policy into practice€¦ · september 2015. good policy • is one component of a ... demographic...
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Policy into practiceImproving Immunisation coverage in New Zealand
Dr Pat TuohyIMAC ConferenceSeptember 2015
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Good policy
• is one component of a successful outcome
• needs to be put into practice to achieve a public benefit
• is grounded in science and experience
• the components are tied together through clever use of information
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Improving immunisation coverageThe journey
Reach the summit
Encourage the laggards
Boost morale
Manage target fatigue
Leave no‐one behind
Build the team
Plan the route
Get a backer
Define the destination
Check for hazards
Decide on gear
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Getting a backer
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Improving immunisation coverageThe journey
Reach the summit
Encourage the laggards
Boost morale
Manage target fatigue
Leave no‐one behind
Build the team
Plan the route
Get a backer
Define the destination
Check for hazards
Decide on gear
![Page 6: Policy into practice€¦ · September 2015. Good policy • is one component of a ... demographic disparities in coverage Defining the destination. Improving immunisation coverage](https://reader034.vdocument.in/reader034/viewer/2022051604/5ffc883d5856d746df346f69/html5/thumbnails/6.jpg)
• 2007 - to improve immunisation coverage at 2 years to 95% by July 2012
• 2012 - to improve immunisation coverage at 8 months to 95% by July 2012
• To reduce ethnic and socio-demographic disparities in coverage
Defining the destination
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Improving immunisation coverageThe journey
Reach the summit
Encourage the laggards
Boost morale
Manage target fatigue
Leave no‐one behind
Build the team
Plan the route
Get a backer
Define the destination
Check for hazards
Decide on gear
![Page 8: Policy into practice€¦ · September 2015. Good policy • is one component of a ... demographic disparities in coverage Defining the destination. Improving immunisation coverage](https://reader034.vdocument.in/reader034/viewer/2022051604/5ffc883d5856d746df346f69/html5/thumbnails/8.jpg)
Checking for hazards
Targets can be good servants but they are poor masters
• Targets are never a substitute for a clearly expressed strategy and set of priorities
• Successful targets provide focus, but build on and reinforce existing structures, strategies and beliefs in the health system
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Hitting the target but missing the point
• Tunnel vision - narrow focus• Myopia - short term thinking• Measurement fixation - missing the woods for
the trees• Misrepresentation and gaming• Misinterpretation - just getting it wrong
Smith (1995)
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Improving immunisation coverageThe journey
Reach the summit
Encourage the laggards
Boost morale
Manage target fatigue
Leave no‐one behind
Build the team
Plan the route
Get a backer
Define the destination
Check for hazards
Decide on gear
![Page 11: Policy into practice€¦ · September 2015. Good policy • is one component of a ... demographic disparities in coverage Defining the destination. Improving immunisation coverage](https://reader034.vdocument.in/reader034/viewer/2022051604/5ffc883d5856d746df346f69/html5/thumbnails/11.jpg)
Planning the route
• The NIR• The evidence• A Quality Improvement approach
Evidence for interventions to improve coverage
Standing ordersProvider feedbackand assessment ofcoverage
Insufficientevidence torecommend
Insufficient evidence torec ommend unless multi-component approach
Recommended onevidence
Stronglyrecommended onevidence
Community-wideeducation
Provider educationProvider reminder/recall
Client-heldmedical records
Provider incentivesReducing cost ofvaccination
Client/familyincentives
School- and childcare centre-based programmes
Home visitsLinks to well childprovider services
Increas ing accessto immunisation ,includingopportunisticimmunisation
School or child-care basedprogrammes
Community wide educationEntry requirementsto school /childcarecentre
Clientreminder/recall
Task Force on Community Preventive Services 2000
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PolicyWhat does the evidence say?
– A population‐based focus – Ensuring that every child is enrolled in primary care and followed up
– Outreach immunisation services – Performance‐based incentives for immunisation in primary care settings
– A promotion campaign tailored to those who find services ‘hard to reach’
– Reliable individual and national coverage information.
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What does our clinical experience show?– The “courageous conversation” can reduce the prevalence of immunisation “decliners’ and “objectors”
– Personal commitment by nursing and medical staff is a fundamental requirement
– Successful primary care systems “build‐in” a sound immunisation workflow
– Targets help, but they are not a “silver bullet”
Practice
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An unpredictable businessComplex systems and a QI approach
• Predicting outcomes assumes causality and repeatability.
• In a complex system this assumption breaks down.
• Any attempt to create an outcome will be subject to the law of unintended consequences. – You may achieve your
target, but a complex system can adjust in ways that may be neither predictable nor beneficial
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Increasing immunisation coverageHigh degree of certainty (NIR) and agreement (strong evidence)
Immunisation
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Evidence ‐ Increasing agreementEvidence for interventions to improve coverage
Standing ordersProvider feedbackand assessment ofcoverage
Insufficientevidence torecommend
Insufficient evidence torec ommend unless multi-component approach
Recommended onevidence
Stronglyrecommended onevidence
Community-wideeducation
Provider educationProvider reminder/recall
Client-heldmedical records
Provider incentivesReducing cost ofvaccination
Client/familyincentives
School- and childcare centre-based programmes
Home visitsLinks to well childprovider services
Increas ing accessto immunisation ,includingopportunisticimmunisation
School or child-care basedprogrammes
Community wide educationEntry requirementsto school /childcarecentre
Clientreminder/recall
Task Force on Community Preventive Services 2000
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Increasing immunisation coverageHigh degree of certainty (NIR) and agreement (strong evidence)
Immunisation
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The NIR - increasing certainty• A cornerstone of immunisation coverage
• The “Gold Standard”• Now 10 years old and showing it’s age
• Still learning new tricks• New NIR in development
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Improving immunisation coverageThe journey
Reach the summit
Encourage the laggards
Boost morale
Manage target fatigue
Leave no‐one behind
Build the team
Plan the route
Get a backer
Define the destination
Check for hazards
Decide on gear
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Stacey RD. Strategic management and organisational dynamics: the challenge of complexity. 3rd ed. Harlow: Prentice Hall, 2002
Decide on gear
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Run charts
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Immunisation coverage by DHBFunnel plot
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Improving immunisation coverageThe journey
Reach the summit
Encourage the laggards
Boost morale
Manage target fatigue
Leave no‐one behind
Build the team
Plan the route
Get a backer
Define the destination
Check for hazards
Decide on gear
![Page 24: Policy into practice€¦ · September 2015. Good policy • is one component of a ... demographic disparities in coverage Defining the destination. Improving immunisation coverage](https://reader034.vdocument.in/reader034/viewer/2022051604/5ffc883d5856d746df346f69/html5/thumbnails/24.jpg)
Building the team• Target champions at every level• General practice teams• PHO and DHB management• Medical Officers of Health• Immunisation coordinators• NIR administrators• NIR IT support• Outreach teams• MoH teams• PHARMAC• IMAC• Immunisation TAG
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Improving immunisation coverageThe journey
Reach the summit
Encourage the laggards
Boost morale
Manage target fatigue
Leave no‐one behind
Build the team
Plan the route
Get a backer
Define the destination
Check for hazards
Decide on gear
![Page 26: Policy into practice€¦ · September 2015. Good policy • is one component of a ... demographic disparities in coverage Defining the destination. Improving immunisation coverage](https://reader034.vdocument.in/reader034/viewer/2022051604/5ffc883d5856d746df346f69/html5/thumbnails/26.jpg)
Leaving no‐one behind
Jun 2009 = 78%Ethnicity (Māori) gap 11% pointsDeprivation gap 5% points
Dec 2014 = 93.5%Ethnicity (Māori) gap 2% pointsNo deprivation gap
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Improving immunisation coverageThe journey
Reach the summit
Encourage the laggards
Boost morale
Manage target fatigue
Leave no‐one behind
Build the team
Plan the route
Get a backer
Define the destination
Check for hazards
Decide on gear
![Page 28: Policy into practice€¦ · September 2015. Good policy • is one component of a ... demographic disparities in coverage Defining the destination. Improving immunisation coverage](https://reader034.vdocument.in/reader034/viewer/2022051604/5ffc883d5856d746df346f69/html5/thumbnails/28.jpg)
Managing target fatigue after E. Kübler-Ross*
1. Denial “Our figures are much better and more accurate”
2. Anger/blame “It’s those lazy parents”3. Bargaining “What’s the lowest target we can
agree to - to keep the Ministry off our back”4. Depression “We can only do so much. Let
some other DHB carry the responsibility”5. Acceptance “OK - its our responsibility, lets
get on with it”
*On Death & Dying, Elisabeth Kübler‐Ross, 1969
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Improving immunisation coverageThe journey
Reach the summit
Encourage the laggards
Boost morale
Manage target fatigue
Leave no‐one behind
Build the team
Plan the route
Get a backer
Define the destination
Check for hazards
Decide on gear
![Page 30: Policy into practice€¦ · September 2015. Good policy • is one component of a ... demographic disparities in coverage Defining the destination. Improving immunisation coverage](https://reader034.vdocument.in/reader034/viewer/2022051604/5ffc883d5856d746df346f69/html5/thumbnails/30.jpg)
Boosting morale
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Improving immunisation coverageThe journey
Reach the summit
Encourage the laggards
Boost morale
Manage target fatigue
Leave no‐one behind
Build the team
Plan the route
Get a backer
Define the destination
Check for hazards
Decide on gear
![Page 32: Policy into practice€¦ · September 2015. Good policy • is one component of a ... demographic disparities in coverage Defining the destination. Improving immunisation coverage](https://reader034.vdocument.in/reader034/viewer/2022051604/5ffc883d5856d746df346f69/html5/thumbnails/32.jpg)
Performance measurement that is directed at reputations can be a powerful driver of improvement Hibbard (2008)
Encouraging the laggards
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Improving immunisation coverageThe journey
Reach the summit
Encourage the laggards
Boost morale
Manage target fatigue
Leave no‐one behind
Build the team
Plan the route
Get a backer
Define the destination
Check for hazards
Decide on gear
![Page 34: Policy into practice€¦ · September 2015. Good policy • is one component of a ... demographic disparities in coverage Defining the destination. Improving immunisation coverage](https://reader034.vdocument.in/reader034/viewer/2022051604/5ffc883d5856d746df346f69/html5/thumbnails/34.jpg)
Reaching the summitThe latest success storyReducing pneumococcal disease in NZ