Without high functioning primary care, our health service
would collapse. Every year, 80 percent of New Zealanders see
their GP at least once, 62 percent will have one to five visits and
12 percent will visit six or more times per year.1
General practice is typically owned by autonomous
practice owners. The work is conducted in small teams caring
for a defined population and there is much closer connection
to the community and other services than is the case with
hospitals. Huge amounts of patient data are collated in GP
practice management systems. Therefore we have the e-data
AND the ‘team power’ to make giant quality improvement
strides.
So what’s been happening in primary care quality improvement?
Over the past twenty years many innovative approaches to
primary care quality improvement have pervaded our thinking
and doing. These include the Primary Healthcare Strategy
(advent of PHOs, capitation and access funding to reduce health
inequalities) and chronic disease management programmes
such as Get Checked Diabetes and Care Plus. Explicit standards
of practice (e.g., Foundation and Cornerstone standards) have
been defined and national guidelines have been developed
and translated into decision support systems, making them
available at the time of a patient consultation. The emphasis
shifted in the last decade to encouraging transparency
through audits of care and organisational benchmarking, with
performance targets increasing the push towards achieving
national goals and reducing unwarranted variation.
Recently the focus has shifted again towards system level
measures, moving the locus of control away from the clinical
microsystem (e.g., the general practice) towards a whole-of-system
approach measured by downstream patient outcomes
such as hospital admissions and amenable mortality. While
some contributory measures have been identified for action
at the local district alliance level, in this brave new world
integration across social and health care sectors will be critical
to success. Patients as partners in care is also in the spotlight.
There has been a swing towards patient engagement in care
delivery through approaches such as co-design, patient portal
access and measuring patient experience of care.
What’s holding us up then?
Is it possible that some of the biggest problems are working as an ‘n of one’ individual practice – reliant on the intrinsic
motivation of individuals – combined with limited experience
of successfully using QI science and processes?
Improvement is often seen more as an art than a science.
When tackling a health care issue and designing improvement
approaches, little effort is put into diagnosing the full extent of
the problem using both qualitative and quantitative data and
really understanding the context of care across community
and other services. In addition, there is not enough emphasis
on establishing who should be involved on this improvement
journey (the team), identifying what you are trying to accomplish
(and for whom), implementing improvement practice that is
based on best evidence and measuring not only the outcomes
but also the costs and unforeseen consequences.
Without systematically attending to these improvement
basics, resources are wasted, the champion loses steam,
enthusiasm wanes, side-effects are unnoticed and changes
are not necessarily an improvement. As Sholtes pointed out
nearly 30 years ago;
Teams that proceed with an improvement project without
careful planning are probably headed for disaster. Without
planning, teams often collect the wrong kind of data, invest
in unnecessary gadgets or machines, or ignore customer
needs. As a result, their solutions may not be solutions at
all. They end up with a process no better than at the start,
an expensive investment that has done little good, or a
product or service the customers don’t want. Perhaps worst
of all, these winless projects create a crowd of once-hopeful
managers and operators who now conclude improvement
projects don’t work here.
Team Handbook- p. 5-1, Scholtes 1988
There is a way through though
The Health Quality & Safety Commission has embarked on a
primary care programme of work to lend a helping hand to
general practice on improvement projects of their choice,
to shine a light on how primary care can make a difference
and advocate for positive change. There is a need to foster
undergraduate and postgraduate training in the science
of improvement. It doesn’t make sense to ask providers to
initiate change without the knowledge, tools and means to
make this a reality. At a postgraduate level, the Commission
is supporting PHO quality improvement facilitator training
to enhance primary care capacity. This is a nine-month
professional development programme being delivered by Ko
Awatea for the Commission until 2019 with approximately 20
scholarships available per year. District Alliances are asked to
nominate primary care quality improvement practitioners who
are able to become a resource for their district to receive the
Commission scholarships.
To date much of the improvement knowledge of what
works has been conducted in hospital settings. We need to
build an evidence-base for what works in primary care.
General practices and associated integrated services wanting
to undertake quality improvement initiatives are encouraged
to enter Whakakotahi, the Commission’s primary care quality
improvement challenge. Whakakotahi means: “To be as one” –
uniting different health professionals for the purpose of hauora (health).”
The challenge sees the Commission partnering with general
practice, community pharmacy, iwi providers, allied health
services and NGOs to choose their own improvement projects.
It then works with successful applicants to look at how those
projects can deliver successful outcomes, and how learnings
can be shared and spread on a larger scale. Early evaluation of
the first three Whakakotahi projects will be shared in June.
Teams wishing to enter can send an expression of interest
to primarycare@hqsc.govt.nz and they will be notified when
entries are open in July, 2017 for the second round of projects.
