National Primary Care Collaboratives

1. National Primary Care Collaboratives What is a collaborative?

2. A collaborative is… An improvement method that relies on spread and adaptation of existing knowledge to multiple settings to accomplish a common aim

4. What should a PDSA look like? Objective • Define the problem • What are you trying to achieve? Plan • Who, what, where, when? • Measurement  Do • Just do it! Study • What worked? What didn’t? Act • Next steps

5. An example… PDSA Objective • To improve prescribing of statins for patients with existing CHD

6. An example… Plan • Practice Nurse will search the practice computer system for all patients under 55 with CHD not prescribed a statin, on Wednesday afternoon.

7. An example… Do • Practice Nurse did search as planned

8. An example… Study • 67 patients under 55 with CHD found • 21 not prescribed a statin • 3 of these tolerant

9. An example… Act • Add reminder to computer screen so GP can commence statin when patient next comes in • Repeat cycle for 55-65 age group

10. Collaborative topics • Secondary prevention of CHD • Care of people with diabetes • Better patient access to primary care services • Aim • Measures • Change principles • Progress to date

11. Secondary Prevention of Coronary Heart Disease Collaborative aim A reduction in the mortality of patients with CHD by 30% in three years and 50% in five years in participating sites

12. CHD Measures • Number of CHD patients on register • % CHD patients on aspirin • % CHD patients who are on a statin • % patients who have had a MI in past 12 months who are on beta-blockers • % CHD patients whose last recorded BP within last 12 months <140/90

13. CHD Change Principles • Establish a system for creating, validating & updating a register • Be systematic & pro-active in managing care • Ensure timely & high quality support from secondary care • Involve patients in delivering & developing care • Build effective links with other key local partners

14. Care of people with Diabetes Collaborative aim To ensure that a minimum of 80% of all people (both Type 1 and Type 2) within participating sites have an HbA1c measured with 50% of these having a HbA1c of 7.0 or less

15. Diabetes measures • Number of diabetes patients on register Within last 12 months % of diabetes pts: • With HbA1c of 7 or less • With last measured total cholesterol <4 • With last recorded BP <130/80 • Have had diabetes SIP claimed

16. Diabetes Change Principles • Establish a system for creating, validating & updating a register • Be systematic & pro-active in managing care • Involve patients in delivering & developing their care • Adopt a multi-skilled, multi-agency approach to ensure effective co-ordination of care of people with diabetes

17. Better Access Collaborative aim 90% of patients should be able to access their health care professional routinely the next day

18. Access Measures • % of patients seen by the practice on the day of their choice • Number of days until the GP 3rd routine available appointment • Number of days until the Practice Nurse 3rd routine available appointment

19. Better Access Change Principles • Understand the profile of demand • Shape handling of demand • Match the capacity of the practice to reshaped demand • Establish & implement contingency plans • Communicate effectively with patients & across the practice team

20. Software Extraction Tool Availability

21. Success Factors • Patient Focused  • Practice Teams • Dedicated or Protected Time • Information Management • Practice Team Buy In

22. Practice Return • Improved patient care & clinical outcomes • Improved systems • Improved access • Whole of practice approach & teamwork • Learn from other practices • Feedback on PDSA cycles • Compare results with other participants