“Quality is never an accident. It is always the result of intelligent effort” John Ruskin

Medicare Locals aim to improve the health of their communities.

They will be ‘system redesigners’ for primary care, creating a more equitable, joined up system. And they will work to improve the quality and capacity of the GPs, specialists, allied health, nurses and other health services who work in their community.

If they are to be successful in generating improvement in others, they must themselves function as ‘improvement organisations’. The rather unsavoury expression that they use in the software industry is that ‘they need to eat their own dog food’.

This article introduces the concept of an ‘improvement organisation’, and asks –

• What are the characteristics of an improvement organisation?
• What principles, values and way of working does a Medicare need to adopt to become an improvement organisation?

An Improvement Organisation

Our experience with more than one thousand practice in the Australian Collaboratives suggests that an Improvement Organisation has six ways of thinking.

1. Kaizen

Kaizen is a Japanese word which means ‘falling forward’, an understanding that we are always moving, in a constant state of change. An organisation that is based on the principle of Kaizen will always be looking for better ways of doing things. Having a spirit of ‘kaizen’ provides an organisation with agility and promotes a ‘can-do’ attitude.

2. Focus North

An Improvement Organisation is guided by the values of its customers. The focus should always be North – towards each person in the community we are serving. How can we make things better for each person? How can we engage our community in our planning?

3. Muda Glasses

Think Lean. An Improvement Organisation will seek out ‘muda’, or waste. Muda is any activity that does not add value to the customers. At all levels, have your team wear ‘Muda glasses’ to identify waste.

4. Think Systematically

Every system produces exactly the outcome it was designed to produce.
If we are not producing a desired outcome, we need to change the system.
An improvement organisation is proactive about system change.

5. Think Differently

An Improvement Organisation will foster innovation.

6. Steal Shamelessly and Share Generously.

Fight against the ‘not invented here’ syndrome and actively seek out solutions from other organisations that can be adapted or extended for use in your organisation. Make what’s possible become the usual.

The Model for Improvement

The Model of Improvement (Langley and Nolan) is a proven way of helping humans improve things effectively. It is is built on three fundamental questions. These will be used by an Improvement Organisation to guide all activity.

1 What are we trying to achieve?

What is our clear and stated aim?

2. How will we know that a change is an improvement?

How will we measure the effects of what we do?

3. What changes can we make that may result in improvement.

Once we have the answers to these three questions, we can make change incrementally, using PDSA cycles to assess the effects of change.
The things that we do, and the results of the changes, are formally documented. This creates a map for our organisation and for those who follow.

“If we apply the knowledge that we have in a systematic way for the benefit of all the lives we touch, we will be successful (in the myriad ways that this can be measured. Start with the patient. Finish with the patient. Everything else is really a proxy measure.” (Ralph Audehm)

The Medicare Local as an Improvement Organisation

The Model for Improvement applies and is useful at all levels in an Improvement Organisation, and every member of the Medicare Local team should be able to explain their role in terms of each of the three questions.

What are you trying to achieve?

“What are you trying to achieve?” needs to be answerable ‘up’ and ‘down’ by each team member. How is your activity contributing to the overall aim of the organisation, and how specifically does it add value to the ‘customer’, to a particular person in the community.

I’m the receptionist in the Mental Health Service. I aim to improve the health of the community by improving mental health. My specific role is to manage access to psychologists so that people can get the care they when they need it, minimising delay.I measure how many days wait there is for a patient to get a routine or urgent appoint. I also measure how many people do not turn up for a scheduled appointment. We actively manage our appointments scheduling using this information.

I’m the chief financial officer for the Medicare Local. My job is to make sure that resources are allocated and used most effectively to improve the health of the community. I can demonstrate that each person is getting better care for each dollar we spend.

Measuring Improvement

Measurement is the Oxygen of Improvement – Sir John Oldham

As well as being able to identify their destination, each member of the ML team will know who far they have progressed on the journey.

An improvement organisation measures the outcomes of all it’s activities, to make sure that the changes that are made do in fact lead to improvement.

Deciding upon measures that can be used to guide improvement is an important skill. Where possible, these should be measures of outcomes that matter to the community. Where outcome measures are impractical or not available, process or structural measures will be required.

Change Ideas

Innovation
An Improvement Organisation will be an expert in the use of improvement tools. It will use there to analyse opportunities and contingencies, and to develop and test innovative solutions.

It will actively monitor what is happening in other Medicare Locals and seek to adapt solutions that have been demonstrated to be effective elsewhere. In turn, it will also share its plans and ideas with other Medicare Locals.

Engaging the Community

A successful Medicare Local will belong to its clincians and to its community. There is good evidence that outcomes are improved when the wider community is involved in the planning, management and evaluation of health services. The Medicare Local will need to engage its local community at the earliest stages of planning.

The Improvement Map

Organisations are familiar with the concept of a strategic plan.

An Improvment Organsiation may choose to use an Improvement Map, which we introduce in this article.

Like a strategic plan, an Improvement Map lists all the Objectives of the organisation in a nested manner. Unlike a strategic plan, an Improvement map is a dynamic document that is changed and updated by all members of the ML team.

Each entry in an Improvement map consists of an objective with a clear statement of what is trying to be achieved, and how that is related to the overall aim of the Organsiation and to an individual customer.

It also contains the measures that are used to record progress towards that objective, and is updated to reflect the latest value of that measure.

It contain a list of the activities that are done to achieve that objective, recorders as PDSA cycles. These cycles build on each other to achieve the aim.

Each entry in an Improvement Map is updated by the team members responsible for that objective in the organisation.

An Improvement Map is therefore a dynamic document that will grow with the organsiation. It will tell the whole story of a Medicare Local. It will allow anyone to see where the ML is up to, and how it got there.

Results are Currency

The Medicare Local is owned by and is accountable to its community.

By measuring what it does, it will be able to demonstrate to the community that it is making a difference. It will produce ‘graphs that go up’. It

A Medical Local will be clear at all levels about what it is trying to accomplish, and will retain focus on things that matter to the community. It will engage the community that own it and the clinicians with which it partners. It will be an ‘innovator’ by responding in an agile manner to opportunities and contingencies that arise, and be an ‘early adopter’ of solutions developed elsewhere in the country. The systems it develops will act as a model for all the organisations that it works with who wish to improve.

It will have a documented ‘improvement map’ of where it has come from, what it has done, and what outcomes have improved as a result.

It will clearly be an Improvement Organisation.