Policy into practice€¦ · September 2015. Good policy • is one component of a ... demographic disparities in coverage Defining the destination. Improving immunisation coverage

Policy into practiceImproving Immunisation coverage in New Zealand

Dr Pat TuohyIMAC ConferenceSeptember 2015

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

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

Getting a backer


Reach the summit


Boost morale



Build the team

Plan the route

Get a backer


Check for hazards

Decide on gear

• 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


Reach the summit


Boost morale



Build the team

Plan the route

Get a backer


Check for hazards

Decide on gear

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

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)


Reach the summit


Boost morale



Build the team

Plan the route

Get a backer


Check for hazards

Decide on gear

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

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.

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

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

Increasing immunisation coverageHigh degree of certainty (NIR) and agreement (strong evidence)

Immunisation

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

Increasing immunisation coverageHigh degree of certainty (NIR) and agreement (strong evidence)

Immunisation

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


Reach the summit


Boost morale



Build the team

Plan the route

Get a backer


Check for hazards

Decide on gear

Stacey RD. Strategic management and organisational dynamics: the challenge of complexity. 3rd ed. Harlow: Prentice Hall, 2002

Decide on gear

Run charts

Immunisation coverage by DHBFunnel plot


Reach the summit


Boost morale



Build the team

Plan the route

Get a backer


Check for hazards

Decide on gear

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


Reach the summit


Boost morale



Build the team

Plan the route

Get a backer


Check for hazards

Decide on gear

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


Reach the summit


Boost morale



Build the team

Plan the route

Get a backer


Check for hazards

Decide on gear

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


Reach the summit


Boost morale



Build the team

Plan the route

Get a backer


Check for hazards

Decide on gear

Boosting morale


Reach the summit


Boost morale



Build the team

Plan the route

Get a backer


Check for hazards

Decide on gear

Performance measurement that is directed at reputations can be a powerful driver of improvement Hibbard (2008)

Encouraging the laggards


Reach the summit


Boost morale



Build the team

Plan the route

Get a backer


Check for hazards

Decide on gear

Reaching the summitThe latest success storyReducing pneumococcal disease in NZ

Documents

Policy into practice€¦ · September 2015. Good policy • is one component of a ... demographic disparities in coverage Defining the destination. Improving immunisation coverage