Skip to 0 minutes and 4 secondsRaj Verma: Firstly, it comes back to the philosophy of not mandating. And so in many health systems, the central agencies will create best practice, or a new model and say, you must implement this. And so what you end up with is a lot of people who feel like they're hostages on a new journey that they don't want to be part of. We don't feel that that is a value added. In fact, that can turn people against good service improvement. So we actually make the offering voluntarily so people join up with us voluntarily. We may fund the project manager or fund some capability development that they need to believe in and they need to volunteer to do it.
Skip to 0 minutes and 45 secondsBut when our teams go out there, they need to work with those front-line people and understand their context of their setting and create a case for change that they can bond with. So our teams will sit with those coalitions of the front line, go through their own medical records, their own data, talk to their patients, and show that there's an issue that needs fixing. Once that's demonstrated, the local team is much more likely to say, yeah, I'm involved. I'm on board. I need to do something about this.
Skip to 1 minute and 14 secondsAnd then we can work with them on the new methodologies, engaging people to make the change, trialling that change, seeing what works, what doesn't, coaching people through the hard times because you're bringing a lot of people along on a change and you're changing behaviour. You're changing people and that's hard. And it's not just about technical change, it's about what people believe in and what people have always done and they feel safe in because health is a very risk-averse setting. People don't want to change from something that they think works because it's not delivering good results to something else because you need to change their behaviour and so you need to work with them. It can be hard.
Skip to 1 minute and 54 secondsIt can be two steps forward, one step back. And so being there for them and being at the end of the phone or being there every other week in their face talking it through them, giving them a box of tissues to wipe away the tears sometimes. It's really hard but without it, change just falls away. We've learned through hard experience. Everyone starts with a we've got a great idea, everyone should do it. Why isn't everyone else just doing this? It makes sense. It saves money, it's better for patients but it's not that easy. We've learned that through bitter experience and now it's much-- in fact, the term rollout should be banned, I believe, because there's no such thing as rollout.
Skip to 2 minutes and 35 secondsEvery change in every place is localised and has to be adapted to those local circumstances and the people who are there. I believe that capability development is the biggest thing. So once you develop people's capability of changing locally, they can do further change themselves so the next time you come with a great idea to improve care, they're capable of doing it themselves, a lot less hand-holding is required. But they can also then go to their sister hospitals and become the champions for that change and actually do it themselves.
Skip to 3 minutes and 7 secondsIan Kirkpatrick: This requires very specific skills and knowledge on the part of your change team--
Skip to 3 minutes and 13 secondsRaj Verma: Yeah.
Skip to 3 minutes and 14 secondsIan Kirkpatrick: Your change leadership team.
Skip to 3 minutes and 15 secondsRaj Verma: Yes.
Skip to 3 minutes and 16 secondsIan Kirkpatrick: You mentioned that they were-- they behave like internal consultants that they were--
Skip to 3 minutes and 20 secondsRaj Verma: Yes. We spent a lot of time building up our teams and all of my staff have to go through our redesign school and develop those skills. We do a lot of professional development, staying up with the latest and greatest in terms of change and coaching and supporting people to go through change, so yes.
Skip to 3 minutes and 39 secondsIan Kirkpatrick: Are they mainly clinicians?
Skip to 3 minutes and 41 secondsRaj Verma: Yeah, I'd say 80% of my staff are clinicians, nurses, and allied health in domain.
Skip to 3 minutes and 45 secondsIan Kirkpatrick: Does that make a difference?
Skip to 3 minutes and 47 secondsRaj Verma: I think it makes a difference because they can talk to front-line clinicians and relate to them much better one-on-one. But I have gotten on clinicians who can do the same but it's a much harder job because they have to get up to speed and sound like they're a clinician. Clinicians love talking to clinicians.
Using managed clinical networks to re-design services: the Agency for Clinical Innovation in New South Wales
Here we will explore the implementation of networks in a more developed health system: the Australian state of New South Wales. Specifically we look at networks that involve not just clinical professionals but also organisations and which are concerned both with disseminating best practice and developing entirely new innovations. In an earlier step we described these as ‘integrated service delivery networks’
We will hear from Dr Raj Verma, Head of Clinical Programme Design and Implementation at the Agency for Clinical Innovation (ACI) in NSW, Australia. Please watch the video and read the supporting text below.
As you will see, the ACI represents an exciting example of how a state supported clinical network can assist with the development and translation of solutions to increasingly complex (‘wicked’) public health problems (see week one). To accomplish its mission of innovating healthcare practice, the ACI acts like an umbrella organisation for many other more specific clinical networks, helping to engage multiple stakeholders to develop solutions and translate them into practice at the state level. In what follows, you will learn more about the specific approach adopted by ACI and, in particular, its focus on engaging and facilitating change that is led by clinicians themselves, as opposed to mandating change in a top down fashion.
With 7.3 million inhabitants, New South Wales is the most populous state in Australia. Health care is provided by 15 geographically defined Local Health Districts and the Justice and Forensic Mental Health Network. As we saw in week two, Australia is a federal country, with public funding and responsibility for health care divided between its states, territories or provinces and the federal government (the Commonwealth). Although the system provides universal access to health care, the Commonwealth is responsible for general practitioner (GP) services while the states run hospitals. Victoria is one of six states and two territories. In total, Australia spends 9.3 per cent of its gross domestic product on health care.
The origins of the ACI date back to 2008 when a Special Commission of Inquiry was convened following an avoidable death of a young girl in a Sydney emergency department. This involved a wide-ranging investigation into acute care services in NSW. Among other things, the Commission’s Report recommended the bringing together of existing but as yet dispersed networks and task forces to form a “new, more comprehensive agency … tasked to coordinate and drive constant innovation across the whole system … and be responsible for continuing reform and improvement of clinical models of care and practices” (Garling, 2008: 4). This led to creation of the ACI in 2010, tasked with consolidating and expanding the work done by existing networks. Specifically the ACI was designated as the “primary agency for engaging clinical service networks and designing and implementing new models of care” (NSW Health, 2011). Although a statutory body, ACI has no formal powers to mandate changes in practice across the system through engagement and voluntary participation.
In 2016 ACI employed 111 full time equivalent staff, approximately 80% of whom have clinical backgrounds. ACI is led by an Executive Team consisting of a Chief Executive, a part time Clinical Lead Staff Specialist and six Executive Directors. Staff are grouped across three clinical portfolios to reflect their main area of work: Acute Care; Surgery, Anaesthesia and Critical Care; and Primary Care and Chronic Services. Together these portfolios house a total of 40 clinical networks. These networks are extremely diverse in nature, ranging from those that represent organisations or units within organisations (such as intensive care), specialist diseases, or which cohere around particular patient groups or demographics (for example care for the elderly). Participation is high, with over 6000 volunteers signed up to various networks and 3000 who are more actively involved through roles such as members of working groups.
To support the process of developing and translating new innovations, the ACI employs a variety of strategies. Initial support is provided to develop ideas, including economic evaluations. The process of change itself is then supported by a dedicated Implementation team who work closely with clinicians and managers on the ground and by a Redesign School. The latter is a dedicated resource aimed at teaching clinicians how to deliver change, providing certificates and training in specific implementation technology created by the ACI. As part of this process, a Patient Experience team also becomes involved to ensure the ‘patient view of the problem and solution’ is always factored into any project. Last but not least, an Evaluation Team is employed to gather summative and formative information of the performance of new innovations. This has been important to strengthen the evidence base for new innovation and provide legitimacy for the ACI itself in the eyes of clinicians and politicians responsible for continued funding.
Garling, P. (2008) Final report of the Commission of Inquiry: Acute Care Services in NSW Public Hospitals. Sydney: State of NSW.
NSW Health (2011) The Future Arrangements for Governance of NSW Health. Report of the Director General. North Sydney: NSW Health.
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