CHOOSING Wisely is an international campaign that encourages conversations about what tests, treatments and procedures are truly necessary. In doing so, it seeks to support a culture shift in how clinicians and consumers think about health care and complements an increasing focus on the delivery of value in health care across Australia.

Choosing Wisely Australia, facilitated by NPS MedicineWise, launched in 2015 and boasts a multidisciplinary membership that includes physicians, GPs, physiotherapists, pharmacists and nurses.

The success of Choosing Wisely to date, having spread to 20 countries, has been attributed to six core principles (Table 1) as well as a focus on professional values and the role of clinicians in resource stewardship, and on improving conversations to reduce unnecessary care.

Table 1: Six core principles governing Choosing Wisely
1 Health profession-led to build and sustain the trust of both clinicians and patients
2 Clear emphasis on improving quality of care and on harm prevention
3 Patient-focused communication between clinicians and patients is a central tenet
4 Evidence-based and reviewed on an ongoing basis
5 Multidisciplinary – encouraging physicians, nurses, pharmacists and other health care professionals to participate
6 Transparency – processes used to create the recommendations, as well as supporting evidence, are published

From the outset, Australian health services actively sought to engage in the campaign. NPS MedicineWise established the Choosing Wisely Australia Champion Health Services network in direct response to this energy and desire to implement Choosing Wisely activities in the hospital setting.

Champion health services must have the support of executive and clinical leadership teams, agree to the core principles and commit to implementing and evaluating activities that support these principles. NPS MedicineWise provides support including communication and evaluation tools, and regular forums to share learnings.

With membership continuing to grow, five original Champion Health Services — Austin Health (Victoria), Monash Health (Victoria), Royal Brisbane and Women’s Hospital (Queensland), Sir Charles Gairdner Hospital (Western Australia), and Western Australia Country Health Service (Wheatbelt) — were invited to share insights from their Choosing Wisely programs to date, in particular, to identify the key enablers for initiating activities that seek to successfully align culture shifts across their organisations. This article shares these insights alongside case scenarios that demonstrate how these organisations have approached implementation.

Five lessons for a Choosing Wisely Champion Health Service:

Lesson 1: Engage multidisciplinary teams

Engagement of staff across all levels and disciplines is recommended, with a whole-of-hospital approach preferable (Table 2):

  • executive engagement is essential to provide leadership and remove roadblocks;
  • senior clinician leadership is critical as key influencers (Table 3);
  • consumers provide valuable insights and can meaningfully contribute to successful implementation;
  • students and junior medical staff are keen to be part of the decision making process and are a valuable resource; and
  • clinical school representatives should be included on steering committees.
Table 2. A whole-of-organisation approach to Choosing Wisely – Royal Brisbane and Women’s Hospital (Queensland)
When clinician leaders from the Royal Brisbane and Women’s Hospital received executive endorsement and active support to implement value-based health care, all parts of the organisation were challenged to think differently about health care delivery. Health professionals were encouraged to consider if the test, treatment or procedure that they were providing to patients were really necessary and added value to patients’ outcomes and experiences, and consumers were empowered to be proactive in asking questions and discussing their care with their health professionals
The Choosing Wisely Clinical Lead and governance team, with active support of senior clinicians, facilitated the implementation of a connected network approach to the Choosing Wisely program to link “on-the-ground” workgroups with existing resources within the facility. Other strategies included: regular communication pieces, embedding Choosing Wisely into the Performance Framework (including job descriptions, orientation programs, policy documents), promoting and celebrating the achievements of teams, and a hospital-wide approach to consumer engagement
Local strengths of the program came from its inclusion in existing performance frameworks and the high level of Executive Director leadership

 

Table 3. Senior clinical leadership as a key enabler to success – Sir Charles Gairdner Hospital (Western Australia) and Austin Health (Victoria)
Sir Charles Gairdner Hospital and Austin Health have both targeted and engaged senior clinicians as leaders in their Choosing Wisely initiatives
Sir Charles Gairdner Hospital established the Evidence in Practice Committee, which helped engage senior clinical staff and identified areas to focus on. The Committee membership includes consultants from each medical department, senior representation from nursing and allied health disciplines, and junior medical staff. The multidisciplinary nature of the committee was time-efficient in identifying the multiple factors involved in any project. With time, the Committee devolved into a small group of senior clinicians who worked to continue Choosing Wisely themes across the hospital and drew in staff from the relevant departments for the projects

Lesson 2: Dedicate resources

Allocation of sufficient resources to support implementation is critical. This includes:

  • provision of project support in form of a project resource (failure to allocate a dedicated resource is seen as a major barrier to success) (Table 4);
  • allocation of non-clinical time for clinical leads to engage;
  • information and communication tools to drive engagement;
  • access to data and associated supports; and
  • multidisciplinary steering committee that has executive support.
Table 4. Managing the challenges of resource constraints – Sir Charles Gairdner Hospital (Western Australia)
Making the transition from ideas to action at Sir Charles Gairdner Hospital was achieved by obtaining a project officer. Due to resource constraints, the project officer was only able to dedicate one day a week to Choosing Wisely projects. As a result, the strategies undertaken to maximise impact were:

  • aiming to spread projects that had already been successfully piloted in one department;
  •  working with finance and pathology to obtain access to accurate usage data, which reduced the need for manual audit;
  •  engaging resident medical officers to undertake manual audits when administrative data were insufficient; and
  • selecting clinical champions in a number of departments to help generate new guidelines and education modules
The project officer was essential in coordinating these activities and ensuring feedback to the relevant staff such that the profile of Choosing Wisely projects is maintained

Lesson 3: Leverage existing resources, structures and learnings

A central philosophy to the successful implementation of Choosing Wisely initiative is to embed, whenever possible, projects into business as usual activities and leverage existing infrastructure and resources. Examples of leveraging that have been established include:

  • safety and quality governance structures and clinical groups (Table 5);
  • data sources and evaluation activities to monitor impact;
  • quality improvement initiatives, past learnings and personnel;
  • information and resources from other organisations (leveraging learning network) including Choosing Wisely Australia;
  • alignment with other business activities (eg, hospital accreditation standards, other quality improvement initiatives);
  • alignment with organisational mission and vision; and
  • internal workflows and garnering support along the way.
Table 5. Leveraging internal governance structures by a regional health service – Western Australia Country Health Service (Wheatbelt)
As a clinician-led initiative, the Choosing Wisely program has provided a unique space for regional staff in the Western Australia Country Health Service (Wheatbelt) to critically examine opportunities to improve aspects of rural health care. Engagement was undertaken by the regional Patient Safety and Quality team with each regional clinical quality group assigned to review Choosing Wisely recommendations relevant to their discipline and to identify regionally appropriate recommendations to include within their existing quality improvement processes. Clinicians noted that the patient journey was often shared with metropolitan tertiary facilities. As such, the most appropriate tests and treatment were at times dependent on where definitive care would occur and whether tests would contribute to achieving this in a safe and timely manner
The application of the Choosing Wisely ethos helped to engage clinicians in identifying and establishing a framework for discussing which tests and treatments were appropriate in the context of regional capacities relative to clinical presentation and patient needs. Understanding these capacities in rural health care is essential in guiding clinical pathways for tests, treatments and procedures

Lesson 4: Focus on the principles

The principles of Choosing Wisely (Table 1) are as important as the Choosing Wisely recommendations themselves Clinicians are encouraged to take a leadership role broadly across quality improvement activities and not be limited to Choosing Wisely recommendations. Many sites have introduced initiatives that are not explicitly associated with Choosing Wisely recommendations but are governed by the principles; for example, projects related to specialty areas (eg, infectious diseases) or identified by local evidence of inappropriateness. Recognising and rewarding this desired behaviour across the organisation can sustain programs and help support a culture of Choosing Wisely in clinical decision making.

Lesson 5: A positive conversation

A focus on clinician leadership and stewardship and engaging with consumers in conversations in order to reduce risks of harm and waste have been key. The established branding of Choosing Wisely and its clinical, non-financial focus have credibility with both health professionals and consumers. In addition, the concept of sustainable health systems and clinician’s role in this inherently resonate with junior medical officers.

A growing conversation for change

There are many lessons for health services looking to join the growing connected network of Choosing Wisely Champion Health Services who are willing to collaborate and share their experience and learnings for adaptation at other sites. Whether through grand rounds, departmental presentations, orientation or intranet materials, these conversations have sparked a refreshing degree of support from busy hospital staff.

Lasting culture change will require the commitment of both individuals and organisations to ensure that every conversation is one that promotes value-based health care.

Dr Kitty Yu is a qualified pharmacist and has a PhD in medication safety. She has an interest in the implementation aspects of e-health and quality use of medicines.

Dr Matthew Anstey is a specialist intensive care physician at Sir Charles Gairdner Hospital in Perth, WA, and the current chair of Choosing Wisely Australia Advisory group.

Joseph Cuthbertson is Regional Clinical Risk Management Coordinator at WA Country Health Service (Wheatbelt) where he is a clinical lead for their Choosing Wisely Program.

Asmara Jammali-Blasi is project lead for the current Victorian Choosing Wisely Collaboration. Asmara has worked in health research, epidemiology and project management. She’s a registered nurse and has an MPH and an MBA.

Angela Melder is an expert in evidence-based practice, and leads a team facilitating clinical and operational teams at Monash Health with the translation of evidence to inform evidence-based decision making.

Jessica Toleman is an experienced hospital and community pharmacist. She is currently Acting Executive Director at the Royal Brisbane and Women’s Hospital and supports the facility’s Choosing Wisely Program as clinical lead.

Dr Robyn Lindner is a Client Relations Manager at NPS MedicineWise and has led the introduction of Choosing Wisely in Australia.

 

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.

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