Delivery system design

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Delivery system design

• Implementing a system that supports
  chronic/complex care

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• A journey in two community health services

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From Navigating self-management, Jill Kelly et
al, 2007
Kelly et al, 2007
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Our teams

• In both cases a group with a representative from
  every profession or service
• Physio, OT, dietitian, nurse, diabetes educator,
  drug and alcohol, counselling, podiatry, social
  support service, child and family service

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Project definition phase

• What projects were undertaken and how did we
  identify them?

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The client journey
Ongoing management
Access
Assessment
Care planning
Recall and review
Discharge planning
Self-management included in all steps
The pilot will assist us to address the steps in
lighter green
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Defining projects
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Diagnostic phase

• Diagnosing the issues

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Investigating problems

• Process tools
• Process mapping
• Client journey mapping
• Data tools
• Audits
• Analysis of documentation
• Consumer stories
• Surveys/interviews
• Client experiences/ journeys

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Overall findings

• Significant gaps in best practice screening
• Assessment duplication and inconsistency
• Service-specific planning
• Existing methods of teamwork took effort and were
  inefficient
• multiple similar discussions re client
• Case discussion difficult to organise due to each
  service working differently
• No clearly defined outcomes and goals across a
  team where are we going with the client??
• No defined intervention or discharge process
  across a team

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Intervention and impact phase

• Putting the plan into action

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Our projects

• Central Bayside CHS
• Improving diabetes care
• Common assessment
• Assessment and care plan pilot

• Banyule CHS
• 6 year journey of EICD and establishing a
  self-mgt program and key worker role
• Now assessment and care planning pilot

Emphasis make it part of usual practice
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The Model for Improvement
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Developing the pilot
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Three fundamental questions

1. What are you trying to accomplish? (Aim)

To raise staff awareness about the upcoming pilot
and required training

1. How will we know that a change is an improvement?
   (Measures)

Identify problem
Staff outside the improvement team are seeing the
nominated clients but dont know about the pilot
Staff are asking about the pilot and are
expressing interest. We also anticipate some
resistance and uncertainty.

1. What changes can we make? (strategies)

Assess the outcome
Improvement team members to consult their
colleagues who are also seeing the chosen client
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Plan-Do-Study-Act
Act Communication from senior managers about the
pilot, its purpose and expectations occurred.
Team leaders were also engaged in discussions to
promote it to their staff.
Plan Improvement team members will spend the next
month engaging their required colleagues in the
upcoming pilot
ACT PLAN STUDY DO
Study Other staff expressed interest, however,
there was also a significant degree of
uncertainty about the purpose and expectations.
Do Each member talks with their colleagues.
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Results to date

• Increased staff engagement
• All staff involved with the nominated client are
  actively engaging with the pilot
• Staff value contributing to the how
• There is only one rule innovation. Current
  systems inhibit teamwork, we encourage them to
  think differently and explore other ways.

What would you do if you could?
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Sustaining improvement

• Building on common assessment work at Central
  Bayside

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Current work

• Recently split the common assessment into risk
  screening and assessment
• Actively working with our team leaders to
  implement the common assessment in their
  respective teams
• Each team leader has developed a PDSA cycle to
  address their challenges

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Learnings

• Current models of care do not support chronic
  care
• Overall this is about change keeping an open
  mind is crucial e.g. key worker
• The model for improvement is hugely successful in
  motivating change
• Project leaders need to lead people to the what
  but let staff dictate the how.