Building Capacity and Capability for Quality Improvement and System Integration – The System Level Measures Framework

Dr Peter Jones

July 2018

What is SLM framework?

A framework to improve health outcomes for people by supporting the health system to deliver integrated care using continuous quality improvement

System Level Measures (SLMs):

• were co-produced with the clinical, managerial and analytical expertise from across the health sector

• are outcomes focussed

• are set nationally

• require all parts of the health system to work together

• focus on children, youth, Māori and vulnerable populations

• connected to local clinically led quality improvement activities and contributory measures.

Contributory measures:

• Process and activity measures used to measure local progress against quality improvement activities

• chosen locally based on local needs, demographics and service configurations

All measures held in an online Measures Library (www.hqmnz.org.nz)

Genesis of SLMs

• From General Practice Leaders forum

• Measure performance of the whole health system that is achieved through integration of services and systems

• Shift health sector performance from outputs to outcomes

• Align with NZ Triple Aim and five themes of NZ Health Strategy

• Contribute to the four government and Ministry priorities – addressing inequities, child wellbeing, primary care and mental health

• Enhance people’s experience of integrated health care

• Build capacity and capability for quality improvement and use of data to better understand local population needs

• Reduce demand on hospital resources through strengthening of primary health care

Current System Level Measures

1. Ambulatory sensitive hospitalisations (ASH) rates for zero-to-four year olds – ie, Keeping children out of hospital

2. Acute hospital bed days per capita – ie, Using health services effectively and managing acute demand

3. Patient experience of care – ie, Person-centred care

4. Amenable mortality rates – ie, Early detection and prevention

5. Babies living in smokefree homes – ie, A healthy start

6. Youth access to and utilisation of youth appropriate health services –ie, Youth are healthy, safe and supported – this is made up of five domains that reflect feedback from the broader health and social sectors and the young people

Implementation of SLMs

District alliances are responsible for implementing SLMs in their districts

Role of district alliances:

• Harnessing perspectives from all relevant parts of health system to identify shared vision and key objectives for their districts

• Having a whole of system focus

• Having a clear focus on delivery of integrated care by placing their population and patient at the centre at all times

• Applying alliancing principles - develop local relationships and trust between health system partners in their district

• Using SLMs to drive system integration in their districts

• Leading the development of the SLM improvement plan

• Allocating resources required for the development, implementation, monitoring and reporting of the SLMs in their districts.

DHB, on behalf of their alliance, is responsible for submitting the SLM improvement plan and the quarterly reports

Outcome versus Accountability/Performance

Attribute Outcome Measures Performance

Timeframe Long term Short/Medium term

Scope Broad range of influencers Tight set of influencers

Attribution Ambiguous Clear

Purpose Continuous improvement Process or performance improvement

Interaction Limited/no impact on performance measures

Contribute to outcome measures

Example System Level Measures National Health targets

6

Different types of measures have different attributes and different uses. We need to recognise this when deploying them.

Old power New Power

• Performance management

• Accountability

• Targets

• Sanctions

• Leader-driven

• About economic resources ($$, materials, technology which diminish over time)

• Important part of the system but is it the whole part?

• Uses intrinsic motivation (values)

• Participation and peer-coordination

• Do it yourself

• Informal networks (alliancing, collaboration, community)

• Building capacity and capability

• About social resources that grow with use

• Co-producing and sharing

• Transparent

Currency

Held by few

Pushed down

Commanded

Closed

Transaction

Current

Made by many

Pulled in

Shared

Open

Relationship

Jeremy Heimans, Harvard Business Review, Dec 2014, Vol.92(12), pp.48-56

So what’s different about SLMs?

What are we looking for in the Improvement Plan

•action focused and achievable in one year

•contribute to the achievement of the improvement milestone

•reflect the integrated approach across the health system

•reflect the health investment needed based on local population needs, demographics and service configurations

•selected based on health information tools and improvement science methods

•based on available and reliable data

•measurable with defined numerator and denominator

•chosen from the Measures Library

•have a clear line of sight to the improvement milestone and quality improvement activities

•based on the district’s trend and baseline data

•a number that improves performance from baseline

•addressing inequalities for Māori, Pacific and other population groups with significant health disparities

•determined through the use of health information tools and improvement science methods

•integrated and partnership approach for the development of the plan

•includes all health system partners in the district eg patients/communities, ambulance, WCTO, LMCs, YOSS, pharmacy

Signatures of partners to

the plan

Improvement milestone

Quality improvement

activities

Contributory measures

PHO Incentive funding

$23M of PHO Performance Programme funding re-purposed to support PHOs to implement SLMs; which is paid in three payments.

Payment 1 - 25% up front capacity/capability

Payment 2 – 50% capacity/capability on Ministry approval of the Improvement Plan

The 75% capacity and capability payment is to build quality improvement and analytic capacity and capability in primary care that may include clinical and non-clinical infrastructure eg building ’continuous quality improvement’ competencies and culture, implementation of primary care patient experience survey, improving information technology and analytics, enabling clinical leadership and outreach services.

Payment 3 (25%) - decision for this payment is made by the Ministry based on the quarter four report from the district alliance, taking into consideration:

• that the alliance had a plan approved by the Ministry

• that the plan was implemented by all partners

• alliance’s reflection on the insights gained and how will it be different for following year

DHBs can use flexible funding pool to incentivise other health system partners

How is this relevant to GPs

• Opportunity to highlight role of GPs and PHOs in the broader health system

• Opportunity for local clinically led quality improvement activities

• Shift from pay-for-performance to building capacity and capability in primary care

• Discussions at the district alliances informs district level funding decisions including service improvements that contribute to SLM achievement eg

• maintaining or introducing GP access to diagnostics

• reorienting models of care eg implementation of Health Care Home, Integrated Family Centres

• uptake of the Primary Options for Acute Care service directly contributes to the Acute hospital bed days SLM,

• immunisation contributes to ASH rates for children

• uptake of primary care patient experience survey contributes to the Patient experience of care SLM

Learning so far………

Successful implementation dependent on:

• Maturity of alliances (high trust local relationships, inclusive membership and common shared purpose)

• Clinical leadership and engagement

• Focus on patient experience and safety

• Focus on addressing health inequities

• Capacity and capability for quality improvement and information technology

• Happy and sustainable workforce

• Robust financial performance and accountability

• Use of commissioning to target investment

What the sector is saying about SLMs

The System Level Measures approach will have tangible results for people’s health. Those results

are much more difficult to get to –but this actually feels like

medicine.” – Luke Bradford, GP, Western Bay of Plenty PHO

Before the framework, there was less motivation for various

disciplines to talk to each other –such as GPs, midwives,

pharmacists. Now we have the opportunity to drive integration

and build relationships.” – Dr Allan Moffitt, Clinical Director, Procare

PHO

It’s great to bring together experts from different roles and

organisations to agree a plan that is really going to make a difference to

the health of people in our community, particularly children.” –Dr Nick Baker, Nelson Marlborough

Chief Medical Officer and paediatrician

A great thing about the SLMs is that really strong equity focus. For the ASH rates, it’s been quite an eye

opener, with things like oral health to see just what inequities there are

and being able to put some real focus on those areas.” – Kim

MacRae, Practice Advisor, Alliance Health Plus PHO

You have to understand first, A: is there a problem, B: what is the

problem, what are the underlying things, what’s modifiable, and then how do we modify it?” – Professor

Les Toop, Canterbury Clinical Network Alliance Leadership Team

The SLM approach enables DHBs to align their existing work with a

framework that has clear outcomes” – Tim Wood, Funding

and Development Manager, Auckland and Waitemate DHBs