“The only thing to do with good advice is to pass it on. It is never of any use to oneself.” – Oscar Wilde
Like a new golfer, general practice is a frequent recipient of advice.
Towers of guidelines rise threateningly above our desks, taunting us in their unopened plastic sheaths. Evidence floods our mailboxes like spam does our email boxes. Your patient’s cholesterol should be this, their BP should be less than such and such, everyone should take this, no-one should do that.
Common to the advice we receive is that no one offering it knows how to achieve the suggested outcomes in practice. We are told to hit the ball into the hole, but we are not told how to achieve that.
Barbara Starfield (Professor of Medicine at John Hopkins School of Public Health) has studied the effectiveness of health care systems around the world. She tells us that chronic illness is not improved by more specialists, better diagnostic tools, or new treatments. Chronic illness is improved by the better delivery of primary care.
The National Primary Care Collaborative (NPCC) program is working to bridge the gap between what the evidence tells us and what is achieved in practice. The program assists practices to improve their systems through a process of small, incremental changes, and measuring the result of each action to ensure that the change is an improvement.
487 practices Australia wide have participated in the fist three waves of the program, with another 68 currently involved in local collaboratives. In total, 29 practices from this division will have been trained in the process.They are sharing their stories and the steps that they take to improve their systems.
So what have we learnt from our peers about the best way to ‘hit the ball into the hole’ with regard to our diabetic patients? Every practice is unique, of course, but successful practices have many of the following characteristics
They have allocated time to examine the systems and process that are used in their practice.
They have an accurate diabetes register and know their patient population. They have systems in place to measure the outcomes their patients are achieving. They know the percentage of their practices who are reaching targets in HbA1C, blood pressure, cholesterol, etc. and they can identify those who are not to target.
They have decided as a whole practice they will be proactive and systematic in the management of their diabetic patients and have engaged their practice team to assist in this process.
Most use Practice Nurses as Chronic Disease Managers, as it seems RNs often have better skills in being systematic then doctors. In addition, some practices have appointed practice management staff to act as Administrative Disease Register Managers, to manage recalls and reminders, and to assist in identifying patients who might benefit from more intensive interventions.
They provide integrated care.
Often diabetic educators, dieticians or exercise physiologists perform clinics in the practice. Care delivered outside the practice will be co-ordinated so that communication is comprehensive and timely.
Patient self management is fostered.
Patients who understand their own condition and the targets they should achieve are significantly more likely to have better control of their diabetes. Some practices organise supermarket visits, and others group educational evenings.
They have developed comprehensive cycles of care for their diabetic patients.
The practice system ensures that each patient receives the appropriate care from the appropriate team member at the appropriate time. They have adopted a continuous quality improvement model, and therefore continue to make small changes and measure the outcomes. They utilise EPC and practice nurse item numbers optimally to improve their practice finances, ensuring the sustainability of their processes.
If you keep doing what you’re doing, you keep getting what you’re getting.
Practices that have developed skills in the collaborative method often report that it is exciting to adopt a more proactive approach to diabetic management. The team approach has enabled them to improve the patient’s heath outcomes and the practice incomes, while making work easier for the doctors. That’s got to be better than par.