Elaine Meertens

Early Results After Regionalization of Thoracic Surgical Practice in a Single-Payer System

BACKGROUND Regionalization of the practice of thoracic surgery into designated centers was carried out in Ontario to manage volume, improve outcomes, and facilitate comprehensive care. This article describes the process used by Cancer Care Ontario (CCO) to regionalize thoracic surgery practice and reports early results. METHODS A thoracic surgery standard was created by CCO, specifying criteria for level I (tertiary) and level II (secondary) thoracic surgery centers based on current volumes and projected population growth and referral patterns, and then implemented the standard using various incentives and disincentives. RESULTS Before regionalization (2004), 46 hospitals performed thoracic surgical procedures compared with 13 level I and 2 level II centers in 2010. From 2007 to 2011, a mean

Enabling quality improvement in systemic cancer treatment through a collaborative approach.

8.4 million was distributed annually to designated centers to fund a mean 625 additional thoracic operations annually. By 2009 to 2010, the number of esophagectomies performed at designated centers increased from 212 to 285 (89% being performed in designated centers). Correspondingly, the number of lung resections increased from 1,396 to 1,858 (94% being performed in designated centers). Median wait time for lung cancer resection did not change. Regionalization achieved a significant reduction in 30-day mortality after pneumonectomy (10.9%-5.6%; p = 0.03) but no change for esophagectomy (5.9%-5.8%; p = 0. 96) or lobectomy (2.2%-1.9%; p = 0. 37). CONCLUSIONS Regionalization was challenging but feasible and was associated with reduced 30-day mortality after pneumonectomy. More data are required to evaluate other short- and long-term outcome measures to further validate benefits from regionalization.

Using Breakthrough Series Collaborative Methodology to Improve Safe Delivery of Chemotherapy in Ontario

88 Background: The Regional Systemic Treatment Program at Cancer Care Ontario (CCO) aims to ensure the highest quality of systemic treatment is available to Ontarians, as close to home as possible. CCO initiated a provincial collaborative with the aim of improving the safe delivery of parenteral chemotherapy from orders through preparation, to administration, for patients, and providers. METHODS From April 2011 to March 2012, interdisciplinary hospital teams across Ontario followed multiple Plan, Do, Study, Act cycles to perform QI projects focusing on safe delivery of systemic treatment. Over this period, three in-person sessions educating participants on improvement methodology were held. Monthly teleconferences and an electronic discussion forum encouraged a culture of knowledge sharing and collaboration. RESULTS 113 participants from 26 teams participated in a total of 81 improvement initiatives. 96% of participants surveyed indicated that the collaborative provided a valuable opportunity to network with peers, share ideas, and discuss lessons learned. During the collaborative, teams reported their progress on a scale of 1-5. At May 2011, teams averaged a self-assessment score of 1, indicating no progress had been made. By February 2012, this increased to an average score of 4, indicating significant progress and achievement of at least one improvement objective/goal. CCO has leveraged the foundations built by the collaborative to develop a Regional Quality and Safety Network. This network provides a regular forum for health care providers and administrators to share knowledge and collaborate on strategies for improving quality and safety in the delivery of systemic treatment. CONCLUSIONS The collaborative demonstrated that the use of a formal quality improvement model is a successful mechanism for regional engagement; that provides the foundation necessary for building a provincial network with common goals and understanding regarding quality improvement. By educating participants, supporting local efforts and enabling knowledge transfer and exchange, the collaborative showed that shared ideas and even small changes can lead to large-scale improvements for patients and providers.

An approach to implementing meaningful change in a provincial health care system.

PURPOSE Chemotherapy delivery is complex, involving multiple providers across settings to deliver safe, effective care. Cancer Care Ontario initiated a provincial breakthrough series collaborative, based on methodology from the Institute for Healthcare Improvement (IHI), to improve the safe delivery of chemotherapy, from ordering through preparation and administration. METHODS Over the 1-year period of the collaborative, three in-person sessions educated participants on improvement methodology. Twenty teams tested and implemented elements of a predefined change package in their local systems. Monthly teleconferences supplemented the education while encouraging a culture of knowledge sharing. Teams completed monthly self-assessment surveys that evaluated their progress using a 6-point scale, where 1 indicated no evidence of improvement and 5 indicated achievement of all goals and improvement objectives. RESULTS Monthly self-assessment surveys revealed that over time, scores improved from 1 to 4, indicating significant progress. Moreover, 100% of participants reported in an exit survey that the collaborative had improved the culture of safety in their organizations. The gains of the collaborative have been sustained through development of a practice community and provision of ongoing coaching through the IHI Open School. CONCLUSION Participation in the collaborative enabled local interdisciplinary teams to develop processes and structures to support ongoing quality improvement, including formation of a sustainable structure for knowledge translation and exchange. However, lack of a shared provincial target limited overall evaluation. Other lessons learned included providing adequate time for planning and clearly defining roles and responsibilities of involved teams and project sponsors.

Bringing provincial improvements to oral chemotherapy prescribing through co-ordinated regional initiatives.

120 Background: Radiation treatment (RT) is essential to cancer management, contributing to cure and symptom control. With increasing cancer incidence and treatment complexity, health systems must adapt to ensure patients (pts) receive the highest quality of care. METHODS With the objective of ensuring equitable access to high-quality, safe care, Cancer Care Ontario (CCO), a provincial government agency, identified provincial variability in RT activities. As a result, CCO prioritized 3 quality initiatives over the past 7 years: 1) Access to Intensity Modulated RT (IMRT) (2008-2013); 2) Peer Review of RT plans due to increasing RT planning complexity and the existence of high-profile RT errors (2012-present); and 3) Ensuring equitable access to RT (RT Utilization) (2014-present). Strategic plans were developed using change management framework adapted from the Kotter process for leading change (Kotter, JP. Harvard Bus Rev 73:59-67, 1995). In each initiative, CCO created a climate for change, engaged the provincial RT community to move priorities forward, and worked to sustain achieved gains. RESULTS CCO found that building a project team, communicating a clear understanding of goals and objectives, providing sufficient resources to cancer centres, and public reporting of results were key contributing success factors. IMRT project: Currently in sustainability phase. IMRT rates increased from 20% in 2008/09 - full implementation and target attainment in 2012/13. Public reporting continues. Peer Review of RT plans: Currently moving from engagement to implementation phase. Increase from 44% of RT cases undergoing peer review in 2013/14 to 68% in 2014/15. RT Utilization Project: Currently in engagement phase. Provincial shortfall of 11% in annual RT rates correlates to roughly 2500 pts who do not receive RT as needed. Engaging data experts and consulting with regional administrators, RT utilization is the current change priority for CCOs RT program. CONCLUSIONS These projects demonstrate the possibility of using change management practices to achieve quality improvement in healthcare. Ongoing work continues to ensure that pts in Ontario receive the highest quality cancer care.

Development of a capital investment strategy for radiation (RT) equipment in Ontario.

107 Background: Oral chemotherapy delivery is complex, making safe medication practices a high priority. Cancer Care Ontario, the provincial government agency responsible for continually improving cancer services in Ontario, undertook a jurisdiction-wide quality improvement initiative to ensure that all oral chemotherapy drugs are prescribed using Computerized Prescriber Order Entry (CPOE) or standardized Pre-printed Orders (PPO). The initiative was further enabled by changes to the provincial funding approach that flows facility funding for oral chemotherapy delivery. METHODS All 35 facilities prescribing chemotherapy in Ontario across 14 regions implemented strategies to work towards the common aim of reducing handwritten/verbal oral chemotherapy prescribing to zero by June 30th, 2015. Baseline audits were completed between Sept-Nov 2014; repeat audits were performed between Mar-May 2015. Each facility reported the number of patients that received an oral chemotherapy prescription, and the method of prescribing. RESULTS At baseline, 30% of audited prescriptions across the province were handwritten or verbal, which decreased to 9% by June 2015. Improvements were seen in thirteen of the 14 regions. Thirteen out of 35 facilities met the aim of 0 handwritten/verbal orders, with an additional 16 facilities seeing an improvement. Alignment with funding mechanisms, an early physician engagement strategy, and education of key stakeholders on CPOE systems were identified as key enablers to implementation. CONCLUSIONS Though the goal of zero handwritten/verbal prescriptions was not met by all facilities, the initiative encouraged a change in implementing safe prescribing practices for oral chemotherapy. Further audits will assess that the gain was sustained and that the provincial goal is achieved. This initiative is part of a larger strategy to standardize care for systemic treatment patients and promote a culture of safety in hospitals. [Table: see text].

Patient navigation in cancer diagnostics: Providing information and support for more effective care.

279 Background: To ensure appropriate access to radiation treatment (RT) for Ontario cancer patients for the next decade and that future capital investments in radiation equipment are appropriately timed and strategically placed, Cancer Care Ontario (CCO) has updated its RT Capital Investment Strategy. The strategy was designed around 4 core principles: i) recognizing treatment machine capacity should match the demand resulting from increasing cancer incidence rates and increasing utilization rates as per CCO goals; ii) keeping pace with advancing technology; iii) ensuring value for money by maximising the use of current infrastructure; and iv) minimizing costs through centralized planning and procurement processes. METHODS A multidisciplinary provincial expert panel reviewed and revised the planning parameters used to project treatment demand and required capacity (including fractions of RT per treated case, number of cases treated per hour, uptime of treatment units). The panel reviewed current practice, impact of new and emerging treatment technologies and benchmarks from other jurisdictions. To project the future demand for radiation therapy, growth in cancer incidence (by county) as well as modest improvement in RT utilization rates were assumed. RESULTS Recommendations included: i) moving to 12-hour treatment days in all large centres and on 50% of equipment in centres operating fewer than 6 treatment units; ii) ensuring appropriate funding for the replacement of existing RT equipment; iii) equipping constructed rooms in 4 regional cancer centers - thereby adding 6 linacs; iv) equipping swing bunkers across the province - thereby adding 10 linacs; and v) planning for the construction of new facilities to add RT capacity in 3 regions of the province. CONCLUSIONS Funding to implement recommendations from previous capital investment strategies has resulted in an equitable distribution of RT resources across the province. We believe the planning strategies and recommendations outlined in the strategy will improve access to quality RT care as close to home as feasible for Ontario patients.

The power of knowledge: Sharing patient test results electronically to improve quality of care.

5 Background: Patients frequently have a difficult time finding their way through the process of diagnostic testing for cancer; the uncertainty is stressful and anxiety can impede effective communication and decision-making. Patient navigation is an ideal approach to supporting patients during the diagnostic phase of cancer care. METHODS Between 2010 and 2011, 14 Patient Navigators were trained and introduced into Diagnostic Assessment Programs (DAPs) across Ontario. DAPs are designed to provide coordination and supportive care to patients undergoing diagnostic testing and assessment. A patient survey served to evaluate the impact of patient navigation on the patient experience. Standardized tools were introduced to measure symptom severity and symptom management. Interviews were done to gauge provider and team perspectives on the role. RESULTS During the pilot, patient symptoms improved in the areas of well-being, tiredness, anxiety and shortness of breath, each by 30% or more. The patient survey indicated that through the program, patients got the information and support they needed; 91% of patients surveyed said that they were either satisfied or very satisfied with their experience with the patient navigator. The navigation pilot sites saw their diagnostic wait times fall by 55%. The Patient Navigators have found their work to be highly satisfying and rewarding, enjoying the opportunity it provides to use their full scope of practice in a multidisciplinary environment. Physicians expressed a high degree of satisfaction with the support provided by the Patient Navigators, reporting that patients were better prepared and informed when they arrived for their clinic appointments. CONCLUSIONS This work has shown that patient navigation enhances the experience of patients as they move along the diagnostic continuum. Patient Navigators assist patients with managing their physical and psychosocial symptoms and play a critical role in providing the information and support patients need during a time that is full of uncertainty and distress. The diagnostic phase is a prime example of where navigation can have an impact on both the quality of patient care and the effectiveness of the health care team.

Integrating Cancer Care Beyond the Hospital and Across the Cancer Pathway: A Patient-Centred Approach

305 Background: For many patients going through the cancer diagnosis journey, the time from suspicion to diagnosis or rule-out can be a confusing and anxious time. To better support patients during this time, Cancer Care Ontario (CCO) is supporting Diagnostic Assessment Programs (DAPs) and the web-based tool known as the Diagnostic Assessment Program-Electronic Pathway Solution (DAP-EPS). DAPs consist of multi-disciplinary healthcare teams who provide diagnostic and supportive care services in a patient-focused environment, improving access to care and the patient experience. DAPs help manage and coordinate a patients diagnostic care from testing to a definitive diagnosis and part of this support involves providing access to personal health information through the DAP-EPS. This work was undertaken to determine the best approach to sharing test results with patients, including the type of test results that should be released and the most effective method for sharing these results with patients, from both the patient and provider perspective. METHODS The exploratory project involved conducting key informant interviews with individuals who had been involved with implementing similar patient portals, a targeted literature review, and a series of engagement sessions with physicians to measure the clinical response to this new strategy. RESULTS Initial discussions with patients and nurses yielded a strong endorsement for releasing all results, with no time delay. Key Informant interviews yielded similar results from the majority of the hospital contacts consulted. The environmental scan did not suggest that releasing results was associated with any adverse patient or provider effects. The physician engagement sessions generated both positive and negative feedback but overall, doctors were comfortable releasing all results, provided there was a delay built into the system. CONCLUSIONS The release of diagnostic test results is seen as a valuable component of quality of care from the perspective of informing and empowering the patient. As the DAP-EPS moves forward with this initiative, the DAP program will continue to monitor the impact that the release of results has on both patients and providers.