quality management partnership title of deck - etouches · pdf filetakeda, johnson &...

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Quality Management PartnershipColonoscopy

Dr. David Morgan, QMP, Colonoscopy Clinical Lead

October 2, 2014

Speaker Bureau:

Pfizer, Merck, Astra Zeneca, Altana, Abbott, Janssen Ortho (JOI), Negma,

Novartis, Scherring, Axcan, Wyeth, Proctor & Gamble, Solvay, Takeda,

Johnson & Johnson

Consultant:

Pfizer, Merck, Astra Zeneca, Altana, Abbott, Janssen Ortho (JOI), Negma,

Novartis, Scherring, Axcan, Wyeth, Proctor & Gamble, Solvay, Ferring,

Takeda, Johnson & Johnson, Kellog’s

Research Funding:

Heart and Stroke Foundation, Astra, JOI, Altana, Novartis, Pfizer, Negma,

Aptalis,

Conflict of Interest Disclosure:

D Morgan MD MSc FRCPC

The Times They are a Changing!

The Ontario MOHLTC is changing the how

colonoscopy is funded.

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MOHLTC & Health System Reform

As part of the health system funding reform initiative, MOHLTC has identified a list of Quality-Based Procedures (QBPs). This list includes colonoscopy (for all indications).

Funding for QBPs will be linked to quality frameworks beginning in fiscal year 2013/14.

MOHLTC established Clinical Expert Advisory Groups to guide the development of the quality frameworks

OHP: Background

~25% of colonoscopies done in OHPs (2010)

OHPs are regulated under the Medicine Act (April

2010)

CPSO assesses OHPs

Plan for integration into CCC program

Plan to change OHPs to IHFs

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Quality Management Partnership Overview

Quality Management Partnership 16

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Quality Management Partnership


The partnership between the College of Physicians and Surgeons of Ontario (CPSO) and Cancer Care Ontario (CCO) was established by the Ministry of Health and Long-Term Care in March 2013

CPSO CCO

Quality Management Partnership

(QMP)

QMP: Driving Forces

A series of quality and patient safety incidents across Canada

Variation in the quality of care in hospitals and in the community

Variation in the ability for facilities and system administrators to proactively identify quality concerns

Ontario’s Action Plan for Health (2012) and the focus on quality across the health system

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19Quality Management Partnership

Quality Management Partnership Mandate

Work closely with stakeholders to develop and implement credible, comprehensive quality

management programs for identified healthcare services, beginning with colonoscopy,

mammography, and pathology

Improve patient care by driving continuous quality improvements and fostering efficiency and

integration across the provider, organizational, and system levels

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Five Program Elements

• How do we define quality? 1. Quality

Framework

• How do we measure and report on quality?

2. Quality Reporting

• How do we make sure we are meeting minimum standards?

3. Quality Assurance

• How do we drive for excellence?4. Quality

Improvement

• Can we improve quality by re-considering how we deliver this service?

5. Quality by Design


All Quality Management Programs will include five elements,

although each health service will do so in its own way…

Link to QBP and Community-Based settings strategy


Improve cost-effectiveness of

services using best practice

guidelines

Reduce practice variation and

improve patient outcomes among

providers

Improve accountability within the

System for providing best practice

Services

Improve effectiveness of the funding

model in future funding years

Fund GI Endoscopy service providers for

providing best practice services

Provide best practice GI Endoscopy

services to Ontarians (via development of

interim facility and provider standards and a GI

Endo QBP clinical pathway)

Monitor and evaluate success of QBP via

provincial, regional and facility reporting (funding and quality measures)

Implement Year 1 of GI Endoscopy

Funding Model

QBP Long Term

ObjectivesQBP Short Term Objectives

As of April 1, 2014 CCO is responsible for allocating funds for all GI Endoscopy.

Partnership alignment

QMP Link to the GI Endoscopy Community-Based Clinics Strategy


Develop and implement program for

GI-Endoscopy community-based

settings

Identify high-quality community-

based service providers in the field

Fund GI Endoscopy community-based

settings for providing best practice services

Inform quality based selection criteria and

evaluation approach to support the

selection of GI-Endoscopy community-

based settings

Long Term Objectives Short Term Objectives

CCO is working with the Ministry of Health and Long Term Care to develop a

strategy to shift appropriate GI-Endoscopy hospital volumes to community based

settings.

Partnership alignment

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Quality Management Partnership: MOHLTC Reports

Phase 1 (September 2013 to March 2014): Engage Expert Advisory Panels to start the design of provincial quality management programs and identify some Early Quality Initiatives that could be initiated in the short-term to move Ontario forward with quality management programs.

The Phase 1 report was submitted to the MOHLTC in March 2014.

Phase 2 (April 2014 to March 2015): Continue the design of the provincial quality management programs, conduct stakeholder consultations on program design, and initiate the Early Quality Initiatives (if approved by the MOHLTC), and develop a high level implementation plan.

The Phase 2 report will be submitted to the MOHLTC in March 2015.

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Quality Management Partnership Colonoscopy Early Quality Initiatives


Early Quality Initiative Criteria

Projects that can be initiated in 2014/15

Projects that move Ontario forward in building the comprehensive quality management programs

Projects that will have strong stakeholder support

Projects that feasible from IM/IT perspective

Projects that are feasible from Legs & Regs perspective

Each project was presented to stakeholders for review and feedback

Additional stakeholder input will also be obtained at critical junctures.


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Early Quality Initiatives

The Partnership Colonoscopy Expert Advisory Panel has identified the following early quality initiatives: 1. Bowel Preparations Dosing Reference Card

2. Guidelines for Standardized Endoscopy Report for Referring Providers

3. Guidelines for Standardized Patient Discharge Information

4. Pre-Procedure and Post-Procedure Checklists

5. Launch a Version 1 of a Physician Performance Report for Colonoscopy


Preliminary assessments to include:1. IM & IT feasibility

2. Legislative and regulatory feasibility

3. Broad stakeholder support

1. Bowel Preparations Dosing Reference Card

Project Description:

Develop and disseminate a bowel preparation “dosing reference card” for referring physicians, endoscopists and perhaps pharmacists that does not remove the decision-making from providers, but assists them in choosing the most appropriate prep based on a patient’s current health state, age, co-morbidities etc.

Project Benefits:

a) May result in better compliance and better outcomes

b) May reduce the need for recall examinations because the prep is more effective

c) May improve integration of pre-procedure and procedure, benefitting both patients and providers

d) May result in optimization of resources (in this case, most appropriate prep) to achieve desired outcomes


2. Standardized Endoscopy Report


Develop and trial a standardized endoscopy report template for referring providers. Currently there is wide variation in reporting among physicians and centres. There are several guidelines and policy documents describing the importance of standardized colonoscopy reporting to facilitate clear communications between providers as well as to contribute to quality improvement programs.

Project Benefits:

a) May result in an improved continuum of care for patients

b) May reduce repeated examinations due to lacking information determining the quality of examination, including bowel preparation quality and specific cecal landmarks

c) May reduce inappropriate decisions for the timing of surveillance colonoscopy because the key polyp descriptors (size and/or morphology) are absent

d) May reduce uncertainty about the follow-up arrangements and the provider who is responsible for follow-up

e) Referring providers will benefit from this quick win – they can send patients to different endoscopists and get back very similar narrative in terms of structure and description.


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3. Standardized Patient Discharge Information


Develop and trial guidelines for standardized discharge information for patients. The reports trial would engage an initial cohort. The project would begin in 2014/15 but extend into 2015/16 to ensure time for uptake, utilization and impact evaluation.

This early initiative acknowledges the effects of anaesthesia and anxiety on patients post-colonoscopy. There is evidence that sedation causes impaired memory retention (amnesia), which causes people to forget post-procedure instructions (e.g., do not resume taking NSAIDs or aspirin 14 days following colonoscopy) and follow-up appointments (Hayes, 2001)

The goals and objectives are to improve patient compliance with follow-up, ensure the patient understands what to do if problems arise, and to reduce anxiety.


Project Benefits: a) Improved patient recall of endoscopy findings and recommendations,

b) Better patient compliance with follow-up recommendations, c) Decreased patient anxiety,

d) Better knowledge about how to obtain final endoscopy results,

e) Improved patient understanding of what to do if problems arise post-colonoscopy.

4. Pre-Procedure and Post-Procedure Checklists


Develop and trial pre- and post-procedure checklists in OHPs and hospitals. Checklists have been used traditionally in the aviation industry as a standard safety measure. Research within that industry has illustrated that errors with significant impact on safety often relate to non-technical skills rather than technical ability. A study by Haynes et al (N Engl J Med 2009;360:491-9) in the New England Journal of Medicine on Surgical Safety Checklists demonstrated that checklists could be very valuable in reducing complication rates, including death.


Project Benefits:

a) Build assurance that patients are receiving the same standard of care throughout the province

b) Team members will benefit by not having to rely only on “memory” to ensure that all steps pre and post procedure are covered.

c) Patients will benefit with an added level of safety and standardization for the procedure.

5. Physician Performance Report


Develop and trial a physician performance report for colonoscopy in 2014/15. A physician performance report will provide regular feedback to allow self and peer comparison and to encourage continuous skills improvement for all providers.

The physician performance report would not be a decision tool, but rather an assessment tool –a regular “snapshot” - to inform skills development.

This early initiative includes selection of appropriate measures, identification of targets where applicable, design/language elements and trial. There are significant IM/IT considerations associated with this early initiative, so it is anticipated that several trials and evaluations will be conducted before system-wide implementation occurs.


Project Benefits: a) Avoiding, preventing and ameliorating adverse outcomes through feedback activities

that identify areas where skills could be improved

b) Responsive and timely feedback for all providers to inform their practice and QI activities

c) No opting-out – all physicians have access to feedback and comparison against their peers, whether high-performing or low-performing.

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Ongoing and Upcoming Panel work


Review of current states

Colonoscopy standards

Reporting standards

Quality Indicators

QA / QI tools and initiatives

Recommendations for standards and reports

Provider, Facility

Recommendations for the Quality Management Model (system implementation)

Consultation with Stakeholders

The Partnership’s Proposed Quality Management Model:


Provincial Lead: Responsible for providing

provincial quality management program oversight

for colonoscopy quality in Ontario.

Regional Leads: Responsible for providing


for colonoscopy quality within their region and

providing support to Facility Leads.

Facility Leads: Responsible for providing


and accountable for the quality of care for

colonoscopies provided within their facility.

Quality Management Model


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Phase 2 Broad Panel Recommendations:


All facilities should adhere to a common set of standards based on the

Out of Hospital Premises Inspection Program.

All scope technicians must participate in a formalized training program

(beyond the training provided by manufacturers).

All facilities must participate in a common quality assurance program that

includes regular inspections and assessments.

All facilities must use the Global Rating Scale (GRS) as a quality

assurance/ quality improvement tool. Implementation of this should be

thoughtful, gradual and well supported, with financial and educational

resources. Implementation of this tool will be carefully planned to ensure

appropriate support is provided.

A centralized, electronic repository should be developed to include past

procedural reports and relevant pathology findings, as well as images

and/or video related to the procedure.

All facilities must adopt both electronic and synoptic reporting, and that

the implementation of these methods of reporting where they do not

currently exist is implemented thoughtfully and with proper support.

Facility Report Indicator Recommendations:


Cecal intubation rate

Colonoscopies performed by endoscopists meeting volume standard

Adherence to CCC Screening Program Wait Times

Adherence to CCC Screening Program Wait Times

Tier I and Tier II Adverse Events

Patient Satisfaction

Facility Report Indicators cont…


Patient Satisfaction using a standardized tool such as the GRS, starting with the following indicators (but expected to expand):

• Measures of the patients’ ability to provide feedback

• Aftercare experience

• Equality of access

• Timeliness

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Provider Report Indicators


Colonoscopy Volume

Bowel Prep

Polypectomy Rate

Cecal Intubation Rate

Polypectomy Associated Bleeding Rate

Outpatient Perforations

Detected CRC Rate

Post Colonoscopy CRC Diagnosis

Adenoma Detection Rate

Ongoing Partnership Work


Recommendations for QI

Complete recommendations for reporting structure

Review and assess consultation results

Complete Phase II recommendations for report

Contact Information

Dr. David Morgan

Colonoscopy Clinical Lead, Quality Management Partnership

email: [email protected]

Laura Silver

Project Manager, Quality Management Partnership

Email: [email protected]

Partnership website

www.qmpontario.ca


mailto:[email protected]

mailto:[email protected]

http://www.qmpontario.ca/

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