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Peterborough Health Link

HealthLinkShare Day

James Meloche

on 26 February 2013

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Transcript of Peterborough Health Link

Peterborough Health Link Client Experience Step 1: Client Stories Step 2: Focus
Target Client Population Step 4: Improve. Sustain Step 3:
Create Team.
Test. Learn. Spread. Refine the description of the priority client cohorts through “circle of care” providers
Responsible for completion of business plan and design of proposed future state
Oversee Quality Improvement approaches, including Experience Based Design. Triple Aim Quality is defined by the population/client
Design must include: role for clients, families, care givers; redesign of primary health care; and cost control strategies; quality improvement processes; and role of the integrator Top Down, Bottom Up
& the perils of data? Directive Approach
a priori understanding of "value"
Trusts data explicitly
Directive spread and implementation
health care's traditional comfort zone Client stories and explicit quality improvement approach provides the key to identifying targeted improvement ideas informed by patients and front-line providers. Cohort I:
Senior with Advanced Congestive Heart Failure
+ a co-morbidity (e.g. COPD, Diabetes)
+ complicating factor (e.g. caregiver/family support, dementia, housing, palliation etc)
Exacerbation of CHF and at least 1 readmission and/or 1 ED visit within the past 90 days Are we building short-term solutions for a distinct group of clients? OR, Are we building a system that is sustainable and responsive to the complex/complicated needs of clients today and over time?

The journey of patient engagement must generate changes in system design at all levels. Using Client Stories to Begin the Journey Learning Approach
a posteriori - experience informs value; strategy is learned
Informed data skepticism
Quality improvement science drives design: iterative spread and scale Both approaches have value and can be complementary
Leadership and commitment to holding to both approaches is critical.

Don’t fall into old ways of short changing the patient experience and client engagement to expedite planning. Identify the target population
12+ agencies separately submit 3-5 stories of complex clients, patients who challenge front-line providers
70+ patient stories collaboratively reviewed by a range of front line staff, management
Facilitate selection of 2-3 patient cohorts
For each, identify 5 change opportunities Questions to Facilitate Consensus & Opportunities
For this client group:
What is role of Clients and Family? Primary Care? Specialist Care? Acute Care? Community Health Service Providers?
What is the potential for cost containment?
What is the role for prevention and health promotion?
What is the opportunity for integration (Macro, Meso, Micro) Identify change opportunities through completion of 5 “real” client (stories) within each cohort
Support design of future state
Highlight individual clients and/or stories to be analyzed; gather appropriate consent as required
Review and discuss client journey and care needs of priority cohorts Early Days. Continue to:
Keep focus/energy on “why this is different" and the whole client experience.
Resist expedient (unless justified) or data-driven only solutions.
Balance “patience and trust with the process” (including patient engagement and direction) and need to implement a "solution".
Patients are “the biggest untapped resources in the health system” … “users will pay a far larger role in helping to identify needs, propose solutions, test them out and implement them, together”
National Health Service, Design Council, 2004 Defined small sample of target population.
Implement Small tests of change.
PDSA cycles.
Scale Up and Spread (5x).
PDSA cycles. Personalize the Experience. Standardize the System. 3 dimensions of Patient Experience, Health, Cost Control 5x Principle
Focus > Learn > Spread > Sustain
Cohort II:
Serious Mental Illness and Addictions issues
+ advanced/serious chronic condition
+ complicating factor (e.g. caregiver/family support, housing, concurrent disorder)
Re-admits and or ED visits from inpatient psychiatric perspective/admissions to medical units
1 readmission and/or 1 ED visit within the past 90 days Design Team Circle of Care Team Communications, Client Engagement & Decision Support Working Groups Core Steering Committee (Leadership Team) TRUTH
Today someone will make a poor decision on the basis of information that was enormously difficult and expensive to collect, or incorrectly applied to a problem.
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