Implementation

Effective ACP implementation requires a whole-of-system response that is coordinated, integrated and underpinned by quality assurance. The response will consistently and effectively support New Zealand consumers across the health system to think about, talk about and plan for their future and end-of-life care.

To support such a response, the ACP programme has drawn on national and international experience and developed a deployment model. This is a high-level guide to the things that need to be considered for ACP to be successfully implemented in New Zealand.

The system-wide change ACP requires over many years can appear overwhelming for steering groups, deployment teams and managers. So, to help break down the deployment model into more manageable chunks, we have created three stages or levels of implementation maturity – foundation, progressing and embedding – and applied them to the activities and processed associated with each of the four quadrants.

The deployment model acknowledges that we need appropriate policies and resources to underpin deployment. It focuses on four key areas or quadrants – engagement, education, system infrastructure and continuous quality improvement.

Successful change requires a structured and managed approach. The deployment model is built on the idea that, to deliver a whole-of-system change like ACP and make it ‘business as usual’, providers need to think about and address a number of different areas simultaneously. They need to:

• engage people in the need to change
• overcome any obstacles to the change
• build processes to support and sustain the change.

This approach is consistent with systems thinking and large-scale change literature. It also maps to Kotter’s 8-Step Process for Leading Change.

1) Engagement

The engagement quadrant focuses on promoting ACP to the general public and health care sector. It aims to normalise future care planning.

At an organisational level, engagement requires the getting and retaining of support and involvement of health care leadership. At a community level, it requires engaging the general public in ACP development, deployment and participation.

Measuring success –We will know we are improving in this area when:

Consumers are:
• bringing up the topic of ACP or seeking clarification about future care options from health care providers and relevant others
• expecting to have ACP conversations as part of whole-person care
• expecting what matters to them to form the basis of care and partnership in decision-making (includes compassionate communication, information delivered in culturally appropriate ways and power sharing)

Organisational leaders are:
• advocating for and prioritising ACP (creating an expectation/mandate)
• empowering consumers with information, tools and an empathetic care team (skilled to communicate and support consumers).

2) Education

The education quadrant focuses on increasing the skills and knowledge of the health workforce and consumers.

Our health workforce requires training in ACP and support so they can initiate, participate in and facilitate ACP with consumers. This includes a working knowledge of the legal framework, good clinical communication skills and an understanding of associated systems and processes.

Consumers need information, training and resources to understand ACP, what the benefits are in planning their future care and what they need to be thinking about and planning for.

Communities, whānau and carers need skills and resources to effectively and appropriately support people to think about and talk about what matters most to them and how that might impact their preferences in the future.

Measuring success – We will know we are improving in this area when:

Consumers are:
• developing advance care plans regardless of geographic location, ethnicity or socioeconomic situation
• co-leading ACP programmes (with knowledge and confidence) within organisations (includes projects, steering groups, co-design, generating ideas, sharing stories and initiating ACP activities)
• confidently supporting others in their family/whānau and community to start ACP

Health and social care workers:

• are aware of their role in ACP and advocating for the consumer voice and in shared decision-making
• feel capable and confident, and are competent in their role in ACP (clinical decision-making, ACP knowledge and communication skills)
• know where to find advance care plans and how to use ACP to underpin care delivery
• role-modelling shared decision-making and values-based care planning.

3) System infrastructure

The system infrastructure quadrant focuses on the systems and processes required to maximise the investment in ACP and training so what is important to consumers is recorded, shared and valued.

Measuring success –We will know we are improving in this area when:

• treating clinicians and other health care workers are aware of and use consumer preferences and advance directives
• a central repository is developed to store ACP conversations and completed plans together with an alert or notification that they are there
• there is a linked-up system of ACP records and accessibility reflected in local processes and policies for documentation, retrieval and reviewing ACP conversations and plans. Local systems are consistent and link with national processes and policies
• completed advance care plans are quality assured.

4) Continuous quality improvement
The continuous quality improvement quadrant focuses on developing an ACP culture that uses measurement and evaluation tools to determine quality processes and applies them practically for quality improvement. The processes must be based on what matters to consumers.

Measuring success – We will know we are improving in this area when:

• DHBs have ACP policies and protocols in place, and adherence is monitored
• sufficient human resources are allocated to drive the system changes required in DHBs
• process and outcome measures are tracked and opportunities for improvement are acted on.

1) Foundation

First steps. These are the activities and processes to be considered in the first couple of years. They include building a guiding team, creating a platform and desire for change, going where people are willing, trying/piloting and sharing the small wins to build momentum.

View foundation activities and downloadable resources here

2) Progressing

The next steps building on foundation activities, either through broadening application or deepening understanding. Activities include increasing the quantity and quality of ACP, building on wins, sharing successes, widening advocacy and building clinical leadership.

View progressing activities and downloadable resources here

3) Embedding

Developing maturity. This is the period when we are moving from creating change to sustaining change. ACP becomes business as usual, an expected activity, and there is entrenched clinical leadership.

View embedding activities and downloadable resources here

Mixed stages

Note that teams, departments and DHBs may be at different stages within and between the various quadrants. Some examples follow.

Within quadrant:
• You might have great clinical leadership (embedding within the engagement quadrant) but only be starting community presentations (foundation in the engagement quadrant).
• You may have a robust electronic ACP process and systems in the hospital (embedding in the systems quadrant) but have no system or process for making those electronic advance care plans available to community health teams (foundation in the systems quadrant).

Between quadrants:
• You may have trained many of your clinicians and have a waiting list for clinicians wanting to do training (embedding in the education quadrant) but no mandate or expectation that clinicians initiate ACP conversations (foundation in the engagement quadrant).
• You might have GPs who are actively creating advance care plans with consumers (embedding in the engagement and systems quadrants) but have no way of measuring that or checking the quality of those plans (foundation in the continuous quality improvement quadrant).