Assistant Professor Tim Shaw - Defining and Prioritising Success Factors for Coordinated Cancer Care

3. Tim Shaw
Sarah York
Nicole Rankin
Deborah McGregor
Sanchia Aranda
Kahren White
Jane Young
Shelley Rushton
Deb Baker
Megan Varlow
Tina Chen
Tracey Flanagan

4. Background
 CI NSW looking to develop Key Performance
Indicators to measure coordinated care
 University of Sydney Commissioned to
undertake a consultative approach to develop
and prioritise success factors as first step

5. Cancer care
workshop
Scoping lit
review
Stakeholder
survey
Consumer
input
Small group refinement
and testing
20 success factors
for coordinated care
Priority setting workshops
Priority factors
CI NSW develop KPIs

6. Coordinated Cancer Care
Success Factors
 Success Factors - relatively broad statements
which collectively describe successfully
coordinated care from a systems, practitioner
and patient POV.
 A number of indicators could sit under each
success factor

7. Example
Success Factor: Patients receive timely &
appropriate care on the pathway from first
presentation to diagnosis and to
commencement of treatment.
Indicator: Time from first presentation to
treatment is recorded and meets recognised
tumour specific benchmark
Indicator: Patient survey indicates time to
treatment acceptable'

8. Coordinated Cancer Care - Success Factors
1. Patients receive best practice care defined by clinical practice guidelines or a
clinical pathway for each tumour group.
2. Patients receive timely and appropriate care on the pathway from first
presentation to diagnosis and to commencement of treatment.
3. Patient care takes into account patient and carer needs and preferences (e.g.
service locations).
4. Patients at elevated risk of disjointed care and poorer outcomes (e.g. CALD,
Aboriginal & Torres Strait Islander) are identified and systems are in place to
ensure care is appropriately managed and coordinated.
5. All patients have a comprehensive care plan that is created jointly by
patients, family and health professionals and that is documented, accessible
by relevant care providers and patients and maintained over the course of
their care.
6. Transition of patients across each point of the care trajectory (e.g. from
diagnosis to treatment) is well managed and takes into consideration the
patient’s physical, social and emotional needs.

9. Coordinated Cancer Care - Success Factors
7. Transfer of patient information (e.g. test results) between members of the
multidisciplinary team is timely and well managed at each transition point.
8. Patients, families and carers receive timely, relevant and appropriate
information at key points along their care trajectory; this may include their
diagnosis, prognosis and intention of treatment (e.g. curative/palliative),
depending on cultural appropriateness
9. Patients have timely referral and allocation to a key contact person to assist
with the coordination of their care.
10. Transfer of information and care between primary and community care
providers and specialist services is timely and appropriate.
11. Patients, carers and families know who to contact for information at
different stages during their care trajectory.
12. All patients are considered for discussion at an MDT meeting in a timely
manner and exclusions are guided by protocols
13. All appropriate team members from core disciplines (including diagnostic,
oncology clinicians, GPs, allied health and supportive care) attend and
contribute at weekly/fortnightly MDT meetings.

10. Coordinated Cancer Care - Success Factors
14. MDT meeting members are made aware of patient concerns, preferences
and social circumstances and MDT meeting discussions consider a patient’s
medical and supportive care needs.
15. The roles and responsibilities of all health care professionals involved in
patients care are communicated and understood.
16. Side effects of disease and treatment are managed in a timely and
appropriate manner by the care team to reduce unnecessary visits to ED
and hospital admissions.
17. Patients are routinely screened for physical, psychological and supportive
care needs using validated tools and referred to required services in an
appropriate and timely manner.
18. Patients are aware of and have access to practical assistance and financial
entitlements as appropriate (e.g. transport and accommodation).
19. Patients receive clear follow-up care plans according to tumour specific
guidelines and appropriate survivorship information.
20. Patients receive timely screening and referral to palliative care services.

11. Priority Setting Workshop
Implement a process of selecting the
most significant and measurable
success factors for future KPI
development
Based on Sydney Catalyst
Methodology

12. Individual Matrix Activity
Significance Measurability
Criteria
Success Factor
Transfer of information
and care between
primary and community
care providers and
specialist services is
timely and appropriate.
Patients receive timely
screening and referral to
palliative care services.
Agree
Least
Agree
Most
1 2 3 4 5

13. Priority Setting Criteria
Significance Measurability
Most likely to impact on
patient outcomes
Could a KPI be developed that
could be feasibly measured and
reported on across the board?
Current data point or system in
place to allow for data collection
(or soon to be)
Data sources
- Electronic database (OMIS/RIS)
-Patient Reported

14. ‘Dotmocracy’

16. Identified Priorities

17. Next steps..
4 x priority setting workshops with
care coordinators
1 x priority setting workshop with
Cancer Council NSW consumer group
Develop initial set of indicators built
around success factors

18. Conclusion
First time success factors have been
identified
Good agreement on priorities across
workshops to date
Approach represents a constructive way
to begin to measure improvement across
the cancer system in NSW'