In 2012 Waitemata DHB’s board recognised the need to transform the way healthcare services are delivered, and approved the implementation of an Enhanced Care Management and Clinical Leadership Model. The model was endorsed as a primary mechanism for realigning the DHB to its new purpose and values and realising its priorities: to reliably generate the best possible health outcomes and achieve the best patient experience.
The Enhanced Care Management and Clinical Leadership Model is based on evidence drawn from the last decade of research into the characteristics of healthcare organisations that have achieved sustained, outstanding performance by providing high quality, high value care and improved health outcomes. The research shows that transformation in performance comes substantially from clinicians: clinicians not only make frontline decisions that determine the quality and efficiency of care but also have the technical knowledge to help make sound strategic choices about long term service delivery.
The model involves clinicians leading the design of services and care processes that improve health, cost and patient experience outcomes. The model depends on clinicians at all levels engaging in care process redesign and tracking outcomes, with a group of clinical leaders taking on an enhanced management role with control of, and responsibility for, service design and day-to-day clinical operations.
Five Key Components
There are five key components of the Enhanced Care Management and Clinical Leadership Model:
- New management and service structures, with disease and service-line focused clinical units
- An enhanced clinical management role for clinician leaders, with accountability for clinical, operations and financial outcomes and paired administrative support (administrators assisting with day-day administration and reporting to clinician leaders)
- Strengthened leadership training and development for clinicians and managers to prepare them for an enhanced care management role
- Operations redesign led by clinicians, with a focus on designing care processes using standardised , best practice patient care protocols and pathways with protocol-specific measures, and routine reporting of clinical quality, patient experience and financial outcomes
- Development of supporting resources to support clinicians and ensure they have all the resources they need to undertake care redesign and enhanced care management
Five key components of Enhanced Care Management and Clinical Leadership Model
- A clinical pathway is defined as a set of specified and standardized steps and decision rules, allocation of clinical and non-clinical tasks, clinician and patient education materials, and a measurement and reporting system
Clinical Leadership Programme
Implementation of the Enhanced Care Management and Clinical Leadership Model commenced with a clinical leadership training programme delivered by Professor Richard Bohmer, Professor of Business Management, Harvard Business School and Visiting International Fellow, The King's Fund, London, aimed at preparing our clinical leaders and managers for new and expanded enhanced care management roles. The programme consists of a series of modules based on four interdependent tasks of clinical management and care redesign: defining strategy and value; analysing and redesigning operations; understanding and evaluating culture and change; and identifying improvement and innovation:
There is a practical focus to the programme with activities between modules requiring participants to apply the theory and tools taught in a module session and sharing their work with other participants.
To date, two cohorts of clinicians and managers have enrolled in the programme (almost 100 participants). Most participants have attended in teams/groups and have identified significant subpopulations / clinical conditions / key work processes for care redesign. As they have undertaken programme activities they have started to form the beginning of a clinical programme structure that brings together clinicians who provide care to a particular patient subpopulation with particular clinical conditions, and who share one or more work processes.
Clinical Programme activities underway
A significant amount of work has been undertaken by many of the programme participants and a number of changes have been developed and tested, and improvements implemented and measured.
1. Best Care Bundles in ED
For example, the Emergency Department has developed, tested and is measuring Best Care Bundles and care processes; the department’s clinical director has worked with a data architect to develop a customised electronic data infrastructure including an ED data mart and a business intelligence tool that allows data analysis, tracking, trend reporting and document sharing; and the department has begun an analysis of operations that support clinical care processes:
2. Frail Elderly initiatives
A multidisciplinary team of clinicians and managers from our Medicine and Health of Older People Services have been working at identifying and designing services to key subpopulation of patients, the frail elderly. The team has examined ways that frail elderly can be identified, developing and testing a Frail Elderly Assessment Score, which groups elderly patients and allocates a frailty score according to their level of fitness, the presence of disease and their level of independence.
Frail Elderly Assessment Score used by our Frail Elderly team
The frail elderly assessment score was then used to assess 417 patients in our Emergency Department and the Acute Assessment and Diagnostic Unit in March 2014. An analysis of the results of was undertaken to further understand the nature of patients with particular frailty scores and their particular needs, for example the relationship between a patient’s frailty score and the number of presentations to our Emergency Department and Acute Assessment and Diagnostic Unit (see graph below); the relationship between frailty score and admissions to our medical wards and rehabilitation wards (assessment, treatment and rehabilitation (AT&R) wards) (see graph below).
Comparison of patients with frailty score of 5-7 and the number of presentations to ED and ADU
Comparison of patient frailty scores to admissions to our medical and rehabilitation (AT&R) wards
The team has also completed an extensive ‘Why am I here today?’ audit of every patient 65 years and over in hospital over a four-week period, auditing patients every day to develop a better understanding of our frail elderly patients requiring a hospital admission.
Data from the audits is currently being analysed, for example looking at the changing needs of patients throughout their hospital stay.
Analysis of the changing needs of patients throughout their hospital stay
The team has developed a framework for the design of services for frail elderly across the continuum of care (in the community and in hospital); and a framework for in-hospital services for frail elderly. The results of the audit will further inform design of future services for frail elderly patients.
Framework for the design of services for frail elderly across the continuum of care
Framework for in-hospital services for frail elderly
A multidisciplinary team led by the Chief of Surgery is working with a group of patients to co-design the care journey for patients with upper gastrointestinal cancer.
We have commenced the development of an innovations library as resource for teams participating in the programme. The library includes in-depth reviews and summary analyses of new care models, case studies of successful clinician-led enhanced care management, and contact details for experts in the subject matter, which are tailored to the subpopulations and clinical conditions identified by the clinical groups. Here is an example of a review of models of care for frail elderly patients with linked resources that our innovation library has developed:
A new cohort of clinicians will join the programme in 2015.