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“Babies who are delivered safely, born in the healthy weight range, begin life exclusively breastfed, and have all the early checks they to me, that’s a healthy start,” says Dr Damian Tomic, following his recent work helping develop potential measures for the evolving Integrated Performance and Incentive Framework (IPIF).

It is expected that a group of potential measures anticipated to sit at the heart of an integrated health system will soon be presented to the Minister of Health.

Midlands Health Network Medical Director and Hamilton general practitioner, Dr Tomic, and Christchurch general practitioner, University of Otago Professor of General Practice, and Chair of Pegasus Health, Professor Les Toop, led teams of health sector representatives who refined the selected measures before they were endorsed by a Joint Project Steering Group in November.

Dr Tomic and Professor Toop have significant experience in their practices and have been involved in numerous national and international conferences focused on improvements for the health sector. They share the belief that IPIF is an exciting development which will enhance the care of patients. “IPIF is going to have measures the country can be proud of,” says Dr Tomic. “It’s about the steps needed for a healthy start, for healthy ageing, and more. I think we can all relate to that.”

By using system performance measures IPIF addresses equity, safety, quality and cost of services. The measures are made up of composite measures, the stepping stones for reaching the overall goal – all New Zealanders can access the health services they need in order to be healthy.

IPIF is currently in a transitional phase and five measures were selected to provide continuity with the PHO Performance Programme (PPP) which ended in June, 2014. These are:

  • More heart and diabetes checks
  • Better help for smokers to quit
  • Increased immunisation for children at age eight months
  • Increased immunisation for children at age two years
  • Increased cervical screening

Behind the scenes work has continued on other possible measures to be added for 2015/16. Three different measures development groups met, with Professor Toop leading the Healthy Ageing Development Group, and Dr Tomic leading the Healthy Start Development Group. Compass Health CEO Martin Hefford led the Capacity and Capability Group, and Ministry of Health Chief Advisor Dr Peter Jones has supported all of the work.

Healthy start

Dr Damian Tomic: “It was important from the beginning that we had coalface clinicians and staff involved. That way you get measures that are meaningful and real.”

Dr Tomic says there was wide engagement during the Healthy Start Measures Development Group workshops with Well Child/Tamariki Ora providers, paediatricians, general practitioners, allied health staff, equity experts and nurses. He says this is a sign they were curious about IPIF and wanted to get it right.

“Some people working in the health sector are wary of measures, of targets. By inviting so many representatives it meant they could all see how their work will contribute, not only to meeting the measures, but the bigger picture of an integrated health system.”

The aim of the Healthy Start measure is to improve integration of services, equity and health outcomes for pregnant women and newborns through to the first year of life. Measures being considered include:

  • Pre-conception factors such as smoking status of women in the reproductive years
  • Antenatal measures such as early registration with a Lead Maternity Carer (LMC) and maternal Body Mass Index (BMI) at presentation
  • Birthing and new born factors such as gestational age at birth and early enrolment with a PHO
  • First year of life factors such as breastfeeding
“Now to me, that’s a healthy start. That’s a conversation starter and something we can all aspire to. If you live in a region where this is currently not happening, you can look at the measures that are agreed on as driving change.”

System Performance Measures

  • Encourage better clinical integration using clinically meaningful indicators
  • Align with the high-level goals of the health system

The first five measures fit with a Life Stages development approach: Healthy Start, Healthy Child, Healthy Adolescent, Healthy Adult and Healthy Ageing.

Eventually they will be complemented by measures relating to capacity and capability. All measures have a focus on equity of health outcome for everyone.

Component Measures

Each system performance measure will comprise several component measures – tangible stepping stones for achieving each system performance measure.

Contributory Measures

An exciting tool for district alliances will be a set of contributory measures they can use to inform their quality improvement programmes. Eventually there will be a contributory measures dictionary ensuring national consistency in data collection. Work is still being done in this area.

Healthy ageing

Professor Les Toop: “Patients want their doctors and the rest of their health care team to focus on them as people, and not pieces of a jigsaw puzzle. The development of IPIF will hopefully help build an integrated system with the person or patient at the centre, firmly involved in decision making.”

Professor Toop is an advocate for professionalism, for independent high-quality general practice teams working collaboratively across the health system, and for the provision of evidence-informed education for primary care clinicians and for consumers. Having contributed to work on measures elsewhere in the country, he was asked by IPIF’s Joint Project Steering Group co-chair Graham Scott to help develop potential system performance measures for 2015/16.

IPIF system performance measures are being organised according to the Triple Aim* principles as well as life stages. “I was really keen to work in the healthy ageing workgroup with help from elderly care experts in general practice and pharmacy, as well as secondary care clinicians working in elderly health care and general medicine. We also included a DHB analyst, planning and funding representatives and a number of academics,” says Professor Toop.

The group met twice in Christchurch and Professor Toop says they worked quickly and efficiently on refining a number of the potential measures which had initially been identified by a national group and then screened by a team of Health Ministry analysts. He says successful measures needed to reflect “whole of system performance in elder person care”. “We were interested in measures that required integration and not simply the work of just one group. The suggested measures for 2015/16 due for presentation to the Minister clearly require the contribution of multiple organisations to overall achievement”.

Professor Toop says the aim of the healthy ageing measure is to improve integration of services, equity and health outcomes for older people. Examples of potential measures include the sector’s ability to provide as much care as possible to people close to home (freeing up hospitals for those most in need), and system-wide safety issues such as polypharmacy.

He says the measures anticipate an environment of high trust, in which effective local relationships set the agenda for quality improvement. “Unlike the PPP which happened almost exclusively within general practice, the recommended measures require system wide integration and collaboration. District alliances will be important enablers.”

Professor Toop says if IPIF fulfils its potential, built-up capacity will lead to effective clinical governance overseeing a much wider sweep of clinical activity than in the current scope of IPIF. “IPIF is predicated on trust and responsibility. If we get this right, it will be of international importance as an alternative to traditional accountability frameworks.”

*The Triple Aim is a healthcare improvement policy that was initially developed in the United States. It outlines a plan for better healthcare systems by pursuing three aims: improving patients’ experience of care, improving the overall health of a population and reducing the per-capita cost of health care.

In New Zealand the policy has been adapted by the Health Quality & Safety Commission and is one of the key tenets of IPIF.

The way forward

Dr Peter Jones: “Meeting the present and future challenges in health care requires a transformational change in how we get our great health professionals working together. IPIF aims to promote and support that change.”

Dr Peter Jones is Ministry of Health Chief Clinical Advisor, Sector Capability and Implementation. He is a practicing rheumatologist who worked for 15 years with the multidisciplinary team at Rotorua’s QE Health. More recently he was Associate Professor of Medicine at the Waikato Clinical School, Auckland University.

Dr Jones has been working with the Ministry of Health since 2013 and is very grateful to the number of high-calibre health sector representatives who have contributed to the process of developing the 2015/16 potential measures. “The co-development approach across its entire evolution is one of IPIF’s strengths”.

Many people and organisations involved with the health system significantly contributed to the development of IPIF with an Expert Advisory Group releasing its report in February 2014. Later in the year sector representatives met again to consider the measures to be introduced in 2015. From there, a team of analysts drawn from DHBs, PHOs, and the Ministry of Health worked through the long lists of potential measures in the healthy start and healthy ageing life stages. Dr Jones says they assessed the feasibility and suitability for implementation of each measure based on data availability, timeliness for regular performance feedback, existence of agreed data definitions, and technical ability for the measures to be disaggregated by ethnicity and deprivation status. He says the measure development groups took the analyst’s group assessments and considered each measure for the degree to which it reflected correlation with good clinical practice, system integration, transparency and meaningfulness. The groups also looked for evidence the measure would affect clinical outcomes, and echoed the Triple Aim.

“It was important to the process that the measure development groups consisted of leaders from the sector. They voiced the sector perspective ensuring decisions made were applicable in the workplace.”

Dr Jones says it is likely that capacity and capability measures will be assessed as part of a business improvement and audit process, rather than as continuous data collection. Measures could include aspects of e-health, clinical pathways, spectrum of care via investment, workforce development, models of care, and fit for purpose infrastructure. At the same time the Health Quality and Safety Commission (HQSC) is working to develop a patient experience tool for primary care.

The Minister’s decision on the new IPIF measures is expected by the end of the year.

For further information on IPIF and latest updates, see:

“It was important to the process that the measure development groups consisted of leaders from the sector. They voiced the sector perspective ensuring decisions made were applicable in the workplace.”