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Cancer Imaging Program The Quality Agenda J. Dobranowski MD FRCPC MITT 2013.

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Presentation on theme: "Cancer Imaging Program The Quality Agenda J. Dobranowski MD FRCPC MITT 2013."— Presentation transcript:

1 Cancer Imaging Program The Quality Agenda J. Dobranowski MD FRCPC MITT 2013

2 2 Cancer Imaging Program Cancer Care Ontario No conflicts of interest to disclose ( i.e. no industry funding received or other commercial relationships)

3 3 Agenda About CCO About CIP Why Quality Improvement Priorities The CIP Quality Journey Access to Care

4 4 Who is Cancer Care Ontario? Directs and oversees more than $1 billion to hospitals and other cancer care providers to deliver high quality, timely cancer, kidney and other healthcare services Uses information technology/management, informatics, project management and clinical expertise to execute provincial strategies Cancer CCOs core mandate since 1943 as mandated by the provincial Cancer Act Chronic Kidney Disease Ontario Renal Network launched June 2009 Access to Care Building on Ontarios Wait Times Strategy

5 5 CCOs Evolution Cancer Act passed; Ontario Cancer Treatment Research Foundation (OCTRF) born 1940 THE EVOLUTION Ontario Renal Network Access to Care Today Specialized Cancer Services Cancer Care Ontario Ontario Cancer Registry transferred to OCTRF Ontario Breast Cancer Screening Program launched CCO launches under new name to promote better integration of cancer services Cancer Quality Council of Ontario created to measure system performance CCO implements Wait Times Information System public reporting of wait times Ontario Renal Network created Specialized cancer services (i.e., Bone Marrow Transplant) 1970 1990 1997 2002 2004/5 2009 2010

6 6 Our Core Competencies Performance Management and Management Cycle Standards and Guidelines Public Reporting and Transparency IM/IT Health System Policy Expertise Clinical Engagement and Alignment Regional Partnerships Cancer As mandated by the Cancer Act; Ontario Cancer Plan III Access to Care Building on Ontarios Wait Time Strategy Chronic Kidney Disease Ontario Renal Network launched June 2009 Driving performance and quality Mandated ServiceCore Competencies

7 7 Performance Management Data/Information Knowledge Transfer Our Performance Improvement Cycle Quality and its continuous improvement is a critical goal across the health care system.

8 8 Vision and Mission

9 9 Areas of Focus Patient-Centred Care Prevention of Chronic Disease Integrated Care Value for Money Knowledge Sharing & Support

10 10 Presented by: Michael Sherar, President & CEO April 8,2011 Ontario Cancer Plan2011-2015 Patient-centered, quality driven cancer care

11 11 1.Develop and implement a focused approach to cancer risk reduction 2.Implement integrated cancer screening 3.Continue to improve patient outcomes through accessible, safe, high quality care 4.Continue to assess and improve the patient experience 5.Develop and implement innovative models of care delivery 6.Expand our efforts in personalized medicine Six strategic priorities in Ontario Cancer Plan III

12 12 Why Imaging? Prevention Screening Diagnosis Treatment Recovery End-of-Life Care IMAGING 2009

13 13 Cancer Imaging Program Regional Leadership Provincial Priorities PET Scans Ontario PET Steering Committee Operations Reimbursement PET Access Evidence building PEBC review Registry/Access Clinical Trials Communication SETTING PRIORITIES

14 14 SafeEffective Accessible/ Timely Patient Centred/ ResponsiveEquitableIntegratedEfficient Prevention Screening Diagnosis Treatment Recovery End-of-Life Care Cancer Imaging Program-Opportunities

15 15 Cancer Imaging Program – Priorities Four priority areas: Appropriateness Timely Access to Imaging Standardized/Synoptic Reporting Development and Fostering of Imaging Communities of Practice

16 16 Appropriateness Ensure patients are being referred for tests that would benefit them. Optimize safety and system resources by avoiding tests that wont. How: Endorsement guidelines One-stop decision support for appropriate use of cancer imaging Collation of existing guidance, packaged into a useable form Topic-specific guideline development Often target areas of emerging technology (breast MRI, suggesting prostate MRI)

17 17 CIP Guideline Endorsement - Methods Review Lung Cancer Diagnosis DPM Guideline selection and Review Recommendations compiled Endorsed recommendations externally reviewed Disease Pathway Maps (DPMs) comprehensive pathways of disease-specific cancer journeys The CIP worked with the DPM team to create a radiology cut of the pathway Critical imaging nodes identified in pathway

18 18 CIP Guideline Endorsement - Methods Guideline selection and review Review Lung Cancer Diagnosis DPM Recommendations compiled Endorsed recommendations externally reviewed Guidelines were screened for relevance by lead author All relevant guidelines reviewed by other members of the working group. Selected relevant guidelines assessed for quality Using the AGREE II scores available through the SAGE database Lung cancer imaging guidelines identified by internet search using: The Program in Evidence Based Care preferred list of guideline developers Guideline directories of Canadian and international health organizations The National Guidelines Clearinghouse

19 19 CIP Guideline Endorsement - Methods Recommendations compiled Review Lung Cancer Diagnosis DPM Guideline selection and review Endorsed recommendations externally reviewed Recommendations relevant to the decision identified through DPM complied and reviewed by the working group as candidates for endorsement

20 20 CIP Guideline Endorsement - Methods Endorsed recommendations externally reviewed Review Lung Cancer Diagnosis DPM Guideline selection and review Recommendations compiled Endorsed recommendations were reviewed: Internally by CIP Clinical leads Externally by a group of health professionals including radiologists and other imaging professionals, medical oncologists, radiation oncologists, surgeons

21 21

22 22

23 23 Timely Access to Cancer Imaging To support and ensure timely, equitable access to quality imaging across the province. But first, we need data…. Wait times – Interventional Radiology Initial, then ongoing survey of wait times for priority (high-volume, high impact) procedures Report in preparation Wait times – Cancer Flag Leverage ATC CT/MRI wait time data collection – addition of cancer flag Improving clarity regarding use

24 24 IR Wait Time Collection - Methods Identify Procedures Data collection Analysis and Interpretation Priority procedures identified via consensus Selected based on volume and impact to patient care PICC (peripherally inserted central catheter) lines, portacaths and CT-guided lung biopsies (CTBx)) Data Collection Identify Procedures Analysis and Interpretation Participating hospitals emailed 1x per month and asked to submit first and second available appointments for each procedure

25 25 IR Wait Time Collection - Methods Analysis and Interpretation Data collection Identify Priorities Data collected between Apr 2012 to Jan 2013 analyzed to determine: Median wait times 90 th percentiles; and Variance for each procedure Target timelines identified through consensus to aid interpretation of results: 7 Days 14 Days 28 Days Data Limitations: High level data, non-patient level Does not capture all possible PICC line and poratcath insertions Assumes referral is complete and procedure occurs on given date

26 26 IR Wait Time Collection – PICC Line Results *LHIN Numbers removed and data placed in random sequence for anonymity Number/percentage of hospitals meeting timeline (number of participating hospitals = 36) 1st Available Appointment2nd Available Appointment Value n (%) Within 7 days29 (81%)24 (67%) Within 14 days35 (97 %) Within 28 days36 (100%)

27 27 IR Wait Time Collection – CTBx Results Number/percentage of hospitals meeting timeline (number of participating hospitals = 35) 1st Available Appointment2nd Available Appointment Value n (%) Within 7 days 13 (37%)7 (20%) Within 14 days 26 (74%)21 (60%) Within 28 days 35 (100%) *LHIN Numbers removed and data placed in random sequence for anonymity

28 28 Timely Access to MRI/CT - ATC Cancer Surgery Expansion to major Surgical Areas Cataract Surgery Hip & Knee Replacement MRI & CT Scans Cardiac Procedures Perioperative Efficiencies (SETP) Key Health Services Targeted Ontarios Wait Time Strategy was introduced by the Ministry of Health and Long-Term Care in November 2004. The Wait Time Strategy was developed to improve access to five key health services by reducing wait times, and then expanded to include wait time data for major surgeries as well as perioperative efficiencies.

29 29 MRI CT Approach

30 30 Ontario MRI CT Targets 2005 MRI 62 per 1000 CT 114 per 1000 P1- 4 targets

31 31 96 CT scanners hospitals 4 CT in IHFs ATC- CT 81 day P4 wait

32 32 CT 2005 How did we compare? (OECD)(CIHI) CT Scan Rate per 1,000 population200520062007 Ontario79.4 Canada 101.6 Australia 88.6 France 111.1 United States 194.8 Denmark 71.4

33 33 Provincial Wait Time Trend: CT CT wait time has been relatively stable since late 2010 at just above the 28 days priority 4 target.

34 34 CT scans ordered and completed by Fiscal Year 171 scanners (base 94)

35 35 CT scan rates per 1,000 population Data Source: 2008-2011 – Wait Time Information System, Cancer Care Ontario

36 36 CT Scan Rate per 1,000 population – comparison (OECD)(ATC) CT Scan Rate per 1,000 population 20072008200920102011 Ontario --- 78.381.579.778.5 Canada --- 119.0125.4--- Australia 88.693.493.9--- France 120.3130138.7--- United States 227.9--- Denmark 73.683.8 ---

37 37 CT what changed? Capacity- bulk buy incremental funding Demand- Completed Scan Volume YEARCTPopulation 20081,012,86812,919,572 20091,065,47013,050,754 20101,053,54013,193,809 20111,050,59713,349,125

38 38 CT- 2013 current wait time P4 February 2013 – P4 Wait time 90 percentile = 28 days Increased capacity Improved efficiencies Stable or decreasing demand

39 39 ATC- MRI 52 MRI scanners in hospitals 5 MRI in IHFs 257,042 total scans 120 day P4 wait

40 40 MRI 2005 How did we compare? (OEDC) (CIHI) MRI Scan Rate per 1,000 population200520062007 Ontario 27.4 Canada 30.7 Australia 20.2 France 38.2 United States 84.3 Denmark 27

41 41 Provincial Wait Time Trend: MRI Wait time for MRI scans peaked on October 2010 at 127

42 42 Comparison of MRI Orders Received & Scans Completed

43 43 MRI scan rates per 1,000 population

44 44 MRI Scan Rate per 1,000 population – comparison (OECD)(ATC) MRI Scan Rate per 1,000 population 20072008200920102011 Ontario --- 38.741.243.747.5 Canada ---40.643.0 --- Australia 20.221.423.3--- France 44.248.455.2--- United States 91.2 --- Denmark 3637.8---

45 45 Removing variability

46 46 Provincial Wait Time Trend: MRI and CT

47 47 Backlog demand capacity time

48 48

49 49

50 50 Looking at the MRI backlog

51 51 Backlog management- The Blitz

52 52 MRI Blitz: Impact on Overall Provincial Wait Times Participating hospitals were notified of their additional volume allocations in November 2010, December 2010, January 2011 Provincial wait times closely followed wait times for blitz hospitals Participating hospitals reached the lowest wait time of 93 days in June 2011, 3 months after receipt of funding

53 53 MRI – System improvement

54 54 Data Captured in Weekly Performance Dashboards by MRI-PIP Hospitals Outcome Indicators 1.MRI Wait Times Time between requisition received and exam completed By priority By body division By hospital site (for multi-site facilities) By contrast/non-contrast 1.MRI Report Turnaround TimesTime between exam completed and report verified 1.MRI Exams Requested Number of exams requested (i.e. demand) By priority By body division 1.MRI Volumes Performed Number of exams completed By priority By body division By hospital site (for multi-site facilities) By contrast/non-contrast 1.Planned Operating Hours Utilization [Sum of actual scanning time for pre-booked patients/Sum of operating hours dedicated to pre- booked patients] *100 1.Unplanned Operating Hours Utilization [Sum of actual scanning time for unscheduled patients (e.g. inpatients and emergency) /Sum of operating hours dedicated to unscheduled patients] *100 PIP Outcome Indicators

55 55 Process Indicators 1.Requisition Completeness [Number of complete requisitions / Number of requisitions received] * 100 2.Booking Turnaround Time Time between requisition received and appointment booked 3.Booking Volumes Number of appointments booked 4.Booked Time Utilization [Sum of hours planned time of booked exams/Sum of operating hours available to be booked] *100 3.Requisitions Received Relative to Time Allocated [Sum of hours of incoming requests/Sum of hours in scheduling template] *100 By priority By body division By contrast/non-contrast 3.Actual Hours Performed Relative to Time Allocated [Sum of actual scanning time/Sum of hours in scheduling template] *100 By priority By body division By contrast/non-contrast 3.Protocolling Turnaround Time Time between requisition sent for and received from protocolling 3.No Show Rate [Number of no shows / Number of appointments booked] * 100 3.No Shows Filled [Number of no shows filled / Number of no shows] * 100 3.On-Time Scan Starts [Number of early and on-time exams / Number of exams completed] * 100 3.Patient Prep Time Time between registration and scan start 3.Room Turnaround Time Time between patient 1 exiting scan room to patient 2 entering 3.Planned Scan Time Accuracy Planned scan time – Actual scan time By procedure

56 56 MRI PIP Wait Times Improve in London Patients Getting Needed MRIs Sooner The London Free Press. Aug 2010 The improvements mean 780 more patients can be scanned each year with MRI at St. Josephs, said Glen Kearns, integrated vice president, clinical support services and information technology services at St. Joes and London Health Sciences Centre (LHSC). As part of a project with Ontarios Health Ministry, St. Joes dissected every MRI process, assessed what worked and what could be tweaked, then put the process back together more effectively for patients and staff. The results: An average 50 days wait for semi-urgent patients (down from 104 days a year ago) and 60 days (down from 149) for non-urgent patients; 212 MRI exams each week, or 15 more a week than a year ago. LHSC is in the middle of a similar process, one made more complex by the wider range and type of MRI services offered for inpatients and outpatients. So far, the waits there have dropped to an average 86 days, from 150 as recently as six months ago. That pace of improvement means 1,000 more patients can be scanned each year, he said. MRI PIP

57 57 MRI PIP Wait Times Improve in Ottawa Improving Equitable Access to Imaging J American College of Radiology. Aug 2010 The Ottawa Hospital Rapid Improvement Event team was assembled and completed a 4-day review of the booking process and scheduling in MRI. They then delineated additional steps that could be initiated to potentially reduce wait times. This was undertaken using Lean methodology brought forth by the Ontario government to evaluate process improvement and patient throughput at all stages of navigation through the system. Some of the main goals and strategies of the Lean project include the following: Improving efficiency of each scan Improving patient flow and throughput Improving booking process Evaluating the patterns of unfilled spots and adjusting the schedule commensurately Reducing physicians redundant ordering of diagnostic imaging tests through education on appropriate indications MRI PIP

58 58 MRI- 2013 current wait time P4 February 2013 – P4 Wait time 90 percentile = 60 days Increased capacity Improved efficiencies

59 59 Future considerations If no significant wait time… Then are we doing enough or are others doing too much? ?Over or Underutilization

60 60 Standardized/Synoptic Reporting Collect uniform and complete data to improve the information available to referring clinicians for diagnosis and treatment planning How: Champion rectal cancer MRI template Developed by SOP to ensure surgeons get information needed, distributed in part by Leads and working towards implementation Multi-disciplinary Expert Panel To determine minimum standards needed in synoptic reports, identify disease sites of focus, recommend development and maintenance framework Roadmap To guide provincial deployment

61 61 May 20, 1896 Dear Dr Stieglitz: The X ray shows plainly that there is no stone of an appreciable size in the kidney. The hip bones are shown & the lower ribs and lumbar vertebrae, but no calculus. The region of the kidneys is uniformly penetrated by the X ray & there is no sign of an interception by any foreign body. I only got the negative today and could not therefore report earlier. I will have a print made tomorrow. The picture is not so strong as I would like, but it is strong enough to differentiate the parts. Yours very sincerely W.J. Morton Synoptic reporting

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64 64 PET/CT 1999 OANM - Request for Provincial funding for PET 2000 ICES- Review of Evidence 2001 ICES- Report- Health Technology Assessment of PET despite the availability of PET scanning for almost three decades, the number of methodologically high quality studies (and the numbers of patients within these studies) is distressingly small. Institute for Clinical Evaluative Sciences. 2001 (May) Health Technology Assessment of Positron Emission Tomography (PET) – A Systematic Review. An ICES Investigative Report.

65 65 Program Objective: Introduce and use PET according to high-quality evidence, insuring availability of PET for appropriate indications on a timely basis 2004 Ministry of Health in Ontario (MOH) takes evidence-based approach to the introduction of PET imaging 2009 MOH insured nine indications, and transitioned oversight of a continuing evaluative program for new indications to Cancer Care Ontario (CCO)

66 66 PET (Positron Emission Tomography) Ensure PET/CT scans are available to Ontario patients for appropriate indications on a timely basis. What is appropriate? Use of PET scanning where there is evidence that the scan has the potential to impact patient management How? Access Evidence Advice Communication

67 67 Evaluative Program Elements: PET Steering Committee Expert advisors to MOH PET Registry Field evaluation of promising indications Clinical Trials Testing diagnostic accuracy and impact to patient management PET Access Program Case-by-case review for patients not meeting other eligibility criteria Evidence Review Continuous review, ensuring recommendations are current Communication Ongoing promotion of equitable access across Ontario

68 68 PET Scans Ontario www.petscansontario.ca

69 69 Measuring

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71 71 Questions/Discussion


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