Collaborative Handbook


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Collaborative Handbook

  1. 1. Collaborative Handbook
  2. 2. 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 docu- ment, 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.
  3. 3. November 2006 A message from the Chief Executive Officer katchewan’s health care to care is a key component community. of chronic disease manage- ment. 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 re- port, 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
  4. 4. 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
  5. 5. 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
  6. 6. Overview Included in this section: Mission…..Vision…..Three models together…..Learning model…..Model for Improvement…..Chronic care model © Health Quality Council 2005
  7. 7. 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 profession- als 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 applica- tion of quality improvement methods and skills. © Health Quality Council 2006 1-1
  8. 8. Three models together The Chronic Disease Management Collaborative brings to- gether 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 fel- low learners (the Collaborative Learning Model) in order to gain skills in performing rapid, small tests that lead to the im- plementation of changes that make sense in each unique set- ting (Model for Improvement). The next few pages will go over each of these three models in more detail. © Health Quality Council 2006 1-2
  9. 9. The Learning Model The Collaborative Learning Model makes health care profes- sionals and organizations part of a network of experts and fel- low learners. A Collaborative is a learn-by-doing approach to quality im- provement. It brings together practitioners from various disci- plines and sites. A Collaborative teaches ideas on how to im- prove practices (based on evidence found in research litera- ture). Throughout the Collaborative, participants and sites share their experiences and learn from one another, and net- works are established. Quality improvement Collaboratives have been used success- fully 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 qual- ity 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
  10. 10. 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 re- ceiving information, but Learning Workshops are about sharing information. • A passive exercise. Between Learning Workshops, participants engage in an Action Period. They imple- ment 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 con- cepts. © Health Quality Council 2006 1-4
  11. 11. 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 improve- ment, including the Model for Improvement and data meas- urement. They are also introduced to available support peo- ple 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 improve- ments. 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
  12. 12. Why a Collaborative? The Collaborative approach does not work for every improve- ment project. But under the right circumstances, it can acceler- ate 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 pa- tients with coronary artery disease, improving access to ap- pointments, and improving access to routine secondary ser- vices. Since then, they have completed Collaboratives in areas such as improving care for patients with diabetes and develop- ing 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 dis- ease mortality in Collaborative sites, compared to the rest of England • Estimated to have saved 6,070 lives • A 17% improvement in diabetic patients with excel- lent 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:, accessed September 12, 2006. © Health Quality Council 2006 1-6
  13. 13. Why a Collaborative? Scottish Primary Care Collaborative (Scotland) The Scottish Primary Care Collaborative is a partnership be- tween 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 prac- tices 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 cho- lesterol < 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:, accessed September 12, 2006. National Primary Care Collaborative (Australia) The National Primary Care Collaborative is a partnership be- tween 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 practi- tioners. They too have vast distances, remote and rural popula- tions, and an Aboriginal population. The NPCC program is national in scope and focuses on three © Health Quality Council 2006 1-7
  14. 14. 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 be- ing 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:, 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:, accessed September 12, 2006. © Health Quality Council 2006 1-8
  15. 15. 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:, 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
  16. 16. Why a Collaborative? • 1000% increase in the proportion of patients with self-management goals Source:, accessed September 12, 2006. The Vancouver Island Health Authority also launched a diabe- tes 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
  17. 17. 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 im- pact. 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 improve- ment 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
  18. 18. Model for Improvement The three fundamental questions for achieving improve- ment 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 meas- ure 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
  19. 19. 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 con- secutive 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 en- sure 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 be- cause 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
  20. 20. 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 prob- lem 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 some- thing 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 re- sults of what you have tried, it is also a great way of © Health Quality Council 2006 1-14
  21. 21. 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 gener- ally 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
  22. 22. 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 pa- tient 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, adjust- ing 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 diag- nosing 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
  23. 23. 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 contin- ues 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 sci- ence, on the other hand, is a paradigm that crosses all sys- tems. 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 ta- ble 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 educa- tion 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 learn- ing takes place Testing strategy One large study No tests Many sequential tests © Health Quality Council 2006 1-17
  24. 24. 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 pol- icy, creating supportive environments, and strengthening com- munity 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 pro- vincial framework for the Saskatchewan Diabetes strategy. The © Health Quality Council 2006 1-18
  25. 25. Chronic Care Model CCM is evidence-based, and its implementation has been re- ported 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 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 sup- ported 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 re- ceived 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
  26. 26. 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 proac- tive 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 re- sources and support they need to pursue quality improvement efforts. Community resources and policies Health care professionals identify effective programs and en- courage their patients to participate. Practices form partner- ships with community organizations to support or develop evi- dence-based programs. © Health Quality Council 2006 1-20
  27. 27. 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
  28. 28. 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 ( • On average, the life expectancy for some- one with diabetes is 13 years shorter than for a person without diabetes ( • Diabetes is a growing concern in our prov- ince. According to Saskatchewan Health, it is estimated that by the end of 2016, more than 70,000 peo- ple 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 compli- cations—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
  29. 29. 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 complica- tions. © Health Quality Council 2006 2-2
  30. 30. 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 ( • 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 inhibi- tors, statins) proven to save lives and prevent secondary heart attacks. • With better drug management, we could save approxi- mately 45 lives each year in our province. © Health Quality Council 2006 2-3
  31. 31. Why coronary artery disease Figure 1: 90-day post-discharge dispensing rates for beta- blockers, ACE inhibitors, and statins for acute myocardial in- farction (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
  32. 32. Why coronary artery disease Table 1: Provincial comparison of 90-day dispensing rates for beta-blockers, ACE inhibitors, and statins for new acute myo- cardial 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
  33. 33. 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 aver- age patient wait time was re- duced 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 out- comes, especially in chronic disease management. In one NPDT Collaborative, improving access facilitated better chart reviews and improved coronary heart disease regis- tries. • Practices report improved patient, staff, and provider satis- faction, 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 signifi- cant reductions in wait times for both long and short ap- pointments. (See page 2-76 for a profile of Saskatoon Com- munity Clinic.) © Health Quality Council 2006 2-6
  34. 34. 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 labo- ratory. 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 ar- tery 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
  35. 35. 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 evi- dence-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 popu- lation 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 participat- ing 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 diabe- tes 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
  36. 36. Change Package Chronic Disease Management © Health Quality Council 2006
  37. 37. 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 re- ceived 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 vis- its, patient follow-up, and proactive care. The roles and respon- sibilities 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
  38. 38. 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: 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 peo- ple 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
  39. 39. Change package—chronic disease management people with diabetes and/or CAD. Key local partners include specialty/acute care, community-based health care organiza- tions, 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 im- plemented 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
  40. 40. 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 deci- sion support and QI tools. Your initial work will focus on ensur- ing that the registry is complete and that the information in it is correct. Please see the Measurement section for information on creat- ing 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
  41. 41. Change ideas—chronic disease Develop systems to maintain valid registries Once the registry has been estab- lished and validated, it is important that systems are developed to maintain its accuracy. This should include a system to en- sure 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 diag- nosed, 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 de- velop 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 reg- istry manager of any changes to patient informa- tion? • 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 work- ing. These checks can be done using the PDSA cy- cle and can be useful for highlighting any gaps in your system. • What do you need to write down about how the sys- tem 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