The Zero Patient Harm programme just underway at Counties Manukau District Health Board (CMDHB) has a banner line ‘Let’s stop accepting the unacceptable’. Although the logo refers to all patient safety activity, there are five initiatives that are using the problem solving methodology and weekly meetings to build momentum:
1. Zero central line associated bacteraemia (CLAB)
2. Zero harm from patient falls
3. Zero pressure injuries
4. Zero cross infection from poor hand hygiene
5. Zero patients misidentified
These are great targets in our focus to improve healthcare quality and safety.
Better, Sooner, More Convenient Primary Care in the metro Auckland region will involve better coordinated after hours care with a minimum of 10 operational clinics open until 10pm. Links to Integrated Family Health Centres, Community Health Hubs, Whanau Ora Centres means that there will be a new system in place to provide appropriate after hours care and reduce inappropriate presentations to emergency departments across the region. But to reach the solutions that we need will involve systems thinking and understanding the mix of elements such as proper access to care, availablity of medicines, affordability of copayments, transport, IT systems etc. Work continues to develop the best system for quality after hours care.
Better, Sooner, More Convenient Primary Care in the metro Auckland area involves further transfer of care to Primary Health Organisations; for example GPs will undertake excision of more minor skin lesions than previously (with reduced waiting times for minor surgery as well), avoiding referring in to busy hospital clinics. By using an e-referral processes it is intended that five evidence-based clinical pathways will be used to support best practice for such conditions as dyspepsia. This should mean that more care is delivered in primary care, nearer to the patient. A programme called Primary Options for Acute Care means that there is resource for GPs and nurses to support patients at home for such conditions as cellulitis and community-acquired pneumonia requiring IV therapy. This has been shown to reduce acute demand for hospital admissions by 85%. Ultimately this means better value healthcare.
Better Sooner, More Convenient Primary Care is where DHBs are working with primary health organisations (PHOs) in the Auckland Region to improve health service delivery for people. Improving GP access to diagnostics such as X-Rays, CT Scans, and Ultrasound using clinical triage criteria allows DHB Radiology facilities to approve direct referrals because the right study is being ordered for a patients condition. Because these tests can now be ordered by GPs, it means fewer referrals to hospital clinics just to get a test done. Makes sense doesn’t it?
Professor Dinny Lennon tells us that rheumatic fever causes serious valvular heart disease yet is still strongly prevalent in South Auckland with annual incidence rates of 28/100,000 children aged 0-14 yrs in Manurewa, Otara and Mangere. For CMDHB this means about 50 new cases a year. If we want to crack this problem then we will need to reprioritise a school-based nurse-led programme by doing less low value healthcare elsewhere and manage this as high value healthcare. A health economic evaluation would be helpful here.
Grass roots
I am back from a week’s locum general practice in Taupo and am reminded what it is like practising at the grass roots. Evidence-based decision-making should be at the core of general practice and Right Care should be where we are heading. Great people and a great practice.
The healthcare workforce has a tendency to silo like activity as a result of rigid role demarcation. This has much to do with protection of professsional boundaries whereas a flexible approach would be more productive. Sibbald et al (2004) says that the healthcare workers of the future will enhance their work by taking opportunities such as
- Enhancement – increasing the depth of a job by extending the role or skills e.g. nurse prescribing
- Delegation – handing tasks over to others
- Substitution – expanding the breadth of a job working across professional divides e.g. pharmacists monitoring INR levels and prescribing warfarin doses
- Innovation – creating new roles where they were not there previously
We can apply learnings from Improving NHS productivity: More with the same not more of the same to New Zealand to improve quality and productivity. There are specific actions and enablers available to us. See Action for Better Value Healthcare suggesting local ways for tackling these challenges.
The Kings’ Fund has just published Improving NHS productivity: More with the same not more of the same. This is a ‘must read’ for those interested in improving productivity in healthcare systems.
In New Zealand we too know what to do, and the emphasis has now to shift to execution and implementation. We need to focus on variations in clinical practice and to find ways of managing demand. At the same time we will move away from low value activities to those with high value. We will need to find ways to manage demand for hospital care through a renewed emphasis on the needs of people with long-term conditions.
In the UK the Quality, Innovation, Productivity and Prevention (QIPP) programme will be important in helping make the necessary adjustments. We need to think about how we can implement a similar programme here. Counties Manukau DHB is already thinking about better value healthcare.
Productivity is a measure of output from a production process, per unit of input according to Wikipedia. This applies to the health system too and district health boards can be expected to increase productivity year on year. One way productivity can be measured is on the production of elective surgery per unit of cost. Counties Manukau DHB has increased its electives productivity this last year and delivered 107% of the electives target without additional funding. This is the kind of performance we should come to expect of a productive health system and shows good leadership for better value healthcare.
