The Clinical Support Systems Program: supporting system-wide improvement

The Program’s mechanism of change, the Clinical Support Systems (CSS) model, was based on a patient-centred systems approach to evidence-based care. It contained simple rules that multidisciplinary teams could adapt locally to their particular patient group. The simplicity of the model and its underlying principles accord with the systems approach to practice improvement that is gaining increasing credibility internationally.1

The improvements in systems of care achieved by the CSSP in a relatively short time were vast,2 suggesting that major gains can be derived from programs of change to transform the entrenched structure and culture of providing patient care. While these programs may not always deliver the easily measurable or immediate gains sometimes evident in narrowly targeted projects, the legacies of the broad systemic approach to change are more likely to be sustained in the long term.

Local practice change was not the only outcome of the systems orientation of the CSSP. The Program also generated important messages for the wider healthcare system.

Clinical practice improvement (CPI) initiatives usually focus on clinicians, who are assumed to be responsible for quality of care, and strategies to engage clinicians’ commitment to better practice are a major part of the change agenda. However, creating a culture in which clinicians accept that “quality is everyone’s business” is seen as a means of improving the safety and quality of clinical care.3

An analysis of the experiences of the clinicians involved in implementing the CSSP indicated that they were constrained by variables over which they had no direct control.2 These variables were both locally specific (eg, features of their organisation) and more general healthcare system variables (eg, dual funding models or the lack of integrated electronic medical records).

The key message was that responsibility for quality clinical care cannot be borne solely by clinicians. The change agenda needs to involve people and systems beyond local clinical teams. It needs to permeate many different healthcare “systems” (eg, organisational or professional) that contribute, either directly or indirectly, to clinical practice.

The CSSP experience indicated that much can be done to improve the support clinicians receive in the following five key areas.

However, focusing solely on professional education programs overlooks an equally important component: on-the-job professional socialisation.4,5 Much of what junior clinicians learn occurs within the work setting — it is partly based on observation of the behaviour of senior clinicians and partly the result of senior clinicians’ expectations of junior clinicians’ performances.6

The CSSP illustrated that senior clinicians can consciously ensure that this on-the-job socialisation routinely supports evidence-based practice. However, further work is needed to ensure that it does not replicate current practice, and thereby undermine the practice change agenda. This includes equipping senior clinicians with the skills and knowledge to support their mentoring roles in the work setting.7

It is often at the points of intersection between structurally isolated segments of the healthcare system that evidence-based practice breaks down.8 However, these same points may present the greatest opportunities for improvement. Further work is needed to ensure that mechanisms for practice dialogue and reflection across traditional boundaries are available for clinicians within the organisational structures of hospitals and between healthcare sectors.

Within acute care, the absence of wider forums, such as clinical governance committees, acts as a systems barrier to change.1 While clinicians can work on change within their immediate areas, organisational issues beyond their control, but affecting their practice, also need to be addressed. Structures that span traditional organisational boundaries provide clinicians with forums to present these issues for resolution.

Further work is needed on the evidence base supporting the full spectrum of medical practice, as well as that supporting nursing and allied health practice.1 Multidisciplinary teams struggled to determine the evidence base and performance measures for the whole team (rather than the individual disciplines within the team). A challenge for the healthcare system is whether, in the future, the focus will be on individual disciplines or multidisciplinary teams.1

Despite heavy emphasis on data and documentation, clinicians do not have ready access to meaningful information about clinical practice. Yet, routine evidence-based practice relies on timely access to this information,9 and clinicians are keen to have this access. The CSSP projects developed very different approaches to fulfil this need, ranging from paper-based to handheld personal digital assistants, and these experiences indicate that further debate and resolution of important inter-related issues are needed in developing information systems for evidence-based practice. These pertain to:

• whose practice should such systems inform;

• what governance structure do they need;

• how and to whom should responsibility for data collection and analysis be allocated;

• what technical support needs to be provided to maintain such systems; and

• how the necessary infrastructure and personnel are to be funded.

Privacy and legal privilege may also be issues that need to be addressed.

The original government intent for partnering with the Royal Australasian College of Physicians (RACP) was to increase interest among and engagement by doctors in the movement for quality of care. There is no doubt that the RACP’s role in actively championing the CSSP has achieved this intent.2 At the same time, there have been mutual flow-on benefits between the CSSP and other national activities sponsored through the Australian Council for Safety and Quality in Health Care and the National Institute of Clinical Studies.

The RACP is continuing to build on the experiences gained through its involvement in the CSSP. It has supported the uptake and roll-out of the CSS model itself, through funds attracted from the New South Wales, Western Australian, South Australian and New Zealand governments for CSS projects.10 As an example: after initial piloting at the John Hunter and Nepean hospitals (NSW), and Townsville (QLD) and Frankston (VIC) hospitals, the NSW government, through the NSW Institute for Clinical Excellence, in collaboration with the RACP, has introduced the “Towards a Safer Culture” project (see page 92) to 29 hospitals in 12 area health services, enabling clinicians to embed best evidence-based practice routinely in clinical care with the aim of increasing survival from heart attack and stroke and improving functional results. This is the first time that integrated data, on this scale, have been systematically fed back to front-line clinicians for the purpose of CPI.11

At the same time, the College has formed a Better Practice Coordinating Committee, which is exploring a range of strategies to support College fellows and trainees in evidence-based practice improvement initiatives. The most tangible outcome to date has been the development of an online manual, linked to the RACP and based on implementation experiences from the CSSP,12 which offers simple, practical support for clinicians.

There is now an established network of organisations coordinating a national quality and safety effort, each contributing to addressing the systems issues necessary to support clinicians in evidence-based practice. The growing momentum for change is evident by the inclusion, for the first time, of quality and safety within the Commonwealth–State Health Care Agreements (2003).13 The CSSP has contributed to this momentum, and continues to do so, not only through the RACP and further projects based on the CSS model, but through the clinicians who participated in the CSSP and contributed to the lessons informing the wider healthcare system.