Clinician Engagement in Busy Clinical Environments & Strategically Embedding National Standards -Associate Professor Rebecca Kimble - University of Queensland

Department of Health

Translating evidence into best

clinical practice

Engaging Clinicians in Busy Clinical

Environments – Strategically Embedding

National Standards

Associate Professor University of Queensland, Australia

Director Obstetric & Statewide Paediatric and Adolescent Gynaecology Services

Director Queensland Clinical Guidelines

Royal Brisbane and Women’s Hospital, Brisbane, Australia

Rebecca KimbleMBBS, FRANZCOG, GAICD, Grad Cert IV TA

Authors: Assoc. Professor Rebecca Kimble, Dr Brent Knack

Queensland Clinical Guidelines 2

AIHW 2014 Mortalities Inequalities Australia

2009-2011

Queensland Clinical Guidelines 3Australian Institute of Health and Welfare, Bulletin 124 (August, 2014)

http://www.aihw.gov.au/publication-detail/?id=60129548021

http://www.aihw.gov.au/publication-detail/?id=60129548021

Health Expenditure as a Proportion of

Gross Domestic Product (GDP)OECD Countries - 2011

9.29.1

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

United

Sta

tes

Fra

nce

Germ

any

Neth

erla

nds

Sw

itze

rla

nd

Cana

da

Austr

ia

Denm

ark

Belg

ium

Ja

pa

n

New

Ze

ala

nd

Gre

ece

Port

ug

al

Sw

ede

n

Spa

in

Norw

ay

Italy

United

Kin

gd

om

OE

CD

AV

ER

AG

E

Austr

alia

Slo

ven

ia

Icela

nd

Fin

land

Ire

land

Hung

ary

Slo

vak R

epu

blic

Czech R

ep

ub

lic

Kore

a

Isra

el

Luxe

mb

ou

rg

Chile

Pola

nd

Me

xic

o

Esto

nia

Tu

rkey

Healt

h t

o G

DP

(%

)

OECD Health Statistics 2014 – Frequently Requested Data

http://www.oecd.org/els/health-systems/OECD-Health-Statistics-2014-Frequently-Requested-Data.xls


http://www.oecd.org/els/health-systems/OECD-Health-Statistics-2014-Frequently-Requested-Data.xls

Annual Growth of Health Expenditure and GDP

(Australia)

0

2

4

6

8

10

12

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Gro

wth

(%

)

YearGrowth in GDP Growth in Government Healthcare expenditure

(National Currency Units)

5.46.2

8.1 9.1

0

2

4

6

8

10

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Healt

h

Exp

en

dit

ure

a

s

Perc

en

tag

e

of

GD

P

Government Expenditure Total expenditure OECD Health Statistics 2014

http://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT#


http://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT

Evidence Based Practices

• 30-40% patients do not receive care according to current scientific evidence

• 20-25% care medically unnecessary and potentially harmful

• Non-compliance: poor information

lack of support

practitioner resistance

Health Care Management Review, March 2011, 36(1),4-17


Healthcare Goals


High quality healthcare

Efficient and effective service delivery

Transparency and accountability in governance

Best possible experience for consumers

Continuous improvement

The Healthcare Environment


Queensland

Clinical

Guidelines

Corporate Systems

Translation, Decision support,

Internal controlsAustralians

receiving

healthcare servicesClinician

decisions



http://www.performance.health.qld.gov.au/hospitalperformancehttps://www.health.qld.gov.au/system-governance/health-

system/managing/org-structure/default.asp

http://www.performance.health.qld.gov.au/hospitalperformance

https://www.health.qld.gov.au/system-governance/health-system/managing/org-structure/default.asp

The Healthcare Environment:

To Clinicians


Creswick, Westbrook and Braithwaite, 2009

Queensland Health Image Library (obtained with consent)

Culture: staff who are engaged and who have

high morale deliver a better patient experience,

fewer errors, lower mortality rates, less

absenteeism and better clinical outcomes

Braithwaite J; Hyde P; Pope C, 2010, Culture and climate in health care

organizations, Palgrave Macmillan

http://www.palgrave.com/products/title.aspx?PID=353942


Why invest in engaging clinicians?



Patient Focus: clinicians have the ability and

motivation to keep the needs of patients at the

forefront






Microsystems: what makes a difference to

patients is the team who delivers their care. The

design and running of local teams and systems is

critical









• Clinician decisions determine:

◦ Consumer experience

◦ Efficiency

◦ Effectiveness

• Translates to cost, quality, time, risk

Clinicians are the effectors of care and

health services

Clinician Engagement

“A clinicians’ personal commitment and

investment of effort in pursuit of a goal that

benefits people”


Personal commitment

Effort

A clear goal

Benefit to people – Consumers, peers

Clinician priorities


Frontline clinician

Clinician priority

Clinician priorities


Frontline clinician

Clinician priority

Clinicians have been let down

before


CentraliseDevolve

Endless IT systems

“We have done this before?!”

Clinicians have been let down

before


• No apparent return on effort

• No benefit to day to day work

• Diminishes enthusiasm and trust

• Clinicians Re-focus on immediate priority

A Strategic ApproachAim:

• Establish culture, systems and environments that seek

improvement and permit appropriate variability

Cultivate:

• A shared vision and focus

• Resilience, adaptability, autonomy in clinicians

• A majority of skilled clinical leaders


Clinical Network

Need: A growing network of influential clinicians,

consumers, quality and safety personnel, and policy makers


Networks:

• Grow culture from the ideas and knowledge of many

clinicians

• Tackle big picture issues by co-ordination of clinician

leadership and effort

• Advocate and communicate achievements

Statewide (QLD) Maternity and

Neonatal Clinical Network


1800 Clinicians,

Consumers & Policy

Makers

(2007- 2015)

Statewide (QLD) Maternity and

Neonatal Clinical Network


Queensland Clinical Guidelines




A Strategic Approach

• Bottom up and top down

• Manage expectations

• Facilitate and support within capacity to deliver

(clinician capacity and facility capacity)

• Support leveraging for additional benefit


Bottom Up and Top Down

Top Down: Strategic oversight, Legitimacy, Reputation,

Resources, Push capability

(e.g. Directives, information requests)


Bottom Up: Local champions, Needs identified,

Available capacity,

Contact with: Clinicians, First managers, Local governance

Bottom Up and Top Down

Top Down: Strategic oversight, Legitimacy, Reputation,

Resources, Push capability

(e.g. Directives, information requests)


Bottom Up: Local champions, Needs identified,

Available capacity,

Contact with: Clinicians, First managers, Local governance

Operational and Strategic Capability

Strategic capability:

Strategic oversight,

Legitimacy, Reputation,

Resources, Push

capability

(e.g. Directives,

information requests)


Operational capability:

Local champions, Needs

identified, Available

capacity,

Contact with: Clinicians,

First managers, Local

governance



Queensland

Clinical

Guidelines

Corporate Systems

Translation, Decision support,

Internal controlsAustralians

receiving

healthcare servicesClinician

decisions

Strategic:

• Strategic alignment

• Demonstrated benefits

• Governance

• Business cases

• Represent interests


Operational:

• Clinician led

• Consultation and

feedback

• Products for clinicians

• Local champions

• Support further benefits

• Represent interests

Methods to build Capability

Supporting capability- Implementation

Checklist1. Governance systems

Systems to promote and support guideline integration are established and utilised

2. Awareness and distributionStaff are informed about opportunities to participate in guideline development and the publication of new or amended guidelines

3. Clinical educationClinical education is provided on clinical guidelines

4. Quality and safetyClinical care is aligned with guideline recommendations





Strategic and Operational capability



(clinician capacity and facility capacity)



Managing Expectations


Too High:

• Unattainable benefit

• Can’t be demonstrated

• Insufficient resources

Too Low:

• Insufficient benefit

• Waste resources

Disengagement

Disengagement

Engagement

Facilitate within capacity


Disengage Engage

Success

Visible benefit

Failure

No visible benefit

37Queensland Clinical Guidelines: Preterm labour implementation

Example

Australian Commission on Safety and Quality Health Care (2010)

Incremental Successes of QCG

Need: Evidence informed healthcare

Initial Expectations: Guidelines, education,

consumer info, systems integration,

measurement, reporting



Guidelines

Guideline

Recommendations

Supplement

Education

PowerPoint

Videoconference

Online knowledge assessment

Consumer information

By partnership

In house

Measurement

Suggested measures

Indicators

Process Support

Incremental Successes of QCG

Support:

• Awareness

• Access

• Endorsement

• Responsiveness

Queensland Clinical Guidelines, Queensland Health 40

Build:

• Confidence

• Relevance

• Applicability

• Usefulness

• Practicality

In All Activities

Designing Methods

Methods must:

• Meet many purposes

• Reach a range of clinical groups

• Promote ownership

• Be practical and cost effective

• Span geographical distances

• Provide a take home benefit

Multiple concurrent strategies required

Queensland Clinical Guidelines: Preterm labour implementation 41




Clinical guidelines Evidence informed clinical guidelines

Guidelines

Supplement

Levels of evidence

Clinical quality measures

NSQHS alignment

Flowcharts Clinical decision support

EducationStatewide videoconference

Online knowledge assessments

PowerPoint (for download)

Audit Draft audit tools

Implementation

checklist

Suggested implementation actions:

• Governance

• Awareness & distribution

• Clinical education

• Quality & safety

Queensland Clinical GuidelinesTranslating evidence into best clinical practice

Guidance

Implementation

Engagement



Guidelines


Implementation strategies

Scoping and review of the evidence

Working party consultation

Statewide consultation

Working party consultation

Queensland Health endorsement

Clinician endorsement

Communities, consumers

Clinicians

Policy makers

Patients

Working Party and

Statewide Consultation

• Consumers

• Clinicians

• Allied health

• Private providers

• Co-ordination centres

• Geographic distribution

Website

• One stop for all resources

• Simple design & navigation

• Located or linked on

respected websites (e.g. Government, NHMRC)

• Feedback form – web-based

email

• Statewide Desktop icon


Queensland Clinical

Guidelines

• 6000-9000 visits per month

• >30,000 users annually

• 30% growth per year

• Positive feedback from

clinical community


Count of sessions

Countries accessing QCG website May 2015 – June 2015



Statewide videoconference education

• 84 facilities

• 16 HHS’s, DoH & RFDS

• Rural & Remote

• 2400+ reported participants

239 local site champions

• $596,000 baseline benefit

(development & delivery,

decreased duplicationQueensland Clinical Guidelines, March 2012-June 2015

Statewide videoconference education


Queensland Clinical Guidelines, March 2012-June 2015

Online Knowledge Assessments


N = 1661 to 1712

Queensland Clinical Guidelines, Jan 2013-June2015

Consumer information

• 15 Information sheets

• Formal consumer recruitment and

consultation


Clinical Outcome

Patient contact

Clinical Decisions

Clinical Decisions

Clinical Decisions

Individual Case

Clinician Experience

Service availability and policy

Best available evidence

Queensland Clinical

Guidelines

Consumer autonomy

Clinical Consensus

Complexity of healthcare delivery &

outcome measurement


Quality indicators

• Suggestions of areas for Audit – Few

people engaged with this

• Must provide quick & easy tools and make

reporting / Feedback the focus






(clinician capacity and own capacity)



• Support clinician initiated actions aligned

to the agreed intent and expectation

• Promotes ownership, autonomy,

leadership, and focus on the shared vision


Support leveraging for additional

benefit

Inter-hospital transfers for false labour RBWH

2003-2014


QCG Audit Project benefits

58

Indicator October

2013

February

2014

Women received

written information

about Induction of

Labour (IOL)

61%

30%

Women who had

an Oxytocin

infusion and CTG

monitoring

100%

93%

Actions:

• Targeted staff

education

• Updated parent

information

• Detailed review

of IOL services

• Update ward

reference

materials

Audit

Education

Aw

are

ness a

nd

dis

trib

ution

Clinical Pathways



Queensland Maternity Early Warning

Tool



Integrated electronic medical

record & Fetal Link



Perinatal social and emotional

wellbeing screeningTo create ‘champions/resource persons’ who will

assist others in their local area with the learning

package and psychosocial screening

Neonatal Resuscitation

Education Program



NeoResus: Neonatal Resuscitation

Education ProgramJune 2012 • Green - Queensland Health

neoResus program providers

• Yellow - Serviced by providers

• Pink - Not receiving NERP

Pink represents 30% of

indigenous population

of Queensland



Education ProgramMay 2013June 2012 June 2014



Education Program

June 2015

Midwifery Advisory Group


• Criteria Led Discharge

• Eligible Private Practice

Midwives

• Midwifery models of care

• Standardised Antenatal

Education- Resources /

Workforce issues

Engaging within a unit or service line

• Promote understanding of requirements among clinical

leaders

• Templates:

◦ Agendas, minutes, Activity records

• Align clinical audits to standards

• Encouraging champions for a standard


“It has taken the mystery out of the process.

Some seemed to think accreditation is a secret business”

Summary


Perinatal Care at

the Threshold of

Viability

Guideline

Education

· Videoconferencing

· Powerpoint

· Videos

· Knowledge

assessments

Breastfeeding

Initiation

Guideline

Clinical Audit(Point of care or

retrospective)

Statewide Alignment

· Pregnancy health record

· Intrapartum record

· Clinical pathways

Consumer

Information

Newborn

Examination

Guideline

Neonatal

Resuscitation

Guideline

Preterm labour

Guideline

www.health.qld.gov.au/qcg

http://www.health.qld.gov.au/qcg

Promote ownership, autonomy,

leadership, and focus on the shared

vision• Make People FEEL valued

• Use a strategic approach

• Make incremental improvements

• Multiple concurrent methods

• Identify and support local champions

• Awareness, Access, Endorsement, ResponsivenessQueensland Clinical Guidelines 70

Acknowledgements


Hon. Cameron Dick, Minister for Health and Ambulance Services (Queensland)

Statewide (Queensland) Maternity and Neonatal Clinical Network

Ms Karen Lang, CNC Safety and Quality Officer, Women’s and Newborn Service,

Royal Brisbane and Women’s Hospital

Queensland Clinical Guidelines team:

◦ Associate Professor Rebecca Kimble, Director

◦ Ms Jacinta Lee, Manager

◦ Ms Lyndel Gray, Clinical Nurse/Midwifery Consultant

◦ Dr Brent Knack, Program Officer

◦ Ms Stephanie Sutherns, Clinical Nurse/Midwifery Consultant

Contact



• Email: [email protected]

• Website: www.health.qld.gov.au/qcg

• Phone: 07 3131 6777

mailto:[email protected]


Conflict of Interest Statement:

The presenter and authors declare to have no conflict of interests in respect to the content of this presentation and Informa Clinical Audit Improvement Conference 2015 (Sydney, Australia).

Cite this presentation:

Kimble R, Knack B, 2015, Engaging Clinicians in Busy Clinical Environments, Clinical Audit Improvement Conference, Sydney 2015.

Feedback and contact details:

M: GPO Box 48 Brisbane QLD 4001 | E: [email protected] | URL: www.health.qld.gov.au/qcg

Copyright:

© State of Queensland (Queensland Health) 2015

This work is licensed under a Creative Commons Attribution Non-Commercial No Derivatives 3.0 Australia licence. In essence, you are free to copy and communicate the work in its current form for non-commercial purposes, as long as you attribute Queensland Clinical Guidelines, Queensland Health and abide by the licence terms. You may not alter or adapt the work in any way. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/3.0/au/deed.en

For further information contact Queensland Clinical Guidelines, RBWH Post Office, Herston Qld 4029, email [email protected], phone (+61) 07 3131 6777. For permissions beyond the scope of this licence contact: Intellectual Property Officer, Queensland Health, GPO Box 48, Brisbane Qld 4001, email [email protected], phone (07) 3234 1479.




http://creativecommons.org/licenses/by-nc-nd/3.0/au/deed.en


Like what you see?Be part of our conversation.

informa.com.au

Join our e-newsletter

http://my.informa.com.au/inbound/text_SlideShare

http://my.informa.com.au/inbound/text_SlideShare