Eye & Vision Care Toolkit

2. Continuous Quality Improvement

2.3. Eye Care Systems Assessment

WHAT? This is a list of questions to help stakeholders gauge how the eye care system in their health service, region, or area is performing according to the
following aspects of an eye care system: organisation, community and patient linkages, referral pathways and continuity of care, clinical information systems,
integration with primary care.

WHO? Who to involve in this exercise will depend on who makes up the eye care ‘system’ and how broadly you chose to look at the system’s performance.
For example, you may only be interested in the system within your individual health service, or across a collection of health services, or across an entire
region. Ideally, it should aim to include people from across the entire pathway of care (from primary care to hospital), from a mix of areas: Primary care,
Secondary eye services (consultations), Hospital-based care, Coordination, Healthcare systems or governance.

WHY? This tool aims to assist the process of all relevant stakeholders together identifying which aspects of the eye care system are performing well, and
which to work on improving, to then strategically address these as a team. If done regularly (annually), it may help guide collaborative processes and collective
goals or work plans for eye care for the region.

FORMAT: There are several ways you may choose to do this:

• Invite all stakeholders to anonymously complete the questionnaire, then average the group responses, and use those average as a starting point for
group discussions around strengthening eye care systems

• Set up the questions as an online survey (e.g. using free software such as Survey Monkey), which will also be a handy way to collect this information
each year to see how things improve over time.

• Use the questions to guide a group discussion, with facilitation, to arrive at a shared understanding of how the eye care system is performing and –
importantly – trigger discussion about ways to further improve the system.

Please note: these questions are merely the starting point – they aim to guide discussions among the range of people in your eye care system,
so that solutions and ideas can be collectively identified and goals set. This activity is not intended to be done for its own sake – it is only
valuable if it is linked to a collaborative approach to strengthening the eye care system in your region.

Eye & Vision Care Toolkit - 2. Continuous Quality Improvement | 2.3. Eye Care Systems Assessment 1
Instructions:

Please rate each component on a scale of 0 – 11, where 0 indicates limited or no performance, and 11 indicates optimal performance. A description of each
ranking for four levels (Level A – D) is provided, to assist you with deciding on the score you will allocate.

Circle the score (0 – 11) you chose, and where relevant provide brief comments of clarification or explanation.

If you are uncertain or unable to score a particular component, please leave it unmarked.

Results will be kept anonymous and used to determine the ‘average score’ from this group of stakeholders’ collective assessment of the Eye Care System. You do
not need to calculate the Part or Overall averages – that will be done when analysing the results.

Respondent Info: NB: this will be kept confidential and only used to inform the analysis of results


Please tick  which part of the regional eye care system you are involved in:

 Primary care  Secondary eye services (consultations)  Hospital-based care

 Coordination  Healthcare systems or governance

Date: ___ / ___ / _____ Location: _____________________________________

Eye & Vision Care Toolkit - 2. Continuous Quality Improvement | 2.3. Eye Care Systems Assessment 2
Part 1: Organisation of the Regional Eye Care Delivery System.
How well structured and organised are the services and systems for eye and vision care, in this region?
Components Level D Level C Level B Level A
Eye care workforce …there is no / negligible … there is a supply of eye care … there is an adequate supply … there is a good supply of eye care
for the region eye care workforce in the service delivery and of eye care service delivery and service delivery and coordination
region. coordination personnel, but coordination personnel, who are personnel, who are being used to a
they are currently not used to being used to a good capacity. maximally efficient capacity, which
their full capacity. includes coordination between their
services.

Score 0 1 2 3 4 5 6 7 8 9 10 11
Comments:

Overall organisation …eye care services are …eye care services are …eye care services are …organisation of a regional eye care
and clarity about provided in an ad hoc provided in a predictable predictably provided and there service delivery system is well
structure of the manner. manner but there is no clear are some systems in place established and communicated to all
regional eye care structure or organisation between the various aspects of relevant stakeholders, and regularly
system between the various levels of the eye care pathway, but there reviewed and updated as necessary
eye care, in the region. is not a clear organisational
structure for the entire ‘eye care
system’ serving the region

Score 0 1 2 3 4 5 6 7 8 9 10 11
Comments:

Regional goals and …does not exist, or limited …exist but are not actively …goals are measurable and …goals are measurable, reviewed
improvement to one or two conditions. reviewed; uses ad hoc reviewed; some form of routinely, and are incorporated into
strategy for eye approaches for targeted improvement strategy is in plans for improvement. Uses a
care services problems as they emerge. place. Some changes followed proven improvement strategy (such
through. Quality improvement as continuous quality improvement)
personnel have some proactively in meeting regional eye
involvement in eye care services care goals.

Score 0 1 2 3 4 5 6 7 8 9 10 11
Comments:

PART 1 – Organisation: TOTAL Score ________ AVERAGE Score (Total / 3) _________

Eye & Vision Care Toolkit - 2. Continuous Quality Improvement | 2.3. Eye Care Systems Assessment 3
Part 2: Community and Patient Linkages.
Are there good links between eye care delivery system (including visiting providers and primary care) and communities? This is important to
promoting active uptake of eye care services.

Components Level D Level C Level B Level A

Patient information …is not done. …happens on request by …is done routinely using patient …is done routinely, including
and education patient, or only done by visiting education materials. systematic reminders about eye
about eye care eye care practitioners. examinations due; includes use of
patient education materials about
specific conditions, describing key
management and prevention
messages.

Score 0 1 2 3 4 5 6 7 8 9 10 11
Comments:

Promoting visiting …is not done. …is occasionally done, but in …is accomplished by promoting … is accomplished through active
eye care services to an ad hoc manner. visiting services with advance coordination between the eye health
communities notice, using promotional system, primary health care service,
materials where relevant and community service agencies and
advising patients due for an eye patients. Patients are actively
exam with notice. engaging with visiting eye services.

Score 0 1 2 3 4 5 6 7 8 9 10 11
Comments:

PART 2 – Community Linkages: TOTAL Score ________ AVERAGE Score (Total / 2) _________

Eye & Vision Care Toolkit - 2. Continuous Quality Improvement | 2.3. Eye Care Systems Assessment 4
Part 3: Referral pathways and continuity of care
Are there evidence-based systems, processes, and tools in place to support the clinical decision making regarding eye care, and clarify the best-
practice referral pathways for eye care in the region?

Components Level D Level C Level B Level A

Evidence-based …are not available. …are available but does not …are available for the entire eye …are available and routinely used to
guidelines or cover the entire eye care care pathway, and routinely guide eye care referrals. Regional
defined referral pathway (primary, secondary used to guide eye care referrals referral pathways are regularly
pathways for eye tertiary). in the region reviewed, updated and
care communicated. Systematic processes
are in place to ensure patients
complete referral pathways.

Score 0 1 2 3 4 5 6 7 8 9 10 11
Comments:

Continuity of eye …is not a priority. …depends entirely on …incorporates shared case …is a priority and systematically
care communication between eye management via communication implemented: eye care interventions
care practitioners. between PHC practitioners, and include active coordination between
eye care providers. Is a priority PHC practitioners, eye care providers
but not implemented and tertiary (surgical) centres.
systematically. Information sharing enables optimal
patient care.

Score 0 1 2 3 4 5 6 7 8 9 10 11
Comments:

PART 3 – Referral pathways: TOTAL Score ________ AVERAGE Score (Total / 2) _________

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Part 4: Clinical Information Systems.
How well are clinical software utilised to facilitate eye care service delivery lists, scheduling, and a more seamless eye care ‘journey’ for patients
through the primary, secondary and tertiary levels?

Components Level D Level C Level B Level A

Appointment / …is not utilised for
recalls system preparing patient lists for
eye care services.
…is utilised by individual
practitioners (at PHC clinic
and/or hospital), to schedule or
flag patients needing an eye
examination.
…is routinely and systematically
used to flag and recall patients
requiring an eye exam.
…is automated and linked to existing
processes, enabling auto-generation
of patient lists in order of priority
requiring optometry and/or
ophthalmology care.

Score 0 1 2 3 4 5 6 7 8 9 10 11
Comments:

Patient eye records, …files disorganised; hard
referrals and filing to find; poorly kept; no
systems summary sheet; referrals
not recorded
…files organised, but
inefficient system; files
generally legible; eye
examination records are not
uploaded/recorded into
computer software; referrals
and diagnosis missing.
…files well organised and
accessible; eye examination
records uploaded/scanned into
computer software; files legible;
key diagnoses listed on patient
summary.
…files well organised and rapidly
accessible; eye examination records
entered into computer system, with
summary linked to updated recalls
and auctioning of referrals; is
accessible and used by all eye care
staff; referrals and follow up recorded

Score 0 1 2 3 4 5 6 7 8 9 10 11
Comments:

PART 4 – Clinical Information Systems: TOTAL Score ________ AVERAGE Score (Total / 2) _________

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Part 5: Integration with Primary Health Care
Are there established links between primary care and eye care services, both in terms of eye and vision checks being more integrated with routine PHC
checks, and integration of visiting and hospital eye care services with PHC case management for patients?

Components Level D Level C Level B Level A

Integration of eye …eye care services are
care with primary delivered and coordinated
health care checks solely by visiting eye
and processes practitioners, who maintain
their own patient lists
…some patients are identified
for review by an eye
practitioner via vision/eye
screening by PHC staff,
conducted as required or
indicated by presenting
complaints.
…vision and eye screening
conducted in adult health checks
or diabetes care management is
used to identify and refer
patients for review by eye
practitioners.
…vision and eye screening is
comprehensively conducted as part
of adult health checks or diabetes
care management, and linked to
systems for listing/referral for visiting
eye practitioners, as per best practice
guidelines.

Score 0 1 2 3 4 5 6 7 8 9 10 11
Comments:

Involvement of …is primarily through …is achieved occasionally …is achieved by optometrists … is achieved effectively and
optometrists and traditional referral. through optometrists and and ophthalmologists providing consistently by optometrists and
ophthalmologists ophthalmologists providing a feedback regarding patients’ ophthalmologists routinely providing
in improving summary to primary care treatment and prognosis, and feedback regarding primary care
primary eye care practitioners about patient involving primary care practitioners’ ongoing case
prognosis and treatment. practitioners in their ongoing management for eye patients at the
management plan PHC level, including in-service
training when possible by visiting eye
practitioners.

Score 0 1 2 3 4 5 6 7 8 9 10 11
Comments:

Feedback to … feedback is not provided … feedback is provided to … feedback is regularly …feedback is regularly and
primary care to primary care centres primary care centres provided to primary care centres consistently provided to primary care
centres about about ophthalmology sporadically or upon request using consistent mechanisms centres and about patients’ progress,
patient progress for patients’ progress about ophthalmology patients’ (e.g. secure electronic including required actions at the PHC
ophthalmology progress messaging of surgical reports) level for ongoing patient management
(hospital/surgical) about patients’ progress or hospital attendance.

Score 0 1 2 3 4 5 6 7 8 9 10 11
Comments:

PART 5 – Integration: TOTAL Score ________ AVERAGE Score (Total / 3) _________

Eye & Vision Care Toolkit - 2. Continuous Quality Improvement | 2.3. Eye Care Systems Assessment 7
Briefly describe the process you used to fill out the form (e.g., reached consensus in a face-to-face meeting; filled
out by the team leader in consultation with other team members as needed; each team member filled out a separate form and the responses were averaged).
Description: ________________________________________________________________________

Scoring Summary

• Part 1 - Average Organisation Score

• Part 2 - Average Community Linkages Score
• Part 3 - Average Referral Pathways Score
• Part 4 - Average Clinical Information Systems Score
• Part 5 - Average Integration Score
• TOTAL Eye Care Systems Assessment Score
• (sum of all Average Part scores)
• AVERAGE Eye Care Systems Assessment Score
• (Total score / 5)

What does it mean?

The Eye Care Systems Assessment is organised such that the highest possible “score” (11) on any given item or subscale indicates optimal systems are in place
for that particular aspect. The lowest possible “score” (0) on any given item or subscale, suggests no system is in place for that aspect of eye care. Interpretation
guidelines are as follows:
Between 0 and 2 = limited support for eye care systems
Between 3 and 5 = basic support for eye care systems
Between 6 and 8 = reasonably good support for eye care systems
Between 9 and 11 = fully developed eye care systems
It is fairly typical for teams to begin a collaborative with average scores below 5 on some (or all) areas. It is also common for teams to initially believe they are
providing better care than they actually are. As you progress in your team-based assessment, you will become more familiar with what an effective system for eye
care involves. You may even notice your Eye Care System Assessment scores “declining” even though you have made improvements; this is most likely the
result of your better understanding of what a good system of care looks like  Over time, as your understanding of good care increases and you continue to
implement effective practice changes, you should see overall improvement on your scores.

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SAMPLE RESULTS - Eye Care Systems Assessment

For your information, please see below some ‘sample results’ for an Eye Care Systems Assessment conducted in one region on two subsequent
occasions (about two years apart). This may give you an idea of the sort of information it can help obtain, and importantly how it can help identify key
areas to work on to support improvement in the eye care system:

Figure 1: Group average scores (0 – 11 scale) and comments from Eye Care Systems Assessment

2013 2015 Difference

(n = 12) (n = 13) (2015 - 2013)
Eye care workforce for the region 4.1 7.3 3.2
Part 1: Organisation of the
Overall organisation and clarity about structure of the regional eye care system 3.5 7.3 3.8
Regional Eye Care Delivery 3.6 7.3 + 3.7
System.
Regional goals and improvement strategy for eye care services 3.1 7.2 4.1

Patient information and education about eye care 4.6 8.3 3.7
Part 2: Community and Patient
5.0 8.0 + 3.0
Linkages. Promoting visiting eye care services to communities 5.3 7.8 2.5

Part 3: Referral pathways and Evidence-based guidelines or defined referral pathways for eye care 4.1 6.9 2.8
4.4 7.0 + 2.6
continuity of care
Continuity of eye care 4.6 7.2 2.6

Part 4: Clinical Information Appointment / recalls system 4.8 7.3 2.5

5.1 7.4 + 2.3
Systems. Patient eye records, referrals and filing systems 5.3 7.5 2.2

Integration of eye care with primary health care checks and processes 5.8 8.3 2.5

Part 5: Integration with Primary Involvement of optometrists and ophthalmologists in improving primary eye care 5.5 7.1 1.6
5.2 7.1 + 1.9
Health Care
Feedback to primary care centres about patient progress for ophthalmology
4.2 6.0 1.8
(hospital/surgical)

Eye & Vision Care Toolkit - 2. Continuous Quality Improvement | 2.3. Eye Care Systems Assessment 9
Figure 2: Spider chart of Eye Care Systems Assessment average scores Identified priority areas for action from the initial Eye Care
Systems Assessment were:

• Organisation of the regional eye care delivery system, via:

- Regional goals and improvement strategy for eye care
services
- Overall organisation & clarity about structure of the
regional eye care system
- Eye care workforce for the region

• Referral pathways and continuity of care

- Evidence based guidelines
- Continuity of eye care

Other areas to target, according to those rating lower on the

scale, were:
- Feedback to primary care centres about patient
progress for ophthalmology (hospital/surgical)
- Patient information and education about eye care
- Appointment / recalls system

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