Jayne James, SESLHD - T2 The Road to Self-Management
-
Upload
informa-australia -
Category
Health & Medicine
-
view
333 -
download
7
description
Transcript of Jayne James, SESLHD - T2 The Road to Self-Management
T2 The Road to Self Management
Tom Chapman
– SESLHD Chronic Care Redesign Manager
Jayne James
– SESLHD Integrated Diabetes Pathway Manager
South Eastern Sydney Local Health District
SESLHD Region
• 9 Local Government Areas
• Sydney's Central Business District to the Royal National Park Sydney
• 2011 census
– Population 830,000
– Northern Sector 45%
– Southern Sector 55%
South Eastern Sydney Local Health District
SESLHD
• 7 Hospitals
• 2 Medicare Locals
– Eastern Sydney
– South Eastern Sydney
Trends in obesity and inadequate physical
activity
Since 1997, the proportion of overweight or obese residents has increased
by about a third. This is a prime driver for the escalating rate of
hospitalisations for diabetes among our residents. In turn, the increasing
prevalence of diabetes is driving increases in people requiring dialysis for
chronic kidney disease.
4.7%
7.8%
0123456789
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Pe
rce
nta
ge o
f p
op
ula
tio
n
Smoothed estimate (%) Actual estimate (%)
Diabetes or high blood glucose, persons ≥16 years, South Eastern Sydney LHD
Centre for Epidemiology and Evidence. Health Statistics New South Wales. Sydney: NSW
Ministry of Health. Available at: www.healthstats.nsw.gov.au. Accessed (08/07/2013).
SESLHD Diabetes population
is increasing ~ 0.3% per year
At this rate in 5 years time 10% of
the population will have Diabetes
or high Blood Glucose
Hospitalisations for Chronic Ambulatory
Care Sensitive Conditions Diabetes is overtaking all
other Chronic Conditions for
hospitalisation rates
In SESLHD every day around 60
residents are
hospitalised with Diabetes as the
principal diagnosis or an
important comorbidity (2011 stats)
Diabetes Complications
Increasing numbers of patients with complications of diabetes due to poor self management and poor glucose
control.
Over the past decade 20,000 amputations have occurred in
Australia due to diabetes1.
In Australia over the past decade, 10,000 people have lost their sight
due to diabetes1.
1: National Diabetes Strategy and Action Plan 2013: Diabetes Australia
Our Community, Our Services…A snapshot (August 2012)
Based on current trends, diabetes, followed by falls, are
expected to have the greatest future impacts on our health
system.
High Priority Initiatives
Establish an integrated,
multidisciplinary diabetes program to
facilitate increased patient knowledge
and skill necessary for both diabetes
self-care and active collaboration with
health care providers, to improve
clinical outcomes and reduce the need
for hospital care.
Integrated Diabetes Project ( Sept. 2012)
SESLHD Integrated
Diabetes Project
Type 1 Type 2
T2 the road to self management
Gestational Adolescent/Tra
nsitional
Project Overview
Improve access to standardised validated education and self-management
support for newly diagnosed type 2 diabetes patients in the Northern sector of
SESLHD.
Aim
Why?
SESLHD Diabetes population is
increasing ~ 0.3%/ year
Up to 50% of patients with T2DM do
not access education
Diabetes hospitalisations are
escalating
Solution Design Project Initiation &
Start - up
Diagnostics
Solution Design
Implementation
Planning Implementation
Checkpoints
• Post Implementation Evaluation
• Review & Redesign of Unsuccessful Initiatives
• Continuous Cycle of Redesign – Sustainability
• Sharing of Knowledge
• Writing For Publication
• Implement Quick Wins
• Implement all Solutions
• Trouble Shooting
• Coaching & Support
• Monitoring and Reporting
• Implementation Plans for Quick Wins
• Business Cases
• Implementation Teams
• Change Readiness Assessment
• Sponsorship Roles & Responsibilities
• Project, Stakeholder, Communication & Change Management Plans
• Performance Management
• KPI Definition & Measurement Plan
• Piloting Initiatives
• Literature Search for Best Practice Solutions
• Facilitated Problem Solving & Brainstorming
• Solutions Identification
• Cost/Benefit Analysis of Solutions
• Prioritisation of Solutions
• Detailed Solution Statements
• Develop Quick Wins
• Process Mapping
• Diagnostic Tools & Techniques
• Staff Interviews
• Patient Interviews
• Patient Tag Alongs
• Data Collection & Analysis
• Baseline KPI ’ s
• Issues Identification
• Issues Prioritisation
• Root Cause Analysis
• Building the Case For Change
• Project Management
• Project Objectives & Measuring Benefits
• Project Scoping
• Governance & Reporting
• Roles & Responsibilities
• Project Deliverables & Scheduling
• Project Costs
• Risk Management
• Change Management
• Stakeholder Management
• Communications Management
Pu
rpo
se
Centre for Healthcare Redesign - Methodology
Implementation
Planning
Evaluation
Sustainability
Knowledge
Sharing
To identify ways to improve the process, share lessons and drive sustainability
To design and prioritise solutions to issues and build stakeholder support
To collect and assess critical data about processes, patients and staff. Identify key issues to be resolved and build the case for change
To develop the project scope and set up project, change, communication and stakeholder management plans
To implement solutions and confirm that benefits are being delivered
To develop a comprehensive plan for implementing solutions and measuring benefits
Diagnostics Project Initiation &
Start - up
Diagnostics
Solution Design
Implementation
Planning Implementation
Checkpoints
• Post Implementation Evaluation
• Review & Redesign of Unsuccessful Initiatives
• Continuous Cycle of Redesign – Sustainability
• Sharing of Knowledge
• Writing For Publication
• Implement Quick Wins
• Implement all Solutions
• Trouble Shooting
• Coaching & Support
• Monitoring and Reporting
• Implementation Plans for Quick Wins
• Business Cases
• Implementation Teams
• Change Readiness Assessment
• Sponsorship Roles & Responsibilities
• Project, Stakeholder, Communication & Change Management Plans
• Performance Management
• KPI Definition & Measurement Plan
• Piloting Initiatives
• Literature Search for Best Practice Solutions
• Facilitated Problem Solving & Brainstorming
• Solutions Identification
• Cost/Benefit Analysis of Solutions
• Prioritisation of Solutions
• Detailed Solution Statements
• Develop Quick Wins
• Process Mapping
• Diagnostic Tools & Techniques
• Staff Interviews
• Patient Interviews
• Patient Tag Alongs
• Data Collection & Analysis
• Baseline KPI ’ s
• Issues Identification
• Issues Prioritisation
• Root Cause Analysis
• Building the Case For Change
• Project Management
• Project Objectives & Measuring Benefits
• Project Scoping
• Governance & Reporting
• Roles & Responsibilities
• Project Deliverables & Scheduling
• Project Costs
• Risk Management
• Change Management
• Stakeholder Management
• Communications Management
Pu
rpo
se
Centre for Healthcare Redesign - Methodology
Implementation
Planning
Evaluation
Sustainability
Knowledge
Sharing
To identify ways to improve the process, share lessons and drive sustainability
To design and prioritise solutions to issues and build stakeholder support
To collect and assess critical data about processes, patients and staff. Identify key issues to be resolved and build the case for change
To develop the project scope and set up project, change, communication and stakeholder management plans
To implement solutions and confirm that benefits are being delivered
To develop a comprehensive plan for implementing solutions and measuring benefits
Diagnostics
Project + Change + Stakeholder + Communication Management
Solution Design Project Initiation &
Start - up
Diagnostics
Solution Design
Implementation
Planning Implementation
Checkpoints
• Post Implementation Evaluation
• Review & Redesign of Unsuccessful Initiatives
• Continuous Cycle of Redesign – Sustainability
• Sharing of Knowledge
• Writing For Publication
• Implement Quick Wins
• Implement all Solutions
• Trouble Shooting
• Coaching & Support
• Monitoring and Reporting
• Implementation Plans for Quick Wins
• Business Cases
• Implementation Teams
• Change Readiness Assessment
• Sponsorship Roles & Responsibilities
• Project, Stakeholder, Communication & Change Management Plans
• Performance Management
• KPI Definition & Measurement Plan
• Piloting Initiatives
• Literature Search for Best Practice Solutions
• Facilitated Problem Solving & Brainstorming
• Solutions Identification
• Cost/Benefit Analysis of Solutions
• Prioritisation of Solutions
• Detailed Solution Statements
• Develop Quick Wins
• Process Mapping
• Diagnostic Tools & Techniques
• Staff Interviews
• Patient Interviews
• Patient Tag Alongs
• Data Collection & Analysis
• Baseline KPI ’ s
• Issues Identification
• Issues Prioritisation
• Root Cause Analysis
• Building the Case For Change
• Project Management
• Project Objectives & Measuring Benefits
• Project Scoping
• Governance & Reporting
• Roles & Responsibilities
• Project Deliverables & Scheduling
• Project Costs
• Risk Management
• Change Management
• Stakeholder Management
• Communications Management
Pu
rpo
se
Centre for Healthcare Redesign - Methodology
Implementation
Planning
Evaluation
Sustainability
Knowledge
Sharing
To identify ways to improve the process, share lessons and drive sustainability
To design and prioritise solutions to issues and build stakeholder support
To collect and assess critical data about processes, patients and staff. Identify key issues to be resolved and build the case for change
To develop the project scope and set up project, change, communication and stakeholder management plans
To implement solutions and confirm that benefits are being delivered
To develop a comprehensive plan for implementing solutions and measuring benefits
Diagnostics Project Initiation &
Start - up
Diagnostics
Solution Design
Implementation
Planning Implementation
Checkpoints
• Post Implementation Evaluation
• Review & Redesign of Unsuccessful Initiatives
• Continuous Cycle of Redesign – Sustainability
• Sharing of Knowledge
• Writing For Publication
• Implement Quick Wins
• Implement all Solutions
• Trouble Shooting
• Coaching & Support
• Monitoring and Reporting
• Implementation Plans for Quick Wins
• Business Cases
• Implementation Teams
• Change Readiness Assessment
• Sponsorship Roles & Responsibilities
• Project, Stakeholder, Communication & Change Management Plans
• Performance Management
• KPI Definition & Measurement Plan
• Piloting Initiatives
• Literature Search for Best Practice Solutions
• Facilitated Problem Solving & Brainstorming
• Solutions Identification
• Cost/Benefit Analysis of Solutions
• Prioritisation of Solutions
• Detailed Solution Statements
• Develop Quick Wins
• Process Mapping
• Diagnostic Tools & Techniques
• Staff Interviews
• Patient Interviews
• Patient Tag Alongs
• Data Collection & Analysis
• Baseline KPI ’ s
• Issues Identification
• Issues Prioritisation
• Root Cause Analysis
• Building the Case For Change
• Project Management
• Project Objectives & Measuring Benefits
• Project Scoping
• Governance & Reporting
• Roles & Responsibilities
• Project Deliverables & Scheduling
• Project Costs
• Risk Management
• Change Management
• Stakeholder Management
• Communications Management
Pu
rpo
se
Centre for Healthcare Redesign - Methodology
Implementation
Planning
Evaluation
Sustainability
Knowledge
Sharing
To identify ways to improve the process, share lessons and drive sustainability
To design and prioritise solutions to issues and build stakeholder support
To collect and assess critical data about processes, patients and staff. Identify key issues to be resolved and build the case for change
To develop the project scope and set up project, change, communication and stakeholder management plans
To implement solutions and confirm that benefits are being delivered
To develop a comprehensive plan for implementing solutions and measuring benefits
Diagnostics
Project + Change + Stakeholder + Communication Management
Solution Design Project Initiation &
Start - up
Diagnostics
Solution Design
Implementation
Planning Implementation
Checkpoints
• Post Implementation Evaluation
• Review & Redesign of Unsuccessful Initiatives
• Continuous Cycle of Redesign – Sustainability
• Sharing of Knowledge
• Writing For Publication
• Implement Quick Wins
• Implement all Solutions
• Trouble Shooting
• Coaching & Support
• Monitoring and Reporting
• Implementation Plans for Quick Wins
• Business Cases
• Implementation Teams
• Change Readiness Assessment
• Sponsorship Roles & Responsibilities
• Project, Stakeholder, Communication & Change Management Plans
• Performance Management
• KPI Definition & Measurement Plan
• Piloting Initiatives
• Literature Search for Best Practice Solutions
• Facilitated Problem Solving & Brainstorming
• Solutions Identification
• Cost/Benefit Analysis of Solutions
• Prioritisation of Solutions
• Detailed Solution Statements
• Develop Quick Wins
• Process Mapping
• Diagnostic Tools & Techniques
• Staff Interviews
• Patient Interviews
• Patient Tag Alongs
• Data Collection & Analysis
• Baseline KPI ’ s
• Issues Identification
• Issues Prioritisation
• Root Cause Analysis
• Building the Case For Change
• Project Management
• Project Objectives & Measuring Benefits
• Project Scoping
• Governance & Reporting
• Roles & Responsibilities
• Project Deliverables & Scheduling
• Project Costs
• Risk Management
• Change Management
• Stakeholder Management
• Communications Management
Pu
rpo
se
Centre for Healthcare Redesign - Methodology
Implementation
Planning
Evaluation
Sustainability
Knowledge
Sharing
To identify ways to improve the process, share lessons and drive sustainability
To design and prioritise solutions to issues and build stakeholder support
To collect and assess critical data about processes, patients and staff. Identify key issues to be resolved and build the case for change
To develop the project scope and set up project, change, communication and stakeholder management plans
To implement solutions and confirm that benefits are being delivered
To develop a comprehensive plan for implementing solutions and measuring benefits
Diagnostics Project Initiation &
Start - up
Diagnostics
Solution Design
Implementation
Planning Implementation
Checkpoints
• Post Implementation Evaluation
• Review & Redesign of Unsuccessful Initiatives
• Continuous Cycle of Redesign – Sustainability
• Sharing of Knowledge
• Writing For Publication
• Implement Quick Wins
• Implement all Solutions
• Trouble Shooting
• Coaching & Support
• Monitoring and Reporting
• Implementation Plans for Quick Wins
• Business Cases
• Implementation Teams
• Change Readiness Assessment
• Sponsorship Roles & Responsibilities
• Project, Stakeholder, Communication & Change Management Plans
• Performance Management
• KPI Definition & Measurement Plan
• Piloting Initiatives
• Literature Search for Best Practice Solutions
• Facilitated Problem Solving & Brainstorming
• Solutions Identification
• Cost/Benefit Analysis of Solutions
• Prioritisation of Solutions
• Detailed Solution Statements
• Develop Quick Wins
• Process Mapping
• Diagnostic Tools & Techniques
• Staff Interviews
• Patient Interviews
• Patient Tag Alongs
• Data Collection & Analysis
• Baseline KPI ’ s
• Issues Identification
• Issues Prioritisation
• Root Cause Analysis
• Building the Case For Change
• Project Management
• Project Objectives & Measuring Benefits
• Project Scoping
• Governance & Reporting
• Roles & Responsibilities
• Project Deliverables & Scheduling
• Project Costs
• Risk Management
• Change Management
• Stakeholder Management
• Communications Management
Pu
rpo
se
Centre for Healthcare Redesign - Methodology
Implementation
Planning
Evaluation
Sustainability
Knowledge
Sharing
To identify ways to improve the process, share lessons and drive sustainability
To design and prioritise solutions to issues and build stakeholder support
To collect and assess critical data about processes, patients and staff. Identify key issues to be resolved and build the case for change
To develop the project scope and set up project, change, communication and stakeholder management plans
To implement solutions and confirm that benefits are being delivered
To develop a comprehensive plan for implementing solutions and measuring benefits
Diagnostics
Project + Change + Stakeholder + Communication Management
Solution Design Project Initiation &
Start - up
Diagnostics
Solution Design
Implementation
Planning Implementation
Checkpoints
• Post Implementation Evaluation
• Review & Redesign of Unsuccessful Initiatives
• Continuous Cycle of Redesign – Sustainability
• Sharing of Knowledge
• Writing For Publication
• Implement Quick Wins
• Implement all Solutions
• Trouble Shooting
• Coaching & Support
• Monitoring and Reporting
• Implementation Plans for Quick Wins
• Business Cases
• Implementation Teams
• Change Readiness Assessment
• Sponsorship Roles & Responsibilities
• Project, Stakeholder, Communication & Change Management Plans
• Performance Management
• KPI Definition & Measurement Plan
• Piloting Initiatives
• Literature Search for Best Practice Solutions
• Facilitated Problem Solving & Brainstorming
• Solutions Identification
• Cost/Benefit Analysis of Solutions
• Prioritisation of Solutions
• Detailed Solution Statements
• Develop Quick Wins
• Process Mapping
• Diagnostic Tools & Techniques
• Staff Interviews
• Patient Interviews
• Patient Tag Alongs
• Data Collection & Analysis
• Baseline KPI ’ s
• Issues Identification
• Issues Prioritisation
• Root Cause Analysis
• Building the Case For Change
• Project Management
• Project Objectives & Measuring Benefits
• Project Scoping
• Governance & Reporting
• Roles & Responsibilities
• Project Deliverables & Scheduling
• Project Costs
• Risk Management
• Change Management
• Stakeholder Management
• Communications Management
Pu
rpo
se
Centre for Healthcare Redesign - Methodology
Implementation
Planning
Evaluation
Sustainability
Knowledge
Sharing
To identify ways to improve the process, share lessons and drive sustainability
To design and prioritise solutions to issues and build stakeholder support
To collect and assess critical data about processes, patients and staff. Identify key issues to be resolved and build the case for change
To develop the project scope and set up project, change, communication and stakeholder management plans
To implement solutions and confirm that benefits are being delivered
To develop a comprehensive plan for implementing solutions and measuring benefits
Diagnostics Project Initiation &
Start - up
Diagnostics
Solution Design
Implementation
Planning Implementation
Checkpoints
• Post Implementation Evaluation
• Review & Redesign of Unsuccessful Initiatives
• Continuous Cycle of Redesign – Sustainability
• Sharing of Knowledge
• Writing For Publication
• Implement Quick Wins
• Implement all Solutions
• Trouble Shooting
• Coaching & Support
• Monitoring and Reporting
• Implementation Plans for Quick Wins
• Business Cases
• Implementation Teams
• Change Readiness Assessment
• Sponsorship Roles & Responsibilities
• Project, Stakeholder, Communication & Change Management Plans
• Performance Management
• KPI Definition & Measurement Plan
• Piloting Initiatives
• Literature Search for Best Practice Solutions
• Facilitated Problem Solving & Brainstorming
• Solutions Identification
• Cost/Benefit Analysis of Solutions
• Prioritisation of Solutions
• Detailed Solution Statements
• Develop Quick Wins
• Process Mapping
• Diagnostic Tools & Techniques
• Staff Interviews
• Patient Interviews
• Patient Tag Alongs
• Data Collection & Analysis
• Baseline KPI ’ s
• Issues Identification
• Issues Prioritisation
• Root Cause Analysis
• Building the Case For Change
• Project Management
• Project Objectives & Measuring Benefits
• Project Scoping
• Governance & Reporting
• Roles & Responsibilities
• Project Deliverables & Scheduling
• Project Costs
• Risk Management
• Change Management
• Stakeholder Management
• Communications Management
Pu
rpo
se
Centre for Healthcare Redesign - Methodology
Implementation
Planning
Evaluation
Sustainability
Knowledge
Sharing
To identify ways to improve the process, share lessons and drive sustainability
To design and prioritise solutions to issues and build stakeholder support
To collect and assess critical data about processes, patients and staff. Identify key issues to be resolved and build the case for change
To develop the project scope and set up project, change, communication and stakeholder management plans
To implement solutions and confirm that benefits are being delivered
To develop a comprehensive plan for implementing solutions and measuring benefits
Diagnostics
Project + Change + Stakeholder + Communication Management
Solution Design Project Initiation &
Start - up
Diagnostics
Solution Design
Implementation
Planning Implementation
Checkpoints
• Post Implementation Evaluation
• Review & Redesign of Unsuccessful Initiatives
• Continuous Cycle of Redesign – Sustainability
• Sharing of Knowledge
• Writing For Publication
• Implement Quick Wins
• Implement all Solutions
• Trouble Shooting
• Coaching & Support
• Monitoring and Reporting
• Implementation Plans for Quick Wins
• Business Cases
• Implementation Teams
• Change Readiness Assessment
• Sponsorship Roles & Responsibilities
• Project, Stakeholder, Communication & Change Management Plans
• Performance Management
• KPI Definition & Measurement Plan
• Piloting Initiatives
• Literature Search for Best Practice Solutions
• Facilitated Problem Solving & Brainstorming
• Solutions Identification
• Cost/Benefit Analysis of Solutions
• Prioritisation of Solutions
• Detailed Solution Statements
• Develop Quick Wins
• Process Mapping
• Diagnostic Tools & Techniques
• Staff Interviews
• Patient Interviews
• Patient Tag Alongs
• Data Collection & Analysis
• Baseline KPI ’ s
• Issues Identification
• Issues Prioritisation
• Root Cause Analysis
• Building the Case For Change
• Project Management
• Project Objectives & Measuring Benefits
• Project Scoping
• Governance & Reporting
• Roles & Responsibilities
• Project Deliverables & Scheduling
• Project Costs
• Risk Management
• Change Management
• Stakeholder Management
• Communications Management
Pu
rpo
se
Centre for Healthcare Redesign - Methodology
Implementation
Planning
Evaluation
Sustainability
Knowledge
Sharing
To identify ways to improve the process, share lessons and drive sustainability
To design and prioritise solutions to issues and build stakeholder support
To collect and assess critical data about processes, patients and staff. Identify key issues to be resolved and build the case for change
To develop the project scope and set up project, change, communication and stakeholder management plans
To implement solutions and confirm that benefits are being delivered
To develop a comprehensive plan for implementing solutions and measuring benefits
Diagnostics Project Initiation &
Start - up
Diagnostics
Solution Design
Implementation
Planning Implementation
Checkpoints
• Post Implementation Evaluation
• Review & Redesign of Unsuccessful Initiatives
• Continuous Cycle of Redesign – Sustainability
• Sharing of Knowledge
• Writing For Publication
• Implement Quick Wins
• Implement all Solutions
• Trouble Shooting
• Coaching & Support
• Monitoring and Reporting
• Implementation Plans for Quick Wins
• Business Cases
• Implementation Teams
• Change Readiness Assessment
• Sponsorship Roles & Responsibilities
• Project, Stakeholder, Communication & Change Management Plans
• Performance Management
• KPI Definition & Measurement Plan
• Piloting Initiatives
• Literature Search for Best Practice Solutions
• Facilitated Problem Solving & Brainstorming
• Solutions Identification
• Cost/Benefit Analysis of Solutions
• Prioritisation of Solutions
• Detailed Solution Statements
• Develop Quick Wins
• Process Mapping
• Diagnostic Tools & Techniques
• Staff Interviews
• Patient Interviews
• Patient Tag Alongs
• Data Collection & Analysis
• Baseline KPI ’ s
• Issues Identification
• Issues Prioritisation
• Root Cause Analysis
• Building the Case For Change
• Project Management
• Project Objectives & Measuring Benefits
• Project Scoping
• Governance & Reporting
• Roles & Responsibilities
• Project Deliverables & Scheduling
• Project Costs
• Risk Management
• Change Management
• Stakeholder Management
• Communications Management
Pu
rpo
se
Centre for Healthcare Redesign - Methodology
Implementation
Planning
Evaluation
Sustainability
Knowledge
Sharing
To identify ways to improve the process, share lessons and drive sustainability
To design and prioritise solutions to issues and build stakeholder support
To collect and assess critical data about processes, patients and staff. Identify key issues to be resolved and build the case for change
To develop the project scope and set up project, change, communication and stakeholder management plans
To implement solutions and confirm that benefits are being delivered
To develop a comprehensive plan for implementing solutions and measuring benefits
Diagnostics
Project + Change + Stakeholder + Communication Management
Solution Design Project Initiation &
Start - up
Diagnostics
Solution Design
Implementation
Planning Implementation
Checkpoints
• Post Implementation Evaluation
• Review & Redesign of Unsuccessful Initiatives
• Continuous Cycle of Redesign – Sustainability
• Sharing of Knowledge
• Writing For Publication
• Implement Quick Wins
• Implement all Solutions
• Trouble Shooting
• Coaching & Support
• Monitoring and Reporting
• Implementation Plans for Quick Wins
• Business Cases
• Implementation Teams
• Change Readiness Assessment
• Sponsorship Roles & Responsibilities
• Project, Stakeholder, Communication & Change Management Plans
• Performance Management
• KPI Definition & Measurement Plan
• Piloting Initiatives
• Literature Search for Best Practice Solutions
• Facilitated Problem Solving & Brainstorming
• Solutions Identification
• Cost/Benefit Analysis of Solutions
• Prioritisation of Solutions
• Detailed Solution Statements
• Develop Quick Wins
• Process Mapping
• Diagnostic Tools & Techniques
• Staff Interviews
• Patient Interviews
• Patient Tag Alongs
• Data Collection & Analysis
• Baseline KPI ’ s
• Issues Identification
• Issues Prioritisation
• Root Cause Analysis
• Building the Case For Change
• Project Management
• Project Objectives & Measuring Benefits
• Project Scoping
• Governance & Reporting
• Roles & Responsibilities
• Project Deliverables & Scheduling
• Project Costs
• Risk Management
• Change Management
• Stakeholder Management
• Communications Management
Pu
rpo
se
Centre for Healthcare Redesign - Methodology
Implementation
Planning
Evaluation
Sustainability
Knowledge
Sharing
To identify ways to improve the process, share lessons and drive sustainability
To design and prioritise solutions to issues and build stakeholder support
To collect and assess critical data about processes, patients and staff. Identify key issues to be resolved and build the case for change
To develop the project scope and set up project, change, communication and stakeholder management plans
To implement solutions and confirm that benefits are being delivered
To develop a comprehensive plan for implementing solutions and measuring benefits
Diagnostics Project Initiation &
Start - up
Diagnostics
Solution Design
Implementation
Planning Implementation
Checkpoints
• Post Implementation Evaluation
• Review & Redesign of Unsuccessful Initiatives
• Continuous Cycle of Redesign – Sustainability
• Sharing of Knowledge
• Writing For Publication
• Implement Quick Wins
• Implement all Solutions
• Trouble Shooting
• Coaching & Support
• Monitoring and Reporting
• Implementation Plans for Quick Wins
• Business Cases
• Implementation Teams
• Change Readiness Assessment
• Sponsorship Roles & Responsibilities
• Project, Stakeholder, Communication & Change Management Plans
• Performance Management
• KPI Definition & Measurement Plan
• Piloting Initiatives
• Literature Search for Best Practice Solutions
• Facilitated Problem Solving & Brainstorming
• Solutions Identification
• Cost/Benefit Analysis of Solutions
• Prioritisation of Solutions
• Detailed Solution Statements
• Develop Quick Wins
• Process Mapping
• Diagnostic Tools & Techniques
• Staff Interviews
• Patient Interviews
• Patient Tag Alongs
• Data Collection & Analysis
• Baseline KPI ’ s
• Issues Identification
• Issues Prioritisation
• Root Cause Analysis
• Building the Case For Change
• Project Management
• Project Objectives & Measuring Benefits
• Project Scoping
• Governance & Reporting
• Roles & Responsibilities
• Project Deliverables & Scheduling
• Project Costs
• Risk Management
• Change Management
• Stakeholder Management
• Communications Management
Pu
rpo
se
Centre for Healthcare Redesign - Methodology
Implementation
Planning
Evaluation
Sustainability
Knowledge
Sharing
To identify ways to improve the process, share lessons and drive sustainability
To design and prioritise solutions to issues and build stakeholder support
To collect and assess critical data about processes, patients and staff. Identify key issues to be resolved and build the case for change
To develop the project scope and set up project, change, communication and stakeholder management plans
To implement solutions and confirm that benefits are being delivered
To develop a comprehensive plan for implementing solutions and measuring benefits
Diagnostics
Project + Change + Stakeholder + Communication Management
Solution Design Project Initiation &
Start - up
Diagnostics
Solution Design
Implementation
Planning Implementation
Checkpoints
• Post Implementation Evaluation
• Review & Redesign of Unsuccessful Initiatives
• Continuous Cycle of Redesign – Sustainability
• Sharing of Knowledge
• Writing For Publication
• Implement Quick Wins
• Implement all Solutions
• Trouble Shooting
• Coaching & Support
• Monitoring and Reporting
• Implementation Plans for Quick Wins
• Business Cases
• Implementation Teams
• Change Readiness Assessment
• Sponsorship Roles & Responsibilities
• Project, Stakeholder, Communication & Change Management Plans
• Performance Management
• KPI Definition & Measurement Plan
• Piloting Initiatives
• Literature Search for Best Practice Solutions
• Facilitated Problem Solving & Brainstorming
• Solutions Identification
• Cost/Benefit Analysis of Solutions
• Prioritisation of Solutions
• Detailed Solution Statements
• Develop Quick Wins
• Process Mapping
• Diagnostic Tools & Techniques
• Staff Interviews
• Patient Interviews
• Patient Tag Alongs
• Data Collection & Analysis
• Baseline KPI ’ s
• Issues Identification
• Issues Prioritisation
• Root Cause Analysis
• Building the Case For Change
• Project Management
• Project Objectives & Measuring Benefits
• Project Scoping
• Governance & Reporting
• Roles & Responsibilities
• Project Deliverables & Scheduling
• Project Costs
• Risk Management
• Change Management
• Stakeholder Management
• Communications Management
Pu
rpo
se
Centre for Healthcare Redesign - Methodology
Implementation
Planning
Evaluation
Sustainability
Knowledge
Sharing
To identify ways to improve the process, share lessons and drive sustainability
To design and prioritise solutions to issues and build stakeholder support
To collect and assess critical data about processes, patients and staff. Identify key issues to be resolved and build the case for change
To develop the project scope and set up project, change, communication and stakeholder management plans
To implement solutions and confirm that benefits are being delivered
To develop a comprehensive plan for implementing solutions and measuring benefits
Diagnostics Project Initiation &
Start - up
Diagnostics
Solution Design
Implementation
Planning Implementation
Checkpoints
• Post Implementation Evaluation
• Review & Redesign of Unsuccessful Initiatives
• Continuous Cycle of Redesign – Sustainability
• Sharing of Knowledge
• Writing For Publication
• Implement Quick Wins
• Implement all Solutions
• Trouble Shooting
• Coaching & Support
• Monitoring and Reporting
• Implementation Plans for Quick Wins
• Business Cases
• Implementation Teams
• Change Readiness Assessment
• Sponsorship Roles & Responsibilities
• Project, Stakeholder, Communication & Change Management Plans
• Performance Management
• KPI Definition & Measurement Plan
• Piloting Initiatives
• Literature Search for Best Practice Solutions
• Facilitated Problem Solving & Brainstorming
• Solutions Identification
• Cost/Benefit Analysis of Solutions
• Prioritisation of Solutions
• Detailed Solution Statements
• Develop Quick Wins
• Process Mapping
• Diagnostic Tools & Techniques
• Staff Interviews
• Patient Interviews
• Patient Tag Alongs
• Data Collection & Analysis
• Baseline KPI ’ s
• Issues Identification
• Issues Prioritisation
• Root Cause Analysis
• Building the Case For Change
• Project Management
• Project Objectives & Measuring Benefits
• Project Scoping
• Governance & Reporting
• Roles & Responsibilities
• Project Deliverables & Scheduling
• Project Costs
• Risk Management
• Change Management
• Stakeholder Management
• Communications Management
Pu
rpo
se
Centre for Healthcare Redesign - Methodology
Implementation
Planning
Evaluation
Sustainability
Knowledge
Sharing
To identify ways to improve the process, share lessons and drive sustainability
To design and prioritise solutions to issues and build stakeholder support
To collect and assess critical data about processes, patients and staff. Identify key issues to be resolved and build the case for change
To develop the project scope and set up project, change, communication and stakeholder management plans
To implement solutions and confirm that benefits are being delivered
To develop a comprehensive plan for implementing solutions and measuring benefits
Diagnostics
Project + Change + Stakeholder + Communication Management
Project Objectives
1. Establish an integrated clinical framework to support an integrated patient
pathway that provides for newly diagnosed type 2 diabetes patients by
August 2013.
2. To have 10% of GP’s in ESML accessing and implementing this referral
pathway for patients newly diagnosed with type 2 diabetes by March
2014; increasing incrementally to achieve 50% by March 2015
3. To have 20% of newly diagnosed patients with type 2 diabetes following
the established integrated pathway; receiving standardised, validated
diabetes self management education by March 2014; increasing
incrementally to 75% by March 2015
Project Initiation and start-up
Established a steering and working group
SESLHD Integrated
Diabetes Project
Type 1 Type 2
T2 the road to self management
T2 Steering Group
T2 Working group
Gestational Adolescent/Transitional
Project Initiation and start-up
Key Role Map South Eastern Sydney Local Health District
CE SESLHD
Director of
Medicine
Endocrinologist,
POW
Head of
Endocrinology
Nursing Manager
POW Diabetes
Centre
Diabetes Centre
EducatorsPOW Community
Nurses
NUM
Community
Health
Director,
Community Health
Project Team
Jayne James
Tom Chapman
Chronic Care
Integration Unit
Manager
Director of
Ambulatory and
Primary CareDirector of
Operations POW
CEO Eastern
Suburbs
Medicare Local
ESML
Manager,
Population
Health
Eastern Suburbs
GP’s
Eastern Suburbs
Practice Nurses
Primary Care
Co-Director
Community Health
and Aged Care
Governance
and
Management
Patient
Contact
= direct line management
= influence only
Medical
StreamCommunity
HealthAmbulatory and
Primary Care
Co-Director Acute,
Cardiac and
Comm. Care
SESLHD
Redesign Leader
GP & ESML
Board member
POW Nursing Co-
DirectorJenny
Wilson
Northern Network
Executive
Directly
consulted at
some stage
Part of
committees/
working groups
Community
Pharmacy
PATIENTS
Executive
Sponsor
Key
Stakeholder
Key
stakeholders
Key
stakeholder
Key
Stakeholder
Project Initiation and start-up
Scoping the Project
IN SCOPE Reason
Patient Newly diagnosed Type2 diabetes (within last 12 months)
Adult
GP diagnosed Impaired Fasting Glucose or Impaired
Glucose Tolerance
This patient group identified as being
the fastest growing and currently
only 50% receive diabetes
education.
Process Northern sector chosen as the ESML
most able to partner at the time.
SESML still in restructure.
Patient with Type
2 Diabetes
Diabetes Centre
Community Health
Other Health
Specialists
Practice nurse
GP
Stakeholders Surveys File
Audit
Patient
Journey
Interviews Mapping Issues
log
GP’s
Practice
Nurses POW
Diabetes
Centre
POW
Community
Health
Patients
District
Resources
Diagnostics Tools / Methods used
Diagnostics
Key findings Patient Interviews
“Assumed tablets were going to
control it and there wasn’t much to it,
now I realise there is lots to it as far
as eating right and exercise”
“New GP
takes time to
explain things
– it seems
like he really
cares.
I feel more
re-assured
“First doctor
was too
business like
– wouldn’t
talk”
“Initially cut
down sugar in
tea and coffee
and didn’t
really do any
thing else”
Was getting
blackouts – tried
jelly beans, brother
said get treatment
“Nuisance with no car for
shopping and day trips I stay
at home now, I some times
feel depressed’
24 Diagnostics
Mapping Eastern Sydney Medicare Local
93 Solo GP’s 53 Small GP
Practices (2-5)
43 Large GP
Practices 6+
86 Practice
Nurses
• Eastern Sydney Medicare Local has the largest proportion of solo GP
Practices than any other Medicare Local.
• This is significant in that solo GP practices can rarely afford a Practice
Nurse, or have the space for a Practice Nurse to work.
25 Diagnostics
Practice Nurse Distribution in Suburbs
0
5
10
15
20
25
Practices with Practice Nurse's
Number of Practice Nurse's
= lowest socioeconomic suburbs.
These areas are poorly resourced with practice nurses 26
Diagnostics
Summary of Key Diagnostic Data
Nearly 80% of referrals to the POW DEC are made by GP’s
32% of referrals had
all the relevant information
Time from referral to first appointment varied from 1
week to 6 months.
Diagnostics
Process mapping:
GP > Diabetes Centre
Practice Nurse Survey
Only 10% of Practice Nurses
provide diabetes education in a
structured format.
No recognised format was
identified.
28
No diabetes group education
is provided.
36% do not provide any
diabetes education.
Issues Prioritisation
Impact on patient
Ability to
Influence
Low
High
Low High
Low Priority
Medium Priority
Medium Priority
High Priority
2.Consistent
pt education
3.Education to
reduce
variation in
practice
1.Flexible
pt access
4.IT/
Communication 5. Knowledge
gap of what is
available in
primary care
29
Current patient Journey
Diabetes Education Pathway
Newly Diagnosed with Type 2 Diabetes
ISSUE
Large variation not only in
where to go but what is
delivered.
Patient diagnosed
with Type 2
Diabetes
Diabetes
Centre
Community
Nurse
Dietitian Practice
Nurse
Community
Health
Centre
Internet
Podiatrist
Pharmacist
Endocrinologist
Exercise
Physiologist
Friends
Family ISSUE
Patient options for Diabetes
Self-Management Education
and Support are dependent on
GP connectivity. There is no
standard treatment
ISSUE
Knowledge of current services
both primary and hospital
based
Diagnostics
Solutions Prioritisation
Description
Ability to Influence Impact
Ease of
Implementation
Cost of
Implementation
Total
Ability to
Influence
Impact on KPI Benefits for
Patients Benefits for Staff
Total
Impact
Scoring System Easy (9)
Moderate (3)
Difficult (1)
Low (9)
Medium (3)
High (1)
Sum
previous 2
Positive:
Significant impact
(9)
Moderate impact (3)
Low impact (1)
Positive Impact (9)
Neutral Impact (3)
Negative Impact
(1)
Positive Impact (9)
Neutral Impact (3)
Negative Impact (1)
Sum
previous
3
Develop/enhance networking
forums and events 9 7 16 7 7 9 23
Develop a referral pathway 5 7.5 12.5 7.5 6.5 8 22
Common service directory 4 8 12 8 9 9 26
Standardise correspondence 9 9 18 3 3 3 9
Single point of access 4 4 8 9 9 8 26
Collaborate on one education
package for health staff 4 4 8 7.5 5 9 21.5
Train a broad range of health
care workers from diverse
backgrounds and cultures to
deliver standardised
training/education
4.5 2.5 7 6 9 7.5 22.5
Solution Design
0
9
18
0 13.5 27
Solutions Prioritisation In
flu
en
ce
(e
ase
+ c
ost o
f
imp
lem
en
tatio
n)
Impact (KPI’s + patients + staff)
Common service directory
Develop/enhance networking
forums and events
Develop a
referral
pathway Standardise
correspondence
Collaborate on one
education package
for health staff
Single point of access
Train a broad range of health care
workers from diverse backgrounds
and cultures to deliver
standardised training/education
Solution Design
Will be covered by
the larger Diabetes
Project
Desired patient Journey
Diabetes Education Pathway
Newly Diagnosed with Type 2 Diabetes
Patient diagnosed
with Type 2
Diabetes
Diabetes
Centre
Community
Nurse
Dietitian
Practice Nurse
Community
Health Centre
Internet
Podiatrist
Pharmacist
Endocrinologis
t
Exercise
Physiologist
Friends
Family
ComDiab
Generalist
Community based
diabetes self
managament
education.
Those requiring more comprehensive
Diabetes Education. Or more immediate referral.
Triaged by
Access and
referral centre
staff
SOLUTION
Develop a Referral Pathway +
a Single Point of Access
SOLUTION
ComDiab General education
on self management, the
multidisciplinary team and
annual cycle of care.
SOLUTION
Common service directory
available to all sectors
Service Directory
Solution Design
Implementation planning
• Prioritise Actions
• Implementation
teams
• Build Business Case
• Piloting Initiatives
• Identify KPI’s &
evaluation measures
• Change Management
Plans are nothing -planning is everything (Dwight D. Eisenhower)
Implementation planning
Accelerating Implementation
Methodology (AIM) Identify the C.A.S.T
Champion
Agent
Sponsor
Target
Implementation planning
A.I.M Communication
Strategy
Modes
Timing
Newsletter
Implementation planning
A.I.M Readiness and
Resistance
‘The path to least resistance
is what makes the river
crooked’(Elbert Hubbard)
Implementation planning
A.I.M Assess the Climate
‘Insanity is doing the same
thing over and over again
and expecting different
results’ (Albert Einstein)
Implementation Checkpoints
Implementation checkpoints
2013 Aug Sept Oct Nov Dec 2014 Jan Feb March
Evaluation check points
First ComDiab Sessions
held
IT links to directory
Book venues
Training complete
Business plan
endorsed
Directory complete
Engage Sponsor
Plan endorsed
Achievements
GP or other Dr diagnoses
Type 2 Diabetes with in last 12
months or Impaired Glucose
Tolerance or Impaired Fasting
Glucose
Is patient appropriate for
ComDiab referral?*
Would ComDiab supplement
GP education for patient to
promote self management?
GP or health
professional provide
patient with referral
information to call
NNARC
or
GP calls NNARC
Or
Either ****
YES
Open new referral
in CHIME
And inform Patient
of referral
NO*ComDiab eligibility Criteria
· Diagnosis: Newly diagnosed
T2DMwith last 12 months
· IGT, IFG
· Not on insulin therapy
· Ability to partake in interactive
group session.
· English comprehension ability
· English reading ability
· Or is Carer of above
· Carers welcome to attend
· Can attend existing multicultural
group **POW Diabetes Centre eligibility
Criteria
*** GP working group to define
**** Investigate electronic referral via
GP to NNARC
Does patient meet
criteria for referral to
Diabetes Centre?**
Does patient meet
criteria for ComDiab
referral?*
NO
YES
Contact referral
source for
information
NO
Is referral
information
complete?
YES
Confirmation letter
generated in CHIME and
sent to patient and GP
YESRefer to Diabetes
Centre
***
Meds check
Private Endo
Private DE
NO
Are there other
options for this
patient?
YES
NO
***
Meds check
Private Endo
Private DE
Refer back to GP
Pathway approach
Achievements
Networks Relationships & Responsibility
Two Registered Nurses
Complete
• Online training (12 hours)
• 3 day workshop
To do:
Observed and assessed
delivering community sessions.
Ongoing:
Attend an annual review day.
Achievements
Staff trained in
ComDiab
Achievements
Integration &
Collaboration
Australian
Diabetes
Council
Patient
SESML
Community
Health
GP’s SESLHD
Chronic
Care
Team
Diabetes
Education
Centre
Practice
Nurses
Challenges
Implementation checkpoints
Where to ….
Where to ….
Solution 1: Co-build a common service directory ESML and SESLHD
Solution 2: Develop a referral pathway with a single point of access
Solution 3: ComDiab General Education on self management, the multidisciplinary team and annual cycle of care
Acknowledgements
Sponsors - Dr Greg Stewart and
Linda Soars
South Eastern Sydney Medicare
Local
Australian Diabetes Council
Prince of Wales Diabetes Centre
Prince of Wales Community Health
Elizabeth Mason – Redesign
Manager
NSW Health Redesign School
Steering Committee
Working Party
Only 15% of the job is
figuring out what to do.
Making it happen – that is
where the action is (F Warren Mcfarlan)