Quality improvement is a cyclical or iterative process. The Archetypal CQI cycle was described by Deming – Plan Do Check ActIt requires a series of conscious actions which improve quality by first setting standards which act as an agreed baseline or a “chock” for the quality cycle. This is complemented by continuous activity which identifies opportunities for improvement, and puts in place agreed actions, monitors results and restarts the cycle.However there are three fundamentals1 – Know where you are heading2 - Know how you are going to get here3 - Know when to stop
However one of the essentials is knowhing what you want your quality improvement activity to cover. It’s essential to have a clear concept of the outcomes you want, and ensure that all aspects of quality are addressed. The Triple Aim model addresses the range of quality domains curently consisered important in the provision of healthcare. In the context of child health these are Improved safety and quality experience of child, family/and community, Improved health and equity across populations and Best value for health system resource
The WCTO qi
As you can see we have increased coverage and reduced inequalities since the target initiative commended in 2007. We have had a threefold reduction in inequalities and an almost 20% increase in coverage. Children from both the lowest and highest quintile now have identical coverage of 94%.We did this through a systematic approach which involved being clear about the evidence, agreeing a national plan of action, monitoring results using our NIR, and revising the plan if results were not as we expected.
The basis of this is getting best efficiency. For immunisation this is maximising coverage within existing funding. No new money went into the increasing immunisation programme, apart from some infrastructure enhancements – NIR and training for staff, and the payments ($21 per vaccination given) for the additional coverage which is undertaken on a fee for service basis.
The B4 School Check is a Universal offer Well child check which aims to identify and address any health, behavioural, social, or developmental concerns which could affect a child’s ability to get the most benefit from school, such as a hearing problem or communication difficulty.The Check is highly manualised, has it’s own dedicated information system, and is delivered in a range of settings by trained nurses, mainly practice nurses, public health and well child nurses.It is the eighth core contact of the Well Child Tamariki Ora Schedule of services.The value for money for this check is maximised by ensuring optimal referral rates for any issues found.
The B4school check efficiency gains revolved aroungmaximising referrals for children with significant issues identified at the check. We also need to measure and analyse outcomes as referrals are only a proxy for outcomes.
Enhancing health and wellbeing in New Zealand children and young people
Quality Improvement cycles Act Plan Quality improvement actions Check Do SmallMaintaining the gains with steps ofStandards and QualityAssurance continuous improvement
Well-child/Tamariki Ora Draft Quality frameworkHealth Quality and Safety Commissionadapted the IHI Triple Aim for NZ.The three dimensions in the NewZealand adapted model are:• improved quality, safety and experience of care• improved health and equity for all populations• best value for public health system resources.The three sides of the WCTO triangleare:• improved safety and quality experience of child, family/and community• improved health and equity across populations• best value for health system resource
Quality initiatives in Child health in New ZealandWell-child/Tamariki Ora quality framework• Immunisation coverage target• B4School check quality initiative• Reducing rheumatic fever• Children’s Commissioners Compass• Development of clinical networks• QI for maternal and newborn screening• Maternity quality initiative
The B4 School Check is a universal-offer Well-Child check It aims to identify and address any health, behavioural, social, or developmental concerns which could affect a child’s ability to get the most benefit from school.
10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 0.0% 10.0% 30.0% 50.0% 70.0% 90.0% 20.0% 40.0% 60.0% 80.0% 0.0% Auckland AucklandBay of Plenty Bay of Plenty Canterbury Canterbury Capital and… Capital and Coast Counties … Counties ManukauHawkes Bay Hawkes Bay Hutt Hutt Lakes Lakes Midcentral Midcentral Nelson… Nelson… Northland Northland Otago Otago South… South Canterbury Southland Southland Tairawhiti Tairawhiti % of PEDS Pathway A referred Taranaki Taranaki Waikato Waikato % of Decay Level 2 - 6 referred Wairarapa Wairarapa Waitemata Waitemata West Coast West Coast Whanganui Whanganui % of Extreme Obese Referred 100.0% 120.0% 20.0% 40.0% 60.0% 0.0% 80.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 0.0% AucklandBay of Plenty Auckland Canterbury Bay of Plenty Capital and… Canterbury Counties… Capital and… Hawkes Bay Counties… Hutt Hawkes Bay Lakes Hutt Lakes Midcentral When we started Midcentral Nelson… Nelson… Northland Northland Otago Otago South… South… Southland Southland Extreme Obese that are referred Tairawhiti Tairawhiti Taranaki Taranaki Waikato % of Abnormal SDQ scores referred Waikato Wairarapa Wairarapa Waitemata Waitemata West Coast West Coast Whanganui Whanganui
The quality letter.• A Quality Improvement process for the 4 year old check.• Shared with providers and DHB management• An opportunity to provide up to date information and share good practice• Provision of benchmarking information
Quality improvement in action45.00%40.00%35.00%30.00%25.00%20.00%15.00%10.00% 5.00% 0.00% 01-July-2011 01-January-2012 01-April-2012 01-July-2012 Lift the Lip % of 2-6 referred % of BMI>=21 referred PEDS % of pathway A referred SDQ-P abnormal that were referred
Improved safety and quality experience for child, family and communityImproving communityinvolvement and parentsatisfaction with theB4School check
Improved safety and quality experience for child, family and community We developed a relationship with Richard Taylor of Weta workshop to promote the B4School checks using the Wot- Wots.
Improved safety and quality experience for child, family and communityValidation of the Strengthsand DifficultiesQuestionnaire
SDQ validation• The SDQ is a behavioural and emotional screen used in many countries and translated into over 30 languages• Parents and early childhood teachers have told us that they were uncertain about he screen because it had not been tested on New Zealand children• Ministry of Health has contracted Auckland University of Technology to validate the SDQ on New Zealand children
Conclusion• Reframing difficult problems within a QI perspective can lead to rapid gains• A Quality Framework will ensure that all aspects of quality are considered and addressed• Once you have had success, your learning is generalisable to other areas• Improving quality doesn’t always save money, but it can increase efficiency