Supporting Best Practice for COPD Care Across the System

Transcription

1 Supporting Best Practice for COPD Care Across the System May 3, 2017 Health Quality Ontario The provincial advisor on the quality of health care in Ontario

2 Overview Health Quality Ontario background QBP overview Quality Standards overview Program background Development process Measurement Adoption COPD Quality Standard Timeline Scope 1

3 Develop Evidence Based Guidance Support Quality Improvement and Adoption Monitor and Report on the Quality of the System Strategic Partnerships and Patient Engagement 2

4 The quality standards program is part of our legislated mandate (c) to promote health care that is supported by the best available scientific evidence by, (i) (i) making recommendations to health care organizations and other entities on clinical care standards making recommendations to the Minister concerning, A. the Government of Ontario s provision of funding for health care services and medical devices, and A. clinical care standards and performance measures relating to topics or areas that the Minister may specify 3

5 Variation in hysterectomy rates is just one example that shows why we need standards Little variation in treatment of fibroids and prolapse 10-fold variation in hysterectomy rate for heavy menstrual bleeding across LHINs Little variation in hysterectomies performed for cancer 4

6 Time and Regional Crude Rates for Patients Hospitalized with COPD, FY : Rate per 100,000 -North East LHIN had the highest rates overall across all three years, but ended the reporting period at their lowest. -North East and South East LHINs had the two highest rates for COPD in FY 1,400 1,200 1, Data Source: Discharge Abstract Database, provided by the Ministry of Health and Longterm Care (using the QBP 5 Methodology)

7 COPD Emergency Visits Admitted into Inpatient bed by LHIN Region, Fiscal Year Toronto Central LHIN had the highest proportion of emergency department visits admitted into acute inpatient care Percent All COPD Emergency Visits Admitted to Inpatient Bed % 37% 36% 33% 33% 33% 32% 30% 28% 27% 24% 24% 23% 22% Toronto Central Central West Mississauga Halton Central Hamilton Niagara Haldimand Brant Central East Waterloo Wellington Champlain South East North Simcoe Muskoka South West Erie St. Clair North West North East Data Source: Quality Based Procedures Cohort using Discharge Abstract Database and National Ambulatory Care Reporting System 6

8 Patients who Received Follow-up Care 7 days Post Hospital Discharge by LHIN Regions 60% % 40% 30% 20% 10% 0% Data Source: Quality Based Procedures Cohort using Discharge Abstract Database and Registered Person Database, provided by the 7Ministry of Health and Long-term Care

9 Health Equity Lens Health equity allows people to reach their full health potential and receive high-quality care that is fair and appropriate to them and their needs, no matter where they live, what they have or who they are. What can the quality standard do to mitigate variations in access, experience and outcomes that may be related to patient or community characteristics such as race/ethnicity, income, and geographic location? 8

10 Quality Standards and QBPs: A short history 19 Quality-Based Procedures Clinical Handbooks developed Handbooks are 80+ pages with 50+ recommendations of varying importance and evidentiary support Quality Standards is a new program that addresses Where should I start? What are the top 5 + things I should focus on? Quality Standard recommendations ( quality statements ) focus on areas where there are gaps between current Ontario practice and best practice according to evidence 9

11 Example of how a QBP Pathway and a QS could intersect Sample Quality Statement: Access to pulmonary rehabilitation Sample Quality Statement: Comprehensive assessment Sample Quality statement: Follow up after discharge 10 HQO QBP COPD, 2015

12 HQO s COPD QBP journey Integration & update (completed Fall 2014) Post-acute episode (completed Summer 2014) Acute episode (completed Winter 2012) 11

13 The episode of care model for COPD in acute care Legend Care module Mild Level of care Usual medical care (in ED / outpatient) N = 19,337 P = Recovers Assess recovery Treatment fails Discharge planning & full clinical assessment Go to usual medical care (inpatient) Home Assessment node Episode endpoint Moderate Level of care Recovers Discharge planning & full clinical assessment Home Patient presents with suspected exacerbation of COPD N = 43,215 P = 1.0 Assess level of care required Usual medical care (inpatient) N = 22,054 P = Assess recovery Treatment fails Go to ventilation (NPPV or IMV) Severe Level of care NPPV Recovers Assess recovery Usual medical care (inpatient) Discharge planning & full clinical assessment Home N = 1,824 P =.042 Decision on ventilation modality or palliative care N = 773 P =.018 IMV N = 1051 P =.024 Recovers Wean from IMV Assess recovery Treatment fails 12 Treatment fails Go to IMV End of life care Usual medical care (inpatient) Death Discharge planning & full clinical assessment Home

14 Following the patient after discharge from acute care: The post-acute episode model 13

15 Bringing it all together: A combined acute / post-acute model for COPD 14

16 Recommendations in QBP Clinical Handbook 15

17 COPD QBP Indicator Recommendations Admission rate? % received recommended in-hospital pharmacotherapy Legend Care module Mild Level of care Usual medical care (in ED / outpatient) N = 19,337 Pr = Recovers Assess recovery Treatment fails Discharge planning & full clinical assessment Go to usual medical care (inpatient) Home? % had diagnosis confirmed with spirometry Use of NPPV LEGEND Patient presents with suspected exacerbation of COPD N = 43,215 Pr = 1.0 Indicators that are in current use Assessment node Episode endpoint Indicators that are potentially feasible with currently available data? Indicators that are not feasible with currently available data Assess level of care required Moderate Level of care Severe Level of care N = 1,824 P =.042 Decision on ventilation modality or palliative care Usual medical care (inpatient) N = 22,054 Pr = NPPV Recovers Assess recovery Treatment fails Recovers Assess recovery Usual medical care (inpatient) Discharge planning & full clinical assessment Go to ventilation (NPPV or IMV) N = 773 Go to IMV Treatment fails P =.018 Recovers Wean Usual medical from IMV care (inpatient) IMV Assess recovery N = 1051 End of life care Treatment fails Pr =.024 Death Discharge planning & full clinical assessment Length of stay In-hospital mortality Home Discharge planning & full clinical assessment Home Home 30-day readmissions In-hospital mortality Post-discharge physician follow-up? % referred to pulmonary rehab 16

18 What about the QBP Clinical Handbooks? Changing the approach to Clinical Handbook development Quality then funding HQO s mandate is to make recommendations based on evidence, support quality improvement, and report on the quality of care MOHLTC determines funding Advisory committee s objective is to define quality care (quality statements and indicators) for the patient population (which is defined using clinical criteria) 17

19 Example: Order Sets, EMR Core content for inclusion in order sets Embed evidence in systems that support care 18

20 Adoption Supports for QBPs 19

21 We have released 3 quality standards Care in hospitals and long-term care homes Care in all settings Care in hospitals 20

22 Quality Standards Status Finalized (board approved) Major depression Behavioural Symptoms of Dementia Schizophrenia In Development (late phase) Diabetic Foot Ulcers (post-consultation) *Summer 2017 Venous Leg Ulcers (post-consultation) *Summer 2017 Pressure Injuries (post-consultation) *Summer 2017 Hip Fracture Vaginal birth after C- section (post-consultation) *Summer 2017 Heavy Menstrual Bleeding In Development (early phase) Dementia Care (community) *Fall 2017 Opioid Use Disorder *Winter 2018 Prescribing opioids for pain *Winter 2018 Schizophrenia Care (community) *Winter 2018 Palliative Care *Spring 2018 Osteoarthritis COPD Pre-Development (topic approved) Transitions in Care Lower Back Pain Heart Failure 21

23 Quality Standards: Development Process 1. Scoping and planning (~4 months) Determine scope, initiate and plan project, engage partners, stakeholders and establish QSAC Open Call for advisory committee (QSAC) members and co-chairs Identification of key stakeholders and potential partners Scoping options and background analysis Data analysis Pre-Standard: Topic selection and Prioritization Feasibility analysis, stakeholder engagement; apply prioritization criteria 2. Development (~6-7 months) Develop quality statements and indicators with AC; plan for adoption 3-4 QSAC meetings Draft quality standard documents (clinical guide and the patient reference guide) Develop Information and Data Brief Recommendations for adoption 3. Finalization/launch (~6-7 months) Finalize Quality Standard and HQO Board approval. Adoption supports available for use by the field. Internal Approvals Post draft for public feedback; Finalize Quality Standard Adoption begins 22

24 Quality Standards Process Development Adoption Topic selection and prioritization Content development and production Development of Quality Standard Recommendations for Adoption Take actions to support adoption and quality improvement Monitoring and evaluation Topic identification via scans, partners, MOHLTC Prioritization using criteria and a matrix QSAC recruitment and formation QSAC meetings Public consultation Standards finalized, approved by HQO Board, and published on HQO website Broad engagement and input Initiated when draft standard is available Plan is approved and published Range of adoption tools and supports developed/disseminated Engage areas of system to use the standard, and quality improvement approaches to change practice where needed Evaluation of uptake Assess need to update standards * Patient and public engagement incorporated throughout 23

25 Each quality standard comprises the following products 24

26 Quality Standards Clinical Guide 25

27 Quality Standards Clinical Guide The Quality Statement The Quality Indicators The Audience Statements The Definitions 26

28 Quality Standards Patient Reference Guide 27

29 Quality Standards Adoption Recommendations and Resources to Support

30 Quality Standards Information and Data Brief

31 Measuring Adoption of Quality Standards If you can t measure it, you can t manage it - Peter Drucker One of the tools that is needed to facilitate adoption of the standard and each statement through quality improvement methods is measurement In creating and supporting this standard, we would like to provide users with a set of measures that can be used to track improvements in the quality of care of patients with COPD These set of measures, called indicators, can be used to assess the successful adoption of each statement and the standard overall There are 3 types of indicators: structural, process and outcome 30

32 Relationship between quality statements, statement-specific indicators and outcomes for the standard Quality statements Quality indicators Statement-specific quality indicators help measure progress and success adopting specific statements Outcomes for the standard Outcome indicators help measure success overall (3-5 in total) Quality Statement Process / Structural / Outcome Indicators Outcome 1 Quality Statement Quality Statement Process / Structural / Outcome Indicators Process / Structural / Outcome Indicators Outcome 2 Outcome 3 Outcome 4 Quality Statement Process / Structural / Outcome Indicators Outcome 5 Note: Diagram for illustrative purposes only 31

33 How We Will Measure Our Success A limited number of overarching outcomes are set for each quality standard; these guide measurement of the successful adoption of each quality standard as a whole Criteria for these overarching outcomes: Can be influenced by adopting the standard Important to patients and the system At least some of the outcomes should be currently measureable 32

34 What will Successful Adoption Look Like? Patient and Caregivers - Know that the quality standard exists - Know where to access it - Use the quality standard - Know what to anticipate - Feel empowered by it Providers - Know that the quality standard exists - Share and use the quality standard with their patients - Embed quality standards into their practice Health System - Actively shares and promotes quality standards - Incorporates the quality standard into professional education - Requests new quality standard topics - Uses quality standards: - For monitoring & reporting - To guide QI initiatives - For funding decisions 33

35 Quality Standards Adoption Two major activities for each standard: 1 2 Develop Quality Standard Adoption Recommendations Resources to support adoption & improvement Recommendations will be unique though consider common elements required for successful adoption. Reflects a system-level approach for what is needed to support the adoption of the quality standard Informed by the Quality Standards Advisory Committee, key stakeholders/potential partners (including MOHLTC), targeted structured interviews with front line providers, relevant evidence Source for recommendations of the Ontario Quality Standards Committee Resources to support adoption initiated in parallel and/or expected within the timeline indicated in the recommendations 34

36 Adoption Approaches Develop the Adoption Recommendations Readiness assessment including regional context Policy or regulatory implications Use of levers (contracts, QIP) Identified needs for clinical tools Proposed Quality Improvement strategies Partners (specific to each of above) Resources / costs 1 2 Expectations on timing (what can start immediately or is longer term) Monitoring and evaluation plan Resources to support adoption and Improvement Getting started guide Other examples of tools and QI: Clinical pathways Decision aids Order sets, methods to embed in systems of care Audit & feedback Education / training *appropriate partners and existing programs where they exist 35

37 COPD Quality Standard Timeline Spring 2018: Spring to Fall 2017: Development and adoption meetings Fall 2017: Public consultation and stakeholder engagement Winter : Finalizing quality standard products Winter 2018: Approval by HQO Board and Ontario Quality Standards Committee Quality Standard launch and adoption 36

38 COPD Quality Standard Scope Inclusion: Adults who have or are suspected of having COPD, including people with complex health needs or comorbidities All settings, with focus on primary care and community care Diagnosis and management of COPD (stable and acute exacerbations) Exclusion: Management of specific COPD comorbidities Lung surgery End-of-life and palliative care 37

39 Respiratory Therapists Lived Experience Advisors Physicians: primary care & respirology Nurse practitioners 24 Members COPD Quality Standard Advisory Committee Physical & Occupational Therapists Psychologist Pharmacist Administrators 38

40 Prioritizing outcomes and areas for improvement for people living with COPD Early identification of COPD Improved Quality of Life & ADL Improved access to PR Reduced rates of AECOPD Diagnosis and comprehensive assessment Education and selfmanagement Pulmonary rehabilitation Pharmacologic management of stable COPD & AECOPD Transitions in care Multidisciplinary care / Primary care / Referral to specialized care Reduced hospitalizations Reduced ED visits Increased smoking cessation Improved follow-up 39

41 Your Role in this Process Opportunities for engagement: Town Hall June 12 th Public consultation - October Share your: Tools, templates and innovative practices Learnings and progress Existing programs and initiatives that can support adoption 40

42 Questions? Contact: Sarah Burke Dimitrova, Lead COPD Quality Standard