Achieving better practice: the Clinical Support Systems Program

Practice based on the best available evidence and the quality and safety of healthcare have become a major focus for governments, healthcare providers and consumers. This increased awareness comes at a time when new heights have been reached in the technical sophistication of care, healthcare systems have become incredibly complex, and there is a potential for patients to be harmed by healthcare interventions.1 Adverse events can seldom be attributed to a single human error and are usually associated with the complex system interactions.1-3 The Quality in Australian Health Care Study,4 published in 1995, served as a catalyst in Australia for promoting system-based approaches to safety and quality improvement. The Clinical Support Systems Program (CSSP)5 is a practical example of this. The CSSP emerged through collaboration between the Royal Australasian College of Physicians (RACP) and the Australian Government Department of Health and Ageing (the Department), and was subsequently sponsored and managed by the RACP. The Department provided most of the funding, with the Victorian Department of Human Services and NSW Health each contributing $500 000, resulting in combined funds of $5.5 million. The formal funded phase of the Program ran from 2000 to 2002. The Program sought to assist the routine uptake of best evidence within clinical practice through a Clinical Support Systems (CSS) model. This model combined the principles of clinical practice improvement (CPI)6 and evidence-based medicine (EBM)7 into a broad framework to enable clinicians to embed best practice routinely in clinical care. It had the following broad specifications (see also Box 1): involvement by clinical teams, health managers and consumers in design, development, implementation and evaluation; establishment of organisational and management structures and tools necessary to develop and maintain capacity for CPI; systematic use of evidence within clinical settings; systematic clinical work practices to reduce inappropriate variation; development of data and analysis systems to support CPI; and routine measurement and review of clinical practices. The CSS model was tested through four consortium-based projects that collectively involved 17 clinical sites across three states. The four projects were selected through a competitive tendering process, based on specific criteria: the projects should involve areas of care that were high cost, high volume or high risk; and for which there was a significant level of evidence relating to diagnosis and treatment, and tangible indicators for a difference between this evidence and current practice. The successful consortia and their projects were: Austin Bowel Cancer Consortium — implemented National Health and Medical Research Council guidelines for colorectal cancer care,8 spanning multiple episodes of acute care (surgery and oncology) in three hospitals: metropolitan, regional and private. Brisbane Cardiac Consortium — adapted national guidelines for management of acute coronary syndromes9 and congestive heart failure10 and systematically implemented the evidence within three hospitals and in general practice. Monash University Consortium — developed local protocols based on the best available evidence (in the absence of national guidelines) for managing patients with acute stroke (first 7 days) and implemented them in four hospital sites: tertiary, regional, rural and private. Towards a Safer Culture (TASC) Consortium — focused on management of acute coronary syndromes9 and stroke (for which there were no such guidelines). The principal area of interest was the emergency department. This program was subsequently extended to the inpatient setting of four hospitals in New South Wales, Queensland and Victoria. The primary aim of each project was to embed the best available evidence into local routine clinical practice. The focus was not on generating new evidence or on proving that evidence-based care improves outcomes for patients. Instead, the projects focused on the structural and cultural dimensions of care, with tangible outcomes such as developing information systems, protocols, tools and organisational pathways necessary to support evidence-based care and influence clinicians to use evidence routinely and sustainably. There was considerable variation between the projects. This heterogeneity included the clinical focus, the amount and type of evidence available and the tasks required to implement the evidence; the environment in which changes were sought; and the number, type and geographical spread of project partners. Projects also varied in their interpretations of the CSS model, change management strategies, project objectives and methods. Each project evolved into a unique, integrated combination of these defining features. The 2-year time frame, and local and wider health system issues over which projects had no direct control, resulted in the projects experiencing varying success. Nevertheless, the consortia all increased their capacity to provide evidence-based care for their patients. The details of their achievements are described in this Supplement (pages S79, S83, S89 and S92).11-14 These projects illustrate the changes required in the structural and cultural dimensions of care to progress towards evidence-based practice becoming routine (Box 2). The projects also uncovered many issues relating to the clinicians and the environments involved, as well as the underlying strategies needed to support implementation of both EBM and CPI. Aspects of the CSSP projects have continued beyond the 2-year funding phase in each of the participating hospitals. In two instances, important project components were taken up by state governments. The Brisbane Cardiac Consortium data sets for acute coronary syndrome and congestive heart failure have been adopted by Queensland Health for wider application. The TASC methodology for management of patients presenting to emergency departments with acute coronary syndromes and stroke is now in use in public hospitals in NSW, funded by the NSW Institute for Clinical Excellence. The RACP has actively promoted uptake of the CSS model in other settings. There is a TASC stroke project in Western Australia, a project targeting otitis media in northern South Australia, another in rural Victoria focusing on community-acquired pneumonia (CAP), and three projects in New Zealand. Clinicians around Australia are now implementing various forms of the CSS model. The CSSP has generated a unique web-based tool that provides a practical introduction to the CSS model and draws heavily on the experiences of clinicians involved in the CSSP.15 An overarching outcome of the CSSP is that it has confirmed that healthcare providers are committed to improving the quality of care. Participants have welcomed the opportunity to reflect on their practice in the light of the best available evidence and CPI. Indeed, the CSSP has created a learning laboratory for its participants and contributed to an increased system capacity to improve healthcare. Further information about the CSSP can be found by visiting the RACP website www.racp.edu.au/bp The Clinical Support Systems model 2: The CSSP projects’ achievements in targeting the structural and cultural dimensions of care Effective teams crossing entrenched structural and professional boundaries Improved care systems across interfaces Improved attitudes towards clinical practice guidelines, clinical practice improvement and consumer involvement Improved staff morale and sense of empowerment Evidence-based tools for clinicians and consumers Information systems providing clinicians with timely, meaningful feedback Improvements in many clinical and organisational outcome indicators

Jenni A Leigh · Paul W Long · Paddy A Phillips · Robin H Mortimer

The concept of the Clinical Support Systems Program (CSSP) was transformed from an idea into reality through the efforts of representatives of the Australian Government Department of Health and Ageing and the Royal Australasian College of Physicians. This collaboration involved developing common ground between two different perspectives: those of the funder/policy/administrative sector and those of the clinical practice world. Bridging these differences to establish an agreed approach to moving forward was a lengthy and difficult process. The process is aided by tension for change. Compromise, persistence and commitment to the end-goal by the parties involved were important features in building and maintaining the momentum of the change process. Many of the difficulties experienced could be traced to differences in decision-making processes between the clinical and the administrative paradigms. Knowledge brokers can assist in bridging the different languages and perspectives of the groups involved.

Jill Sewell FRACP · Paul W Long GradDip (CommMgt) · Jenni A Leigh BA(Hons), BSocAdmin

The Austin Bowel Cancer Consortium aimed to identify drivers of clinical decision-making so as to inform a continuous practice improvement approach to the use of evidence. Strategies for engaging clinicians included a direct clinician–clinician approach, gaining the support of opinion leaders and using the clinicians’ desire for patient outcome data. Interviews with clinicians identified barriers to using evidence in practice. These included poor integration of medical and surgical disciplines, different learning styles, negative attitudes to guidelines and pathways, and no consensus as to what is an effective multidisciplinary team. A clinical implementation group provided a forum for interaction between disciplines. The group agreed on management pathways covering the continuum of care and developed decision-support software for use in the clinic. Interviews with patients and carers highlighted psychosocial and communication difficulties and prompted greater clinician awareness. Consumers developed patient information resources with minimal assistance from project staff. The clinical encounter is the prime site for change for putting evidence into practice, rather than trying to change individual clinicians.

Paul L R Mitchell MB ChB, FRACP, MD · Craig A White MB BS, MBus

In patients hospitalised with acute coronary syndromes (ACS) and congestive heart failure (CHF), evidence suggests opportunities for improving in-hospital and after-hospital care, patient self-care, and hospital–community integration. A multidisciplinary quality improvement program was designed and instigated in Brisbane in October 2000 involving 250 clinicians at three teaching hospitals, 1080 general practitioners (GPs) from five Divisions of General Practice, 1594 patients with ACS and 904 patients with CHF. Quality improvement interventions were implemented over 17 months after a 6-month baseline period and included: clinical decision support (clinical practice guidelines, reminders, checklists, clinical pathways); educational interventions (seminars, academic detailing); regular performance feedback; patient self-management strategies; and hospital–community integration (discharge referral summaries; community pharmacist liaison; patient prompts to attend GPs). Using a before–after study design to assess program impact, significantly more program patients compared with historical controls received: ACS: Angiotensin-converting enzyme (ACE) inhibitors and lipid-lowering agents at discharge, aspirin and β-blockers at 3 months after discharge, inpatient cardiac counselling, and referral to outpatient cardiac rehabilitation. CHF: Assessment for reversible precipitants, use of prophylaxis for deep-venous thrombosis, β-blockers at discharge, ACE inhibitors at 6 months after discharge, imaging of left ventricular function, and optimal management of blood pressure levels. Risk-adjusted mortality rates at 6 and 12 months decreased, respectively, from 9.8% to 7.4% (P = 0.06) and from 13.4% to 10.1% (P = 0.06) for patients with ACS and from 22.8% to 15.2% (P < 0.001) and from 32.8% to 22.4% (P = 0.005) for patients with CHF. Quality improvement programs that feature multifaceted interventions across the continuum of care can change clinical culture, optimise care and improve clinical outcomes.

Ian A Scott MHA, FRACP · Annabel C Hickey MMSc(Clin Epi), BAppSc(OT) · Daniela C J Sanders BPharm(Hons) · Mark A Jones BSc(Hons) · Charles P Denaro MD, FRACP · Cameron J Bennett MB BS, MBiomedE, FRACP · Alison M Mudge MB BS, FRACP · Justine M Thiele BPharm · Judy L Flores BA, MD, FRACP · Beres Wenck FRACGP · John W Bennett BMedSc, MB BS, BA(Hons), FRACGP

As part of the Clinical Support Systems Program, the Monash University Consortium conducted a project to identify factors influencing the implementation of clinical evidence into routine hospital practice. Training was required in the process of clinical practice improvement (CPI) and the nature of evidence. One of the most helpful instruments for change was to point to active models of quality assurance as exemplars. Staff can be trained to be good managers, but leadership is less susceptible to training and is better obtained by selective recruitment. CPI requires rapid feedback on the effectiveness of the implementation. Access to this information and the confluence of management skill, an ability to translate research evidence into routine clinical behaviour and an understanding of the process of quality assurance are central. Effective CPI is only possible when the larger hospital administrative culture is committed to providing the necessary resources.

Malcolm K Horne MB BS, PhD, FRACP

Towards a Safer Culture (TASC) aims to provide a safer culture in hospital departments by introducing clinical pathways for the management of patients with acute coronary syndromes or stroke. Specific clinical pathways have been implemented for patients with different levels of risk to guide the most appropriate evidence-based medical care for each patient. Pathways facilitate continuity of care across different clinical departments by identifying gaps in care, and clarifying tasks and responsibilities. A multidisciplinary and interdepartmental approach to managing patients is seen as an effective way of effecting change. A system for “point-of-care” data acquisition, a centralised database and web-based reporting enable benchmarking for participating hospitals. A comprehensive range of educational/training strategies is used to facilitate multidisciplinary teamwork and promote clinical leadership. Phase 1 of TASC was successfully piloted at four hospitals in New South Wales, Victoria and Queensland. TASC is currently being rolled out to 29 hospitals in NSW and three hospitals in Western Australia.

Catherine T Ferry BN, GradDipPubHlth · M Andrew Fitzpatrick BSc(Med), MD, FRACP · Paul W Long GradDip(CommMgt) · Christopher R Levi BSc(Med), FRACP · Roderick O Bishop BSc(Med), MPH, FACEM

The increasing array of strategies and models for improving clinical practice and patient outcomes can be confusing for clinicians. The Clinical Support Systems (CSS) model has proved to be effective in local environments because it demystifies the design and implementation of evidence-based practice improvement projects. The CSS model is simple and has a wide scope. It provides a broad framework with minimalist specifications, enabling clinicians to design their own systems of care that cut across fragmented organisational structures. Implementing simple rules can be an effective strategy for change in complex care systems. These rules do not impose solutions on clinicians, but rather, help them to find creative solutions that have meaning for them and are contextually relevant.

Robin H Mortimer FRACP · Jillian R Sewell FRACP · Don M Roberton MD, FRACP, FRCPA · Napier M Thomson MD, FRACP · Paul W Long GradDipCommMgt · Jenni A Leigh BA (Hons), BSocAdmin

The Clinical Support Systems Program (CSSP) provided a mechanism for change from the existing entrenched structure and culture of patient care to one based on patient-centred, evidence-based care. The spectrum of change and improvement achieved by the CSSP was extensive, with support from government and active and enthusiastic involvement of clinical champions, practising clinicians, consumers and managers. The CSSP experience confirmed that responsibility for quality clinical care cannot be borne solely by clinicians, and highlighted key areas where improvement in the support clinicians receive is needed. Many barriers to improvement in our complex healthcare system can be removed by recognising the need for accurate data recording and data systems, teamwork, and high-level organisational buy-in, with collaboration between teams and organisations trying to improve the quality of patient care. System-wide improvement has been stimulated and facilitated by the CSSP experience, with mutual flow-on benefits for the activities of the Australian Council for Safety and Quality in Health Care and the National Institute of Clinical Studies.

Jenni A Leigh BA(Hons), BSocAdmin · Paul W Long GradDip(CommMtg) · Bruce H Barraclough AO, FRACS

Steering GroupDr Robin Mortimer, RACP Dr Vin McLoughlin, Department of Health and Ageing Ms Susan Garner, Department of Health and Ageing Ms Mary Draper, Department of Human Services Victoria Ms Maureen Robinson, NSW Health Dr Jill Sewell, RACP Prof Jim Hyde, RACP Mr Paul Long, RACP Evaluators Ms Jenni Leigh and Mr John Pilla, BearingPoint Australia Reference GroupChair: Prof Richard Smallwood, Chief Medical Officer, Commonwealth of Australia Ms Meredith Carter, Health Issues Centre Prof Enrico Coiera, University of New South Wales A/Prof Judith Dwyer, La Trobe University Dr Peter Greenberg, RACP Dr Peter Kennedy, RACP Prof Richard Larkins, Monash University Dr Rick McLean, RACP Prof Jeanette Ward, RACP Mr Robert Wells, Department of Health and Ageing Dr Vin McLoughlin, Department of Health and Ageing Prof Paddy Phillips, Australian Council for Safety and Quality in Health Care Prof George Rubin, Australian Centre for Effective Health Care Prof Nicholas Saunders, NHMRC A/Prof Steven Boyages, RACP Ms Rosemary Bryant, Royal College of Nursing, Australia Mr Lou McCallum, Consumers’ Health Forum Dr Geoffrey Metz, RACP Ms Sally Nathan, Australian Consumers Association Mr Craig G Patterson, RACP Dr Karen Luxford, National Breast Cancer Centre A/Prof Stephen Bolsin, Geelong Hospital Ms Amanda Adrian, NSW Health Care Complaints Commission Ms Fiona Wheatland Tito, Enduring Solutions Prof Bruce Barraclough, Australian Council for Safety and Quality in Health Care Department of Health and AgeingMr Robert Wells, Dr Vin McLoughlin, Ms Susan Garner, Ms Kerrie Murphy, Mr Martin Fletcher, Ms Jenny Thomas, Mr Gerry Van Wyk, Mr Peter Harlow, Mr Julian Hamon Austin Bowel Cancer ConsortiumDr Craig White, Austin and Repatriation Medical Centre Dr Paul Mitchell, Austin and Repatriation Medical Centre Ms Ryhl Gould, Austin and Repatriation Medical Centre Ms Jane Evans, Austin Bowel Cancer Consortium Ms Meredith Carter, Health Issues Centre Prof Susan Long, Swinburne University of Technology Dr John Newton, Swinburne University of Technology Mr Andrew Bui, Austin and Repatriation Medical Centre Mr Andrew Barling, Bendigo Health Care Group Brisbane Cardiac ConsortiumPrincess Alexandra Hospital:Mr Ian Coombes Dr Paul Garrahy Ms Annabel Hickey Prof Thomas Marwick A/Prof Charles Mitchell Ms Daniela Sanders A/Prof Ian Scott Royal Brisbane Hospital:Dr John Atherton Dr Cameron Bennett Mr Neil Cottrell A/Prof Charles Denaro Dr Mark Dooris Dr Alison Mudge Ms Therese Theile Ms Justine Thiele Prof Michael Ward Queen Elizabeth II Hospital:Dr Judy Flores Mr Adam La Caze Dr Malcolm Wright Brisbane North Division of General Practice: Dr Ann McBryde Mr Ian Watts Dr Beres Wenke Dr John Bennett Brisbane Southside Central Division of General Practice:Dr John Aloizis Mr David Gardner Dr John Turnbull Monash University ConsortiumProf Malcolm Horne, Howard Florey Institute Ms Judith Dwyer, Southern Health Ms Julie Andrews, Southern Health Mr Michael Robinson, Southern Health Ms Martine Thompson, Southern Health Ms Jill Peterkin, Southern Health Ms Janelle Finn, Southern Health Prof Chris Silagy (deceased), Monash Institute of Health Services Research A/Prof Jeremy Anderson, Monash Institute of Health Services Research Ms Louise Corben, Monash Medical Centre Ms Cate Wilson, Monash Medical Centre Dr Paul Talman, Monash Medical Centre Mr Neville Kelly, Frankston Hospital Dr Prakash Nayagam, Frankston Hospital Dr Bruce Maydom, West Gippsland Hospital Ms Meredith Carter, Health Issues Centre Dr Judith Frayne, St Frances Xavier Cabrini Hospital Ms Maureen Flaherty, St Frances Xavier Cabrini Hospital Ms Fiona Symington, Project Manager Towards A Safer Culture Consortium (Phase 1 & 2)Prof Katherine McGrath, Hunter Health Ms Robyn Considine, Hunter Health Prof Peter Fletcher, John Hunter Hospital Dr Chris Levi, John Hunter Hospital Dr Julia Lowe, John Hunter Hospital A/Prof Drew Fitzpatrick, Nepean Hospital Dr Rod Bishop, Nepean Hospital Dr Greg Stewart, Wentworth Area Health Service A/Prof Jane Gordon, Wentworth Area Health Service A/Prof Jeff Wasserthiel, Frankston Hospital Dr Carolyn Hullick, Townsville Hospital Dr Christopher Kennedy, Townsville Hospital Dr Andrew Johnson, Townsville Hospital Dr Liz Mullins, Healthcare Risk Resources International Dr Maree Bellamy, Standards Australia Mr Raj Verma, Hunter Health Mr Paul Long, RACP Ms Fiona Wheatland Tito, Enduring Solutions Pty Ltd Mr John Windle, Nepean Blue Mountains Cardiac Support Group Prof Michael Boyer, RACP Dr Ian O’Rourke, NSW Institute for Clinical Excellence Prof Phil Harris, NSW Institute for Clinical Excellence Ms Cate Ferry, NSW Institute for Clinical Excellence Ms Maureen Robinson, NSW Health