Combining Systems Thinking and Improvement Science to Improve Outcomes in Paediatric Asthma

A system thinking specialist was engaged to assist and map the relationships, flows and dynamics between many separate agents involved. This involved engagement with over 25 different organisations and consumers to unearth the multiple perspectives and forces underpinning the behaviours seen. The resulting system map generated new perspectives and understandings between each component and was the basis to locate areas for intervention.

The DH ICAM team oversaw the program comprised of six interlinked projects, and adopted a unique approach, allocating projects to the following organisations:

• Asthma Australia (AA)
• National Asthma Council of Australia (NACA)
• cohealth
• Royal Children’s Hospital (RCH)
• SCV

SCV in partnership with North West Melbourne Primary Health Network lead the Community of Practice (COP) involving cross-sector and interdisciplinary clinicians, and representatives from government, peak bodies and consumers. The CoP convened virtually each month, and was co-facilitated by a by a paediatrician and a local General Practitioner to emphasise the importance of integrated care. This forum not only provided information about asthma care and services but was a safe space to generate and galvanise relationships, raise issues and work together towards possible solutions, given that relevant local stakeholders were in attendance to make improvements.

SCV utilised the Model for Improvement to design the strengthening integrated care pathways project. Seven sites participated, including general practices, community pharmacies, and hospitals. The pilot consisted of five virtual workshops and one-to-one coaching with an improvement coach to build improvement science capability, promote cross-sector collaboration and empower clinicians to make changes to their local health services.

Achievements:

• Twenty-nine change ideas were identified, tested, and implemented across sites. *Case studies demonstrated service improvement
• Increased referrals to the cohealth community asthma program
• CoP and the integrated pathway project extended to the north and west region of metropolitan Melbourne in a new phase

Healthcare is a complex system where multiple stakeholders have differing needs and priorities, all of which are required to be acknowledged and suitably accommodated to ensure impactful and sustainable change.

The systems approach began with respectful, inclusive and curious engagement and the six projects were developed through a collaborative codesign approach. The different consumer and practitioner voices were all heard, accepted and practicable actions were undertaken. Participants unanimously reported high levels of support, trust and achievement.

‘Being involved has highlighted how by working together to achieve a common goal of improving asthma management we can break down perceived biases and barriers and make a difference.’ – Project Lead.

“I have found the CoP sessions really conducive to working collaboratively with a range of stakeholders in the management of childhood asthma. I’ve learnt a lot during each session and have felt empowered and really positive about discussing clients and less apprehensive about approaching GPs to discuss their patient’s asthma.” – CoP participant.

• SCV led three consumers workshops, uniquely designed to ensure representation across the consumer spectrum:
• Online, multi-lingual workshop with interpreters available representing different languages.
• In-person after school consumer workshop and education session
• Online workshop for adolescents.

These workshops allowed over 30 consumer voices to inform the project design.

This project sets a benchmark in project design by demonstrating:

• How key stakeholders can lead government commissioned projects
• Invaluable partnership between DH and SCV, bringing together expertise to achieve a common goal
• That cross-sector collaboration between primary care, community and acute care providers is viable and can enable clinicians to create local change that can break down silos.
  
  
  ‘Being involved has highlighted how by working together to achieve a common goal of improving asthma management we can break down perceived biases and barriers and make a difference.’ – site lead.

Often public health sector interventions target low-leverage points in a system, such as communication campaigns and education packages. While these interventions may be known, easy to achieve, and evaluate, they may not always address the core problem. The systems approach has significant benefits in complex adapting systems but is not frequently applied in the health sector. Local, safe to fail, codesigned interventions, with rapid assessment, feedback, learning and adaption is eminently achievable and effective.

This execution approach enabled key organisations to lead projects, utilising critical expertise, whilst simultaneously collaborating to strengthen each of the six projects of the program. For example, AA and SCV attended GP sites together, to strengthen Asthma Action Plan usage using improvement science methodology and clinical practice resources.

While most CoP are led by clinicians for clinicians, the ICAM CoP provided an opportunity to engage government and peak bodies in the conversation, allowing local issues to be tabled seamlessly with those with ability to make change. Clinicians at one session provided feedback on the AA asthma action plan, as regular participants within the CoP, AA were able to discuss this feedback and update their nationally available AAP.

The cross-sector design for the strengthening integrated care project demonstrated how collaboration provides vital insights to other areas of the system to focus improvement efforts. This was demonstrated by a participating GP who advised that consumers frequently lost their AAP after hospital discharge, and before presenting to the GP. This sparked a change idea for the participating hospitals who tested the simple idea of prompting families take a photo of their AAP prior to discharge to share with their GP.

The consumer voice was creatively captured through a multi-lingual workshop, a school-based session and a virtual adolescent workshop, demonstrating how diverse voices across age groups can be captured.

Twenty-nine change ideas were identified, designed, and implemented by sites in the integrated care project, including:

• Creation of referral pathways from community pharmacy to community asthma programs.
• Standard procedures established in hospitals to book follow-up appointments with GPs prior to patient discharge

Follow-up phone calls from GP asthma educators for children and their carers following discharge on referral.

Case studies demonstrated improved patient outcomes at pilot sites, whilst project data showed a 12% increase in referrals to a local community asthma program between January to May 2023 compared to the same time the previous year.

Over 209 attendees participated in the CoP, with feedback encouraged after each session, of those who provided feedback, 76% reported they would likely make a change in their own practice because of the CoP.

The CoP continues today, with ongoing support from the NWMPHN in partnership with SCV. All organisations involved in leading projects for the ICAM Program continue to work as part of the CoP steering group. The group is currently organising an in-person symposium for clinicians across the asthma care continuum in September 2024.

The design of the integrated care project influenced the design of the subsequent SCV-led ICAM phase which has extended to four hospitals, two community asthma programs and the Victorian Virtual Emergency Department in the north and west metropolitan regions of Victoria. The project launched in March 2024 and will run until December 2025. This new phase of ICAM will primarily focus on M.A.G.I.C., medicines in hand, asthma action plan, GP follow-up, inhaler technique and community asthma program, the five essential elements of change identified by the initial ICAM program.

Due to the chronic nature of asthma, ICAM impacts on hospitalisation rates require monitoring over time. Murdoch Children’s Research Institute is evaluating all ICAM phases with results expected in 2026.