BMJ-IHI International Forum on Quality and Safetyaws-cdn.internationalforum.bmj.com/pdfs/D6_parts_a,b,c.pdf2015/04/23  · BMJ-IHI International Forum on Quality and Safety April 23,

Carolyn Canfield

citizen-patienthonorary lecturer, Faculty of MedicineUniversity of British Columbia

BMJ-IHI International Forum on Quality and Safety

April 23, 2015

disclosures• volunteer without income

• expenses and/or honoraria

from publicly-funded, non-profits

(Canada, Sweden, Norway, Denmark, UK, USA)

ERAS Society

• NO commercial interests or sponsors

S

Nick Francis1929 - 2008

Closed

Hierarchical

Organization

Network of

Relationships

Patient Engagement

Why bother??

BMJ 2013;346:f2614 doi: 10.1136/bmj.f2614 (Published 14 May 2013)

“the citizen-patient”

Why engage citizen-patients?

to improve the quality of healthcare

to inform and educate patients and the public

to build confidence with the public

to make better use of health care resources

to improve how health services are evaluated

to transform healthcare culture

Adapted from Cartwright and Crowe, 2011

We’re all patients, Carolyn!

So, David.

What do patients think?

“What, all of them?”

Green S., Involving people in healthcare

policy and practice. 2007. Oxford: Radcliffe.

~ David Gilbert

Recruiting

• Seek the right fit of skills and attributes

• “Strength in Diversity”

• Your citizen-patients are likely nearby

• Build on small successes

• Enthusiasm is contagious

• Invest in valued relationships

www.healthinnovationforum.org/

www.healthinnovationforum.org/

www.1000livesplus.wales.nhs.uk/opendoc/224646

Cartwright, J., Crowe, S., (2011).

Patient and public involvement

toolkit. BMJ Books/Wiley-Blackwell.

12 tough questions before you start

The first five…

What are we aiming to achieve?

Where have we got to so far?

What will the citizen-patients get out of it?

Are we prepared to resource it properly?

Why have we not done this before?

Adapted from Cartwright and Crowe, 2011

Involve citizen-patients from the start?

Honest in managing their expectations?

What are our expectations?

Prepared to give up some power?

Prepared to take some criticism?

Next five of 12 tough questions…

Adapted from Cartwright and Crowe, 2011

Commitment to this from the top and the

bottom of the organization?

Long-term change, or one-off effort?

The last of 12 tough questions…

Adapted from Cartwright and Crowe, 2011

www.hpoe.org/resources/hpoehretaha-

guides/1828

www.hpoe.org/resources/hpoehretaha-

guides/1828

Boyd H, McKernon S, Old A. 2010.

Health Service Co-design: working with patients

to

improve healthcare services. Auckland:

Waitemata

District Health Board. October 2010

engagementcycle.org

www.albertahealthservices.ca/PatientsFamilies/if-pf-pe-engage-

toolkit.pdf

www.albertahealthservices.ca/PatientsFamilies/if-pf-pe-engage-toolkit.pdf

speaker

coach

Honorary Lecturer

instructor

advisor

champion

team member

What it means to Patientsand Families AND Staff

skills

respect

awareness

competence

clarity

calmness

accountability

intuition

communications

interdependence

and more!

Really??!

Thank you!

Carolyn Canfieldcitizen-patient

honorary lecturer

UBC Faculty of Medicine

Vancouver, Canada

carolyn.canfield@ubc.ca

Achieving prudent healthcare in NHS Wales

Prudent healthcare in NHS Wales

Paul Gimson, National Programme Manager for Primary Care1000 Lives Improvement

Increasing and complex demand on healthcare

• Our population is increasing and getting older

• More people are being diagnosed with one or more long-term health conditions like diabetes and dementia

• Frail and older people increasingly have more complex needs

Insert name of presentation on Master Slide

The Challenge

In Wales one third of adults or 28% of the population

report living with at least one chronic condition

Of people over 65 yrs two thirds reported having at

least one chronic condition and one third had

multiple chronic conditions

Over three-quarters of people aged over 85yrs

reported having a limiting long term illness

Over two thirds of all NHS Wales resources are spent

treating people with chronic conditions

These figures are expected to grow, however NHS

Wales is tasked with improving quality and reducing

costs

‘Imprudent Healthcare’

• 10% Healthcare interventions associated with harm

• 20% of work done by health service has no effect on outcomes

• Only 18% of time spent in clinical environment offers immediate value –the rest is spent waiting

Achieving prudent healthcare in NHS Wales, 1000Livesi, 2014

Prudent healthcare

“Healthcare which is conceived,

managed and delivered in a cautious

and wise way characterised by

forethought, vigilance and careful

budgeting which achieves tangible

benefits and quality outcomes for

patients.”

Achieving prudent healthcare in NHS Wales

Prudent healthcare

“Healthcare which is conceived,

managed and delivered in a cautious

and wise way characterised by

forethought, vigilance and careful

budgeting which achieves tangible

benefits and quality outcomes for

patients.”

Achieving prudent healthcare in NHS Wales

Establishing the principles

Achieving prudent healthcare in NHS Wales

Dec 2013: ‘Simply Prudent Healthcare’Bevan Commission

Jan 2014: Prudent healthcare in a time of austerity – the Minister’s speech

Four workshops

• 30 delegates

• Patients, managers

and clinicians

• 10 guests

Achieving prudent healthcare in NHS Wales

• Identify opportunities

• Indicate methods

• Comment on principles

Four workshops

• Adult pain management

– Cardiff & Vale University Health Board

• Medicine prescribing

– Cwm Taf University Health Board

• Adult hearing loss, dizziness and tinnitus

– ABMU Health Board

• Knee and hip problems

– Aneurin Bevan University Health Board

Achieving prudent healthcare in NHS Wales

Review of the workshop

Achieving prudent healthcare in NHS Wales

Principles revised

Achieving prudent healthcare in NHS Wales

• Do no harm.

• Carry out the minimum appropriate intervention.

• Organise the workforce around the “only do, what only you can do” principle.

• Promote equity.

• Remodel the relationship between user and provider on the basis of co-production.

Revised principles in Ministerial statement, July 2014

Principles revised – again!

Insert name of presentation on Master Slide

Insert name of presentation on Master Slide

www.prudenthealthcare.org.uk/

Implementing prudent healthcare

1. Greater focus on prevention, promoting wellness and healthy behaviours, improving community cohesion

2. Prudent Prescribing – tackling de-prescribing and polypharmacy

3. Shared goal setting and shared decision making (better outcomes & use of evidence)

4. Working together across primary and secondary care – alternatives to referral, improving access to specialists & patient experience

5. Refraining from interventions with low clinical value and no robust evidence base (e.g. NICE do not do)

Insert name of presentation on Master Slide

Some further Thoughts on Prudent Healthcare

• It directly involves patients in designing their own care and participating in co-creating services – and taking responsibility

• It focuses on obtaining the best outcomes for patients, discarding practices which are of marginal or no benefit, or may even cause harm (EXNOVATE!!!)

• It is allied with a global movement seeking to reduce harmful overmedicalisation

Prudent healthcare – a wider perspective

Achieving prudent healthcare in NHS Wales

• Choosing Wisely Canada– Targeting unnecessary tests,

treatments and procedures

• Better Value Healthcare

https://www.youtube.com/watch?v=FqQ-JuRDkl8

How?

• Leadership

• Organisational development

• Clinical Engagement

• Values driven working and recruitment culture

• A greater emphasis on patient-set goals and priorities

• Exploring lifestyle interventions rather than medical responses

• Understanding (and delivering) what matters most to people who use the service

• A focus on PERSON CENTRED CARE

Insert name of presentation on Master Slide

PERSON CENTRED

CARE

SHARED

DECISION

MAKING

CO-

PRODUCTION

SUPPORTED

SELF

MANAGEMENT

PARTNERSHIP

WORKING

Co-Production and Prudent Healthcare

1. Education Programme for Patients

2. Learning in Action – A national co-production / partnership programme

3. Prudent Interactions Collaborative

Insert name of presentation on Master Slide

What skills do individuals need?

Goal setting and planning

for action

Problem solving

Follow up

Pacing and balancing life

Communication – with

family, friends and

effectively with clinicians

Agenda setting

Making choices, deals and

decisions.

Relaxation & mindfulness

Managing setbacks

Handling and challenging

difficult emotions

Planning to stay well

Insert name of presentation on Master Slide

What does EPP Cymru Offer

A choice of health and well being courses for adults

•Health & Well Being course - Chronic Disease Self

Management Programme

•A course for carers - Looking After Me

•A short half day course - Introduction to Self

Management

•Diabetes Self Management Programme

•A course to manage breathlessness

Insert name of presentation on Master Slide

EPP - Benefits for Participants

Increased confidence, self-esteem and feeling of self-

worth

Improved ability to cope with symptoms

Develop more effective relationships with those caring

for them

Manage their condition more effectively, working in

partnership with healthcare professionals

Use new skills and knowledge to improve quality of life

Insert name of presentation on Master Slide

Prudent Interaction Collaborative

• Bringing together Shared Decision Making and Supported Self-Management

• A structured programme to clinical teams over 3 learning sessions complemented by ‘action periods’ between sessions

• Impact on patients measured using the National Service User Experience core questions at intervals throughout

Insert name of presentation on Master Slide

Learning in Action

• A programme to support the practical application of co- production values into health and social care delivery across all sectors and in so doing build a critical mass to ensure the spread of co production at community level.

• Builds capacity through a ‘Train the Trainer’ approach with a focus on Shared Decision Making

• Supported and measured by an IT Platform (Sensemaker)

Insert name of presentation on Master Slide

Learning in Action

WHY?

Whole System Integrated Care

Living longer

and living well

Co-designing integrated care policy with patients and carers:

the NW London experience

Professor Lis PaiceMichael Morton,

Co-Chairs of Embedding Partnerships NW London Whole Systems Integrated Care

Living longer

and living well

Introduction to North West London (NWL)

• Diverse, aging population

• Pockets of deprivation

• Variable primary care

2 million people

£4bn annual health & care spend

400+ General Practices

10 acute & specialist hospital trusts

2 mental health trusts

2 community health trusts

Living longer

and living well 73

• Integrated Care in NW London

Pilot launched in 2011

Tackling: -Fragmented careUnreliable primary careVariable patient experienceSteadily rising unplanned admissions

Provider partnershipGradual involvement of patient group

Living longer

and living well

NWL ‘Whole Systems’ Integrated Care (WSIC) - 2013

Family

Community

as assets

Carer

Community

care

Social care

Mental

health

Hospital

Housing

Voluntary

sector

Employment

Education

Assistive technology

Underpinned by:• Information systems• Governance• Reimbursement

Held together by resilience

Supported to self manage

General Practice

Other neighbouring

practices

Patient’s

own GP

practice

Community pharmacy

Living longer

and living well

Recruitment and support

• Nominations• ‘Role profiles’• Information • Expenses, briefings,

admin support• Finding a name –

‘Lay Partners’• Training day

“The Effective Lay Partner” workshop 2013

“After today’s workshop I am going to resume

pushing for change on issues about which I feel

strongly”

“My key insight from the day was how

important it is to adopt a collaborative

approach in resolving difficult issues”

Living longer

and living well

WSIC programme governance structure: co-design phase

NWL Integration Board

Programme Board

Embedding Partnerships

Communications and PMO

Programme Executive Group Programme Team Points of contact

Population and Outcomes

working group

GP Networks working group

Provider Networks

working group

Informatics working group

Commissioning & Finance

working group

WSIC Lay Partners ForumWSIC Lay Partners

Advisory Group

Co

-de

sign

wo

rkin

g gr

ou

ps

= Lay Partner representation

Living longer

and living well 77

Early lessons

77

• Need to prepare and educate professionals • ‘Touchstone’ setting out principles of coproduction• Lay Partners more effective in pairs than solo• Lay Partners need to meet as a group • Realism about time commitment• Equity of professional support

Living longer

and living well

Impact of Lay Partners

• Lay Partners bring courage and encouragement

• Whole life assets – not just experience of ill health

• Push for and maintain ‘blue sky’ thinking

• Hold projects to account• Maintain a healthy tension

between delivery and co-design

• Bring patients to the centre of policy

• Embed insights and expertise from different backgrounds

• Influence and challenge language and behaviour

“The essence of Whole Systems is about being inclusive – we need to reach out to a broad spectrum of provider partners.”

“It did feel to me like a culture changing moment, to seek to represent our work in an accessible and people focused way… but it is a challenging and time consuming and will take real commitment!”

The NWL Whole Systems Integrated Care toolkit

“Lay partners are the guardians of the vision”

Living longer

and living well 7979

Living longer

and living well

Issues & challenges

Issues that have arisen• Pace and scale pressures – need for significant commitment (unpaid)• The need for Lay Partners to have both knowledge and confidence for effective

challenge• Lack of diversity among the Lay Partners - can they speak for everyone?

Future Challenges• Roll-out to local areas – are enough patients and carers skilled and motivated to contribute?• How do we get new people in while retaining the experience and learning of the original team?• How do we make sure the vision of co-production is not lost in the pressure to deliver?• How do we move from ‘pilot’ to ‘the way we do things round here’?