Partnering for performance 16 April 2010 - Department of Health

Partnering for performance
Quality, Safety and Patient Experience Branch
Friday 16 April 2010
Department of Health

Agenda
9.00am – 9.15am Welcome Alison McMillan
Department of Health
9.15am – 9.30am
9.30am – 10.30am
10.30am – 11.00am
Partnering for performance launch
Background
Partnering for performance
overview
Performance development and
support framework
Morning tea
Lance Wallace
Department of Health
Dr Grant Phelps
Department of Health
Dr Heather Wellington
DLA Phillips Fox
11.00am – 11.30am Peer review Professor Margaret Banks
Australian Commission on Safety
and Quality in Healthcare
11.30am – 12.00pm Integrated quality system Professor Alan Wolff
Wimmera Health Care Group
12.00pm – 12.30pm Discussion Delegate question time
12.30pm – 1.30pm
1.30pm – 2.30pm
2.30pm – 3.00pm
Lunch
Understanding clinical practice
toolkit
Implementation support
Next steps
Dr Grant Phelps and Dr Martin Lum
Department of Health
Alison McMillan
Department of Health

Partnering for performance
Welcome
Alison McMillan
Director
Quality, Safety and Patient Experience Branch

Partnering for performance
Partnering for performance launch
Lance Wallace
Executive Director
Hospital & Health Service Performance
Division

Partnering for performance
Background
Partnering for performance
Dr Grant Phelps
Clinical Engagement Program

Partnering for performance

Background
• Clinical Engagement Program 2007
• High performance health care through
engagement of senior medical staff
• We know engagement by and with doctors is an
issue for our system
• Quality, Safety and Patient Experience
Branch, Department of Health
• Clinically led
• Clinical Engagement Advisory Group
• Senior clinical, management, college and
industry representatives

www.health.vic.gov.au/clinicalengagement

Clinical engagement
The active contribution of doctors within
their normal work to enhance the
performance of the organisation which
itself supports and encourages high
quality care.
Adapted from Applied Research 2008

Background
• 2007 Statewide Credentialling and
scope of practice policy
• Embedded critical relationship between
organisation and senior medical staff
• Focus on patient care and organisational
responsiveness
• Shared responsibility
• Expected implementation by October 2012

Clinical Engagement Program
Policy updated 2009
• Forms updated
• Dentists – clarified process
• Residential Aged Care Facilities – extended process
• IT support – continued to encourage
• Ongoing support from clinical engagement program
• Continue to engage with hospitals and DMS to
support policy implementation
• Ongoing discussion with MPBV, national group

Formative policy evaluation
• Initial impact positive
• Some impact on workload for medical leaders
• Requirement for IT support
• Recognition of need for medical leadership
• Remains an issue in rural Victoria
• Some initial fears appear not to have been
realised
• e.g. impact on rostering
• e.g. withdrawal from practice

Why Partnering for performance?

Credentialling
The formal process used to verify the qualifications,
experience, professional standing and other
relevant professional attributes of medical
Who are you?
practitioners for the purpose of forming a view
about their competence, performance and
professional suitability to provide safe, high quality
health care services within specific organisational
environments.

Defining scope of clinical practice
Follows on from credentialling and involves
delineating the extent of an individual medical
What will you
practitioner’s clinical practice within a particular
organisation based on the individual’s credentials,
do here?
competence, performance and professional
suitability and the needs and the capability of the
organisation to support the medical practitioner’s
scope of clinical practice.

New appointment
Credentialling
and Scope of
Practice
Re‐credentialling
and Scope of
Practice supported
by Peer Review
process
Appointment
‐ Contract
Process of ongoing
review and
support
•Process is Patient Centred
•Clinically led & focussed

Recognised a need to:
• Support the Credentialling cycle
• Maximise the benefits to patient, doctor and organisation
• Ensure drives engagement and performance at all levels
• Build a framework to support quality practice
• This is core business
• Provide opportunities for development of shared goals
and shared understandings

Recognised a need to:
• Create context and opportunity for a two way
performance conversation
• Identify and support outstanding performance across
a range of domains
• Work achievement, Professional behaviours,
Learning and development, Career progression
• Identify and support underperformance

Through……
……..
• Build medical leadership as a key
success factor
• Encourage organisational support for leadership
• Ensure ‘no surprises’ at re-credentialling
• Ensure robust processes

Guiding principles
• Doctor engagement (‘by and with’) is critical to a
successful and high performance system
• Credentialling as an enabler
• Most doctors are doing a great job
• Those that aren't need to be identified and
encouraged/supported back to excellence
• We can’t afford to lose doctors from the system

Partnering for performance

Partnering for performance
is a policy about:
• Culture
• Patient care as core business
• Relationships between organisations and their SMS
• Understanding and enhancing clinical care
• A peer based understanding of clinical practice
• Looking for opportunities to improve performance
• Supporting medical professionalism
• 'Demonstrable professionalism‘
• College and other CPD processes

Partnering for performance is an
integrated program which combines:
• Regular performance conversations
• ‘the Guide’
• Based around individual performance with emphasis on clinical
care
• Organisational engagement and responsiveness
• Shared goals around patient care
• Use of clinical level information
• ‘Understanding clinical practice toolkit’
• Standardised processes to help understand clinical practice
• Driving an improvement based approach to clinical governance
• Credentialling cycle as the framework

The credentialling cycle as...
• An engagement system
• Focusing the system on patient care
• A leadership system
• Ensuring clinical leadership of core business
• A clinical improvement system
• Identifying opportunities for real improvement
• A driver of professionalism
• Promoting transparency and accountability
• A governance system
• Cost effective regulation
You need all of these to deliver high performance

Partnering for performance policy
• Policy
• Guide
• Understanding clinical
practice toolkit
• Case studies
• Glossary, references,
resources

Partnering for performance
Performance development and
support framework
Dr Heather Wellington
Consultant
DLA Phillips Fox

Agenda
9.00am – 9.15am Welcome Alison McMillan
Department of Health
9.15am – 9.30am
9.30am – 10.30am
10.30am – 11.00am
Partnering for performance launch
Background
Partnering for performance
overview
Performance development and
support framework
Morning tea
Lance Wallace
Department of Health
Dr Grant Phelps
Department of Health
Dr Heather Wellington
DLA Phillips Fox
11.00am – 11.30am Peer review Professor Margaret Banks
Australian Commission on Safety
and Quality in Healthcare
11.30am – 12.00pm Integrated quality system Professor Alan Wolff
Wimmera Health Care Group
12.00pm – 12.30pm Discussion Delegate question time
12.30pm – 1.30pm
1.30pm – 2.30pm
2.30pm – 3.00pm
Lunch
Understanding clinical practice
toolkit
Implementation support
Next steps
Dr Grant Phelps and Dr Martin Lum
Department of Health
Alison McMillan
Department of Health

Partnering for performance
Peer review
Professor Margaret Banks
Australian Commission on Safety and Quality
in Healthcare

Partnering for performance
An integrated quality system
Professor Alan Wolff
Wimmera Health Care Group

Discussion

Agenda
9.00am – 9.15am Welcome Alison McMillan
Department of Health
9.15am – 9.30am
9.30am – 10.30am
10.30am – 11.00am
Partnering for performance launch
Background
Partnering for performance
overview
Performance development and
support framework
Morning tea
Lance Wallace
Department of Health
Dr Grant Phelps
Department of Health
Dr Heather Wellington
DLA Phillips Fox
11.00am – 11.30am Peer review Professor Margaret Banks
Australian Commission on Safety
and Quality in Healthcare
11.30am – 12.00pm Integrated quality system Professor Alan Wolff
Wimmera Health Care Group
12.00pm – 12.30pm Discussion Delegate question time
12.30pm – 1.30pm
1.30pm – 2.30pm
2.30pm – 3.00pm
Lunch
Understanding clinical practice
toolkit
Implementation support
Next steps
Dr Grant Phelps and Dr Martin Lum
Department of Health
Alison McMillan
Department of Health

Partnering for performance
Understanding clinical practice toolkit
Dr Grant Phelps and Dr Martin Lum
Department of Health
Clinical Engagement Program

Understanding clinical practice
toolkit – the process
• Literature review by Centre for Clinical
Governance Research in Health UNSW
• Evidence for use of tools in
understanding clinical practice at level
of individual doctor?
• How best design and use?

Recognised:
• Most organisations already doing
elements of this to varying degree
• Need to
• Provide a suite of tools to encourage
organisations and clinicians to focus on
importance of patient care
• Standardising processes
• Ensuring based in evidence and clinical practice

Tools
• Peer review
• Adverse occurrence screening
• Mortality and morbidity reviews
• Clinical audit
• Clinical indicators
• Patient satisfaction and complaints

For each tool we provide
• Definition
• Background
• Purpose
• 'How to'
• Critical risks
• 'Victorian approach'
• Weighting

Peer review
Process by which individuals of the
same profession, experience and
working in similar organisational
settings, critically assess their
colleague(s) performance, in order to
reinforce areas of strength and quality
in patient care, and to identify areas for
development or improvement.

Peer review - background
• Based in self examination by the
profession
• Value in driving improvement and
improving professional practice
• High levels of profession and system
acceptability

Informal Peer review throughout cycle

Formal Peer review - purpose
1. Credentialling/re-credentialling
• Process is peer based
2. Investigation and management of
possible underperformance
• If that underperformance is unable to be
managed at the local level

Formal Peer review - Credentialling
Victorian approach
• Key process to support re-credentialling
• Principles
• Framed in clinical practice
• Standardised measures
• A number of peers
• Sits within Credentialling and scope of practice
processes
• Proper resourcing

Formal Peer review – Underperformance
Victorian approach
• SMS should undertake if concerns about performance unable to
managed at the local (medical lead) level
• Is NOT an initial investigation tool
• Is NOT a routine monitoring tool
• Requires:
• Clear terms of reference
• Individual to be involved in developing the assessment process
• Agreed measures
• Independence
• Confidentiality
• Links to re-credentialling processes

Adverse occurrence screening /
Targeted case note review
The review of selected or targeted
medical records by medical colleagues
using screening criteria which may be
associated with care related adverse
events.

AOS/TCNR background
• Harvard medical management analysis
system
• Markers of potential for adverse event
• Wimmera LAOS program
• Broader DHS program for GP Divisions
aligned with rural hospitals
• Traditional 'audits'
• All deaths, MET calls, neonatal deaths, etc

AOS/TCNR Victorian approach
• All hospitals should be using at an
appropriate level
• Define local ‘markers’ at
hospital/department/unit level
• Link to clinical governance processes
• Ensure is case based
• Model forms provided

Mortality and morbidity
reviews
A routine, structured forum for the open
examination and review of cases which
have led to illness or death of a patient,
in order to collectively learn from these
events and to improve patient
management and quality of care.

MMR background
• Longstanding technique with significant
profession level acceptance
• Applied variably and inconsistently
• Variable outcomes
• Need to standardise processes
• Need a clear link into organisational
processes to ensure responsiveness

Mortality and morbidity reviews –
Victorian approach
• All SMS should participate
• Should occur at appropriate level
(which allows peer input)
• Consider cases identified through a
range of processes including AOS/TCNR
• Clear and consistent approach
• Model proformas available

Clinical audit
The systematic review of elements of
clinical care against predetermined
criteria, with the aim of identifying
areas for improvement and then
developing, implementing and
evaluating strategies intended to
achieve that improvement.

Clinical audit
• Cyclical to continuous process
• Clinical data sets
• Local
• Registry level
• Clinical topic/area (not whole of care)

Clinical audit – Victorian approach
• All SMS 'should be supported by their
organisation'
• Audit elements of care on at least an
annual basis
• SMS should be involved in management
of clinical audit, including design,
oversight and subsequent improvement
processes
• Guide to existing literature provided

Clinical indicators
Clinical indicators are measures of
elements of clinical care which may,
when assessed over time, provide a
method of assessing the quality and
safety of care at a system level.

Clinical indicators
• May document quality of care
• May assist in benchmarking care
• Use a range of data sets but often
administrative data sets (e.g. AusPSIs)
• Usually looking at system level

Clinical indicators – Victorian approach
• ‘Considerable caution’ re linking to individual
clinician’s care
• ‘Careful judgement’ of indicators suggesting
underperformance
• Clinical indicators must be part of an
improvement strategy
• SMS must be actively engaged
• SMS where possible ‘should be supported by their
organisation’ to contribute to clinical registries

Patient satisfaction and complaints
• Patient satisfaction - the degree to
which the patient’s expectations, goals
and preferences are met by the health
service.
• Patient complaints - arise from
dissatisfaction with elements of their
health care experience.

Patient satisfaction and complaints
• Influenced by many variables
• Attribution not always clear
• Victorian Patient Satisfaction Monitor
(VPSM)

Patient satisfaction and complaints
- Victorian approach
• Doctors should be made aware of any
complaint about them
• Medical lead to initiate investigation of
multiple complaints
• ‘Great care’ should be taken in using
complaints or evidence of patient
dissatisfaction in monitoring the
performance of individual doctors

Using the tools to understand an
individual doctor’s s clinical practice
Formal Peer review Strong evidence Strongly
supported
AOS/TCNR Good evidence Supported
Mortality and Good evidence Supported
morbidity reviews
Clinical audit Good evidence Supported
Clinical indicators Limited role Don’t use in
isolation
Patient satisfaction
and complaints
Limited role
Don’t use in
isolation

Key success factors
• Medical leadership at all levels
• Issue for smaller hospitals
• Formal leadership/management positions and
professional leadership
• Clinically focussed culture
• ‘Quality is what we do’
• Processes defined and consistent
• Must be robust
• SMS engaged and leading
• Appropriate resources available including
time

Putting it together

Discussion

Partnering for performance
Implementation support
Next steps
Alison McMillan
Director
Quality, Safety and Patient Experience Branch

www.health.vic.gov.au/clinicalengagement

Implementation support
• Information sessions for senior doctors
• 30min – 1hour sessions at your hospital
• Overview of Partnering for performance
• e.g. presentations at senior medical
staff meetings

Training program
• Commencing August 2010
• Multiple metropolitan and regional sessions
• Program one
– 3 hour workshop for
medical directors/
medical leads
– Undertaking
performance
conversations
• Program two
– One day workshop for
medical directors
– Performance
development and
support processes
– Train-the-trainer

Partnering for performance

Thank you
We welcome and appreciate your input and support