Full Report

The IPs pinpointed specific aspects of each ECCM
element where the Department believed chronic
disease improvements were achievable:
• Diabetes IP: Self-management support – the
integration of self-management support into
regular care
• Renal IP: Decision support and information
systems – clinical pathways and service agreements
as coordination tools in health system design
• Mental health IP: Health system design and
decision support – the use of clinical practice
guidelines in decision support; and the use of
the NWT’s new EMR information system as a
patient database
The aim of the IP evaluation is to generate lessons
learned about how small-scale improvement projects
can be used to build local capacity in chronic disease
change management – and about the impact they
have on the quality of services and care. The evaluation
of the CDM project addresses a mix of implementation,
quality and performance improvement questions
(see Appendix I for detailed evaluation methods).
With IP implementation complete, the
Department is ready for the next step in
the creation of a territory-wide integrated
CDM strategy.
Informing effective strategy development
With IP implementation complete, the Department
is ready for the next step in the creation of a territorywide
integrated CDM strategy. This step involves not
only identifying opportunities for synergy with other
system improvement initiatives, but also developing
a clear understanding of the IP outcomes and the
cross-case implications and lessons that will inform
design of the strategy.
This report evaluates the activities, professional
and organizational changes, and patient and system
outcomes related to phases I and II of the diabetes,
renal disease and mental health IPs. The Department
will draw on the report’s findings to spread and scale
the most effective components of these improvement
projects throughout NWT and contribute to
the development of an effective, integrated and
over-arching CDM strategy based on best practices
and sound evidence.
Spread and scale
Each pilot was meant to not only achieve
incremental change in the management of a
specific disease, but also present lessons for
improvement that could be spread and scaled
in the treatment of other chronic conditions.
Spread and scale are essential to the success
of an integrated CDM strategy:
• Spread refers to the diffusion of innovations
and the broad acceptance of an approach.
The spread of pilot improvement is already
taking place through staff support for the
pilots and adoption of many improvements
in daily practice.
• Scale refers to the increasing size
of an improvement initiative from
limited application in specific sites to
full application across NWT. With the
progressive engagement of more patients,
staff, communities and HSSAs comes the
need to manage complex structural issues
related to growth.
Making the Case for Change
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