Transcript Document

Disease Pathway Management:
Cancer Care Ontario’s Approach
Canadian Foundation for Healthcare Improvement’s
CEO Forum
Dr. Carol Sawka MD, FRCPC
VP, Clinical Programs and Quality Initiatives
Cancer Care Ontario
Professor of Medicine, University of Toronto
February 6, 2013
The Cancer Journey: connected but still siloed
Surgery
Survivorship
Diagnostic
Imaging
Prevention &
Screening
Pathology
Radiation
Oncology
End of Life
Medical
Oncology
Primary Care
Palliative Care + Psychosocial Oncology
Patient Education
2
The patient’s view: comprehensive
Not:
“I’m a suspected case”
“I’m a confirmed diagnosis”
“I’m a referral to the cancer
centre”
“I’m a radiation patient”
“I’m a chemo patient”
3
But instead:
“I’m a lung patient”
“I’m a colorectal patient”
“I’m on a journey”
“What lies ahead?”
Disease Pathway Management is an innovative
approach to quality improvement at CCO
 Inherently patient centered
 Recognizes that the patient journey differs
for each type of cancer
 Identifies improvement opportunities at
regional and system levels
4
DPM applies a phased approach to identifying areas
for improvement and acting on them
Step 1: Understand the Journey
Map the disease-site specific journey
Step 2: Evaluate System Performance
Use data and front-line experience
Identify areas for improvement
Step 3: Identify and Share Priorities for Action
Prioritize areas for improvement
Share them with community
Step 4: Support Action Against Priorities
Offer expert opinion, people, financial support
Provincial and Regional
Step 5: Measure Results
Regional: quarterly reporting, CSQI
5
RADIATION
SYSTEMIC
Apr-Jun 10/11
Region
Apr-Jun 10/11
WT
Ref-Con
(% w/in
14 days)
WT
RTT-Tr
(% w/in
target)
Vol
(C1R)
PROVINCE
▲
▲
▼
100%
▲
▼
▲
100%
▲
Waterloo
Wellington
▼
▲
▼
4%
▲
▼
▼
6%
▲
North Simcoe
Muskoka
▼
▼
▲
1%
▼
▼
▲
6%
▲
Central
▲
n/a
▲
0.2%
▲
▲
▲
2%
South East
▲
▲
▼
4%
▲
▼
▼
Toronto Central
South
▼
▲
▼
23%
▲
▲
▼
North West
▲
▼
▼
2%
▼
▼
▼
Central East
▲
▲
▼
5%
▲
▲
South West
▲
▲
▼
9%
▲
▲
▲
▲
4%
▲
▲
▲
▼
16%
▲
Champlain
▲
▼
▲
10%
Erie St. Clair
▲
▼
▲
North East
▲
▼
Hamilton NHB
▲
▼
Central West &
Miss. Halton
Toronto Central
North
% of
WT
WT
Budgeted Ref-Con
Con-Tr
Vol in the (% w/in (% w/in
Province 14 days) 14 days)
SURGERY
COLONOSCOPY
Apr-Jun 10/11
Apr-Jun 10/11
STAGE
Rate = Apr-Jul 2009
% Hosp = Mar 10, 10
PATHOLOGY
% hosp = May 27, 10
% Complete = OctMar 09/10
RSTP Safe
Handling
as of
April 2010
*
▲
▬
▼
▲
▼
▬
1
0
▬
▼
▲
n/a
2
0
▲
▲
▼
▬
n/a
3
1
▼
▼
▬
▼
▬
4
n/a
▲
▬
▼
▬
5
0
▼
▼
▬
▲
▼
6
-3
▼
▲
▼
▲
▬
▲
7
-1
▬
n/a
▲
▲
▲
▲
▼
8
6
▲
▲
n/a
▼
▲
▲
▲
▲
▼
9
▬
▲
▼
▼
▲
▬
▼
10
0
▲
n/a
▲
▼
▬
▲
▬
11
-3
▼
▲
▼
▼
▼
▬
▼
▬
12
-1
4%
▼
▼
▼
▲
▲
▲
▲
▬
12
0
16%
▬
▲
▲
▲
▲
▼
▲
14
-5
WT
(FOBT+)
WT
(Family
History)
Vol
▲
100%
▲
▲
▲
100%
▼
▲
▲
4%
▲
▲
▲
8%
▲
▬
▲
1%
▲
▼
▲
2%
▼
▬
▼
▼
11%
▲
▲
▲
6%
▼
▲
5%
▲
▼
4%
▲
▲
▲
7%
▼
▲
16%
▼
▲
20%
▼
▲
▲
3%
▼
4%
▲
▼
2%
▲
▲
▼
4%
▼
7%
▲
▼
3%
▼
▲
▲
▼
▼
10%
▲
▲
11%
▼
▲
▲
▲
5%
▲
▲
12%
n/a
▲
n/a
▲
▼
▲
11%
▲
▼
8%
▲
▲
▲
▼
▲
11%
▲
▲
10%
▲
▲
3%
▲
▼
▲
4%
▲
▼
3%
▲
▼
5%
▼
▲
▲
4%
▼
▼
3%
▲
12%
▼
▼
▲
8%
▲
▲
9%
Vol
(cases)
SYMPTOM MGMT
Apr-Jun 10/11
MCC
Q1 10/11
% Hosp. % Hospitals
% of
%
Combine Collabora Discrete
Budgeted
Completetive
d Rate
Path
Vol in the
ness
Staging
*
Report
Province
*
*
*
% of
Budgeted
Vol in the
Province
Vol
(C1S)
% of
WT
Budgeted
(% w/in
Vol in the
target)
Province
Lung
All
Other
▼
▲
▲
▼
▲
▲
n/a
▼
▼
▼
▲
▲
▼
▲
▬
▼
15%
▲
▲
▼
6%
▲
n/a
▼
6%
▼
▼
2%
▼
▲
13%
▼
▲
▲
8%
▲
▼
▼
▲
▲
▲
THORACIC
Apr-Dec
09
*
HPB
Apr-Dec
09
*
IMRT
Q4
09/10
*
Change
Overall
from
Provincial
Previous
Rank
Rank
3
3
Step 1: Develop Pathway Maps
Pathway development is evidence-based and informed by expert opinion
• Evidence-based
• Ontario
• National
• International
• Multidisciplinary
involvement
• Iterative process
• Internal: DPM co-chairs,
• Disease site teams
• External review teams
• Patient/caregiver
advisory group
Pathway
Drafted
6
Expert
Panel
Review
Clinical
Council
Review
External
Consultative
Review
Final
Expert
Panel
Review
Clinical
Council
Review
DPM teams, Clinical
Council
• Wide provincial
consultative review
Pathway
Finalized
Pathway
Published
to CCO
Website
Regular
updates
7
8
Clinical pathways serve as an analytical
framework for quality improvement
Clinical Pathway Depicting Ideal State
Gap Analysis:
- Quality of Care
- Processes
- Patient Experience
Setting Expectations
for Regional
Performance
Modeling
Set Provincial Priorities
Regions: act and organize care
9
MoHLTC
Step 2: Gap Analysis
Use the pathways to identify priorities for action
Provincial Investigation Project:
ID underlying causes and address them
Lead by: Lung DPM team
10
Step 3: Identify and Share Priorities for Action
11
Setting Expectations: using the pathways as a
means to support regional improvement
Regions provided with:
• Priorities for Action
• Cross-journey data
and targets
• Funding
Expectations:
• Determine diseasespecific areas of focus
• Use funds to improve
measurably
12
Setting Expectations: using the pathways as a
means to support regional improvement
Guidance
for
13
Diagnostic
Assessment
Programs
and DAP-EPS
Step 4: Support Action
Multiple options:
Centrally-driven pilot projects (e.g. Dyspnea Management)
Support for provincial clinical guidelines
Provincial support to a specialty (people, expertise, funding)
Regional support for local priorities (e.g. 10/11 funding to RCPs)
14
Step 5: Measure Results
In development, but will include:
Regional quarterly reporting
CSQI
Others
Region
SYSTEMIC
SURGERY
COLONOSCOPY
Apr-Jun 10/11
Apr-Jun 10/11
Apr-Jun 10/11
WT
WT
Ref-Con RTT-Tr
(% w/in (% w/in
14 days) target)
Vol
(C1R)
% of
WT
WT
Budgeted Ref-Con Con-Tr
Vol in the (% w/in (% w/in
Province 14 days) 14 days)
Vol
(C1S)
% of
WT
Budgeted
(% w/in
Vol in the
target)
Province
Vol
(cases)
% of
Budgeted
Vol in the
Province
WT
(FOBT+)
WT
(Family
History)
Vol
STAGE
PATHOLOGY
% hosp = May 27, 10 SYMPTOM MGMT
RSTP Safe
Apr-Jun 10/11
% Complete = OctTHORACIC
HPB
Handling IMRT
Change
Mar 09/10
MCC
Overall
Apr-Dec Apr-Dec
as of
Q4
from
% Hosp. % Hospitals
Q1 10/11
Provincial
09
09
April
2010 09/10
Previous
% of
%
Rank
Combine Collabora Discrete
*
*
*
*
Rank
Budgeted
CompleteAll
tive
d Rate
Path
Lung
Vol in the
ness
Other
Staging
*
Report
Province
*
*
*
Rate = Apr-Jul 2009
% Hosp = Mar 10, 10
PROVINCE
▲
▲
▼
100%
▲
▼
▲
100%
▲
▲
100%
▲
▲
▲
100%
▼
▲
▼
▲
▲
▲
▬
▼
Waterloo
Wellington
▼
▲
▼
4%
▲
▼
▼
6%
▲
▲
4%
▲
▲
▲
8%
▲
▬
▼
▲
▲
▲
▼
▬
1
0
North Simcoe
Muskoka
▼
▼
▲
1%
▼
▼
▲
6%
▲
▲
1%
▲
▼
▲
2%
▼
▬
n/a
▼
▼
▬
▼
▲
n/a
2
0
Central
▲
n/a
▲
0.2%
▲
▲
▲
2%
▼
▼
11%
▲
▲
▲
6%
▼
▲
▼
▲
▲
▲
▼
▬
n/a
3
1
South East
▲
▲
▼
4%
▲
▼
▼
5%
▲
▼
4%
▲
▲
▲
7%
▼
▲
▼
▼
▬
▼
▬
4
3
Toronto Central
South
▼
▲
▼
23%
▲
▲
▼
16%
▼
▲
20%
▼
▲
▲
3%
▼
▲
▼
n/a
▲
▬
▼
▬
5
0
North West
▲
▼
▼
2%
▼
▼
▼
4%
▲
▼
2%
▲
▲
▼
4%
▲
▬
▼
▼
▼
▬
▲
▼
6
-3
Central East
▲
▲
▼
5%
▲
▲
▼
7%
▲
▼
3%
▼
▲
▲
15%
▲
▲
▼
▲
▼
▲
▬
▲
7
-1
South West
▲
▲
▼
9%
▲
▼
▼
10%
▲
▲
11%
▼
▲
▼
6%
▲
▬
n/a
▲
▲
▲
▲
▼
8
6
▲
▲
▲
4%
▲
▲
▲
5%
▲
▲
12%
n/a
▲
n/a
▲
n/a
▼
6%
▼
▲
▲
n/a
▼
▲
▲
▲
▲
▼
9
3
▲
▲
▼
16%
▲
▼
▲
11%
▲
▼
8%
▲
▲
▼
2%
▼
▬
▲
▼
▼
▲
▬
▼
10
0
Champlain
▲
▼
▲
10%
▲
▼
▲
11%
▲
▲
10%
▲
▲
▲
13%
▼
▲
n/a
▲
▼
▬
▲
▬
11
-3
Erie St. Clair
▲
▼
▲
3%
▲
▼
▲
4%
▲
▼
3%
▲
▲
▲
8%
▼
▲
▼
▼
▼
▬
▼
▬
12
-1
North East
▲
▼
▼
5%
▼
▲
▲
4%
▼
▼
3%
▲
▼
▼
4%
▼
▼
▼
▲
▲
▲
▲
▬
12
0
Hamilton NHB
▲
▼
▲
12%
▼
▼
▲
8%
▲
▲
9%
▲
▲
▲
16%
▬
▲
▲
▲
▲
▼
▲
14
-5
Central West &
Miss. Halton
Toronto Central
North
15
RADIATION
Apr-Jun 10/11
In summary:
 Good experience so far
 Work in progress
 Great potential
 Ongoing evaluation of effort/impact of
various approaches to development and
maintenance of disease pathways
16
www.cancercare.on.ca
www.csqi.on.ca
17