1. www.pspbc.ca Shared System of Care COPD HF Prototype Session 4 February 28, 2013 Wireless: Westin-Meeting Wireless Code: bcma2013

2. Session Opening Dr. Gordon Hoag

3. www.pspbc.ca Brian Deakin The Good The Bad The Ugly

4. 4

5. 5  COPD  Heart Failure  Ischemic Heart Disease  Diabetes  Renal Problems  Hypertension  Barretts Esophagus  Sleep Apnea  Former Smoker  Reformed Alcoholic My Health

6. 6 How Many Health Professionals Share My Care? 2007  Uncoordinated  Sporadic  Loosely Structured 2012  Coordinated  Continuous  Comprehensive & proactive

7. 7 Then  As I saw fit  Loosely structured  Sporadic  Incomplete  Easy Comparing My Care … Then and Now Now  Shared Coordinated  Continuous  Comprehensive  Complex

8. 8 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. My experience with COPD & HF

9. 9  “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 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! This WAS my Experience THEN

10. 10 Now  Communication  Education  Resources  Active interest › in my life › in my health My Self Management… Then  Invincible  Self-Denial  Smoked  Drank  Medications?  Huh?

11. 11  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 What Has Happened?

12. 12 Shared Care

13. 13  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 Break Out Sessions – Part 1

14. Break

15. Break Out Sessions – Part 2

16. Creating Shared Care in a Northern Health Practice

17. Shared Care – Heart Failure Prototyping in Maple Ridge July – December 2012

18. 18  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 Our Team

19. 19  Focus on clinical pearls  Build the Network  Connect with resources Our Goals

20. 20  2 team meetings to plan learning sessions  2-2 hour learning sessions  Optional Practice/Support visits What We Did

21. 21  Clinical Review  Case Studies  Registry Building  Boardwalk Activity Content of Learning Sessions

22. 22  Patient Self Management › Local Community Resources › Heart Failure Zones › Smoking Cessation Content of the Learning Sessions

23. 23  Registry building  Smoking Cessation  Case Finding  Resource Access Support Visits

24. 24  Shared Care COPD Module to begin in April The Future

25. 25 For more information Jennifer Montgomery Jennifer.montgomery@fraserhealth.ca Sophia Tanaka Sophia.tanaka@fraserhealth.ca

26. Lunch

27. Idea BONANZA! Christina Southey

28. 28 Pa, I think these folks have some ideas in ‘em.

29. 29 If you were 10 times bolder, what would you test to improve shared care for HF/COPD in your community.

30. 30 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. Step 1

31. 31 Walk around the space trading cards with everyone you pass Step 2

32. 32 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! Step 3

33. 33 Repeat 4 more times Step 4

34. 34 After 5 rounds tally up the numbers on the back of the 5 th cue card. Give a score out of 25. Step 5

35. www.pspbc.ca Planning for Sustainability aka Holding the Gains Connie Davis

36. 36  Define sustainability  Describe what ‘sustainability actions’ to take during testing and implementation  Create a sustainability plan Objectives

37. 37 What is Sustainability?

38. 38 › 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 What is Sustainability?

39. 39 The challenge is not starting, but continuing after the initial enthusiasm is gone Ovretveit, 2003

40. 40 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? Model for Improvement ActPlan StudyDo Langley et al, The Improvement Guide, 2009

41. 41  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 vs Implementation vs Spread

42. 42 Spreading to other locations/processes Developing a change Implementing a change (HTG) Testing a change ActPlan StudyDo Theory and Prediction Test under a variety of conditions Make part of routine operations Robert Lloyd The Sequence for Improvement and Spread

43. 43 Improvement Hold Gains Spread Improvement Hold Gains Spread BETTER Design Spread Langley GJ, Nolan KM, Nolan TW, Norman CL, Provost LP. San Francisco: Jossey-Bass; 2009 Creating a New System

44. 44  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 During Testing— Before We Even Implement!

45. 45  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? Think of a Time

46. 46  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 During Implementation

47. 47 Collect Data Over Time When Conditions are Expected to Change Baseline Testing Successful Testing Begin implementation on pilot unit Evidence of improvement during implementation

48. 48 Project Name: Project Manager: Source: Improvement Guide, Pg 185 Implementation Cycle

49. 49 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 Key Factors for Holding the Gains Health Quality Ontario

50. What are You Sustaining?

51. 51  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 for Sustainability

52. 52  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 Involving Front Line Staff

53. 53  WIIFM for each group identified  Data is tracked real-time and shared  Stories, updates and visual display of data routinely shared  Information on benefits Communication Strategy

54. 54  The change is an improvement  It has been widely tested  No further testing needed (at this time)  Targets have been achieved Readiness to Implement

55. 55  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 Embed the Improved Process

56. 56  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 Strategy

57. 57  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? Sustainability at Every Stage

58. Evaluation Introduction Marcus J. Hollander, PhD

59. 59  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. Evaluation Overview

60. 60  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. Evaluation Overview (cont’d)

61. 61  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. Evaluation Overview (cont’d)

62. Next Steps Fraser Health Lulu Island Interior Health Bridgeport Northern Health Gulf of Georgia Vancouver Coastal Steveston A VIHA Steveston B

63. Report Out