Transcript Monitoring and Enhancement of the Practice of Physicians

Expect the Unexpected: Are We Clearly Prepared?
The Quebec system of Monitoring and
Enhancement
of Physicians Performance
André Jacques, MD, Director
Practice Enhancement Division
Collège des médecins du Québec
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Potential conflict of interests disclosure
Dr André Jacques declare:
“ I do not have any affiliation or
financial interest of any nature in a
business corporation, or I do not
receive remuneration, royalties or
research grants from a business
corporation”
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Mission of the College
The mission of the Collège
des médecins du Québec is
to promote a quality
medicine
in order to protect the
public
and to contribute to
enhance
Presented at the 2006 CLEAR Annual Conference
the
health of Quebecers
September 14-16 Alexandria, Virginia
Governance of the College
Bureau
(28 Governors)
Executive Committee
(5 Governors)
President
Professional
Inspection
Committee
Committee
on Budget
Committee
on Revision
Committee
on CPD
Committee
on Discipline
Committee
on Admission
to practice
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Management structure
General Division
Administrative
Services
Division
Legal
Services
Division
External Affairs
Division
Medical
Education
Division
Practice
Enhancement
Division
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Inquiry Division
Role of the College of physicians
• Admission to practice - registration
– Accreditation of training programs and sites
– Licensure examination for family physicians
(written and oral examinations, OSCE and SOO)
– Specialist certification examination (written and
oral and/or clinical examination)
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Role of the College of physicians
• Supervision of physicians’ practice
– Assessment of practice of physicians in :
• Offices
• Hospital
• Nursing homes
• Etc.
– Interventions to promote quality of practice
• CME activities
• Training programs
• Coaching
• Etc.
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Role of the College of physicians
• Investigation of complaints related
to both physicians and illegal
practitioners
– Disciplinary process (for physicians)
– Legal proceedings against illegal
practitioners
– Alternate resolution of complaints
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Role of the College of physicians
• Political role
– Physicians and medical organizations
– Public and media's
– Government and official bodies
– Other health professions
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Human and financial resources
• Staff of the College:
– 23 full time physicians
– 78 support staff
• Budget
:
– 18.6 millions (Canadian dollars)
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Quebec medical manpower
Distribution by type of practice (N = 18 746)
49,30%
50,70%
GPs ( N= 9 242)
Specialists (N = 9 504)
Based on data of December 2005
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Quebec medical manpower
Distribution by sex (N = 18 746)
64,60%
35,40%
Male (N = 12 120)
Female (N = 6 626)
Based on data of December 2005
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Code of ethics
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Code of Ethics of physicians
• A physician must practice his
profession in accordance with the
highest current standards; to that end
he must improve and keep his
knowledge up to date.
(Section 44)
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Professional Code
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
By-laws related to supervision of
physicians practice
• A Professional Inspection Committee is
established within each order.
(Professional Code, section 109)
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
By-laws related to supervision of
physicians practice
• The committee shall supervise the
practice of the profession by the
members of the order.
(Professional Code, section
112)
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
By-laws related to supervision of
physicians practice
• The committee may recommend that it
require a member of the order to serve
a period of refresher training or take a
refresher course or both and that it
restrict or suspend his right to engage
in professional activities during the
training period or course.
(Professional Code, section 113)
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
By-laws related to supervision of
physicians practice
• It is forbidden to hinder in any way a
member of the committee, an
inspector or an expert in the
performance of the duties conferred
upon him by this code.
(Professional Code, section
114)
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Professional Inspection Committee
Functions
• Inquiries into the professional
competence of a physician
• Inquiries into the the quality of the
medical care provided in establishments
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Practice Enhancement
Division
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Practice Enhancement Division
Mandate
The mandate of the Practice
Enhancement Division of the College of
physicians of Quebec is the monitoring of
the practice of physicians and its
enhancement in order to protect the
public and contribute to enhance the
health of Quebecers
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Practice Enhancement Division
Human and Financial Resources
• Staff of the Division :
– 10 physicians
•1 director
•2 assistant directors
•6 inspectors-investigators
•1 physician for sick MD
– 1 coordinator
– 1 research agent
– 11 secretaries
• Budget 2006-2007 : 4.3 M $
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Practice Enhancement Division
Functions
• Evaluation of the quality of physicians'
practice in office as well as in hospital
• Evaluation of the quality of the practice
of medicine in health establishments
• Support to the Professional Inspection
Committee
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Practice Enhancement Division
Functions
•Intervene to enhance the physicians'
performance in office as well as in
hospital
•Support the Continuing Professional
Development (CPD) Committee
•Maintain the secretariat of the Conseil
québécois du développement
Presented at
the 2006 CLEAR
Annualmédecins
Conference
professionnel
continu
des
September 14-16 Alexandria, Virginia
Who will be the
winner !
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Study of a representative sampling of 100 GPs
• Observational analysis of medical
records randomly selected
• Assessment of some aspects of the
quality of general practitioners’
professional practice
• Period : 1995-1996
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Study of a representative sampling of 100 GPs
• Professional inspection visits to 100
family physicians
• Random selection among Quebec’s
family physicians :
– practicing either entirely or partially in a
private office
– in the greater metropolitan Montreal region
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Study of a representative sampling of 100 GPs
• Two random sample groups :
– 52 family physicians licensed before
1980
– 48 family physicians licensed between
1980 and 1996
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Study of a representative sampling of 100 GPs
• Professional inspection visits made
by
– 5 inspectors/investigators from the College
– Average of 10 years of experience in
assessment of competence
• Study of at least 30 patients records
randomly chosen
• Using of a standard grid listing the
criteria,Presented
including
a scores
scale
at the 2006 CLEAR
Annual Conference
September 14-16
Alexandria, Virginia
Sampling of 100 GPs Criteria of evaluation
• Office practices
• Record-keeping
• Quality and quantity of CME
• Quality of practice
–
–
–
–
Investigation
Diagnosis accuracy
Treatment plan
Relevance of care
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Sampling of 100 GPs Demographic data
Distribution of physicians by sex
Physicians of the
study
Board of Collège des
médecins du Québec
0%
25%
Male
50%
Female
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
75%
100%
Sampling of 100 GPs Demographic data
Distribution by licensing period
Physicians of the study
Board of Collège des
médecins du Québec
0%
25%
50%
75%
License obtained after 1980 (Group 1)
License obtained before 1980 (Group 2)
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
100%
Sampling of 100 GPs Results
• Comparisons between physicians of
groups 1 and 2 regarding :
–
–
–
–
–
Sex
Age
Status in hospital
University of issuance of the medical degree
Average number of consults per week
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Sampling of 100 GPs Results
• No significant statistical difference
detected between the two groups
(except for record-keeping)
• No link between demographic
variables and quality of care
• Strong link between :
– record-keeping and quality of care
– CME activities and quality of care
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Sampling of 100 GPs Results
Combined results (Groups 1 and 2)
Quality and quantity
of CME
Record-keeping
Office practices
0%
20%
Satisfactory
40%
60%
Unsatisfactory
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
80%
100%
Sampling of 100 GPs Results
Combined results (Groups 1 and 2)
Relevance of care
Diagnosis accuracy
Investigation plan
Treatment plan
0%
20%
Satisfactory
40%
60%
Unsatisfactory
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
80%
100%
Sampling of 100 GPs Conclusion of the study
• Results enable the College to reassure
the public with regard to the overall
quality of the professional practices of
family physicians in Quebec
• Study confirms the PIC decision to
evaluate the practice of physicians who
present a potential risk of deviant profile,
based on quality indicators
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Monitoring and enhancement
of physician’s performance
Step 3
Detailed needs
assessment
Step 2
Monitoring
Assessment of
physicians in need
or at risk
Monitoring
Remediation
programs
Enhancement
CME programs for
groups and/or
individuals
Enhancement
Step 1
Screening of all physicians
Feedback to all physicians
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Step
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Development of indicators for
individual physicians
• Choice of indicator
– By Professional Inspection Committee and
Practice enhancement division, after
consultation with different organizations
• Responsibility of the development
– One staff physician
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Development of indicators for
individual physicians
• Elaboration with :
– Group of «experts» in the domain
– Group of interested physicians in a hospital
– Research group
• Pilot process evaluating feasibility
• Validation of the indicator
• Diffusion of the indicator with
appropriate guidelines
• Implementation of the indicator
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
The use of PSA levels as a means of
detecting prostate cancer
The use of PSA level as a means of
detecting prostate cancer …
When available data does not always
allow to document practices and
changes inducted by an intervention
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
The use of PSA levels as a means of
detecting prostate cancer
• Medical controversy about
extended use of PSA as a
means of detecting prostate
cancer
• Publication of an evidencebased guideline
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
The use of PSA levels as a means of
detecting prostate cancer
• Publication of an information
booklet for patients (in
French)
• Local CME activity (in a single
region)
• Analysis of physicians'
perceptions :
– 90% say they are aware of it
– 76% agree with it
– 58% say it has influenced their
at the 2006 CLEAR Annual Conference
practice Presented
September 14-16 Alexandria, Virginia
The use of PSA levels as a means of
detecting prostate cancer
Evolution of prescription profiles in Québec and in the region where a continuing
medical intervention was conducted
Evolution of the number of PSA tests
(all of Quebec excluding Montreal)
Average number of PSA tests
(excluding cases of prostate cancer)
250000
15
200000
10
150000
Dissemination
of guideline
100000
5
50000
0
0
93-94
94-95
95-96
96-97
Follow-up PSA
Screening PSA
97-98
98-99
Period 1
Period 2
Period 3
After dissemination
After intervention
Physicians who attended a workshop
All physicians
Physicians who did not attend a workshop
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
The use of PSA levels as a means of
detecting prostate cancer
• Data analysis …
– Significant decreasing of the use of
PSA levels as a means of detecting
prostate cancer
– Incomplete and impossible to
analyze data
•Especially in Montreal area
– Data to be collected locally by
archivists (in patient records)
•Hard and long job
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Step
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Professional Inspection Committee
Composition
• 2 physicians from the Practice
Enhancement Division :
•The Director
•One Assistant director
• 6 physicians in practice,
representative of both medical and
surgical specialties
• 10 meetings per year
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Professional inspection visits
Usual procedures
• Sending of a notice and a questionnaire to
be completed before the visit by the
physician or the establishment
• Inspection visit, with or without an expert
• Writing of a report and of a project of
recommendations
• Submission of the report to the Professional
Inspection Committee
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Professional inspection visits’ algorithm
Recommendations
Meeting with
PIC secretary
CME
Syndic
Administrative
Committee
PAM
With expert
No control
Control
Without expert
Structured
oral interview
New
recommendations
Voluntary
training
Imposed
training
No control
Control
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
No limitation of
practice
Limitation of
practice
Professional inspection visits’ algorithm
Good practice
Unsatisfactory practice
Sending of recommendations
Felicitations from the PIC
Without expert
No control visit
Control visit
With expert
Transfert to the PAMQ
Good practice
Unsatisfactory practice
Meeting with PIC secretary
Transfert to Syndic
New recommendations
No control visit
Control visit
SOI
Volontary training program
Without limitation of practice
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Imposed training
program
With limitation of practice
Individual inquiries
50
152 individual inquiries
49
45
40
35
30
25
24 25
20
18
15
12
10
10
10
7
5
0 0 0 0
0 0 0 0 0
7
0
0
Number of visited physicans
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Requests from Syndic Office
Received information
Diplomees >35 years
>25% of psychoth. (GP's)
>50% house calls (GP's)
>40% outside of specialty
Walk-in clinics (GP's)
Requests from Exec. Comm.
NSAID's prescription
Witness group
Aesthetic Medicine (GPs)
>30% diagn.-ther. Acts
Substitute doctors
Work in office only
Methadone
Failure at licence exam
Pursuit of evaluation
Restrictive permit
Other programs
Results of inquiries
100%
84,2%
80%
Adequacy of :
73,6%
69,7%
60%
72,8%
61,2%
54,4%
Office practices
Record Keeping
CME
Medical Examination
46,7%
40%
Accuracy of Diagnosis
Pertinencen of care
Treatment
20%
0%
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Decisions of PIC
15
Congratulations letter Good practice
Meeting with PIC
secretary
Referral to Syndic office
30
6
Recommendation of a
training program
Referral to Executive
Committee
Recommendations to
physicians' council
Referral for a SOI
7
Referral for CME
6
18
7
7
Request for a report
from hospital
Request for a report
from physician
Control visit
0
7
35
Recommendations to
physician
144
0
20
40
60
80
100
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
120
140
160
Practice enhancement activities
• Sending of recommendations from the
Professional Inspection Committee
• Follow-up of recommendations by
inspectors
• Organization of CME group activities
(workshops on patient-doctor
relationship, workshops on periodical
health examination,
courses)
Presented at the 2006 CLEAR Annual Conference
September 14-16
Alexandria, Virginia
Enhancement activities
1991-2003 (n=533)
80
79
78
66
64
60
52
51
46
40
39
31
20
12
11
4
0
'91-92
'92-93
'93-94
'94-95
'95-96
'96-97
'97-98
'98-99
'99-00
'00-01
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
'01-02
'02-03
Workshops on Physician-patient
relationship 1992-2000 (n=296)
Number of workshops
84
Better communication
67
Right distance
70
Difficult relationship
Breaking bad news
75
0
20
40
60
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
80
100
Workshops on Physician-patient
relationship 1992-2000 (n=296)
Attendance to workshops
1217
Better communication
823
Right distance
913
Difficult relationship
1036
Breaking bad news
0
300
600
900
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
1200
1500
Other courses and workshops 1992-2000
(n=125)
Number of sessions
4
Record-keeping
Pharmacotherapy
37
Periodical examination
0
84
20
40
60
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
80
100
Step
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Detailed needs assessment
• Structured oral interview
–
–
–
–
–
Specific tool developed for GP’s
Individual evaluation of the performance
25 clinical cases to resolve
5 cases with simulated patients
Goal of the evaluation : personalized
remedial CME prescription
• Evaluation training period
– Used for needs assessment of specialists
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Structured oral interview
• Since 1990 : clinical cases
– Assessment of knowledge
• In 1997 : addition of OSCE cases
– Assessment of skills and attitudes
• In 2000 : addition of Script
concordance tests
– Assessment of clinical reasoning
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Structured oral interview
Domains assessed
Content of the report
• Analysis of resolved cases
• «SOI» (20 cases)
• Analysis of referred cases
–Knowledge (data collection)
• Detail of strengths and
weaknesses
–Problems solving
• Analysis of performance :
–Interpretation of lab tests
–Emergency cases
• «OSCE» (5 cases)
–Pharmaceutical treatments
–Knowledge (data collection)
–Follow-up
–Physical examination (skills)
• Interpretations
–Interpretation of lab tests
–Responsibility level able to handle
–Physician patient relationship
–Knowing of its limits
• Script concordance test
–Inappropriate but not dangerous
–Knowledge (data collection)
conducts
–Clinical reasoning
–Harmful of dangerous conducts
–Interpretation of lab tests
–Informed of recent conducts
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Structured oral interviews
1995-2005 (n=101)
12
17
11
10
10
10
10
9
8
8
8
2003
2004
6
6
6
6
1999
2000
4
2
0
1995
1996
1997
1998
2001
2002
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
2005
Structured Oral Interviews 1995-2001
Personnal request
26%
Request from Syndic
31%
Recommendation from
Committee on
discipline
5%
Re-entering the roll
3%
Others
7%
Recommendation of
PIC (16)
28%
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Individualized CME programs
• Clinical training programs
• Focused readings
• Tutorial chart recalls
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Individualized CME
70
68
60
50
40
30
20
10
2
9
0
Clinical training programs
Focused reading
Tutorial chart recalls
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Personalized CME (1992-2000) Statistics for all
physicians (n=240)
Who are the candidates ?
63
Specialists
177
General practitioners
Female
41
199
Male
0
20
40
60
80
100
120
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
140
160
180
200
Personalized CME (1992-2000) Statistics for all
physicians (n=240)
Who referred candidates ?
Executive Committee
4
Committee on Discipline
18
Syndic office
62
PIC
97
Personal request
59
0
20
40
60
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
80
100
Personalized CME (1992-2000) Statistics for all
physicians (n=240)
Why do candidates need remedial CME ?
3
Striking off the Roll
19
Reorientation
Return to practice
41
Quality problems
177
0
20
40
60
80
100
120
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
140
160
180
200
Personalized CME (1992-2000) Statistics for all
physicians (n=240)
What problems are encountered ?
4,60%
35,80%
8,70%
Record-keeping
Diagnosis accuracy
2,40%
Treatment plan
Judgement
Skills
Communication
16,70%
31,80%
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Personalized CME (1992-2000)
Training programs (n=225)
66
General Practice
6
Anaesthesia
13
Emergency
17
General Surgery
21
Geriatrics
23
Medical Specialties
Obs.-Gynaecology
15
Petiatrics
3
Psychiatry
15
Public Health
1
Radiology
3
Surgical Specialties
12
0
10
20
30
40
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
50
60
70
Personalized CME (1992-2000)
Results of remedial CME
3,0%
15,0%
Successful activities
Abandon retraining
Non successful activities
82,0%
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Monitoring and enhancement for improving
performance in hospitals
Step 3
Control visit
Step 2
Monitoring
Screening of
establishments in
need or at risk
Monitoring
Step 1
Screening of all health
establishments
Meeting with
authorities
Enhancement
Feedback to the
establishment
Enhancement
Comparative feedback to all
health establishments
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Step
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Monitoring of Health establishments
Choosing of the indicators
• In collaboration with the concerned
professional Association :
– Selection of experts of the working group
– Proposition of indicators by the working
group
– Evaluation of the feasibility by a pilot
– Validation of indicators
– Extension of the project to a group of
hospitalPresented at the 2006 CLEAR Annual Conference
September 14-16
Alexandria, Virginia
Monitoring with indicators
Content of the
pathological report of
breast cancer
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Why choosing the pathology ?
• Request from the Professional
Inspection Committee
• Interest of the Quebec's Pathologists
Association for implementing a
monitoring program with quality
indicators
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
And why the breast cancer pathology ?
• Integral part of most of pathologists
• Media coverage of unhappy events in an
hospital
• Launching of Provincial program of
breast cancer screening
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Main steps of the program
• Fall 1998 :
– Nomination of the experts' group
• Winter 1998-1999 :
– Completion of a pilot project
– Final choice of quality indicators
• Summer 1999 :
– Data collection (First study)
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Main steps of the program
• Winter 1999-2000 :
– Analyze and evaluation of data by the
experts' group
• Spring 2000 :
– Feedback to hospitals
• Summer and Fall 2000 :
– Enhancement activities by the Quebec’s
Pathologists Association
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Main steps of the program
• Spring 2003 :
– Data collection (Second study)
• Fall and winter 2003-04 :
– New feedback to hospitals
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Experts' group
• Mandate : Identify quality
indicators
–
–
–
–
Easy to monitor
Non expensive
Valid
Allowing to get a global view of the
practice of pathologists
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Experts' group
• Composition :
– The 5 members of the Quality-insurance
Committee of Quebec's Pathologists
Association
– One member of College of Physicians'
Practice Enhancement Division
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Quality indicators (Spring 1999)
• Evaluation of the last 20 medical
records of breast cancer surgery in
each of participating hospital
• Essential information for physicians in
order to plan the treatment and
establish the prognosis
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Quality indicators (Spring 1999)
• Number of cases with research of
hormonal receptors
• Indication - in the report - of
dimension of the tumor
• Mention in the report of the distance
between lesion and at least one
resection margin
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Quality indicators (Spring 1999)
• Mention of histological type in final
diagnosis
• Mention of histological / nuclear grade
• Mention of the presence or absence of
lymphatic or vascular invasion
• Mention of histological evaluation of
resection margins
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
The first study (Summer 1999)
• Questionnaire sent to 53 hospitals
• Rate of answers : 100 %
• Number of records evaluated : 1040 (from
the 53 hospitals)
• Number of pathologists aimed at the
program : 247
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Results - Percentage of appearance of
each element
Hormonal receptors (94,0 %)
Size of tumor (95,5 %)
Lesion / margin distance (68,7 %)
Histological type (99,8 %)
Histological or nuclear grade (85,5 %)
Vascular / lymphatic invation (61,6 %)
Histological evaluation of margins (90,2 %)
0%
10%
20%
30%
40%
50%
60%
70%
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
80%
90%
100%
Feedback to hospitals
• Feedback made by the Professional
Committee in March 2000 at each of
the 51 hospitals aimed at the program
• Feedback made to each hospital :
– with tables and graphics
– about results of the study for all hospitals
aimed at the program
– about their individual performance
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Feedback to hospitals
Histological evaluation of margins
Number of consistent records
20
15
10
5
0
0
5
10
15
20
25
30
35
40
Serial number of hospital
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
45
50
55
Feedback to hospitals
Vascular / lymphatic invasion
20
Number of consistent records
15
10
5
0
0
5
10
15
20
25
30
35
40
Serial number of hospital
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
45
50
55
Feedback to hospitals
Distance between lesion and margin
20
Number of consistent records
15
10
5
0
0
5
10
15
20
25
30
35
40
Serial number of hospital
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
45
50
55
Enhancement activities
• By Quebec's Pathologists Association
– Production of a CD-ROM (prototype only)
about breast cancer pathology
– Presentation of the CD-ROM prototype at
Quebec's Pathologists Association's annual
meeting
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Enhancement activities
• By Quebec's Pathologists
Association
– Production and implementation of
guidelines about elements to include in
the pathological report of breast cancer in
order to help physicians and surgeons to
plan treatment and evaluate the
prognosis.
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
The second study
• Period of the study : Fall / winter
2002-03
• Questionnaire sent to the 51
hospitals aimed at the first study
• Rate of answers : 100 %
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
The second study
• Number of record evaluated : 999
– 1 hospital excluded (not enough records)
– 1 hospital sent 19 records
• Number of pathologists aimed at the
study : 246
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Results - Percentage of appearance of
each element
Hormonal receptors (97,1 %)
Size of tumor (96,2 %)
Lesion / margin distance (86,8 %)
Histological type (99,7 %)
Histological or nuclear grade (92,1 %)
Vascular / lymphatic invation (81,6 %)
Histological evaluation of margins (92,7 %)
0%
10%
20%
30%
40%
50%
60%
7 0%
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
80%
90%
100%
Compared results
Rate of consistency per criteria
100%
80%
60%
40%
20%
0%
First study
Margin
ev aluation
Vscular /
ly m phatic
Inv asion
Histological /
nuclear Grade
Histological Ty pe
Lesion / m argin
Distance
Size of tum or
Horm onal
receptors
90,2 %
61 ,6%
85,5%
99,8%
68,7 %
95,5%
94,0%
Second study
92 ,7 %
81 ,6%
92 ,1 %
99,7 %
86,8%
96,2 %
97 ,1 %
.
p= 0,09
p< 0,01
p< 0,01
p= 1 ,00
p< 0,01
p= 0,57
p< 0,01
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Compared results
Evaluation of lesion/margin distance
Number of consistent records
20
15
10
5
0
0
5
10
15
20
25
30
35
40
Serial number of hospital
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
45
50
55
Performance enhancement
Evaluation of lesion/margin distance
100%
80%
Performance enhancement rate
60%
40%
20%
0%
-20%
-40%
-60%
-80%
-100%
0
5
10
15
20
25
30
35
40
Serial number of hospital
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
45
50
55
Step
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Visits in Health Establishments
2002-2003 (n=24)
30
25
20
20
15
10
5
2
1
1
0
Hospitals
Nursing homes
CLSC
Others
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Activities of practice enhancement in
health establishments
• Sending of recommendations by the
Professional Inspection Committee and
coaching by one of the College staff
physician
• Organization of courses for answering
specific needs
• Workshops on evaluation of quality given
in health establishments
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Step
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Control visits with an expert
• In 1998-1999 :
– 10 control visits of hospitals
– 1 control visit of a nursing home
– 1 control visit in another establishment
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Meetings with authorities in
1998-1999
 On 3 occasions, meeting with
administrative authorities of an
establishment (1 hospital and 2 nursing
homes)
 On 8 occasions, meeting with the “Régie
régionale” (in regard with 2 hospitals
and 4 nursing homes)
 On 4 occasions, meeting with Health
Minister (in regard with 1 hospital and 3
at the 2006 CLEAR Annual Conference
nursing Presented
homes)
September 14-16 Alexandria, Virginia
The Future !
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Components of physician’s performance
Patient
Patient
Use
of ressources
TEAM
TEAM
Competency
Professionnalism
Hability to
Patient
Attitude
practice
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Patient
What are the conditions of success of that
system?

4 key words who support that system:
Commitment
Investment
Team work
Partnership
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
First key word: Commitment
 Commitment from my organization to
the mandate of the Practice
Enhancement Division:
 Assessment and Remediation at all levels
 More formative then punitive
 Research agenda
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Second key word: Investment
 Support from my organization to the
mandate of the Practice Enhancement
Division:
 Budget from 860,000 $ to 4.3 M $
 10 full time physicians dedicated to the
mandate
 1 research agent (4 days/week)
 22 full time persons
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Third key word: Team work
 Merging, in 1997, the CPD Division with
the Peer Assessment Division to the new
Practice Enhancement Division with a
new mandate of assess physicians with
a goal of remediate those in need.
 Developing the new levels (level 1) to
enhance a wider scope of physicians.
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Fourth key word: Partnership
 This system cannot work without
collaboration and partnership with:




The
The
The
The
four Universities in Quebec
two Unions (FMOQ-FMSQ)
two others Colleges (RCPSC-CFPC)
major medical associations
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia
Questions and
Exchanges
Presented at the 2006 CLEAR Annual Conference
September 14-16 Alexandria, Virginia