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Better Cancer Services Every Step of the Way






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Better Cancer Services Every Step of the Way Better Cancer Services Every Step of the Way Presentation Transcript

  • Regional Performance Improvement & Quality in Cancer Services: Aligning Energy, Resources and Metrics Better cancer services every step of the way Terrence Sullivan PhD CEO, Cancer Care Ontario September 2009
  • Provincial-Regional Planning and Delivery of Cancer Services at a Glance Ministry of Health and Long-Term Care Cancer Care Ontario Integrated Cancer Program LHIN 1 Integrated Cancer Program LHIN 2 Integrated Cancer Program LHIN 3 Integrated Cancer Program LHIN 14 Cancer Quality Council of Ontario Other regional cancer providers Other regional cancer providers Other regional cancer providers Other regional cancer providers
    • Public agency
    • Purchasing agent
    • Information management
    • Standard setting
    • Chief cancer advisor to Ministry
    • Routine performance measurement & monitoring
    • Advisor to CCO
    ~ 30% of expenditures ~ 70% of expenditures
  • 2008-2011 Ontario Cancer Plan
    • Six Goals
    • Reduce the incidence of cancer
    • Reduce the impact of cancer through effective screening & early detection
    • Ensure timely access to effective diagnosis and high quality cancer care
    • Improve the patient experience across continuum
    • Improve the performance of cancer system
    • Strengthen translation of research into improvements in cancer control
    • Four Key Initiatives
    • Transform cancer screening
    • Streamline and speed up cancer diagnosis
    • Regional Cancer Programs to achieve high quality cancer services in every LHIN
    • Prepare our services to respond to molecular oncology
  • How are we Doing and How do we Manage? Cascading indicators
    • Macro = System
    • Meso = Region / Facility
    • Micro = Clinician /Program/ Care Team
    e.g., Population FOBT participation rate e.g., facility level wait times for cancer surgery e.g., % of stage 1 or 2 breast cancer cases treated with radiation following breast conserving surgery
  • 25 indicators that measure progress against 5 system goals Improve measurement Increase use of evidence Increase efficiency Increase access Reduce burden of cancer (improve outcomes) Primary input www.cancercare.on.ca/qualityindex2006
  • Choosing the indicators Modified Delphi panels Master List 689 indicators Initial filtering by working group 575 indicators 1 st expert panel (9 practice leaders) 419 indicators 2 nd expert panel (17 practice leaders) 179 indicators CQCO member panel 88 indicators 1 st strategy mapping exercise 45 indicators 2 nd strategy mapping exercise 35 indicators Feasibility assessment (Year 1) 25 indicators Systematic literature review Strategy-based scorecard
  • Visible System Level Public Reporting On Access and Quality
  • Focused Yearly Clinical Priorities 2009-10 Priority and Target Setting
  • 09/10 Priorities
    • Wait Times (Radiation, Systemic, Surgery, Colonoscopy)
    • Pathology Reporting
    • Stage Capture
    • Cancer Symptom Management (OCSMC)
    • Multidisciplinary Cancer Conferences (MCCs)
    • Thoracic Standards Implementation
    • HPB Standards Implementation
    • Regional Systemic Treatment Program (RSTP)
    • Intensity Modulated Radiation Therapy (IMRT)
  • 2009/10 Performance Targets Current Performance Provincial Target Standard New Target 100% of RSTP hospitals will have current policies & procedures related to safe handling of cytotoxic agents Regional Systemic Treatment Program New Target 100% of RSTP hospitals will establish a process of identifying & reporting serious systemic treatment adverse events Regional Systemic Treatment Program New Target 100% of RSTP programs will have nursing/pharmacy leads identified Regional Systemic Treatment Program
  • 2009/10 Performance Targets Current Performance Provincial Target Standard New target 50% of targeted disease sites in each hospital have standards-compliant MCCs MCC 20% 25% of radiation treatment courses delivered using IMRT IMRT
  • MCC Implementation in Ontario
    • Ontario Goals:
    • Improve the quality of existing MCCs
      • Bringing them up to standard
    • Improve access/coverage of MCCs
      • More disease sites and more hospitals
    • CCO Action
    • Published standard http:// www.cancercare.on.ca/common/pages/UserFile.aspx?fileId =14320
    • Providing tools and education to regional cancer programs
    • Supporting coordinators in each region
    • Supporting use of technology to enable MCCs across regions
    • Collecting of near-real time data on MCCs and monitoring progress
  • MCC Status
    • Performance Goal: Standards-compliant MCCs in all hospitals receiving surgery agreement funding
    • Standards-compliant means
      • Held weekly/biweekly,
      • Chair and coordinator in place
      • Prospective case review
      • Relevant disciplines attend
    • Approximately 20% of current MCCs are standards-compliant (Nov. 2008)
  • Thoracic Standards: Purpose
    • Ontario Cancer Plan 2004 Goal #1: Broaden the development and use of provincial standard and guidelines
    • Standards implementation will: improve the quality and the organization of thoracic cancer surgery services within each region
    • Standards are available at http://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=14332
  • Strategy for implementation
    • Strategic engagement of key stakeholders (Surgeons, Institutions and LHINs)
    • Regional plans
    • Consolidation of thoracic cancer surgery at the designated centres
        • Incentives (incremental funding)
        • Base forgiveness for those hospitals getting “out of the business”
    • Targets established for provincial and regional implementation
    • Public Reporting on regional compliance with standards
  • Screen shots from CSQI
  • Pay for Participation...
  • Reimbursement Standards for Wait times Reductions in Thoracic Cancer Surgery (lung and esophageal )
    • Surgeons -Certification in Thoracic Surgery, or equivalent
    • Hospitals - commitment of resources, support services and organization etc.
    • Volumes
      • Level 1: 3+ surgeons; 150 lung, 20 esophagus
      • Level 2: 1+ surgeons; 50 lung, 7 esophagus
  • Improving Quality
    • (06/07) 4 centres meet volume standard
    • (07/08) 7 centres meet volume standard
    Sundaresan, S., Langer, B., Oliver, t>, Schwartz, F., Brouwers, M., Stern, H. Standards for thoracic surgical oncology in a single payer healthcare system. Ann Thorac Surg. 2008 May:84(2): 693-701.
  • http://csqi.cancercare.on.ca/cms/One.aspx?portalId=40955&pageId=41185
  • IMRT
    • 25% of all radical courses will treated using IMRT by Q4, 2010
  • Wait Time Targets
    • Systemic:
      • Referral to Consult 60% seen within 14 days
      • Consult to Treatment: 50% treated within 14 days
    • Surgery:
      • 85% of patients treated within 3 priority targets
      • LHIN Target 90 th percentile wait time 55 days
    • Radiation:
      • Referral to Consult 80% seen within 14 days
      • Ready to Treat to Treat 85% treated within target
  • Draft 2009/10 Performance Targets 80% 85% of thoracic cancer operations within LHIN are performed in designated centre by Sep 09 Thoracic Cancer Surgery 24% (2 yr period Jan 06 – Dec 07) 35% FOBT participation in target population FOBT Participation 71% Colonoscopy: 75% of Fam History colonoscopies completed within target Colonoscopy 59% Colonoscopy: 65% of FOBT+ colonoscopies completed within target Colonoscopy Current Performance Provincial Target Standard
  • Pathology Reporting
    • Synoptic reporting in discrete data field format implemented in 100% of hospitals for 5 common cancer resections by March, 2010
    • 90% of discrete synoptic reports complete against CAP/CS standards
  • Stage Capture
    • 100% of eligible hospitals reporting stage at diagnosis for 5 common cancers
    • 90% of all RCC and surgery only patients will have stage reported at diagnosis
    • 90% of lung cancer patients screened for symptom severity using ESAS
    • 60% of all other cancer patients screened for symptom severity using ESAS
  • MCCs/Standards Implementation
    • Standards compliant MCCs in place for 50% of incrementally funded disease sites
    • 85% of thoracic cancer-related operations are performed in a designated centre
    • 80% of HPB cancer-related operations are performed in a designated centre
  • RSTP
    • 100% of RSTP hospitals will have current policies and procedures related to safe handling of cytotoxic agents in accordance with CCO guidelines
    • 100% of RSTP hospitals will have nursing and pharmacy RSTP administrative leads identified to manage strategic and operational issues related to implementation
    • 100% of RSTP hospitals will establish a process of identifying and reporting serious systemic treatment adverse events
  • Q1 Performance Summary 09/10
  • Note: Central’s 2009 referral to consult data is excluded due to data issues. Radiation
  • Systemic
  • Notes: Wait times include treatment cases only and exclude lymphoma, skin and priority 1 cases. Surgery
  • Colonoscopy
  • Colonoscopy
  • Stage Capture
    • Notes:
    • Central and Central East June 2009 is not available.
    • Due to historic corrections of CVH disease information, an adjustment occurred in April 2009 related to the CVH OCSMC assessment rate. The decrease in assessment rates from 2008/09 to 2009/10 is a result of the refinement in capture of disease information.
    • Champlain excludes April 2009 due to data issues.
    • Source: Cancer Care Ontario, ISAAC database (ESAS data) and Activity Level Reporting (Population data)
    Symptom Management
  • Thoracic Standards
  • Multidisciplinary Cancer Conference
  • Provincial Summary – September 2009 Performance against the previous scorecard Improved Decreased No change
    • Note:
    • Overall Provincial Ranking = Sum of all rankings relative to all other Regions normalized to number of measures available.
    • Colours = Performance against your regional target. See legend.
    • Cancer surgery ranking is based on provincial performance, not LHIN targets.
    • The previous scorecard include the following measures: Radiation Apr-Mar 09, Systemic Apr-Mar 09, Surgery Apr-Mar 09, Colonoscopy WT Jan-Mar 09, Colonoscopy Vol Apr- Mar 09, FOBT Participation 2006-07, Staging Apr-Jul 08, Symptom Management (Lung) Apr-Mar 09, (All Other) Mar 09, Thoracic Apr-Jan 09 and MCC Q4. Note for FOBT Participation, Thoracic and MCC, the data in the current scorecard is the same as the previous one.
    • There is no trend symbol for data being measured for the first time in the scorecard.
    Performance against the regional target Not meeting target Not meeting target, but improving or meeting provincial target Meeting or within 2% of target. If the region has a stretch target, it is within 5%.
  • Acronyms
    • C1R = Number of New Radiation New Cases
    • C1S = Number of New Systemic New Cases
    • ESAS = Edmonton Symptom Assessment System
    • FOBT = Fecal Occult Blood Test
    • OCSMC = Ontario Cancer Symptom Management Collaborative
    • Region Names
      • CE = Central East
      • CW/MH = Central West and Mississauga Halton
      • ESC = Erie St. Clair
      • HNHB = Hamiton Niagara Haldimand Brant
      • NE = North East
      • NSM = North Simcoe Muskoka
      • NW = North West
      • TC = Toronto Central
      • WW = Waterloo Wellington
  • Ontario Cancer Programs What are the Regional Levers for change?
    • Implementing provincial programs including Wait Time Strategy; Colon Cancer Check
      • Rads, Chemo, Surgical Wait time Targets
      • Colonoscopy*
    • Implementing quality standards in every LHIN, focusing on a key clinical program areas:
      • Intensity modulated radiation therapy (IMRT)*
      • Regional Systemic Therapy Programs*
      • Multidisciplinary Case Conferences for all cancer patients*
      • Thoracic Surgery Standards*
  • What are the Provincial Levers for change
    • Aligned and Accountable Cancer leadership
    • Designated Provincial and Regional Clinical Practice Leaders by specialty
    • Clinical Indicator Development and Reporting
    • Clinical Communities of Practice Initiatives
    • Culture of evidence and performance
    • Volume and quality linked to $$ funding
    • Pay for Participation, Pay for volumes, Pay for Quality in Hospital Level Agreements
    • Quarterly Performance Reviews with each LHIN - Regional Scorecards
    • ANNUAL Public Reporting on 30+ access and quality measures; Annual Provincial Scorecard
    • Mandate to advise MOHLTC
    • Greenberg A, Angus H, Sullivan T, Brown A. Development of a set of strategy-based system-level cancer care performance indicators in Ontario, Canada. Int J Qual Health Care 2005;17:107-114.
    • Sullivan, T. Waiting for the Referee or Refereeing the Wait? CCO’s Role in Hosting and Deploying the Wait Time Information System in Ontario. Health Care Quarterly (12) 2009, 20 -21.
    • Cowan, D.H. 2004. Closing the circles: A history of governance of cancer control in Ontario. Accessed August 17, 2009. http:// www.cancercare.on.ca/common/pages/UserFile.aspx?fileId =13708 .
    • Sullivan, T., Dobrow, M., Thompson, L., and Hudson, A. 2004. Reconstructing cancer services in Ontario. HealthcarePapers 5(1): 69-80.
    • Sullivan, T., Thompson, L. and Angus, H.  2005. Transforming cancer services in Ontario: A work in progress. HealthcarePapers 5(4): 43-51.
    • Thompson, L.J. and Martin, M.T. 2004. Integration of cancer services in Ontario: The story of getting it done. HealthcareQuarterly 7(3): 42-48.
    • Dobrow MJ, Paszat L, Golden B, Brown AD, Holowaty E, Orchard MC, Monga N, Sullivan T. Measuring Integration of Cancer Services to Support Performance Improvement: The CSI Survey. Healthcare Policy (in press) 2009
    • Dobrow MJ, Sullivan T, Sawka C. Shifting clinical accountability and the pursuit of quality: aligning clinical and administrative approaches. Healthcare Management Forum , 21(3), 6-19. 2008
    • Sullivan T, Dobrow MJ, Schneider E, Newcomer L, Richards M, Wilkinson L, Borella L, Lepage C, Glossmann GP, Walshe R. (2008). Améliorer la responsabilité cliniques et performance en cancérologie [Improving clinical accountability and performance in the cancer field]. Pratiques et Organisation des Soins [Practices and Organization of Care] , 39(3), 207-215.
    DRAFT - Please do not circulate Background Reading