How to make quality improvement science acceptable and successful in primary care Lessons from a 10 year project in Australia Andrew Knight April 2014

Conflicts Clinical Advisor to the Improvement Foundation Shared funding to attend between IF and role as staff specialist Acknowledgements The Australian Primary Care Collaboratives program is funded by the Australian Government and conducted by the Improvement Foundation Colleagues – Dale Ford and many others who have contributed since 2004.

Plan 1.Explain what we have done The problem The selected solution What happened Lessons 2.Ask you reflect and discuss Are 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 6

What we did Small teams - 18 months 3 workshops – aims, evidence, improvement, change principles, measures Activity periods – PDSA cycles, measures, Monthly reports and cohort comparisons Local support Sharing of ideas

What happened Based on NPDT, Sir John Oldham Transferred 2004 and we are still doing it Multiple overlapping cohorts - national Total services participating 1949 (unique 1230 approx. 18% of total) Diabetes registers CHD registers COPD registers PDSAS 36000

What happened Access, diabetes, CHD Prevention COPD Patient self management Diabetes prevention Aboriginal health E health Quality Improvement training Chronic Kidney Disease Patient safety Cancer screening

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 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 – system change Data extraction tool Data management portal Culture change knowledge, skills, attititudes Spread National KPI reporting Aboriginal medical services

Lessons - transfer Not for profit Independence, nimbleness Adjust to local needs…politics Rigour structured sharing of intellectual property Expensive

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 Jul 18. Knight AW, Ford D, Audehm R, Colagiuri S, Best J. The Australian Primary Care Collaboratives Program: improving diabetes care. BMJ Qual Saf 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 principle Right topic Local 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