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

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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 cate.dingelstad@health.nsw.gov.au • Quic Network manager at ACI • Implementation Support – Sean.LOMAS@health.nsw.gov.au

• 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

Thanks

Lea Kirkwood

Lea.Kirkwood@health.nsw.gov.au

94644657