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Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
Access to Care: MRI/CT Ontario Update
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Access to Care: MRI/CT Ontario Update

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Cancer Care Ontario

Cancer Care Ontario

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  • 1. Access to Care: MRI/CT Ontario UpdateMeeting: Taming of the QueueDate: March 29, 2012 Julian Dobranowski, MD, FRCPC Provincial Lead ATC MRI/CT Provincial Lead Cancer Imaging Program CCO 1
  • 2. Source : Wait Time Alliance report 2011 2
  • 3. Overview in 3 parts Add images CT PET/CT MRI 3
  • 4. Wait Time Strategy Key Elements Empowering patients and demonstrating accountability to the public Increasing health system capacity Using a single provincial wait time information system Obtaining feedback and recommendations from clinical stakeholders 4
  • 5. Ontario’s Wait Time Strategy MRI & CT Scans Cancer Surgery Key Health Services Cataract Surgery Targeted Hip & Knee Replacement Cardiac Procedures Expansion to major Surgical AreasOntario’s Wait Time Strategy was introduced by theMinistry of Health and Long-Term Care in November 2004. Perioperative Efficiencies (SETP)The Wait Time Strategy was developed to improve accessto five key health services by reducing wait times, and thenexpanded to include wait time data for major surgeries aswell as perioperative efficiencies. 5
  • 6. MRI CT Wait Times-ApproachExpert panel2005200620102012- ATC DI subcommittee 6
  • 7. MRI CT Approach- Quality dimensions Safe Effective Efficient VALUE FOR MONEY Accessible Equitable Integrated Responsive 7
  • 8. MRI CT Approach – Change Management Data/Information Knowledge Performance Management Knowledge Transfer 8
  • 9. MRI CT Approach 9
  • 10. Ontario MRI CT Targets 2005MRI 62 per 1000CT 114 per 1000P4 90th percentile 80 days 10
  • 11. PART 1 CT 2004 2005 Starting out96 CT scanners hospitals 4 CT in IHF’s 11
  • 12. CT 2005 How did we compare? (OECD)(CIHI) CT Scan Rate per 1,000 2005 2006 2007 population Ontario 79.4 Canada 101.6 Australia 88.6 France 111.1 United States 194.8 Denmark 71.4 12
  • 13. Provincial Wait Time Trend: CT• CT wait time has been relatively stable since late 2010 at just above the 28 days priority 4 target. 13
  • 14. CT scans ordered and completed by Fiscal Year 171 scanners (base 94) 14
  • 15. CT scan rates per 1,000 populationData Source:2008-2011 – Wait Time Information System, Cancer Care Ontario 15
  • 16. CT Scan Rate per 1,000 population –comparison (OECD)(ATC) CT Scan Rate per 1,000 2007 2008 2009 2010 2011 population Ontario --- 78.3 81.5 79.7 78.5 Canada --- 119.0 125.4 --- --- Australia 88.6 93.4 93.9 --- --- France 120.3 130 138.7 --- --- United States 227.9 --- --- --- --- Denmark 73.6 83.8 --- --- --- 16
  • 17. CT what changed?Capacity- bulk buy incremental fundingDemand- Completed Scan Volume YEAR CT Population 2008 1,012,868 12,919,572 2009 1,065,470 13,050,754 2010 1,053,540 13,193,809 2011 1,050,597 13,349,125 17
  • 18. CT- 2012 current wait time P4February 2012 – P4 Wait time 90 percentile = 29 daysIncreased capacityImproved efficienciesStable or decreasing demand 18
  • 19. PART 2 PET/CT 1999 OANM - Request for Provincial funding for PET 2000 ICES- Review of Evidence 2001 ICES- Report- Health Technology Assessment of PET“despite the availability of PET scanning for almost three decades, the number ofmethodologically high quality studies (and the numbers of patients within thesestudies) is distressingly small.” Institute for Clinical Evaluative Sciences. 2001 (May) Health Technology Assessment of Positron Emission Tomography (PET) – A Systematic Review. An ICES Investigative Report. 19
  • 20. PET/CTApproach to PET key elements: -Access to PET through high quality clinical trials -Access to PET through registry studies -Access to PET through the PET Access Program -Quality assurance standards for PET -Ontario’s PET infrastructure -Coordination of the PET program -Communications Evidence based approach to PET/CT Evidence to support all demand 20
  • 21. PET/CT 2009- OHIP funded indications – 9 2010 CCO Oversight of non-funded PET/CT scan PET Access program PET Registry Clinical trials 21 21
  • 22. 22
  • 23. Recommendations by PSC for ChangeInsured UninsuredInsured Indications Additions OCOG Trials Registry Indications PET Access• Solitary pulmonary Nodule • PET REC • Pancreatic • Case- cancer by-case• Thyroid cancer • Melanoma• Germ cell tumours • Testicular Cancer• Colorectal cancer • PET LACE• Lymphoma• Non-small cell lung cancer• Stage III non-small cell lung ca• Limited disease small cell lung ca• Myocardial viability 23 23
  • 24. 24
  • 25. PART 3 MRI 2004 2005 Starting out52 MRI scanners in hospitals 5 MRI in IHF’s257,042 total scans 25
  • 26. MRI 2005 How did we compare? (OEDC) (CIHI) MRI Scan Rate per 1,000 2005 2006 2007 population Ontario 27.4 Canada 30.7 Australia 20.2 France 38.2 United States 84.3 Denmark 27 26
  • 27. Provincial Wait Time Trend: MRI• Wait time for MRI scans peaked on October 2010 at 127 days but has since decreased to 87 days by January 2012. 27
  • 28. Comparison of MRI Orders Received & Scans Completed 91 scanners (base 52) 28
  • 29. MRI scan rates per 1,000 population Data Source: * ** MRI 2005/2006 to 2006/2007 data: You, J., Venkatesh, V. and Laupacis, A. (2009). Better access to outpatient magnetic resonance imaging in Ontario – But for whom?. Open Medicine, Vol 3, No 1. Outpatient MRI Utilization only. 2008-2011 – Wait Time Information System, Cancer Care Ontario 29
  • 30. MRI Scan Rate per 1,000 population –comparison (OECD)(ATC) MRI Scan Rate per 1,000 2007 2008 2009 2010 2011 population Ontario --- 38.7 41.2 43.7 47.5 Canada --- 40.6 43.0 --- --- Australia 20.2 21.4 23.3 --- --- France 44.2 48.4 55.2 --- --- United States 91.2 --- --- --- --- Denmark 36 37.8 --- --- --- 30
  • 31. Removing variability 31
  • 32. Provincial Wait Time Trend: MRI and CT 32
  • 33. Backlog time demand capacity 33
  • 34. 34
  • 35. 35
  • 36. Looking at the MRI backlog 36
  • 37. Backlog management- The Blitz 37
  • 38. MRI Blitz: Impact on Overall Provincial Wait Times Participating hospitals were notified of their additional volume allocations in November 2010, December 2010, January 2011 Provincial wait times closely followed wait times for blitz hospitals Participating hospitals reached the lowest wait time of 93 days in June 2011, 3 months after receipt of funding 38
  • 39. MRI – System improvement 39
  • 40. PIP Outcome Indicators Data Captured in Weekly Performance Dashboards by MRI-PIP Hospitals Outcome Indicators Time between requisition received and exam completed • By priority 1. MRI Wait Times • By body division • By hospital site (for multi-site facilities) • By contrast/non-contrast 1. MRI Report Turnaround Time between exam completed and report verified Times Number of exams requested (i.e. demand) 1. MRI Exams Requested • By priority • By body division Number of exams completed • By priority 1. MRI Volumes Performed • By body division • By hospital site (for multi-site facilities) • By contrast/non-contrast 1. Planned Operating Hours [Sum of actual scanning time for pre-booked patients/Sum of operating hours Utilization dedicated to pre-booked patients] *100 1. Unplanned Operating [Sum of actual scanning time for unscheduled patients (e.g. inpatients and Hours Utilization emergency) /Sum of operating hours dedicated to unscheduled patients] *100 40
  • 41. Process Indicators1. Requisition Completeness [Number of complete requisitions / Number of requisitions received] * 1002. Booking Turnaround Time Time between requisition received and appointment booked3. Booking Volumes Number of appointments booked4. Booked Time Utilization [Sum of hours planned time of booked exams/Sum of operating hours available to be booked] *100 [Sum of hours of incoming requests/Sum of hours in scheduling template] *1003. Requisitions Received •By priority Relative to Time Allocated •By body division •By contrast/non-contrast [Sum of actual scanning time/Sum of hours in scheduling template] *1003. Actual Hours Performed •By priority Relative to Time Allocated •By body division •By contrast/non-contrast3. Protocolling Turnaround Time Time between requisition sent for and received from protocolling3. No Show Rate [Number of no shows / Number of appointments booked] * 1003. No Shows Filled [Number of no shows filled / Number of no shows] * 1003. On-Time Scan Starts [Number of early and on-time exams / Number of exams completed] * 1003. Patient Prep Time Time between registration and scan start3. Room Turnaround Time Time between patient 1 exiting scan room to patient 2 entering Planned scan time – Actual scan time3. Planned Scan Time Accuracy •By procedure 41
  • 42. MRI PIP Wait Times Improve in London St. Joe’s MRI Wait Time 300Patients Getting Needed MRIs Sooner 250 Number of DaysThe London Free Press. Aug 2010 MRI PIP 187 200 177 172The improvements mean 780 more patients can be scanned 156 151 145each year with MRI at St. Joseph’s, said Glen Kearns, 150 128integrated vice president, clinical support services and 113 94information technology services at St. Joe’s and London 100 56 56 63Health Sciences Centre (LHSC). 50As part of a project with Ontario’s Health Ministry, St. Joe’sdissected every MRI process, assessed what worked and 0 Jan-Feb-Mar Jan-Feb-Mar Jan-Feb-Mar Jul-Aug-Sep Jul-Aug-Sep Jul-Aug-Sep Oct-Nov-Dec Oct-Nov-Dec Oct-Nov-Dec Apr-May-Jun Apr-May-Jun Apr-May-Junwhat could be tweaked, then put the process back together 08 09 10more effectively for patients and staff. 08 08 09 09 10 10 07 08 09The results:•An average 50 days’ wait for semi-urgent patients (downfrom 104 days a year ago) and 60 days (down from 149) fornon-urgent patients; LHSC MRI Wait Time•212 MRI exams each week, or 15 more a week than a year 300ago. 250 Number of Days 215 MRI PIPLHSC is in the middle of a similar process, one made more 195 187complex by the wider range and type of MRI services offered 200 162 144 146 152 150for inpatients and outpatients. So far, the waits there have 135 150 120dropped to an average 86 days, from 150 as recently as sixmonths ago. That pace of improvement means 1,000 more 100 86 75patients can be scanned each year, he said. 50 0 Jan-Feb-Mar Jan-Feb-Mar Jan-Feb-Mar Jul-Aug-Sep Jul-Aug-Sep Jul-Aug-Sep Oct-Nov-Dec Oct-Nov-Dec Oct-Nov-Dec Apr-May-Jun Apr-May-Jun Apr-May-Jun 08 09 10 08 08 09 09 10 10 07 08 09 42
  • 43. MRI PIP Wait Times Improve in Ottawa TOH MRI Wait Time 400 352 349 347 348Improving Equitable Access to ImagingJ American College of Radiology. Aug 2010 307 MRI PIP Number of Days 300 263 237The Ottawa Hospital Rapid Improvement Event team wasassembled and completed a 4-day review of the booking process 188and scheduling in MRI. They then delineated additional steps 200that could be initiated to potentially reduce wait times. This was 117 96undertaken using Lean methodology brought forth by the Ontario 65 100 58government to evaluate process improvement and patientthroughput at all stages of navigation through the system . Someof the main goals and strategies of the Lean project include the 0 Jan-Feb-Mar Jan-Feb-Mar Jan-Feb-Mar Jul-Aug-Sep Jul-Aug-Sep Jul-Aug-Sep Oct-Nov-Dec Oct-Nov-Dec Oct-Nov-Dec Apr-May-Jun Apr-May-Jun Apr-May-Junfollowing: 08 09 10 08 08 09 09 10 10 07 08 09•Improving efficiency of each scan•Improving patient flow and throughput•Improving booking process•Evaluating the patterns of unfilled spots and adjusting the Montfort MRI Wait Timeschedule commensurately 400•Reducing physicians’ redundant ordering of diagnostic imagingtests through education on appropriate indications Number of Days 300 MRI PIP 193 202 200 163 90 82 84 76 75 76 100 63 63 39 0 Jan-Feb-Mar Jan-Feb-Mar Jan-Feb-Mar Jul-Aug-Sep Jul-Aug-Sep Jul-Aug-Sep Oct-Nov-Dec Oct-Nov-Dec Oct-Nov-Dec Apr-May-Jun Apr-May-Jun Apr-May-Jun 08 09 10 08 08 09 09 10 10 07 08 09 43
  • 44. Impact of all interventions on Provincial Wait Times(data as of February 2012) 44
  • 45. Summary of the Ontario Approach1. Capacity building through additional MRI/CT scans2. Capacity building through system and process redesign to improve efficiencies “Value for Money”3. Managing demand by decreasing the backlog4. Managing demand through appropriate referrals 45
  • 46. Next steps:Maintain equilibrium -Appropriateness -Point of care decision support -CapacitySustainable backlog management -focus on LHINs with greatest backlog -continue collecting data on demand -determine best practices related to backlog management 46
  • 47. Next steps:Process improvement - -Optimising the ordering process- dated examinations and booking optimization -CTDisease specific wait timesRevisiting the benchmarks -National benchmarks 47
  • 48. Questions?Thank YouAccess to CareATC@cancercare.on.ca 48

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