainability? 37 What is Sustainability? › 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 38 The challenge is not starting, but continuing after the initial enthusiasm is gone Ovretveit, 2003 39 Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Langley et al, The Improvement Guide, 2009 Act Plan Study Do 40 Testing vs Implementation vs Spread 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 41 The Sequence for Improvement and Spread Make part of routine operations Test under a variety of conditions Theory and Prediction Testing a change Developing a change Spreading to other locations/processes Implementing a change (HTG) Act Plan Study Do Robert Lloyd 42 Creating a New System Improvement Hold Gains Spread BETTER Improvement Hold Gains Design Spread Spread Langley GJ, Nolan KM, Nolan TW, Norman CL, Provost LP. San Francisco: Jossey-Bass; 2009 43 During Testing— Before We Even Implement! 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 44 Think of a Time 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? 45 During Implementation 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 46 Collect Data Over Time When Conditions are Expected to Change Baseline Begin implementation on pilot unit Testing Successful Testing Evidence of improvement during implementation 47 Description of change: Implementation Cycle Implementation dates: From to . Predicted impact of change on key measures: •Current Level of Performance •Measure ACT PLAN •1 • • • •2 • • • •3 • • • •4 • • • •5 • • • •6 • • • •7 • • • •8 • • • Processes or Products affected by the change: •Processes or Products Affected - Objective - W hat changes are to be made? - Questions and predictions - Next cycle? - Plan to answer the questions (who, what, where, when) STUDY - Complete the analysis of the data - Compare data to predictions - Summarize what was learned DO - Carry out the plan - Collect the data - Begin analysis of the data •Predicted Level after Change •Process or Product Owner •Number of People Affected •Change in Standard? •Yes/No •Predicted Acceptance •High/Med/Low •1 • • • • • •2 • • • • • •3 • • • • • •4 • • • • • •5 • • • • • •6 • • • • • •7 • • • • • •8 • • • • • 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: Impact on training: Training procedure defined for implementation. Comments: Training resources allocated. Comments: Training schedule complete. Comments: New employee training procedure complete. Comments: 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: Source: Improvement Guide, Pg 185 48 Key Factors for Holding the Gains 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 Health Quality Ontario 49 What are You Sustaining? Leadership for Sustainability 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) 51 Involving Front Line Staff 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 52 Communication Strategy WIIFM for each group identified Data is tracked real-time and shared Stories, updates and visual display of data routinely shared Information on benefits 53 Readiness to Implement The change is an improvement It has been widely tested No further testing needed (at this time) Targets have been achieved 54 Embed the Improved Process 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 55 Measurement Strategy 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! 56 Sustainability at Every Stage 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? 57 Evaluation Introduction Marcus J. Hollander, PhD Evaluation Overview 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. 59 Evaluation Overview (cont’d) 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. 60 Evaluation Overview (cont’d) 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. 61 Next Steps Fraser Health Lulu Island Interior Health Bridgeport Northern Health Gulf of Georgia Vancouver Coastal VIHA Steveston Steveston B A Report Out