>> Hi, my name is Nicole Rasmussen
and I'm the Director of Patient Safety
and Improvement at Alfred Health.
Over the next little while
I'm going to take you on the Hitchhiker's Guide
to the Galaxy of Clinical Variation,
and also a practical approach to the identification
and management of unwarranted variation.
Before we begin, I would like to acknowledge
the Boon Wurrung clan of the Kulin nation
who are the custodians of the land and waters
in which I stand, and pay my respects
to the Elders past, present, and emerging.
In terms of where I am coming to you today
is from the Moss Room,
which is the recently opened innovation
and education hub at the Alfred.
Behind me you will see a solid wall of green,
and believe it or not, that's actually live moss,
and this surrounds all of the walls in this room.
The intention of this room
is to promote thinking and conversations
that are energised, expansive and elevated.
And I thought that's quite fitting given
the conversation that we are having
in the presentation that we are covering today.
A little bit about Alfred Health.
We are a quaternary health service located
in the inner Bayside suburbs
of Melbourne, metropolitan Melbourne.
We provide acute, sub-acute, community
and specialist outpatient services,
as well as a total of 17 statewide services,
so essentially caring for all Victorians.
What this means is that at any one time
over 50% of patients that are with us
actually reside outside our immediate catchment area.
We are a major provider of trauma service
and we have a sizable ICU of 44 beds
split over two levels creating a surgical
and a medical ICU service.
So essentially, we care for some
of the most complex and sickest patients within our state.
And that context is particularly important
as I'll step through one of the examples
of clinical variation analysis and improvement
that we've undertaken at Alfred Health.
Why are we focused on clinical variation?
Variation in practice
in and of itself isn't bad as such when
it's aligned with or in accordance
with the patient's clinical care needs
or in accordance with the patient's preferences
and healthcare choices.
Variation that isn't aligned with these factors,
can link to suboptimal patient outcomes, patient harm
and ineffective use of clinical resources,
either through over-servicing or importantly under-servicing
where patients don't receive or have access
to the care that would make a big difference
to their quality of life.
It's difficult I think
in healthcare, we have finite resources,
multiple priorities, competing priorities, and loads of data.
So it's really difficult to identify where or how to begin.
And this is where the User Guide
to Review Clinical Variation is important.
It outlines some key criteria
that health services can use to inform their priority areas.
I've listed just a few here that are most relevant
to Alfred Health and that we routinely use
to inform our identification of areas
for a priority focus and analysis.
So the next step is identifying how
to assess clinical variation.
And the first part of this is actually looking
to the data that's available.
And in my mind, this forms into two broad categories.
One is around a top-down approach
and the other is bottom-up which I'll come
to on the next slide.
The top down approach consists of benchmarked external data.
Some examples are listed there,
but I'll pay particular attention
to clinical quality registries as this has been an area
of focus for us at Alfred Health over
the last three to four years.
The clinical quality registries are important data sets
that provide oversight to the appropriateness
and effectiveness of care delivery
within a very specific domain.
They provide opportunity for comparison of
performance against our peers,
and also provide an opportunity
to identify outliers where they occur.
Alfred Health participates in over 70 clinical registries
and 25 of these have a consistent benchmarkable data.
And they've become a critical data set
that we routinely review and use
to inform our opportunities for improvement.
Interesting, the clinical quality registries
also align, some of them align
to the clinical care standards.
So it allows for a streamlined approach
to the evaluation of the performance against
those clinical care standards.
So they are a critical information source
for us around appropriateness and effectiveness of care.
The other data set is bottom-up
or what I consider internally derived.
So it's information and performance data around our quality
and safety delivery, often at a
patient level or unit level.
It's learnings from serious adverse event reviews,
it's the learnings or referrals that come
from mortality and morbidity review meetings
and also, of course, the comparison of performance
either across units,
quality and safety across units within the health service,
or aligned with those external KPIs and benchmark targets.
So once you understand the data sets available,
you identify which data sets are appropriate
for comparison in line
with the priority area that's in focus.
The next step is to undertake analysis.
And the purpose of undertaking analysis
is to understand, identify where there
is clinical variation,
but importantly understand where that variation
is unwarranted and identify
opportunities for improvement.
It's at this point that the data
in and of itself will not provide the answer.
It's important to engage the clinical workforce
and the expertise
that's within the health service to help understand
and accurately triangulate the data
to form a picture around patient care and outcomes.
Importantly, engagement of clinicians
and the custodians of the data is important.
We found that particularly the case
with the clinical quality registries
because it's understanding the data definitions
that sit behind that, the risk adjustment
if there is any, and so on.
Equally important is to consider the interdisciplinary team
beyond what we traditionally consider
to be medical, nursing, allied health
and pharmacy, for example.
But drawing on expertise within the organisation
that provides a more holistic lens
of the data that's available for the analysis.
So that's where calling on the health information managers
because of their coding expertise
and also the health informaticians that are
within our performance units.
Using the triangulation and the deep dive into
the data, combined with the important conversations
and analysis from clinicians
on how they are delivering care goes a long way
in identifying what are the contributing factors
to variants in clinical practice
and what are those contributing factors that can be improved
to help minimise unwarranted variation.
Documentation audits, observational practices,
all of the observation
of practice, are all important data sources
or information sources to help create that picture
of where we need to improve.
This slide is information dense
but I really just wanted to illustrate the coming together
and the interdisciplinary analysis that occurs
in lots of different ways.
We've got Risk Based Committees,
so where there are identification
of clinical risks they are aligned
to those established committees
and they have the clinical leadership around the table
to inform where we need to improve.
We have an Evidence Based Review Committee
and 'committee' is probably not quite the accurate term,
it's probably more of a 'council'
in that it's not decision-making,
but it provides the organisation with recommendations based
on the evaluation of best practice,
and ensuring the practice is consistent and cost effective.
It's really underpinning
those appropriateness effective domains of quality that
that committee oversees.
The other element is around topic-specific working groups
or task forces,
and these arise in response to emerging risks
or in response to the coming together of people
that are enthusiastic, curious and have energy
about understanding the appropriateness and effectiveness
of the care that's delivered within their domain.
So here I've called I've given example
of our Hospital Acquired Complication working group.
Others for example, in more recent times
there was the Sternal Wound Infection Task Force.
So again, bringing senior clinicians together
with the right people around the table
to be able to accurately understand the clinical workflows
that are leading to the patient outcomes,
and identifying opportunities for improvement.
I'll step through an example at Alfred Health.
This is an actual, whilst it says case study
it's actually an example
of where we've identified clinical variation
and suboptimal patient outcome outcomes
and where we've had a targeted intervention approach
to improve patient care in this space.
It relates specifically
to hospital acquired anticoagulant related complications.
In terms of this particular issue in patient care,
we knew that we had a problem
through our serious adverse event process,
and we knew that we had patient mortality
where suboptimal anticoagulation therapy
had been considered a potential contributing factor
to the patient's outcome.
It's been identified as a risk on the High Risk Register
and in review of patient-level data as part
of the routine audit against best practice guidelines.
It also identified challenges ... and in conversations
with clinicians identified the challenges
that they are experiencing on a day-to-day basis,
caring for our complex patient cohort.
There's often conflicting indications
for prophylaxis management.
Managing that delicate balance between the risk
of bleeding versus the risk of developing an inpatient
PE or DVT.
We were also flagged
as an outlier in the Health Roundtable data around
the hospital acquired complication VTE.
So, all of these came together and formed a picture
that we had an issue and we needed to have some targetted
intervention to understand what the issues were
and then address them systematically.
So what did we find as part of that analysis?
We convened the interdisciplinary group,
it revealed lots of useful insights
that helped that informing improvements.
Completion of risk assessments
on admission wasn't as consistent
as the evidence would advise that it should be.
Talking with clinicians highlighted the challenges
that they faced in terms
of the complex patient cohort,
particularly the surgical patients,
and trauma being a significant proportion of those.
Documentation of mechanical prophylaxis.
So as part of the medical record review,
identifying patients that clinically would
have been appropriate for mechanical prophylaxis
yet, there was no evidence of the consideration
for that as an intervention.
And then the fourth point which was perhaps
the most interesting, and also it's an important learning,
was that there were some cases
where patients, despite our best efforts,
developed an unavoidable DVT or PE.
And this was due to again the complex nature
of our patient cohort
and the unmodifiable patient factors that contributed
to the patient risk profile.
Altogether it provided a roadmap
of where we needed to improve, implement strategies
to support clinicians, and they're listed here.
As you can see, it's a comprehensive programme
and it's been underway for quite some time now.
As a result of the reviews,
a dedicated VTE specialist pharmacist role was established.
They carry a pager, the numbers on it, spell out CLOT
and they're a fantastic resource.
That's at the elbow, at the end of the phone,
for clinicians to be able to obtain advice
when they're navigating those high-risk patient groups,
and the surgical group as I said in particular.
The governance has been established,
there's a well-established,
Anti-coagulation Stewardship Committee. It's modelled
on the antimicrobial and stewardship approach.
And again, senior clinicians around
the table have very clear remit
in the oversight of the safety and quality of care delivery
within these particular domain.
We had opportunities with the implementation
of the electronic medical record,
which was rolled out a couple of years ago.
Ss part of that design and implementation,
there was the opportunity to build
in evidence-based practice and guidelines
that support clinicians at the time,
but in terms of clinical care delivery.
This occurs in the form of risk alerts,
so there are alerts that trigger
and prompt clinicians to complete VTE risk assessment
and also to then guide them
in appropriate care management.
And then lastly, there's been intensive effort working
with the clinical units targeting
those high risk patient groups
and tailoring the evidence-based practice guidelines
to better meet their unique care needs.
So has it made a difference?
And the answer is 'Yes'.
So you can see over the last four years
we've managed to achieve around a 66% reduction
in the rate of hospital acquired PEs and DVTs.
So it's fantastic, it's certainly - we're kicking goals.
You can see from this slide,
in terms of the risk profile
of medical versus surgical patients
that you can see that the surgical patients
continue to be our high risk group
but they also are heading in the right direction
in terms of the occurrence
of hospital acquired PEs and DVTs.
But the challenge is,
'Do you think we're there? Have we solved it?
Have we arrived at our destination?' And the answer is 'No'.
It is absolutely a journey.
We're continuing to do a deeper dive
with our Health Roundtable data
to better understand the contributing factors
to our outlier status with early indications,
with thinking that it's the trauma cohort
that are contributing to that.
It remains on our organisational risk register.
And just recently we've identified a couple
of key metrics to elevate it to the executive,
or organisational quality and safety performance report,
so that it has that high level view
and profile in terms of this being a particular risk for us.
And then of course,
continuing to work with the high-risk groups,
for example, burns patients. We provide a statewide service
for burns, and working
with that particular group in again tailoring
the evidence-based guidelines
to better support those patients.
So in summary,
a systematic review of clinical variation
is an iterative journey,
and it needs to be underpinned by strong clinical engagement
as well as data-led continuous improvement.
Embedding and integrating the approach
with the clinical governance framework
of a given health service will provide
a solid foundation enduring oversight
of the appropriateness and effectiveness
of healthcare delivery and patient outcomes.
Regardless of where you are on your journey,
make sure that you stop, you pause to celebrate your wins
and successes in improving patient care
and sharing your learnings along the way.
The Alfred Health, this takes the form of a Chair
of a Board Award for Patient Safety and Quality Improvement.
I've got a couple of examples of last year's winners,
they're on the screen for you.
It also takes the form of sharing showcase events
for our clinical programmes, providing them opportunity again
to identify where they have -
to share where they have identified opportunities
for improvement in the clinical care delivery,
and the achievement of improvements
in patient care experience and outcomes.
For our clinical units, they provide
an annual report presenting their quality
and safety performance over the year,
and highlighting any key improvements
that they have undertaken and outcomes that they have achieved
in terms of progressing, improving patient care.
The annual audits consist of -
there is a requirement that consists of benchmark data.
So there certainly is the maturity in terms
of that analysis of performance and the identification
and proactive management of unwanted variation.
This concludes my journey with you
to the Hitchhiker's Guide of Clinical Variation,
and I thank you for your time.
I'll leave you with the wise, friendly words
of Douglas Adams, and that is, 'Don't panic'.
And I wish you all the very best on your own journey through
the review of clinical variation
and improving patient care
and outcomes. Thank you.