Collaborative Handbook

The material contained within the handbook was based on an original concept, designed by the National Primary Care Development Team (NPDT) in England, now known as the Improve- ment Foundation Limited. Some of the material within the handbook was supplied by and is used with the kind permission of the Improvement Foundation, who retain copyright over their original work. Other material has been adapted from the Improvement Foundation’s work. © 2006 Health Quality Council (HQC) Please contact the Health Quality Council for written permission to distribute or copy this document, in whole or in part. Permissions do not extend to any materials within this document that are used with the permission of a third party. Please use the following citation style when referring to this document: Health Quality Council. Saskatchewan Chronic Disease Management Handbook. Saskatoon, SK: Health Quality Council. 2006.

November 2006 A message from the Chief Executive Officer katchewan’s health care to care is a key component community. of chronic disease management. And so we added the We began thinking about a third topic area to the Col- Collaborative after the re- laborative. lease of our first major report, looking at the quality of Wave 1 began in November care for post-heart attack 2005, with more than 200 patients. There was great health care providers, medi- interest from providers and cal office staff, managers, health regions to improve and others, including pa- care in this area, and the tients, taking lead roles. For W Collaborative approach was the past year, these teams elcome to a natural fit. As we ap- have been making small but Wave 2 of the proached our stakeholders powerful changes. Indeed, Saskatche- with the idea, we heard many of these are shared in wan Chronic Disease Man- again and again that diabe- the Ideas in Action section of agement Collaborative, and tes and heart disease were this handbook. I know that congratulations on being strongly linked. Indeed, this Wave will also contrib- part of the largest quality there is a push to consider ute a wealth of knowledge improvement initiative in our diabetes as a cardiovascular and ideas that will help pro- province. As CEO of Health disease. pel change forward. Quality Council, I speak for everyone involved with our We were encouraged to Thank you for taking up the organization when I say how consider running a Collabo- challenge to make the Col- proud we are of all the rative on both topics, and we laborative vision a reality: to champions participating in agreed that the two be- improve the care and health this initiative. longed together. As the pro- of people living with coro- ject progressed, we linked nary artery disease and dia- HQC may be leading the with other organizations that betes in Saskatchewan, and Collaborative, but I truly con- had run Collaboratives – the to improve access to physi- sider it a “grassroots” initia- National Primary Care De- cian practices. tive. We would not be em- velopment Team, the Insti- barking on this journey with- tute for Healthcare Improve- out the encouragement of ment, and the British Colum- our health care partners. It bia Heart Healthy Collabora- has been heartening to see tive. These dialogues high- the drive and enthusiasm for lighted the importance of Ben Chan, MD MPH MPA improvement from Sas- improving access, as access Chief Executive Officer

November 2006 A message from the Clinical Chair valuable parts of the Col- There are a few that I have laborative. found particularly exciting. Group visits are a new way The second thing that to deliver care, and a comes to mind is how moti- method that I think will be- vating it is to know what kind come more prevalent. Col- of care you are providing. laborative teams have tried Not just to think you are pro- the group visit and found viding good care, but to that it offers some important know without a doubt when benefits to patients. I have you have achieved it. This also watched with interest as I information is inspiring for team members have tried t has been almost patients as well as care pro- new roles, and looked at dif- one year since I, viders. When a patient ferent, more efficient ways of along with 200 brave comes to an appointment dividing the work. We’ve pioneers, embarked on a and sees his flowsheet, and seen non-clinicians learn journey to improve the qual- can see that the lifestyle more about patient care and ity of care for patients with choices—diet and exer- pharmacists providing en- diabetes and coronary artery cise—are making a differ- hanced patient education, to disease, and to improve ac- ence, that flowsheet be- name just a few changes. cess to practices. As we comes a powerful tool for start Wave 2, I can’t help but change. You can see that for I know this next year will be look back on the first 12 the first time, the patient as exciting as the first, be- months of this experience. truly understands how to cause there is still much we manage his or her chronic can learn together. Through- The first thing that comes to disease. The patient transi- out the journey, you will be mind is how exciting it has tions from being a user of supported by your Clinical been to be part of a some- health care services, to be- Leadership team, the Col- thing so innovative. It has ing a partner in care. laborative Facilitators in been rewarding to work dif- each region, and by the en- ferently with people and pro- The past year has also held tire HQC team. Together we viders in my community, and moments of amazement, will make Saskatchewan a to connect with people out- learning about what other leader in managing chronic side of my community. So participants are doing to disease. often in health care we work make change. There seems in silos; the opportunity to to be no end to the great engage other clinicians be- ideas being tried. You can yond my region’s borders read about these ideas in Dr. Vino Padayachee has been one of the most the Ideas in Action section. Clinical Chair

Acknowledgements Development of this Handbook was led by Shari Furniss, HQC Communications Consultant, with input from the following HQC staff: • Helena Klomp, Senior Researcher • Katherine Stevenson, Knowledge Exchange Consultant • Tanya Verrall, Researcher • Debra Woods, Knowledge Exchange Consultant • Maureen Bingham, Director of Linkage and Exchange • Pete Welch, Informatics Consultant • Bonnie Brossart, Program Director/Deputy CEO Our sincere appreciation to Dr. Mark Cameron, Dr. Carla Eis- enhauer, Dr. Tessa Laubscher, Dr. Vino Padayachee, and Dr. Ben Chan, for their review of and expert feedback on working versions of this document. ISBN 1-897155-24-7

Overview Included in this section: Mission…..Vision…..Three models together…..Learning model…..Model for Improvement…..Chronic care model © Health Quality Council 2005

Vision and mission Our vision is to improve the care and health of people living with coronary artery disease and diabetes in Saskatchewan, and to improve access to physician practices. Our mission is to assist Saskatchewan health care professionals and organizations to develop their capacity and capability to deliver rapid, sustainable, and systematic improvements in the care they provide to patients with chronic disease. This will be achieved through understanding and the effective application of quality improvement methods and skills. © Health Quality Council 2006 1-1

Three models together The Chronic Disease Management Collaborative brings together three key models to improve quality of care for people with chronic disease. Although at first three models may seem overwhelming, they actually work together quite easily. Guided by the evidence-based principles of good chronic care (Expanded Chronic Care Model), health care professionals and organizations become part of a network of experts and fellow learners (the Collaborative Learning Model) in order to gain skills in performing rapid, small tests that lead to the implementation of changes that make sense in each unique setting (Model for Improvement). The next few pages will go over each of these three models in more detail. © Health Quality Council 2006 1-2

The Learning Model The Collaborative Learning Model makes health care professionals and organizations part of a network of experts and fellow learners. A Collaborative is a learn-by-doing approach to quality improvement. It brings together practitioners from various disciplines and sites. A Collaborative teaches ideas on how to improve practices (based on evidence found in research literature). Throughout the Collaborative, participants and sites share their experiences and learn from one another, and networks are established. Quality improvement Collaboratives have been used successfully in many countries over the last decade to achieve rapid improvements in healthcare delivery, and covering a variety of topic areas. This unique and results-oriented approach to quality improvement was pioneered by the Institute for Healthcare Improvement (IHI) and Associates in Process Improvement. In 1995, the IHI organized a series of Collaboratives referred to as the Breakthrough Series. These Collaboratives targeted ten topic areas needing improvement, as identified in surveys and interviews with healthcare leaders. Topic areas included: caesarean section rates, physician prescribing practices, adult intensive care, neonatal intensive care, adult cardiac surgery, asthma care, low back pain, adverse drug events, inventory levels and supplier management, and, reducing delays and wait times. The Collaborative model has been successful in supporting quality improvement in health care in the US, the UK, Australia, Europe, and Canada. A review of the outcomes from the Cana- dian Adult ICU Collaborative demonstrates that the Collabora- tive approach combined with a change method (the Improve- ment Model) and a supporting infrastructure can and has made significant improvements in delivery of intensive care to adults. © Health Quality Council 2006 1-3

Key features of a Collaborative It’s Collaborative with a capital “C”. A Collaborative is not just working together collaboratively, nor is it: • A fix-all solution. The Collaborative approach does not work for every improvement project. • A research project for new knowledge. A Collabora- tive is about putting evidence into practice. • A set of conferences. Four Learning Workshops are held during the course of a Collaborative. These Learning Workshops are structured events used to spread best practices. Conferences are about receiving information, but Learning Workshops are about sharing information. • A passive exercise. Between Learning Workshops, participants engage in an Action Period. They implement and test small-scale changes to meet the overall improvement aims. • An easy option. The Collaborative culture is about group learning and rapid doing, flexibility in ideas and methods, but firm on results. Participants are challenged to build a stronger team, share success, and learn from failures. Collaborative Process How a Collaborative works Select Topic Participants 1. A Collaborative begins with the selection of a topic. Factors typically considered in choosing a topic: Reference Panel Pre- • Are there gaps in existing service? work Identify Change • Is it a common problem? LW0 LW1 LW2 LW3 Concepts • Is there evidence of a better system? SPREAD • Is it a priority for clinicians? Support Adapted from the 2. Based on the topic chosen, appropriate National Primary Care experts are invited to join an Expert Reference Panel. The Development Team. Expert Reference Panel advises the planning group on goals, aims, measurement strategies, and change concepts. © Health Quality Council 2006 1-4

Key features of a Collaborative 3. Sites are then invited to participate in the Collaborative. In- formation meetings are held to discuss the project with key stakeholders. Each participating site establishes a multi- disciplinary quality improvement team. 4. The Learning Workshop Orientation (LWO) is held. QI teams review expectations and learn about quality improvement, including the Model for Improvement and data measurement. They are also introduced to available support people such as Collaborative Facilitators and the Clinical Team. 5. Participants attend three more Learning Workshops (LWs) during the course of the Collaborative. At these sessions, participants share results, exchange ideas, and develop strategies for change. In between Workshops, teams test and implement changes, collect data, and track improvements. This is called the Action Period. y p Act Plan • Objective • What changes • Questions/predictions During Action Periods, are to be made? • Plan to carry out the cycle QI teams use the Plan- (who, what, where, when) Do-Study-Act cycle to • Next cycle? •Plan for data collection implement and test small changes. Study Do • Complete the • Carry out the plan analysis of the data • Document problems • Compare data to and unexpected predictions observations • Summarize what • Begin analysis was learned of the data © Health Quality Council 2006 1-5

Why a Collaborative? The Collaborative approach does not work for every improvement project. But under the right circumstances, it can accelerate change and be enormously effective. Examples of Collaborative achievements The Improvement Foundation Formerly the National Primary Care Development Team (England) The non-profit Improvement Foundation incorporates the work of the former National Primary Care Development Team (NPDT). The NPDT was originally established in February 2000 to run the National Primary Care Collaborative (NPCC), currently the world’s largest improvement program. To start, the focus was on three areas: improving care for patients with coronary artery disease, improving access to appointments, and improving access to routine secondary services. Since then, they have completed Collaboratives in areas such as improving care for patients with diabetes and developing healthy communities. The NPCC, the first of the NPDT’s programs, now engages 5,000 practices covering more than 32 million people. A few examples of their achievements: • A four-fold greater reduction in coronary heart disease mortality in Collaborative sites, compared to the rest of England • Estimated to have saved 6,070 lives • A 17% improvement in diabetic patients with excellent control (A1C<7.5%) • More than 70% improvement in waiting times to see a GP • Average patient wait to see a GP reduced from 5 days to less than 1.5 days Source: www.improve.nhs.uk, accessed September 12, 2006. © Health Quality Council 2006 1-6

Why a Collaborative? Scottish Primary Care Collaborative (Scotland) The Scottish Primary Care Collaborative is a partnership between the NPDT and the Scottish Executive Centre for Change and Innovation. It was established as a result of the success of Phase I and II of the National Primary Care Collaborative. The focus of the Scottish Collaborative is on improving access to physician practices and improving the care of patients with diabetes. The SPCC Phase I involves 38 sites, 182 core practices and 13 of the 15 Health Boards in Scotland, and has the potential to benefit 3.2 million patients within Scotland. In the first 5 months they have achieved the following results: • 20% improvement in proportion of patients with A1C < 7.5% • 25% improvement in proportion of patients with cholesterol < 5 mmol/L • 23% improvement in proportion of patients with blood pressure < 140/80 • More than 35% improvement in days to 3rd next available appointment with GP Source: www.show.scot.nhs.uk, accessed September 12, 2006. National Primary Care Collaborative (Australia) The National Primary Care Collaborative is a partnership between the NPDT and Australia’s Flinders University. Australia is similar to Saskatchewan in that they have a mix of fee-for- service and alternate payment family physicians/general practitioners. They too have vast distances, remote and rural populations, and an Aboriginal population. The NPCC program is national in scope and focuses on three © Health Quality Council 2006 1-7

Why a Collaborative? topic areas: secondary prevention of coronary heart disease, diabetes, and better patient access to appointments. A few examples of their achievements to date: • 90% improvement in CHD patients recorded as being on a statin • 51% increase in percentage of diabetes patients with last recorded A1C of ≤ 7.0% • 69% improvement percentage of diabetes patients with last measured total cholesterol of < 4.0 mmol/L • 21% increase in patients seen by practice on day of choice Source: www.npcc.com.au, accessed September 12, 2006. Health Disparities Collaborative (Institute for Healthcare Improvement, USA) In 1998 the Health Resources and Services Administration in the United States partnered with the Institute for Healthcare Improvement (IHI) on a Health Disparities Collaborative. The goal of the Collaborative was to provide support to over 3,500 communities and 12 million underserved and underinsured people, such as the homeless and migrant workers. The first Health Disparities Collaborative focused on diabetes. Other Collaboratives have been done on asthma, depression, cardiovascular disease, and cancer. Some highlights from their work: • 300% increase in the number of patients meeting the goal of two A1C tests per year • More than 30,000 patients enrolled in active care registries Source: www.healthdisparities.net, accessed September 12, 2006. © Health Quality Council 2006 1-8

Why a Collaborative? Partners in Health (Peru) In 1990, only half of patients in Peru diagnosed with tuberculo- sis (TB) were able to get treatment. Of those, nearly 50% were unable to complete the six-month course of therapy, and drugs were often in short supply. Partners in Health implemented a community-based treatment program. In 2002, they partnered with the IHI and launched a Collaborative to study and spread improvement in TB treatment. Some of their achievements to date: • In Peru, 9 out of 10 people with TB die; Partners in Health’s patients are now seeing an 80% cure rate • Of the original 1,450 patients treated under the Part- ners project, only 438 remained on treatment by the end of 2004 • Results have persuaded the World Health Organiza- tion to add TB medicines to their list of essential drugs Source: www.pih.org, accessed September 12, 2006. Healthy Heart Society (British Columbia) In 1997, congestive heart failure was the primary cause of death for people in British Columbia and was a tremendous burden on the health system, costing more than $96 million per year. The Healthy Heart Society, together with the Ministry of Health Services and the Health Authorities, launched a 15- month Collaborative to improve chronic disease management for patients with heart failure. Some of their achievements: • 272% increase in the proportion of patients on ACE or ARB • 256% increase in the proportion of patients on Beta- Blocker © Health Quality Council 2006 1-9

Why a Collaborative? • 1000% increase in the proportion of patients with self-management goals Source: www.heartbc.ca, accessed September 12, 2006. The Vancouver Island Health Authority also launched a diabetes Collaborative. It involved 6,000 patients in 52 GP practices receiving care according to evidence-based guidelines. Im- provement from March 2004 until August 2005: • Patients with A1C < 7.0% improved from 63.8% to 75.5% • Patients with systolic blood pressure of < 130/80 improved from 50.7% to 75.3 • Patients with lipid ratio < 4.0 mmol/L improved from 50.2% to 72.4% Source: Presentation by Dr. Art Macgregor, SK CDM Collabo- rative Learning Workshop Orientation, November 2005. © Health Quality Council 2006 1-10

Model for Improvement This section was adapted from England’s National Primary Care Development Team and includes references from: Langley, G. J., et al. The Improvement Guide : A Practical Approach to Enhancing Organizational Performance. San Francisco: Jossey-Bass. 1996. Introduction Our environment is constantly changing. Some changes are imposed on us and we have to find a way to manage the impact. At other times, change is something we choose to make, motivated by the desire to make things better. It is obvious to say it, but while every improvement is certainly a change, every change is not always an improvement. Making changes to the way that we do things can be time- consuming and can sometimes feel risky. The Model for Im- provement (Langley et al. 1996) is a tried and tested approach to achieving successful change. Use of the Model for Improve- ment offers the following benefits: • It is a simple approach that anyone can apply; • It reduces risk by starting small; • It can be used to help plan, develop and implement change; and, • It is highly effective. The Model for Improvement The Model for improvement was first published in 1996 by Langley et al. in The Improvement Guide: A Practical Approach to Enhancing Organisational Performance. The Model for Im- provement provides a framework for developing, testing and implementing changes to the way that things are done that will lead to improvement. The Model for Improvement consists of two parts that are of equal importance. The first, the ‘thinking part’, consists of three fundamental questions that are essential for guiding improvement work. The second part, the ‘doing part’, is made up of Plan-Do-Study-Act (PDSA) cycles that will help you make rapid changes. © Health Quality Council 2006 1-11

Model for Improvement The three fundamental questions for achieving improvement A planned approach to improving things will give you a better chance of being successful. The three fundamental questions for achieving improvement are a useful way of framing your work. 1. What are we trying to accomplish? What are we trying to This question is intended to help you be clear about accomplish? the improvements that you would like to make, what results you would like to get, and how you would like things to be different. Having a clear vision of your aims is crucial. How will we know that a change is improvement? 2. How will we know that a change is an improvement? Without measurement it is impossible to know whether you have improved. Think about how you want things to be ACT PLAN different when you have implemented your change and agree what data you need to collect to measure it. You can focus your measurement on your What changes can we results or how outcomes might be different, how make that will result in the service that your patients receive will be improvement? better, or how your processes might change. STUDY DO 3. What changes can we make that will lead to an improvement? Adapted from the National Primary Finally, you need to decide what changes you will try in order to Care Development Team. achieve the results you are looking for. What evidence do you have from elsewhere about what is most likely to work? What do you and your team think is a good idea? What have other people done that you could try? This is where you can adapt ideas or be completely creative. Remember that you know your own system best, so keep your objectives in mind and use your knowledge and experience to guide you. Gather together as many ideas as you can. These will form the basis for the next step – your PDSA ramps. © Health Quality Council 2006 1-12

Model for Improvement PDSA ramp Once you have decided exactly what you want to achieve, you can use a PDSA ramp, a series of Plan-Do-Study-Act rounds to test out your ideas developed from the third question, ‘What changes can we make that will lead to an improvement?’ The key to a PDSA ramp is to try out your change on a small scale to begin with and to rely on using many consecutive cycles to build up information about how effective your change is. This makes it easier to get started, gives results rapidly and reduces the risk of something going wrong. If what you try doesn’t work as well as you hoped, you can always go back to the way you did things before. When you have built up enough information to feel Within a PDSA ramp, you will cycle confident about your change, you can then implement it as part through many PDSAs. of your system. Think of a ‘small’ PDSA cycle in terms of the scope of your test. You might, for example, like to run your cycle over one day, with one person or in one clinic. You might wish to look at the last ten patients seen, the last twenty referrals made, or the next dozen reports. It helps to spend some time making your ‘Plan’ explicit and ensure that you are clear on the objective of the particular PDSA: what you are specifically trying to do, who will carry it out, and when and where. It is also crucial to voice your predictions because we often find what we are looking for (confirmation bias) and making our predictions explicit helps us to learn more when that prediction is confirmed or refuted. Finally, your plan should include the measures you are going to use to see if the change you are trying in this PDSA is an improvement. The ‘Do’ is simply that – try it out and document what you did as sometimes your plan and how it gets realized are somewhat different. The ‘Study’ part of the cycle gives you the opportunity to reflect © Health Quality Council 2006 1-13

Model for Improvement on what happened, think about what you have learned, and to build your knowledge for further improvement. Finally, you can move on to your next steps – the ‘Act’ part of the cycle. Do you need to run the same cycle again, gathering more evidence or making some modifications based on what you learned? Or do you need to develop further cycles to move your work forward? Practicalities • Improvement is nearly always a team endeavour. Try to ensure that you involve the right people in your work. • People have a tendency to jump straight to solutions rather than really work out what the root of the problem is. If you use the three fundamental questions, it will help you be sure that you are dealing with the issue that really needs to be addressed. • When you plan your cycle, make sure you are clear about who is doing what, where, and when. Your results are dependent on how good your plan is. PDSA planning templates (Individual and Ramp) are included in the Additional Information & Resources section. • Discuss what you think will happen when you try out your change. What is your hunch? When you have carried out the cycle, compare your expectations with what actually happened. You may learn something interesting about how things work. • Record your PDSA as you go along: the plan, the results, what you learned, and what you are going to do next. Not only is it very motivating to see the results of what you have tried, it is also a great way of © Health Quality Council 2006 1-14

Model for Improvement accumulating information about your systems and a good way of sharing your learning with other people. • Use PDSAs consecutively to build up the information about your change and then use them to implement it systematically into your daily work. PDSA cycles generally do not operate in isolation – you should expect to have a series of them leading towards your goal. And finally…. PDSAs cannot be too small One PDSA will almost always lead to one or more You can achieve rapid results They help you to be thorough and systematic They help you learn from your work Anyone can use them in any area © Health Quality Council 2006 1-15

More about PDSAs PDSA is the basis of quality improvement. It is very natural to most healthcare providers, because it mirrors the way you might approach assessing and treating a patient. When a patient presents with a problem you quite instinctively move through a PDSA. First, you need baseline data, so you collect information like temperature, BP, heart rate, throat swab, etc. Then, based on that data, you make a plan. Let’s assume that all signs point to a bacterial infection. For your do, you decide to try an antibiotic. You and your patient will study the impact of this antibiotic, looking to see if it’s having a positive or negative effect, or no effect at all. Based on this, you will act by adjusting the treatment, adjusting your diagnosis, or calling for more data through additional tests. In quality improvement, we help you move this natural process used in diagnosing and treating patients, to the level of diagnosing and treating systems; in this case, your office practice. Please see the Additional Information & Resources section for PDSA examples and templates for individual PDSAs and PDSA Ramps. © Health Quality Council 2006 1-16

Comparing QI science When we think about data and measurement, many of us who work in health care are most familiar with thinking and applying these terms within the research paradigm. This model was the foundation for the courses we took in our training and it continues to be a mainstay of our working lives. The accountability paradigm, which is likely most familiar to those with policy- making responsibilities in the public sector and those involved in quality assurance and accreditation programs, also relies on data and measurement to achieve its aim. Improvement science, on the other hand, is a paradigm that crosses all systems. Although relatively new to healthcare, it has been around for decades, most often in sectors where optimizing production processes and systems engineering has been critical for an organization’s success. The following table illustrates the three paradigms. As the table shows, the debate is not meant to be an “either/or” one but rather “why and when”. Each paradigm is distinct and unique in its purpose and methodology. Table: Comparing Measurement Paradigms Research Accountability Improvement Aim Discovery of new health Comparison, judgment, Improvement in every- care knowledge springboard for change, day care, practice, and promote public choice, healthcare delivery reassurance and education Methods Test observability Blinded test No testing, evaluate Sequential, observable current performance tests to build the will to change Bias Eliminate bias Measure and adjust to Accept stable and reduce bias consistent bias over time Sample size Collect large amounts of Obtain 100% of Collect “just enough” data “just in case” available information useful data Flexibility of hypothesis Fixed hypothesis No hypothesis Continual adaptation of the hypothesis, theories, and changes, as learning takes place Testing strategy One large study No tests Many sequential tests © Health Quality Council 2006 1-17

Chronic Care Model Part of the framework for the CDM Collaborative is the Chronic Care Model (CCM) originally developed in 1993 by Dr. Ed Wagner, in cooperation with the Robert Wood Johnson Foun- dation (Improving Chronic Illness Care), and later (2002) adapted by British Columbia as part of the Expanded Chronic Care Model (see diagram, below). British Columbia expanded the model to recognize the intrinsic role that social determi- nants of health play in influencing individual, community, and population health. All areas of action within the expanded CCM are situated within the community—building healthy public policy, creating supportive environments, and strengthening community action. Expanded Chronic Care Model Implementing Policy to Enhance Community Health Creating Supportive Develop Personal Skills Health Care Organization Environments Clinical Self Information Management Reorienting Systems HC Services Strengthening Community Delivery System Decision Action Design Support Productive Interactions Informed, Prepared, Prepared, Activated Activated & Relationships Proactive Practice Proactive Community Community Patient Team (partners) Population Health Outcomes/ Functional and Clinical Outcomes Adapted from : Victoria Barr, Anita Dotts, Brenda Martin-Lind, Darlene Ravenadale, Sylvia Robinson, Lisa Underhill (2002) This model has been successfully used to guide health system re-design for optimal chronic disease management in other ju- risdictions, including British Columbia, and is currently the provincial framework for the Saskatchewan Diabetes strategy. The © Health Quality Council 2006 1-18

Chronic Care Model CCM is evidence-based, and its implementation has been reported to improve quality of chronic care, patient outcomes, and professional satisfaction. There was general consensus among our Expert Reference Panel (held in May 2005) that the change concepts for the CDM Collaborative fit under one or more components of the Chronic Care Model. More information about the link between the Chronic Care Model and the CDM Collaborative change concepts is provided in the Change Package (See Section 2 on Improvement). According to the Institute for Healthcare Improvement, trans- forming the health care system from a system that is reactive to one that is proactive is critical to improving chronic illness care. In order to do this, health care needs to work on the following six essential elements. Six Components of the Chronic Care Model This section on six components is adapted from Self-management support the Health Disparities Patients have a central role in determining their care, one that Collaborative Training Manual for Chronic Conditions: fosters a sense of responsibility for their own health. The most successful health teams use a collaborative approach: one in http://www.ihi.org/IHI/ Topics/ChronicConditions/ which providers and patients work together to define problems, AllConditions/Tools/ set priorities, establish goals, create treatment plans, and solve HealthDisparitiesCollaborati problems along the way. vesTrainingManualforChron icConditions.htm Decision support Evidence-based guidelines are integrated into care and supported by provider education, links with specialty expertise, and reminder and fail-safe systems. Clinical information systems In order to provide good chronic care, physicians must know who the chronic care patients are, and whether they have received the medical services that are critical to managing their illness. A registry is a necessity when managing chronic illness or preventative care. It is the foundation for successful integra- tion of all the elements of the Care Model. The entire care team © Health Quality Council 2006 1-19

Chronic Care Model uses the registry to guide the course of treatment, anticipate problems, and track progress. Delivery system design Office infrastructure and clinical processes must be redesigned to accommodate planned visits, patient follow-up, and proactive care. The roles and responsibilities of clinic team members must be maximized to achieve effective and efficient work flow. In a well-designed delivery system, clinicians plan visits well in advance, based on the patient’s needs and self-management goals. During “group visits” patients see their clinician and meet with other patients with similar health problems. Non-physician clinical staff are cross-trained to provide care via standing or- ders (e.g., making referrals, ordering labs, doing foot exams, and even changing insulin under protocol). Health care organization The entire organization must be engaged in the improvement effort. Senior leaders and clinical champions are visible and committed members of the team. Personnel are given the resources and support they need to pursue quality improvement efforts. Community resources and policies Health care professionals identify effective programs and encourage their patients to participate. Practices form partner- ships with community organizations to support or develop evidence-based programs. © Health Quality Council 2006 1-20

Improvement Included in this section: Why diabetes?…..Why coronary artery disease?…..Why access? …..Definitions…..Aims…..Chronic disease management: change concepts and ideas…..Access: change concepts and ideas…..Ideas in action © Health Quality Council 2006

Why diabetes • Diabetes is a life-threatening condition. If not managed appropriately, diabetes will lead to complications such as heart disease, eye complications, kidney disease, and premature death (www.diabetes.ca). • On average, the life expectancy for someone with diabetes is 13 years shorter than for a person without diabetes (www.diabetes.ca). • Diabetes is a growing concern in our province. According to Saskatchewan Health, it is estimated that by the end of 2016, more than 70,000 people in Saskatchewan will be diagnosed with diabetes. • The total annual cost for health care for an individual with diabetes is approximately 2 to 2 1/2 times the total cost for the same individual not yet diagnosed with the condition. Johnson, J et al. The cost of developing diabetes in a co- hort of Saskatchewan residents 1991-1996. 2002. A snapshot of diabetes care in Saskatchewan In January 2006, the HQC released the results of our study on the quality of diabetes care in Saskatchewan. It showed that Saskatchewan people with diabetes need better control of blood sugar and cholesterol, and more frequent testing. With better diabetes management, the number of major complications—such as stroke, kidney disease, heart attack and death—could be reduced. Please see Figures 1 and 2 on next page for more information. © Health Quality Council 2006 2-1

Why diabetes Figure 1: Percent of Saskatchewan patients with diabetes with lab values in the optimal range, 2004. Patients were deemed to have diabetes if, in 2003, they had 3 or more A1C tests done or had an A1C value > 7%. Figure 2: Number of major diabetes-related complications is stable; persistent core of patients developing major complications. © Health Quality Council 2006 2-2

Why coronary artery disease • Coronary artery disease is a significant health concern for people in Saskatchewan. • Diabetes and heart disease are a lethal combination; 80% of people with diabetes die of heart disease or stroke. • Cardiovascular disease accounts for the death of more Ca- nadians than any other disease. In 2001 (the last year for which Statistics Canada has data) cardiovascular disease accounted for 74,824 Canadian deaths (www.heartandstroke.ca). • In September 2004, the Health Quality Council released a report on the quality of post-heart attack care in Saskatche- wan. It showed that many of our province’s patients were not receiving key medications (beta-blockers, ACE inhibitors, statins) proven to save lives and prevent secondary heart attacks. • With better drug management, we could save approximately 45 lives each year in our province. © Health Quality Council 2006 2-3

Why coronary artery disease Figure 1: 90-day post-discharge dispensing rates for beta- blockers, ACE inhibitors, and statins for acute myocardial infarction (AMI) patients age 20 and older in Saskatchewan, 1997-98 to 2001-02 Target=85% 100% (Beta-blockers and ACE inhibitors) 80% Target=70% (Statins) Dispensing rate 60% 40% 20% 0% 1997-98 1998-99 1999-00 2000-01 2001-02 Beta-blockers ACE inhibitors Statins Figure 2: Dispensing rates for beta-blockers, ACE inhibitors, and statins at 3, 90, and 365 days post discharge, for acute myocardial infarction (AMI) patients age 20 and older, in Sas- katchewan, 2000-01 100% Dispensing rate 80% 65% 63% 57% 54% 60% 51% 53% 40% 33% 32% 36% 20% 0% Beta-blockers ACE-inhibitors Statins 3 day 90 day 365 day © Health Quality Council 2006 2-4

Why coronary artery disease Table 1: Provincial comparison of 90-day dispensing rates for beta-blockers, ACE inhibitors, and statins for new acute myocardial infarction (AMI) patients 65 and older, 1999-2000 Saskatchewan Nova Scotia Quebec Ontario British Columbia Beta-blockers 68% 83% 68% 68% 56% ACE inhibitors 65% 58% 57% 65% 53% Statins 29% 36% 43% 40% 35% © Health Quality Council 2006 2-5

Why access • Improvement is possible in a variety of clinical settings. • The National Primary Care Development Team’s Collabora- tive on Improved Access achieved remarkable success. Participants showed more than 70% improvement in waiting times to see a GP and over 60% improvement in waiting times to see a practice nurse. The average patient wait time was reduced from 5 days to less than 1.5 days. • Improving access frees up capacity to expand other areas of work. • Improving access can help practices improve clinical outcomes, especially in chronic disease management. In one NPDT Collaborative, improving access facilitated better chart reviews and improved coronary heart disease registries. • Practices report improved patient, staff, and provider satisfaction, in addition to improved clinical outcomes. “The advantages to the Practice have been that the staff are happier, the majority of patients are happier and the doctors are less stressed.” -from a participant in the NPDT Access Collaborative • The Saskatoon Community Clinic was the first practice in Saskatchewan to implement an Improved Access model. Since starting the process in 2004, they have seen significant reductions in wait times for both long and short appointments. (See page 2-76 for a profile of Saskatoon Com- munity Clinic.) © Health Quality Council 2006 2-6

Definitions For the purposes of the Saskatchewan Chronic Disease Man- agement Collaborative, diabetes and coronary artery disease have been defined as follows: Diabetes The Collaborative follows the Canadian Diabetes Association Important note! definition of diabetes mellitus: Patients already diagnosed ...a metabolic disorder characterized by the presence of hyper- with diabetes DO NOT need to be retested for the glycemia due to defective insulin secretion, insulation action, or Collaborative. both. The chronic hyperglycemia of diabetes is associated with significant long-term sequelae, particularly damage, dysfunc- tion and failure of various organs—especially the kidneys, eyes, nerves, heart, and blood vessels. Diagnostic criteria for diabetes are summarized below. These criteria are based on venous sample methods used in the laboratory. FPG ≥7.0 mmol/L Fasting = no caloric intake for at least 8 hours or Casual PG ≥ 11.1 mmol/L + symptoms of diabetes Casual = any time of the day, without regard to the interval since the last meal Classic symptoms of diabetes = polyuria, polydipsia and unexplained weight loss or 2hPG in a 75-g OGTT ≥ 11.1 mmol/L A confirmatory laboratory glucose test (an FPG, casual PG, or a 2hPG in a 75-g OGTT) must be done in all cases on another day in the absence of unequivocal hyperglycemia accompanied by acute metabolic decompensation. 2hPG = 2-hour plasma glucose / FPG = fasting plasma glucose / OGTT = oral glucose tolerance test / PG = plasma glucose Ref: Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2003 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes 2003;27(Suppl 2):S1-152. Coronary Artery Disease Coronary artery disease (CAD) is defined as an established history of CAD including (acute) myocardial infarction (AMI), acute coronary syndrome, revascularization (i.e. coronary artery bypass surgery, angioplasty), or angina. Co-morbidity can exist. The definition excludes patients with isolated diagnoses of the following: PVD, TIA, ischemic stroke, atrial fibrillation, and heart failure. © Health Quality Council 2006 2-7

Aims Aims are developed to provide direction for all CDM Collaborative participants. They are an explicit statement about we hope to achieve through the CDM Collaborative. They are evidence-based, reflective of current guidelines on diabetes and heart disease management, and are based on leading practice in delivering care. Each team in the CDM Collaborative will capture their own baseline measures and then report on percent improvement for each aspect of the Diabetes, Coronary Artery Disease, and Ac- cess aims. The aims are not set at 100% because there will always be a segment of the population who cannot or should not be achieving the target values. Diabetes Patients living with diabetes (Types 1 and 2) within participating practices are well-managed, as evidenced by each of the following targets: • 75% of patients with A1C ≤ 7.0 % • 75% of patients with blood pressure ≤ 130/80 • 75% of patients with TC/HDL ratio < 4.0 Coronary artery disease Over the next five years, there will be a greater reduction in mortality of patients with coronary artery disease in participating practices, compared to the rest of Saskatchewan. There is an improvement in the management of patients with coronary artery disease in participating practices, as evidenced by each of the following targets: • 75% of patients receiving anti-platelet therapy • 75% of patients with blood pressure < 140/90 or ≤130/80 (if patient has diabetes or renal disease) • 75% of patients with TC/HDL ratio < 4.0 Improved access Eighty percent of patients in participating practices are seen on the day of their choice. © Health Quality Council 2006 2-8

Change Package Chronic Disease Management © Health Quality Council 2006

Change package—chronic disease management Change package A change package is an evidence-based set of changes that are critical to the improvement of an identified care process. The Chronic Care Model serves as the foundational change package that guides improvement in chronic illness. Expanded Chronic Care Model Components of the Chronic Care Model Implementing Decision support—The Community Policy to Enhance Health clinical care provided must Creating be consistent with evi- Supportive Develop Personal Skills Health Care Organization Environments Self Clinical Information dence-based best prac- Management Strengthening Reorienting HC Services Systems tices. Community Delivery System Decision Action Design Support Clinical information sys- Productive Interactions tems—In order to provide Activated Informed, Activated & Relationships Prepared, Prepared, Proactive Practice Proactive Community good chronic care, physi- Community Patient Team (partners) cians must know who their chronic care patients are, Population Health Outcomes/ Functional and Clinical Outcomes and whether they have received the medical ser- Adapted from : Victoria Barr, Anita Dotts, Brenda Martin-Lind, Darlene Ravenadale, Sylvia Robinson, Lisa Underhill (2002) vices that are critical to managing their illness. A mechanism for physician reminders, patient recall, and follow-up are also needed. Self-management—Patients must be knowledgeable about their chronic illness and have the skills and confidence to take responsibility for the management of their chronic illness. Delivery system design—Office infrastructure and clinical processes must be re-designed to accommodate planned visits, patient follow-up, and proactive care. The roles and responsibilities of office and other clinical team members must be maximized to achieve effective and efficient workflow. Health care organization—A health system that recognizes the importance of improved chronic illness care and supports © Health Quality Council 2006 2-9

Change package—chronic disease management the redesign effort is critical for improving patient outcomes. Commitment from senior leadership and the allocation of needed resources for chronic illness are necessary to sustain health system redesigns. Community resources and policies—Effective community- based programs must be identified and/or developed to meet This section was adapted from the needs of patients with chronic illness. Resources must be and used with kind permission coordinated for maximum benefit. Public policy and govern- by the Institute for Healthcare mental regulations related to health care facilitate the provision Improvement: www.ihi.org of quality care. Change concepts A change concept is a general principle or approach, based on evidence from the literature and from practical application. Change concepts are usually at an abstract level, but evoke multiple specific ideas for how to change processes. Concept An opportunity to create a new connection Specific idea A Thought Process Specific idea B Diagram developed by: Provost, L. Associates The following change concepts have been successfully used in in Process Improve- other CDM Collaboratives and will be applied in this Collabora- ment, 2005. tive: 1. Know all your patients who have diabetes and/or CAD. 2. Be systematic and proactive in managing care for people with diabetes and/or CAD. 3. Involve patients with diabetes and/or CAD in delivering and developing care. 4. Develop effective links and communication strategies with key local partners involved in care and support of © Health Quality Council 2006 2-10

Change package—chronic disease management people with diabetes and/or CAD. Key local partners include specialty/acute care, community-based health care organizations, and others. “The change concepts are not specific enough to be applied directly to making improvements. Rather, the concept must be considered within the context of a specific situation and then turned into an idea. The idea will need to be specific enough to describe how the change can be developed, tested, and implemented in the specific situation. Sometimes, a new idea seems at first to be a new change concept; but often, with further thinking, it is seen to be an application of one of the more general concepts.” Langley, G.J. et al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco: Jossey-Bass. 1996. Change ideas In contrast to a change concept, a change idea is an ‘actionable and specific’ idea for changing a process. These are practical ideas that your team may adopt according to your local context and the unique needs of your practice. It is these change ideas that your team will test to determine whether they result in improvements within your local environment (practice). The ideas included in this handbook are those that we know currently have the greatest impact on achieving improvements in access to appointments and the care of people with diabetes and/or CAD. They are not the only changes that can be made but they are the ones that have proven elsewhere to have the biggest effect. We know however, that you and your colleagues have your own practical approaches and examples that can improve on these ideas. These improvements and those made by other practices on the original ideas will, as the Collaborative progresses, be added to the knowledge here. This resonates with the philosophy behind the Collaborative of people working together to share, learn, apply, and ultimately improve best practice to deliver better patient care. For local and other examples of change ideas, please see Ideas in Action, starting on page 2-53 in this section. © Health Quality Council 2006 2-11

Change ideas—chronic disease 1. Know all your patients who have diabetes and/or CAD Implementing Policy to Enhance Community Health Creating Supportive Develop Personal Skills Health Care Organization Environments Clinical Self Information Management Reorienting Systems HC Services Strengthening Community Delivery System Decision Action Design Support Productive Interactions Informed, Prepared, Prepared, Activated Activated & Relationships Proactive Practice Proactive Community Community Patient Team (partners) Population Health Outcomes/ Functional and Clinical Outcomes Adapted from : Victoria Barr, Anita Dotts, Brenda Martin-Lind, Darlene See Ideas in Ravenadale, Sylvia Robinson, Lisa Underhill (2002) Action on Examples of change ideas page 2-53 for • Agree on a clear definition of diabetes/CAD. local and other exam- • Develop a diabetes/CAD registry. ples of change ideas • Develop systems to maintain valid registries. See page 2-7 for Agree on a clear definition of diabetes and/or CAD the Collaborative’s working definitions of diabetes and coronary artery disease. An accurate, com- Develop a diabetes/CAD registry plete, and current registry is the crucial starting point for improving the care given to people with chronic disease. Registries can be as simple as recipe cards in a box or as sophisticated as computer-based programs. HQC, with the support of Saskatchewan Health, is pleased to offer participating practices access to the CDM Toolkit, a web-based registry tool that also offers clinical decision support and QI tools. Your initial work will focus on ensuring that the registry is complete and that the information in it is correct. Please see the Measurement section for information on creating a registry, and for more about the CDM Toolkit and user support offered by the HQC and the Health Information Solu- tions Centre (HISC). © Health Quality Council 2006 2-12

Change ideas—chronic disease Develop systems to maintain valid registries Once the registry has been established and validated, it is important that systems are developed to maintain its accuracy. This should include a system to ensure that new information on existing patients is gathered and recorded, and to ensure that people who are newly diagnosed with diabetes/CAD, or new patients who are already diagnosed, are identified and added to the registry. When developing your registry, think about the following: • Who will be responsible for maintaining the registry? Identify a named person within your team. Many practices benefit from having an RN or Office Man- ager lead this work. Whoever you choose, think about whether they may need some training to develop their clinical knowledge, to help them carry out this task most effectively. • How will you identify new cases? Where does the information come from—the hospital, the lab, within your practice? How will you ensure the information reaches the person responsible for maintaining the registry? • How will the clinicians in your practice notify the registry manager of any changes to patient information? • Do you need a system to routinely check the quality of the information on the registry? You might wish to build in regular checks on samples of data to be sure your system for registry maintenance is working. These checks can be done using the PDSA cycle and can be useful for highlighting any gaps in your system. • What do you need to write down about how the system works? Recording your system for registry maintenance can be useful to ensure consistency and helps when the person responsible is away or leaves. © Health Quality Council 2006 2-13

Change ideas—chronic disease 2. Be systematic and proactive in managing care for people with diabetes and/or CAD Implementing Policy to Enhance Community Health Creating Supportive Develop Personal Skills Health Care Organization Environments Clinical Self Information Management Reorienting Systems HC Services Strengthening Community Delivery System Decision Action Design Support Productive Interactions Informed, Prepared, Prepared, Activated Activated & Relationships Proactive Practice Proactive Community Community Patient Team (partners) Population Health Outcomes/ Functional and Clinical Outcomes Adapted from : Victoria Barr, Anita Dotts, Brenda Martin-Lind, Darlene Ravenadale, Sylvia Robinson, Lisa Underhill (2002) See Ideas in Examples of change ideas Action on page 2-58 for • Establish a small, multi-disciplinary team (micro-team) to local and manage the care and delivery of service to people with dia- other exam- betes/CAD. ples of change ideas • Identify a lead health professional who has a special interest in the care of people with diabetes/CAD. • Establish practice protocols (or customize existing protocols) for the care of people with diabetes/CAD. • Embed the use of protocols through the use of computerized templates. • Establish proactive call and recall arrangements for people with diabetes/CAD. • Ensure people with diabetes/CAD receive optimal care including the use of drug therapies and access to support for lifestyle management. • Use a checklist for reviews of people with diabetes/CAD. Chronic diseases are multi-faceted conditions, so managing care effectively and consistently across the practice requires a planned, systematic, and proactive approach. Consideration needs to be given to the care of patients with particular needs, such as hard-to-reach patient groups © Health Quality Council 2006 2-14

Change ideas—chronic disease (housebound, rural, and long-term care residents) and patients with English as a second language. Practices may find it useful to use the principles of Improved Access to plan how they can best manage demand for diabetes care. (Improved Access, starting on page 2-28, provides more details.) Organizational Establish a multi-disciplinary team to manage the care of people with diabetes/CAD arrangements for chronic disease management should be agreed upon and communicated to all members of the care team. Establish a small multi-disciplinary team to lead the work, a micro-team. A micro-team for diabetes might include the patient, physician, nurse, podiatrist, dietitian, diabetes educator, pharmacist, and clinic staff. Together they can ensure that all aspects of the system are developed and managed, and that improvements are shared across the whole care delivery team. You can form a ‘team’ with other providers serving the same population, whether they be administrative staff in your office, a community pharmacist down the street, or a home care nurse in your community. Just because you aren’t co-located doesn’t mean you can’t be an effective team. Think broadly and creatively about ways to work together that don’t involve having to hire more staff and providers. Identify a lead health professional who has a special Identify a lead interest in the care of people with diabetes/CAD health care provider with overall responsibility for organizing care across the team. Many practices find that a nurse-led approach is very effective, with other members of the practice team becoming involved where appropriate. The role of the physician is crucial in providing professional support to nurses, especially for complex cases and in medication review processes. It may also be of value to the practice to involve the community pharmacist in medication reviews for peo- © Health Quality Council 2006 2-15

Change ideas—chronic disease ple with diabetes and/or CAD. One randomized control trial in the United States found that nurse case managers for people with diabetes led to a 1% further reduction in A1C levels than non-nurse case managers were able to achieve. Aubert RE, et al. Nurse case management to improve glycemic control in diabetic patients in a health maintenance organization. A randomized, controlled trial. Ann Intern Med.1998 Oct 15;129(8):605- 12. Establish practice protocols (or customize existing Whatever method is ones) for the care of people with diabetes/CAD chosen for delivering chronic disease care in the practice, basing your service around agreed protocols means that the entire team can be clear about roles, responsibilities, and how patients are managed. The micro-team should develop practice-level protocols that are adapted to the needs of your practice. These protocols will ensure all members of the team are aware of their personal responsibilities within the system of care delivery. Embed the use of protocols through the use of Use of computer computerized templates templates allows a systematic, consistent approach to delivering care to patients. Templates also improve accuracy and completeness of patient data. The CDM Toolkit flow sheet is a resource to help you manage your patient information. You may want to provide training and support to the team members using the system. As a team, you may also want to regularly use QI reports to inform yourselves of your progress. For more information on the CDM Toolkit, please see Section 3 on Measurement. The ongoing man- Establish proactive call and recall arrangements for people with diabetes/CAD agement of your patients with diabetes and/or CAD is dependent on having a clearly defined system for call/recall that ensures patients are invited for review at © Health Quality Council 2006 2-16

Change ideas—chronic disease regular intervals, and that attendance is tracked. Some things to keep in mind about your call/recall planning: • How will you manage the care of patients who do not attend? The CDM Toolkit will provide recall information for your team. It can be used to help clinicians remind patients their review is overdue, or be used to initiate opportunistic reviews (for example, a patient comes in for a prescription renewal and the team takes the opportunity to measure blood pressure, weight, etc.). Some practices find it useful to use a mixed clinic, covering asthma, diabetes, and CAD for example. This makes it more likely that patients attend and improves attendance rates for the practice. Special consideration needs to be given to how you will deliver care to patients who are residents of long-term care homes, live in rural areas, the housebound, and patients with English as a second language. • Think about having a system in place to follow up with patients receiving specialist care, particularly Type 1 diabetes patients. • The CDM Toolkit can help you manage your patients with chronic disease. It can assist you with recalling patients who are overdue for a review. It is also a useful tool for keeping you informed about how many CDM patients you have—this may help you plan more effectively. In order to ensure Ensure people with diabetes/CAD receive optimal care including the use of drug therapies and access that people with dia- to support for lifestyle management betes and/or CAD receive optimal care, your practice may want to consider staff skills and training. It is important to have the right people, in the right place, with the right skills, at the right time. This may also involve your practice considering the equipment used or needed to deliver optimum care. © Health Quality Council 2006 2-17

Change ideas—chronic disease It is important that patients with chronic disease be given consistent messages by all members of the care team. As such, practices need to consider the consistency of education for professionals involved in the delivery of care to people with a chronic condition. It is likely that roles will change and that there will be an extension of responsibility and flexibility for several professionals within the care delivery team. When considering equipment, practices are encouraged to share information and discuss ideas with their colleagues. Training may be necessary at a practice level for insulin initia- tion in the management of Type 2 diabetes. Your practice will need to consider who might be the most appropriate professional to be trained within the clinic, most likely your nurse, or consulted from outside the office, perhaps a diabetes educator. When initiating insulin therapy, the physician/nurse/diabetes educator will need to consider: • Identifying patients who may benefit from insulin; • Selection of suitable insulin regime; and, • Implementation of customized education program for the patient. It’s important that teams work systematically to track and review whether patients are being prescribed the appropriate medication. The CDM Toolkit allows you to quickly pull this information from the database. Practices may find it useful to engage community pharmacists for this element, as they can support and monitor patients’ therapy. The baseline measures are the starting point for this work. Other Collaboratives have found it useful to develop PDSA cycles to determine how they look at whether patients are being treated appropriately. Looking systematically at your patients will help you to understand your results and improve the quality of care. The CDM Toolkit will enable your practice to monitor some key © Health Quality Council 2006 2-18

Change ideas—chronic disease components of lifestyle change in chronic disease management, such as frequency of aerobic exercise and review of diet, alcohol intake, and stress. Use a checklist for reviews of people with diabetes The checklist for and/or CAD reviews of people with diabetes and/or CAD might include four main areas: Discussion areas: Begin by inquiring about the patient’s expectations of the review. Discussion areas might include smoking, alcohol consumption, stress, sexual problems, physical activity, dietary/nutritional issues, and symptom management (for example, chest pain). Laboratory tests and investigations: Tests for monitoring diabetes and/or CAD might include A1C levels, lipid profile, renal function tests (urea, creatinine, electrolytes), urine Albu- mine:creatine ratio, and complete blood count (CBC). Investi- gations might include ECG, exercise tolerance test, or retinopa- thy. Physical examination: Exam would include weight, height, and blood pressure, as well as extremity exam, cardiac exam, eye exam, and possibly injection sites (for those patients who are on insulin). Lifestyle issues: This area would cover general wellbeing and mental health, current treatment, and self-management. Through the CDM Toolkit, practices will have the option of tracking improvement on a number of lifestyle issues, such as: • Smoking • Referral to diabetes educator/education • Referral to cardiac rehabilitation or education For certain elements on the flow sheet, including ones related to lifestyle, the CDM Toolkit allows physicians to enter additional information for why a “No” response might have been checked (for example, Patient Refused). By tracking things such as why referrals are not made, the information can help © Health Quality Council 2006 2-19

Change ideas—chronic disease identify gaps in the system that may need to be addressed at a broader level. For more information on the CDM Toolkit, please see Section 3 on Measurement. © Health Quality Council 2006 2-20

Change ideas—chronic disease 3. Involve patients with diabetes and/or CAD in delivering and developing care Implementing Policy to Enhance Community Health Creating Supportive Develop Personal Skills Health Care Organization Environments Clinical Self Information Management Reorienting Systems HC Services Strengthening Community Delivery System Decision Action Design Support Productive Interactions Informed, Prepared, Prepared, Activated Activated & Relationships Proactive Practice Proactive Community Community Patient Team (partners) Population Health Outcomes/ Functional and Clinical Outcomes Adapted from : Victoria Barr, Anita Dotts, Brenda Martin-Lind, Darlene Ravenadale, Sylvia Robinson, Lisa Underhill (2002) Examples of change ideas: See Ideas in • Have a deliberate strategy for self-management. Action on page 2-63 for • Maximize self-management by people with diabetes/CAD. local and • Integrate the patient’s perspective constantly in the design other examples of of services. change ideas • Ensure written communication is appropriate and understood. • Pay special attention to the needs of hard-to-reach groups. Develop a deliberate strategy for self-management Patients live with their chronic disease 24 hours a day, 365 days a year. Patient self- management is more than simply educating patients about their condition or giving them relevant information. The aim of education is to improve the patient’s knowledge and confidence, to enable the patient to take control of his/her own condition, and to integrate self-management into daily life. The Canadian Diabetes Association offers Peer Support Groups. The groups are led by volunteer Peer Facilitators and meet regularly to discuss relevant topics and issues, as decided by each group. This also helps promote awareness of available resources in the community. © Health Quality Council 2006 2-21

Change ideas—chronic disease The Saskatchewan chapter of the Heart and Stroke Foundation offers several programs, such as Heart to Heart, Coronary Ar- tery Rehabilitation Group, South Saskatchewan Cardiac Sup- port Group, Second Chance Cardiac Support Group, and the Moose Jaw CardiAction Support Group. Develop self- Maximize self-management by people with diabetes/ CAD management plans and goals in con- junction with the patient. For instance, the health care team and patient may agree to explicit goals for blood pressure, cholesterol, weight or glycemic control. The patient’s plan may out- line what he or she can adjust in order to help meet those targets (e.g. diet, physical activity, or insulin dose). Consider the use of written, patient-held records. This allows providers involved in the patient’s care to have access to the same information. It also keeps the patient informed as to his/her goals and progress. Consider using a community-based program focused on patient self-management and peer support. These types of programs often empower patients and give them the skills to help others. Practices might want to use group consultations for people with a chronic disease. For patients with diabetes, they could be grouped according to diabetes type. In one randomized control trial based in the United States, they found that using cluster visits (another name for group consultations), alongside nurse case management, reduced the A1C levels of the patients involved by a further 1%, compared to having nurse case management alone (Aubert, et al, 1998). Develop the system Integrate the patient’s perspective in the design of services of care delivery with patients. They may be able to provide valuable information on: • The style and content of letters/patient literature; • The organization and timing of clinics/appointments © Health Quality Council 2006 2-22

Change ideas—chronic disease to maximize attendance; • How to best deliver care to patients with more than one chronic condition; • Understanding issues around adherence to medication; and, • Developing patient self-care programs. Patients and caregivers offer unique in- sights into services, and their participation in redesign is crucial to truly enhance care. A change is only an improvement if the patient thinks it is. Teams should consider how they might meaningfully involve patients and caregivers in decision- making about care delivery. It would be useful to ensure the views of patients are incorporated into a range of initiatives around chronic disease management, such as the development of guides and protocols, patient information, and in clinic initiatives. Most practice Ensure written communication is appropriate and understood teams have written materials to support patient care, such as information sheets and brochures. It may be useful to review this information with patients to ensure it is appropriate and clear. Many teams invest significant amounts of time in patient education and health promotion for disease-specific care, and patients can be a valuable source of evaluation/critique for this material. The Plain English Campaign provides some writing guides and lists of words to avoid (and their substitutes). Some computer programs, such as Microsoft Word, will calculate the reading level of a document. There are also other readability tests (such as SMOG) to help you determine the grade level of your document. (Please see the Additional Information & Resources section for more information.) © Health Quality Council 2006 2-23

Change ideas—chronic disease It may seem obvi- Pay special attention to the needs of people from hard-to-reach groups ous, but pay special attention to people who have particular needs, such as patients from minority ethnic groups and patients with disabilities. Patients who are housebound or residents of long-term care will need on-site eye tests and podiatry services, as well as medical and nursing services. A podiatry service generally available within nursing homes does not include the specialist services that would be required for optimum care of people with diabetes neuropathy and peripheral vascular disease (PVD). Local community representatives and volunteer organizations can be valuable resources in helping to identify culturally appropriate methods of communication and service delivery. © Health Quality Council 2006 2-24

Change ideas—chronic disease 4. Develop effective links and communication strategies with key local partners involved in care and support of people with diabetes and/or CAD. Key local partners include acute/specialist care, community-based health care organizations, and others. Implementing Policy to Enhance Community Health Creating Supportive Develop Personal Skills Health Care Organization Environments Clinical Self Information Management Reorienting Systems HC Services Strengthening Community Delivery System Decision Action Design Support Productive Interactions Informed, Prepared, Prepared, Activated Activated & Relationships Proactive Practice Proactive Community Community Patient Team (partners) Population Health Outcomes/ Functional and Clinical Outcomes Adapted from : Victoria Barr, Anita Dotts, Brenda Martin-Lind, Darlene Ravenadale, Sylvia Robinson, Lisa Underhill (2002) See Ideas in Examples of change ideas Action on page 2-70 for • Ensure coordination and support collaboration between pri- local and mary/hospital care and primary/specialist care interfaces. other examples of • Analyze the patient journey and redesign where necessary. change ideas • Engage local organizations in developing diabetes/CAD services. • Support collaboration between health care professionals in a clinic setting and health professionals in the regional health authority to enable integrated care for patients. This is a well- Ensure coordination and support collaboration between primary/hospital care and primary/specialist recognized issue care interfaces in our health care system. HQC’s 2004 Patient Experience Survey found that the greatest opportunities for improvement in Saskatchewan hospitals were related to provider-patient communications, particularly around discharge planning. Several regions have identified improved primary/hospital care communications as a focus area. This © Health Quality Council 2006 2-25

Change ideas—chronic disease Collaborative is also an opportunity to create some solutions. Analyze the patient journey and redesign where Process mapping necessary between physician practices and spe- cialized services/programs from a patient’s perspective is an effective approach in starting to understand whether current service provision is timely and high quality. Once this has been agreed upon, the following questions are useful in developing ideas to improve the patient journey: • What are the problems—barriers and bottlenecks— in the patient’s journey, especially in handovers between primary and specialist care? • Can delays be reduced by using group education or consultation sessions? • Can constraints, such as waiting times for investigations, be addressed? Some practices have a fax back system for expert opinion from specialist care that allows the patient to be dealt with in primary care, which is more efficient and effective for the patient. • How might the shortage of dietetic and podiatry services best be overcome? • Are the right people with the right skills in the right place to provide the right care at the right time? Do opportunities exist to relocate services in primary care? • What are the training and development implications for staff and how can these be addressed? • What should be measured to demonstrate the effec- tiveness of the service and the improvements made? Engage local organizations in developing diabetes/ Practices may find CAD services it useful to be aware of other local organizations that have an influence or potential influence on diabetes and CAD services. Many local communities have a vibrant and active voluntary sector and © Health Quality Council 2006 2-26

Change ideas—chronic disease community networks with the potential to make an effective contribution. Support collaboration between health care profes- Saskatchewan sionals in a clinic setting and health care profession- Health’s Provincial als in the regional health authority to enable inte- Diabetes Plan out- grated care for patients lines key components and objectives for prevention, optimal care, and provider education related to diabetes. Among their objectives: • Create an infrastructure within each RHA, with senior leadership involvement, to support planning, fi- nancing, implementation and evaluation of optimal diabetes care for persons with diabetes, their families, and communities. • Create teams to address regional diabetes care needs. • Develop relationships with primary care teams to ensure quality diabetes care and ongoing support for persons with diabetes and their families. • Participate in building networks between primary care providers, diabetes teams, and medical specialists. • Encourage and formalize processes and systems that ensure follow-up care for all regional residents with diabetes. This may require working with care providers to establish specific processes to serve First Nations on-reserve populations. • Develop mechanisms to reduce barriers to optimal care. Many of the ideas can be easily transferred into the area of CAD management. © Health Quality Council 2006 2-27

Change Package Improved Access © Health Quality Council 2006

Change package—improved access Introduction Improved Access, also known as Advanced Access, was pioneered by Mark Murray (MD, MPA) and Catherine Tantau (RN, MPA). They developed the concept in the early 1990s while working for Kaiser Permanente, a large health maintenance organization (HMO) in the United States (Singer, 2001). The principles of Improved Access are really about clinical office redesign. If you truly understand your office processes, you can make sage and strategic decisions about if and how to reorganize. Why would you want to change the way you book appointments or other office processes? Most clinics go down this road because they are straining under long waitlists and feel as though they will never catch up. In clinics that don’t have a waitlist, the motivation is related to improving quality of life for the providers and staff, creating a more predictable pace, or finding extra room in the schedule to try new things like group visits. What is clear is that most offices are set up very well to treat episodic illness, but are struggling to handle the different demands generated when treating chronic diseases. It is our in- tention to provide you with the tools of Improved Access in order to assist you in successfully redesigning your clinical practice. Successful redesign will result in effective systems to proactively manage chronic disease; improved satisfaction among patients, staff, and providers; and, if a waitlist currently exists, improve access to your practice for all patients. Important note about the Improved Access section of this handbook: Significant source of content: Institute for Healthcare Improvement (IHI), c 2005. Available from URL: www.ihi.org. Used with permission. © Health Quality Council 2006 2-28

Change package—improved access Change package A change package is an evidence-based set of changes that are critical to the improvement of an identified care process. The Improved Access model serves as the foundational change package that guides improvement in access. Change concepts A change concept is a general principle or approach, based on evidence from the literature and from practical application. Change concepts are usually at an abstract level, but evoke multiple specific ideas for how to change processes. Concept An opportunity to create a new connection Specific idea A Thought Process Specific idea B Diagram developed by: Provost, L. Associates The model for improved access uses five change concepts. in Process Improve- These concepts are at the heart of improved access and all five ment, 2005. should be explored to fully develop and implement the system. Remember, the concepts are meant to stimulate practical ideas appropriate to your practice setting. Not all ideas will work in every practice. 1. Understand your practice’s supply and demand. 2. Shape the handling of demand. 3. Match the supply of the practice to the reshaped demand. 4. Establish and implement contingency plans. 5. Communicate effectively with patients and across the practice team. © Health Quality Council 2006 2-29

Change package—improved access “The change concepts are not specific enough to be applied directly to making improvements. Rather, the concept must be considered within the context of a specific situation and then turned into an idea. The idea will need to be specific enough to describe how the change can be developed, tested, and implemented in the specific situation. Sometimes, a new idea seems at first to be a new change concept; but often, with further thinking, it is seen to be an application of one of the more general concepts.” Langley, G.J. et al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco: Jossey-Bass. 1996. Change ideas In contrast to a change concept, a change idea is an ‘actionable and specific’ idea for changing a process. These are practical ideas that your team may adopt according to your local context and the unique needs of your practice. It is these change ideas that your team will test to determine whether they result in improvements within your local environment (practice). The ideas included in this handbook are those that we know currently have the greatest impact on achieving improvements in office redesign and the care of people with diabetes and/or CAD. They are not the only changes that can be made, but they are the ones that have proven elsewhere to have the biggest effect. We know, however, that you and your colleagues have your own practical approaches and examples that can improve on these ideas. These improvements and those made by other practices on the original ideas will, as the Collaborative progresses, be added to the knowledge here. This resonates with the philosophy behind the Collaborative of people working together to share, learn, apply, and ultimately improve best practice to deliver better patient care. For local and other examples of change ideas, please see Ideas in Action, starting on page 2-76 in this section. © Health Quality Council 2006 2-30

Change ideas—access Supply and demand are concepts usually associated with business, but they can also be very useful when applied to the clinic setting. The premise of the Improved Access model (or office redesign) is simple—if you understand your supply (clinic and human resources) and demand (requests for appointments) then you can organize your clinic to meet demand and maximize supply. Improved Access is an approach to clinical office redesign that reduces delays, improves flow, and, in the end, improves patient, provider, and staff satisfaction. 1. Understand your practice’s supply and demand Implementing Policy to Enhance Community Health Creating Supportive Develop Personal Skills Health Care Organization Environments Clinical Self Information Management Reorienting Systems HC Services Strengthening Community Delivery System Decision Action Design Support Productive Interactions Informed, Prepared, Prepared, Activated Activated & Relationships Proactive Practice Proactive Community Community Patient Team (partners) Population Health Outcomes/ Functional and Clinical Outcomes Adapted from : Victoria Barr, Anita Dotts, Brenda Martin-Lind, Darlene Ravenadale, Sylvia Robinson, Lisa Underhill (2002) See Ideas in Examples of change ideas Action on • Measure your practice supply, overall and by clinician. page 2-76 for local and • Measure the totality of demand for the practice. other exam- • Measure the variation in the daily demand. ples of • Measure the variation in the types of demand. change ideas • Understand the daily demand for each clinician. • Understand the balance of demand between booked appointments and on-the-same-day appointments. Measure your practice supply, overall and by clini- Improved access cian begins by understanding the practice supply (i.e. total number of available appointments). For example, if your clinic has four time slots per hour, and is open © Health Quality Council 2006 2-31

Change ideas—access eight hours per day, with 2.5 FTE physicians, then your overall daily supply is 80 appointments (i.e. 4 x 8 x 2.5). You will also need to know the supply for each clinician in the practice. Please see sample template in the Additional Information & Re- sources section to help you calculate practice supply. Measure the totality of demand for the practice To redesign your office effectively you need a full understanding of demand. The information you gather will naturally lead you to develop a fuller understanding of your office system. The best way to measure demand is by counting the number of requests for appointments on each day of the week. It is important to remember that daily activity (the number of patients seen) is not the same as daily demand (the number of patients that would like to be seen). You may wish to use a tick-sheet to collect this data. A sample template is provided in the Additional Information & Resources section. If you choose to develop your own process, we recommend that you keep the task as simple as possible for busy receptionists. It is vital for the reception team to fully understand the importance of this step, and their role within it, to the success of improving access. All decisions relating to improving access are dependent on the accuracy of this step. Measure the variation in daily demand Measuring the variation in demand profile for the practice across each day of the week gives a very useful overview of where the system has the most opportunity for improvement. A sample tick-sheet template is provided in the Additional Information & Resources section. This is a simple step and receptionists may find it valuable to start here. When you have measured demand, your team will find it useful to discuss the following questions: • Does our demand appear to outstrip our capacity on any or all of the days? © Health Quality Council 2006 2-32

Change ideas—access • If ‘yes’, what might be the reason? Was this really a typical week in relation to our demand (e.g. seasonal highs and lows, clinicians away, health scare)? • Does this exercise need to be repeated during a different week, or over a longer period, to give us more information about our capacity and demand? We could have predicted that! The gap between supply and demand not only contributes to a delay in meeting patients’ needs, but it can also be expensive and generate waste in the system. The experience of many health care organizations demonstrates that demand is not really insatiable, but actually predictable. In fact, the demand for any kind of service—appointment, advice, or message to a provider— can be predicted accurately based on the population, the scope of the provider practice, and, over time, the particular practice style of each provider. Understand the variations in the types of demand You may find it useful to gather information on the types of appointments demanded: • What proportion are follow-ups? This is an aspect of care that clinicians have control over—who is seen, how often, by what means, and on what day of the week. You can collect data on the number of follow- ups that are seen each day by using a tick sheet in reception, or by asking the clinician to note this on the chart. • What are the types of consultation? Developing an understanding of the type of work that different members of the team are seeing provides an excellent insight into the practice’s work. Which types of consultation form the bulk of the practice’s workload? Do particular clinicians see more patients with certain problems? This type of data could be useful for potential changes to the skill mix within the team. It is a very useful Understand the daily demand for each clinician exercise to ex- plore the demand data further, to better understand the varia- © Health Quality Council 2006 2-33

Change ideas—access tion between clinicians within the same discipline and across disciplines. This information can be extremely valuable when looking at the sustainability of your office redesign program and contingency plans. This step in the process can generate issues for the clinical team to consider, such as additional commitments outside of the practice and their impact on access, and popular doctors or nurses. Understand the balance of demand between booked Understanding appointments and on-the-same-day appointments the demand for booked appointments and on-the-same-day appointments will help you gather information about the proportion of patients that you would normally expect to pre-book each day. Many patients wish to book either for a follow-up appointment or because they need to fit their care into a busy lifestyle. Under- standing how many patients need to do this is critical in design- ing an appointment schedule that will support an Improved Ac- cess system. Many practices are surprised to find that despite the constant feeling of pressure within the practice, their supply and demand are usually matched. Sometimes practices find that their total demand is similar to supply but there are problems on certain days of the week that they need to address. Measuring demand on a regular basis (e.g. weekly to begin with, then monthly or quarterly) is invaluable to build a comprehensive understanding of what to expect and to identify fluctuations and their causes, such as seasonal variation. © Health Quality Council 2006 2-34

Change ideas—access 2. Shape the handling of demand Implementing Policy to Enhance Community Health Creating Supportive Develop Personal Skills Health Care Organization Environments Clinical Self Information Management Reorienting Systems HC Services Strengthening Community Delivery System Decision Action Design Support Productive Interactions Informed, Prepared, Prepared, Activated Activated & Relationships Proactive Practice Proactive Community Community Patient Team (partners) Population Health Outcomes/ Functional and Clinical Outcomes See Ideas in Adapted from : Victoria Barr, Anita Dotts, Brenda Martin-Lind, Darlene Action on Ravenadale, Sylvia Robinson, Lisa Underhill (2002) page 2-76 for Examples of change ideas local and • Reduce demand. other exam- • Increase efficiency. ples of change ideas • Reduce scheduling complexity. Reduce demand Maximize personal contact with the clinician of patient choice. We know that if patients are able to see someone they trust, re-visits are reduced. In fact, continuity of care can decrease demand by up to 15%. In order to achieve this, you need to ensure that each member of the team is working appropriately and effectively. This can free up spare capacity, which will improve continuity for those patients who do need care from a particular clinician. Think about the most appropriate person in the team to see the patient and look at what can be carried out appropriately by someone else (e.g. home care nurse or chronic disease management nurse). If patients are used to seeing one care provider, it can be helpful for the doctor or nurse to ‘validate’ the change by letting the patient know that this is part of a management plan that will give them the best possible care. Practices have found that understanding their demand allows © Health Quality Council 2006 2-35

Change ideas—access them to book a locum further ahead. This often allows them to book the same locum, who can develop relationships with patients and reduce the number of re-visits. Please note: If you have a provider that works less than 0.6 FTE it may be difficult to achieve continuity of care with a specific provider; in this case, you may wish to look at continuity of care with the team, not the clinician. Challenge visit intervals. Internally generated demand is the demand you have the most control over. One of the largest sources of internally generated demand is the physician directed request for follow-up. Your practice can examine your protocols around these requests and challenge yourselves regarding the rationale and evidence behind your routines. What does the evidence say regarding requirements for regular follow-up intervals for different conditions and preventive procedures? Do all physicians in your practice follow the same guidelines? Can your group agree upon some evidence-based protocols for specific situations? QI advisors working with fee- for-service practices in Calgary report that challenging visit intervals is one of the most effective ways to reduce demand and is relatively easy to accomplish. Involve patients in the design and delivery of your service. Involve patients in redesigning services. Where appropriate, patients can contribute to support services such as running help desks or patient information desks, or providing support to other patients, particularly where they have similar conditions. Increase your patients’ self-help skills. Patients can manage some conditions without the need for consultation. Practices can develop a consistent line on managing minor illness in the care team and include information and self-help material in the clinic or on a web site. Patients with chronic illness should have increased involvement in their care. Group consultations have been used successfully with high users of health services by bringing them © Health Quality Council 2006 2-36

Change ideas—access together for an hour session. Patients can then discuss their condition jointly. The sessions are supported by an appropriate clinician, such as a nurse or doctor. Residents in Saskatchewan have free access to The Cochrane Library via the public library system. The Cochrane Library is a collection of six databases that deal with health information and it may be a useful resource. More information can be found on the HQC web site, www.hqc.sk.ca. Develop alternate ways for your patients to access care. A practice may want to consider using telephone management to handle same-day demand. Either a nurse or a doctor can do this. In general, telephone management reduces the need for a face-to-face consultation by 40-50%. Practices have used telephone management by nurses to alter the way demand for same-day appointments with a physician are handled. The nurse may be able to offer the patient an alternative member of the team who can safely deal with the care situation. Due to increasing demands and stresses, many physicians currently use telephone consultations, despite the potential impact on their income. However, to minimize that impact, physicians have found that planning ahead can improve the efficiency of these interactions. Some physicians ask their office staff to keep a list of patients who call and advise patients that they will return the calls at a specific time. The charts are pulled ahead of the call so that the physician has ready access to information; the patient can anticipate the call and can arrange to be home, which reduces telephone-tag and repeat calls from an anx- ious patient; and because the physician initiates the call, they can often better control the length of the conversation to ensure effective use of time. Web sites offer a range of opportunities for education, and to highlight links to other sites, for advice on minor illness. Email also has a range of uses in practice: © Health Quality Council 2006 2-37

Change ideas—access • Checking test results • Checking instructions given at a recent consultation • Ordering repeat prescriptions • Clinical advice • Non-clinical advice (e.g. queries about hospital appointments) • Requesting sick notes Increase efficiency Anticipate associated needs. Whenever feasible, maximize the number of interactions at a single visit to the practice (e.g. blood tests, medication reviews, routine BP/weight checks). Build this ability into the system. For example, work with a nurse to enhance capacity to deal with related needs. Move work to the most appropriate person within the team. Practices will find it useful to examine the workload of the various members of the practice team. This will enable you to look at the types of case mix across the clinical team and then to decide who would be the most appropriate person to deal with certain types of care issues. We recommend that the practice use the Model for Improvement to test out changes in care provision between the different members of the team. Focus on improving workflow and other processes. Improving the flow of work and eliminating waste ensures that the clinical office runs as efficiently and effectively as possible. Some reports estimate that up to 40% of clinical office work is redundant or otherwise wasted effort. For example, preparing for an office visit when a patient doesn’t show up for the appointment, or taking messages and looking for a patient chart in response to a phone call requesting a prescription refill. There are many excellent tools for understanding your current workflow and tips for improvement in the Clinical Microsystem Action Guide; it is available online at: www.clinicalmicrosystem.org. © Health Quality Council 2006 2-38

Change ideas—access Reduce scheduling complexity The majority of clinical practices use many appointment types and lengths in an effort to exert some control over the schedule. The belief is that limiting the number of a certain type of appointments scheduled on a daily basis, or assigning patients to different times or types of appointments, will improve access in the practice. Queuing theory, however, suggests that reducing the number of separate “lines” or “queues” for different services creates more flexibility in the system and reduces delays associated with distinct queues. Therefore, having many appointment types actually increases total delay in the system because each appointment type creates its own differential and queue. Maintain truth in scheduling. This means that scheduled appointment times should match the actual time that the patient is seen by the care team. Often we create schedules around the ideal, i.e. six patients in one hour, and apply it to all clinicians’ appointment templates, even though some clinicians can’t match that pace, because it isn’t their style or because they have a high volume of patients who need more time. Gaps between scheduled visit time and actual visit time drive significant patient dissatisfaction, are related to patients not showing up for scheduled visits, and lead to office staff time spent in expla- nation or apology. If clinicians in your practice aren’t sure how long their appointments really are, measure from the start of one appointment to the start of the next appointment. Do this for 50 or 100 consecutive appointments to find out how long it takes. Create a schedule template that matches the reality of the clinician’s pace. Reduce scheduling restrictions. In addition to reducing appointment types and times, practices can create more flexibility in their schedules by reducing, as much as is feasible, other constraints. For example, offering physicals only on certain days of the week or times of the day. While some providers may initially fear that this change will create days with multiple back-to-back physicals, natural variation in demand means that © Health Quality Council 2006 2-39

Change ideas—access the requests for physicals or other types of complex appointments are actually fairly evenly distributed across the appointment calendar. Reduce appointment times by using “building blocks” to create short and long appointment times. The first step is to decide on the scheduling increment or building block. For example, the increment may be 15 minutes and is used for the length of a short appointment. The long appointment is usually a multiple of the short appointment, for example, 30 or 45 minutes. The scheduler simply combines two or three short appointments to make a long appointment. Some practices standardize on a single appointment type and length so that pace for the day can be set and maintained (e.g. a 20-minute appointment). The appointment length must be long enough to accommodate many different types of services and patient needs, and to allow providers to stay on time. For example, one patient visit may only require 10 to 15 minutes, leaving extra time for the next appointment, should it take longer than the allotted 20 minutes. Reduce appointment types. Practices with Improved Access make no distinction between urgent and routine appointments. To distinguish between urgent and routine care only contributes to attempts to “game the system” by both patients and providers. This in turn results in much wasted time for office staff negotiating with patients about how urgent their problem really is, and contributes to the “war zone” atmosphere present in many clinical reception areas. For primary care, the only distinctions needed between appointment types are: • Provider is present vs. provider is absent • A short appointment type for return visits • A long appointment type for physicals, new patients, chronic disease management, etc. © Health Quality Council 2006 2-40

Change ideas—access When the provider is present the patient is seen, and when the provider is absent the patient is offered the choice of an appointment the next time the provider is present, or today with another care team member. If the patient would like to pre- book even though there are appointments available today with their provider, they are offered the next available time that meets their scheduling requirements. All other special appointment types, such as those for disease entity or physicals by age groups, can be eliminated. © Health Quality Council 2006 2-41

Change ideas—access 3. Match the supply of the practice to the reshaped demand Implementing Policy to Enhance Community Health Creating Supportive Develop Personal Skills Health Care Organization Environments Clinical Self Information Management Reorienting Systems HC Services Strengthening Community Delivery System Decision Action Design Support Productive Interactions Informed, Prepared, Prepared, Activated Activated & Relationships Proactive Practice Proactive Community Community Patient Team (partners) Population Health Outcomes/ Functional and Clinical Outcomes Adapted from : Victoria Barr, Anita Dotts, Brenda Martin-Lind, Darlene Ravenadale, Sylvia Robinson, Lisa Underhill (2002) See Ideas in Examples of change ideas Action on • Optimize the available supply within the team. page 2-76 for local and • Use and develop skills within the team to better meet the other exam- demand profile. ples of change ideas • Remove the backlog. The initial analysis Optimize the available supply within the team of demand and supply usually highlights interesting issues for the team. These often include: • High numbers of follow-ups on busy days (such as Monday) that can almost always be booked for other less busy days (such as Wednesdays). • Clinics on days of high demand that could be moved elsewhere in the week. • Arrangements for part-time staff or people with outside commitments that do not best match the pat- tern of demand. Addressing some of these issues can make a big difference in practices being able to match their capacity to the demand profile. © Health Quality Council 2006 2-42

Change ideas—access Use and develop skills within the team to better meet You can form a the demand profile ‘team’ with other providers serving the same population, whether they be administrative staff in your office, a community pharmacist down the street, or a home care nurse in your community. Just because you aren’t co-located, doesn’t mean you can’t be an effective team. Think broadly and creatively about ways to work together that don’t involve having to hire more staff and providers. Developing the skill mix within the team is an excellent way to better meet the profile of patient demand. Many practices have developed existing members of the team or recruited new staff with different skills to enhance the service they are able to offer. Ideas include the development of receptionists to take heights and weights, healthcare assistant roles, nurse-led mi- nor illness clinics, and nurse-led chronic disease management. The practice can look at ways of making more effective use of the skills of the existing teams and, when the opportunity arises, developing the skill-mix of the team over time. Under- standing the range of demand and needs of patients is vital in helping you match your team to the work. The following questions may help you guide change: • What is the work? e.g. follow-up post-AMI patients • Who does it now? e.g. GP • Who could do it? e.g. practice nurse • What support might they need? e.g. a doctor available to support nurses running CAD clinics • What is the next step? e.g. develop plans for testing the change using the PDSA cycles Again, the Clinical Microsystem Action Guide provides many tools for helping you analyze your current team, and then strategize around skill building and team development. Identifying, remov- Remove the backlog ing, and prevent- ing backlog returning is crucial to improving office redesign. © Health Quality Council 2006 2-43

Change ideas—access Clearing backlog is one time during the system redesign where the practice will have to work harder. However, backlog is a finite quantity of patients and once they have been seen, the task need not be repeated. The backlog should be reduced during the reshaping of demand so that its impact will be mini- mized. Backlog is made up of those patients waiting to be seen who are not there by choice—patients who wanted to be seen sooner but had to be pushed off into future appointments due to unavailability of supply. Remember that some of your current backlog will be patients who wanted an appointment in the future and are happy to be waiting. If you have demonstrated that supply and demand match, then you really have a delay problem rather than a supply problem. (Your supply and demand match if you can say that the wait time for your clinic is stable, be the wait consistently two days, four weeks, or six months.) The aim of clearing the backlog is to remove the delay so that you are able to match supply to demand on a daily basis. There are a number of ways to remove backlog. • Work smarter: Shape the handling of demand, and choose a quiet time of the year to work down the backlog. • Work harder: Negotiate to add extra appointments, and reduce time out of practice temporarily. • Add temporary supply by employing a locum, or hiring a temporary practice nurse. © Health Quality Council 2006 2-44

Change ideas—access 4. Establish and implement contingency plans Implementing Policy to Enhance Community Health Creating Supportive Develop Personal Skills Health Care Organization Environments Clinical Self Information Management Reorienting Systems HC Services Strengthening Community Delivery System Decision Action Design Support Productive Interactions Informed, Prepared, Prepared, Activated Activated & Relationships Proactive Practice Proactive Community Community Patient Team (partners) Population Health Outcomes/ Functional and Clinical Outcomes Adapted from : Victoria Barr, Anita Dotts, Brenda Martin-Lind, Darlene Ravenadale, Sylvia Robinson, Lisa Underhill (2002) See Ideas in Action on Examples of change ideas page 2-76 for • Measure the impact of reduced supply. local and • Develop plans to address reduced supply and to other examples of meet increased demand. change ideas Managing the sys- Measure the impact of reduced supply tem on a daily basis means ensuring sufficient supply is in place to meet demand each day. However, there will be times when supply is reduced or demand is unusually high. Special arrangements will be needed to cope. Practices are used to finding ways to manage holidays, sick- ness, health scares or outbreaks. Having practical, docu- mented plans for such eventualities, and ensuring that the whole team knows them, can help to minimize the effect on waiting times and pressures on the team. Three steps will help you understand what will happen when your supply is reduced: • Calculate the total number of appointments that you will lose when each clinician is away. Seeing this data is a powerful tool to help with the development of, and acceptance of the need for, contingency plans. © Health Quality Council 2006 2-45

Change ideas—access • Link this information to your knowledge of daily demand to identify which parts of the week will be affected and to what extent. Exactly how short of appointments will you be on each day of the week that a particular clinician is away? • Identify what you can do to meet the loss of supply on those days and develop clear plans as to who will do what and when. Develop plans to address reduced supply and to There are different meet increased demand ways in which you can detect the effect of rising demand and anticipate changes in demand: • Measuring the third next available appointment. An increase in the measure will alert you that the system is coming under pressure. Why look at the 3rd next available appointment? The third next available appointment is quite simply the third open slot on the schedule. It is the gold standard for measuring delay. It removes chance occurrences of available appointments (i.e. the first and second appointments are often open due to cancellations) and gives you a more accurate picture of your clinic’s handling of demand. See the Measurement section for more information. • Monitoring the proportion of appointments that re- main free. If you know what proportion of your appointments are usually booked in advance, and more than usual are taken, this will help you recognize when you need to initiate your contingency plan. This will also act as an early warning system for changes in demand due to outside influences and allow you to be alert to times when you will need to re-profile your demand and possibly re- format your appointment template. • Horizon scanning. Many practices find that gathering data over time helps them build up a profile of demand that can be used for planning. Combining this information with knowledge of past events © Health Quality Council 2006 2-46

Change ideas—access (outbreaks, health scares) and information from a variety of sources (media, health, and social organizations) can help to keep you alert to possible increases in demand. Practices can handle increased demand in a variety of ways. Sometimes it can be helpful to review pre-booked appointments and to see if they can be postponed or handled differ- ently. Another plan is to ask clinicians to add additional appointments for a short period of time, until demand returns to its normal levels. Knowing exactly how much additional work to expect can make the process of managing less stressful. It can be useful in the short-term to make more practice time available by postponing meetings, administrative sessions, medicals, or insurance appointments. Remember, internally generated demand is the demand that you can influence the most. It may help to consider when the times of high demand fall, and think about staffing levels. Some practices agree that no more than one doctor can be away at any one time, or that no doctors can take holidays during a certain time. When a doctor returns from holidays, it can be helpful if no patients are pre- booked during the week or first few days after his/her return. While locums are usually the most convenient approach for finding the supply you need, they may not always be available. Practices often find that improving their system management enables them to plan further ahead and book locums that can otherwise be difficult to find on short notice. It can be useful to book the same locum whenever possible, so that patients become familiar with the doctor and do not simply book an appointment to see their ‘own’ doctor after they have seen the locum. © Health Quality Council 2006 2-47

Change ideas—access 5. Communicate effectively with patients and across the practice team Implementing Policy to Enhance Community Health Creating Supportive Develop Personal Skills Health Care Organization Environments Clinical Self Information Management Reorienting Systems HC Services Strengthening Community Delivery System Decision Action Design Support Productive Interactions Informed, Prepared, Prepared, Activated Activated & Relationships Proactive Practice Proactive Community Community Patient Team (partners) Population Health Outcomes/ Functional and Clinical Outcomes Adapted from : Victoria Barr, Anita Dotts, Brenda Martin-Lind, Darlene Ravenadale, Sylvia Robinson, Lisa Underhill (2002) See Ideas in Examples of change ideas Action on • Involve the team in developing, testing, and implementing page 2-76 for local and change. other exam- • Use team communication methods. ples of • Involve patients in, and inform them about, your changes in change ideas advance. • Use the Model for Improvement to develop, test, and implement change. Involve the team in developing, testing, and imple- It may be difficult menting change or impractical to involve all members of the team equally in your work because everyone is so busy. Many practices find it helpful to identify a small but representative improvement team to lead the work, with a responsibility to communicate and involve other team members where appropriate. Everyone on the team will have ideas and contri- butions to make, so it will be useful to ensure that there are regular meetings and feedback on progress and for harvesting ideas for PDSAs. Use team communication methods In order to optimize communication, care teams should plan to meet regularly through huddles, team meetings, and staff meetings. The creation of communi- © Health Quality Council 2006 2-48

Change ideas—access cation short-cuts, flexible cues, and sequencing can also optimize team communication. Huddles. The idea of using quick huddles, as opposed to the standard one-hour meeting, arose from a need to speed up the work of improvement teams. Huddles enable teams to have frequent but short briefings so that they can stay informed, review work, make plans, and move ahead rapidly. Huddles have a number of benefits: • They allow fuller participation of front-line staff and bedside caregivers, who often find it impossible to get away for the conventional hour-long improvement team meetings. • They keep momentum going, as teams are able to meet more frequently. • They enable PDSA cycles to proceed rapidly. To conduct a “huddle”, the care team assembles at a predeter- mined time each day to look ahead on the schedule and anticipate the needs of the patients coming to the clinic that day. For example, a patient may need a potassium test before he or she meets with the physician. Instead of waiting until the patient is in the exam room with the physician, the staff can send the patient to the lab immediately after checking in at the clinic. The clinic staff can then adjust the schedule, because they know the patient won’t be using the original appointment slot but will need a slot 30 to 45 minutes later, after the test is conducted. Start huddles with a small bit of work and grow the work as the team gains proficiency. For example, in their huddles teams can discuss which patients on the schedule are unlikely to show up for their appointments (because they are in the hospital, they called to cancel, or were seen just last week), what equipment will be needed in the room, and what additional services the care team can provide for the patient at today’s appointment to make a re-visit less likely. Lessons learned from the huddles are recorded and reviewed at weekly team meet- © Health Quality Council 2006 2-49

Change ideas—access ings. Team meetings. Team meetings review lessons from huddles. The care team also needs concentrated time together to plan their roles and responsibilities, as well as to discuss opportunities for improvement in their work. Planned team meetings, scheduled weekly or monthly, are the most effective tool for accomplishing these types of important activities. Staff meetings. Office practices with more than one care team should have coordinated meetings with all staff. Some smaller offices combine team meetings and staff meetings, although most find that their care teams need their own time to discuss team-specific issues that would be too detailed and prolonged for the larger all-staff meeting. Weekly staff meetings are used to discuss the lessons learned from huddles, as well as to identify issues beyond the care team. For example, a care team huddle may identify a problem with the location of a computer or the need to deflect patients away from the team due to reaching the limits of supply. Staff meetings are good place to raise practice-wide staffing issues. Production planning meeting. Larger practices, academic centres in particular, benefit from a more formal approach to staffing: a weekly meeting including the practice medical director, nursing director, and administrative director. Each brings requests from their constituents for increases or decreases in provider availability for patient care. They review the next four weeks of supply compared to expected demand and manage the contingency plans to close any gaps. These production planning meetings review lessons from the teams, looking for patterns indicating systematic problems such as the following: • Time off, vacation policies based on critical thresh- old • Develop staffing requirements, space and equip- © Health Quality Council 2006 2-50

Change ideas—access ment requirements • Plan how much of a provider’s schedule to hold for another absent provider, discuss philosophy as well as numbers Communication shortcuts. These are visual displays of information that provide effective ways to make adjustments in the schedule, coordinate emerging patient needs, or reassign staff responsibilities. For example, use a large board in the clinic workroom to note daily patient appointments (including special needs) by provider, along with nursing staff assignments. This provides staff with the “big picture” of what’s going on in the clinic each day so that the care team can help where needed. Flexible cues and sequencing. These are a type of communication that keeps a practice flowing smoothly without the need for verbal or face-to-face communication. Some examples: • A chart in the blue basket means that the patient has arrived and is ready for rooming, and a chart in the red basket means that the patient has gone for testing. • Flags on the room indicate which member of the care team is in the room, or if the patient is ready for the next stage of the visit. • Paper tasks that will take longer than one minute to complete are placed in an in-basket for the physician, while tasks that are quick (and will contribute to continuous flow) are placed in a prearranged “hot-spot” for immediate attention. Involve patients in, and inform them about, your changes in advance Patients should be informed about any changes you make that affect them. Some of the changes will affect patients more than others, so you need to let them know why the change has been planned and what it means to them. Posters, brochures, web sites, and conversations during consultations are all ways you can let them know what’s hap- pening. Patients or patient groups can also help you design © Health Quality Council 2006 2-51

Change ideas—access changes to services, contributing their personal experience of what works well and not so well. Use the Model for Improvement to develop, test, and Making changes implement change using the Model for Improvement (see page 1-11 in the Overview section) has a number of benefits. First, you can try things on a small and manageable scale, and avoid affecting the entire practice at once. Second, you can build up data and knowledge about what is effective. This means that you will be able to demonstrate your results to the practice and gain their support for implementing what works. Third, as long as you are clear about what your objectives are, everyone in the team can use PDSAs and contribute to the new system. More about Improved Access and Clinical Office Redesign • Clinical Microsystem Action Guide: www.clinicalmicrosystem.org • Starting a Revolution in Office-Based Care, American Academy of Family Physicians: www.aafp.org/fpm/20011000/29star.html • Implementation of an Open Access Scheduling System in a Residency Training Program, Society of Teachers of Family Medicine: www.stfm.org/fmhub/fm2003/October/ Kennedy.pdf • A Controlled Trial of an Advanced Access Appointment System in a Residency Family Medicine Center, Society of Teachers of Family Medicine: www.stfm.org/fmhub/fm2004/ May/Francis341.pdf • Institute for Healthcare Improvement web site resources: www.ihi.org/IHI/Topics/ OfficePractices/Access/Literature • Advanced Access: A New Paradigm in the Delivery of Ambulatory Care Services, National Association of Public Hospitals and Health Systems: http://www.naph.org/Content/ ContentGroups/Publications1/AdvancedAccessANewParadigm.pdf • Same-Day Appointments: Exploding the Access Paradigm, American Academy of Family Physicians: http://www.aafp.org/fpm/20000900/45same.html • Alaska Native Medical Center - Values-Driven System Design: Institute for Healthcare Im- provement: http://www.ihi.org/IHI/Topics/PatientCenteredCare/ PatientCenteredCareGeneral/ImprovementStories/ AlaskaNativeMedicalCenterValuesDrivenSystemDesign.htm • Warrender, TS. Promoting Advanced Access in Primary Care: A Handbook. West Sussex: Aeneas Press, 2002. © Health Quality Council 2006 2-52

Ideas in © Health Quality Council 2006

Ideas in Action Know all your patients who have diabetes and/or CAD. • Agree on a clear definition of CAD/diabetes. • Develop a registry. • Develop systems to maintain valid registries. Local examples • Dr. Nayar (Saskatoon) identified approximately 200 patients with diabetes by using the 250 billing code, going back a period of 12 months. • Dr. Nayar identifies new patients with diabetes by rigorously screening for diabetes (using the 2003 guidelines) at their annual physical check-up. • The Leader Medical Clinic used green (CAD) and pink (diabetes) coloured index tabs to identify the charts for their patients with CAD and diabetes. • The Saskatoon Community Clinic prints all their flow sheets on paper with a bold green strip down one side. This makes the flow sheet easy to find in medical charts that can sometimes be overflowing. • The Saskatoon Community Clinic created a plastic overlay stencil that they use to highlight key measures on the flow sheet, for easy identification during the clinical visit. • Family Medicine Unit in Regina put an alert into the computer scheduling system, to identify patients as part of the CDM Collaborative. • Academic Family Medicine in Saskatoon used coloured stickers to help identify their diabetes and CAD charts during the audit process. As an unexpected benefit - they now find that when testing an improvement idea, it's very easy to select a patient chart or two to start with, as the relevant © Health Quality Council 2006 2-53

Ideas in Action charts are so quickly identifiable. • Family Medicine Unit put patient privacy information brochures on the reception desk, for the receptionist to hand out when a Collaborative patient reported to reception. • A practice in North Battleford placed a patient privacy information brochure into every chart after they finished auditing for clinical information. This ensured that all CDM patients would receive a brochure on their next visit. • Family Medicine Unit overcame the issue of blank probabil- istic lists by using the MCIB fee codes and the practice scheduling program to identify patients with CAD and diabetes, by physician. • Sandra Hintz, office assistant with the Maidstone Medical Clinic, was finding it a challenge to audit charts for medications, since she didn’t know all the trade names related to the drug classes. To make it easier, she created her own list of all the generic and trade names related to the drug classes. As a result, she was able to audit charts more effectively and feels more connected to the medical care of patients who come to the clinic. “Now I can see that someone is on Crestor, and I know what it’s for! It was really quite an interesting and useful experience.” • As a data quality check for the accuracy of A1C lab values entered into the CDM Toolkit, one clinic used the Advanced Search feature. They did a search for “A1C over 10%” and ran the Selected Indicators report to get a detailed table with patient names and phone numbers. As a result, several errors were found in the transcription of lab data. After the data entry errors were corrected in the Toolkit, the average A1C value for that clinic was lower. © Health Quality Council 2006 2-54

Ideas in Action Other examples • Dr. Neil Hilliard has a fee-for-service solo family practice, set in the rural community of Chilliwack, BC. He conducted chart reviews to identify his registry of 35 patients with congestive heart failure, then started a flow sheet for each CHF patient. He approached the task by reviewing two patient charts per week, each chart review taking about 15 minutes. To help maintain the registry, CHF patient charts are flagged with a red sticker and the Office Manager helps track down some flow sheet data, such as patient weight. • Dr. Sue Turgeon is based in a multi-physician Mid Main Community Health Centre in urban Vancouver, BC. Her practice has a diverse population of approximately 5,400 patients. To set up her patient registry, CHF patients were identified by finding the ICD-428 code in the office’s billing system. The clinic’s physicians then confirmed which of these patients had an established CHF diagnosis, and these charts were tagged with a colour sticker. The next step was to set up a file box filled with patient flow sheets. Each time a CHF patient chart was pulled, the flow sheet was attached and physicians updated the information as they went along. The clinic’s nurse and clinical pharmacist took on the tasks of the initial patient chart review and entry of baseline data. • Dr. Lokanathan’s (Queen Charlotte Island, BC) practice enlists the Clinic Manager to help maintain the registry. For each CDM patient visit, an encounter form is attached to the chart. The Clinic Manager ensures this is done prior to the clinic, using a list generated by the CDM Toolkit. The receptionist requests encounter forms as needed for walk- in patients. After the visit, the Clinic Manager enters the data into the CDM Toolkit, filling in gaps such as lab data as it arrives. Once the information has been added to the Toolkit, the paper encounter forms are shredded. If there is no new information recorded, the encounter form is simply © Health Quality Council 2006 2-55

Ideas in Action left in the chart for the next visit. • Dr. Anis Lahka is a single physician practice in North Van- couver, with two part-time medical office assistants. Dr. La- hka has 65 patients with diabetes. The first step for the registry was to enter all diabetic patients into the CDM Tool- kit—Dr. Lahka spent two long evenings entering all the baseline. To maintain the registry, diabetic patient charts were switched to blue so they could be easily identified. All flow sheets are completed by the doctor and placed on the inside page of the chart. A new encounter form is then printed off and placed in the back of the chart before filing. The doctor has the most recent information at each visit and can easily identify if diagnostic information is missing. The data is entered into the CDM Toolkit on the same day as the visit by the Medical Office Assistant. Both part-time MOAs have been trained on using the Toolkit. For frequent visits and to avoid taking data more often than what’s required, prior to the appointment, the MOA reviews the form to assess whether it needs to be completed. • Wrose Surgery in Bradford (UK) thought they had an accurate diabetes registry, but found that many patients listed had an incorrect diagnosis. The practice tackled this by standardizing the protocols for diagnosis of diabetes. They held a clinicians meeting to discuss WHO guidelines and agree on a protocol. A copy of the protocol was laminated and put into each consulting room, so all clinicians were diagnosing in the same way. Tips and ideas • Use community nurses to pick up “missed” patients, for example through flu vaccination campaigns. • Use a new patient questionnaire that includes questions on chronic disease. This helps ensure that new patients are added to the registry at the earliest opportunity. • Store all chronic disease charts separately for easy access. © Health Quality Council 2006 2-56

Ideas in Action • Identify patients with chronic disease during visits for other purposes. • Design a chart identification system for the office that helps providers/staff readily recognize patients with a chronic disease. • At baseline, conduct a chart review and complete the patient flow sheet for about 6 patients. Document how you did those so the nurse or office assistant can repeat the process and complete the remaining flow sheets. © Health Quality Council 2006 2-57

Ideas in Action Be systematic and proactive in managing care for people with diabetes and/or CAD. • Establish a small, multidisciplinary team (micro-team) to manage the care and delivery of people with chronic disease. • Identify a lead health professional to coordinate the care for people with diabetes/CAD. • Establish practice protocols (or customize existing protocols) for the care of people with diabetes/CAD. • Embed the use of protocols through the use of computerized templates. • Establish proactive call and recall arrangements for people with diabetes/CAD. • Ensure people with diabetes/CAD receive optimal care including the use of drug therapies and access to support for lifestyle management. • Ensure the use of a checklist for the review of people with diabetes/CAD. Local examples • Dr. Nayar has noticed an improvement in managing care for patients with diabetes by using a paper-based diabetes care flow sheet, adapted from the most recent clinical practice guidelines. The practice is now switching to an electronic flow sheet system. • Dr. Nayar’s practice uses a hard copy of an excel spreadsheet to track patient visits and ensure follow-up care is provided in a timely manner. This system will be fully electronic in the near future. • Dr. Nayar uses certain days of the week to focus on common disease-specific areas. For example, Wednesday is “diabetes focus” day. • Dr. Nayar’s practice has found his call-back system to be very effective for follow-up care. Copies of test results re- quiring patient follow-up are placed in the “Call-back Binder”. The office assistant keeps a detailed account of efforts to contact the patient on the copied page. Once the patient is contacted and the follow-up appointment is made, the copied page goes back into the patient chart. A blue © Health Quality Council 2006 2-58

Ideas in Action sticker is placed beside the patient’s appointment to flag that it is a call-back appointment. If the patient does not attend, the entire process starts over again. • The Central Butte Primary Health Care Site has also implemented a flow sheet for improved care. The flow sheet is based on Canadian Diabetes Association guidelines, and has helped standardize charting. It is also more convenient to have the patient information in one place. Integrating the flow sheet into the daily work helped the team identify areas that were not being consistently charted. • The Central Butte team has developed an excel spreadsheet to track clients’ progress on key indicators, such as blood pressure and A1C. The team uses the spreadsheet to produce run charts that they share with patients. • Saskatoon Community Clinic has created a committee that meets biweekly for one hour, to troubleshoot any issues, proactively discuss upcoming tasks and events, and keep communication lines open and people informed. Each meeting they alternate focus on CDM and Improved Ac- cess. • Dr. Maree, Craik Medical Practice, sends a letter and lab requisition to all her CDM patients, asking them to go for lab work prior to booking their review. This means current results are available to her and it reduces the need for another follow-up visit. • Dr. Tessa Laubscher’s (Saskatoon) patients with diabetes and/or CAD are given a prescription with refills of their medications for only four months. Her patients know they cannot get further refills without having their lab work done (as needed) and coming in for a diabetic or CAD review. This system works well to ensure regular follow-up visits for these patients. © Health Quality Council 2006 2-59

Ideas in Action • Several Wave 1 practices are proactive with foot screening. In order to ensure busy physicians remember to screen for diabetic neuropathy, office staff instruct patients to remove their shoes and socks when they are roomed. For example, the Southwest Medicentre’s (Dr. Olfert, Lana, Melanie and Tamara) objective is to have consistent lower extremity exams (LEE) for patients with diabetes. To achieve this, they use the following process: • CDM Toolkit flow sheets are placed in the charts of patients with diabetes. • When rooming the patients, the nurse checks the flow sheet to see if the foot exam has been completed. • If a foot exam is needed, the nurse asks the patient to remove shoes and socks. • The patient receives the foot exam and this is noted on the flow sheet. • Next steps are to use the Recall Report to identify patients due for a LEE. • The Lucky Lake Primary Health Care Centre use flow sheets to identify patients with missing height and weight measures. The entire practice, including the front desk staff, work together to identify people with missing or out of date information. When those people come in for appointments, they work to update the missing information, prior to rooming the patient. • The Rosthern Clinic has developed a stamp that they use in more than one place on the patient record, to ensure patients are regularly asked about their smoking status. This has resulted in discovering that a number of people they assumed didn’t smoke actually did! • Leader Clinic chose to assess Tobacco Use among their patients, rather than Smoking Status, as they wanted to broaden the Key Measure to include all forms of tobacco, including chewing tobacco. © Health Quality Council 2006 2-60

Ideas in Action • A critical success factor in being proactive and systemic in managing care is involving the whole practice team, especially the office manager, in developing and maintaining new systems and processes. Office staff, particularly those managing information systems, are often in the best position to lead such improvements. Other examples • Dr. Rick Nutall (Vancouver Island) and his practice participated in the BC Diabetes Collaborative. After finishing his baseline data, he discovered that only 70% of his patients had their blood pressure measured in the previous year, and just 58% had their A1C tested. Surprised at how many patients had not been in to see him, he began to call them to set up appointments. Each week he called four patients, and in just three months had made significant improvements towards meeting his targets. • Dr. David Atwell is a GP from Victoria. Although he knows many physicians recall patients by phone, he prefers to in- vite patients for a visit by letter. For his practice, the small expenditure on postage is worth it to keep the phone lines free for other patients and to keep the office staff from being tied up with calls for too long. Tips and ideas • Use the registry to generate reminders about patient follow- up. • Assign roles, duties, and tasks for planned visits to all members of the micro-team. Use cross-training to expand staff capability. • Designate staff to be responsible for patient follow-up (by telephone, home visit, etc). • Office assistants are valuable members of your team. Dis- cuss how you can work together to identify the practice’s population of chronic care patients, and set up a patient recall system. © Health Quality Council 2006 2-61

Ideas in Action • If recalling your patients via telephone, have a script that your office staff can use to describe the purpose of the planned visit and why it is important. If recalling patients by mail, develop a standard letter that you can easily adapt to communicate what you want to achieve in the planned visit. © Health Quality Council 2006 2-62

Ideas in Action Involve patients with diabetes and/or CAD in developing and delivering care. • Have a deliberate strategy for self-management. • Maximize self-management by people with diabetes/CAD. • Integrate the patient’s perspective constantly in the design of services. • Ensure written communication is appropriate and understood. • Pay special attention to the needs of hard-to-reach groups. Local examples • Dr. Ted Kusch (Saskatoon) writes a letter to inform selected patients about their cholesterol test results. He has a set format for the letter. He sends a copy of the test results, explains the results, and offers suggestions for healthy eating and physical activity. • Dr. Nayar gives patients a requisition form in advance for A1C tests for one year to ensure appropriate frequency of testing and to involve the patient in taking some responsibility for getting the tests done. When the patient has his/her follow-up appointment, the results are ready for discussion and action between the patient and physician. • Dr. Nayar uses a non-disease specific flow sheet to write down all the medications a patient is taking to track and update them. This system is especially useful for patients who have multiple chronic conditions. These flow sheets are free and are available for download from the following websites: www.formedic.ca (Canada) www.formedic.com/index.html (United States) • The Central Butte Primary Health Care Site involved patients from the very beginning when setting up their monthly diabetes clinic. The team held a public meeting for their patients with diabetes, along with their support persons, to learn first-hand what patients wanted to gain from the clinic. © Health Quality Council 2006 2-63

Ideas in Action • Central Butte used PDSA cycles to refine the diabetes clinic. They tried ideas one month, discussed what worked and what didn’t, then retooled the clinics for the following month. For example, when the clinic first started, patients saw each health care provider individually. Based on client feedback and their own observations, the health care team realized that clients received duplicate information during the one-on-one consultations. The team then tried a general group education session prior to the one-on-one visits. They found that by first providing a 15-minute group visit, duplicate information during individual visits was reduced resulting in greater patient and staff satisfaction. • Central Butte maximizes clinic time by giving patients lab requisitions and asking them to complete their lab work one week prior to the clinic. This allows the health care team to review each patient’s results on the day of the diabetes clinic. • In 2002, Saskatoon Health Region (SHR) started running a community based self-management program called Living A Healthy Life with Chronic Conditions. Developed at Stanford University (the Stanford Chronic Disease Self- Management Program) and delivered under a licensing agreement by SHR, the 6-week program is offered to people in SHR who have a chronic disease and/or caregivers. The program is not specific to any particular chronic disease or condition but provides practical suggestions and support that build confidence in coping with the common everyday challenges of a chronic condition—such as pain, isolation, and communication needs. The program, delivered by pairs of volunteer leaders who have a chronic condition themselves, is offered free of charge to ensure that it is financially accessible to all. Participants also receive a free copy of the Canadian version of the book Living a Healthy Life with Chronic Conditions (Lorig K, Sobel D Gon- zalez V et al, Colorado USA; Bull Publishing Company ISBN: 0-923521-53-4). Canadian and American research studies confirm that the Stanford program makes a real dif- © Health Quality Council 2006 2-64

Ideas in Action ference in the lives of participants and reduces acute care services including ER visits and days in hospital. Since 2002, SHR has run 27 six-week sessions with approximately 320 participants. Ninety-one percent of SHR participants surveyed were satisfied with the program and would recommend it to a friend. Eighty-two percent of participants said that it helped them learn to manage and cope with their chronic condition. SHR has two Master Trainers who have trained 35 volunteer leaders, of which 27 are still active. Five of the leaders are from rural SHR and there are sessions running in Humboldt and, in the future, in Wa- dena. • Dr. Tootoosis from North Battleford Medical Clinic tested a PDSA on self-management, starting with five patients. She began by finding out if they were interested in self- management. If interested, she gave them a “Discovery Re- cord” adapted from the Diabetes Management and Training Centres Inc., a one-page self-management record that allows the patient to identify their own goals. All but one patient returned the Discovery Record. Dr. Tootoosis is fur- thering this PDSA with other patients and addressing barriers to self-management as they arise. • Melville Medical Clinic organized a diabetes education evening for a group of 15 patients. They invited the rest of their Regional Improvement Team, including a pharmacist, diabetes educator, the Collaborative Facilitator, and office staff to join the physician in providing updated info to the patient group on the latest in diabetes management. At the group visit, each patient also received their chart and had time to look through it. The evening was filled with discussion and sharing of experiences among the group. • Dr. Maree’s clinic in Craik decided to try some ideas shared at a Learning Workshop, to improve patients’ involvement in their own care. In August 2006, the practice team (including a diabetes nurse educator and a pharmaceutical © Health Quality Council 2006 2-65

Ideas in Action representative) tested their first group education session. The session included eight selected patients with diabetes. The purpose was to provide current, accurate information on diabetes, in a supportive environment. The group session was followed one week later with 30-minute individual patient appointments with the diabetes nurse educator. The purpose of the follow-up visit was to provide one-on-one counselling and do some patient goal-setting. Evaluations from the participating patients have been positive. Patients indicated that they liked the learning component with other people in a group setting and knowing they were not alone in the challenges they face managing diabetes. The participants recommended that they would like additional group education sessions, with individual follow-up appointments on a quarterly basis. An unexpected outcome was additional “drop in” visits to the community pharmacist by participating patients, to ask more detailed questions about their medications. This could be the seed for another PDSA. Other examples • Dr. Quentin Smith, along with his team of GPs from Chilli- wack (BC), have developed a binder for their diabetes patient. Each binder contains: -Copy of their flow sheet and personal history sheet -Diary for home blood sugar recording -Information sheet for recording medications -Notes page for physician instructions or questions for their next appointment • Laurel DeGoeij, a Diabetes Nurse Educator from Kitimat (BC) used to be viewed as the “diabetes police”. Her approach consisted of inundating patients with information, in case the patient never came back. Since joining the Col- laborative she has a new approach and her patients no longer avoid her. Instead of telling patients what they need © Health Quality Council 2006 2-66

Ideas in Action to do, patients tell her what lifestyle changes they are willing and prepared to make in their lives and then identify realistic goals to work towards. If the goal proves too difficult to attain, it is reset to something more manageable. • Dr. David Wong (Burnaby, BC) started working on self- management with a few of his patients. A goal was set that the patient wanted to accomplish and felt confident that they could achieve. The specific goal was then recorded on the comment section of the diabetes patient flow sheet. Two weeks later, the patient attended an office visit for a follow-up on their progress in reaching their goal. Patients who did not achieve their goal received encouragement and reset their goal to something more realistic. Dr. Wong believes that patient self-management doesn’t involve more time on the part of the doctor. He recommends picking two or three patients a week and trying to set self-management goals with the small group. • Dr. Vanita Lokanathan recounts how a patient avoided going to the doctor. The patient felt like a failure because she couldn’t achieve the goals that had been set for her. She felt that the doctor thought she was overweight and lazy. Now, by having the patient set her own self-management goals, she is making progress in getting her A1C under control. Dr. Lokanathan gives her patients a copy of their flow sheet and the patient education graphs, generated by the CDM Toolkit, so they can see the progress they are making. • Dr. Anis Lakha began including self-management by giving patients a copy of their flow sheet and asking them to record their height and weight. Then they discussed goals the patient wanted to achieve. Some patients identified being more active and exercising as their goal. She started with six patients who would go for a walk and then take their glu- cometer reading. Having patients see the changes in their numbers as a result of moderate exercise was motivating © Health Quality Council 2006 2-67

Ideas in Action for them to make lifestyle changes. • Dr. Richard Welsh (Vancouver Island) recognizes the important contribution Lynda Vanson, his practice nurse, has made to ensure patients are engaging in self-management. They do a combined planned visit, with Lynda taking blood pressure and working with patients to set self-management goals. Dr. Welsh completes the assessment and imple- ments the care plan. Lynda has taken on a number of duties that Dr. Welsh used to do, which frees him to see more patients. The additional MSP income he earns is used to pay for her additional salary. • To help educate patients about healthy food choices, one practice (located in the UK) has a grocery display in the office. This allows practice staff to enter into discussion with the patient around good foods and which brands might be more appropriate to use. It gives them a chance to talk about food labeling and how to read the labels to make informed choices. • Wrose Surgery (UK) did a search of all patients with diabetes who were housebound or lived in a special care home. They identified 21 patients and discussed this list at a Pri- mary Health Care Team meeting so they could get feedback on these patients from any clinician, whether practice or community-based, who came into contact with them. The meeting helped reduce this number as it became evident some of the patients were treated at the hospital. The practice was left with 5 patients, who were receiving no contact for their diabetes. They decided on a team approach, with the community nurse visiting the patients for blood work, and the GP or diabetes nurse educator visiting and reviewing the results with the patient. Tips and ideas • Remember the five A’s of patient self-management: © Health Quality Council 2006 2-68

Ideas in Action Assess the patient’s concerns, behaviour, values, preferences, and knowledge Advise regarding specific information about health risk and benefits of change Agree to set goals based on the patient’s preference Assist the patient in identifying personal barriers and use problem-solving techniques to overcome them Arrange follow-up • Make sure the goal is something the patient wants to achieve. • Take baby steps towards reaching goals. • Encourage and applaud progress—show that you are in their corner. • Be a coach—when someone fails, reset the goal to something more realistic and attainable. • Patients do get it—they see what happens to blood sugars when they make appropriate lifestyle changes. • Group visits can be effective for some patients in denial; they leave feeling it is worthwhile to monitor their chronic condition. • Make sure you put the patient goals down in writing so that you can track progress. Start a patient goal sheet and keep it in the chart. • Goals are personal, and a group visit may not be the ideal context for initial goal setting. Use the group visits for more general concepts that are applicable to all patients. • There is no such thing as a non-compliant patient; patients are not able to reach their goals because they lack the necessary skills or confidence. • It is critical to understand what is important in the patient’s life, what they want to achieve, and use this knowledge to personalize their self-management goals. © Health Quality Council 2006 2-69

Ideas in Action Develop effective links and communication strategies with key local partners involved in care and support of people with diabetes and/or CAD. Key local partners include specialty/acute care, community- based health care organizations, and others. • Ensure coordination and support collaboration at the primary /hospital care and primary/specialist care interfaces. • Analyze the patient journey and redesign where necessary. • Engage local organizations in developing diabetes/CAD services. • Support collaboration between healthcare professionals in a practice setting and health professionals in the regional health authority to enable integrated care for patients. Local examples • Dr. Nayar regularly refers patients with chronic illness to the “First Step” program in Saskatoon to increase levels of physical activity. Patients are also regularly updated on the mall walking program schedules in the city. • The Central Butte Primary Health Care Site established a monthly diabetes clinic in March 2004. The goal of these clinics is to provide Central Butte residents diagnosed with diabetes with access to local diabetes health education, monitoring, treatment, and self-care support. At these clinics, patients are seen by the physician, nurse practitioner, diabetes nurse educator, dietitian, and medical specialist as required. • Dr. Glaeske’s Clinic (from Assiniboia) worked with a fellow Regional Improvement Team member, community pharmacist Alicia Keller, to develop an improved refill authorization process. The result was an improved assessment of the patients’ medication profiles, reduction of repeated faxes from the pharmacy, and fewer unnecessary repeat visits to the physician. • Looking for ways to improve the system for diabetes educa- © Health Quality Council 2006 2-70

Ideas in Action tion referrals and follow-up in Rosetown, Dr. Dan Ledding used the many opportunities at Collaborative Learning Workshops to discuss the subject with Bev Kernohan. Bev is the local diabetes educator, and she attended workshops as a member of the Heartland Regional Improvement Team. By having these one-to-one discussions, they brain- stormed small, feasible ideas that could improve their system of care. After testing and fine-tuning these ideas, both parties (and most importantly the patients) were pleased with the outcome. Bev saw a larger volume of patients and was able to see patients for follow-up visits more frequently. Having access to Dr. Ledding’s patients in the CDM Toolkit helped the diabetes educator see the most update clinical information, and tailor her education sessions accordingly. Bev was also able to be proactive in scheduling timely follow-up visits by using the Toolkit “Patient Recall” function. Bev and Dr. Ledding have continued to meet regularly with other office members, to review current system operations and entertain improvement ideas. They have also initiated discussions with other clinicians in the care team (i.e. podiatrist and pharmacist) to organize their first group visit for diabetes patients. • Standardized regional patient education is one of the goals for the Wave 1 Cypress Regional Improvement Team. Dur- ing Wave 1, Cabri Medical Clinic worked with health educators, diabetes educators, and a regional dietitian (all of whom were also RIT members) to pilot a series of group education classes in Cabri. This series of classes targeted patients with diabetes and covered topics such as carbohy- drate counting, label reading, portion distortion, prevention of diabetes-related complications, benefits of physical activity, Type 2 diabetes self-management, and glucose monitoring. The plan is to take this pilot initiative and implement it throughout the region. The Regional Improvement Team is thinking of expanding the educators who provide these classes to include health professionals from home care, to optimize the number of education opportunities that can be © Health Quality Council 2006 2-71

Ideas in Action offered. • Dr. Maree’s clinic in Craik works with other providers in the community, such as diabetes educators and pharmacists. Mel Wandzura, a local pharmacist, has been working with Maree to improve medication management for her patients. “I think I’m doing a good job in the office with explaining things, but if you ask patients three weeks later why they’re on a medication, they often don’t remember,” says Maree. “Mel follows up a bit more – he encourages them to come in on a regular basis. He explains why they have to take medication. It’s a more relaxed setting, so it’s easier for them to focus on the information.” Other examples • Dr. Vanita Lokanathan has made the diabetes nurse educator, Cindy Talarico, an active member of the team. One of their initiatives has been to work with the local hospital cook and nutritionist on healthy eating choices for people with diabetes. Cindy has put together a binder for patients, filled with diabetes care resources including recipes. She has also worked with the new manager of a local grocery store to improve food labeling. • Dr. Greg Rosenfeld (Coquitlam, BC) partnered with a local kinesiology/exercise facility. His Office Manager reviewed the diabetes registry to identify patients who might benefit from an exercise program, then sent them a letter of invita- tion. Patients (who ranged in age from 8 to 74 years) were coached to foster their self-efficacy and confidence, then exercised on their own time. The group dynamic helped to keep participants motivated. A pre-post assessment showed a significant decrease in body mass. • Dr. Margaret Murray (UK) and her colleagues have found an effective way to ensure communication between primary and secondary care. They worked with patients to design a © Health Quality Council 2006 2-72

Ideas in Action patient-held record, which is used as a communication tool between the family physicians and the hospital specialists. It also helps patients become more active in their care. • Family physicians in Combe Down (UK) were concerned about the quality of information they received from specialist care. One of the GPs contacted the consultant diabetolo- gists about the lack of information in the clinic letters. To- gether they produced a template letter that contained all the necessary diabetic review information. The teamwork didn’t end there. The initial discussion led to the development of another template, this one for practices to use when referring their diabetic patients to a specialist. • Dr. Neil Hilliard (BC) has multiple demands in his busy practice, so supporting patient self-management was a challenge for him. He worked with his local health authority to get assistance from community-based programs. Rita Bergsma, a registered nurse with considerable experience in cardiac care, will be providing one-to-one patient visits. • At the Burnaby Chronic Disease Prevention and Manage- ment Program they use a triage system where they see people with diabetes and CHF whose physicians have identified them as being in crisis. They ensure that their work connects back to the GP and they do this by faxing the patients’ risk assessment and self-management plan to the physician. • Dr. Andrew Sear (Quesnel, BC) worked with his health authority’s Primary Care Coordinator Margie Wiebe, R.N. To- gether they are helping to further embed good diabetes management into the health care community. For example, LPNs at the hospital are being trained to undertake foot exams and enter the patient information into the CDM Toolkit. Because many of the local pharmacists provide patient education on proper glucose meter use and other issues, they have now been linked with the Diabetes Education © Health Quality Council 2006 2-73

Ideas in Action Centre so that patients can benefit from more coordinated care. Linkages are also being made with physiotherapists in the care of diabetes patients. • Dr. Shirley Sze (Kamloops, BC) and her colleagues have partnered with a local grocery store. A nutritionist leads an interactive group visit to the store and provides information on healthy food choices and how to read food labels. • In East Leeds (UK) they use a fax back system to obtain speedy secondary care advice that enables the patient to be treated in primary care the majority of the time. Tips and ideas • Use a daily office huddle to proactively plan care and dele- gate team member responsibilities before the patients ar- rive. • Develop a referral agreement between specialty and primary care. • Provide skill-oriented interactive training programs for all physicians and staff in support of diabetes management. • Train providers and office staff on how to help patients with self-management goals. • Provide individualized tools for each patient that clearly list the medications ordered (times and dosages) and medications that should be avoided, define changes in condition (symptoms, etc.) that should be immediately reported to the physician, and identify patient limitations prescribed by the physician. • Set a standard meeting time for team to review patient outcome data and to evaluate/plan for new tests of change. • Provide a list of community resources to patients, families, and staff. • If there is not enough room in the clinic for group visits, look at community resources. For example, one practice found that the local church rented suitable meeting rooms for as little as $25 per day. © Health Quality Council 2006 2-74

Ideas in Action • Start a pedometer challenge. Use a community web site - or a poster in your clinic - to post the number of steps office staff take each day and use this as a motivation for patients. © Health Quality Council 2006 2-75

Ideas in Action Improved Access • Understand your practice’s supply and demand. • Shape the handling of demand. • Match the supply of the practice to the reshaped demand. • Establish and implement contingency plans. • Communicate effectively with patients and across the practice team. Profile: Saskatoon Community Clinic The Saskatoon Community Clinic (SCC) was founded in 1962, through the Community Health Services (Saskatoon) As- sociation. The clinic employs 150 full and part time staff and has 12 disciplines involved in providing interdisciplinary primary health care. They work out of three sites located on 2nd Ave- nue, 1st Avenue, and 20th Street West in Saskatoon. The clinic also provides physician services to the Delisle Primary Health Care. Starting in March 2004, SCC became the first clinic in the province to implement the Improved Access model. The clinic had identified a number of access challenges, such as stress and decreased satisfaction for staff and patients, inefficiency of clinic visits, and lack of continuity of care due to long waits for patients to see their own family doctor. Led by Dr. Carla Eisen- hauer, the clinic’s quality improvement team established goals to help guide them during the process: • Ensure quality and timeliness of care by most appropriate health care provider; • Improve continuity of care; • Improve clinical outcomes; and, • Provide access to health care provider of choice within two working days. The QI team began by collecting data on essential measures: • Third next available appointment; • Supply and demand for each provider and overall; daily and weekly, appointment types (same-day and © Health Quality Council 2006 2-76

Ideas in Action booked), and % utilization; • Patient and staff satisfaction; and, • Continuity of care. The data allowed them to create both individual and overall plans for improving access. Part of the plan involved working down the backlog. With summer typically being a quieter time of year for the clinic, they decided on this time frame to eliminate the backlog, and hired additional staff (a Nurse Practitioner) on a short-term basis. Although the QI team was leading the effort, it involved the participation of the entire group. The QI team worked to educate, engage, and excite clinic staff and patients. The initiative was shared during the general staff assembly, and also with smaller health care provider groups. Patients were notified of the upcoming changes through Focus (the SCC newsletter), pam- phlets, and one-on-one conversations with staff and providers. As shown below, the results have been impressive: • In March 2004 (pre-implementation) average waiting time was 36 days for a complete physical and eight days for a regular appointment; with implementation of Improved Access average waiting time was reduced to two working days for most types of appointments. • In 2006, average waiting time continues to be two working days for most appointments. • Patient satisfaction with waiting time was measured before implementation and one year following implementation with significant improvements in the following areas: availability of particular doctor; availability of any doctor, and continuity of care. • In 2006 the clinic continues to consistently meet the 80% patient satisfaction access outcome target established by the Health Quality Council Collabora- tive. Patient and staff feedback has also been positive: © Health Quality Council 2006 2-77

Ideas in Action • Clinic staff hear comments such as “I can’t believe I got in to see you today!” • Staff say “yes” instead of “no”. • Patient satisfaction survey found that 91% of patients felt an appointment was provided within their expected timescale, and 78% saw their own family doctor. Key challenges and lessons learned: • Resistance to change—need champions to help overcome this fear of trying something new. • Misperceptions and misunderstandings—make sure you have a clear and consistent communications with providers, patients, and staff. • If one provider struggles with the system, it can have a cascading effect on other practices. Share success and make system adjustments based on measurement and individual practice needs. • Ensure continual education. What do you mean by two working day goal and same-day appointment types? What types of problems would constitute a doctor’s request? Remind and review. • Develop contingency plans. What will you do during high volume times and during physician absences? • Ensure you are using demand data to develop your appointment templates so that you are setting aside the right number of same-day slots and allowing people to pre-book if need be. • Work in progress; continuous monitoring and adjust- ment is required to maintain the system and meet established goals. • Third available appointment measure, demand studies and patient satisfaction measures on-going; QI team continues to meet weekly to monitor progress on access goals and make adjustments based on patient needs and provider availability. © Health Quality Council 2006 2-78

Ideas in Action Profile: Saskatoon Medical Associates Dr. Vicki Holmes can see the light at the end of the tunnel. When the Saskatoon family doctor joined the CDM Collabora- tive, she had a backlog of more than 100 patients waiting for completes and the average wait for regular appointments was about three weeks. Through her participation in this initiative, Holmes expects to be completely caught up on her waiting list by early fall 2006, and seeing patients within a few days of when they call. When Holmes and her office manager Sandy Hulm measured the supply and demand, they found there were enough appointments available to meet demand. Knowing that it was possible to reduce wait times, Holmes made some key changes to her practice: • Since Mondays had the highest demand for appointments, Holmes now books completes in the morning only, leaving the afternoon available for same-day requests. • Holmes hired a locum for the summer. She planned to have the locum work through her backlog of completes, but this approach didn’t work with her patients, who preferred to see Holmes for their annual check ups. Instead, the locum has been taking short appointments while Holmes does completes. • A letter was sent to all her patients, explaining the changes. The letter asked for their co-operation in making Improved Access a success at the clinic. • Hulm and her office staff have answered questions and addressed patient concerns about the changes. Holmes credits the entire team – Hulm, frontline staff, her patients, and the other physicians at the clinic – for making Im- proved Access possible. “There’s no way I could have done this on my own. You need the support of the entire team.” Despite the challenges, Holmes and Hulm agree the improve- © Health Quality Council 2006 2-79

Ideas in Action ment was worth the effort. Staff are looking forward to saying “yes” to patients when they call for an appointment and Holmes is looking forward to providing more timely care. Although her clinic will always be a busy one, the changes will help make it more manageable for staff and patients. In the end, it’s about providing the best care possible. “Many of my patients have been with me for generations,” says Holmes. “I even have one patient who is a fifth generation. That’s the beauty of family medicine.” Profile: Regina Community Clinic Regina Community Clinic shares their lessons learned from Improved Access. • It’s imperative to collect accurate supply and demand measurements so as to make an accurate template. This also adds credibility to the Access system and makes for a smooth transition. • The backlog of the physician needs to be understood and clinics must identify existing resources to manage that backlog prior to starting Access. Examples include: • The physician staying longer everyday to see more patients; • Other physicians, who have some available spaces, see more patients; and, • The nurse practitioner may see some patients. • Patient education is very important as you will need their cooperation for this system to get started. This should be done by informing all the patients through a letter. It is important that the receptionist has key messages to help guide conversations with patients. • The receptionist(s) must be given the power to book appointments and should have support for decisions. © Health Quality Council 2006 2-80

Ideas in Action • It’s imperative that everyone understands that measurements for supply and demand will continue even after your clinic is using an Improved Access system. • Start with one practice at a time as you can transfer the lessons learned when starting another practice. • All staff need to be involved when looking at the big picture, as you will need their expertise for problem-solving issues with supply and demand. Examples include: • On busy days do not book completes unless you have to, and then only book the first two appointments in the morning or afternoon. • If part-time physicians need to have schedules changed then show them the trend and discuss solutions. • Have some faith and do not be afraid to try Improved Ac- cess. Other local tips and ideas • After hours, the Kenderdine Medical Clinic was finding that people were calling their on-call nurse for simple, non- clinical information—such as hours, wait time to see a doctor, and call schedule. They decided to measure these types of telephone demand and then developed a telephone auto-prompt message. Now the on-call nurse only has to field calls that are clinical in nature. • When Dr. Mark Cameron (Broad Street Clinic, Regina) decided to work down his backlog, part of his strategy was to work a bit harder, but he needed to find the time. Since his daughter had dance classes near his office, he decided that he would drop her off and come back to the clinic to © Health Quality Council 2006 2-81

Ideas in Action see a handful of patients before picking her up again. He also opened up one extra spot first thing Tuesday through Friday mornings. In relatively short order, his backlog was gone! • In order to free up the front desk staff’s time to participate in more of the clinical tasks of the practice, Porcupine Plains Medical Clinic decided to reorganize their medical charts to make filing more efficient. This seemed like a daunting task, but Sandy Pieterse, Nurse Practitioner, decided to take it in small chunks. She focused only on the charts that crossed her desk for each day’s visits. In no time at all, they had most of them done and office staff had significantly reduced time for filing. As well, the physician now finds the visits more efficient, as it is easier to find documents within the chart. • When Debi Letkeman began working for Dr. Rye (Prince Albert) 18 years ago, she scheduled time to discuss the goals of the office, and to understand what Dr. Rye’s goals were for the office and home life. This gave Debi an understanding of his limits for starting and ending the work day, number of patients an hour he would see, preferences for visit types, and willingness to work longer days to avoid a waiting list. After the discussion, Debi took charge of the bookings. Now if she calls him on his Operating Room day and says he needs to come back to see a few more patients, he does—never questioning why, knowing that Debi is ensuring a smoother day for tomorrow. They have grown into a working team as a result of good communication and mutual respect. • To keep staff informed and excited, the Ile-a-la-Crosse Clinic has created a “Celebration Wall” in their staff room. They can post ongoing PDSAs and the results of their efforts in one place. Using non-verbal cues like a data wall can help facilitate efficient communication and cut down on the need for face-to-face meetings. © Health Quality Council 2006 2-82

Measurement Included in this section: Measuring for improvement…..KEY measures…..About the CDM Toolkit…..CDM measures: patient flow sheets…..Access measures….CDM Toolkit user guide © Health Quality Council 2005

Measuring for improvement You can’t manage what you don’t measure! Why measure? Regular and frequent tracking of results and good stories are key features of the Collabo- rative methodology. It establishes a momentum that encourages early engagement and active participation in the process of delivering rapid and sustainable improvements. Regular tracking is a powerful tool for participants to assess their progress and bench- mark themselves against others. Initially you might find some resistance to data tracking. Data collection can be perceived as a threat if it is handled poorly. There are two types of measurement data: Data to Improve and Data to Judge. Data to Judge is based on the question Who? Data to Improve, on the other hand, is based on the questions Why? How? and What? Quality improvement uses Data to Improve, not Data to Judge. If people feel measurement may be used against them, they may not participate fully or they may present inaccurate data. Remember! The ulti- mate purpose of tracking is to allow you to monitor your clinic’s progress, and to help you decide where to focus your time and resources. Key messages to remember and share: • Measurement is essential to quality improvement • You need to know where you are and where you are going • Data collection is a powerful tool for change “It’s one thing to think you are providing good care. It’s another thing entirely to know you are.” Dr. George Wray Family physician and BC Collaborative participant © Health Quality Council 2006 3-1

KEY measures What will you measure? The CDM Collaborative will track and facilitate improvement for a selected number of measures contained in the flow sheets. These measures were chosen as a result of feedback and consultation with the Expert Reference Panel (Saskatchewan leaders in chronic disease management) and our Clinical Leader- ship Team, as well as a review of current clinical guidelines. There are eight measures for Diabetes, eight measures for CAD and two measures for Access. The KEY measures will be tracked and shared at an aggregate level with practices on a monthly basis, and at the quarterly Learning Workshops. Prac- tices can also check their own progress on any measure as often as they wish. KEY measures Diabetes CAD Access % of patients with a BP level % of patients with a BP level Number of days to 3rd next ≤ 130/80 <140/90 available appointment % of patients with a A1C % of patients who are non- % of patients seen by the level ≤ 7.0% smoking practice on the day of their choice % of patients with total cho- % of patients with a total cholesterol/HDL ratio < 4.0 lesterol/HDL ratio < 4.0 % of patients who are non- % of patients on a beta- smoking blocker % of patients on antiplatelet % of patients on antiplatelet therapy (e.g., ASA) therapy (e.g., ASA) % of patients screened for % of patients on an ACE/ARB microalbuminuria (Albumin:Creatinine test) % of patients on a statin % of patients on a statin % of patients referred to % of patients referred to patient education cardiac rehab © Health Quality Council 2006 3-2

KEY measures Sharing improvement ideas PDSA Ramp In addition to the KEY Measures, during each Action Period participating practices are required to submit a minimum of one completed PDSA ramp for each of the three topic areas of the CDM Collaborative (i.e., diabetes, CAD and Improved Access). In addition, practices and RIT members are strongly encouraged to regularly and frequently share their PDSAs with other Collaborative participants. PDSAs are the basis of quality improvement and every PDSA is an opportunity for learning, especially those that may be considered failures. By sharing your successes and lessons learned, other Collaborative participants can benefit from the ideas you have tested; they might decide to test the same idea in their own practice setting, build on your idea, or apply the idea to a new context. On the other hand, you may discover innovative improvement ideas by drawing on the experiences of others. In keeping with the spirit of the Collaborative, sharing and spreading ideas is central to the improvement methodology. Remember… A Collaborative is a learn-by-doing approach to quality improvement. It brings together practitioners from various disciplines and sites and teaches them how to improve practices. It is an improvement method that relies on the spread and adaptation of existing knowledge to multiple settings to accomplish a common aim. Sharing PDSA improvement ideas and ramps can easily be done by using the PDSA catalogue, which is a searchable database that is accessible to all RIT members in the CDM Tool- kit. The PDSA catalogue offers a “living” account of ongoing and completed PDSAs that will help participants to share successes and lessons learned from testing their improvement ideas. Together with HQC staff, Collaborative Facilitators will support their RIT members in learning how to document PDSAs and work with this simple tool in the improvement activities of Collaborative participants. © Health Quality Council 2006 3-3

CDM Toolkit The Chronic Disease Management (CDM) Toolkit is a secure, web-based registry and decision support tool that is designed to assist health care providers in tracking patients with CAD and/or diabetes. The CDM Toolkit is a valuable resource for you and your team, and is particularly useful for practices not equipped with an electronic medical record system. All practices participating in the Collaborative will have access to this tool. The CDM Toolkit can help you to: • Access clinical guidelines for diabetes and CAD management; • Complete patient flow sheets; • Generate a list of patients who need to be recalled for an office visit; • Generate clinical and administrative reports crucial to optimal chronic care (e.g. patient profiles, practice profiles, patient education reports); • Share flow sheets with other colleagues within the circle of care; and, • Monitor population outcomes. The CDM Toolkit was first developed and successfully used by the British Columbia Heart Healthy Collaboratives, through a partnership with the BC Ministry of Health and the IBM Corpo- ration. An adapted version of the Toolkit is now being implemented in both Saskatchewan and Manitoba. The SK CDM Collaborative has worked closely with Saskatchewan Health and the Western Health Information Collaborative (WHIC) in developing this tool. There are currently more than 130 physicians and 280 office staff and allied health professionals in Saskatchewan who use the CDM Toolkit. More information about the CDM Toolkit, including a User Guide and Technical requirements, is available on the CDM Toolkit on-line site. © Health Quality Council 2006 3-4

CDM measures: patient flow sheets Patient flow sheets are a critical success factor for managing your patients with a chronic condition. Flow sheets can help you to: • Review patient charts for any gaps in care • Recall patients for tests or procedures • Remind you what needs to be accomplished during the next planned visit The patient flow sheet is also an excellent patient education tool. The CDM Toolkit provides you with two flow sheets to assist with data collection and entry—a diabetes flow sheet and a CAD flow sheet. These flow sheets are based on current guidelines and contain the recommended information providers need to manage patients living with a chronic disease. Use the diabetes flow sheet if your patient has diabetes, or diabetes and CAD. The diabetes flow sheet incorporates the necessary CAD measures. You can use the CDM Toolkit to produce run charts for your practice on any element from the flow sheets. These run charts will show you how your practice is doing and also provides a comparison line representing the whole Collaborative. For KEY measures, such as statin prescription, you can be confident that you are comparing yourself to a majority of the Collaborative participants. However, Sample Diabetes (+/- as practices are only required to enter the CAD) flow sheet. KEY measures, for non-KEY measures the completeness of the data contained in the line graph representing the whole © Health Quality Council 2006 3-5

CDM measures: patient flow sheets Collaborative cannot be assured. So, while you can see how your practice is doing on BMI, for example, we would advise caution when comparing yourselves to the whole Collaborative, as not all participants may be entering BMI information into the Toolkit. Your practice may already be using a flow sheet that works well for your clinic. By all means, continue to use your flow sheet. You do not have to use the CDM Collaborative flow sheets. As long as the KEY measures are captured and the data is entered, it is up to you what tool your practice uses to collect the information on paper. However, to make data entry more efficient, you may want to re-order the fields on your paper flow sheet to match the order of the fields on the data entry screen of the Toolkit. © Health Quality Council 2006 3-6

Access measures Improving access uses just two simple, but very important, measures: 3rd next available appointment and % patients seen on day of their choice. 3rd next available appointment The 3rd next available appointment is the standard measure for assessing how effectively an Improved Access system is working for the clinic. The first or second available appointment are highly subject to random effect, for example a sudden cancellation. The 3rd next available is a more reliable and authentic measure of the patient’s experience, but still relatively easy to calculate. How to measure: • Pick a different day in each of four consecutive weeks on which you will measure. • On each measurement day, and for each physician, at 12:00 pm look at your appointment system and find the next three consecutive appointments. For example: 1st appointment: 4:00 pm today 2nd appointment: 4:30 pm today 3rd appointment: 8:45 am tomorrow • Looking at the 3rd next available appointment, when does it fall? For the example above, 8:45 am translates to a third available appointment of one day. If the third appointment falls today, the measure is zero. If it is the day after tomorrow, it is two days, and so on. • Round to the nearest 1/2 day. Do not include: • Any physician who is on holiday for three days or more during the measurement week, unless they are covered by a locum. © Health Quality Council 2006 3-7

Access measures • Days when the clinic is closed. For example, if you are collecting data on a Friday and the clinic is closed on weekends, a 3rd next available appointment on Monday would only be counted as one day. % of patients seen on day of their choice Because some patients might not want to be seen as soon as possible, it is important to look at how many patients are seen when they want. This, combined with the 3rd next available appointment, will give you a good indication of the experience of patients making appointments at your clinic. How to measure: Use a small random sample of patients (a minimum of five in the morning and five in the afternoon) and, every day over the course of one week, ask this number of patients whether they had an appointment on the day they requested. Make sure that patients are asked at different times of the day. Count the number of patients who said they were able to get an appointment on the day of their choice, and calculate this as a percentage of the total number of people interviewed. Improved Access measurement templates are included in the Additional Information & Resources section. © Health Quality Council 2006 3-8

Access measures Frequently asked questions What if we have more than one site for our practice? If the practice has a main site and one or more branch sites that physicians work at then this needs to be considered. For tracking purposes record the measurements for the main clinic only. It would be helpful to implement the Im- proved Access principles and ideas at all sites, and it is important that you are tracking your own improvements for all branch clinics as this gives a clearer picture of the issues at each site. Tracking measurements for the main site only, however, will still give a good indication of how the practice is improving as a whole. What about locum staff? Treat the locum as if they are the physician they are replac- ing. How do I calculate 3rd next available appointment for a physician on holiday? If a physician is on holiday for 3 days or more during the measurement week, and this time is not covered by a locum, then do not calculate the 3rd next available appointment for this clinician for this week. Note: You will be able to see the impact of the clinician’s absence by measuring the 3rd next available appointment for their colleagues. However, if the clinician is on holiday for one or two weeks after the measurement week and there is no locum cover, then still calculate the 3rd next available appointment. What if we have a physician who is rarely in the practice? If there is one member of the clinical staff with very few clinical sessions and whose figures would unfairly distort the summary measure for the practice, they can be ex- cluded from the figures. © Health Quality Council 2006 3-9

Additional Information & Resources Included in this section: Learning Workshop schedule…..Collaborative timeline…..Contact information…..About the clinical team…..Structure and team roles…..Expectations and commitments…..Continuing education credits information…..Sample PDSAs and templates…..Glossary of terms…..Internet resources...Access templates © Health Quality Council 2006

Learning Workshop schedule Learning Workshop November 17-18, Delta Bessborough Orientation 2006 601 Spadina Cres E Learning Workshop 1 February 23-24, Delta Bessborough 2007 601 Spadina Cres E Learning Workshop 2 May 25-26, 2007 Delta Bessborough 601 Spadina Cres E Learning Workshop 3 October 26-27, 2007 Delta Bessborough 601 Spadina Cres E Please note: Due to unforeseen circumstances, these dates may change over the course of the Collaborative. However, every effort will be made to provide ample notice to participants. Room bookings and dietary requests may be directed to Detailed maps with Meghan Jones, Event Coordinator (tel: 306-668-8810 ext 102; driving instructions are email: mjones@hqc.sk.ca). available upon request. The Delta Bessborough offers its guests the following recreation and services: • Indoor atrium with swimming pool, steam room and whirlpool • Fitness facility with strength/cardio equipment • 24-hour business centre with high-speed Internet access, printer, scanner fax, and laptop hook-up © Health Quality Council 2006 4-1

Collaborative timeline Date Event Note: PDSAs November 17-18, 2006 Learning Workshop Orientation may be 2007 entered into the CDM February 23-24 Learning Workshop 1 Toolkit at any time. March 21 KEY measures—batch date April 18 KEY measures—batch date Mary 23 KEY measures—batch date May 25-26 Learning Workshop 2 June 20 KEY measures—batch date July 18 KEY measures—batch date August 22 KEY measures—batch date September 19 KEY measures—batch date September 20 KEY measures—batch date October 24 KEY measures—batch date October 26-27 Learning Workshop 3 November 21 KEY measures—batch date December 19 KEY measures—batch date 2008 January 23 KEY measures—batch date February 20 KEY measures—batch date March 19 KEY measures—batch date April 23 KEY measures—batch date May 21 KEY measures—batch date June 18 KEY measures—batch date July 23 KEY measures—batch date August 20 KEY measures—batch date September 24 KEY measures—batch date October 22 KEY measures—batch date November 19 KEY measures—batch date December 17 KEY measures—batch date 2009 January 21 KEY measures—batch date February 18 KEY measures—batch date March 18 KEY measures—batch date © Health Quality Council 2006 4-2

Contact information Health Quality Council Team Collaborative Directors • Karen Barber, Program Director Tel: 306-668-8810 ext 137 Email: kbarber@hqc.sk.ca • Bonnie Brossart, Deputy CEO Tel: 306-668-8810 ext 119 Email: bbrossart@hqc.sk.ca Assistant Collaborative Directors • Katherine Stevenson, Senior Knowledge Exchange Consultant Tel: 306-668-8810 ext 107 Email: kstevenson@hqc.sk.ca Athabasca, Keewatin Yatthé, Mamawetan Churchill River • Sinead McGartland, Knowledge Exchange Consult- ant Tel: 306-668-8810 ext 143 Email: smcgartland@hqc.sk.ca Five Hills, Sun Country, Regina Qu’Appelle, Prairie North • Erin Walling, Knowledge Exchange Consultant Tel: 306-668-8810 ext 121 Email: ewalling@hqc.sk.ca Cypress, Prince Albert Parkland • Helena Klomp, Senior Researcher Tel: 306-668-8810 ext 105 Email: hklomp@hqc.sk.ca Saskatoon, Sunrise • Lisa Clatney, Researcher Tel: 306-668-8810 ext 106 Email: lclatney@hqc.sk.ca Kelsey Trail, Heartland © Health Quality Council 2006 4-3

Contact information Health Quality Council Team IT Support • Catherine Flegel, Network Administrator/Computer Support Tel: 306-668-8810 ext 117 Email: cflegel@hqc.sk.ca Evaluation • Tanya Verrall, Researcher Tel: 306-668-8810 ext 142 Email: tverrall@hqc.sk.ca Communications Support • Shari Furniss, Communications Consultant Tel: 306-668-8810 ext 112 Email: sfurniss@hqc.sk.ca Event Coordination • Meghan Jones, Administrative Assistant Tel: 306-668-8810 ext 102 Email: mjones@hqc.sk.ca Health Quality Council mailing address: Atrium Building, Innovation Place #241—111 Research Drive Saskatoon, SK S7N 3R2 Tel: 306-668-8810 Fax: 306-668-8820 Web: www.hqc.sk.ca/cdm © Health Quality Council 2006 4-4

Contact information Collaborative Facilitators List current as of November 1, 2006 Athabasca Health Region Patrick Blais Email: pblais@athabascahealth.ca Tel: 306-439-2200 / Fax: 306-439-2212 Cypress Health Region Denise Levorson Email: denise.levorson@cypressrha.ca Tel: 306-587-2353 / Fax: 306-587-2927 Five Hills Health Region Jenny Blatchford Email: jblatch@fhhr.ca Tel: 306-694-0389 / Fax: 306-692-0282 AND Kathy Filopowich Email: kfil@fhhr.ca Tel: 306-691-1563 / Fax: 306-692-5758 Heartland Health Region Sadie Gross Email: sadie.gross@hrha.sk.ca Tel: 306-858-2123 / Fax: 306-858-2090 Kelsey Trail Health Region Heather Genik Email: hgenik.kthr@shin.sk.ca Tel: 306-862-7248 / Fax: 306-862-3250 Keewatin-Yatthé Health Region Chris Christenson Email: chris.christenson@kyrha.sk.ca Tel: 306-235-5848 / Fax: 306-235-4604 © Health Quality Council 2006 4-5

Contact information Mamawetan Churchill River Health Region Jeannie Coe Email: jeannie.coe@mcrrha.sk.ca Tel: 306-425-2174 ext 2 Prince Albert Parkland Health Region Lori Briggs Email: lbriggs@paphr.sk.ca Tel: 306-765-6655 / Fax: 306-765-6624 Prairie North Health Region Linda Moore Email: linda.imoore@pnrha.ca Tel: 306-820-6262 / Fax: 306-820-6251 Regina Qu’Appelle Health Region Jody Burnett Email: jjburnett@sasktel.net Tel: 306-536-1637 / Fax: 306-924-5330 Saskatoon Health Region Judi Whiting Email: judi.whiting@saskatoonhealthregion.ca Tel: 306-655-7406 / Fax: 306-655-6758 AND Dona Dixon Email: dona.dixon@saskatoonhealthregion.ca Tel: 306-655-7406 / Fax: 306-655-6758 Sun Country Health Region Wanda Miller Email: wmiller@schr.sk.ca Tel: 306-637-3631 / Fax: 306-634-5240 Sunrise Health Region Jacqueline Byblow Email: jacqueline.byblow@shr.sk.ca Tel: 306-786-0768 / Fax: 306-786-0122 © Health Quality Council 2006 4-6

Contact information Clinical Team Clinical Chair Dr. Vino Padayachee Estevan Medical Clinic Box 5000-200 1174 Nicholson Road Estevan, SK S4A 2V6 Tel: 306-637-3600 or 306-634-2661 Email: vpadayachee@schr.sk.ca Fax: 306 -634-7824 Clinical Lead—Access Dr. Carla Eisenhauer Saskatoon Community Clinic 455 Second Avenue North Saskatoon SK S7K 2C2 Tel: 306-652-0300 Email: CEISENHAUER@communityclinic.sk.ca Fax: 306-664-4120 Clinical Lead—Coronary Artery Disease Dr. Mark Cameron Associated Family Physicians 2156 Broad Street Regina SK S4P 1Y5 Tel: 306-781-8080 Email: mcameron_physn@sasktel.net Fax: 306-781-5644 Clinical Lead—Diabetes Dr. Tessa Laubscher Department of Family Medicine Royal University Hospital 103 Hospital Drive Saskatoon SK S7N 0W8 Tel: 306-655-6800 Email: Tessa.laubscher@usask.ca Fax: 306-655-6822 © Health Quality Council 2006 4-7

About the Clinical Team Dr. Vino Padayachee, Clinical Chair Dr. Padayachee began his distin- guished career in South Africa, where he obtained his medical degree from the University of Natal. He stayed on there after graduating, working in teaching hospitals attached to the Uni- versity. He has a broad range of experience, including pediat- rics, surgery and trauma, obstetrics, and has special training in cardiology. Dr. Padayachee has also managed a Coronary Care Unit and obtained his diploma in Anesthesiology. In 1992 Dr. Padayachee moved to Canada and began practic- ing as a GP Anesthetist in Estevan. He has a keen interest in quality improvement. In response to the increasing prevalence of asthma in southern Saskatchewan, Dr. Padayachee established an asthma clinic in 2003. He is assisted at the clinic by a nurse practitioner and a physiotherapist, both of whom have completed the AsthmaTrec (Asthma Training and Educator) course. He is also involved with the Heart to Heart Coronary Heart Disease Secondary Prevention program in Estevan, working in partnership with a pharmacist, dietitian, and educator. Dr. Padayachee has been actively involved in the Saskatche- wan Medical Association as a member of the Representative Assembly and recently was elected President. Although he dedicates much time to his profession, he manages to fit in the occasional game of golf and volleyball. He has a passion for travel and flying, and has earned his pilot’s license. His wife Dr. Di Naidu is also a family physician, with a special interest in obstetrics. The couple have two daughters. Despite his busy personal and professional life, Dr. Paday- achee is excited about being part of the Collaborative. He was already using some of the change concepts in his own practice. Two years ago, he implemented a flow sheet for his patients with diabetes. “I find that it is much easier to track the numbers (eg. A1C, © Health Quality Council 2006 4-8

About the Clinical Team creatinine clearance), and it is easier to demonstrate the progress to the patient. Patients certainly appreciate seeing all their recent results on one sheet, and seeing the progress they've made....it seems to motivate them.” Both the physician and the nurse manage the information and make sure the flow sheet is updated. Whenever a patient comes in a for a visit, the flow sheet is attached on the inside cover of the file. Entering the information after the visit takes about 5 minutes to complete. Participating in the Collaborative has allowed for Dr. Padayachee and his team to try out other change ideas. “This Collaborative is timely and an appropriate step in improving the quality of health of the people in Saskatchewan. I cannot guarantee that all change will produce improvement, but I do know that in order to improve, we need to have change.” Dr. Mark Cameron, Clinical Lead, CAD Dr. Mark Cameron was born and raised in Saskatoon, Saskatchewan. He attended the University of Saskatchewan, where he earned his Bachelor of Arts and Medical Degrees, and completed his Residency in Family Medicine at University Hospital (now Royal University Hospi- tal). After his residency, Dr. Cameron moved to Regina where he joined a long-established group practice and has remained there for 15 years. The practice is on the forefront of technology in the province. It was one of the first fully computerized offices in Regina, and continues to work toward a paperless office. The practice has recently linked with the Laboratory Ser- vices Department system at Regina Qu’Appelle Health Region. Lab results are immediately available on the patient’s chart, a huge boost to the efficiency of patient care. Before the launch of the Collaborative, Dr. Cameron’s office conducted user reviews of the CDM Toolkit, providing feedback to help customize it for use in Saskatchewan. © Health Quality Council 2006 4-9

About the Clinical Team In addition to his practice, Dr. Cameron has participated in research on cardiovascular disease in hypertensive patients, is a member of the Pharmaceutical Information Program Clinical Working Group, and is a member of the Primary Health Care Steering Committee. Dr. Cameron is married and has five children. He enjoys spending time with his family, camping in northern Saskatche- wan and in the Cypress Hills area. Occasionally he puts on his illusionist hat and performs the magic show that helped pay his way through medical school. Dr. Cameron is looking forward to the next wave of the Collaborative. The newer physicians in his clinic will be participating and he expects they will have many great improvement ideas. Dr. Carla Eisenhauer, Clinical Lead, Access Dr. Eisenhauer was born in Kingston, Ontario and grew up in Ottawa. She completed her medical degree and family medicine residency at Queen’s University in Kingston. In 1981 Dr. Eisenhauer moved to Saskatoon and joined the Saskatoon Community Clinic (SCC). The Clinic was founded in 1962 and was one of the first health care co-operatives in Sas- katchewan. The SCC achieved another first in the summer of 2004, when it became the first clinic in the province to implement an Improved Access model. Although it was a team effort, Dr. Eisenhauer was instrumental in championing the model in the clinic and across the province. Evaluations have shown increased patient and provider satisfaction, and shorter waiting times. (Please see page 2-76 for a profile of the Saskatoon Community Clinic’s work in improved access.) Dr. Eisenhauer became head of the SCC medical group in 2000. She recently resigned from the position to focus on her family practice, and to take on the role of Access Clinical Lead in the Saskatchewan Chronic Disease Management Collabora- tive. © Health Quality Council 2006 4-10

About the Clinical Team Dr. Eisenhauer is married to Rick Boldt, a chartered account- ant. They are the proud parents of Maddy, a golden retriever, and Jasper, a shepherd-greyhound cross. She enjoys playing duplicate bridge and often travels to visit friends and family. Although her schedule is demanding, she continues to make the Collaborative a priority. “Although there were definitely challenges along the way, the clinic’s experience with Improved Access was overwhelmingly positive,” says Dr. Eisenhauer. “I’m looking forward to sharing our experiences, and being a support to other practices as they improve access.” Dr. Tessa Laubscher, Clinical Lead, Diabetes Dr. Laubscher was born and raised in Zimbabwe (Rhodesia) and studied medicine at the University of Cape Town. She completed her MBChB (Bachelor of Medicine, Bachelor of Surgery) degree in 1987. After working for two years in South Africa, she decided to travel around the world. During her travels, Dr. Laubscher worked as a locum physician in general practice in the community of La Ronge in northern Saskatchewan for the summer of 1990. She returned to La Ronge in spring 1991 for another short-term locum and stayed in the community for nine years. In 1997, she obtained her certification in family practice (CCFP) from the College of Physi- cians and Surgeons. While in La Ronge, she began teaching medical students, family medicine residents, and nurse practitioners. From 1996 to 1999, she was Chief of Staff at the La Ronge Health Centre and for the Mamawetan Churchill River Health District. During this time, she developed a further interest in medical administration and quality. In 1999, Dr. Laubscher moved to Saskatoon, where she maintained a busy family practice and assumed a half-time position as Assistant Medical Director of Northern Medical Services, University of Saskatchewan. In July 2004, Dr. Laubscher moved to a full-time position with the College of Medicine at the U of S, as an Assistant Professor of Family Medicine in the De- partment of Academic Family Medicine. She is involved with © Health Quality Council 2006 4-11

About the Clinical Team clinical family practice, undergraduate and postgraduate teaching, primary care initiatives, and research. Over the past five years Dr. Laubscher has been a physician advisor to the RxFiles academic detailing program, and a facilitator for the PAACT (Partners for Appropriate Anti-infective Community Therapy) Mainpro-C course. One of her special interests is diabetes care and education; her research includes the development of a screening program for diabetic retinopa- thy in northern Saskatchewan, using a digital retinal camera. She also developed a diabetes flow sheet currently being used by the Physician Enhancement Program. She uses the flow sheet within her own practice. \"I have been using flow sheets for my patients with diabetes for over 4 years. I couldn't provide the same level of care without them. Other physicians appreciated the flow sheets when caring for my patients as all the pertinent information was in one place - so much so that they now use them for their own patients\". Although she is actively involved in many professional activities, Dr. Laubscher finds time for outdoor recreation such as walking, biking, canoeing, swimming, and gardening. She also enjoys spending time at her cabin in northern Saskatchewan. © Health Quality Council 2006 4-12

Structure and team roles Health Quality Council RHA Senior Leadership Clinical Chair Each RIT must have the support Clinical Leads of Senior Leadership. Each area (CAD, Diabetes, Access) has a Clinical Lead. Collaborative Facilitator RHA will designate a manager for the Collaborative Facilitator. There will be approximately 6.0 FTE CFs across the province. Regional Improvement Team Additional members (RIT) Participate but do not attend Learning Workshops. Physicians, nurses, managers, educators, patients, dietitians, pharmacists, physical/exercise therapists. FP/GP Practice Consider the Pharmacy Representation Number of practices will vary by region. balance of Acute Care or Community Pharmacist 2 designates attend Learning Workshops. your team composition. We strongly recommend GP/FP Site Rep RN/LPN/Office Mgr. Site Rep including reps Diabetes Education Representation from these Diabetes Educator or Community Worker four areas. Primary Health Care Site Minimum 1, maximum 50% of total practices. 2-3 designates attend Learning Workshops. Patient Representation GP/FP Site Rep RN/LPN/Office Mgr. Site Rep Pharmacy/NP Site Rep First Nations and/or Métis Representation RHA, First Nations, and/or Métis Health Program 3 designates attend Learning Workshops. Suggested members:Specialist, Pharmacist, CDE, Rehab Collaborative Facilitators The Collaborative Facilitator (CF) plays an important role in the Collaborative. Key tasks of the position include: • Supporting and coaching practices and Regional Improvement Teams (RITs) in developing knowledge of quality improvement techniques to facilitate improved care for patients with CAD and diabetes, and improvement in access to primary care • Coordinating and facilitating the collection of data to support improvement • Ensuring data completeness • Assisting to spread learning across the region • Providing feedback to the HQC Collaborative Team As part of the position, the CF regularly visits the practices and members of the RIT. The CF coaches participants, assists in removing barriers, and identifies good examples to spread across practices and RITs. They may also hold local meetings to facilitate quality improvement. © Health Quality Council 2006 4-13

Structure and team roles Regional Improvement Teams Each Regional Improvement Team is comprised of the following members: Family Physician/General Practitioner practices The number of physician practices varies according to the size of the region, with a target of 20 per cent of practices within a region. Each practice designates two site representatives to attend the Learning Workshops. Designates include one physician and one of the following: Registered Nurse, Licensed Practical Nurse, or Of- fice Manager/Receptionist. Primary Health Care site Each RIT includes a minimum of one Primary Health Care site, to a maximum of 50 per cent of total practices. Each PHC designates two to three site representatives to attend the Learning Workshops. Designates include one physician, and one of the following: Regis- tered Nurse, Licensed Practical Nurse, or Office Man- ager/Receptionist. The PHC site may also choose to send one of the following: pharmacist or nurse practitioner. RHA, First Nations, and/or Métis Health programs Each RIT includes three additional designates from RHA, First Nations and/or Métis Health programs. It is up to each region to choose the three designates. Sug- gested designates include: specialists, pharmacists, Certified Diabetes Educator, and rehabilitation therapists. The three designates should be prepared to share what they learn at Learning Workshops and participate in quality improvement activities with the broader RIT, as coordinated by the Collaborative Facilitator. Additional team members Each RIT includes additional members who are not required to attend the Learning Workshops. For example, the broader RIT may include: physicians, nurses, man- © Health Quality Council 2006 4-14

Structure and team roles agers, educators, patients, dietitians, pharmacists, physical/exercise therapists, community groups, information management specialists, and others. Regions should consider the balance of their team composition. In particular, it is strongly recommended regions include representatives from the areas of pharmacy, diabetes education, patients, and First Nations and/or Métis Health programs. © Health Quality Council 2006 4-15

Expectations and commitments Health Quality Council agrees to: • Provide evidence-based information on the Collaborative topics and improvement science, both during and between the Learning Workshops. • Provide mentoring and quality improvement support to the Collaborative Facilitators, practices, Primary Health Care sites, and the broader Regional Improvement Team. HQC will provide support in a number of areas, such as: quality improvement methodology, team building and facilitation, communications, and event support. • Provide access to the CDM Toolkit, a secure, web-based registry and decision support tool that allows participants to track progress on flow sheet measures. HQC will also offer user support for the CDM Toolkit, in collaboration with Sas- katchewan Health. • Coordinate, fund, and deliver four Learning Workshops for each of the two Waves of the Collaborative. For both Waves these Learning Workshops have met the requirements for CME Mainpro-C and Mainpro-M1 credits. • Offer practices an incentive package to offset some of the costs related to participating in the CDM Collaborative. (Please the SHIN/HQC Joint Services Policy for further details related to reimbursement for participating practices.) • Promote the process and outcomes of the CDM Collabora- tive to local, provincial, and national forums, and the media. • Assure adherence to internal confidentiality procedures and take all reasonable steps to keep the information confiden- tial and secure. (Please review the SHIN/HQC Joint Ser- vices Policy for further details related to confidentiality.) The Collaborative offers practices and providers many levels of support. © Health Quality Council 2006 4-16

Expectations and commitments Participating practices agree to: • Be open to changing actions and system in order to improve clinical management and office efficiency. • Appoint a GP/FP site representative, and an RN/LPN/Office staff site representative. To the degree that circumstances allow, the same physician and designate will attend all four Wave 2 Learning Workshops. (Note: Primary Health Care sites have the option of including one other representative.) • Ensure that baseline data for all CAD and diabetes patients is captured and entered into the CDM Toolkit between De- “Data is the cember 1, 2006 and February 16, 2007. nutrition of the • Engage in at least one PDSA Ramp per Collaborative topic (diabetes, CAD, and access) during each of the Action Peri- Collaborative.” ods following LW1, LW2, and LW3. Data for the PDSA cycles can be submitted at any time, but at a minimum must Sir John Oldham, be submitted by the monthly batch dates. National Primary Care • Commit to filling in the necessary data for all KEY meas- Development Team ures into the CDM Toolkit, by the specified monthly batch dates. • Provide team time to devote to testing and implementing changes in the practice. • Interact with your Collaborative Facilitator on a regular basis to facilitate the testing and implementing of rapid cycle improvements. • Participate in the Regional Improvement Team in a supportive manner. • Document and share information on quality improvement efforts, including details of changes made, and data to support these changes, both during and between Learning Workshops. Actively participate in the spread of best practice to other sites. • Participate as speakers (if requested) at Learning Work- shops, to disseminate best improvements and practice stories to the wider CDM Collaborative. • Safeguard the privacy and confidentiality of patient and provider personal information in accordance with applicable laws. © Health Quality Council 2006 4-17

Continuing Education Credits Physicians This program meets the accreditation criteria of The College of Family Physicians of Canada and has been accredited for 25 Mainpro-C credits and 11.5 Mainpro-M1 credits. Dietitians Continuing competency credits can be achieved by submitting appropriate forms to the Saskatchewan Dietitians Association. For further information visit the website: www.saskdietitians.org Pharmacists Continuing Professional Development for Pharmacists (CPDP) non-accredited professional development continuing education units can be achieved by submitting the appropriate forms (Saskatchewan Pharmacists Learning Portfolio). For further information visit the website: http://www.usask.ca/pharmacy-nutrition/services/ cpdp.shtml Certified Diabetes Educators (CDE) Certification maintenance credits can be achieved by submitting appropriate forms as part of the Continuing Diabetes Edu- cator Certification Board (CDECB) credit portfolio process. For further information visit the website: www.cdecb.ca Registered Nurses / Nurse Practitioners For further information regarding the Continuing Competence Program for the Saskatchewan Registered Nurses Association (SRNA) visit the website: www.srna.org © Health Quality Council 2006 4-18

PDSA examples Individual PDSA This PDSA belongs to Ramp #: Recall & Review PDSA Title Author(s) June 1, 2 June 9 Start Date End Date (estimated) PLAN Specific Objective: What idea or process do you want to test during this cycle? Have you established a measurable target? Recall report to review 1 patient, up to 3. What exactly will you do? What are the steps involved in carrying out your test? Recall patient, set up clinic to see patient and audit chart. Who will be involved in each step? What are each person’s roles and responsibilities? Doctor Milan, K. Hercina, Nurse practitioner in Black Lake, and clerical staff. Where will it take place? Clinic Site, Black Lake nursing station, Stony Rapids Facility. When will it take place? If appropriate, when will each person need to complete their step? June 1, June 2 What do you predict will happen? How does your prediction relate to your measurable target? Review chart, parameters for client care, assess client. What do you need to measure to see if your idea is leading to improvement? (counts, short surveys, percentages, verbal feedback). Also consider staff and patient satisfaction. Patient attendance. Length of time for process includes – lab, staff discussion. Describe what happened. Was the test carried out as planned? Did anything unexpected DO cause us to deviate from the plan? What did we observe that was not part of the plan? The visit was scheduled (mandated) by the clinic; however, the patient had to postpone it at the last minute…and yet again the next day. The chart audit went well, but it became very clear that he patient was not well informed about our screening tests, the significance of the parameters, the importance of regular follow-up and the self-management actions to be taken on a regular basis. We uncovered a whole hornet’s nest of gaps in communication in proper patient care. What were the results of your measurements? How did or didn’t the results agree with STUDY your predictions? What were your key learnings? Include data gathered through your measures. We established the length of time it would take (on average) to audit a chart with the patient present (at least 30 minutes). We also stumbled across unexpected obstacles in the form of huge gaps in the “assumed knowledge” of the patient. Although much, if not all, of this information had been shared with the patient before, the overall level of comprehension was not satisfactory. This demonstrated the need to repeat basic and important information very frequently. Furthermore, it demonstrated the importance of bridging the gap between the science of chronic disease and the practical implications for the patients. This especially true in a setting with obstacles like language barriers, cultural differences, and logistical difficulties in optimal care (transportation, food supply, service delivery). ACT Next steps? Do we abandon? Modify and test again? Move to testing of implementation? This was a great experience, no an eye-opener! We will need to have more interaction with our patients with chronic ideas. We will repeat this procedure with a few more patients and then gauge the need for information session, probably in a group setting. This is the last PDSA cycle in this Ramp: YES NO © Health Quality Council 2006 4-19

PDSA examples Individual PDSA This PDSA belongs to Ramp #: Weight or no weight Westgate Clinic PDSA Title Author(s) Monday, May 29, 2006 Wednesday, June 7, 2006 Start Date End Date (estimated) PLAN Specific Objective: What idea or process do you want to test during this cycle? Have you established a measurable target? 100% patients should have weight recorded within the last 3 months. What exactly will you do? What are the steps involved in carrying out your test? Pull out patient files and check if their weight has been recorded within 3 months when they come in. Record it on a piece of paper. If weight not done, then do it and record it on flowsheet. Who will be involved in each step? What are each person’s roles and responsibilities? Office staff (Van, Carma, Marlene, Diane) will pull and check charts; do and record weights. Dr Rai will double check and do weight if missed. Where will it take place? At the clinic When will it take place? If appropriate, when will each person need to complete their step? The next 8 working days between 9 a.m. and 5 p.m. What do you predict will happen? How does your prediction relate to your measurable target? Predict that 60% will have their weights done and 40% will not. We will try to achieve the target. What do you need to measure to see if your idea is leading to improvement? (counts, short surveys, percentages, verbal feedback). Also consider staff and patient satisfaction. Staff satisfaction feedback. Number of patients seen during the 8 days for both CAD and diabetes (total). Weight data stats. Describe what happened. Was the test carried out as planned? Did anything unexpected DO cause us to deviate from the plan? What did we observe that was not part of the plan? On a piece of paper, we put the days and date on it then we divided into 2 columns – one for weight, the other for no weight. We put a tick for each patient that came in. if they did not have their weight within 3 months, then we did the weight. The test went smoothly. Nothing went unexpected. What were the results of your measurements? How did or didn’t the results agree with STUDY your predictions? What were your key learnings? Include data gathered through your measures. We had the exact same number of patients with weights and no weights. So it was 50/50/ A key learning point was that if a patient is coming for their 3 month check, of course they will not have their weights done (in the last 3 months). ACT Next steps? Do we abandon? Modify and test again? Move to testing of implementation? We will not be doing another weight PDSA but we will continue doing weight every 3 months as requested for our patients. This is the last PDSA cycle in this Ramp: x YES NO © Health Quality Council 2006 4-20

PDSA examples Individual PDSA This PDSA belongs to Ramp #: Diabetes Education PDSA Title Author(s) Tuesday May 30/06 Monday June 5/06 Start Date End Date (estimated) PLAN Specific Objective: What idea or process do you want to test during this cycle? Have you established a measurable target? Opportunity for diabetic education for our diabetic patients What exactly will you do? What are the steps involved in carrying out your test? Place letter of upcoming sessions on diabetic education in clients’ folders and give them out when they see the physician. Who will be involved in each step? What are each person’s roles and responsibilities? Office staff=put letter in folder; Physician=verbal communication; collaborative facilitator=photocopy letter. Where will it take place? Medical Clinic When will it take place? If appropriate, when will each person need to complete their step? Tuesday to Tuesday May 30-June 6 What do you predict will happen? How does your prediction relate to your measurable target? Clients will be informed of session and will phone to confirm a spot. What do you need to measure to see if your idea is leading to improvement? (counts, short surveys, percentages, verbal feedback). Also consider staff and patient satisfaction. Counts - # taking the education classes Verbal feedback – evaluation forms at end of class Describe what happened. Was the test carried out as planned? Did anything unexpected DO cause us to deviate from the plan? What did we observe that was not part of the plan? CF photocopied information letter. Office staff put the letters with the clients’ folders that were CDM Collaborative patients. Some patients cam in to pick up their prescriptions so office staff gave them the letter for education classes as well. We are only reaching some of the CDM patients. What were the results of your measurements? How did or didn’t the results agree with STUDY your predictions? What were your key learnings? Include data gathered through your measures. We roughly handed out 20 letters, and to date we have 5 people registered. Sometimes people just show up without prior registering. Good way to get info. To the patients compared to just reading it on a poster. It’s a good indication of my prediction as to how many registered. ACT Next steps? Do we abandon? Modify and test again? Move to testing of implementation? We are implementing the classes on June 15 and 19th. We will ask the clients about the process of being informed. This is the last PDSA cycle in this Ramp: YES NO © Health Quality Council 2006 4-21

Individual PDSA template Individual PDSA This PDSA belongs to Ramp #: PDSA Title Author(s) Start Date End Date (estimated) PLAN Specific Objective: What idea or process do you want to test during this cycle? Have you established a measurable target? What exactly will you do? What are the steps involved in carrying out your test? Who will be involved in each step? What are each person’s roles and responsibilities? Where will it take place? When will it take place? If appropriate, when will each person need to complete their step? What do you predict will happen? How does your prediction relate to your measurable target? What do you need to measure to see if your idea is leading to improvement? (counts, short surveys, percentages, verbal feedback). Also consider staff and patient satisfaction. Describe what happened. Was the test carried out as planned? Did anything unexpected cause us DO to deviate from the plan? What did we observe that was not part of the plan? What were the results of your measurements? How did or didn’t the results agree with your STUDY predictions? What were your key learnings? Include data gathered through your measures. ACT Next steps? Do we abandon? Modify and test again? Move to testing of implementation? This is the last PDSA cycle in this Ramp: YES NO © Health Quality Council 2006 4-22

PDSA Ramp template PDSA RAMP Ramp Title Ramp # Author RIT: Start Date End Date (estimated) TOPIC Access Change Concept: Understand your practice’s supply and demand Shape the handling of demand Match the supply of the practice to the reshaped demand Establish and implement contingency plans Communicate effectively with patients and across the practice team TOPIC CDM-Diabetes & CAD CDM-Diabetes only CDM -CAD only Change Concept: Know all your patients who have diabetes and/or CAD Be systematic and proactive in managing care for people with diabetes and/or CAD Involve patients with diabetes and/or CAD in delivering and developing care Develop effective links and communication strategies with key local partners involved in care and support of people with diabetes and/or CAD GOAL What are you trying to achieve with this group of PDSAs? © Health Quality Council 2006 4-23

Glossary of terms A1C—is a simple laboratory test used with people with diabetes that monitors blood sugar (glucose) control by indicating the average level of glucose in the blood over a 3-month period. The target level for A1C is ≤ 7.0%. The Canadian Diabetes As- sociation recommends that A1C testing be done approximately every 3 months. A1C is also known as: Hemoglobin A1c, HbA1c, Glycohemoglobin, Glycated hemoglobin, Glycosylated hemoglobin. ACE-I (Angiotensin Converting Enzyme Inhibitor)—are a class of drugs that are widely prescribed in the treatment of hypertension, as well as certain forms of heart failure and immediately after a heart attack. ACE inhibitors are often recommended after a heart attack because these medicines may prevent further damage to the heart muscle. ACE inhibitors are also frequently prescribed for people with diabetes to prevent or treat kidney damage. Action period—the period of time between Learning Work- shops when teams work on small-scale tests of change. In order to facilitate the sharing of their change ideas at each workshop, practices are asked to complete one PDSA Ramp for each topic, for a minimum of 3 PDSA Ramps per Action Period. Aim—a written, measurable, and time-sensitive statement of the expected results of an improvement process. The intent of the aim is to motivate improvement. Albumin:Creatinine test—is a single sample urine test that is used to assess kidney function by screening for microablumin- uria. An elevated albumin:creatinine ratio can be an early indicator of kidney damage. The test is measured in units of mili- grams of albumin per milimoles of creatinine. Normal values for albumin:creatinine are less than 2.0 mg/mmol for men and less than 2.8 mg/mmol for women. The Canadian Diabetes Asso- ciation recommends that people with diabetes be screened an- nually for microalbuminuria. Antiplatelet therapy—aspirin is a drug with \"antiplatelet\" prop- © Health Quality Council 2006 4-24

Glossary of terms erties which means that it stops blood cells (called platelets) from sticking together and forming a blood clot. Most patients who have had a heart attack are given aspirin or other antiplatelet therapy to prevent further blood clots from forming in the coronary arteries. Antiplatelet drugs such as aspirin are recommended for many people with diabetes and CAD to reduce the risk of cardiovascular disease and cardiovascular related deaths. ARB (Angiotensin II Receptor Blocker)—are medications that produce similar effects as ACE inhibitors. ARBs lower blood pressure and are commonly prescribed for the treatment of hypertension, heart failure and post-heart attack care. Simi- lar to ACE inhibitors, ARBs are can be prescribed for people with diabetes to prevent or treat kidney damage. Beta blockers—are a class of medications that reduce the workload of the heart and lower blood pressure. They are recommended for most patients who have had a heart attack to prevent future heart attacks. Beta blockers are commonly prescribed to relieve angina (i.e., chest pain) or to treat heart failure. They are also prescribed for people who have hypertension (high blood pressure). Blood pressure—blood pressure is a measure of the pressure or force of the blood against the walls of the blood vessels. The pressure is measured in units called mm Hg (a measurement that is short for millimetres of mercury). Since the pressure changes when the heart contracts and relaxes, blood pressure is expressed as two numbers: • Systolic pressure represents the pressure when the heart contracts and forces the blood into the blood vessels. This is the higher of the two numbers and is usually expressed first (e.g. a blood pressure of 120/70 means the systolic pressure is 120 mm Hg). • Diastolic pressure represents the pressure when the heart is relaxed. This is the lower of the two numbers and is usually expressed second (e.g. a blood pressure of 120/70 means the diastolic pressure is © Health Quality Council 2006 4-25

Glossary of terms 70 mm Hg). An acceptable blood pressure for most adults is less than 140/90. For people with diabetes or kidney disease, an acceptable blood pressure is less than or equal to 130/90. High blood pressure (also known as hypertension) is a major risk factor for heart attack, strokes, and kidney damage. Chair—the leader of the Collaborative, usually a champion and expert in quality improvement science. Champion—an individual in the organization who believes strongly in the improvements and is willing to try them and work with others to learn them. Teams need at least one physician champion on their team. Champions in other disciplines who work on the process are important as well. Change concept—a general principle proven to be effective for changing a process. Change concepts are usually at a high level of abstraction, but evoke multiple, specific ideas for how to change processes. Cholesterol/HDL ratio—the total cholesterol to HDL cholesterol ratio is a number that is helpful in predicting a person’s risk for coronary artery disease. High ratios indicate higher risks of heart attacks, low ratios indicate lower risk. As a rule, when cholesterol testing is done, the total amount of cholesterol is measured, as well as the amount of LDL (“bad”), HDL (“good”) cholesterol and triglyercides. The total cholesterol:HDL ratio is obtained by dividing total cholesterol by HDL cholesterol. A cholesterol:HDL ratio less than 4 is the recommended target for adults. Clinical information systems—computer program that supports the work of healthcare providers by enabling easier, faster, more effective management of patient information. It can store and display a patient's history in a variety of formats, provide decision support to the clinician throughout the episode of care, and streamline common tasks like patient scheduling and billing. © Health Quality Council 2006 4-26

Glossary of terms Collaborative—a learn-by-doing approach to quality improvement that brings together a network of learners for rapid and sustained improvements. Decision support—methods used, including reminders and prompts, to have information available to enable patients and providers to make informed choices about optimal care. This includes the use of evidence from the medical and health services literature, education of providers, and the interaction between specialists and primary providers. Delivery system design—how care is provided to patients, including the types and roles of the provider team, types of appointments, and follow-up techniques used by the practice to ensure good care. The most commonly used method is a planned chronic care visit. Innovations include group visits. Early adopter—in the improvement process, the opinion leader within the organization who brings in new ideas from the outside, tries them, and uses experiences with positive results to persuade others in the organization to adopt the successful changes. Early majority/late majority—the individuals in the organization who will adopt a change only after it is tested by an early adopter (early majority) or after the majority of the organization is already using the change (late majority). Implementation—taking a change and making it a permanent part of the system. A change may be tested first and then implemented throughout the organization. Innovators—small number of individuals (usually about 2%) who quickly see the value of a change and serve as early examples to others. In the world of technology, these are the folks that were the first to get a cell phone, the first to have a PDA, etc. Laggards—there will always be a small number (usually about © Health Quality Council 2006 4-27

Glossary of terms 15%) of people who don’t and won’t see the value of a change and doing things in a new way. Most of us can identify a time when, due to the nature of the change, we have been laggards. Learning Workshop—a 1.5 day workshop during which participating teams meet with Leadership teams (Clinical, Collabo- rative Facilitators, HQC team) to learn about key change concepts in the topic area, including ideas on how to implement them, an approach for accelerating improvement, and a method to overcome obstacles to change. Teams have time during the workshop to plan their next steps for the Action Pe- riod. Teams leave the workshop with new knowledge, skills, and materials that prepare them to make immediate changes. Teams also have the opportunity to share their own success stories and improvement ideas. Measure—KEY measures are focused on achieving the overall Collaborative aims. Microalbuminuria—refers to a condition that describes consistently detectible amounts of albumin in a person’s urine and can be an indicator of kidney damage. Albumin is a protein that is present in high concentrations in the blood. Normally func- tioning kidneys do not allow albumin to leak through into the urine. However, if a person’s kidneys become damaged or dis- eased, they begin to lose their ability to filter proteins out of the urine. Increasing amounts of protein in the urine reflecting increasing kidney damage. Model for Improvement—an approach to process improvement, developed by Associates in Process Improvement, which helps teams accelerate the adoption of proven and effective changes. PDSA—a key part of the Model for Improvement, involving small, manageable changes that include 4 steps—Plan, Do, Study, Act. PDSAs that are used in sequence and are connected to the same goal are called a PDSA Ramp. • PLAN—first step in a PDSA cycle. A specific plan- © Health Quality Council 2006 4-28

Glossary of terms ning phase for carrying out a small-scale test of change. • DO—the second step of the PDSA cycle. A time to try the change and observe what happens. • STUDY—the third step in the PDSA cycle. An analysis of the results of the trial of change. • ACT—last step in the PDSA cycle. Devising the next steps based on analysis. PDSA Ramp—a series of PDSA cycles, connected to a common specific goal, that builds knowledge and confidence that an idea is suitable for implementation. Population—identifying patient populations is the backbone to the population-based care delivery system. Without identification of the members of the sub-population, changes cannot be achieved. To identify members, a clinic team needs to be able to access data that can distinguish populations with different health problems. Run chart—a graphic representation of data over time, also known as a “time series graph” or “line graph”. This type of data display is particularly effective for process improvement activities. It can also be motivational for staff and patients. Self-management support—on-going efforts to assist patients in learning to live with a chronic condition. This includes goal- setting, identification of barriers and challenges, personalized problem–solving, and follow-up support. Spread—the intentional and methodical expansion of the number and type of people, units or organizations using the improvements. The theory and application comes from the literature on Diffusion of Innovation (Everett Rogers, 1995). Statins—are a class of drugs that are the mostly widely used medications today for lowering LDL (“bad”) cholesterol. They also increase the HDL (“good”) cholesterol level. © Health Quality Council 2006 4-29

Internet Resources Patient Education Tools Aim for a Healthy Weight. Information for Patients and the Public: This web site contains guidelines from the National Heart, Lung, and Blood Institute (NHLBI) to provide patients with a new approach for the measurement of overweight and obesity and a set of steps for safe and effective weight loss. www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/ patmats.htm Calculate Your Body Mass Index (BMI): This tool allows patients to calculate your body mass index (BMI), a measure of body fat based on height and weight that applies to both adult men and women. www.nhlbisupport.com/bmi/bmicalc.htm Canada’s Physical Activity Guide to Healthy Active Living: A guide to help patients make wise choices about physical activity. Choices that will improve health, help prevent disease, and allow people to get the most out of life. http://www.phac- aspc.gc.ca/pau-uap/paguide/index.html. As well as the Physi- cal Activity Guide for Older Adults: www.phac-aspc.gc.ca/pau- uap/paguide/older/phys_guide.html Canadian Diabetes Association - Nutrition Guidelines, Tools and Resources: This provides a direct link to the Pro- fessionals section of the Canadian Diabetes Association web site. There are a number of tools and resources available through this site. www.diabetes.ca/Section_Professionals/ ng_index.asp Chart Your Progress - Reach Your Goal: This worksheet is designed to help patients keep track of their cholesterol numbers. http://hin.nhlbi.nih.gov/cholmonth/track3.htm DASH* to the Diet: Prevent and Control High Blood Pres- sure Following the DASH Eating Plan: This tool presents information to consumers on how to prevent and control high blood pressure by following the Dietary Approaches to Stop © Health Quality Council 2006 4-30

Internet Resources Hypertension (DASH) eating plan. http://hin.nhlbi.nih.gov/ mission/partner/healthy_eating.pdf Diabetes and Your Feet: This brochure provides information to people with diabetes about foot injuries that can be caused by this condition. www.maclearinghouse.com/ CatalogPageFrameSet.htm Diabetes Can Harm Your Vision: This brochure provides information for people with diabetes about vision and eye disease. www.maclearinghouse.com/CatalogPageFrameSet.htm Diabetes Care Card: This wallet card helps people with diabetes to maintain records of medical tests and identify personal goals. www.maclearinghouse.com/CatalogPageFrameSet.htm Diabetes Self-Management Health Tips: This health tips summary is derived from the evidence-based clinical practice guideline, Management of Diabetes Mellitus, developed by the Department of Veterans Affairs and Department of Defense (VA/DoD), and is intended to help people develop the confidence and motivation to use their skills and knowledge to be the expert decision-makers in their diabetes management. www.oqp.med.va.gov/cpg/DM/P/DMHealthTips.pdf Diabetes: Women’s Health: Take Time to Care. Developed by the US Food and Drug Administration. www.fda.gov/ womens/taketimetocare/diabetes/diabetes_broc_eng.pdf Dietitians of Canada website (resource centre): This resource centre includes nutrition resources (patient education tools) for a wide variety of interests, including clinical nutrition as well as nutrition and lifestyle. All resources have been reviewed by dietitians to assure quality information. Search the inventory listing to find resources with the information you are looking for. The inventory includes resources available in Eng- lish as well as French. www.dietitians.ca/resources/ resourcesearch.asp © Health Quality Council 2006 4-31

Internet Resources Health Canada’s Guide to Healthy Living: This website provides information about healthy living, and covers topics such as physical activity, eating, mental health, and smoking cessa- tion. You can find information specific to different groups, such as children, women, and seniors. www.hc-sc.gc.ca/hl-vs/ index_e.html High Blood Cholesterol—What You Need to Know. This fact sheet explains the risks of having a high blood cholesterol level. Please note that it uses American units. Developed by the National Cholesterol Education Program (US). www.nhlbi.nih.gov/health/public/heart/chol/wyntk.htm How To Read a Food Label. This tool provides information about the details found on a food label. Developed by National Women's Health Information Center - Federal Government Agency (US). http://www.4woman.gov/tools/foodlabel.cfm I Have Diabetes...What Can I Do to Stay Healthy? This fact sheet provides information to people with diabetes about how to manage their condition and stay healthy. www.maclearinghouse.com/PDFs/Diabetes/ DiabetesFactSheetSet/WhatCanIDotoStayHealthy.pdf If You Have Diabetes, A Flu Shot Could Save Your Life This brochure for people with diabetes emphasizes the importance of flu and pneumonia shots. http://www.maclearinghouse.com/ CatalogPageFrameSet.htm If You Have Diabetes, Know Your Cholesterol Numbers: This brochure for people with diabetes describes the links between diabetes and cardiovascular disease. http:// www.maclearinghouse.com/CatalogPageFrameSet.htm Just the Basics: Tips for Healthy Eating, Diabetes Preven- tion and Management: This resource is geared to help diabetes educators, those affected by diabetes, and consumers to implement the Guidelines for the Nutritional Management of © Health Quality Council 2006 4-32

Internet Resources Diabetes Mellitus in the New Millennium which were released in 1999. www.diabetes.ca/files/JTB17x_11_CPGO3_1103.pdf Know Your Blood Sugar Numbers: This brochure for people with diabetes addresses the importance of blood sugar control. http://www.maclearinghouse.com/CatalogPageFrameSet.htm Live Healthier, Live Longer. Cholesterol-Lowering Medica- tions and You: This section of the Live Healthier, Live Longer Web site will provide people with information about the medications available for patients who need to combine cholesterol lowering medications with changes in life habits to get enough of a reduction in cholesterol. www.nhlbi.nih.gov/chd/meds.htm Live Healthier, Live Longer. How You Can Lower Your Cho- lesterol Levels: This section of the Live Healthier, Live Longer Web site helps people find out more about cholesterol and how to keep cholesterol levels low or how to lower high cholesterol levels. http://nhlbisupport.com/chd1/how.htm Live Healthier, Live Longer. Therapeutic Lifestyle Changes (TLC): This section of the Live Healthier, Live Longer Web site teaches people how changes in lifestyle can help lower cholesterol and reduce the chance of developing heart disease as well as improve health in other ways. http://nhlbisupport.com/ chd1/tlc_lifestyles.htm Low Blood Sugar, High Blood Sugar, and Sick Days : This fact sheet provides information for people with diabetes about the following complications: Low blood sugar (hypoglycemia); High blood sugar (hyperglycemia), and sick days. www.maclearinghouse.com/PDFs/Diabetes/ DiabetesFactSheetSet/LowandHighBloodSugar.pdf Men's Health Awareness Tool Kit. This toolkit contains preventive health care information for men in order to maintain a healthy lifestyle. Developed by National Women's Health Re- source Center (US). www.healthywomen.org/menshealth/ index.html © Health Quality Council 2006 4-33

Internet Resources My Blood Pressure Wallet Card: This wallet card from the \"Seventh Report of the Joint National Committee on Preven- tion, Detection, Evaluation, and Treatment of High Blood Pres- sure (JNC 7)\" helps patients manage their blood pressure. www.nhlbi.nih.gov/health/public/heart/hbp/hbpwallet.pdf My Bright Future: Physical Activity and Healthy Eating Guide for Adult Women. This booklet focuses on the importance of physical activity and healthy eating in daily life. It follows the US Food Pyramid. Developed by Health Resources and Services Administration (US). www.hrsa.gov/ womenshealth/mybrightfutureadult/menu.html Quit Smoking: Consumer Interactive Tool: This program is an interactive tool that helps consumers to prepare to quit smoking. Included is a 5-day countdown to their quit date that can be inserted into their calendar, as well as a number of helpful resources. http://pda.ahrq.gov/consumer/qscit/qscit.htm Self-Management @ Stanford: Healthier Living With Ongo- ing Health Problems: This online interactive workshop and study is designed for people diagnosed with heart conditions, lung conditions, or Type 2 diabetes. https:// healthyliving.stanford.edu/hl/index.asp Some Answers About High Blood Pressure: This fact sheet provides information about high blood pressure. http:// hin.nhlbi.nih.gov/NHBPEP_Kit/answers.htm Systolic High Blood Pressure Q&A: This fact sheet presents information on systolic high blood pressure. http:// hin.nhlbi.nih.gov/NHBPEP_Kit/systolic.htm Take Charge of Your Diabetes: This guide suggests ways for adults with diabetes to work with a health care team to prevent diabetes-related health problems. www.maclearinghouse.com/ PDFs/Diabetes/TakeCharge_Eng.pdf © Health Quality Council 2006 4-34

Internet Resources Take Steps to Prevent and Control High Blood Pressure: This tool describes steps that consumers can take to control their blood pressure. http://hin.nhlbi.nih.gov/NHBPEP_Kit/ steps.htm Ten Commandments for a Healthy Heart: This tool presents ten recommendations for a healthy heart. www.nhlbi.nih.gov/ health/hearttruth/material/commandments.htm The Healthy Heart Handbook for Women. This guide gives women practical suggestions for reducing risk of heart-related problems. Developed by the National Heart, Lung and Blood Institute (US). www.nhlbi.nih.gov/health/public/heart/other/hhw/ hdbk_wmn.pdf The Heart Truth for Women: If You Have Heart Disease: This fact sheet gives women the key steps on how to survive a heart attack and prevent serious damage to heart muscle. www.nhlbi.nih.gov/health/public/heart/other/hhw/hdbk_wmn.pdf Tips To Help You Remember To Take Your High Blood Pressure Medication: This fact sheet provides tips for patients to help them remember to take their blood pressure medications. http://hin.nhlbi.nih.gov/NHBPEP_Kit/rem_tips.htm Trans Fat Fact Sheet: An educational Brochure on Trans Fats: http://www.diabetes.ca/files/trans-fat.pdf What is the Hemoglobin A1c Test? This fact sheet provides information for people with diabetes about the hemoglobin A1c test. www.maclearinghouse.com/PDFs/Diabetes/ DiabetesFactSheetSet/HemoglobinA1c.pdf What You Need to Know: Taking Aspirin to Lower Your Risk of Heart Attack: This consumer fact sheet provides you with information about aspirin and heart attack risk. www.ahcpr.gov/consumer/aspneed2.htm You Can Quit Smoking. Information Kit for Consumers: © Health Quality Council 2006 4-35

Internet Resources The You Can Quit Smoking kit is a one-stop source for information to help smokers become tobacco-free. www.ahrq.gov/ consumer/tobacco Your Guide to a Healthy Heart. This guidebook helps users find out about their own risk of heart disease and take the steps to prevent it. Developed by National Heart, Lung, and Blood Institute (US). www.nhlbi.nih.gov/health/public/heart/other/ your_guide/healthyheart.pdf Your Guide to Living Well With Heart Disease. This tool is a step-by-step guide to helping people with heart disease make decisions that will protect and improve their heart health. It provides information about lifestyle habits, medicines, and other treatments that can lessen the chances of having a heart attack. Developed by National Heart, Lung, and Blood Institute (US). www.nhlbi.nih.gov/health/public/heart/other/your_guide/ living_well.pdf Provider Tools A Guide to Choosing and Adapting Culturally and Linguis- tically Competent Health Promotion Materials. This tool provides guidance on how to assure that health promotion materials reflect the principles and practices of cultural and linguistic competence. Developed by the National Center for Cultural Competence (Georgetown University, US). www.healthdisparities.net/hdc/Library/11-23-2005.1608/ GuideForCulturalCompetency_Apr2003.pdf Adapting Your Practice: General Recommendations for the Care of Homeless Patients. This tool provides general recommendations that specify what experienced clinicians know works best for patients who are homeless, with the realistic understanding that limited resources, fragmented health care delivery systems and loss to follow-up often compromise adherence to optimal clinical practices. Developed by Health Care for the Homeless Clinicians’ Network (US). © Health Quality Council 2006 4-36

Internet Resources www.healthdisparities.net/hdc/Library/7-15-2005.3187/ HomelessCareAdaptingYourPractice_2004.pdf Conducting a Continuing Care Clinic: Handbook for Prac- tice Teams: This guide is intended to assist practice teams in using the continuing care clinic model for managing patients with a selected diagnosis or condition, such as diabetes or frail elderly. www.improvingchroniccare.org/improvement/docs/ cccguide.doc Diabetes Mellitus Algorithm D: Core: This algorithm is derived from the evidence-based clinical practice guideline, Man- agement of Diabetes Mellitus, developed by the Department of Veterans Affairs and Department of Defense (VA/DoD). www.oqp.med.va.gov/cpg/DM/DM3_cpg/content/modD/ modD_fr.htm Diabetes Mellitus Algorithm E: Eye Care: This algorithm is derived from the evidence-based clinical practice guideline, Management of Diabetes Mellitus, developed by the Depart- ment of Veterans Affairs and Department of Defense (VA/ DoD). www.oqp.med.va.gov/cpg/DM/DM3_cpg/content/ModE/ modE_fr.htm Diabetes Mellitus Algorithm F: Foot Care: This algorithm is derived from the evidence-based clinical practice guideline, Management of Diabetes Mellitus, developed by the Depart- ment of Veterans Affairs and Department of Defense (VA/ DoD). www.oqp.med.va.gov/cpg/DM/DM3_cpg/content/ModF/ modF_fr.htm Diabetes Mellitus Algorithm G: Glycemic Control This algorithm is derived from the evidence-based clinical practice guideline, Management of Diabetes Mellitus, developed by the Department of Veterans Affairs and Department of Defense (VA/DoD). www.oqp.med.va.gov/cpg/DM/DM3_cpg/content/ ModG/modG_fr.htm Diabetes Mellitus Algorithm M: Self-Management and Edu- © Health Quality Council 2006 4-37

Internet Resources cation This algorithm is derived from the evidence-based clinical practice guideline, Management of Diabetes Mellitus, developed by the Department of Veterans Affairs and Department of Defense (VA/DoD). www.oqp.med.va.gov/cpg/DM/DM3_cpg/ content/ModM/modM_fr.htm Diabetes Mellitus Algorithm R: Kidney Function This algorithm is derived from the evidence-based clinical practice guideline, Management of Diabetes Mellitus, developed by the Department of Veterans Affairs and Department of Defense (VA/DoD). www.oqp.med.va.gov/cpg/DM/DM3_cpg/content/ ModR/modR_fr.htm Diabetes Mellitus Algorithm S: Screening and Prevention This algorithm is derived from the evidence-based clinical practice guideline, Management of Diabetes Mellitus, developed by the Department of Veterans Affairs and Department of Defense (VA/DoD). www.oqp.med.va.gov/cpg/DM/DM3_cpg/content/ ModS/modS_fr.htm Evidence Based Medicine Tool Kit This is a collection of tools for identifying, assessing and applying relevant evidence for better health care decision-making. www.med.ualberta.ca/ ebm/ebm.htm Group Visit Starter Kit: Improving Chronic Illness Care This starter kit is designed for health care teams who want to begin offering group visits for their patients. www.improvingchroniccare.org/improvement/docs/startkit.doc Health Disparities Collaboratives: Changing Practice, Changing Lives – Diabetes This manual outlines all of the key elements of a system of excellent care for people with diabetes. www.healthdisparities.net/hdc/content/ Diabetes_Apr2002.pdf Health Disparities Collaboratives: Changing Practice, Changing Lives Training Manual This training manual gath- ers the best of what health centers have learned so far about © Health Quality Council 2006 4-38

Internet Resources improving the care of people with chronic illness. www.healthdisparities.net/hdc/content/chronic_Apr2002.pdf Helping Smokers Quit: A Guide for Nurses This pocket guide gives nurses evidence-based information that they can use to help their patients quit smoking. www.ahrq.gov/about/ nursing/hlpsmksqt.htm National Cholesterol Education Month Kit. This tool kit provides cholesterol information for use by the public (such as worksheets and heart healthy recipes) and health professionals. Developed by National Heart, Lung, and Blood Association (US). http://hp2010.nhlbihin.net/cholmonth/chol_kit.htm National Heart, Lung and Blood Institute: High Blood Cho- lesterol. This is an excellent tool for addressing high blood cholesterol. Developed by the National Heart, Lung and Blood Institute (US). www.nhlbi.nih.gov/health/dci/Diseases/Hbc/ HBC_WhatIs.html Promoting Cultural and Linguistic Competency: Self- Assessment Checklist for Personnel Providing Primary Health Care Services. This checklist is intended to heighten the awareness and sensitivity of personnel to the importance of cultural and linguistic cultural competence in health, mental health and human service settings. Developed by the National Center for Cultural Competence (Georgetown University, US). http://gucchd.georgetown.edu/nccc/documents/Checklist% 20PHC.pdf Physicians for a Smoke-Free Canada: Physicians for a Smoke-Free Canada is a national health organization with the goal of reducing tobacco-caused illness through reduced smoking and reduced exposure to second-hand smoke. www.smoke-free.ca Smokefree.gov Smokefree.gov is intended to help you or someone you care about quit smoking. www.smokefree.gov © Health Quality Council 2006 4-39

Internet Resources Take a Loved One for a Checkup Day: 2006 Checkup Day Toolkit. Checkup Day focuses on major areas in which racial and ethnic minorities experience serious disparities in health access and outcomes, like diabetes, heart disease and stroke, cancer, infant mortality, child and adult immunization, and HIV/ AIDS. Developed by U.S. Department of Health & Human Ser- vices, Office of Minority Health. www.omhrc.gov/healthgap/ toolkit2006.aspx#kit The Provider's Guide to Quality & Culture. This web site is designed to assist health care organizations in providing high quality, culturally competent services to multi-ethnic populations. Developed by Management Sciences for Health (US). http://erc.msh.org/mainpage.cfm? file=2.0.htm&module=provider&language=English&ggroup=&m group= Think Cultural Health: Bridging the Health Care Gap through Cultural Competency Continuing Education Pro- grams. This web site, sponsored by the Office of Minority Health (OMH), offers the latest resources and tools to promote cultural competency in health care. Health care providers can use the resources available on this site as a way to improve the quality of health care services given to diverse populations. http://www.thinkculturalhealth.org Treating Tobacco Use and Dependence--Clinician's Packet. A How-To Guide For Implementing the Public Health Service Clinical Practice Guideline: This Clinician's Packet is a how-to guide for implementing the clinical practice guideline, Treating Tobacco Use and Dependence. It contains information about developing a system, advising patients, special populations, and reimbursement; and products for clinicians and consumers. www.ahrq.gov/clinic/tobacco Other Resources Plain English Campaign: www.plainenglish.co.uk © Health Quality Council 2006 4-40

Internet Resources Readability test, the SMOG test: www.sph.emory.edu/ WELLNESS/reading.html Virtual training programs offered through SIAST: www.siast.sk.ca/virtualcampus/educationtraining/ healthsciences/advanceddiabetes.htm Canadian Diabetes Educator Certification Board: www.cdecb.ca Improvement Leaders’ Guides: www.wise.nhs.uk/cmsWISE/ Tools+and+Techniques/ILG/ILG.htm Other Collaboratives England: Improvement Foundation: www.improvementfoundation.org National Primary Care Collaboratives (Australia): www.npcc.com.au Improving Chronic Illness Care: www.improvingchroniccare.org Heart Healthy British Columbia: www.heartbc.ca/pro/ cdm.htm Scottish Primary Care Collaborative: www.scottishpcc.org The Quality Assurance Project: www.qaproject.org Health Disparities Collaborative: www.healthdisparities.net Association Websites Canadian Diabetes Association: www.diabetes.ca In Motion: Saskatchewan in motion is a province-wide move- © Health Quality Council 2006 4-41

Internet Resources ment aimed at increasing physical activity for health benefits. The vision is that the people of Saskatchewan will be the healthiest, most physically active in Canada. www.saskatchewaninmotion.ca Heart and Stroke Foundation: www.heartandstroke.ca Institute for Healthcare Improvement: www.ihi.org © Health Quality Council 2006 4-42

Collaborative Handbook

0 comments

Notes on slide 1

Favorites, Groups & Events