achs clinical indicator program - department of health · achs clinical indicator program:...

ACHS clinical indicator program:

measuring performance to improve outcomes

Dr Jen Bichel-FindlayWednesday 10 August 2011

Beyond Bricks and Mortar – Building Quality Clinical Cancer ServicesRORIC Symposium, The Sebel Albert Park, VIC

Measurement in health care

ACHS clinical indicator program

Radiation Oncology indicator set review

OVERVIEW

Measurement in health careMeasurement in health care is 250 years old

Year Person Focus

Mid 18th C Uni of Penn Researchers Outcome data

Mid 19th C Florence Nightingale Mortality ratesInfection rates

Early 20th

C Ernest Amory Codman

End resultsBenchmarkingReview meetingsAudit

Mid 20th C Avedis Donabedian Quality dimensions

Measurement in health care

ValidAcceptableEvidence basedAccurateReliable

RelevantConsistentFeasibleSensitiveSpecific

Database comparing indicator results across 670 HCOs in AUS, NZ, and Asia

Public/Private HCOs – 50/50EQuIP and non-EQuIP members351 rate-based indicators | 22 clinical areasExternal benchmarking Data entered (numerator + denominator) either monthly, quarterly, or six-monthly via PIRT Online web based software

Data submitted to ACHS on a six-monthly basis

ACHS clinical indicator program

What is a clinical indicator?Succinct form of measurement that aims to describe the clinical management and/or outcome of care to help understand, compare, predict, improve and innovateUsed in healthcare for:

understanding (know how a system works / how it might be improved)

performance (monitor if/how a system is performing to an agreed standard)

accountability (provide information to patients, government, organisations, etc)

Usually rate-based - the rate of occurrence of an event

Purpose of a clinical indicator?Indicators:

Rarely provide definitive answersUsually suggest the next best question to ask that ultimately will give the answer requiredDesigned to indicate potential problems that might need addressingScreen, flag, draw attention to a specific clinical issueProvide a ‘slice of reality’ – must be understood in contextUsed for comparative internal or external benchmarking (comparing performance metrics to industry bests and/or best practices)

Clinical indicator setsAnaesthesiaDay SurgeryEmergency MedicineGastrointestinal EndoscopyGynaecologyHospital in the HomeHospital-WideInfection ControlIntensive CareInternal MedicineMedication Safety

Mental Health CommunityMental Health InpatientObstetricsOphthalmologyOral HealthPaediatricPathologyRadiation OncologyRadiologyRehabilitation MedicineSurgical

Number of Health Care Organisations (HCOs) providing data for each set of indicators by year

2001 2002 2003 2004 2005 2006 2007 2008 2009Adverse Drug Reaction 118 145 164 155 150 159 172 174 176Anaesthesia 317 331 338 326 340 333 330 308 295Day Surgery 363 374 386 398 403 415 427 400 392Emergency Medicine 203 186 191 204 219 217 209 211 210Gastrointestinal Endoscopy – – – – – 68 81 86 88Gynaecology 143 151 150 128 119 123 88 90 94Hospital in the Home 29 36 34 36 42 45 46 48 48Hospital-Wide 402 372 376 387 412 433 465 460 454Infection Control – 125 167 169 233 265 284 320 325Intensive Care 96 99 100 93 101 104 101 104 105Internal Medicine 150 139 148 146 144 134 124 110 98Mental Health Community – – 17 17 24 32 23 28 28Mental Health Inpatient 104 114 121 121 123 121 124 121 124Obstetrics 217 216 215 220 218 212 210 180 181Ophthalmology 120 132 118 117 111 100 104 99 86Oral Health – 7 11 13 10 15 10 14 11Paediatric 81 77 77 68 70 53 53 53 49Pathology 30 32 34 30 33 41 45 37 49Radiation Oncology 11 10 13 15 16 14 16 18 20Radiology 70 63 67 63 63 65 67 65 66Rehabilitation Medicine 102 98 100 101 109 107 114 109 112Surgical 244 247 237 231 217 209 200 192 176

Radiation oncology indicators Version 3Area Indicator Description (n=10)

1Consultation Process1.1 Radiotherapy – waiting time > 14 days from the ‘ready for care’ date (L)1.2 Informed consent (H)1.3 MEBR – prospective clinical trials (H)

2

Treatment Process2.1 SCC (oral, oropharynx, hypopharynx, larynx) – radiotherapy >6 weeks

postoperatively (L)2.2 SCC (cervix) – curative chemoradiotherapy (H)2.3 Multi-leaf collimators (MLC) (H)2.4 CT Planning rate (H)2.5 Letters to referring doctors and general practitioners (H)

3Outcome Process3.1 Follow-up & outcome for pts treated with RADT for glottic cancer (H)3.2 Follow-up for patients receiving radiotherapy for breast conservation (H)

Radiation oncology indicator setArea Indicator Description

1 Consultation Process - Waiting time1.1 Radiotherapy – waiting time > 14 days from the ‘ready for care’ date (L)

NTotal number of patients waiting more than 14 days, from the date 'ready for care', to the date of commencing radiotherapy, during 1 week in May or November

D Total number of patients commencing radiotherapy, during 1 week in May or November [2010 Stratum Rate7 NSW HCOs=18.5 | 9 Other HCOs=36.8+ 2 Outliers]

Year HCOs Tot N Tot D Rate (20) (80) C S O

2007 14 268 737 36.4 28.5 48.7 58 23

2008 15 349 880 39.7 28.1 58.1 101 12

2009 18 394 1277 30.9 20.0 49.4 139 129 41

2010 16 216 736 29.3 10.8 42.9 136 79 25


1 Consultation Process - Waiting time1.1 Radiotherapy – waiting time > 14 days from the ‘ready for care’ date (L)

NTotal number of patients waiting more than 14 days, from the date 'ready for care', to the date of commencing radiotherapy, during 1 week in May or November

D Total number of patients commencing radiotherapy, during 1 week in May or November [2010 Stratum Rate7 NSW HCOs=18.5 | 9 Other HCOs=36.8 + 2 Outliers]


2007 14 268 737 36.4 28.5 48.7 58 23

2008 15 349 880 39.7 28.1 58.1 101 12

2009 18 394 1277 30.9 20.0 49.4 139 129 41

2010 16 216 736 29.3 10.8 42.9 136 79 25


1 Consultation Process - Informed consent1.2 Radiotherapy – informed consent (H)

NTotal number of patients who have informed consent recorded in the medical record before receiving radiotherapy, during 1 week in May or November

D Total number of patients receiving radiotherapy, during 1 week in May or November [2 Outliers]


2007 9 1055 1306 80.8 89.6 99.9 249 182

2008 10 1239 1305 94.9 96.2 99.9 64 51

2009 13 1523 1774 85.9 85.9 99.8 247 138

2010 12 1849 1892 97.7 97.7 99.9 41 34


1 Consultation Process – Clinical Trial Participation1.3 MEBR – prospective clinical trials (H)

N Total number of patients having megavoltage external beam radiotherapy, during 1 week in May or November

D Total number of megavoltage external beam radiotherapy courses undertaken, during 1 week in May or November [No Outliers]


2006 8 397 9802 4.05 0.76 5.47 139 103

2007 11 28 1299 2.16 1.05 2.61 5

2008 14 41 2058 1.99 0.53 3.56 32

2009 15 51 1984 2.57 1.76 3.58 20

2010 15 67 2258 2.97 0.44 3.34 8


2 Treatment Process – Squamous cell carcinoma (SCC)2.1 SCC (oral, oropharynx, hypopharynx, larynx) – radiotherapy >6 weeks postoperatively (L)

NTotal number of patients with SCC of the oral cavity, oropharynx, hypopharynx and larynx who wait longer than 6 weeks from their definitive surgery to commencing their radiotherapy

D Total number of patients receiving postoperative radiotherapy for SCC of the oral cavity, oropharynx, hypopharynx and larynx [No Outliers]


2007 8 32 102 31.4 9.14 86.1 22

2008 9 19 62 30.6 30.6 30.6

2009 11 40 117 34.2 30.8 46.9 3

2010 11 32 112 28.6 22.2 31.6 7


2Treatment Process – Squamous cell carcinoma (SCC)2.2 SCC (cervix) – curative chemoradiotherapy (H)

N Total number of patients who receive chemoradiotherapy for SCC of the cervix in the definitive or the postoperative setting

D Total number of patients who receive curative radiotherapy or chemoradiotherapy for cancer of the cervix [No Outliers]


2007 8 75 113 66.4 65.9 69.7 3

2008 8 46 78 59.0 59.3 59.3

2009 10 84 113 74.3 73.3 75.3 1

2010 9 59 85 69.4 67.7 74.3 4


2 Treatment Process – Multi-leaf collimators2.3 Multi-leaf collimators (MLC) (H)

N Total number of curative megavoltage radiotherapy courses provided, where CT planning was utilised

D Total number of curative megavoltage radiotherapy courses provided [4 Outliers]


2007 7 16065 26758 60.0 69.9 88.6 7634 3789

2008 10 23020 27247 84.5 75.3 90.7 1690 518

2009 13 25013 29037 86.1 77.5 92.6 1863 849

2010 11 18015 20163 89.3 77.7 94.0 940 466


2 Treatment Process – CT Planning2.4 CT Planning rate (H)

N Total number of patients receiving megavoltage radiotherapy using MLC

D Total number of patients who receive megavoltage radiotherapy [3 Outliers]


2006 10 9226 11523 80.1 67.7 98.1 2075 801

2007 12 7925 8780 90.3 95.7 99.9 849 693 520

2008 11 6014 6655 90.4 92.6 99.9 634 396

2009 13 9158 9759 93.8 96.4 99.9 591 360

2010 12 8153 8242 98.9 98.3 100.0 85 54


2 Treatment Process – Communication2.5 Letters to referring doctors and general practitioners (H)

NTotal number of patients who have a letter on file to the referring doctor and general practitioner, regarding the current radiotherapy course, during 1 week in May and November

D Total number of patients receiving radiotherapy, during 1 week in May and November [2 Outliers]


2007 9 772 998 77.4 93.2 99.8 224 164

2008 11 1023 1293 79.1 92.1 99.7 266 162

2009 12 1660 1745 95.1 91.7 99.7 79 26

2010 11 1617 1785 90.6 89.6 99.8 164 85


3 Outcome Process – Glottic cancer - complete follow-up3.1 Follow-up & outcome for pts treated with RADT for glottic cancer (H)

N Total number of patients who had radiotherapy for glottic cancer(T1-2N0M0) who had complete follow-up

D Total number of patients who receive radiotherapy for glottic cancer [No Outliers]


2006 7 30 35 85.7 70.8 70.8

2007 7 24 31 77.4 72.1 78.9

2008 9 63 72 87.5 86.6 90.0 1

2009 10 70 81 86.4 86.4 86.4

2010 8 53 56 94.6 95.7 97.8 1


3 Outcome Process – Breast conserv - complete follow-up3.2 Follow-up for patients receiving radiotherapy for breast conservation (H)

N Total number of patients who had radiotherapy for breast conservation (pT1-3, any nodal staging, M0) who had complete follow-up

D Total number of patients who receive radiotherapy for breast conservation (pT1-3, any nodal staging, M0) [3 Outliers]


2006 6 451 622 72.5 56.6 86.3 85 34

2007 7 650 919 70.7 43.4 91.3 189 82

2008 9 745 1046 71.2 55.9 89.6 191 66

2009 10 841 1244 67.6 47.5 97.4 371 115

2010 9 614 821 74.8 57.5 96.1 174 63

Development & review of indicator setsFormal process of collaboration, consultation, development,

testing, and refinement every 3 years with:

Health Professional Colleges/Associations / Societies (RAD ONC = FACRO, RANZCR| ACPSEM | AIR | AAPROP)ConsumersAustralian Private Hospital AssociationHealth Services Research Group (HSRG, University of Newcastle)

National Casemix & Classification Centre (NCCC, University of Wollongong)

Other experts as requiredACHS staff

Content Development:Opinions on existing & proposed indicators collected from practising clinicians Aug/Sep 2010

Face to face meeting 7 October 2010


ORG WORKING PARTY REPRESENTATION

FACRO 2 Radiation Oncologists [Vic and Qld]ACPSEM 2 Medical Physicists [Vic and NSW]AIR 2 Radiation Therapists [NSW and Vic]APPROP 1 Radiation Oncologist [WA]

1 Radiation Planning Manager [Qld]1 Medical Physicist [Qld]1 Radiation Oncology Nursing Director [Qld]

CHFA 1 Consumer RepresentativeSTAFF 1 HSRG, 2 ACHS

Radiation oncology indicators Version 4 and Comments Indicator Description (n=6)

1.1 Retain, but > 28 days1.2 Delete, but review by clinicians1.3 Retain, but > sampling to 1/12

Consultation Process (n=2)1.1 Radiotherapy – waiting time > 14 days1.2 Informed consent1.3 MEBR – prospective clinical trials

2.1 Delete2.2 Delete2.3 Delete2.4 Delete2.5 Retain (now 2.2)* Staging annotation (2.1)

Treatment Process (n=2)2.1 SCC (oral, etc) – RADT >6 weeks2.2 SCC (cervix) – curative chemoRADT2.3 Multi-leaf collimators (MLC)2.4 CT Planning rate2.5 Letters to referring doctors/GPs

3.1 Delete3.2 Delete* IMRT for nasopharynx carcinoma (Stages I – IVB, AJCC) (3.1)* Dose escalation for localised prostate carcinoma (high & very high risk) (3.2)

Outcome Process (n=2)3.1 Follow-up - glottic cancer3.2 Follow-up - breast conservation

Content Development:

Additional comments received requesting development of indicators addressing:

Treatment ProlongationReceipt of referral

Literature review to be completed on all indicators


Content Approval:Draft indicators developed via working party meeting discussion and email Jan-Feb 2012

Endorsement of draft indicators by the appropriate health professional college / association / society Mar 2012

Ratification by ACHS Board Mar 2012

Dissemination to Aus & NZ indicator members & health professional colleges Apr 2012

Data collection inclusion 2H 2012 (Jun)


Without data,it is just an opinion

POS Team:Dr Jen Bichel-Findlay

Ms Phoebe ZhangDr Chris Maxwell

02 8218 [email protected]/ClinicalIndicators/

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