Collaborative Handbook

The material contained within the handbook was based on an original concept, designed by
the National Primary Care Development Team (NPDT) in England, now known as the Improve-
ment Foundation Limited. Some of the material within the handbook was supplied by and is
used with the kind permission of the Improvement Foundation, who retain copyright over their
original work. Other material has been adapted from the Improvement Foundation’s work.

© 2006 Health Quality Council (HQC)

Please contact the Health Quality Council for written permission to distribute or copy this docu-
ment, in whole or in part. Permissions do not extend to any materials within this document that
are used with the permission of a third party.

Please use the following citation style when referring to this document:
Health Quality Council. Saskatchewan Chronic Disease Management Handbook.
Saskatoon, SK: Health Quality Council. 2006.

November 2006

A message from the Chief Executive Officer
katchewan’s health care to care is a key component
community. of chronic disease manage-
ment. And so we added the
We began thinking about a third topic area to the Col-
Collaborative after the re- laborative.
lease of our first major re-
port, looking at the quality of Wave 1 began in November
care for post-heart attack 2005, with more than 200
patients. There was great health care providers, medi-
interest from providers and cal office staff, managers,
health regions to improve and others, including pa-
care in this area, and the tients, taking lead roles. For

W
Collaborative approach was the past year, these teams
elcome to a natural fit. As we ap- have been making small but
Wave 2 of the proached our stakeholders powerful changes. Indeed,
Saskatche- with the idea, we heard many of these are shared in
wan Chronic Disease Man- again and again that diabe- the Ideas in Action section of
agement Collaborative, and tes and heart disease were this handbook. I know that
congratulations on being strongly linked. Indeed, this Wave will also contrib-
part of the largest quality there is a push to consider ute a wealth of knowledge
improvement initiative in our diabetes as a cardiovascular and ideas that will help pro-
province. As CEO of Health disease. pel change forward.
Quality Council, I speak for
everyone involved with our We were encouraged to Thank you for taking up the
organization when I say how consider running a Collabo- challenge to make the Col-
proud we are of all the rative on both topics, and we laborative vision a reality: to
champions participating in agreed that the two be- improve the care and health
this initiative. longed together. As the pro- of people living with coro-
ject progressed, we linked nary artery disease and dia-
HQC may be leading the with other organizations that betes in Saskatchewan, and
Collaborative, but I truly con- had run Collaboratives – the to improve access to physi-
sider it a “grassroots” initia- National Primary Care De- cian practices.
tive. We would not be em- velopment Team, the Insti-
barking on this journey with- tute for Healthcare Improve-
out the encouragement of ment, and the British Colum-
our health care partners. It bia Heart Healthy Collabora-
has been heartening to see tive. These dialogues high-
the drive and enthusiasm for lighted the importance of Ben Chan, MD MPH MPA
improvement from Sas- improving access, as access Chief Executive Officer

November 2006

A message from the Clinical Chair
valuable parts of the Col- There are a few that I have
laborative. found particularly exciting.
Group visits are a new way
The second thing that to deliver care, and a
comes to mind is how moti- method that I think will be-
vating it is to know what kind come more prevalent. Col-
of care you are providing. laborative teams have tried
Not just to think you are pro- the group visit and found
viding good care, but to that it offers some important
know without a doubt when benefits to patients. I have
you have achieved it. This also watched with interest as

I
information is inspiring for team members have tried
t has been almost patients as well as care pro- new roles, and looked at dif-
one year since I, viders. When a patient ferent, more efficient ways of
along with 200 brave comes to an appointment dividing the work. We’ve
pioneers, embarked on a and sees his flowsheet, and seen non-clinicians learn
journey to improve the qual- can see that the lifestyle more about patient care and
ity of care for patients with choices—diet and exer- pharmacists providing en-
diabetes and coronary artery cise—are making a differ- hanced patient education, to
disease, and to improve ac- ence, that flowsheet be- name just a few changes.
cess to practices. As we comes a powerful tool for
start Wave 2, I can’t help but change. You can see that for I know this next year will be
look back on the first 12 the first time, the patient as exciting as the first, be-
months of this experience. truly understands how to cause there is still much we
manage his or her chronic can learn together. Through-
The first thing that comes to disease. The patient transi- out the journey, you will be
mind is how exciting it has tions from being a user of supported by your Clinical
been to be part of a some- health care services, to be- Leadership team, the Col-
thing so innovative. It has ing a partner in care. laborative Facilitators in
been rewarding to work dif- each region, and by the en-
ferently with people and pro- The past year has also held tire HQC team. Together we
viders in my community, and moments of amazement, will make Saskatchewan a
to connect with people out- learning about what other leader in managing chronic
side of my community. So participants are doing to disease.
often in health care we work make change. There seems
in silos; the opportunity to to be no end to the great
engage other clinicians be- ideas being tried. You can
yond my region’s borders read about these ideas in Dr. Vino Padayachee
has been one of the most the Ideas in Action section. Clinical Chair

Acknowledgements
Development of this Handbook was led by Shari Furniss, HQC
Communications Consultant, with input from the following HQC
staff:

• Helena Klomp, Senior Researcher
• Katherine Stevenson, Knowledge Exchange Consultant
• Tanya Verrall, Researcher
• Debra Woods, Knowledge Exchange Consultant
• Maureen Bingham, Director of Linkage and Exchange
• Pete Welch, Informatics Consultant
• Bonnie Brossart, Program Director/Deputy CEO

Our sincere appreciation to Dr. Mark Cameron, Dr. Carla Eis-
enhauer, Dr. Tessa Laubscher, Dr. Vino Padayachee, and Dr.
Ben Chan, for their review of and expert feedback on working
versions of this document.

ISBN 1-897155-24-7

Overview

Included in this section:
Mission…..Vision…..Three models together…..Learning
model…..Model for Improvement…..Chronic care model

© Health Quality Council 2005

Vision and mission

Our vision is to improve the care and health of people living
with coronary artery disease and diabetes in Saskatchewan,
and to improve access to physician practices.

Our mission is to assist Saskatchewan health care profession-
als and organizations to develop their capacity and capability
to deliver rapid, sustainable, and systematic improvements in
the care they provide to patients with chronic disease. This will
be achieved through understanding and the effective applica-
tion of quality improvement methods and skills.

© Health Quality Council 2006 1-1

Three models together

The Chronic Disease Management Collaborative brings to-
gether three key models to improve quality of care for people
with chronic disease. Although at first three models may seem
overwhelming, they actually work together quite easily.

Guided by the evidence-based principles of good chronic care
(Expanded Chronic Care Model), health care professionals
and organizations become part of a network of experts and fel-
low learners (the Collaborative Learning Model) in order to
gain skills in performing rapid, small tests that lead to the im-
plementation of changes that make sense in each unique set-
ting (Model for Improvement).

The next few pages will go over each of these three models in
more detail.


The Learning Model
The Collaborative Learning Model makes health care profes-
sionals and organizations part of a network of experts and fel-
low learners.

A Collaborative is a learn-by-doing approach to quality im-
provement. It brings together practitioners from various disci-
plines and sites. A Collaborative teaches ideas on how to im-
prove practices (based on evidence found in research litera-
ture). Throughout the Collaborative, participants and sites
share their experiences and learn from one another, and net-
works are established.

Quality improvement Collaboratives have been used success-
fully in many countries over the last decade to achieve rapid
improvements in healthcare delivery, and covering a variety of
topic areas. This unique and results-oriented approach to qual-
ity improvement was pioneered by the Institute for Healthcare
Improvement (IHI) and Associates in Process Improvement.

In 1995, the IHI organized a series of Collaboratives referred to
as the Breakthrough Series. These Collaboratives targeted
ten topic areas needing improvement, as identified in surveys
and interviews with healthcare leaders. Topic areas included:
caesarean section rates, physician prescribing practices, adult
intensive care, neonatal intensive care, adult cardiac surgery,
asthma care, low back pain, adverse drug events, inventory
levels and supplier management, and, reducing delays and
wait times.

The Collaborative model has been successful in supporting
quality improvement in health care in the US, the UK, Australia,
Europe, and Canada. A review of the outcomes from the Cana-
dian Adult ICU Collaborative demonstrates that the Collabora-
tive approach combined with a change method (the Improve-
ment Model) and a supporting infrastructure can and has made
significant improvements in delivery of intensive care to adults.


Key features of a Collaborative
It’s Collaborative with a capital “C”. A Collaborative is not
just working together collaboratively, nor is it:
• A fix-all solution. The Collaborative approach does
not work for every improvement project.
• A research project for new knowledge. A Collabora-
tive is about putting evidence into practice.
• A set of conferences. Four Learning Workshops are
held during the course of a Collaborative. These
Learning Workshops are structured events used to
spread best practices. Conferences are about re-
ceiving information, but Learning Workshops are
about sharing information.
• A passive exercise. Between Learning Workshops,
participants engage in an Action Period. They imple-
ment and test small-scale changes to meet the
overall improvement aims.
• An easy option. The Collaborative culture is about
group learning and rapid doing, flexibility in ideas
and methods, but firm on results. Participants are
challenged to build a stronger team, share success,
and learn from failures.

Collaborative Process How a Collaborative works

Select Topic Participants 1. A Collaborative begins with the selection
of a topic. Factors typically considered in
choosing a topic:
Reference Panel
Pre- • Are there gaps in existing service?
work

Identify Change • Is it a common problem?
LW0 LW1 LW2 LW3
Concepts • Is there evidence of a better system?
SPREAD • Is it a priority for clinicians?
Support
Adapted from the 2. Based on the topic chosen, appropriate
National Primary Care experts are invited to join an Expert Reference Panel. The
Development Team.
Expert Reference Panel advises the planning group on
goals, aims, measurement strategies, and change con-
cepts.


Key features of a Collaborative
3. Sites are then invited to participate in the Collaborative. In-
formation meetings are held to discuss the project with key
stakeholders. Each participating site establishes a multi-
disciplinary quality improvement team.
4. The Learning Workshop Orientation (LWO) is held. QI
teams review expectations and learn about quality improve-
ment, including the Model for Improvement and data meas-
urement. They are also introduced to available support peo-
ple such as Collaborative Facilitators and the Clinical
Team.
5. Participants attend three more Learning Workshops (LWs)
during the course of the Collaborative. At these sessions,
participants share results, exchange ideas, and develop
strategies for change. In between Workshops, teams test
and implement changes, collect data, and track improve-
ments. This is called the Action Period.

y p

Act Plan
• Objective
• What changes • Questions/predictions
During Action Periods, are to be made? • Plan to carry out the cycle
QI teams use the Plan- (who, what, where, when)
Do-Study-Act cycle to • Next cycle? •Plan for data collection
implement and test
small changes.
Study Do
• Complete the • Carry out the plan
analysis of the data • Document problems
• Compare data to and unexpected
predictions observations
• Summarize what • Begin analysis
was learned of the data


Why a Collaborative?
The Collaborative approach does not work for every improve-
ment project. But under the right circumstances, it can acceler-
ate change and be enormously effective.

Examples of Collaborative achievements

The Improvement Foundation
Formerly the National Primary Care Development Team
(England)

The non-profit Improvement Foundation incorporates the work
of the former National Primary Care Development Team
(NPDT). The NPDT was originally established in February
2000 to run the National Primary Care Collaborative (NPCC),
currently the world’s largest improvement program.

To start, the focus was on three areas: improving care for pa-
tients with coronary artery disease, improving access to ap-
pointments, and improving access to routine secondary ser-
vices. Since then, they have completed Collaboratives in areas
such as improving care for patients with diabetes and develop-
ing healthy communities.

The NPCC, the first of the NPDT’s programs, now engages
5,000 practices covering more than 32 million people. A few
examples of their achievements:
• A four-fold greater reduction in coronary heart dis-
ease mortality in Collaborative sites, compared to
the rest of England
• Estimated to have saved 6,070 lives
• A 17% improvement in diabetic patients with excel-
lent control (A1C<7.5%)
• More than 70% improvement in waiting times to see
a GP
• Average patient wait to see a GP reduced from 5
days to less than 1.5 days

Source: www.improve.nhs.uk, accessed September 12, 2006.


Scottish Primary Care Collaborative
(Scotland)

The Scottish Primary Care Collaborative is a partnership be-
tween the NPDT and the Scottish Executive Centre for Change
and Innovation. It was established as a result of the success of
Phase I and II of the National Primary Care Collaborative.

The focus of the Scottish Collaborative is on improving access
to physician practices and improving the care of patients with
diabetes. The SPCC Phase I involves 38 sites, 182 core prac-
tices and 13 of the 15 Health Boards in Scotland, and has the
potential to benefit 3.2 million patients within Scotland. In the
first 5 months they have achieved the following results:
• 20% improvement in proportion of patients with A1C
< 7.5%
• 25% improvement in proportion of patients with cho-
lesterol < 5 mmol/L
• 23% improvement in proportion of patients with
blood pressure < 140/80
• More than 35% improvement in days to 3rd next
available appointment with GP

Source: www.show.scot.nhs.uk, accessed September 12,
2006.

National Primary Care Collaborative
(Australia)

The National Primary Care Collaborative is a partnership be-
tween the NPDT and Australia’s Flinders University. Australia
is similar to Saskatchewan in that they have a mix of fee-for-
service and alternate payment family physicians/general practi-
tioners. They too have vast distances, remote and rural popula-
tions, and an Aboriginal population.

The NPCC program is national in scope and focuses on three


topic areas: secondary prevention of coronary heart disease,
diabetes, and better patient access to appointments. A few
examples of their achievements to date:
• 90% improvement in CHD patients recorded as be-
ing on a statin
• 51% increase in percentage of diabetes patients
with last recorded A1C of ≤ 7.0%
• 69% improvement percentage of diabetes patients
with last measured total cholesterol of < 4.0 mmol/L
• 21% increase in patients seen by practice on day of
choice

Source: www.npcc.com.au, accessed September 12, 2006.

Health Disparities Collaborative
(Institute for Healthcare Improvement, USA)

In 1998 the Health Resources and Services Administration in
the United States partnered with the Institute for Healthcare
Improvement (IHI) on a Health Disparities Collaborative. The
goal of the Collaborative was to provide support to over 3,500
communities and 12 million underserved and underinsured
people, such as the homeless and migrant workers.

The first Health Disparities Collaborative focused on diabetes.
Other Collaboratives have been done on asthma, depression,
cardiovascular disease, and cancer. Some highlights from their
work:
• 300% increase in the number of patients meeting
the goal of two A1C tests per year
• More than 30,000 patients enrolled in active care
registries

Source: www.healthdisparities.net, accessed September 12,
2006.


Partners in Health
(Peru)

In 1990, only half of patients in Peru diagnosed with tuberculo-
sis (TB) were able to get treatment. Of those, nearly 50% were
unable to complete the six-month course of therapy, and drugs
were often in short supply. Partners in Health implemented a
community-based treatment program. In 2002, they partnered
with the IHI and launched a Collaborative to study and spread
improvement in TB treatment. Some of their achievements to
date:
• In Peru, 9 out of 10 people with TB die; Partners in
Health’s patients are now seeing an 80% cure rate
• Of the original 1,450 patients treated under the Part-
ners project, only 438 remained on treatment by the
end of 2004
• Results have persuaded the World Health Organiza-
tion to add TB medicines to their list of essential
drugs

Source: www.pih.org, accessed September 12, 2006.

Healthy Heart Society
(British Columbia)

In 1997, congestive heart failure was the primary cause of
death for people in British Columbia and was a tremendous
burden on the health system, costing more than $96 million per
year. The Healthy Heart Society, together with the Ministry of
Health Services and the Health Authorities, launched a 15-
month Collaborative to improve chronic disease management
for patients with heart failure. Some of their achievements:
• 272% increase in the proportion of patients on ACE
or ARB
• 256% increase in the proportion of patients on Beta-
Blocker


• 1000% increase in the proportion of patients with
self-management goals

Source: www.heartbc.ca, accessed September 12, 2006.

The Vancouver Island Health Authority also launched a diabe-
tes Collaborative. It involved 6,000 patients in 52 GP practices
receiving care according to evidence-based guidelines. Im-
provement from March 2004 until August 2005:
• Patients with A1C < 7.0% improved from 63.8% to
75.5%
• Patients with systolic blood pressure of < 130/80
improved from 50.7% to 75.3
• Patients with lipid ratio < 4.0 mmol/L improved from
50.2% to 72.4%

Source: Presentation by Dr. Art Macgregor, SK CDM Collabo-
rative Learning Workshop Orientation, November 2005.


Model for Improvement
This section was adapted from England’s National Primary Care
Development Team and includes references from:
Langley, G. J., et al. The Improvement Guide : A Practical
Approach to Enhancing Organizational Performance. San
Francisco: Jossey-Bass. 1996.

Introduction
Our environment is constantly changing. Some changes are
imposed on us and we have to find a way to manage the im-
pact. At other times, change is something we choose to make,
motivated by the desire to make things better. It is obvious to
say it, but while every improvement is certainly a change, every
change is not always an improvement.

Making changes to the way that we do things can be time-
consuming and can sometimes feel risky. The Model for Im-
provement (Langley et al. 1996) is a tried and tested approach
to achieving successful change. Use of the Model for Improve-
ment offers the following benefits:
• It is a simple approach that anyone can apply;
• It reduces risk by starting small;
• It can be used to help plan, develop and implement
change; and,
• It is highly effective.

The Model for Improvement
The Model for improvement was first published in 1996 by
Langley et al. in The Improvement Guide: A Practical Approach
to Enhancing Organisational Performance. The Model for Im-
provement provides a framework for developing, testing and
implementing changes to the way that things are done that will
lead to improvement.

The Model for Improvement consists of two parts that are of
equal importance. The first, the ‘thinking part’, consists of three
fundamental questions that are essential for guiding improve-
ment work. The second part, the ‘doing part’, is made up of
Plan-Do-Study-Act (PDSA) cycles that will help you make rapid
changes.


The three fundamental questions for achieving improve-
ment

A planned approach to improving things will give you a better
chance of being successful. The three fundamental questions
for achieving improvement are a useful way of framing your
work.
1. What are we trying to accomplish?
What are we trying to This question is intended to help you be clear about
accomplish? the improvements that you would like to make, what
results you would like to get, and how you would like
things to be different. Having a clear vision of your aims is
crucial.
How will we know that a change is
improvement? 2. How will we know that a change is an
improvement?
Without measurement it is impossible to know whether you
have improved. Think about how you want things to be
ACT PLAN different when you have implemented your change
and agree what data you need to collect to meas-
ure it. You can focus your measurement on your
What changes can we
results or how outcomes might be different, how
make that will result in the service that your patients receive will be
improvement? better, or how your processes might change.

STUDY DO 3. What changes can we make that will lead to an
improvement?
Adapted from the National Primary Finally, you need to decide what changes you will try in order to
Care Development Team.
achieve the results you are looking for. What evidence do you
have from elsewhere about what is most likely to work? What
do you and your team think is a good idea? What have other
people done that you could try? This is where you can adapt
ideas or be completely creative. Remember that you know your
own system best, so keep your objectives in mind and use your
knowledge and experience to guide you. Gather together as
many ideas as you can. These will form the basis for the next
step – your PDSA ramps.


PDSA ramp
Once you have decided exactly what you want to achieve, you
can use a PDSA ramp, a series of Plan-Do-Study-Act rounds to
test out your ideas developed from the third question,
‘What changes can we make that will lead to an improvement?’

The key to a PDSA ramp is to try out your change on a
small scale to begin with and to rely on using many con-
secutive cycles to build up information about how effective
your change is. This makes it easier to get started, gives
results rapidly and reduces the risk of something going
wrong. If what you try doesn’t work as well as you
hoped, you can always go back to the way you did things
before. When you have built up enough information to feel
Within a PDSA ramp, you will cycle confident about your change, you can then implement it as part
through many PDSAs.
of your system.

Think of a ‘small’ PDSA cycle in terms of the scope of your test.
You might, for example, like to run your cycle over one day,
with one person or in one clinic. You might wish to look at the
last ten patients seen, the last twenty referrals made, or the
next dozen reports.

It helps to spend some time making your ‘Plan’ explicit and en-
sure that you are clear on the objective of the particular PDSA:
what you are specifically trying to do, who will carry it out, and
when and where. It is also crucial to voice your predictions be-
cause we often find what we are looking for (confirmation bias)
and making our predictions explicit helps us to learn more
when that prediction is confirmed or refuted. Finally, your plan
should include the measures you are going to use to see if the
change you are trying in this PDSA is an improvement.

The ‘Do’ is simply that – try it out and document what you did
as sometimes your plan and how it gets realized are somewhat
different.

The ‘Study’ part of the cycle gives you the opportunity to reflect


on what happened, think about what you have learned, and to
build your knowledge for further improvement.

Finally, you can move on to your next steps – the ‘Act’ part of
the cycle. Do you need to run the same cycle again, gathering
more evidence or making some modifications based on what
you learned? Or do you need to develop further cycles to move
your work forward?

Practicalities
• Improvement is nearly always a team endeavour.
Try to ensure that you involve the right people in
your work.

• People have a tendency to jump straight to solutions
rather than really work out what the root of the prob-
lem is. If you use the three fundamental questions,
it will help you be sure that you are dealing with the
issue that really needs to be addressed.

• When you plan your cycle, make sure you are clear
about who is doing what, where, and when. Your
results are dependent on how good your plan is.
PDSA planning templates (Individual and Ramp) are
included in the Additional Information & Resources
section.

• Discuss what you think will happen when you try out
your change. What is your hunch? When you have
carried out the cycle, compare your expectations
with what actually happened. You may learn some-
thing interesting about how things work.

• Record your PDSA as you go along: the plan, the
results, what you learned, and what you are going to
do next. Not only is it very motivating to see the re-
sults of what you have tried, it is also a great way of


accumulating information about your systems and a
good way of sharing your learning with other people.

• Use PDSAs consecutively to build up the information
about your change and then use them to implement it
systematically into your daily work. PDSA cycles gener-
ally do not operate in isolation – you should expect to
have a series of them leading towards your goal.

And finally….
PDSAs cannot be too small
One PDSA will almost always lead to one or more
You can achieve rapid results
They help you to be thorough and systematic
They help you learn from your work
Anyone can use them in any area


More about PDSAs
PDSA is the basis of quality improvement. It is very natural to
most healthcare providers, because it mirrors the way you
might approach assessing and treating a patient. When a pa-
tient presents with a problem you quite instinctively move
through a PDSA.

First, you need baseline data, so you collect information like
temperature, BP, heart rate, throat swab, etc. Then, based on
that data, you make a plan. Let’s assume that all signs point to
a bacterial infection.

For your do, you decide to try an antibiotic.

You and your patient will study the impact of this antibiotic,
looking to see if it’s having a positive or negative effect, or no
effect at all.

Based on this, you will act by adjusting the treatment, adjust-
ing your diagnosis, or calling for more data through additional
tests.

In quality improvement, we help you move this natural process
used in diagnosing and treating patients, to the level of diag-
nosing and treating systems; in this case, your office practice.

Please see the Additional Information & Resources section for
PDSA examples and templates for individual PDSAs and
PDSA Ramps.


Comparing QI science
When we think about data and measurement, many of us who
work in health care are most familiar with thinking and applying
these terms within the research paradigm. This model was the
foundation for the courses we took in our training and it contin-
ues to be a mainstay of our working lives. The accountability
paradigm, which is likely most familiar to those with policy-
making responsibilities in the public sector and those involved
in quality assurance and accreditation programs, also relies on
data and measurement to achieve its aim. Improvement sci-
ence, on the other hand, is a paradigm that crosses all sys-
tems. Although relatively new to healthcare, it has been around
for decades, most often in sectors where optimizing production
processes and systems engineering has been critical for an
organization’s success.

The following table illustrates the three paradigms. As the ta-
ble shows, the debate is not meant to be an “either/or” one but
rather “why and when”. Each paradigm is distinct and unique
in its purpose and methodology.

Table: Comparing Measurement Paradigms
Research Accountability Improvement
Aim Discovery of new health Comparison, judgment, Improvement in every-
care knowledge springboard for change, day care, practice, and
promote public choice, healthcare delivery
reassurance and educa-
tion
Methods
Test observability Blinded test No testing, evaluate Sequential, observable
current performance tests to build the will to
change
Bias Eliminate bias Measure and adjust to Accept stable and
reduce bias consistent bias over time
Sample size Collect large amounts of Obtain 100% of Collect “just enough”
data “just in case” available information useful data
Flexibility of hypothesis Fixed hypothesis No hypothesis Continual adaptation of
the hypothesis, theories,
and changes, as learn-
ing takes place
Testing strategy One large study No tests Many sequential tests


Chronic Care Model
Part of the framework for the CDM Collaborative is the Chronic
Care Model (CCM) originally developed in 1993 by Dr. Ed
Wagner, in cooperation with the Robert Wood Johnson Foun-
dation (Improving Chronic Illness Care), and later (2002)
adapted by British Columbia as part of the Expanded Chronic
Care Model (see diagram, below). British Columbia expanded
the model to recognize the intrinsic role that social determi-
nants of health play in influencing individual, community, and
population health. All areas of action within the expanded CCM
are situated within the community—building healthy public pol-
icy, creating supportive environments, and strengthening com-
munity action.

Expanded Chronic Care Model

Implementing
Policy to Enhance Community
Health

Creating
Supportive Develop Personal Skills Health Care Organization
Environments Clinical
Self Information
Management Reorienting Systems
HC Services
Strengthening
Community Delivery System Decision
Action Design Support

Productive Interactions

Informed, Prepared, Prepared,
Activated
Activated & Relationships Proactive Practice Proactive Community
Community
Patient Team (partners)

Population Health Outcomes/
Functional and Clinical Outcomes
Adapted from : Victoria Barr, Anita Dotts, Brenda Martin-Lind, Darlene
Ravenadale, Sylvia Robinson, Lisa Underhill (2002)

This model has been successfully used to guide health system
re-design for optimal chronic disease management in other ju-
risdictions, including British Columbia, and is currently the pro-
vincial framework for the Saskatchewan Diabetes strategy. The


Chronic Care Model
CCM is evidence-based, and its implementation has been re-
ported to improve quality of chronic care, patient outcomes,
and professional satisfaction. There was general consensus
among our Expert Reference Panel (held in May 2005) that the
change concepts for the CDM Collaborative fit under one or
more components of the Chronic Care Model. More information
about the link between the Chronic Care Model and the CDM
Collaborative change concepts is provided in the Change
Package (See Section 2 on Improvement).

According to the Institute for Healthcare Improvement, trans-
forming the health care system from a system that is reactive to
one that is proactive is critical to improving chronic illness care.
In order to do this, health care needs to work on the following
six essential elements.

Six Components of the Chronic Care Model
This section on six
components is adapted from Self-management support
the Health Disparities
Patients have a central role in determining their care, one that
Collaborative Training Manual
for Chronic Conditions: fosters a sense of responsibility for their own health. The most
successful health teams use a collaborative approach: one in
http://www.ihi.org/IHI/
Topics/ChronicConditions/ which providers and patients work together to define problems,
AllConditions/Tools/ set priorities, establish goals, create treatment plans, and solve
HealthDisparitiesCollaborati problems along the way.
vesTrainingManualforChron
icConditions.htm
Decision support
Evidence-based guidelines are integrated into care and sup-
ported by provider education, links with specialty expertise, and
reminder and fail-safe systems.

Clinical information systems
In order to provide good chronic care, physicians must know
who the chronic care patients are, and whether they have re-
ceived the medical services that are critical to managing their
illness. A registry is a necessity when managing chronic illness
or preventative care. It is the foundation for successful integra-
tion of all the elements of the Care Model. The entire care team


Chronic Care Model
uses the registry to guide the course of treatment, anticipate
problems, and track progress.

Delivery system design
Office infrastructure and clinical processes must be redesigned
to accommodate planned visits, patient follow-up, and proac-
tive care. The roles and responsibilities of clinic team members
must be maximized to achieve effective and efficient work flow.
In a well-designed delivery system, clinicians plan visits well in
advance, based on the patient’s needs and self-management
goals. During “group visits” patients see their clinician and meet
with other patients with similar health problems. Non-physician
clinical staff are cross-trained to provide care via standing or-
ders (e.g., making referrals, ordering labs, doing foot exams,
and even changing insulin under protocol).

Health care organization
The entire organization must be engaged in the improvement
effort. Senior leaders and clinical champions are visible and
committed members of the team. Personnel are given the re-
sources and support they need to pursue quality improvement
efforts.

Community resources and policies
Health care professionals identify effective programs and en-
courage their patients to participate. Practices form partner-
ships with community organizations to support or develop evi-
dence-based programs.


Improvement

Included in this section:
Why diabetes?…..Why coronary artery disease?…..Why access?
…..Definitions…..Aims…..Chronic disease management: change
concepts and ideas…..Access: change concepts and ideas…..Ideas
in action


Why diabetes
• Diabetes is a life-threatening condition. If
not managed appropriately, diabetes will lead
to complications such as heart disease, eye
complications, kidney disease, and premature
death (www.diabetes.ca).
• On average, the life expectancy for some-
one with diabetes is 13 years shorter than for a
person without diabetes (www.diabetes.ca).
• Diabetes is a growing concern in our prov-
ince. According to Saskatchewan Health, it is
estimated that by the end of 2016, more than 70,000 peo-
ple in Saskatchewan will be diagnosed with diabetes.
• The total annual cost for health care for an individual with
diabetes is approximately 2 to 2 1/2 times the total cost for
the same individual not yet diagnosed with the condition.
Johnson, J et al. The cost of developing diabetes in a co-
hort of Saskatchewan residents 1991-1996. 2002.

A snapshot of diabetes care in Saskatchewan
In January 2006, the HQC released the results of our study on
the quality of diabetes care in Saskatchewan. It showed that
Saskatchewan people with diabetes need better control of
blood sugar and cholesterol, and more frequent testing.

With better diabetes management, the number of major compli-
cations—such as stroke, kidney disease, heart attack and
death—could be reduced.

Please see Figures 1 and 2 on next page for more information.


Why diabetes
Figure 1: Percent of Saskatchewan patients with diabetes with
lab values in the optimal range, 2004.

Patients were deemed to have diabetes if, in 2003, they had 3
or more A1C tests done or had an A1C value > 7%.

Figure 2: Number of major diabetes-related complications is
stable; persistent core of patients developing major complica-
tions.


Why coronary artery disease

• Coronary artery disease is a significant health concern for
people in Saskatchewan.
• Diabetes and heart disease are a lethal combination; 80%
of people with diabetes die of heart disease or stroke.
• Cardiovascular disease accounts for the death of more Ca-
nadians than any other disease. In 2001 (the last year for
which Statistics Canada has data) cardiovascular disease
accounted for 74,824 Canadian deaths
(www.heartandstroke.ca).
• In September 2004, the Health Quality Council released a
report on the quality of post-heart attack care in Saskatche-
wan. It showed that many of our province’s patients were
not receiving key medications (beta-blockers, ACE inhibi-
tors, statins) proven to save lives and prevent secondary
heart attacks.
• With better drug management, we could save approxi-
mately 45 lives each year in our province.

2-3

Figure 1: 90-day post-discharge dispensing rates for beta-
blockers, ACE inhibitors, and statins for acute myocardial in-
farction (AMI) patients age 20 and older in Saskatchewan,
1997-98 to 2001-02

Target=85%
100%
(Beta-blockers and
ACE inhibitors)
80%
Target=70% (Statins)
Dispensing rate

60%

40%

20%

0%
1997-98 1998-99 1999-00 2000-01 2001-02

Beta-blockers ACE inhibitors Statins

Figure 2: Dispensing rates for beta-blockers, ACE inhibitors,
and statins at 3, 90, and 365 days post discharge, for acute
myocardial infarction (AMI) patients age 20 and older, in Sas-
katchewan, 2000-01

100%
Dispensing rate

80% 65% 63%
57% 54%
60% 51% 53%

40% 33% 32% 36%

20%

0%
Beta-blockers ACE-inhibitors Statins

3 day 90 day 365 day

2-4

Table 1: Provincial comparison of 90-day dispensing rates for
beta-blockers, ACE inhibitors, and statins for new acute myo-
cardial infarction (AMI) patients 65 and older, 1999-2000

Saskatchewan Nova Scotia Quebec Ontario British Columbia
Beta-blockers 68% 83% 68% 68% 56%
ACE inhibitors 65% 58% 57% 65% 53%
Statins 29% 36% 43% 40% 35%

2-5

Why access
• Improvement is possible in a
variety of clinical settings.
•
The National Primary Care
Development Team’s Collabora-
tive on Improved Access
achieved remarkable success.
Participants showed more than
70% improvement in waiting
times to see a GP and over 60%
improvement in waiting times to
see a practice nurse. The aver-
age patient wait time was re-
duced from 5 days to less than 1.5 days.
• Improving access frees up capacity to expand other areas
of work.
• Improving access can help practices improve clinical out-
comes, especially in chronic disease management. In one
NPDT Collaborative, improving access facilitated better
chart reviews and improved coronary heart disease regis-
tries.
• Practices report improved patient, staff, and provider satis-
faction, in addition to improved clinical outcomes.

“The advantages to the Practice have been that the staff are
happier, the majority of patients are happier and the doctors are
less stressed.”

-from a participant in the NPDT Access Collaborative

• The Saskatoon Community Clinic was the first practice in
Saskatchewan to implement an Improved Access model.
Since starting the process in 2004, they have seen signifi-
cant reductions in wait times for both long and short ap-
pointments. (See page 2-76 for a profile of Saskatoon Com-
munity Clinic.)

2-6

Definitions
For the purposes of the Saskatchewan Chronic Disease Man-
agement Collaborative, diabetes and coronary artery disease
have been defined as follows:

Diabetes
The Collaborative follows the Canadian Diabetes Association
Important note!
definition of diabetes mellitus:
Patients already diagnosed ...a metabolic disorder characterized by the presence of hyper-
with diabetes DO NOT need
to be retested for the
glycemia due to defective insulin secretion, insulation action, or
Collaborative. both. The chronic hyperglycemia of diabetes is associated with
significant long-term sequelae, particularly damage, dysfunc-
tion and failure of various organs—especially the kidneys,
eyes, nerves, heart, and blood vessels.

Diagnostic criteria for diabetes are summarized below. These
criteria are based on venous sample methods used in the labo-
ratory.
FPG ≥7.0 mmol/L
Fasting = no caloric intake for at least 8 hours
or
Casual PG ≥ 11.1 mmol/L + symptoms of diabetes
Casual = any time of the day, without regard to the interval since the last meal
Classic symptoms of diabetes = polyuria, polydipsia and unexplained weight loss
or
2hPG in a 75-g OGTT ≥ 11.1 mmol/L
A confirmatory laboratory glucose test (an FPG, casual PG, or a 2hPG in a 75-g OGTT) must be done in
all cases on another day in the absence of unequivocal hyperglycemia accompanied by acute metabolic
decompensation.
2hPG = 2-hour plasma glucose / FPG = fasting plasma glucose / OGTT = oral glucose tolerance test / PG = plasma glucose

Ref: Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2003 Clinical
Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes 2003;27(Suppl 2):S1-152.

Coronary Artery Disease
Coronary artery disease (CAD) is defined as an established
history of CAD including (acute) myocardial infarction (AMI),
acute coronary syndrome, revascularization (i.e. coronary ar-
tery bypass surgery, angioplasty), or angina. Co-morbidity can
exist. The definition excludes patients with isolated diagnoses
of the following: PVD, TIA, ischemic stroke, atrial fibrillation,
and heart failure.

2-7

Aims
Aims are developed to provide direction for all CDM Collaborative participants. They are an
explicit statement about we hope to achieve through the CDM Collaborative. They are evi-
dence-based, reflective of current guidelines on diabetes and heart disease management, and
are based on leading practice in delivering care.

Each team in the CDM Collaborative will capture their own baseline measures and then report
on percent improvement for each aspect of the Diabetes, Coronary Artery Disease, and Ac-
cess aims. The aims are not set at 100% because there will always be a segment of the popu-
lation who cannot or should not be achieving the target values.

Diabetes
Patients living with diabetes (Types 1 and 2) within participating
practices are well-managed, as evidenced by each of the
following targets:
• 75% of patients with A1C ≤ 7.0 %
• 75% of patients with blood pressure
≤ 130/80
• 75% of patients with TC/HDL ratio < 4.0

Coronary artery disease
Over the next five years, there will be a greater reduction in
mortality of patients with coronary artery disease in participat-
ing practices, compared to the rest of Saskatchewan.

There is an improvement in the management of patients with
coronary artery disease in participating practices, as evidenced
by each of the following targets:
• 75% of patients receiving anti-platelet
therapy
• 75% of patients with blood pressure
< 140/90 or ≤130/80 (if patient has diabe-
tes or renal disease)
• 75% of patients with TC/HDL ratio < 4.0

Improved access
Eighty percent of patients in participating practices are seen on
the day of their choice.

2-8

Change Package

Chronic Disease Management


Change package—chronic disease management
Change package

A change package is an evidence-based set of changes that
are critical to the improvement of an identified care process.
The Chronic Care Model serves as the foundational change
package that guides improvement in chronic illness.

Expanded Chronic Care Model Components of the
Chronic Care Model

Implementing
Decision support—The
Community
Policy to Enhance
Health clinical care provided must
Creating be consistent with evi-
Environments
Self
Clinical
Information
dence-based best prac-
Management

Strengthening
Reorienting
HC Services
Systems
tices.

Clinical information sys-
Productive Interactions tems—In order to provide
Activated
Informed,
Activated & Relationships
Prepared, Prepared,
Proactive Practice Proactive Community good chronic care, physi-
Community
cians must know who their
chronic care patients are,
and whether they have re-
ceived the medical ser-
Ravenadale, Sylvia Robinson, Lisa Underhill (2002)

vices that are critical to
managing their illness. A mechanism for physician reminders,
patient recall, and follow-up are also needed.

Self-management—Patients must be knowledgeable about
their chronic illness and have the skills and confidence to take
responsibility for the management of their chronic illness.

Delivery system design—Office infrastructure and clinical
processes must be re-designed to accommodate planned vis-
its, patient follow-up, and proactive care. The roles and respon-
sibilities of office and other clinical team members must be
maximized to achieve effective and efficient workflow.

Health care organization—A health system that recognizes
the importance of improved chronic illness care and supports

2-9

the redesign effort is critical for improving patient outcomes.
Commitment from senior leadership and the allocation of
needed resources for chronic illness are necessary to sustain
health system redesigns.

Community resources and policies—Effective community-
based programs must be identified and/or developed to meet
This section was adapted from the needs of patients with chronic illness. Resources must be
and used with kind permission
coordinated for maximum benefit. Public policy and govern-
by the Institute for Healthcare
mental regulations related to health care facilitate the provision
Improvement: www.ihi.org
of quality care.

Change concepts

A change concept is a general principle or approach,
based on evidence from the literature and from practical
application. Change concepts are usually at an abstract level,
but evoke multiple specific ideas for how to change processes.

Concept
An opportunity to create
a new connection
Specific
idea A
Thought
Process
Specific
idea B
Diagram developed by:
Provost, L. Associates The following change concepts have been successfully used in
in Process Improve- other CDM Collaboratives and will be applied in this Collabora-
ment, 2005.
tive:

1. Know all your patients who have diabetes and/or CAD.
2. Be systematic and proactive in managing care for peo-
ple with diabetes and/or CAD.
3. Involve patients with diabetes and/or CAD in delivering
and developing care.
4. Develop effective links and communication strategies
with key local partners involved in care and support of

2-10

people with diabetes and/or CAD. Key local partners include
specialty/acute care, community-based health care organiza-
tions, and others.
“The change concepts are not specific enough to be applied directly to making improvements. Rather,
the concept must be considered within the context of a specific situation and then turned into an idea.
The idea will need to be specific enough to describe how the change can be developed, tested, and im-
plemented in the specific situation. Sometimes, a new idea seems at first to be a new change concept;
but often, with further thinking, it is seen to be an application of one of the more general concepts.”

Langley, G.J. et al. The Improvement Guide: A Practical Approach to Enhancing Organizational
Performance. San Francisco: Jossey-Bass. 1996.

Change ideas

In contrast to a change concept, a change idea is an
‘actionable and specific’ idea for changing a process. These
are practical ideas that your team may adopt according to your
local context and the unique needs of your practice. It is these
change ideas that your team will test to determine whether they
result in improvements within your local environment (practice).

The ideas included in this handbook are those that we know
currently have the greatest impact on achieving improvements
in access to appointments and the care of people with diabetes
and/or CAD. They are not the only changes that can be
made but they are the ones that have proven elsewhere to
have the biggest effect. We know however, that you and your
colleagues have your own practical approaches and examples
that can improve on these ideas. These improvements and
those made by other practices on the original ideas will, as the
Collaborative progresses, be added to the knowledge here.
This resonates with the philosophy behind the Collaborative of
people working together to share, learn, apply, and ultimately
improve best practice to deliver better patient care.

For local and other examples of change ideas, please see
Ideas in Action, starting on page 2-53 in this section.

2-11

Change ideas—chronic disease
1. Know all your patients who have diabetes and/or CAD
Implementing
Policy to Enhance Community
Health

Creating
Environments Clinical
Self Information
Management Reorienting Systems
HC Services
Strengthening

Productive Interactions

Informed, Prepared, Prepared,
Activated
Activated & Relationships Proactive Practice Proactive Community
Community


See Ideas in Ravenadale, Sylvia Robinson, Lisa Underhill (2002)

Action on Examples of change ideas
page 2-53 for • Agree on a clear definition of diabetes/CAD.
local and
other exam- • Develop a diabetes/CAD registry.
ples of
change ideas
• Develop systems to maintain valid registries.

See page 2-7 for
Agree on a clear definition of diabetes and/or CAD
the Collaborative’s
working definitions of diabetes and coronary artery disease.

An accurate, com-
Develop a diabetes/CAD registry
plete, and current
registry is the crucial starting point for improving the care given
to people with chronic disease. Registries can be as simple as
recipe cards in a box or as sophisticated as computer-based
programs. HQC, with the support of Saskatchewan Health, is
pleased to offer participating practices access to the CDM
Toolkit, a web-based registry tool that also offers clinical deci-
sion support and QI tools. Your initial work will focus on ensur-
ing that the registry is complete and that the information in it is
correct.

Please see the Measurement section for information on creat-
ing a registry, and for more about the CDM Toolkit and user
support offered by the HQC and the Health Information Solu-
tions Centre (HISC).

2-12

Change ideas—chronic disease
Develop systems to maintain valid registries Once the registry
has been estab-
lished and validated, it is important that systems are developed
to maintain its accuracy. This should include a system to en-
sure that new information on existing patients is gathered and
recorded, and to ensure that people who are newly diagnosed
with diabetes/CAD, or new patients who are already diag-
nosed, are identified and added to the registry.

When developing your registry, think about the following:
• Who will be responsible for maintaining the registry?
Identify a named person within your team. Many
practices benefit from having an RN or Office Man-
ager lead this work. Whoever you choose, think
about whether they may need some training to de-
velop their clinical knowledge, to help them carry out
this task most effectively.
• How will you identify new cases? Where does the
information come from—the hospital, the lab, within
your practice? How will you ensure the information
reaches the person responsible for maintaining the
registry?
• How will the clinicians in your practice notify the reg-
istry manager of any changes to patient informa-
tion?
• Do you need a system to routinely check the quality
of the information on the registry? You might wish to
build in regular checks on samples of data to be
sure your system for registry maintenance is work-
ing. These checks can be done using the PDSA cy-
cle and can be useful for highlighting any gaps in
your system.
• What do you need to write down about how the sys-
tem works? Recording your system for registry
maintenance can be useful to ensure consistency
and helps when the person responsible is away or
leaves.

2-13

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