Recommendations from Programmatic Review on Disease Pathway Management Date: June 12, 2010
Cancer Quality Council of Ontario: Context CQCO founded in 2002 on the recommendations of Ministry review of cancer system Mandate: Enable continuous improvement of services across the cancer continuum, by monitoring & reporting performance to providers, government, and public; advising on opportunities for meaningful improvements 2
And how we do our work Programmatic reviews are one of our tools MISSION: Improve the quality of cancer services in Ontario TOOLS: Cancer System Quality Index Quality and Innovation Awards Synthesis/ Discussion papers Signature Events and internat l reviews OUTCOMES: Reduce prevalence of cancer Improve cancer treatment and survival Improve cancer patient satisfaction Evolve / develop new quality indicators 3
Programmatic Review: Context CQCO renewed mandate focusing on international benchmarking and comparison First annual summative programmatic review Takes a look at an existing program to make improvements Learning from international leaders in cancer disease pathways 4
Program Selection First program reviewed was Disease Pathway Management Program Reasons for the program selection: Program is relatively new with colorectal disease site commencing Year 3 and lung disease site commencing Year 2 of a 3 year initiative two different approaches used. Planning to launch prostate disease site in Fall 2010. Opportunity ripe for review of benefits and challenges of two competing approaches and learn from international approaches to improve effectiveness. 5
Programmatic Review Objectives Objectives: Review the analytical framework of the Disease Pathway Management (DPM) program based on international and internal input. Provide recommendations for improvement and future activities to the DPM program to enhance quality of care received by patients. 6
Disease Pathway Management at CCO was conceived as an analytical framework Its purpose was originally to act as: A quality improvement framework A vehicle to improve internal processes Gap Analysis: map the current patient journey against the ideal, as a tool to visualize needs in quality, patient experience, etc. Provide structure to the organization such that we address disease sites in a cohesive, organized manner A method to prioritize new work AND eventually, an operational tool To be able to provide the Ministry with system-level policy advice aligned with patient pathways To use regional performance data to identify and inform regional quality improvement work It was not intended to be a conventional approach to disease pathways 7 7
DPM approach spans the entire patient journey, focuses on a single disease site Spans all aspects of the continuum of care Brings together disease-focused experts, patients and caregivers Maps patient journey, evaluates system performance, develops integrated improvement program Seeks to improve: Quality of care Care delivery processes Overall patient experience 8 8
Disease sites are worked on in a rolling sequence for 3 years each Fiscal 09/10 Fiscal 10/11 Fiscal 11/12 Fiscal 12/13 CRC Lung Prostate Gyne Year 2 Year 3 Year 1 Year 2 Year 3 Year 1 Year 2 Year 3 Year 1 Year 2 Year 1 Mapping, Intense team-focused idea generation Year 2 Regional engagement, dissemination and pilot projects Year 3 Implementation 9 9
Disease Site Selection High incidence High symptom burden and mortality Significant treatment complications Evidence of practice variations Ongoing work and engagement in regions and at CCO Engaged clinical champions High public and government profile 10
Programmatic Review Methods Literature review Identify who is using DPM pathways as an analytical framework. Research how they are linking the pathway to quality initiatives. Jurisdictional research and interviews Conduct interviews with jurisdictions using disease pathways for quality improvement in their cancer system. Self-appraisal Meeting Interviews with select RVP, CCO staff and DPM working group members. Analysis of themes including the strengths, weaknesses, opportunities and threats of Ontario DPM approach. Critical appraisals of cancer DPM programs from Denmark, Netherlands and Australia Discussion in key areas targeted for improvement 11
Literature & Jurisdictional Reviews Minimal literature evaluating disease pathway management Jurisdictional review showed a number of countries with disease pathway approaches United Kingdom Netherlands Denmark Sweden Australia New Zealand 12
Interviews with Jurisdictions Interviews were conducted with jurisdictions with cancer disease pathways Interviews focused on populating the following template: Interviews were conducted with: Denmark Netherlands Sweden Australia New Zealand 13
Methods of Self-Appraisal Interviewers used guides tailored to the interviewee depending on their involvement with DPM. Interviews conducted with 15 individuals. Qualitative analysis of themes from the interviews. Presented the findings in a Strengths, Weaknesses, Opportunities, Threats (SWOT) framework. 14
SWOT Analysis Strengths: Theoretically a good approach to break down silos and coordinate efforts to improve quality. Patients and caregivers felt the process was looking at the disease from a patient perspective and enjoyed participating. Weaknesses: Resources for projects unknown when prioritizing issues. Lack of involvement of health economists and policymakers to align priorities with resources and government policy. No clear mandate of roles and responsibilities of the DPM program to identify what are within scope, and what falls into the jurisdiction of other programs. Difficulty in obtaining longitudinal data to measure the patient pathway. On-going engagement of working groups after year 1. Unclear what work happens after year 3. Opportunities: Concentrate on fewer priorities for each disease site to have a greater impact. More strategic in focus such as: Key questions that DPM aims to answer Phase of the patient pathway that incurs most costs (e.g. diagnostics) Transitions and case management Issues that are in most need of quality improvements the Threats: Lack of resources to implement priorities discussed at the Symposium. Few internal structures exist within CCO to encourage or enable collaboration of programs. Measures of DPM can bring together access issues and quality. 15
Discussion at Programmatic Review Where DPM started: Analytical tool to identify quality gaps Where DPM needs to go: Prioritizing issues What criteria should DPM use for selecting priorities? Measuring impact of DPM How does DPM demonstrate that the program is making a difference? Engaging with regions and internally How does DPM turn the priorities on paper into meaningful improvement projects for regions and programs? Modeling policy decisions based on the framework How can the DPM approach influence provincial planning and resource allocations? 16
Activities on Day of the Review Critical appraisals from: Niels Hermann, Chief Physician, National Board of Health, Denmark Henk Hummel, Head of Quality Improvement, North East Comprehensive Cancer Centre, Netherlands Karen Luxford, General Manager, National Breast and Ovarian Cancer Centre, Australia Targeted discussion in the following areas: Prioritization Measurement Engagement Model for decision-making 17
Key Findings from International Speakers Denmark: Created a common template to create pathways for 34 disease sites to complete pathway maps quickly. Involvement of specialists and primary care to standardize referral patterns. Netherlands: Quality monitoring is happening pre and post pathway with hospital-based Quickscans (comprised of a number of indicators along the pathway), patient experience surveys, and tumour-specific peer reviews. Research underway on a more robust monitoring system to measure cost effectiveness and the effect of integrated pathways on mortality rates for example. Australia: Significant patient consultation on guidelines and patient advocacy training to ensure strong representation. 18
Organizing Framework for Recommendations Mapping Pathways Gap Analysis & Prioritization Interventions & Regional Engagement Measuring Impact 19
Mapping Pathways Recommendations: Balanced approach between current intensive approach and need to produce pathways more quickly Leverage work from earlier pathways to address other cancers Look at the prevention piece for several disease sites when applicable Include prevention in DPM approach to reflect the entire pathway Include secondary prevention for survivors Strengthen the patient voice Advocacy training for patients Outreach with individuals that CCO does not normally speak to 20
Gap Analysis & Prioritization Recommendations: Consider unique areas of focus for each disease site (e.g. treatment selection for prostate) and start with those areas first to have the most impact. Increase health economics analyses during gap analysis and prioritization Initial feasibility considerations including cost-impact and regional resource availability. 21
Interventions & Regional Engagement Recommendations: Solicit regional input to assist with prioritizing interventions from gaps identified during the mapping process. Work with regions to identify region-specific areas of improvement and provide resources for pilots. 22
Measuring Impact Recommendations: Increase focus on patient outcomes (e.g. stage-specific outcomes) and quality of life measures. Continue focus on quality of care (measures in the CSQI), giving equal focus to patient-oriented measures (e.g. distress) and treatment (e.g. guideline concordance). Explore performing random audits of individual patient journeys to ensure quality of care is being met. Explore and develop a strategy to measure integration or transitions. 23
Measuring Impact Recommendations: Explore using a modeling tool such as CPAC s Cancer Risk Management tool that could be used in the following areas: Identifying the most cost effective interventions from the findings of the gap analysis for lung and colon cancer. Identifying the most effective intervention from the selected priorities for each region. Identifying the most efficient care delivery for each region, using data and expertise from the Resource Modeling working group. 24
Closing the Circle Recommendations were tabled to Clinical Council at Cancer Care Ontario in September. DPM staff and Clinical Leads at Cancer Care Ontario have reviewed the recommendations. Several recommendations have been implemented. 25