UNSW research centre for primary health care and equity

An intervention to enhance teamwork within general practice

Jane Taggart

UNSW Research Centre for Primary Health Care & Equity

InvestigatorsChief Investigators

CIA Professor Mark HarrisCIB Dr Judy ProudfootCIC Professor Justin BeilbyCID Professor Patrick CrookesCIE E/Prof Geoffrey MeredithCIF A/Professor Deborah Black

Associate InvestigatorsA/Professor Elizabeth PattersonDr David PerkinsMr Gawaine Powell DaviesMr Matt HanrahanDr Barbara Booth

Team: Bettina Christl, Jocelyn Tan, Anita Schwartz, Corinne Opt’ Hoog, Pauline Van Dort, Linda Greer, Mahnaz Fanaian, Shane Pascoe, Sue Kirby, Leigh Cantero, Peta Sharrock, Oshana Hermiz

UNSW Research Centre for Primary Health Care & Equity

• Taggart J, Schwartz A, Harris MF, Perkins D, Powell Davies G, Proudfoot J, Fanaian M, Crookes P. Facilitating teamwork in general practice: moving from theory to practice. Australian Journal of Primary Health. 2009; 15: 24-28.

www.publish.csiro.au/journals/py

• Perkins D, Harris MF, Tan J, Christl B, Taggart J, Fanaian M. Engaging participants in a complex intervention trial in Australian General Practice. BMC Medical Research Methodology. 2008; 8:55.

UNSW Research Centre for Primary Health Care & Equity

AimTo describe:• The Teamwork Study and intervention

• What helped / limited practices to achieve goals?

• What worked with the facilitation?

UNSW Research Centre for Primary Health Care & Equity

The Teamwork StudyTo evaluate the impact of an intervention designed

to enhance the role of non GP staff in chronic disease management in general practice

The quality of care to patients with diabetes, ischaemic heart disease/hypertension

Patient satisfactionTeam climate, staff roles, readiness for change and job

satisfaction of staff Clinical linkages

UNSW Research Centre for Primary Health Care & Equity

Our previous researchBuilding effective teams requires:• defined roles and responsibilities• clear protocols• effective communication• leadership• training• linkages with other services

Aspect of teamwork most associated with quality chronic care was utilising administrative staff in

systems

UNSW Research Centre for Primary Health Care & Equity

11 Systems1. Structured Appointment System2. Patient Disease Register3. Recall & Reminder System4. Patient Education and Resources5. Planned Care6. Practice Based Linkages7. Roles, Responsibilities & Job Descriptions8. Communication & Meetings9. Practice Billing System10. Record Keeping11. Quality

UNSW Research Centre for Primary Health Care & Equity

Characteristics of practicesIntervention (n=30) Control (n=30)

Metro / region

Rural / remote

12

18

19

11

1-3 GPs

4 GPs

Mean FTE GPs (SD)

12

18

3.07 (1.70)

13

17

3.49 (2.39)

0 PN

1 PN

2 PNs

Mean FTE PNs (SD)

2

9

19

1.09 (0.77)

3

14

13

1.12 (1.01)

Mean FTE PMs (SD) 0.69 (0.33) 0.92 (0.51)

Mean FTE Admin (SD) 2.55 (1.87) 2.92 (1.96)

Mean FTE Allied Health (SD)

0.13 (0.38) 0.12 (0.38)

UNSW Research Centre for Primary Health Care & Equity

Structure of intervention Education session – 1 to 2 hours

– Background, evidence, clinical guidelines, teamwork and systems– Practices identify driver / practice lead

3 practice visits over 3 to 6 months – 1 to 1.5 hours each– Worked on priority system chosen by practice– Set goals, tasks and timeframes– Roles of non-GP staff

Resources– Manuals and workbooks for each system

UNSW Research Centre for Primary Health Care & Equity

Priorities chosen (29 practices)

Planned care 23 (80%)

Communications and meetings

4 (14%)

Roles and responsibilities

3 (10%)

Patient disease registers

2 (6%)

Recall and reminder systems

1 (3%)

Clinical linkages 1 (3%)

UNSW Research Centre for Primary Health Care & Equity

ObservationsWhat helped practices achieve goalscommitted driverskilled and motivated staffrange of staff involved in intervention meetingsstructured practice visits by facilitatorswriting goals and timeframesuseful resources

UNSW Research Centre for Primary Health Care & Equity

ObservationsWhat limited practices achieving goals no leader or lead person did not have skills to be proactive low staff morale staff not ready for change clinical software limitations or lack of knowledge of clinical

software lack of space other practice priorities not starting on planned care component

UNSW Research Centre for Primary Health Care & Equity

“liked having someone from outside the practice

providing advice and resources and time to

discuss ways to improve the care of chronic disease

patients”. (PN)

“having the goals and tasks written with

target dates helped to set things in motion”.

(PM)

"it made us sit down and look at what we do, what we want to do and how we go about doing

it”. (GP)

What worked with the facilitation

UNSW Research Centre for Primary Health Care & Equity

What worked with the facilitation

• Practices in control• Range of staff participating in visits• Flexibility – cater for differences• Setting follow-up visit in 4 to 6 weeks time• Facilitators with practice support experience • Walking through resources / tools

UNSW Research Centre for Primary Health Care & Equity

UNSW Research Centre for Primary Health Care & Equity

What practices achieved Expanded roles of non-GP staff, electronic templates, diabetes clinic,

group sessions, health assessments

Written procedures and pathways to combine GPMP, TCA and SIP, wallet card for patients with appointments, questionnaire to patients for HMR

Reviewed roles and responsibilities of PNs, planned and structured meetings for all staff, Friday Facts

System to identify diabetes patients at risk, recall for planned care

Diabetes clinic coordinator position, structured meetings

UNSW Research Centre for Primary Health Care & Equity

A case studyGroup practice – regional NSW

5 GPs, 2 PNs, Full Time PM

11 staff attended education session

Visits 1, 2 & 3 with PM and PN

Worked on goal: All diabetes patients onto GPMPs and annual cycle of care

Audit showed 60% were on GPMPs

1. Developed a care pathway and billing charts for GPMPs, TCAs and the Diabetes SIP

2. Designed flexible working model for diabetes clinic in consultation with DGP

3. Took to clinical meeting for input and commitment

4. Whole practice meeting to plan implementation in more detail

5. Started with 1 GP, modified and extended to all GPs

•Whole practice commitment•Leadership from PM and PN•All staff informed and involved

UNSW research centre for primary health care and equity

ThankyouFor more information

M.F.Harris@unsw.edu.au

or

J.Taggart@unsw.edu.au

www.cphce.unsw.edu.au