1

Quality Improvement in Primary Health Care

Southeast LHIN Primary Health Care ForumKingston, 8 Nov 2007

Dr. Ben Chan, MD MPH MPACEO, Ontario Health Quality Council

2

What is Quality?

“Quality health care means doing the right thing at the right time in the right way for the right person and having the best results possible.”

3

Attributes of Quality & High Performing Health System

• Effective• Efficient• Equitable• Accessible• Safe• Patient-centred

• Focused on population health

• Integrated• Appropriately

resourced

4

What’s Wrong with Quality?

5

Effectiveness: The Evidence Gap

• How long does it typically take for clinical evidence to enter mainstream clinical practice in primary care?

6

Effectiveness: The Evidence Gap

The lag between publication of landmark clinical trials and application in practice (to 50% use) is unnecessarily long, in the range of about 15 to 20 years.

Balas and Boren, 2000

7

Landmark Trials and Current Rate of Use

20%1993Diabetic foot care17%1986Fecal occult blood test65%1984Cholesterol screening70.4%1982Mammography61.9%1982Beta blockers after MI38.4%1981Diabetic eye exam35.6%1977Pneumococcal vaccination20%1971Thrombolytic therapy55%1968Flu vaccinationCurrent UseLandmark TrialClinical Procedure

Balas, Boren 2000

8

Why?

9

Why Isn’t Best Evidence Taken Up?• Not knowing the gap from optimal

– “I think I’m doing a good job…”• Time, skills needed to redesign care• Mechanism for spreading good ideas

10

Examples of Upcoming Measures for Quality in Primary Care

OHQC 2008 Report

• Diabetes patients:– % A1C <7– A1C ordered 2x / yr– % BP < 130/80– Foot exam done– Eye exam done– On ACEI

• CHF patients:– On ACEI– On b-blocker

11

Examples of Upcoming Measures for Quality in Primary Care

OHQC 2008 Report

• CAD patients– On b-blocker– On ACEI– On statin– BP < 140/90

• Access (under consideration)– Ease of getting

apptmt with family physician

12

So We’ve Found Problems with Quality – Now What??

13

Hypothetical Case• Study announced today that in Eastern

Ontario patients in diabetes are not managed well. Less than half of these patients have their blood sugar (A1c), blood pressure and cholesterol within recommended targets.

• How would you respond to this?

14

15

learn as you gosmall tests, not (necessarily) small changes

16

Aim Statements for QI Projects

• What are we trying to accomplish?

– “Improve diabetes care for our patients.”

17

Aim Statements for QI Projects

• What are we trying to accomplish?

– Improve diabetes care for our regular patients in the Bay St, May St. and Gray St. clinics. Increase the % of these patients hitting their targets for BP, cholesterol & AIC to 75%. Do this by December 2008.

18

Measures:How Will We Know a Change is

an Improvement? • Mainline measures

– A1C, BP, chol• Consider balancing measures

– Unintended consequences• Consider related process measures

19

What Changes Can We Make That Can Result in Improvement?

• “Let’s implement an electronic medical record!”

20

What Changes Can We Make That Can Result in Improvement?• Avoid jumping immediately to the

perceived panacea solution• Consider best practice examples for

implementation from elsewhere• Conduct careful analysis of system, root

causes, cause & effect, process maps before implementing changes

21

Example – Ishikawa Diagrams

Why is A1C poorly

controlled?

Consider people, policies, procedures, equipment

22

ImplementationExample: Pt Self-Mgt

• We’re going to create a committee. In the next four months they’re going to research pt self mgt tools. We’re going to carefully select a package of materials. Then we’re going to have extensive in-service sessions to train all the staff on how to use the materials.

23

Alternative Approach from QI Science

• Implementing Change: PDSA cycles• Plan, Do, Study, Act• Testing predictions • Learning from small tests of change• Rapid cycle improvement

24

What should a PDSA look like?

Write It down!

ObjectiveWhat do you want to learn/try?

PlanWho, what, where, when?MeasurementPredict outcome as a group

DoJust do it!

StudyWhat worked? What didn’t? Predict correctly?

ActNext steps

25

Multiple PDSA Cycle Ramps

A PS D

A PS D

A PS D

D SP A

Coordination w/ DM educators

Pt self-mgt

A PS D

A PS D

A PS D

D SP A

A PS D

A PS D

A PS D

D SP A

Standing orders, checklists

Try different ways of implementing change concept

26

Case Study Revisited• Describe some PDSA cycles for some

different ideas for improving pt self-management:

PLAN:DO:STUDY:ACT:

27

ImplementationExample: Pt Self-Mgt

• OK, we’re going to try test out some different ways of implementing patient self-management over the next few months. We’ll show a nifty bar chart of how our results for A1C & cholesterol improved before an after.

28

Try Annotated Run Charts% of patients who have set >= 1 written pt mgt goal in past 6 months

23 24 21 23

31

10

34

46 47 50

0

10

20

30

40

50

April

May

June Ju

lyAug

ust

Sept

Oct

Nov

Dec Jan

Time Period

Perc

ent

new doctor

Test new tool

New tool w Group sessions

29

Building a QI Team

30

Building a QI Team• Select representatives of key parts of

process• Identify champions, leaders, resistors• Keep size manageable (~10)• Secure resources for their time• Build in conflict management skills

31

Commitment Mapping

32

Case Study RevisitedYou’ve created the QI team. It includes nurses, admin staff, a couple of docs, a local pharmacist, diabetes educator / nutritionist, and a patient representative. Two months into your work, the team’s momentum is stalling. Attendance at QI meetings is dwindling. People say they will try a PDSA cycle but don’t get around to it in time for the subsequent meeting. Everyone complains that their plate is too full with their other duties.

33

Getting Support for QI• What are competing initiatives?• For employees of organizations: how does

your initiative align with organization’s core strategies, priorities?

• What resources do I need to ask for?• What can I promise to deliver in quality? • Is there a business case for QI initiative?• Especially for independent practitioners –

who can I turn to for support?

34

An improvement methodthat relies on thespread and adaptation of existing

knowledge to multiple settingsto accomplish a common aim.

Brings together multiple QI teams at different sites with practitioners from various disciplines, to share knowledge about what improvement ideas work & how they are implemented.

What is a Collaborative?

35

Learning Collaboratives

Support

SPREAD

LW0

LW1

LW2

LW3

Pre- work

Select Topic Participants Reference Panel

Identify Change Concepts

36

SK CDM Collaborative• Focus on CAD, Diabetes, &

Access

• Two waves deployed (Nov 05, Nov 06)

• Enrolment to date:– 28% of all family physicians in Sask

– All RHAs in province

– Mix of FFS, non-FFS

37

SK Collaborative Topics• Why CAD and DM together?

– Major contributor to burden of illness– Many common measures

• BP control, lipids, smoking, weight

• Why add improving access?– Improving access frees time for better chronic

disease mgt– “triple combo” used successfully in UK’s

Collaboratives

38

Common Aims & Measures• Developed from Reference Panel of local,

international experts• Key Aims:

– 75% of diabetes pts with A1C <7.0%– 75% of pts with HDL/Tchol < 4.0– 75% of pts with BP < 130/80

• Approx. equiv. to ↓ sub-optimal care by 1 / 2

39

Learning Workshops

40

Storyboards – Sharing Learnings

41

Storyboards – Sharing Learnings

42

Regional Improvement Teams

43

Regional Improvement Teams• Interdisciplinary mix• Examine ways to improve coordination,

communication of care within regions• Heavy mentorship, support from

“Collaborative Facilitators” positioned in each region

44

45

Web-Based CDM Toolkit

46

Web-Based Patient Registry

47

CDM Web-based Patient Registry

48

CDM Toolkit - Flowsheets

49

Change Concepts & Ideas

50

51

Wagner’s Chronic Disease Model

52

53

54

KEY MEASURE% of Diabetes Patients with a BP ≤ 130/80

among Wave 1 Practices, Baseline vs Month 9 (Nov 2006)

51.5

75.0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

3 8 23 32 15 18 30 21 31 29 35 11 26 16 1 4 13 2 22 10 27 6 9 24 14 17 20 33 25 34 19 28 7 5

Practices

Monthly Average Baseline Goal

The absence of a practice's bar is due to lack of a baseline value or small counts (i.e., < 6)

55

Sask. CDM CollaborativePreliminary Improvements in Diabetes Care

56

Sask. CDM CollaborativePreliminary Improvements in CAD Care

57

Dr. Vickie HolmesSaskatoon Medical Associates

58

Participant Quotes• “Improved communication between regional

improvement team members. Better coordination of patient care.”

• “Identifying all chronic care patients within our practice and providing them with better health care.”

59

Participant Quotes• “Beginning to speak as a team about the

importance of chronic disease care and adherence to Canadian best practice guidelines.”

• “This experience gave our area a chance to look at our clients and see where they were. It gave us an opportunity to network with many people across the province and realized we are all striving for the best.”

60

Key Messages• Huge opportunities to improve quality in

primary care & chronic disease mgt / prevention

• Quality improvement science & tools essential for change

• Need highly coordinated strategy, campaign to spread change

• Teams need support, training to make it happen

61

Next Steps• OHQC has dual legislated mandate to:

– Report on quality of care– Support quality improvement

• Third report on quality due May 2008• Moving to expanding QI support role• Strong interest in primary care & chronic

disease prevention/management• Examine opportunities, plans to work

together over next year