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 Radiation Oncology Pathology End of Life Medical Oncology Primary Care Palliative Care + Psychosocial Oncology Patient Education

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” But instead: “I’m a lung patient” “I’m a colorectal patient” “I’m on a journey” “What lies ahead?” 3

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

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 Maps patient journey Evaluates system performance Develops integrated improvement program

Step 1: Develop Pathway Maps Pathway development is evidence-based and informed by expert opinion Evidence-based Ontario National International Multidisciplinary involvement Disease site teams External review teams Patient/caregiver advisory group Iterative process Internal: DPM co-chairs, DPM teams, Clinical Council Wide provincial consultative review Pathway Drafted Expert Panel Review Clinical Council Review External Consultative Review Final Expert Panel Review Clinical Council Review Pathway Finalized Pathway Published to CCO Website Regular updates

Clinical Pathway Depicting Ideal State Set Provincial Priorities 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 MoHLTC 9

Provincial Investigation Project: 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 Provincially and Regionally

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 disease-specific areas of focus Use funds to improve measurably 12

Diagnostic Assessment Programs Setting Expectations: using the pathways as a means to support regional improvement Diagnostic Assessment Programs and DAP-EPS Guidance for 13

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)

Step 5: Measure Results In development, but will include: Regional quarterly reporting CSQI Others

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 Maps patient journey Evaluates system performance Develops integrated improvement program

www.cancercare.on.ca www.csqi.on.ca 17