Chronic Disease Management PSP master PowerPoint template specifications Font throughout: Myriad Pro Title font colour: RGB 220 102 30 All text font colour: RGB 76 89 89 Title and ending slides: Title: 44 font Speaker: 32 font Place and date: 20 font Content slide (positions from top left corner): Title: 32 font; title text box: horizontal 0.56” vertical 0.25” Main text box: horizontal 0.56” vertical 0.25” Footnote: 12 font; horizontal 0.56” vertical 7.25” Font sizes and bullets: see slide 2 PSP logo: horizontal 9.23” vertical 7”; size = height 0.75”, width 1.74” Page number: horizontal 10.39” vertical 7.67” Position of graphics and text from top left corner: Top graphic: horizontal -.01” vertical 0.12” (short orange and long taupe) Bottom graphic: horizontal 0” vertical 8.08” (long taupe and short orange) PSP logo: horizontal 1.06” vertical 1.17” ‘ size = h 1.29” w 3” Master title: horizontal 0.56” vertical 3.5” Speaker: horizontal 0.56” vertical 5.08” Date and place: horizontal 0.56” vertical 5.92” Information box: horizontal 1.64” vertical 3.17” MOH / BCMA logos: horizontal 6.72” vertical 7.04”; size = h 0.71” w 2.5” – must be on title and ending slides GPSC / SSC / Shared Care logos: horizontal 3.46” vertical 5.83”; size = h .66” w 4.82” – must be on last/ending slide PSP website URL pspbc.ca: horizontal 1.06” vertical 7.17”; size = h .39” w 3” – must be on title and ending slides Chronic Disease Management Learning Session 3 Presenter’s name here Location here Date here

Faculty/Presenter Disclosure Speaker’s Name: Speaker’s Name Relationships with commercial interests: Grants/Research Support: PharmaCorp ABC Speakers Bureau/Honoraria: XYZ Biopharmaceuticals Ltd Consulting Fees: MedX Group Inc. Other: Employee of XYZ Hospital Group Please fill out all applicable areas (highlighted in red). One slide per speaker.

Disclosure of Commercial Support This program has received financial support from [organization name] in the form of [describe support here – e.g. educational grant]. This program has received in-kind support from [organization name] in the form of [describe the support here – e.g. logistical support]. Potential for conflict(s) of interest: [Speaker/Faculty name] has received [payment/funding, etc.] from [organization supporting this program AND/OR organization whose product(s) are being discussed in this program]. [Supporting organization name] [developed/licenses/distributes/benefits from the sale of, etc.] a product that will be discussed in this program: [enter generic and brand name here]. Please fill out all applicable areas (highlighted in red).

Mitigating Potential Bias [Explain how potential sources of bias identified in slides 1 and 2 have been mitigated]. Refer to the College of Family Physicians of Canada’s “Quick Tips” document. Please fill out all applicable areas (highlighted in red). Please visit the following link for the CFPC’s “Quick Tips” document: http://www.cfpc.ca/uploadedFiles/CPD/Mainpro_-_Maintenance_of_Proficiency/QuickTips_COI_Final_ENGLISH.pdf

Some info A few housekeeping items: cells, washrooms. We know emergencies sometimes come up, please feel free to leave the room if you need to take a call The agenda is on the table in front of you. Of importance you will note we are having a break for coffee around: (time) Housekeeping washrooms and nearest fire exist Ground rules Respect all ideas and opinions Share experiences with your peers On time back from break Cell phones on mute or vibrate?

Overview Welcome 5 minutes Successes and challenges from Action Period 2 80 minutes Break 15 minutes Sustaining the Gains 40 minutes CME and/or community presentation (optional) 40 minutes

Objectives Action Period 2 successes and challenges <insert any relevant CME here> Develop plan for further change and sustainability

Ground Rules Respect all ideas and opinions Share experiences On time back from break

Action Period Report-Out Tests of change Measurement Successes Challenges Attempt to get presenters who can speak to: Changes tried in patient care, changes tried in work flow, and changes tried in MOA role. Have multiple practice presenting to show multiple ideas in action. Note to coordinator: Sharing could begin with your GP champion modeling the format. Patient experience could be shared at this time Optional: Use the next 12 slides as a reporting template Every office to share their stories (successes, challenges, measures/data, what you learned, what you would try next) What was your aim Measures What did you try? Challenges? Successes? Share any patient stories What will you try next? Whenever possible include: Individual run charts that show an improvement Any aggregate data on a run chart …/

Storyboard Template

Our Team Our team aim statement: Our team members (photo encouraged)

Our Results so far Insert numeric data, include run charts on key measures for the module.

Changes tested or implemented…

Other changes we couldn’t resist testing

From all this testing, we have learned…

We are surprised by…

Next, we wonder if we should…

Reflections What is one idea that you want to try? What is one thing you still have questions about?

Practice Support Program Storyboard Template Team Name:___________ Date:___________

Digging deeper into data

Small Table / Group Discussion Challenges in the data How to embed data into practice MOA’s role and experiences in data collection and analysis Questions from action period

CME and/or community presentation (optional)

Sustaining your goals

Why Focus on Sustainability? Up to 70% of change initiatives fail, impacting: Best possible care Staff and provider frustration Reluctance to engage in future Implementing a change in practice does not guarantee it will sustain long term. In order to continue to reap the benefits from your hard work you need to focus on how to ensure your change will ‘stick’. The risk of failing to sustain your changes is not just clinical, but can effect provider and staff satisfaction and future change efforts.

Why don’t changes sustain? Benefits for patients and staff are not clear Changes are not credible Changes are not part of the workflow No one is monitoring over time All staff have not be trained on changes Key clinical leaders have not been engaged The changes do not fit with the priorities of the clinic The good news is that teams involved in this module have had a head start because of your community approach to care. This helps by: Having more partners in caring for patients and their families to insure best practice care is being provided in a patient centered way Team mates to keep you accountable and encourage you to keep going with improvements Using the ability and willingness of patients and families to be partners in their care

What can you do? Clarify what you are sustaining Engage leaders Involve and support front-line staff Communicate the benefits of the improved process Ensure the change is ready to be implemented and sustained Embed the improved process in your electronic and human processes. Build ongoing measurement

What Are You Trying to Sustain? With your community team discuss what you would like to sustain in the practice and community, is it: A specific change? A measured outcome from your efforts? An underlying culture of improvement? Relationships established in the community? A combination? (5 min) Before you focus on specific strategies to sustain your changes over time, you need to be clear on what it is you are trying to sustain. You may be trying to sustain: A specific change you implemented An outcome you have achieved through your work An underlying positive culture and attitude towards improvement Relationships you have established that contribute to your success now and into the future Or a combination of these In your team, discuss what your group would like to sustain. Source: NHS Improvement leader’s Guide: Sustainability, NHS Institute for Innovation and Improvement, 2007

Predictors of Sustainability Staff, providers and patients can describe why they like the change and its impact Providers and staff are confident and can assist in explaining to others Job descriptions reflect new roles Measurement is part of the practice and used to monitor progress The change is no longer ‘new’, but ‘the way we do things around here’ Once you have made some changes towards sustaining your gains, how will you know that your work is paying off? There are some simple ways to tell if your change is more likely to sustain over time. When you ask staff, providers and patients about the changes you have made they will be able to describe to you why the change is a good one and the impact it will have on both patient care and staff/provider experience in the clinic. Providers and staff are confident that they could explain the new way of working to others and help to train new staff or providers. Any effected job description has been changed to reflect changes in roles Measurement is ongoing even after the change has been implemented. The measures are reviewed regularly to monitor progress and any changes indicating a loss in gains results in a correction. People effected by the change do not describe it as ‘new’ or ‘being tested’ but accept it as the ‘new way of working’. Adapted from: NHS Improvement leader’s Guide: Sustainability, NHS Institute for Innovation and Improvement, 2007

Group reflection Using the PSP sustainability planner, reflect on the content of each section and identify some actions you might need to take to improve the chances of sustaining your changes.

Holding your Improvements

“The challenge is not starting, but continuing after the initial enthusiasm is gone” - Ovretveit, 2003

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 Testing is like dating—implementation like marriage

Where are you?

BETTER Creating a New System Improvement Hold Gains Spread Hold Gains What we often see in improvement is a focus on sustainability only after we have seen initial improvements in our system. Preferably we would like to start talking about and implementing aspects of our change that will increase its likelihood of sticking early in the process through how we engage, communicate and monitor what is going on. Hold Gains Design Spread Spread Langley GJ, Nolan KM, Nolan TW, Norman CL, Provost LP. San Francisco: Jossey-Bass; 2009

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. These are some of areas in which we are helping teams build skills during testing that will help the gain be held More Robust testing should lead to more successful implementation- fewer surprises- less chance of sliding back Wide range: weekdays, weekends, young patients, older patients, pts with family support, those without Foolproof: constraints, affordances, reminders, differentiation: computer order entry screen won’t go forward for certain meds w/o pt weight entered. If pain not assessed computer reminds care provider, Technology: this is improved using our manual system…rather than stop their and implement this manual approach, how could technology aid us? Some test cycles using this: replace telephone call to alert someone with test of computer alert. Match medication and id band bar codes..

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

Key Factors for Holding the Gains Clarify what you are sustaining. Engage leaders. Involve and support front-line staff. Communicate the benefits of the improved process. Ensure the change is ready to be implemented and sustained. Embed the improved process in your electronic and human processes. Build ongoing measurement. Research that has been done into what increases the likelihood that changes will be sustained has identified these 7 factors as being critical for success. In the next set of slides we will explore these in more detail. The PSP sustainability planner can help teams go through these elements and apply them to their own changes. Health Quality Ontario

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) Leadership is key to success in all aspect of improvement including sustainability. Here are some of the key actions and aspects of leadership that will impact sustainability.

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 The engagement and training of front line staff is critical to ongoing success. Here are some aspects to consider for your changes.

Communication Strategy “What’s in it for me” for each group identified. Data is tracked real-time and shared. Stories, updates and visual display of data routinely shared. Information on benefits. Communication can be hard within a busy office environment, but the sharing of information and results on your changes is critical. How have you approached the above?

Readiness to Implement The change is an improvement. It has been widely tested. No further testing needed (at this time). Targets have been achieved. Are you sure your changes are ready to be implemented and sustained or is there more testing needed? If changes are implemented before full testing has occurred you fun the risk of having unintended consequences down the road.

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. Changes are sustained best when they become ‘the way we do things around here’ this goes deeper then just everyone’s comfort with the change and extends to how it has been made a formal part of your clinic processes and support systems. As much as possible we should be striving to have the new way be the easy way to conduct our work, and have that be supported in our expectations and work processes.

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! Measurement is critical not only for when we are actively testing changes but after we have implemented as well. While the frequency and reporting may alter, it I important we still have ways to show that the changes we wanted to sustain are still operating as intended.

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? Actions to support sustainability can be taken at all times in your improvement journey. Depending on where you are these may look different. It is always best if you can review and consider the aspects of sustainability as early as possible to insure that how you are testing and engaging your staff and colleagues will support the sustainability of any gains down the road.

Next steps … Ongoing support Informal meeting and calls (3, 6, 12 months) - to help you sustain changes already made and continue to make improvements Informal meeting & calls - to share new experiences and discoveries Session evaluation Compensation forms

Next Learning Session Date Please make a note of the date of the next learning session – evening session, same format to be expected. Thanks to the physician facilitators for their leadership in this module. Again, we at PSP are here to support you and coach you each step of the way.

Practice Support Program For more information Practice Support Program 115 - 1665 West Broadway Vancouver, BC V6J 5A4 Tel: 604 736-5551 www.pspbc.ca