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

We developed an organisation-level view of the systems that produce the current customer experience. The attached artefacts showcase the depth and detail of our work. We have presented our research findings in a way that is as simple and digestible as possible.

Prototyping and testing were extremely important elements of this project. Our team displayed design excellence here.

As part of our Future State Mapping process, for example, we held a series of four workshops, consisting of two sessions dedicated to providers and two sessions focused on aged-care consumers.

During these workshops, we introduced participants to the ideas we’d come up with following the previous research phase and guided them through the envisioned changes to the customer experience.

Our participants were candid with their feedback, pointing out anticipated flaws, floating solutions, and fresh ideas. Based on this feedback, we refined and reworked our design. The end product is the result of this collaboration.

Public confidence in the aged care sector is low. Following the Royal Commission into Aged Care, the ACQSC has new powers and standards to uphold, which means that internal teams must adjust to new circumstances. Providers spoke of shifting goalposts.

In this context, there’s an urgent need for thoughtful service design throughout the whole aged-care sector – not just with the ACQSC. We hope our work can represent a benchmark here. Human-centred service design is the starting point for providing better care services and enhancing public confidence in the sector.

Considering the complexity of this task and the gravity of the problems in the sector, we are proud of this work. It was a privilege to invest our time and design skills to clarify the quagmire of customer experience in aged care.

Our workshops were held remotely. In our sessions with aged-care customers, we were conscious of some participants’ limited digital literacy. We used a really simple storyboard process on Miro during the workshops (see attached). Our facilitators used characters and storyboards to map out scenarios, with participants calling out instructions. We used this method to describe past experiences and explore ways difficult scenarios could have been managed differently. Basically, the participants were art-directing our facilitators during the workshops. They seemed to enjoy this process and shared some very frank insights.

During the course of our project, it became clear that the Commission needed help developing a communication strategy and materials that would help aged-care consumers and their relatives understand the Commission’s role right from the beginning of the journey into aged care. We helped the Commission design brochures and other resources for consumers. These were developed with the specific communication needs of older Australians in mind, as well as the diversity that exists within the ageing population.

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.