Michelle Ang

ReCAP: Improving the Quality of Radiation Treatment for Patients in Ontario: Increasing Peer Review Activities on a Jurisdictional Level Using a Change Management Approach

PURPOSE Peer review of radiation treatment (RT) plans is a key component of quality assurance programs in radiation medicine. A 2011 current state assessment identified considerable variation in the percentage of RT plans peer reviewed across Ontarios 14 cancer centers.In response, Cancer Care Ontario launched an initiative to increase peer review of plans for patients receiving radical intent RT. METHODS The initiative was designed consistent with the Kotter eight-step process for organizational transformation. A multidisciplinary team conducted site visits to promote and guide peer review and to develop education and implementation processes in collaboration with the centers. A centralized reporting infrastructure enabled the monitoring of the percentage of RT courses peer reviewed and the timing of peer review (before completion of 25%of treatment visits, after completion of >25%treatment visits). RESULTS The initiative is ongoing, but early results indicate that the proportion of radical intent RT courses peer reviewed province wide increased from 43.5% (April 2013) to 68.0%(March 2015). This proportion is now a quality metric in Ontario and is publicly reported through the Cancer System Quality Index. The performance target for this metric was initially set at 50%(cases treated with radical intent) and revised to 60% in 2014. Provincial performance exceeded targets in both years (58.2% and 68.2%, respectively). Considerable variation was observed, however, in rates and timing of peer review among Cancer Care Ontario centers. CONCLUSION This initiative demonstrates that a change management framework can be useful for planning and achieving substantial increases in jurisdictional peer review activities.

Improving radiotherapy utilization rates in Ontario.

48 Background: Radiotherapy (RT) utilization is the proportion of patients (Pts) with a new diagnosis of carcinoma that receives at least one course of RT during the duration of their illness (MacKillop et al). In Ontario, the benchmark for utilization is 42%, and the target rate for Cancer Care Ontario (CCO) is 48%. However in 2005/06 Ontarios utilization rate was only 35%. This shortfall implies that a significant number of Pts in Ontario were not receiving the best possible treatment. METHODS CCO has developed Capital Investments Strategies to take into account a growing population, an increased incidence of cancer (2.7% per annum), and changing demographics. The most recent (2012) has developed a plan for a gradual improvement in utilization at a rate of 0.5% per annum. With support from the Ministry of Health and Long-Term Care (MOHLTC), the amount of RT Units (RTUs) available increased from 77 (2005/06) to 103 (2013/14). In addition, the MOHLTC supported training programs for provincial Medical Physicists and Radiation Therapists to ensure effective staffing for increased RTUs. RESULTS Due to investments in RTUs and training, the number of Pts treated in Ontario has risen over 38% from 26,448 in 2005/06 to 36,613 in 2012/13. As a result, provincial utilization rates have risen from 35.1% in 2004/05 to 38.8% in 2012/13, closer to provincial targets. Notable improvements have been seen in centres such as The Carlo Fidani Peel Regional Cancer Centre, where the total number of RT Pts treated increased from 623 (2005/06) to 2532 (2012/13). Similar improvements are seen in other Local Health Integration Networks where comparable investments have been made. These improvements have been attained at the same time as provincial RT wait times have significantly improved from 80.2% (Jan 2010) to 91.6% (Dec 2012) of Pts seen within targets, exceeding provincial targets of 87%. CONCLUSIONS The increase in RT utilization rates provincially demonstrates the success of developing a comprehensive capital investment strategy and coupling it with increased investments in human resource planning. The increased utilization rate has outpaced the increasing cancer incidence and demonstrates the success of these strategies, providing better access to care for cancer Pts in Ontario.

The Clinical Specialist Radiation Therapist (CSRT): A case study exploring the effectiveness of a new advanced practice role in Canada

The Clinical Specialist Radiation Therapist (CSRT), is a new advanced practice (AP) role for radiation therapists (RTTs). Following training, education and evaluation, the CSRT performs specific duties in autonomous ways, making advanced clinical decisions in their area of specialization. This case study examines the CSRTs impact on quantity (i.e., increasing capacity), improving quality and stimulating research and innovation.

Cancer Care Ontario’s Communities of Practice: A Scoping Evaluation

Purpose Communities of practice (CoPs) are defined as groups of people sharing common concerns, problems, or passions about a topic, and who deepen their knowledge and expertise by interacting on an ongoing basis. Cancer Care Ontarios (CCO) Radiation Treatment Program (RTP) has developed multiple CoPs involving staff across 14 regional centres on the basis that knowledge is a critical asset that needs to be managed strategically. This study is to assess the effectiveness of these CoPs on three parameters: knowledge creation, knowledge transfer and exchange (KTE), and community building using the Center for Disease Control and Prevention (CDC) framework for CoP evaluation.

179: It's Crunch Time: Finding Efficiencies With a New; APRT-mediated Model of Care

withdrawn 181 PATIENT EXPERIENCE SURVEY OF EARLY-STAGE BREAST CANCER PATIENTS UNDERGOING WHOLE BREAST RADIOTHERAPY Grace Lee, Robert Dinniwell, Anthony Fyles, Tatiana Conrad, Kathy Han, Wilfred Levin, Fei-Fei Liu, Susanne Lofgren, Alexandra Koch-Fitsialos, Gerald Devins, Nora Emad, Bethany Pitcher, Tony Panzarella, Anne Koch Princess Margaret Cancer Centre, Toronto, ON University of Toronto, Toronto, ON Purpose: Adjuvant breast radiotherapy (RT) is a standard treatment option in women with early-stage breast cancer following lumpectomy. Timeliness of RT treatment can impact patient satisfaction. The objectives of this study are to assess: 1) patient satisfaction of their whole breast RT; 2) patient preference for timing of RT start after CT simulation (CTSim); and 3) factors that influence patient stress and quality of life. Methods and Materials: Women undergoing whole breast RT were given a survey before RT treatment and at treatment completion. Patients were offered treatment either through the conventional process (ConvProcess), where RT starts typically within 1-2 weeks of CTSim, or the QuickStart (QS) process, where RT starts one day after CTSim. The pre-treatment (PRE-Tx) survey included questions to understand the social impact of RT, and the post-treatment (POST-Tx) survey included questions relating to social climate and patient satisfaction. Questions relating to RT start preference, stress (Perceived Stress Scale [PSS]) and quality of life (Illness Intrusiveness Ratings Scale [IIRS]), were assessed both at PRE-Tx and POST-Tx. An analysis of covariance was used to determine if the RT process impacted PSS and IIRS, and t-tests were used as a secondary analysis. Fisher’s Exact test was used where appropriate. Results: Ninety-six patients completed the PRE-Tx survey and 88 completed both surveys (QS process n = 28; ConvProcess n = 60). All patients indicated they had a positive experience with the RT

146: Current Practice of External Beam Radiotherapy and Brachytherapy for Management of Endometrial Cancer in Ontario, Canada

CARO 2016 _________________________________________________________________________________________________________ excluded. The query identified 142 patients who received treatment for clinical Stage II disease. Median age was 38 years (range: 19 – 68), 33 had Stage IIA, 47 IIB, and 62 had IIC disease. Fifty-nine patients were treated with radiation therapy (RT) while 83 received chemotherapy (CT). Only three patients with Stage IIA got CT, and only five with IIC got RT. Median RT dose was 30 Gy. Most common CT regimens used were EP (n = 68) and BEP (n = 13). Results: After a median follow up of 18 years, 24 patients had died, and there were 16 recurrences (three in the contra-lateral testis). Patients were more likely to die of second cancers (n = 7) and myocardial infarctions (n = 6), than from progressive Seminoma (n = 3). Two patients died during treatment (neutropenia and sepsis). The 10and 15-year overall survival (OS) was, IIA: 93.8% and 93.8%; IIB: 91.4% and 88.3%; IIC: 83.2% and 76.0%. The 10-year cumulative incidence of relapse (CIR) for Stage IIA patients treated with RT was 3.4%. Stage IIC patients treated with CT had a 10-yr CIR of 10.6%. The 10-year CIR for Stage IIB patients treated with RT (n = 24) versus CT (n = 23) was 29.8% versus 0% (p = 0.005). Seventeen patients developed a second malignancy (SM); non-melanoma skin cancers were excluded. The 15-year cumulative incidence of SM was 7.3% for patients treated with RT, versus 9.7% for those treated with CT (p = 0.321). Conclusions: Long-term outcomes for patients with Stage II Seminoma continue to be excellent. Patients are more likely to die of second cancers and cardiovascular disease than from progressive seminoma.

Communities of practice: A jurisdictional approach to improving the quality of care in radiation medicine in Ontario.

122 Background: The Radiation Treatment Program (RTP) at Cancer Care Ontario (CCO) established several Communities of Practice (CoPs), with the goal of improving radiation treatment (RT) quality and safety. The RTP identifies variation in practice and quality improvement (QI) opportunities in the 14 Regional Cancer Centres (RCCs) and facilitates the development of CoPs to share best practices and standardize care. METHODS Since 2010, the RTP has formed 7 CoPs ( > 185 members in total): 4 intra-disciplinary (Radiation Therapy, Medical Physics, Advanced Practice Radiation Therapy, Radiation Safety) and 3 inter-disciplinary (Head and Neck (HN), Gynecological (GYNE) and Lung Cancer). Members are recruited with the aim of securing engagement from all RCCs to ensure representation of regional diversity and to facilitate adoption of best practices. CoPs are supported with nominal funding and resources provided by CCO, but are led and driven by members, who identify and prioritize key quality issues and select corresponding QI projects to pursue. The RTP performs regular evaluation activities to assess initiative engagement and impact. RESULTS RTP CoPs have enhanced the quality and safety of RT delivery in Ontario through QI initiatives, advice documents and tools that have enabled: Improved RT safety (use of safety straps in RT delivery); Adoption of best practices (RT plan evaluation guidance); Education and knowledge transfer - (stereotactic body RT implementation and training framework); and Support for infrastructure improvements (recommendation for additional Magnetic Resonance-guided brachytherapy units) ( https://www.cancercare.on.ca/ocs/clinicalprogs/radiationtreatment/ ). Advice documents have improved alignment with recommended practice (40% and 50% absolute increases in two HN initiatives). Evaluation surveys indicate that members believe the CoPs have enhanced inter-regional communication and collaboration (89%), knowledge transfer/exchange (91%), and professional networking between RCCs (92%). CONCLUSIONS CoPs can be a highly effective model for improving quality of care. The establishment of CoPs should be considered for QI in other areas of the healthcare system.

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

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.