IF eNews December 2014


In this issue

New Integrated Care Wave Taking Collaboratives in a New Direction
Primary Care Nurses and Managers take the lead in new APCC Waves
Medicare Local Quality Improvement Partnership Results
New Practice Dashboard available now!
Improving CKD in Aboriginal patients
APCC Diabetes Prevention and Management Wave Results
2014 qiCommunity Webinars
IF Annual Report – celebrating achievements
Season’s Greetings and Christmas Closure
Top festive season resources

New Integrated Care Wave Taking Collaboratives in a New Direction

The APCC Program Integrated Care Wave will provide general practices and health services in the Townsville area the opportunity to collaborate with the Townsville Hospital and Health Service, Ambulatory Service and pharmacies to improve health outcomes and decrease emergency department presentations for people with high care needs.

GPs, hospital clinicians, private specialists and hospital admin staff will work together to build ‘Integrated Care teams’ around a nominated cohort of high care need patients. They will work together over an intensive 6 month period on a ‘narrow and deep’ model.

The project will aim to build a culture of teamwork around each patient. This will involve improved clinical communication and care coordination between all care providers.

Learning Workshop 1 was held on 2nd December in Townsville.

Visit the Integrated Care Wave Page on the IF website for more information.


Primary Care Nurses and Managers take the lead in new APCC Waves

The Practice Manager Lead Wave and the Practice Nurse Lead Wave will focus on training primary care practice nurses and managers in quality improvement (QI) methods and improving chronic disease care.

Supported by a GP in their practice, participating practice managers and practice nurses will be empowered to take on a leadership role in the implementation of QI work within their health services.

IF has worked closely with the Australian Association of Practice Managers and the Australian Primary Health Care Nurses Association in the development of these Waves and received over 200 expressions of interest for these Waves, demonstrating a strong level of support for QI initiatives for frontline staff in primary health care. Eighty seven general practices and health services have now been recruited across these two Waves and representatives will attend a series of workshops to learn how to lead the implementation of QI and improve chronic disease care in their practices and health services.

The Practice Manager Lead Wave is focusing on improving the management of patients with diabetes and the Practice Nurse Lead Wave is focusing on improving the management of patients with cardiovascular disease.

For more information on these new Programs, please visit the IF website.


Medicare Local Quality Improvement Partnership Results

The Medicare Local Quality Improvement Partnership is an innovative program that engaged 24 Medicare Locals and 119 general practices and health services to implement localised quality Improvement initiatives. This 12 month program focused on improving chronic disease management and/or prevention in the topic areas of Cardiovascular Disease, Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease (COPD) and Diabetes.

13 of the 24 Medicare Locals selected COPD as their topic area based on local population health data and Medicare Local strategic objectives. Five of these Medicare Locals recruited pharmacies as well as general practices & other health services to improve the care of patients diagnosed with COPD and implement strategies to improve screening for COPD.

Analysis of the data indicates that there were a total of 378 episodes of screening for COPD and 108 referrals to general practice for follow-up, as seen in the graphs below:
MLQIP graph 1
MLQIP Graph 2

The aim of the Medicare Local Quality Improvement Partnership was to ‘achieve better outcomes in local primary health care through the use of quality improvement’. Increasing the capabilities of Support Organisation staff to design and implement quality improvement initiatives is considered key to achieving this aim. Accordingly, a central Wave measure was participants’ confidence and competence with developing and implementing a quality improvement activity in a Medicare Local environment.

IF utilised the Quality Improvement Knowledge Assessment Tool (QIKAT), which is a validated tool that has been adapted for application to this project. The tool was administered at the start of the first workshop to obtain a pre-workshop assessment score, and at the conclusion of the final workshop to obtain a post-workshop assessment score. IF set the aim of achieving a 20% improvement, or exceeding an 80% rating in the competence and confidence scores of participants.

The overall achievement was a 14 % increase in overall confidence, and a 41% increase in overall competence, as shown in the graph below (which is based on 48 completed pre and post-assessments).
MLQIP graph 3

IF would like to thank participating Medicare Locals, general practices and health services for their dedication and support to this program over the past 12 months in achieving these outstanding results.



New Practice Dashboard available now!

The Improvement Foundation is excited to announce a new and improved practice dashboard on qiConnect, designed to assist practices with their quality improvement (QI) work.

This new dashboard is free for practices and health services to use and provides a wider range of functionality to help focus improvement work in chronic diseases.

New functionality on the dashboard includes:

Improved gauges to display practice metrics
The dashboard now has a gauge style panel which can be customised to select and save your chosen indicator sets. The gauges display practice performance alongside the average of the qiCommunity, made up of almost 800 practices across Australia.

Links to all active programs that practice users are enrolled in through the Improvement Foundation, such as APCC waves.

A summary of data submissions for tracking data workflows

‘Currently Tracking’
A single indicator gauge that is decided upon by the IF Faculty to be a measure of focus for a period of time. This may link with national and international health events, e.g. diabetes week.

Recognition and reward points
A brand new feature for the qiCommunity is the implementation of a points system to demonstrate engagement in QI activities. Points are allocated to an individual user who can achieve status levels, depending on the number of points they have accumulated. Some points will be allocated to all users in a practice for the practice’s involvement in submission of data, completion of an APCC wave etc.

Push Reports
Automatically generated reports can now be configured so that the system will send an email to the practice users, with specified indicator graphs.

This development work provides members of the qiCommunity with a snapshot view of how their practice is performing at a point and over a period of time.


Improving CKD in Aboriginal patients

Bugalwena General Practice is a multi-disciplinary practice located in South Tweed Heads run by North Coast Medicare Local (NCML). It provides bulk-billing services for the Aboriginal and Torres Strait Islander community and their immediate families.

Wishing to improve the care of patients with CKD, Bugalwena set a goal to increase the identification of Aboriginal and Torres Strait Islander patients with potential CKD, thereby enabling the provision of specific management plans and team care arrangements for these patients.

NCML organised a CKD workshop for the team, and Graeme Turner (CKD Nurse Practitioner from Northern NSW Local Health District) gave a presentation on how to improve management of CKD and how to undertake searches through the database.

Bugalwena’s practice manager Jacqueline Moody said Graham’s presentation was really worthwhile as it helped staff to focus on what small steps could be taken to make a difference.

To achieve their objective, the team undertook the following steps:
1. They focused on improving their CKD register by cleaning data to ensure the information was correct. They also updated their processes to ensure the data is kept up to date.

2. The practice manager used the Pen Clinical Audit Tool to create a list of patients on the database at risk of having CKD.

3. A notification was entered into the clinical software so that when a patient at risk of CKD saw their GP, the GP was reminded to code CKD correctly

4. A urinary albumin creatinine ratio (ACR) check was implemented as part of the Aboriginal and Torres Strait Islander health checks and GP Management Plans. This action increased the number of patients on the CKD register.

5. The practice manager sent lists of Bugalwena’s patients at risk of having CKD to pathology companies to see if they had had estimated glomerular filtration (eGFR) or urinary ACR tests done at other general practices. Relevant results were then downloaded into Bugalwena’s software. This also increased the number of patients on the CKD register, saving time and money by preventing duplication of pathology tests.

The graph below shows the increase in patients on the CKD register at Bugalwena General Practice over the five months of data submission (at the point that this graph was created, the data submission for the period of September had not been opened).

Bugalwena Graph

This project increased the number of Bugalwena patients on the CKD register from 17 patients in April 2014 to 77 in August 2014. Specific management plans and team care arrangements were implemented for 50 new patients.

Bugalwena General Practice was engaged in this quality improvement initiative through NCML’s participation in the APCC Program’s Medicare Local Quality Improvement Partnership program.

The Improvement Foundation’s Closing the Gap: Measure and Act project invites general practices around Australia to collect, submit and measure data on key indicators that could lead to better health outcomes for Aboriginal and Torres Strait Islander people. Find out more about IF’s Closing the Gap: Measure and Act initiative at: improve.org.au/projects/ctg to find out more or register.



APCC Diabetes Prevention and Management Wave Results

Formal participation in APCC Diabetes Prevention and Management Wave (Wave 9) concluded at the end of October 2014. The Wave was delivered over an 18 month period, engaging 37 general practices and health services working towards improving health outcomes for more than 11,800 Australians living with diabetes and reducing the risk of developing diabetes for many more.

Key outcomes for this Wave include:

  • 925 more patients with diabetes now have their blood sugar recorded as being within recommended limits
  • 2,332 more patients with diabetes now have their blood sugar recorded
  • 21,815 Annual Cycle of Care elements have been recorded for patients with diabetes
  • 6,147 Diabetes Risk Assessments were administered and recorded

The IF would like to thank Medicare Locals and participating general practices and health services for their dedication and support over the past 18 months, enabling the Wave to achieve outstanding results.


2014 qiCommunity Webinars

2014 has been an exciting year for the qiCommunity with its membership growing to almost 2,000 people, all working in and around primary healthcare. This community has shared ideas and generated discussion about quality improvement in various ways, including free monthly qiCommunity webinars and discussion forum, housed on qiConnect.

Since January 2014, ten qiCommunity webinars hosted by Dr Tony Lembke have been undertaken, with over 570 qiCommunity members attending. Guest presenters have ranged from international quality improvement experts through to Australian health professionals who are making practical improvements within their own organisations.

We have been very privileged to have two prominent international speakers present for the qiCommunity during 2014, Dr John Øvretveit from the Karolinska Institute in Sweden and Dr Doug Eby from the Southcentral Foundation in Alaska.

qiCommunity webinar topics ranged from ‘Appointment Systems 101’, and ‘Appointment Systems 201’ with Dr Andrew Knight, to ‘Behavioural Interviewing and Change Modification’ with Mr David Menzies and Ms Roslyn Rolleston’s two part ‘Care Planning Master Class’ webinar.

IF Quality Improvement Award Winners, Mr Prashiba Thavarajadeva and Mr Brett McPherson also presented informative sessions on the quality improvement work they have undertaken at their practices.

If you missed a webinar or would like to re-watch one, all webinars can be accessed via the Resources page of qiConnect.

We would like to thank you for your participation and involvement in 2014 and look forward to recommencing these free webinars in February 2015.

We’d love to hear your topic or speaker suggestions for future webinars; these can be emailed to qiCommunity@improve.org.au

If you are not a qiCommunity member, simply click here to fill in the online registration form to gain access.


IF Annual Report – celebrating achievements.

As we celebrate the end of what has been a very successful year, with significant results achieved across on a number of projects and programs, it is important to reflect on why we have worked so hard to achieve these results.

The Improvement Foundation (IF) exists to inspire people to think differently about the way services are provided, and to empower them to make changes to the quality of the services delivered, ultimately improving outcomes for their communities. Some of our services include:

  • Australian Primary Care Collaboratives Program. To date we have helped more than 1,800 general practices and health services improve the health outcomes of hundreds of thousands of patients.
  • qiCommunity. The qiCommunity provides a protected online environment for its membership of more than 1,590 health professionals to engage in conversations about how we can improve health systems and patient outcomes.
  • Leading technology. Receipt of an iAward, a new eHealth indicators dashboard in qiConnect, and 49 custom built quality improvement sites in qiConnect are just some of the reasons our reputation as a leading provider of data-driven quality improvement solutions continues to grow.
  • OCHREStreams. We developed and implemented Australia’s first fully electronic reporting system for Aboriginal and Torres Strait Islander Health Services. We continue to work to improve and extend the electronic reporting capabilities to reduce the reporting burden for Aboriginal and Torres Strait Islander Health Services.

Our 2014 Annual Report summarises these successes and more. This year has built on success from previous years and we continue to build essential knowledge, infrastructure and relationships to support the national refocus of the health system on primary care, and on our role as leaders in quality improvement in primary health care.

We are excited about the future of our organisation and the possibilities ahead. As you read our Annual Report, please consider areas where you might want to work together with IF to make a real difference within your own organisation and the communities you serve.

We thank you for your support, and wish you the compliments of the season.

To read the report or to learn more about IF, visit www.improve.org.au. Alternatively you can contact IF on enquiries@improve.org.au or phone 08 8422 7400.


Seasons Greetings and Christmas Closure

The Improvement Foundation office will be closed from midday on Friday 19th December and will reopen on Monday 12th January 2015. We would like to wish you all a very happy and safe holiday season.


Top Festive Season Resources

We all know how easy it is to overdo it this time of year, so we’d like to thank Australian Doctor for doing our work for us this time, they’ve been busy finding you some great resources about nutrition and exercise that will kick off those New Year’s resolutions with a bang!

Go for 2 & 5
Launched in 2005, this Federal Government campaign aims to address health concerns facing people who are overweight and obese. There is a self-assessment tool, lots of tips and recipes, and a state-based resources library available for download. There are also FAQ’s for everything from serving sizes through to wether a tomato is a fruit or a vegetable. Visit www.gofor2and5.com.au

Healthy Living Network
The Healthy Living Network is a registration portal that provides a list of quality registered activities, providers and programs in your local area. Use it to search for healthy activities and programs, or register your own program so you can be found. For more information, visit www.healthylivingnetwork.com.au

The Dieticians Association of Australia
The Dieticians Association of Australia (DAA) is the leader in nutrition for better food, better health and wellbeing for all. The DAA site features a “Find an Accredited Practising Dietician” tool to find a dietician in your area, links to smart eating quizzes and links to their “Fuel Fabulous” advertising campaign. Visit www.daa.asn.au

Exercise is Medicine
Exercise is Medicine aims to make physical activity and exercise a standard part of disease prevention and treatment in Australia, improving community health and reducing long-term health care costs. The website has resources on exercise and chronic disease, tools for health care providers as well as the public, screening tools to see if it is safe for a patient to start an exercise program and promoting the right exercise for the right patient. Visit www.exerciseismedicine.org.au

December 04, 2014

Suite 1, Level 3, 12 Pirie Street, Adelaide SA 5000 | PO Box 3645
T: 08 8100 8700 | TOLL FREE (within Aust): 1800 771 522 | E: enquiries@improve.org.au

The Improvement Foundation acknowledges the Traditional Custodians past and present on whose land we walk and we live.

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