Choosing Wisely at Austin Health Lessons Learnt in An Australian Health Service

1. Choosing Wisely at Austin HealthLessons Learnt in An Australian Health Service

2. Background • Austin Health is tertiary academic public health service, which services its local catchment and also provides a number of state wide services. Austin operates 911 beds and employs over 8000 staff across three sites • The Choosing Wisely project at Austin Health was funded through the 2016/17 BCV Innovation Fund and delivered with support from NPS MedicineWise (Choosing Wisely Australia) and Eastern Health (NUTS program)

3. Choosing Wisely at Austin Health Objectives: • Engage consumers, clinicians and hospital staff in the concept of “More is not always better” when it comes to medical tests, treatments and procedures • Empower health professionals to question what care is truly needed • Engender support for the project among key health services and non-medical stakeholders • Engage with other health services and healthcare providers in supporting the initiative and encourage implementation of the recommendations • Support clinicians to understand and engage in high quality evidence based practice • Encourage consumers to engage in conversations about their care with their healthcare providers

4. Project Governance • Project Manager – 0.8 EFT • Four clinical leads (consultants) – 0.2 EFT each • Emergency Department / Quality & Audit • Medical Oncology • Anaesthetics / Pain Services • Gastroenterology / Medical Education • Multidisciplinary steering committee – Meeting monthly • Junior medical staff committee - Meeting bi-monthly • Additional resources: • Finance Department • Business Intelligence Unit • Clinical Informatics Team • Communications Team

5. Project Development

6. Topic Selection Core topic areas Coagulation Studies Four key areas of behaviour change strategies undertaken for each topic area Urine Cultures • De-prescribing • Opioids • PPIs

7. Topic Selection Core topic areas Coagulation Studies Four key areas of behaviour change strategies undertaken for each topic area Urine Cultures • De-prescribing • Opioids • PPIs

8. Topic Selection Secondary areas Febrile neutropenia management Activities independently undertaken by the Choosing Wisely Clinical Leads with support from project team CRP Ordering in ED Lower back imaging in ED Colonoscopy preparation End of Life Care CT Imaging for Low Risk PE

9. Coagulation Studies Problem Identification • Anecdotal evidence from senior clinicians that there is a high volume of Coagulation Studies ordered inappropriately • WHY? • Coags = INR, APTT, Fibrinogen and PT as a group • Clinicians ordering coags when only INR needed • Coags being on the list of high frequency tests on electronic ordering system

10. Coagulation Studies Baseline Data

11. Coagulation Studies Behaviour Change Strategies Quality & Audit • Hospital wide audit of test ordering by clinical group • Pre- and post-intervention audit and feedback • Regression modelling of factors associated with multiple test ordering

12. Coagulation Studies Behaviour Change Strategies Quality & Audit • Hospital wide audit of test ordering by clinical group • Pre- and post-intervention audit and feedback • Regression modelling of factors associated with multiple test ordering Policy & Guidelines • Development of new pathology guidelines • Development of Decision Support Tool • Linking of guideline document to online ordering system

13. Coagulation Studies Behaviour Change Strategies Quality & Audit • Hospital wide audit of test ordering by clinical group • Pre- and post-intervention audit and feedback • Regression modelling of factors associated with multiple test ordering Education & Peer Support • Lunch time education sessions • Grand round presentations • Presentations to external groups • Intranet information campaigns • Links to publications and resources Policy & Guidelines • Development of new pathology guidelines • Development of Decision Support Tool • Linking of guideline document to online ordering system

14. Coagulation Studies Behaviour Change Strategies Quality & Audit • Hospital wide audit of test ordering by clinical group • Pre- and post-intervention audit and feedback • Regression modelling of factors associated with multiple test ordering Education & Peer Support • Lunch time education sessions • Grand round presentations • Presentations to external groups • Intranet information campaigns • Links to publications and resources Policy & Guidelines • Development of new pathology guidelines • Development of Decision Support Tool • Linking of guideline document to online ordering system Informatics • Pop-up messaging with the ordering of Coagulation Studies on CERNER • Removal of Coags group from list of Common Tests • Splitting of Coags group

15. Coagulation Studies Decision Support Tool

16. Coagulation Studies Feedback Reports

17. Coagulation Studies Promotional Strategies

18. Coagulation Studies Results – ED

19. Coagulation Studies Results – Hospital Wide

20. Coagulation Studies Results

21. Coagulation Studies Results

22. Coagulation Studies Results For every increase in prescriber, 5 additional coagulation studies were ordered.

23. Urine Cultures Problem Identification • High volume of urine cultures being processed in the microbiology labs in addition to • High volume of repeat tests • Poor reporting of indications for why urine culture has been ordered • High rate of contaminated samples • Inconsistent urine sample collection techniques

24. Urine Cultures Behaviour Change Strategies Quality & Audit • Hospital wide audit of test ordering by clinical group • Pre- and post-intervention audit and feedback • Personalised ED clinician feedback

25. Urine Cultures Behaviour Change Strategies Quality & Audit • Hospital wide audit of test ordering by clinical group • Pre- and post-intervention audit and feedback • Personalised ED clinician feedback Policy & Guidelines • Development of pathology & procedure guidelines • Development of Decision Support Tool • Linking of guideline document to online ordering system

26. Urine Cultures Behaviour Change Strategies Quality & Audit • Hospital wide audit of test ordering by clinical group • Pre- and post-intervention audit and feedback • Personalised ED clinician feedback Education & Peer Support • Lunch time education sessions • Hub campaigns • Links to literature via Hub page • ATLAS Learning module • Educational posters in ED Policy & Guidelines • Development of pathology & procedure guidelines • Development of Decision Support Tool • Linking of guideline document to online ordering system

27. Urine Cultures Behaviour Change Strategies Quality & Audit • Hospital wide audit of test ordering by clinical group • Pre- and post-intervention audit and feedback • Personalised ED clinician feedback Education & Peer Support • Lunch time education sessions • Hub campaigns • Links to literature via Hub page • ATLAS Learning module • Educational posters in ED Informatics • Pop-up messaging with the ordering of Urine Cultures on CERNER • Link to new guideline and flowchart upon ordering of Urine Cultures Policy & Guidelines • Development of pathology & procedure guidelines • Development of Decision Support Tool • Linking of guideline document to online ordering system

28. Urine Cultures Results – Hospital Wide

29. Urine Cultures Results - ED

30. Urine Cultures Promotional Strategies

31. Urine Cultures Decision Support Tool

32. Urine Cultures Results Results

33. CRP Results - ED

34. CRP Results – Hospital Wide

35. Organisation-wide Activities • Updated governance and procedures for Care Set and Order Set development • Nursing, Medical and Consumer surveys • Monthly newsletters • Dedicated intranet page • MDRP Student Projects – Developing adaptive learning platforms • GP newsletter articles and meeting presentations • Creating links with new projects • Discharging Wisely • Testing Wisely – Frequency of discordance HER2 results

36. Organisation-wide Activities • 63% of surveyed staff were aware of Choosing Wisely and the 5 Questions for Consumers • 78% believe Choosing Wisely to be a worthwhile investment • 65% would feel comfortable encouraging the use of the 5 Questions • 84% had heard Choosing Wisely discussed at hospital meetings • Top 3 Enablers for Conversation between Patient and Clinicians • 1. More Time • 2. More information • 3. Clinician Skill • 75% of consumers felt that the 5 Questions for consumers had utility in the consultation space • 84% felt comfortable asking their health professionals about necessary care • 89% of consumers had their last test at the hospital initiated by the clinician • 84% would use the Urine Culture poster to guide them on the correct way to collect a sample • Top 3 Barriers to Asking their Clinician Questions • 1. Insufficient appointment time • 2. Trust the doctor‘s expertise • 3. Worried about taking up doctor time

37. Sustainability Strategies

38. Sustainability Strategies

39. Lessons Learnt • Multi-disciplinary engagement and motivation • Culture change • Making successful changes part of everyday practice • Importance of robust data systems • Ongoing monitoring and feedback • Active engagement with established systems: • Intern orientation and education curriculum • Research Week • QI activities across the hospital

40. Next steps • State-wide leadership through the Choosing Wisely Scaling Collaboration 2018-2019 • EOI process will commence early 2018 for 10 health services to join the collaborative • Focus of the collaborative will be reducing unnecessary pathology and imaging tests through empowering and guiding health services in the principles of Choosing Wisely