Histopathology National QI Programme Annual Workshop 10 May 2016
Histopathology National QI Programme Introduction & Update Dr Niall Swan, Chair Histopathology QI Programme Working Group 10 May 2016
Vision of National QI Programme A patient centred Quality Improvement framework within each department, which facilitates their routine review of performance and drives improvement, in key quality areas against intelligent targets.
Development Stage of Programme Radiology programme 39 Sites collecting Quality Data GI Endoscopy 34 sites collecting & recording data on NQAIS Histopathology programme 32 sites - public & private conducting, collecting & reporting on NQAIS Control Measure Initiation Engagement Stakeholders Design: Guidelines Data Collection LIS Data Recording NQAIS Roll-out Conducting Recording Reporting on NQAIS Data analysis Target Setting Methodology Targets set Framework set up : Guidelines Quality Data Collection Quality Data Reporting Intelligent Targets set 08/06/2016 4
Wisdom hierarchy WISDOM KNOWLEDGE INFORMATION DATA
Ongoing Stage of Programme Review by units of their own data on a regular basis against intelligent targets and appropriate learning and actions Quality Improvement by units and shared learning Histopathology programme 32 sites public and private conducting, collecting and reporting on NQAIS 08/06/2016 Annual review of Guidelines, documents, Indicators, intelligent targets, support for quality improvement and learning Relevant national framework Specialists can review their own data and act Opportunity to share learning on improvements Improved patient care 6
Current Status of Histopathology Programme 32 labs conducting quality activity and recording data First data report only included 15 labs Targets set for 22 out of 50 key quality indicators (minimum 12 months data required) National Aggregate Data Reports 2014, & 2016 What the hospital sees? Laboratory Hospital management What the programme sees? What difference has it made? Challenges Opportunities e.g. RCQPS research collaborative, improvements, publications
Data improvements The timeliness, volume and accuracy of data is improving see compliance slides. Completion of Memorandums of Understanding by hospital management seems to support departments overall. Sharing of reports and data in context outside laboratories with Clinical Directors, hospital management, etc increases profile of histopathology facilitates further quality improvement. Help to share learning through the programme and hospital groups Areas for development Areas of best practice
Cancer centre (C) submission rates 6 May 2016 center type Oct 2014 Nov 2014 Dec 2014 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan 2016 Feb 2016 Mar 2016 Upload status cc3 new upload 2M 1 cc7 new upload 1M 0 cc4 new upload 1M 1 cc1 new upload 1M 0 cc5 new upload 1M 0 cc6 new upload 2M 0 cc2 new upload 1M 1 cc8 new upload 1M 0 Total arrears in months (all labs combined) 3 Months behind = Uploaded months = new uploads since last Steering Committee Compliance Report = not applicable/hospital inactive = Upload requested for Dec 15 = months behind Overall status improved 32 sites 8 private, 28 public Including 8 cancer centers. All have uploaded December data, 28 have uploaded January data. Remaining sites have been reminded & are working through issues. 23 sites have also uploaded February 2016 data, which was due on the 1 st May.
General centre (NC) Submission rates 6 May 2016 center type Oct 2014 Nov 2014 Dec 2014 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan 2016 Feb 2016 Mar 2016 Upload status Months behind nc1 new upload 1M 0 nc2 new upload 2M 0 nc3 new upload 2M 0 nc4 new upload 3M 0 nc5 new upload 2M 0 nc6 new upload 1M 0 nc7 new upload 2M 1 nc8 new upload 2M 0 nc9 new upload 1M 1 nc10 new upload 2M 0 nc11 new upload 1M 0 nc12 new upload 1M 0 nc13 new upload 2M 0 nc14 2 nc16 1 nc17 new upload 2M 0 nc18 new upload 1M 0 nc19 new upload 1M 0 nc20 new upload 1M 0 nc21 new upload 1M 1 nc22 new upload 1M 0 nc23 2 nc24 2 nc25 new upload 2M 0 Total arrears in months (all labs combined) 10
Summary of Histopathology Guidelines 1a 1b 1c Workload Key Quality Area (Monitor) Inter-institutional consultation Cases referred externally for review Inter-institutional consultation Received internally for review Inter-institutional consultation Cases referred externally for opinion Key Quality Indicators #, measure Total no of cases 2: % Cases referred, % Agreement 2: % Cases received, % Agreement 1: % Agreement 2 Intradepartmental Consultation 3 Frozen Section Correlation 3: 3-5 % Cases for Histo & Cyto FNA, 7-9% Cyto Exfoliative, 3: 97% Concordance, 5% Deferral rate >10% needs review 4 Frozen Section TAT 85% TAT < 20 minutes 5 Cytological/histological correlation 3: % Discordant, % False positive, % False negative 6a Retrospective review (Focused real time) 1: % Agreement 6b 7 Retrospective review (report completeness) Multi disciplinary Team meetings - By P- Code 1: % Completeness (POS approach cancers of Endometrium & pancreas) 2: % Agreement, % of total cases discussed - By P-Code 8 Non-conformance reporting 2: No. of non-conformances, Clinical impact 9 External Quality Assessment 2: List of Schemes, results 08/06/2016 Yellow discussing today Green targets set Blue potential target/recommendation Dark red Quality Improvement activity 11
Summary of Histopathology Guidelines Key Quality Area (Monitor) 10 Turnaround Time (TAT) Key Quality Indicators #, measure 6 areas 1 indicator: TAT by case type 80% day 5 i. P01 Small Biopsy ii. P02 GI Endoscopic Biopsy 80% day 7 Non Biopsy iii. P03 Cancer resection, P04 Other 80% day 5 Non gynae cytology v. P06 FNA vi.p07 Exfoliative 11 Addendum Reports 3: Quantity, Error classification, Clinical impact 12 Critical Diagnosis/Value reporting 13 Adult Autopsy Intradepartmental Consultation 1: No. of cases reported directly to clinician (audit in progress) 1: 2% all cases 14 Adult autopsy case review 1: % of total cases reviewed 15 Adult autopsy turnaround time 1: TAT by autopsy case type 16 Paediatric Autopsy extra departmental consultation 1: % of total cases reviewed at M&M 17 Paediatric autopsy retrospective review 1: % of total cases reviewed 18 Paediatric turnaround Time 1: TAT by paediatric turnaround time 19 Quality / Discrepancy Meetings participation Possible addition learning opportunities 08/06/2016 Yellow discussing today Green targets set Blue potential target/recommendation Dark red Quality Improvement activity 12
Targets set Set Monitor Target & Key Indicators Round 1 Round 2 Round 1 Round 2 Intradepartmental Consultation Frozen Section 3-5 % All Cases (round 1) 3-5% Histo cases (retain) 3-5% Cytology Exfoliative (retain) 7-9% Cytology FNA 97% Concordance 5 % Deferral rate, >10% <1% needs review, 85% TAT < 20 minutes Round 1 Turn around Time TAT by case type i. P01 Small Biopsy 80% day 5 ii. P02 GI Endoscopic Biopsy 80% day 5 iii. P03 Non Biopsy Cancer resection 80% day 7 iv. P04 Non Biopsy Other 80% day 7 v. P06 Non gynae cytology FNA 80% day 5 vi. P07 Non gynae cytology - Exfoliative 80% day 5 Round 2 Intradepartmental Consultation 2% Adult Autopsy All cases 10/02/ 13
QA to QI Lloyd Provost Ref: The Health Care Data Guide, learning from data for improvement. Lloyd P. Provost & Sandra Murray. Jossey Bass
Group 1 follows rounds 1 and 2 methodology where measures are defined and data is appropriate for national target setting. Group 2 includes quality areas where definitions are agreed but no national data has been collected. Future targets are settable but only when sufficient data is available for review. A minimum of 12 months data will be collected. Group 3 comprises quality areas where the type of data being recorded is not applicable for national target setting as agreed definitions for these KQIs are not currently achievable. A recommendation only is being suggested for local quality improvement activity. Group 4 consists of quality areas where insufficient national data is being collected through the QI programme. Some of these quality areas are captured through other routes e.g. INAB and EQA. The updated guidelines will reflect this. Group 5 sets out new key quality areas following refinement of initial measure and maturing of the data. Recommended codes will be circulated and data collected prior to any potential target setting.
Clinical Governance Oversight proposal 08/06/2016 18
National developments - Award winning Excellence in Healthcare Management (from 18) L R: Sarah Treleaven RCPI, Maureen Flynn HSE QID, Philip Ryan RCPI, Dr Jennifer Martin HSE QID ( Steering Committee Chair), Prof Conor O Keane Faculty of Pathology, Dr Ann O Shaughnessy RCPI, Dr Niall Swan Faculty of Pathology (Working Group Chair). Missing from photo, Dr Julie McCarthy, Dr Sine Phelan, Prof Kieran Sheahan, Dr Ann Treacy (Working Group members) Mairead Guinan RCPI Programme Manager Memorandum of Understanding with participating hospitals Health Information and Patient Safety Bill due for publication in 2017
1. Employ more effective teamwork in the diagnostic process (DP) 2. Enhance healthcare professional education and training in the DP 3. Ensure health IT supports patients & HCP in the DP 4. Develop and deploy approaches to identify, learn from, and reduce diagnostic errors and near misses in clinical practice 5. Establish a work system and culture that supports the diagnostic process and improvements in diagnostic performance 6. Develop a reporting environment and medical liability system that facilitates improved diagnosis through learning from diagnostic errors and near misses 7. Design a payment system and care delivery environment that supports the DP 8. Provide dedicated funding for research on the DP and diagnostic errors 8 Goals from Institute of Medicine
Presentations - International Communications Implementation of a national patient-centred clinician-led Histopathology National Quality Improvement (QI) Programme to enhance patient care and safety, March, Grand Rounds, Dept of Pathology & Laboratory Medicine, Boston Medical Centre & Boston University School of Medicine, USA Jurisdictional Quality plans & indicators in Interpretative Pathology: experience in Canada and abroad: Implementation of a national patient-centred clinician-led Histopathology National Quality Improvement (QI) Programme to enhance patient care and safety, Canadian Laboratory Medicine Congress (CLMC), Canadian Association of Pathologists, CAP-ACP Annual Meeting Jun An Innovative System for Histopathology Quality Improvement / Assurance, Jun Meeting, UEMS Specialist Section of Pathology, European Pathology Board Set up and Implementation of a Patient-centred Clinician-led Histopathology National Quality Improvement (QI) Programme Pathsoc/BDIAP joint meeting, Jun Dissemination, stakeholder engagement and endorsement the Irish Experience Quality Initiative in Interpretive Pathology (QIIP) Meeting, Canada Jun Metric development & implementation for a patient-centred clinician-led Histopathology National Quality Improvement (QI) Programme, QIIP Workshop
Presentations - National Communications Implementation of a patient-centred clinician-led National Quality Assurance (QA) Programme in Histopathology to enhance patient care and safety, National Patient Safety Conference, Dublin November 2014 (12 selected from 1,07l abstracts) submitted Histopathology Quality Improvement Programme an update, Radiology QI Programme Annual Workshop, June Specialty Quality Improvement Programmes, current status and future developments, Clinical Directors Masterclass, September
Posters - National Communications Implementation of a patient-centred clinician-led Histopathology National QI Programme, National Office of Clinical Audit, Inaugural Annual Conference, Dublin, May Implementation of a patient-centred clinician-led National QI Programme in Histopathology, Irish Society of Surgical Pathology, Kildare, October Posters - International Implementing a National Quality Assurance Programme in Histopathology, USCAP, Seattle, USA, March 2016 Impact of Intradepartmental Consultation on Amended Report Rate: Findings from the Irish National Quality Improvement Programme in Histopathology, USCAP, Seattle, USA, March 2016 Communication with Clinicians in Anatomical Pathology, USCAP, Seattle, USA, March 2016
International developments /2016 Maintaining programme in Ireland is top priority. Ireland remains a world leader, as the only country to collect this data nationally across public and private sector. Other countries very interested in the Irish approach Canada, QIIP review in 2016 Presentation of three posters at USCAP meetings over past 3 years BDIAP / Path Soc (8 th Joint Meeting) - differing approach in the UK- individual poor performance focus on EQA schemes UEMS - Opportunities for consultation with Hungary and Germany
Opportunities for participating sites RCQPS research collaborative HSE QID /HRB / RCPI, opportunity to access funds fore research relating to quality and patient safety. Up to 280,000 over 2 years. Research question link with academic researchers, competitive rounds of funding, submit May, final decision Sept. Think about topics next round May 2017. Current topic is LEAN via Bill Bennett Can LEAN Six Sigma Methodology be used to develop integrated software tools to improve patient care in surgical pathology?
Opportunities for participating sites Clinical audit easy access to information via NQAIS Build up CME points Use your data in more detail publications Application Team,Diploma in Healthcare Management & Quality Improvement (link) National data Prof Sheahan
Acknowledgements Programme Team: Ms. Mairéad Guinan, Mr. Philip Ryan, Ms Sarah Treleaven, Working Group: Dr. Julie McCarthy, Prof J. Conor O Keane, Dr Sine Phelan, Prof. Kieran Sheahan, Dr Ann Treacy Dr. Jennifer Martin - HSE QID (current funder) Mr. Seamus Butler & Mr. Brian Dunne - HSE OCIO Mr. Mel McIntyre & Mr. Pawel Starawz - OpenApp Dr. Howard Johnson HSE HII, Dr. Mary Hynes NCCP (initial funder), Mr. Leo Kearns & Ms. Louise Casey - RCPI