Sustainable Systems Change Research Articles

Systems change to improve tobacco use identification and referral in the chiropractic setting: a pilot study

BackgroundTobacco use remains a leading cause of death and disability in the United States. Health professionals need to address the use of tobacco products by their patients, but chiropractic clinical systems often remain unsupported and underappreciated in their role to facilitate tobacco use cessation.MethodsThis pilot study tested an intervention to assist a chiropractic community to implement sustainable health systems changes for tobacco use based on U.S. Public Health Service guidelines. Chiropractors were educated on the Ask, Advise, Refer (AAR) approach, provided with ongoing guidance, and followed for six months to assess systems change. The study was conducted from March 2016 to July 2017.ResultsEvidence of a systematic process in place to conduct AAR was present in all clinics by the end of the fourth month of the intervention period. Although no clinic had sustained health system change for full AAR, all six of the clinics made progress in the individual AAR components. Furthermore, five clinics achieved sustained system change for the Ask component, as after systems change was achieved, the rate of tobacco user identifications did not drop below 50%. For the Advise component, five clinics succeeded in having individual months of ≥50% of tobacco users being advised, and three clinics achieved the formal definition of systems change. For the Refer component, no clinic achieved system change, although four had individual months of ≥50% of tobacco users being referred. The patient quit rate was 13.3% (n = 15) for the 30-day follow-up and 16.7% (n = 6) for the three-month follow-up.ConclusionsThis study demonstrates the feasibility of implementing a health systems change in the chiropractic setting to identify tobacco users, to advise them to quit, and to refer users for cessation services.

Health care reform in Belgium: contracting for co-creating integrated care as change management strategy

Introduction: The Belgian Health Care Reform: “Integrated Care for a better health” was approved by all competent ministers in 20151. This Plan is based on the principles of Triple Aim2, together with equity and job satisfaction for the care providers. The core strategy of the plan is to drive change in a ‘mixed or guided bottom-up approach’, with large-scale locoregional change piloting projects implemented on and by the field, and government as facilitator. Over the past year, field actors of pilot regions worked together to elaborate an actionplan with local collaborations and initiatives in order to achieve integrated care. Different stakeholders from health care as well as social care are involved including patients and citizens. In the course of the co-creation process between the wide variety of field actors and government several difficulties surfaced, both from the projects and policy perspective. Description of policy context and objective: Belgium has an accessible health care with a national, compulsory health insurance (covering 99% of the population). Fee for Service, fragmented services and lack of coordination and communication make the system inefficient and unsustainable for dealing with multimorbidity. A legislative basis is created to allow pilot regions to test new organizational structures (integration management), work across silo’s and operate in a system of shared savings. Predicted expenditure, for the determined target population is guaranteed as revenue: by increasing efficiency, gains can be reassigned by the project. Target Population: The Plan targets the whole Belgian population with a focus on people with a chronic disease. 14 projects (2.584.824 inhabitants) are selected for implementation as from 1.1.2018. Highlights: Facilitators/barriers for implementation: - Anchoring visionary leadership in governance supported by stakeholder leadership on a national level - A national strategy for ICT system and data management is a priority and prerequisite for projects to be operational (national eHealth plan), and needs specific investment. Needs are identified in co-creation. - Close interaction between authorities and pilots - Dealing with institutional and legal hurdles between regional and federal authorities and the wide range of fractionated competencies in health and social care. - The projects are multi-stakeholder consortia with a mix (of conflicting) interests of partners. The uncertainty of achieving the triple aim makes projects hesitant to take risk for pre-financing innovative actions. Uncertainty on the impact on revenue challenges the confidence so hardly needed in the shift towards integrated care. - Need of social entrepreneurship with a population management scope conflicts with traditional social profit service delivery. Comments on transferability and conclusion: From a healthcare policy perspective, each country system is faced with the same complex process of changing the existing structures and cultures. The Belgian approach combines stimulation of bottom up ideas and entrepreneurship with guidance from the policymakers by setting out the framework for innovation, creating a safe environment for setting down sustainable system change. This takes time: uniting different stakeholders around the same vision, the will to embrace the complexity and to take the plunge.

Cost effectiveness of midwifery care for women with complex pregnancy – a structured review of the extant literature

La rectopexie ventrale robotique peut être réalisée sans grand traumatisme pour le patient, la rendant potentiellement intéressante pour une prise en charge ambulatoire. Le but de cette étude est de rapporter notre expérience préliminaire de la rectopexie ventrale robotique ambulatoire chez des patients consécutifs.Dix patients consécutifs ont bénéficié d’une rectopexie ventrale robotique pour prolapsus total du rectum (n = 8) ou entérocèle symptomatique entre février 2014 et avril 2015. Ils ont été sélectionnés pour une prise en charge ambulatoire sur des critères de motivation, de conditions sociales favorables et d’état général satisfaisant. Les caractéristiques du patient, les résultats techniques et le coût ont été relevés.La durée opératoire moyenne a été de 94 minutes (78–150). La durée moyenne d’occupation de salle a été de 254 minutes (222–339). Il n’y a pas eu de complication opératoire, de conversion en laparotomie ou de complication postopératoire. La durée moyenne d’hospitalisation a été de 11 heures (8–32). Deux patients ont dû être hospitalisés : l’un pour douleur persistante et l’autre pour rétention urinaire. La douleur maximale moyenne enregistrée le lendemain a été de 2/10 (0–5) sur échelle visuelle analogique. L’estimation du coût moyen (hors amortissement de l’achat du robot) a été de 9088 euros par procédure.La prise en charge en mode ambulatoire de la rectopexie ventrale robotique est faisable et sûre.Ventral rectopexy can be performed robotically with only limited trauma for the patient, making its performance in an ambulatory setting potentially interesting. The aim of this study is to report our preliminary experience with ambulatory robotic ventral rectopexy in consecutive patients.Ten consecutive patients underwent robotic ventral rectopexy for total rectal prolapse (n = 8) or symptomatic enterocele (n = 2) between February 2014 and April 2015. Patients were selected for outpatient treatment based on criteria of patient motivation, favorable social conditions, and satisfactory general condition. Patient characteristics, technical results and cost were reported.The mean operating time was 94 minutes (range 78–150). The average operating room occupancy time was 254 minutes (222–339). There were no operative complications, conversion to laparotomy, or postoperative complication. The average duration of hospital stay was 11 (8–32) hours. Two patients required hospitalization: one for persistent pain and the other for urinary retention. The average maximum pain score recorded on postoperative day 1 was 2/10 on a visual analog scale (range: 0–5/10). Estimated average cost (excluding amortization of the purchase of the robot) was € 9088 per procedure.Ambulatory management of robotic ventral rectopexy is feasible and safe.

Cultivating a Professional Culture of Peace and Inclusion: Conceptualizing Practical Applications of Peace Leadership in Schools

Beyond the role of educating students across all academic domains, school leaders are tasked with the monumental responsibility of creating positive, engaged systems and cultures that embrace the growing cultural, economic, linguistic and cognitive diversity in the United States landscape. With collective goals to create peaceful learning environments with capacity to serve diverse learners, many school leaders have embraced school-wide prevention and intervention efforts, such as Multi-Tiered Systems of Support (MTSS) for social-emotional and behavioral development of students. Unfortunately, due to the inherent complexities and fragmentation of such efforts, many school leaders have continued to experience significant barriers to sustainable systems change. Throughout the following discussion, the authors argue that the school-wide programs most commonly utilized in schools lack the explicit organizational structures for integrating culturally responsive practice, leadership development, and collaborative community building processes that are essential to sustainable implementation. Therefore, this conceptual paper aims to explore the possibilities for practical applications of the Integral Perspective of Peace Leadership (IPPL; McIntyre Miller and Green, 2015) within school systems change efforts by shifting focus from direct student skill development toward a more integrated and systems-oriented approach aimed at strengthening culture and capacity within communities of educational leaders. The IPPL can “connect the dots” and provide a strong foundation through which school-wide change is possible and more sustainable. By challenging individuals, schools, communities, and organizations to examine and include Innerwork; theories, behaviors and practices, or Knowledge building; Communities of practice; and Environment work, such as systems and global thinking (McIntyre Miller and Green, 2015), the implementation of the IPPL may “challenge issues of violence and aggression and build positive, inclusive social systems and structures” (McIntyre Miller, 2016, p.223). The purpose of this paper is twofold. First, there is a discussion of how the elements of the IPPL connect to school culture and system change. Second, specific examples, such as character development, mindfulness, school-wide positive behavior supports, social-emotional learning, professional learning communities, home-school connection, systems thinking, and distributed leadership, will demonstrate how school leaders might engage, using consultants and an implementation team, in the work to create positive, equitable school cultures.

Integrated care in practice

Introduction: System integration to achieve sustainable systemic change is not a new concept and something that has been around in International practice for a number of years. Experiential, comparative exploration of system models in Alzira, Boston and Washington DC (via an AQuA fellowship) highlight significant similarities with that of the Oldham economy, at the same time as identifying the stark difference in progress to develop and deploy sustainable system models in the UK. Oldham has taken learning from International best practice and used the intelligence and information to better shape the system in Oldham, aligned to the greater Manchester Devolution mandate. By deploying the same strategic approach as International models to the urgent care system in Oldham (via a multi agency alliance partnership) we are able to demonstrate sustained quality improvements for people and system flow via a number of innovative, transformational approaches that have sustained positive impact on a reduction in unplanned admissions in excess of the National expected average (3.5%). This achievement has received National recognition (NHS England) and also shortlist for two HSJ awards (integration and quality improvement). Description of practice change implemented: Oldham Urgent Care Alliance’s (a partnership of 8+ multi agency organisations) aim is to improve the urgent care system across the Oldham locality. It had a number of objectives: to reduce unplanned admissions to hospital by 3.5%, deliver a number of integration projects and take a performance management approach to the use of resilience funding. Via this approach a number of practice changes are evident, Development of a frail elderly unit which has reduced length of stay by 70-50% Development of a multi agency discharge to assess service, impacting upon admissions to residential and acute provision and improving quality of life Development of a multi agency Primary Care practice before the front doors of AE Pennine Acute Hospitals NHS Trust; Pennine Care NHS Foundation Trust; GotoDoc (a social enterprise providing an out of hours GP service) MIO Care, (a limited company owned by the council to provide homecare and re-ablement services), Voluntary Action Oldham; First Choice Homes; GP representation and Oldham CCG. Timeline: 12 months Highlights: (innovation, impact and outcomes) Sustained improvement in quality of care and life chances are evident as a result of deploying this systematic approach. A sustained reduction of 5.8% in unplanned hospital admissions achieved, despite an annual 6% increase in A&E attendances over the same period Total estimated system saving of £2.79m. Paediatric admissions Triage system introduced to assess conditions prior to admission. Almost 600 fewer paediatric admissions in 2015 compared with 2014 Alternative to transfer (minor injuries) A physiotherapy and occupational therapy service established enabling initial assessment of patients quickly to divert the patient from admission. Over 250 deflections from hospital achieved in 2015. Long term conditions Pro-active and self-management within the community. Almost 500 hospital deflections achieved in 2015, compared with the previous year. Early supported discharge for stroke rehabilitation 15 hospital deflections for stroke patients achieved in 2015. End of life care An overall reduction of the number of deaths in hospital per 1,000 population of 2% Intermediate care, A&E – therapy in-reach Over 250 additional hospital deflections in 2015. SPRINT (Senior persons resilience independence team) Reduced length of stay for over 85yrs by 70% Reduced length of stay for 65-85 yrs by 50% Comments on sustainability: Analysis of performance metrics continue to demonstrate sustained system impact despite growing demand. Review of quality impacts continue to yield positive impacts upon quality. Comments on transferability: The model can be replicated in any system/ care setting. Conclusions: The development of a systematic system leadership and governance approach via integrated working across a number of public, private and voluntary sector organisations has yielded a sustained impact upon quality and performance improvements within the urgent care system. The introduction of the Programme Management Office to co-ordinate and manage multiple projects across multiple partners was critical to the success of the transformation programme and the demonstration of sustained outcomes delivered. Discussions: This theory of change continues to be deployed within the Oldham urgent care economy and there are a number of other innovations that have been deployed as a result. This theory and concept has been driven forward by a sustained fastidious leadership approach across the system with interrogation of quality and performance data to evidence outcomes. Lessons learned: Sustained system leadership is critical to success Interagation of International systems has demonstrated the similarities between UK systems, which has been deployed further than theory and concept and implemented to make real and sustained system change Relationships across organisations are key to success Integrated working is a critical success factor Despite perverse financial incentives front line staff working in an integrated way can make real and sustained impact upon quality The deployment of quality improvement methodology enables and embeds rapid improvement

Translating a health service intervention into a rural setting: lessons learned

BackgroundLimited research exists on the process of applying knowledge translation (KT) methodology to a rural-based population health intervention.MethodsThis study reports on the implementation and translational stages of a previously described Co-creating KT (Co-KT) framework in the rural town of Port Lincoln, South Australia (population: 14,000). The Co-KT framework involves five steps: (i) collecting local data; (ii) building stakeholder relationships; (iii) designing an evidence-based intervention incorporating local knowledge; (iv) implementation and evaluation of the intervention; and (v) translating the research into policy and practice. Barriers and enablers to the overall Co-KT implementation process were identified. Our intervention focused on musculoskeletal (MSK) conditions.ResultsAlthough the Co-KT framework was valuable in engaging with the community, translating the final intervention into daily clinical practice was prevented by a lack of an accessible policy or financial framework to anchor the appropriate intervention, a lack of continued engagement with stakeholders, access problems to general practitioners (GPs) and Allied Health Professionals; and the paucity of referrals from GPs to Allied Health Professionals. Consequently, while many aspects of the intervention were successful, including the improvement of both function and pain in study participants, the full implementation of the Co-KT framework was not possible.DiscussionThis study implemented and evaluated a Co-KT framework for a population with MSK conditions, linking locally generated health care system knowledge with academic input. Further policy, health system changes, and on-the-ground support are needed to overcome the identified implementation challenges in order to create sustainable and effective system change.

Governing for sustainable energy system change: Politics, contexts and contingency

This paper offers a new, interdisciplinary framework for the analysis of governing for sustainable energy system change by drawing together insights from, and offering critiques of, socio-technical transitions and new institutionalist concepts of change. Institutions of all kinds, including rules and norms within political and energy systems, tend to have path-dependent qualities that make them difficult to change, whereas we also know that profound change has occurred in the past. Current decisions to pursue climate change mitigation by dramatically changing how energy is produced and used depend to some extent on finding the right enabling conditions for such change. The approach adopted here reveals the highly political and contingent nature of attempts to govern for innovations, how political institutions mediate differently between forces for sustainable change and forces for continuity, as well as specific interactions between governance and practice change within energy systems. It concludes that it is only by being specific about the contingent nature of governing for innovations, and about how this affects practices in energy systems differently, that those of us interested in sustainability can credibly advise policy makers and drive for greater change.

State Fall Prevention Coalitions as Systems Change Agents: An Emphasis on Policy.

Falls among older adults are an escalating public health issue, which requires a multidisciplinary and multilevel approach to affect systems change to effectively address this problem. The National Council on Aging established the Falls Free® Initiative, enfolding and facilitating statewide Fall Prevention Coalitions. Fall Free® activities included developing the State Policy Toolkit for Advancing Falls Prevention to promote sustainable change by supporting the dissemination and adoption of evidence-based strategies. To (1) determine if the policies being implemented were recommended and supported by the Toolkit, (2) identify the perceived barriers and facilitators to implementing policies, and (3) identify Coalitions' current and future fall prevention policy activities. A 63-item online survey was distributed to State Coalition Leads. Descriptive statistics (frequencies and counts) were used to describe Coalition characteristics and activities. Coalitions had several similarities, and varied greatly in their number of member organizations and members as well as meeting frequencies. Key activities included building partnerships, disseminating programs, and pursuing at least one of the eight National Council on Aging-recommended policy goals. The most commonly reported facilitator was active support from the Coalition Leads, whereas the lack of funding was the most cited barrier. This study serves as the first national census of empirical evidence regarding Falls Coalitions' composition, goals, and activities. Results indicate that Coalitions are actively pursuing evidence-based policies but could benefit from additional technical assistance and resources. Findings support the value of Toolkit recommendations by documenting what is feasible and being implemented. Knowledge about facilitators and barriers will inform future efforts to foster sustainable systems change in states with active Coalitions and encourage Coalitions in other states.

Health Care Redesign for Responsive Behaviours—The Behavioural Supports Ontario Experience: Lessons Learned and Keys to Success

Our health care system is ill prepared for the growing number of older adults and their families/caregivers who live with responsive behaviours associated with cognitive impairment. Considering the burden of illness, quality of life issues, and escalating costs, system-wide redesign is warranted. The Behavioural Supports Ontario (BSO) project is a province-wide, regionally implemented, evidence-informed change strategy that utilizes quality improvement principles and knowledge translation best practices as critical enablers. This paper describes the project and key lessons learned in the implementation of this initiative that can be applied to other jurisdictions wishing to enable large-scale system redesign and sustainable system change.

Increased evidence-based tobacco treatment through Oklahoma hospital system changes.

Oklahoma hospitals admit approximately 120,000 tobacco users each year, many for diseases resulting from tobacco use. To describe a unique partnership between the Oklahoma Hospital Association and Oklahoma Tobacco Settlement Endowment Trust to reach more tobacco users through the implementation of sustainable health system changes within hospitals and clinics to integrate an evidence-based tobacco treatment protocol for all tobacco-using patients. The Oklahoma Hospital Association tobacco-cessation model included (1) identifying all tobacco-using patients; (2) assessing addiction level and readiness to quit; (3) prescribing medications to manage withdrawal while in hospital; and (4) proactively faxing a referral to the Oklahoma Tobacco Helpline for all patients ready to quit. Helpline registration patterns and characteristics of fax-referred hospitalized patients were tracked for the 4 years of the initiative (2009-2013); data were analyzed in 2013. Twenty-one hospitals and 12 clinics participated in the initiative. Fax referrals to the Helpline increased by >150% in the first year, from about 600 during the year prior to the implementation of the program (July 2009 to June 2010) to 1,581 from Oklahoma Hospital Association facilities alone in the first year following the launch of the initiative. Nearly 5,600 Oklahoma Hospital Association fax referrals were made during the 4-year study period. About 41% of these referrals resulted in Helpline enrollment (n=2,289). Sustainable, evidence-based tobacco treatment interventions embedded in hospital systems can successfully identify tobacco users and provide effective treatment, including increased proactive Helpline referrals for quit coaching.

Building regional change at scale and pace: Integration lessons from the NSW Chronic Disease Management Program

Introduction: Over the last four years NSW has developed at scale and pace local disease management services following implementation of the Chronic Disease Management Program (CDMP-Connecting Care). Connecting Care has worked to engage and empower people to be actively involved in their health care. This has resulted in a streamlined patient journey with improved care coordination, self-management and coaching for people with long term conditions in the community. Practice and Context: A team of committed managers implemented the CDMP Connecting Care Model across NSW. Person-centred care is increasingly seen as a key indicator of quality and essential to improving healthcare systems and consumers are a key part of the model. In order to improve experiences and outcomes for patients and carers, staff charted a course between the acute, community and primary health care interface by embedding referral lines, recognising care pathways and GP care in the home. Description of Change Implemented: The first steps were to seek engagement and integration between health services and to deliver better health outcomes by streamlining the patient journey, providing greater care coordination and access to coaching for people with long term conditions in their home setting. Empowering consumers to play an active role in decisions about their care is central to the provision of person-centred care. This would lead to improved self-management and is a key goal of the ACI Chronic Care Network. Improvement realized: A central organising entity prioritised primary care engagement across intersection points within the acute care system. This led to the creation of patient navigation hubs for registered patients with long term conditions. Care partnerships, improved technology, outbound call centre protocols and integrated service delivery have meant patients have been more rapidly returned to the community after unplanned hospital admissions. Targeted population: Connecting Care targeted people in NSW with chronic disease i.e. Diabetes, Congestive Heart Failure, Coronary Artery Disease, Chronic Obstructive Pulmonary World Congress on Integrated Care 2014, Sydney, November 23-26, 2014. International Journal of Integrated Care – Volume 14, 8 December – URN:NBN:NL:UI:10-1-116665– http://www.ijic.org/ Disease and Hypertension who were aged 16 years and over and who were at high to very high risk of hospitalisation and who may benefit from care coordination and self-management support. Stakeholders Engaged: At a local level engagement has consisted of Local Health Districts Medicare Locals (MLs) in collaboration with General Practice (GP), Aboriginal Medical Services (AMS), Non-Government Organisations (NGOs), private health care professionals, and private health insurers. Timeline: Connecting Care has been implemented across NSW since 2010. Theory/Methods used: As people often have more than one chronic disease and require different levels of care and access the Kaiser Permanente triangle has been used to inform navigation to a range of services as their disease progresses and changes. Local Health Districts and Specialty Health Networks have been recurrently funded to deliver Connecting Care to eligible people in their community. The aim is to enrol at least 59,000 people into the program by 2014-15. Innovation, Impacts and Outcomes: Results for the program have been measured locally and with the assistance of a state wide evaluation consortium led by the George Institute for Global Health. Case Study based processes and local evaluation reveal a reduction in admissions (66%), bed days (63%) and 2.1 day average length of stay. Patient feedback has shown many have been engaged with disease management services for the first time and appreciate the coaching, locally based interventions and stronger links with their General Practitioners. Sustainability, Transferability: Connecting Care staff were able to chart a course between the acute, community and primary health care interface in NSW; preparing for a regional House of Care locally that had patient and carer centred care, recognition of the importance of the GP led medical home, embedded referral lines, known care pathways and greatly improved outcomes. Conclusions: A central organising entity was created with the Connecting Care program that prioritised primary care engagement and created patient navigation hubs for a registered group of patients with long term conditions. Discussions and Lessons Learnt: Care partnerships, improved technology, outbound call centre protocols and integrated service delivery are the building blocks of a sustainable system change. Other programs are now using this model to implement fracture prevention services and widen the targeted diseases scope.

COPASCities: Building Capacity for Food Systems Change in South Carolina Communities

To use community organization strategies that build coalition capacity for food system changes that support children’s healthy weight. In year one, COPASCities surveyed 75 individuals from 39 community coalitions to determine training needs. Key community organization strategies identified include: 1) food summits; 2) media analysis; 3) advocacy campaigns; and 4) training institutes that use case-based learning. COPASCities will use the capacity assessment results to develop strategies that empower communities to engage in effective and sustainable food system change strategies that prevent childhood obesity.

The changes on intimate partner violence against women in the health system in Portugal

In Portugal, over the last 20 years, we have seen great strides in addressing intimate partner violence against women by their male partners. Measuring and understanding progress, and achieving sustainable systems change is a major challenge and to achieve this aim we need to identify events, persons and settings that contribute for the critical factors that create long term transformations in the systems and the creation of new resources [1]. Since the healthcare system is one of the main actors of intervention with survivors, the goal of this project was to interview key stakeholders from the healthcare system in order to understand the main changes they perceive have happened over the past two decades. Based on interviews with key stakeholders, our study explores the evidences of the changes that occurred in the healthcare system, the intersections with other systems and their visions for the future.

Moving From Partnership to Collective Accountability and Sustainable Change: Applying a Systems-Change Model to Foundations’ Evolving Roles

· In a time of scarce resources and significant needs, funders may seek to maximize the impact of their grantmaking through collaboration. While many foundations move well from identifying a problem to building broader awareness and forging key partnerships, they typically flounder in trying to move beyond collaboration to a sense of mutual responsibility or collective accountability for the greater good, which is a precondition for sustainable systems change.

Heifer International Alternative Break: Sustainable Dietary Impacts

This study examines Heifer International's alternative break and its impact on dietary and sustainable food system change for participants. The program teaches college participants about ending poverty and hunger while caring for the earth through incorporating sustainable practices into daily life. Although increases in local/organic foods were observed, there were no significant changes in dietary quality. Significant increases in local/organic food consumption for individuals who consumed less than 50% of their calories from sustainable foods at baseline were observed, based upon paired t-tests (P < .05). Dietary changes varied in significance based upon previous sustainable food consumption exposure and habits.

Monitoring on-going vision development in system change programmes

Abstract Visions are considered to be of vital importance for programmes aimed at sustainable systems change. Vision development is a programme management instrument, a programme output, and at the heart of programme learning processes. This article addresses the question what constitutes an appropriate monitoring strategy for vision development activities within system change programmes. Based on action research and literature review on monitoring, evaluation and vision development a monitoring framework is proposed. It is suggested to monitor the programme vision against project visions, societal visions and a set of basic criteria. The monitoring activities themselves are context-sensitive and frequently renegotiated between monitors, programme managers and other stakeholders. The framework is illustrated with a national systems change programme on sustainable agriculture in the Netherlands.

Intimate partner violence against women and healthcare in Australia: charting the scene

Intimate partner violence against women is a common problem in all countries and generates a challenging agenda for the health sector. Exchanging experiences between different countries, specifically strategies to respond to this problem, can constitute a tool for stimulating debate and promoting reflection. The scope of this article is to present and reflect on aspects of the Australian health sector response to intimate partner violence, and chart the scenario that surrounds this issue. We draw on a range of methods, combining a literature review and a dialogue with different stakeholders and site visits. We describe historical, contemporary and conceptual aspects of healthcare responses to intimate partner violence in Australia. Further we present some of the strategies, public policies and innovative projects that have been developed in this field in Australia. Some of the strategies include: screening vs. case-finding; primary care approaches for dealing with all family members; respect for diversity; and new randomized trials aiming for sustainable health system change for enhanced health professional care of people experiencing intimate partner violence. Despite the limitations of this approach to such a complex theme, we hope to stimulate thinking and discussion.

Pain management in Australian emergency departments: Current practice, enablers, barriers and future directions

To explore current pain management practice in Australian EDs and identify enablers and barriers for best-practice pain management. Five focus groups and two in-depth interviews were held with ED clinical staff (n= 47) from six hospitals in three states. Participants were asked open-ended questions to determine current pain management practices, enablers and barriers to implementing best-practice pain management, and understand change in practice within the ED setting. Emergency department staff identified a gap between evidence-based pain management recommendations and everyday practice. Perceived barriers to improving pain management included a lack of time and resources, a greater number of urgent and serious presentations that place pain management as a lower priority, organizational protocols and legislative issues. All groups noted difficulty in applying pain management guidelines in the context of competing priorities in the challenging ED environment. A culture of learning clinical practice from respected senior staff and peers was perceived to be a key enabler. Participants consistently expressed the view that evidence-based practice improvement should be championed by senior clinical staff, and that evidence to demonstrate the benefits of change must be presented to support the need for change. Effective and sustainable system change requires a strategy that is initiated within the ED, targets opinion leaders, is supported by evidence, and engages all levels of ED staff.

Fetal Fibronectin Testing in Ontario: Successful Government-Sector Collaboration to Achieve High-Quality and Sustainable System Change

Ontario's province-wide implementation of fetal fibronectin (fFn) technology, a test to identify women unlikely to deliver within two weeks of presentation with symptoms of preterm labour, is a notable example of evidence-informed system improvement and productive government-sector partnership. Increasing demand for costly, high-risk maternal and newborn care in Ontario hospitals prompted a provincial review. Sector experts identified potentially avoidable maternal admissions and transfers to high-risk units for evaluation of suspected preterm labour as an opportunity for system improvement. Limited access to fFn testing was documented, and expert consensus posited that funding rapid clinical testing to identify women at low risk for preterm delivery would yield a significant return on investment. An expert panel recommended evidence-based clinical guidelines. The government swiftly secured funding and initiated a successful implementation strategy, capitalizing on regional perinatal networks. Amassing clinical and care utilization information, framing the data in a policy-relevant context and partnering sector expertise with ministry capability resulted in this technology being effectively implemented in a complex health system.

P1-S6.08 A multifaceted intervention to increase chlamydia testing in Australian general practice

BackgroundThe Australian Government has funded the Australian Chlamydia Control Effectiveness Pilot (ACCEPt), a randomised controlled trial of a chlamydia testing intervention to assess the feasibility, acceptability and cost-effectiveness of chlamydia...