Implementing the ABC Alcohol Approach in Primary Care - To record alcohol intake and provide brief advice and counselling for patients whose ...
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Implementing
CLINICAL effectiveness module
the ABC Alcohol
Approach in
Primary Care
To record alcohol intake and provide brief advice and counselling
for patients whose alcohol behaviours may be harmful.
Contents
contents
Introduction.............................................................................................................3
Clinical Effectiveness Modules...............................................................................3
1. Setting the scene.........................................................................................4
2. Discuss: what am I doing now?..................................................................6
3. Understanding the issues - ABC Alcohol Approach...................................7
4. Identifying local and national referral services, resources,
and support...............................................................................................15
5. Selecting and implementing an IT tool for introducing
the ABC Alcohol programme....................................................................17
6. Professional competencies and training...................................................22
7. Patient recall and re-screening.................................................................24
8. Evaluation..................................................................................................25
9. Implementing improvements and ongoing support.................................26
10. Integration with College programmes.......................................................27
11. Further information - useful links and resources.......................................28
Appendices...........................................................................................................29
A template for practice – based quality improvement activity........................29
Aiming for Excellence in a quality system.......................................................32
PDSA Cycles: a method to measure and improve clinical effectiveness.......33
Clinical effectiveness worksheet.....................................................................34
ALAC Alcohol - Facts and Effects...................................................................37
Disclaimer
While this document has been developed The Royal New Zealand College of General
after consultation with many people and the Practitioners owns the copyright in this work
relevant laws, consideration should be given and has exclusive rights in accordance with the
to the changing nature of the environment and Copyright Act 1994. In particular, prior written
law, and neither the College nor any person permission must be obtained from the College
associated with preparing this document for others, including business entities, to:
accepts responsibility for the results of any • copy the work
action taken, or not taken by any person as a
result of anything contained in or omitted from • issue copies of the work, whether by sale
this publication. or otherwise
Published by The Royal New Zealand College of • show the work in public
General Practitioners, Wellington, New Zealand • make an adaptation of the work
First published in July 2012 as defined in the Copyright Act 1994.
©
The Royal New Zealand College of General
Practitioners, New Zealand, 2012
ISBN: 978-0-9864536-8-7
2 The Royal New Zealand College of General Practitioners
Introduction
Introduction
Clinical Effectiveness Modules
Clinical Effectiveness Modules are designed to help
New Zealand General Practice teams improve patient care
and meet their CORNERSTONE® annual requirements for
clinical improvement activity.i
Working through each Module • help practices undertake the
requires time and reflection by planning, implementation,
the practice team. The systematic evaluation and ongoing
approach of the process helps improvement aspects of the
uncover areas not usually considered PDSA cycle – a clinical worksheet
in quality improvement activities. template based on the PDSA
cycle is in Appendix 4.
Modules:
Acknowledgements
• provide a useful approach for
practice teams undertaking a The College would like to
quality improvement activity acknowledge the contributions
by describing the process of the Project Development Group:
for critically reviewing an area
of practice and can be applied Dr Jane Burrell
by practice teams to any
Dr John McMenamin
topic of interest, practice or
organisational activity Dr Keri Ratima
• contain evidence, information, Jane Ayling
guidance tools and processes
to encourage learning and Stella McFarlane
best-practice improvements
Sue Paton
• encourage teamwork, quality
Kristen Maynard
improvement, critical thinking and
considering data, information or Jeanette McKeogh
other services that could improve
effectiveness of care or support a Mary Nichols
patient’s journey
• encourage practices to make
sense of the relationships or
interactions to support integrated
working environments and identify
where linking might improve
outcomes of care for patients
Clinical Effectiveness Module: Implementing the ABC Alcohol Approach in Primary Care 3
1. Setting the scene
1. Setting the scene
The burden of alcohol
A significant proportion of the disease burden
attributable to harmful drinking arises from unintentional
and intentional injuries, including those due to road traffic
crashes, violence and suicides. Harmful drinking is a major
avoidable risk factor for neuropsychiatric disorders and
other non-communicable diseases such as cardiovascular
diseases, cirrhosis of the liver and various cancers.ii
• In New Zealand, it is estimated • Alcohol is a significant cause
that between 600 and 1000 of avoidable death for Ma-ori;
people die each year from alcohol-attributable deaths are
alcohol-related causes.iii responsible for approximately
8 percent of all deaths among
• More than half of alcohol-related Ma-ori, including 3.9 percent of
deaths are due to injuries, one- deaths among Ma-ori females and
quarter to cancer and one-quarter 11.3 percent of deaths among
to other chronic diseases.iv Ma-ori males.vi
• Nearly one-fifth of all deaths for
males aged between 20 and 24
and one-tenth of all deaths for
females of the same age are
attributable to alcohol use.v
Promoting awareness of
alcohol behaviours
The ‘Ease up on the drink’ campaign provides a platform to
start discussion with GPs, nurses and other people working
within the alcohol and other drugs (AOD) sector.
The advertising campaign effectively and provides an opening for
positions the idea of brief intervention discussion with patients who may
and support into the public domain have seen the advertisements.
4 The Royal New Zealand College of General Practitioners
ABC Alcohol Approach
1. Setting the scene
– Clinical Effectiveness Module
The Clinical Effectiveness Module toolkit will guide
general practices through the necessary steps to establish
the ABC Alcohol approach within their general practice.
The steps include:
• understanding the issues Completing the Clinical Effectiveness
Module ABC Alcohol toolkit will
• identifying local resources, qualify participating general practices
organisations, supports and for CORNERSTONE® practice
practitioners for case referral accreditation pointsvi and participating
general practitioners can also obtain
• selecting and implementing
individual recertification (CPD) points.
an IT tool
• professional competencies
and training
• evaluation.
Clinical Effectiveness Module: Implementing the ABC Alcohol Approach in Primary Care 5
2. Discuss: what am
2. Discuss: what am I doing now?
I doing now?
Practices wishing to implement this Clinical Effectiveness
Module should undertake a clinical audit to understand
their current management of patient alcohol status and
drinking behaviours.
The College recommends that all • hazardous alcohol behaviours
enrolled patients 15 years and over that have been identified
are included in the audit.
• information on treatment or
The audit should collect information referrals to address the alcohol
such as: behaviours identified.
• the percentage of enrolled patient This will provide practices
population 15 years and over with with a snapshot of their current
alcohol status recorded practice activity.
6 The Royal New Zealand College of General Practitioners
3. Understanding the issues
3. Understanding the issues – ABC Alcohol approach
– ABC Alcohol approach
What is the ABC Approach?
The ABC Approach was originally developed to promote
smoking cessation in New Zealand. This approach has been
adopted to identify and provide brief advice to patients who
engage in harmful drinking.
‘ABC’ is a memory aid for health The ABC Alcohol Approach steps are:
care workers to understand the key
steps to helping people recognise • A: Ask
and change their drinking behaviours.
• B: Brief advice
In the context of alcohol, ABC-style
approaches have been shown as an • C: Counselling
effective way of motivating patients to
reduce harmful drinking.viii An overview of the ABC process is
shown in Figure 3.
The purpose of the ABC Approach is
to make the health sector’s approach
to recording alcohol status and
providing advice more systematic by
integrating the ABC Approach into the
everyday practice of all primary health
care workers.
Clinical Effectiveness Module: Implementing the ABC Alcohol Approach in Primary Care 7
A: Ask
3. Understanding the issues – ABC Alcohol approach
All patients 15 years and over attending clinical
appointments are asked by a GP or nurse about alcohol
use using the AUDIT C tool. An example of the AUDIT C
tool is shown in Figure 1.
AUDIT consumption The AUDIT C questions are:
questions (AUDIT C)
1. How often do you have a drink
The AUDIT C tool is a modified, containing alcohol?
three-question version of the Alcohol
Use Disorders Identification Test. 2. How many standard drinks
containing alcohol do you have
The AUDIT C tool consists of on a typical day?
three questions which help health
professionals identify patients who are 3. How often do you have six or
hazardous drinkers or have an alcohol more drinks on one occasion?
dependency or abuse problem during
the initial consultation.
The AUDIT C is scored on a scale of
0 to 12 based on the patient’s answer.
8 The Royal New Zealand College of General Practitioners
FIGURE 1: AUDIT C questionnaire example
3. Understanding the issues – ABC Alcohol approach
What is a standard drink?
Standard drinks measure the RTD (ready to drink)
1
amount of pure alcohol you are
drinking. One standard drink
equals 10 grams of pure alcohol.
approx
30g
1.0 = 20g
10g
Standard 10g of alcohol
330ML can 100ML glass 335ML bottle 750ML bottle 1000ML bottle 3 litre cask
Drinks of beer @ of table wine of RTD1 spirits of wine @ of spirits @ of wine @
4% alc @ 12.5% alc @ 8% alc 13% alc 47% alc 12.5% alc
standard
1 1 2.1 7.7 37 30 drinks
(ALAC standard drink guide)
Do you ever drink alcohol? o No – you do not need to answer the questions below
(please tick answer on right) o Yes – please complete the additional questions below
Please circle your answers below and then calculate
Additional questions and enter your score on the right Your score
0 1 2 3 4
How often do you have a drink - Monthly 2 to 4 times 2 to 3 times 4+ times
that contains alcohol? or less per month per week per week
How many UNITS of alcohol do 1 to 2 3 to 4 5 to 6 7 to 8 10+
you drink on a typical day when
you are drinking?
How often do you have Never Less than Monthly Weekly Daily or
6 or more UNITS of alcohol monthly almost daily
on one occasion?
Your total score
AUDIT C toolix
AUDIT C scoringx (2 and 3 are zero), it can be
assumed that the patient is
• In men, a score of four or more is drinking below recommended
considered positive. This score is limits and it is suggested that
considered optimal for identifying the provider review the patient’s
hazardous drinking or active alcohol intake over the past few
alcohol use disorders. months to confirm accuracy.
• In women, a score of three • Generally, the higher the
or more is considered positive score, the more likely it is
(same as above). that the patient’s drinking
is affecting safety.
• However, when the points
are all from question 1 alone
Clinical Effectiveness Module: Implementing the ABC Alcohol Approach in Primary Care 9
B: Brief advice
3. Understanding the issues – ABC Alcohol approach
Patients identified as consuming alcohol that is above the
recommended drinking guidelines are offered brief advice
about more appropriate levels of alcohol consumption in the
context of their age and relevant health conditions.
Where patients have been identified • can provide patients with brief
as consuming alcohol at a level that is advice about more appropriate
potentially harmful, practitioners: levels of alcohol consumption for
them in the context of their age
• should use the full 10-question and relevant health conditions
AUDIT tool which is an extended
version of the AUDIT C tool and is • where appropriate, can
intended as a complete package encourage patients to access
for health practitioners to use alcohol counselling.
for detecting and treating risky
drinking (the 10-question AUDIT
tool is shown in Figure 2)
10 The Royal New Zealand College of General PractitionersFIGURE 2: Full 10-question AUDIT tool
3. Understanding the issues – ABC Alcohol approach
Do you ever drink alcohol? o No – you do not need to answer the questions below
(please tick answer on right) o Yes – please complete the additional questions below
Please circle your answers below and then calculate
Additional questions and enter your score on the right Your score
0 1 2 3 4
How often do you have a drink - Monthly 2 to 4 times 2 to 3 times 4+ times
that contains alcohol? or less per month per week per week
How many UNITS of alcohol do 1 to 2 3 to 4 5 to 6 7 to 8 10+
you drink on a typical day when
you are drinking?
How often do you have Never Less than Monthly Weekly Daily or
6 or more UNITS of alcohol monthly almost daily
on one occasion?
How often in the past year Never Less than Monthly Weekly Daily or
have you found you were not monthly almost daily
able to stop drinking once you
had started?
How often in the past year Never Less than Monthly Weekly Daily or
have you failed to do what monthly almost daily
was expected of you because
of alcohol?
How often in the past year have Never Less than Monthly Weekly Daily or
you needed an alcoholic drink in monthly almost daily
the morning to get you going?
How often in the past year have Never Less than Monthly Weekly Daily or
you had a feeling of guilt or regret monthly almost daily
after drinking?
How often in the past year have Never Less than Monthly Weekly Daily or
you not been able to remember monthly almost daily
what happened when drinking the
night before?
Have you or someone else been No - Yes, but - Yes, during
injured as a result of drinking? not in the the last year
last year
Has a relative/friend/doctor/health No - Yes, but - Yes, during
worker been concerned about not in the the last year
your drinking or advised you to last year
cut down?
Your total score
Clinical Effectiveness Module: Implementing the ABC Alcohol Approach in Primary Care 11Scoring and patient advice
3. Understanding the issues – ABC Alcohol approach
WOMEN 13 points or more High-risk
Your drinking will cause you or may
MEN 15 points or more have already caused you problems.
WOMEN 6 - 12 points Medium-risk
Your drinking is putting you at risk of
MEN 7 - 14 points developing problems
WOMEN 0 - 5 points Low-risk
Your drinking is not likely to cause you
MEN 0 - 6 points problems if it remains at this level
12 The Royal New Zealand College of General PractitionersC: Counselling
3. Understanding the issues – ABC Alcohol approach
Referral pathways are offered to patients whose alcohol
consumption is identified as potentially hazardous to
their health.
Health practitioners who assess • refer the patient to identified
patients as having risky or potentially local referral services and/or
harmful alcohol behaviours are national referral services
able to:
• refer patients to printed and
• use motivational interview online resources.
techniques to discuss behaviours
with the patient or refer on to
another health practitioner within
the practice, if necessary
Clinical Effectiveness Module: Implementing the ABC Alcohol Approach in Primary Care 13FIGURE 3: ABC process diagramxiii
3. Understanding the issues – ABC Alcohol approach
Patient attends consulation with GP/nurse
ASK
Patient screened for alcohol use using
AUDIT C
Patient exceeds guidelines Patient within guidelines
Engage patient:
Give feedback about
screening, and relevant
brief advice about their
alcohol consumption.
brief advice
Identify whether the
patient is willing and/or
it is appropriate to ask
further questions about
their alcohol use.
NO YES
Complete 10Q AUDIT
brief advice
Offer feedback/advice
around AUDIT outcome
Record outcome/offer
appropriate referral option
dependent on AUDIT
score
COUNSELLING/REFERRAL
Local referral
services (If established)
• Patient
including practice
declines referral National referral
community- specialist or
• No referral service
based, own GP for
required
DHB-based or follow-up
private
Feedback loop between GP
and service provider
Save patient information to PMS system
14 The Royal New Zealand College of General Practitioners4. Identifying local and
4. Identifying local and national referral
national referral services,
services, resources and support
resources and support
It is important that the ABC Alcohol Approach is adapted
to the different needs of each practice. Implementation
approaches should reflect this.
Practices need to identify local Local referral services will differ
and national pathways for patients throughout New Zealand and it is
who may require referral to important that practices use their
another service. community networks to identify the
appropriate pathways.
Referral services by DHB
NORTHLAND TAIRAWHITI
Mental Health & Addiction Service Awhina House – Gisborne
(09) 430 4101 (06) 867 1764
WAITEMATA TARANAKI
Community Alcohol and Drug Alcohol and Drug Service
Services (CADS) – New Plymouth
(09) 845 1818 (06) 753 7838
AUCKLAND HAWKE’S BAY
TRANX Drug & Alcohol Services Inc Addiction Services Hawke’s Bay
(09) 356 7305 – Napier
www.tranx.org.nz/ (06) 834 1815
COUNTIES MANAKAU WHANGANUI
Community Alcohol and Drugs Service Alcohol and Other Drugs Service
(09) 845 1818 – Whanganui DHB
www.cads.org.nz/ (06) 348 1287
WAIKATO MIDCENTRAL
Community Alcohol and Drug Service Alcohol and Other Drug Service
– Hamilton – Palmerston North
(07) 839 4352 (06) 350 9130
0800 764 677
LAKES
Addiction Resource Centre HUTT VALLEY
(07) 377 1132 Alcohol & Drug Assessment
& Counselling
BAY OF PLENTY (04) 475 9420
Bay of Plenty Addiction Services www.adac.co.nz
– Tauranga
(07) 579 839
Clinical Effectiveness Module: Implementing the ABC Alcohol Approach in Primary Care 15CAPITAL AND COAST National referral networks include:
4. Identifying local and national referral
Community Alcohol and Drug Service
– Wellington Alcohol Drug Helpline
(04) 494 9170
http://www.cads.org.nz/
services, resources and support
WAIRARAPA
Wairarapa Addiction Service (Inc)
(06) 377 3156
NELSON-MALBOROUGH
Alcohol and Drug Centre – Wairau
(03) 520 9908
WEST COAST Alcoholics Anonymous
Community Mental Health & Rata 0800 229 6759
Alcohol & Drug Services – Hokitika www.aa.org.nz
(03) 756 9700
For further referral services,
CANTERBURY the Alcohol Drug Association
Community Alcohol and Drug Service New Zealand (ADANZ) has developed
– Christchurch a treatment directory which contains
(03) 335 4350 a regionalised database of all the
publicly funded addiction treatment
SOUTHERN CANTERBURY and advice services in New Zealand.
Alcohol and Drug Service – Timaru
(03) 687 2150 The directory can be viewed at:
www.addictionshelp.org.nz/
SOUTHERN Directory
Community Alcohol and Drug Service
– Oamaru
(03) 433 0002
16 The Royal New Zealand College of General Practitioners5. Selecting and
5. Selecting and implementing an IT tool for
implementing an IT tool
introducing the ABC Alcohol programme
for introducing the ABC
Alcohol programme
Reminder system
An effective reminder system is central to implementing
the ABC Alcohol programme.
Practices will need to ensure that a to the age, gender and medical
reminder system is in place to remind history of the patient.
primary health care practitioners
to discuss and record individual A reminder to ask about alcohol can
patients’ alcohol status. be included for all patients 15 years
and over.
Practices may wish to develop a
reminder system within their practice Dashboard uses traffic light colour
management system. coding to flag the status of alcohol
recording (see Figure 4) .
Examples of useful reminder systems
are as follows. Red: Alcohol status not recorded
Yellow: Alcohol use above
Patient Dashboard
guidelines or under
Patient Dashboard is a software surveillance
tool which populates each time new
Green: Alcohol use within guidelines
patient notes are opened. The items
shown on the Dashboard are specific
Clinical Effectiveness Module: Implementing the ABC Alcohol Approach in Primary Care 17FIGURE 4
5. Selecting and implementing an IT tool for
introducing the ABC Alcohol programme
CLINICAL AUDITS This will require practices to identify and tag any enrolled
patient 15 years and over who does not have their alcohol
Clinical audits with reminder tags may also be used as a status recorded.
reminder system.
18 The Royal New Zealand College of General PractitionersRecording patient alcohol status
5. Selecting and implementing an IT tool for
introducing the ABC Alcohol programme
The practice will need to have in place a recording system
integrated within their PMS that includes the following.
• AUDIT C and Alcohol Use Practices are able to develop their
Disorders Identification Test own forms but these should be
(10-question audit) effectively integrated within the
practice’s PMS system.
• Instances where the patient has
declined to answer Advanced forms
• Patient answers to each of the An advanced form has been
AUDIT tools developed to implement the ABC
Alcohol Approach. Examples of this
• Standard drink calculator
form are shown in Figures 5-8.
• Pregnancy status
• National and local
referral information
• Links to appropriate resources
• Detailed clinical assessment
• Clinician notes
Clinical Effectiveness Module: Implementing the ABC Alcohol Approach in Primary Care 195. Selecting and implementing an IT tool for
introducing the ABC Alcohol programme
20
FIGURE 6
FIGURE 5
The Royal New Zealand College of General PractitionersFIGURE 7
5. Selecting and implementing an IT tool for
introducing the ABC Alcohol programme
FIGURE 8
Clinical Effectiveness Module: Implementing the ABC Alcohol Approach in Primary Care 216. Professional competencies
6. Professional competencies and training
and training
Practice training
The ABC Alcohol programme is opportunistic, and
successfully implementing it relies on support and full
involvement from all practice staff.
Practices will need to undertake necessary. This decision will need
practice-wide CME training on: to take into account the practice
infrastructure, individual nurses
• the role of and skills required by and general practitioners’ interests
primary care teams in prevention, and competencies and the
early detection and management expected need or demand.
of alcohol and other substance
misuse problems If appropriate, the practice may
decide to provide brief interventions,
• introduction to screening, brief counselling or extended consultation
interventions and “must-know” through a nurse-led clinic. However, it
basic information including: is important that all practice staff are
trained to provide brief interventions,
• continuum of use
counselling and, where necessary,
• standard drinks referrals. Sometimes this may need to
take place within the current patient
• useful websites. appointment, as bringing the patient
back in for an extended consultation
Practices should decide who
may not be possible or the patient
and how the practice will provide
may not turn up.
the brief interventions and
extended consultations where
Identification and training
of a project leader
Practices should identify an ‘alcohol champion’ within the
practice or group of practices to lead the project.
The alcohol champion should Essential components of the
attend a certified one-day training training include:
programme to provide them
with the necessary information • case management and
and skills to implement the recovery model – role-play
ABC Alcohol programme. positive engagement
• ALAC’s low-risk drinking
alcohol advice
22 The Royal New Zealand College of General Practitioners• DSM IVR1 criteria for abuse • alcohol
6. Professional competencies and training
and dependence
• benzodiazepines
• brief intervention and advice
techniques using FRAMES • cannabis
(feedback, responsibility, advice,
• amphetamines
menu of options, empathy,
self-efficacy) • psychotropic medication
• motivational interviewing • resources and support
• foetal alcohol syndrome • IT systems training.
• when to refer on – specialist The training is provided through a
alcohol and drug services, train-the-trainers framework. After
scenarios not to refer receiving training, the ‘alcohol
champion’ is expected to lead
• defining a pathway for
practice-based training for all practice
management of alcohol
staff. This may be delivered in
problems that are detected
modular sessions through practice
• management of long-term, meetings or training sessions.
chronic conditions
It is essential that appropriate
• pharmacology – including practice management systems
interactions of commonly already exist or are put in place to
prescribed medications and: train all practice staff on the ABC
Alcohol programme.
College-recognised
training programmes
Blueprint for Learning2
• ABC Alcohol Champion
Train-the-Trainers Workshop
1
Diagnostic and Statistical Manual of Mental Disorders
2
This training programme is pending consideration by the College.
Clinical Effectiveness Module: Implementing the ABC Alcohol Approach in Primary Care 237. Patient recall
7. Patient recall and re-screening
and re-screening
Patient recall
Practitioners need to ensure that patients with hazardous
drinking problems are recalled for a follow-up visit if
appropriate, or referred on to an alcohol counselling service.
It is important that the appropriate PMS and practice-based
reminders are put in place to ensure this happens.
Re-screening patients
Re-screening patients requires practitioners to make a
judgement call based on their knowledge of the patient.
As a general guide we • Patients over the age of 35 who
recommend the following intervals are within the recommended
for re-screening patients. guidelines for the consumption of
alcohol have their alcohol status
• Patients between the ages of recorded every five years
15 and 25 have their alcohol
status recorded annually • Any patient who is identified as
having a hazardous drinking
• Patients between the ages of 25 problem should be screened
and 35 have their alcohol status annually until their status changes
recorded every three years
24 The Royal New Zealand College of General Practitioners8. Evaluation
8. Evaluation
The steps described in this module allow a practice team to
systematically implement the ABC Alcohol Approach. This
step of reflection and feedback is intended to guide ongoing
improvement. Figure 9 is a guide to practice evaluation of
the programme. This is intended to help practices identify
the components of the programme that have worked well
and areas which may need improvement.
FIGURE 9
1. Analysis of results • Were the objectives met?
• W
hat changes can be made to improve
patient care as a result of the
information obtained?
2. Identification of • Knowledge gaps
discussion points • Areas for quality improvement
• L
earning, education or upskilling highlighted
e.g. identification of severity
• Assessment of risk and resilience
• A
vailability of tools in general practice
for risk assessment
• L
evel of skill or comfort in using tools or in
addressing health problems
3. Discussion of results • What are the reasons for the results generated?
• W
hat is the gap between the information
obtained and the expectations?
• Feasibility, limitations etc
4. Required changes at • Systemic issues
individual, organisational • Practice resources
or systems level
• Practice team issues and responsibilities
• Training requirements
• L
ink to educational material – are there any
existing modules or educational materials?
5. Prioritisation checklist • What area will you address first?
6. Activity planning • D
evelop a quality action and management
for ongoing review plan to address outstanding issues
and improvement • Identify who takes responsibility for the actions
• M
eet regularly to ensure actions being
implemented are successful
• Discuss problems or benefits
• Report on activity
• U
ndertake a regular review of progress
against changes agreed
Clinical Effectiveness Module: Implementing the ABC Alcohol Approach in Primary Care 259. Implementing
9. Implementing improvements and ongoing support
improvements and
ongoing support
Practices need to take a longer-term view and look to
identify ongoing needs for the ABC Alcohol programme.
Examples of this will include It is recommended that practices
consideration of the following. develop a quality action and
management plan to address
• Ensuring the alcohol champion is outstanding issues in the ABC
supported in their role Alcohol plan.
• Assessing whether training This will include:
for the alcohol champion has
been effective • identifying who will take
responsibility for the actions
• Assessing the effectiveness
of practice-wide training • barriers to implementating
improvements and changes
• Incorporating discussions
about implementing the ABC • reporting on activities
Alcohol programme into practice
meetings and providing a forum • undertaking a regular review
where issues and solutions can of changes.
be discussed
• Identifying the need for support
or further training at an individual
or practice level
• Identifying PHO support that may
be available
26 The Royal New Zealand College of General Practitioners10. Integration with
10. Integration with College programmes
College programmes
Continuing professional
development
CME and clinical activities
GPs attending College-accredited ABC Alcohol training will
be eligible for MOPS CME credits. Those attending the CME
training session will receive a certificate for attendance and
should enter the course details onto their MOPS page to
claim credits.
GPs participating in the programme provide evidence of implementation
may also be eligible for MOPS of the ABC Alcohol Approach and
Clinical Audit credits as part of the their role within this. GPs may use
clinical audit component of the MOPS the PDSA-based clinical worksheet
programme. GPs wishing to obtain template which is in Appendix 4.
clinical audit credits will need to
CORNERSTONE® annual programme
Completion of the College-approved Clinical Effectiveness
Module can be used for CORNERSTONE® in the
annualised programme.
Further information is available on the CORNERSTONE® website at
www.rnzcgp.org.nz/cornerstone-general-practice-accreditation
Clinical Effectiveness Module: Implementing the ABC Alcohol Approach in Primary Care 2711. Further information: useful
11. Further information: useful links and resourcES
links and resources
ALAC online resources
www.alac.org.nz/research-resources/pdfs-alac-resources
Alcohol Healthwatch
www.ahw.org.nz/
i
Royal New Zealand College of General Practitioners (2011) Aiming for Excellence,
Criterion 10.4, p.24
ii
World Health Organization, The Global Strategy to Reduce the Harmful Use of Alcohol (2010), pg. 5
iii
Connor J, Broad J, Rehm J, Vander Hoorn S, Jackson R. (2005) The burden of death, disease and
disability due to alcohol in New Zealand. New Zealand Medical Journal;118(1213)
iv
Ibid.
v
Law Commission, NZLC R114 Alcohol In Our Lives: Curbing the Harm (2010)
vi
ALAC, The Burden of Death, Disease and Disability due to Alcohol in New Zealand (2005), p.38
vii
Within the new annualised CORNERSTONE® Practice Accreditation Programme
viii
Anderson, P et al (2009) ‘Effectiveness and cost effectiveness of policies and programmes to
reduce the harm caused by alcohol’ Lancet vol.373 pp.2234-2246 and Alcohol and Public Policy
Group (2003) ‘Alcohol: no ordinary commodity: A summary of the book’, Addiction, vol. 98,
pp.1343-1350
ix
Adapted from ‘Alcohol Questionnaire to be complete as part of your Medical Registration’,
University of Leeds, ‘Alcohol 10 Questionnaire’ www.leeds.ac.uk/lsmp/healthadvice/alcohol/
ALCOHOL%2010%20QUESTIONNAIRE.pdf (Accessed April 2011)
x
The National Council, ‘AUDIT C – Overview’ http://www.thenationalcouncil.org/galleries/
business-practice%20files/tool_auditc.pdf (Accessed April 2011)
xi
University of Leeds, ‘Alcohol 10 Questionnaire’ www.leeds.ac.uk/lsmp/healthadvice/alcohol/
ALCOHOL%2010%20QUESTIONNAIRE.pdf (Accessed April 2011)
xii
ALAC, “Drinkcheck” pamphlet, www.alac.org.nz/sites/default/files/useruploads/Resourcepdfs/
Drinkcheck2007.pdf (Accessed April 2011)
xiii
McMenamin, J and Newton, C (2011) Whanganui Regional Primary Health Organisation ABC
Alcohol Pilot Final Report, p.10
28 The Royal New Zealand College of General PractitionersAPPENDIX 1
Appendices
A template for practice-based quality
improvement activity
This template is derived from the Quality Framework (see Appendix 2) and provides a simple
method for general practice teams or practitioners to develop a practice-based, self-directed
CQI activity. By working through each of the stages of the tool it will be possible to learn how
systems or processes in the practice function, to identify any gaps and develop practical
solutions. The tool incorporates the PDSA (see Appendix 3) and facilitates the ability of
practice teams to plan, implement and audit a quality improvement activity.
Choosing a topic
Some activities or measures developed will only be of interest to an individual practice, and may not be useful to other
practices. Others will be of use to regions, or practices with special interests, or have national applicability. Similarly,
measures used to assess change may only be of relevance to a particular practice, while others may use indicators of
performance that have been thoroughly investigated and exhaustively tested. Additionally, it may be inappropriate to use
some measures developed in a local setting in another context.
Involving the team
This tool is most effective when the entire practice team is involved in the analysis, defining the scope of the area of
interest, describing what actually occurs, discussing possible solutions and choosing the solution. The team should
also decide how it will evaluate the activity and what information it will gather as part of its day-to-day work to assess
effectiveness of the activity.
Planning the activity
Define the topic area of interest and aspect of care or service delivery to be addressed: (What is the problem?)
Define the activity: (What do you want to do?)
Determine the drivers for undertaking the activity: (Why do this?)
Determine the goal: (What do you want to achieve?)
Determine the scope of the activity: (What are realistic parameters?)
Determine the resources required: (What do you need? Consider:
• time – identify how the work to be done will fit into existing schedules or whether additional time is required
• people – identify roles, relationships and responsibilities; who needs to be involved?
• buy in – arrange to meet frequently; communicate activity with the whole practice and others involved
outside the practice
• funding – can existing resources be utilised or will external funding be needed?)
Clinical Effectiveness Module: Implementing the ABC Alcohol Approach in Primary Care 29Understanding the issues
Description of current situation Perceived problems or questions Potential
about the current situation solutions
Setting • Identify the setting in which • Is the setting appropriate? Identify what
the aspect of care or service • Is the setting safe? is needed and
delivery takes place the processes
• What features about the setting
• Consider location, infrastructure, required to
can be improved?
hours of operation, personnel achieve the
• In what other settings does this required results
activity occur?
Capability • Identify the competencies • Are the knowledge and skills As above
of relevant required by relevant of all relevant practitioners
professionals practitioners appropriate and sufficient?
• Are additional educational
activities provided by e.g.
RNZCGP available?
Capacity of • Identify relevant supporting • What other activities, support As above
the organisation systems and processes and resources are required
and practice • Consider the IT system in the at a practice or external
practice but also systems in organisational level to undertake
other organisations such as the the activity?
PHO, and manual systems
• Consider both formal and
informal systems
Systems • Identify processes that • What structural and process As above
processes impact on practitioners when gaps can be identified?
that affect the providing that aspect of care • What are the issues?
interface between or service
the supporting
systems and
practitioner
What are the • Consider formal and informal As above
important relationships necessary for
relationships within providing the aspect of care
the practice? or service
What are the • Consider formal and informal As above
important relationships necessary for
relationships with providing the aspect of care
other providers? or service
What are the • Consider formal and informal As above
important relationships necessary for
relationships providing the aspect of care
with patients? or service
What are the • Consider formal and informal • Are there other important As above
important relationships necessary for community relationships?
relationships with providing the aspect of care
the community? or service
Suitable use • Consider how all the above As above
of knowledge affects the application of
and skills by knowledge by practitioners
practitioners during the consultation with
the patient
30 The Royal New Zealand College of General PractitionersMeasuring change
Once a problem or issue has been identified, potential solutions need to be determined, and interventions implemented.
Measuring change resulting from the introduced intervention is important to determine the effectiveness
of the intervention.
Measures must be focused on information useful to the practice and be easy to collect as part of day-to-day activity.
Baseline measures Post intervention review
(pre-intervention) (6 months)
Define data to be collected and methods
for data collection, collation and analysis.
(May include both qualitative and
quantitative information.)
Additional information
Critical events monitoring • What information is currently
Is there a significant events monitoring system available?
in place for this particular problem?
User evaluation • What information can be
How can we find out what patients think? gathered and how?
Cost/benefit • What information can be
What is the cost/benefit to the service gathered and how?
or patients?
Equity • What information can be
Are there issues of equity and how can they gathered and how?
be addressed?
Feedback
1
Fawcett C, Perera R, Gillon M. Template for a Quality Plan for a Practice – based QI Activity. The Royal New Zealand College of General Practitioners.
Wellington, New Zealand. 2011.
Clinical Effectiveness Module: Implementing the ABC Alcohol Approach in Primary Care 31APPENDIX 2
Aiming for Excellence in a quality system
The V2Q Quality Framework Overview (see below) shows how the qualtiy system links to
other inter-relationships and activities that influence day-to-day clinical work, wider practice
activity, health system activity and RNZCGP activity, including CORNERSTONE® general
practice accreditation.
At the centre of the framework, quality improvement environment to enable self-reflection and learning, or for
activities help practices identify where practice teams quality assessment, professional development, continuing
engage in clinical effectiveness activities to improve medical education (CME) or CORNERSTONE® general
outcomes. These can be utilised within a peer review practice accreditation.
32 The Royal New Zealand College of General PractitionersAPPENDIX 3
PDSA Cycles: a method to measure and improve
clinical effectiveness
The quality process can be activated using PDSA cycles (see below) which are fundamental
to clinical improvement activity. All RNZCGP quality activity is based on continuous cycles
of change and improvement. PDSA cycles are a simple method for teams to identify and
manage change.xiv
The PDSA process is used to: • P
DSA cycles guide incremental and continuous
change, gap identification and action.xv
• analyse the effectiveness of practice systems
and processes • PDSA cycles facilitate reflection and learning.
• identify sources of variation causing safety PDSA cycles are useful to:
or risk issues
• target and plan improvement activities
• identify where to target changes or improvements
in patient care. • review any aspect of the practice service
• understand procedures used for care of patients
PDSA cycles - PLAN, DO, STUDY/CHECK, ACT
• understand the effect of care on outcomes
The principle of all clinical
quality activity is that it leads • develop improvements in the quality of life for patients.xvi
to improvement through
change. PDSA cycles are
useful because they outline a
simple approach to systematic
review and can be used by all
members of the practice team.
The approach
• Teamwork is essential and
the approach should always
involve or inform
the whole team.
• PDSA cycles can be applied
to any aspect of care or
service.
• PDSA cycles work
best if there is
“consideration of patients
and wha-nau/families, or
practice populations.
xiv
Deeming E.The PDCA cycle, in The Man Who Discovered Quality. A. Gabor, Penguin Books, 1990
xv
Berwick D, Institute of Healthcare Improvement (IHI), Boston, USA
xvi
Ministry of Health. Toward Clinical Excellence. An introduction to clinical audit, peer review and other clinical practice improvement activities. NZ,
Wellington,2002
Clinical Effectiveness Module: Implementing the ABC Alcohol Approach in Primary Care 3334
APPENDIX 4
Clinical effectiveness worksheet
The College recommends the use of the PDSA cycle when implementing the ABC Alcohol Approach.
Aim of the ABC Alcohol Approach
The programme is intended to identify risky drinking behaviours in patients over the age of 15 and provide brief advice
and counselling when necessary.
PLAN
The Royal New Zealand College of General Practitioners
List the tasks needed to implement the ABC Alcohol Approach in the practice Person responsible Where to be done Date to be completed
Examples may include the following.
1. Identifying local and national referral services, resources and support
2. Recording and reminder systems
• Establish a system for patient reminders and recording alcohol status
• Set up reminder system for patient recall and re-screening
• Identify the data set which needs to be collected
3. Professional competencies
• Consider which staff will provide brief advice and extended consultations, taking into account
practice infrastructure, staff interests and competencies, and expected need or demand
4. Training
• Identify the alcohol champion to attend a certified one-day training programme
• Identify the systems in place to implement training
• Coordinate practice-wide training for practice staffDO
Follow the ABC Alcohol Approach to identify and treat patients with risky alcohol behaviours.
STUDY
Changes/improvements
Comments
identified
Analyse results
• Were the aims met?
What changes can be made to improve the ABC Alcohol Approach as a result of the
information obtained?
Discussion points:
• Knowledge gaps
• Areas for quality improvement
• Learning, education or upskilling highlighted
• Level of skill or comfort in implementing ABC Alcohol Approach
Identify required changes at individual, organisational or systems level:
• Systemic issues
• Practice resources
• Practice team issues and responsibilities
• Training requirements
• Link to educational material
Clinical Effectiveness Module: Implementing the ABC Alcohol Approach in Primary Care
3536
ACT
Describe what modifications to the plan will be made for the next cycle from what you learned.
Modifications/improvements Person responsible Review date
The Royal New Zealand College of General PractitionersAPPENDIX 5
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Level 3, 88 The Terrace, Wellington 6011
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Telephone: +64-4-496 5999
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