Debbie Davies provides leadership within MidCentral District Health Board for a range of initiatives centred on enhancing clinical integration and developing sustainable models of care within the evolving PHC context in New Zealand. Debbie has extensive local and national involvement in service development and delivery primarily within the general practice arena. Debbie is programme lead for implementing the Productive General Practice Programme in New Zealand. This blog is brought to you by BMJ Quality. For more quality improvement resources go to quality.bmj.com
MidCentral District Health Board (DHB) and Central Primary Health Organisation (PHO) in New Zealand are undertaking a large-scale transformational change journey towards excellence in health outcomes, with a focus on integrated care and partnering.
For this concept to be realised, there must be distributed clinical and administrative leadership throughout the health care sector. This leadership should not only have a clear perspective on the local vision, but must be exposed to the best current thinking on health care systems development internationally. It is important that we have a strong group of leaders who are able to see beyond the thinking that binds our current systems to the status quo. Providing a mixed group of primary and secondary care colleagues with the opportunity to participate in a masterclass experience breaks down barriers and develops relationships which will support the integration agenda.
The masterclass experience took 16 people to Ontario, Scotland, England, and the International Forum for Quality and Safety in Healthcare in Paris in April 2014, where several of the participants presented. The participants included leaders from MidCentral DHB (hospital), Central PHO, and a range of other local primary health care providers. It included a mix of clinical and management leaders.
The masterclass experience included time with Professor Ross Baker and Dr Ed Wagner, both acknowledged world leaders in the fields of system performance and long term conditions management. The Masterclass was organised under four broad themes:
- High performing health care systems
- Transformational change
- Integrated care
- Quality improvement.
Participants saw many examples of excellence in systems and services, and collected numerous good ideas that MidCentral can learn from and that we can introduce to our change agenda. The experience was notable for the warmth and hospitality of the sites visited, and for the passionate, well trained, and generally youthful clinicians and managers the group met.
Health Quality Ontario
Health Quality Ontario (HQO) is a major new strategic and system integration programme for Toronto, being in place just three years. A solid evidence based approach to determining resources is to define the evidence including evaluations, appropriateness for tests, surgical procedures, quality based payments, and mega analysis. HQO values quality improvement plans, capacity building, and knowledge translation including data, indicator targets, tools and reporting. We were hosted by the CEO Dr Joshua Tepper, a family physician serving homeless men in his ‘day job’, along with an extensive team of clinicians, researchers, and quality improvement gurus.
At the highest level, the health system of Ontario is driven by legislation passed in 2010, unanimously called by parliament the ‘excellent care for all’ Act. This mandate at senior government level has driven the establishment and implementation phase of the quality programme identified by Dr Ross Baker’s work. Quality champions push the innovation and quality from the forefront. HQO are the principal advisor on quality to the Canadian government with the mandate aligned to systems, quality, frameworks, and facilitations.
We were exposed to extensive modelling of a commitment to ‘Quality by Design’ while being hosted by Health Quality Ontario, which involves embedding quality improvement through health structures and processes, from governance and planning through to team functioning. For example, training health boards in quality improvement governance and requiring that a portion of their meeting agendas be given over to quality matters. Another example is requiring that all health organisations have an annual quality improvement plan.
Ontario also provides key enablers for quality improvement, such as resources, evidence-based guidelines and collaborative clinical pathways, along with a variety of other programmes to support innovation and the dissemination of innovation.
Forth Valley NHS Stirling, Scotland
In Forth Valley we were hosted by Dr. Stuart Cumming alongside a committed and passionate team. It was surprisingly similar to New Zealand in terms of demographics and the increasing complexities of people living longer, managing chronic long term conditions, and the challenges on systems that emphasise the need to re-invent health services through integrative measures.
Legislation has mandated health and social integration; concepts that will require bold measures and brave and difficult decisions to be made over time. Integration at this level requires the stakeholders to address complex strategic issues such as combined financial considerations.
The group was shown a number of presentations or sessions specifically focussed on the ‘Shifting the Balance of Care’strategy. This came from the Kerr Report, which defined a strategic shift of focus not dissimilar to the New Zealand Primary Health Care Strategy, 2001.
“Shifting the balance of care away from reactive episodic care in an acute setting to team based anticipatory care closer to people’s homes is a vital part of implementing our strategy”.
Strategies used to support this shifting of balance included anticipatory care, coordinated planned care, and improved communication and 24/7 partnership working with patient and families in care. Levers to obtain the change included education and training, communication and capacity planning, and shared information. The patient safety programme has followed a staged approach and is now focused on primary care and mental health.
What was evident across the many site visits was a clear culture of commitment to quality improvement training of all staff, and embedding systems and processes to engage and ensure continuous measurement for improvement.
The masterclass experience also gave participants an appreciation of the fact that the scope and composition of our local achievements are truly world leading. MidCentral’s efforts to achieve transformational change can be viewed as well planned, comprehensive, and well resourced. They align with both the research base and international best practice and are very much current.
Anticipatory Care is care planning much similar to advanced care planning tools with additional ‘here and now’ care planning narrative attached and updated as required. These anticipatory care plans are paper based though shared with all clinicians involved in a person’s care.