Quality Standards. Palliative Care Measurement Guide. April 2018

Quality Standards Palliative Care Measurement Guide April 2018

Cntents 1 Hw t Use the Measurement Guide... 3 2 Quality Indicatrs in Quality Standards... 4 2.1 Measurement Principles... 4 2.2 Prcess Indicatrs... 4 2.3 Structural Indicatrs... 5 2.4 Outcme Indicatrs... 5 3 Lcal Measurement... 6 3.1 Lcal Data Cllectin... 6 3.2 Measurement Principles fr Lcal Data Cllectin... 6 3.3 Benchmarks and Targets... 7 4 Prvincial Measurement... 9 4.1 Accessing Prvincially Measurable Data... 9 5 Hw Success Can Be Measured fr This Quality Standard... 10 5.1 Quality Standard Scpe... 11 5.2 Chrt Identificatin... 11 5.3 Hw Success Can Be Measured Prvincially... 12 6 Resurces and Questins... 19 6.1 Resurces... 19 6.2 Questins?... 19 7 Appendix: Data Surces Referenced in This Quality Standard... 20 Palliative Care Measurement Guide Page 2

1 Hw t Use the Measurement Guide This dcument is meant t serve as a measurement guide t supprt the adptin f the quality standard Palliative Care. Care fr adults living with a prgressive, life-limiting illness is a critical issue, and there are significant gaps and variatins in the quality f care that peple receive in Ontari. Recgnizing this, Health Quality Ontari released this quality standard t identify pprtunities that have a high ptential fr quality imprvement. This guide is intended fr use by thse lking t adpt the quality standard Palliative Care, including health care prfessinals wrking in reginal r lcal rles. This guide has dedicated sectins fr each f the tw types f measurement within the quality standard: Lcal measurement: what yu can d t assess the quality f care that yu prvide lcally Prvincial measurement: hw we can measure the success f the quality standard n a prvincial level Imprtant Resurces fr Quality Standard Adptin Health Quality Ontari has created resurces t assist with the adptin f quality standards: A Getting Started Guide that utlines a prcess fr using quality standards as a resurce t deliver high-quality care. It includes links t templates, tls, and stries and advice frm health care prfessinals, patients, and caregivers. Yu can use this guide t learn abut evidence-based appraches t implementing changes t practice A Quality Imprvement Guide t give health care teams and rganizatins in Ontari easy access t well-established quality imprvement tls. The guide prvides examples f hw t adapt and apply these tls t ur Ontari health care envirnments An nline cmmunity called Qurum that is dedicated t wrking tgether t imprve the quality f health care acrss Ontari. Qurum can supprt yur quality imprvement effrts Palliative Care Measurement Guide Page 3

2 Quality Indicatrs in Quality Standards Quality standards infrm prviders and patients abut what high-quality health care lks like fr aspects f care that have been deemed a pririty fr quality imprvement in the prvince. They are intended t guide quality imprvement, mnitring, and evaluatin. Measurability is a key principle in develping and describing the quality statements; each statement is accmpanied by ne r mre indicatrs. This sectin describes the measurement principles behind the quality indicatrs, the prcess fr develping these indicatrs, and the technical definitins f the indicatrs. An effective quality statement must be measurable. Measurement is necessary t demnstrate if a quality statement has been prperly implemented, and if it is imprving care fr patients. This is a key part f the Plan-D-Study-Act imprvement cycle. If measurement shws there has been n imprvement, yu need t cnsider a change r try smething different. 2.1 Measurement Principles Health Quality Ontari uses the prcess, structure, and utcme indicatr framewrk develped by Dnabedian in 1966 t develp indicatrs fr quality standards. The three indicatr types play essential and interrelated rles in measuring the quality f health care and the impact f intrducing and using quality standards. The indicatrs prvided are merely suggestins. It is nt expected that every prvider, team, r rganizatin will be able measure all f them (r even want t measure all f them), but they can identify which indicatrs best capture areas f imprvement fr their care and what is easiest t measure given existing lcal data surces. 2.2 Prcess Indicatrs Prcess indicatrs assess the activities invlved in prviding care. They measure the percentage f specified individuals, episdes, r encunters fr which an activity (prcess) is perfrmed. In mst cases, the numeratr shuld specify a time frame in which the actin is t be perfrmed, established thrugh evidence r expert cnsensus. When a quality statement applies t a subset f individuals rather than the ttal ppulatin, the denminatr shuld reflect the ppulatin f the apprpriate subgrup, rather than the entire Ontari ppulatin. If exclusins are required r stratificatins are suggested, they are reflected in the indicatr specificatins. Prcess indicatrs are central t assessing whether r nt the quality statement has been fllwed; nearly all quality statements are assciated with ne r mre prcess indicatrs. In mst cases, the numeratr and denminatr fr prcess indicatrs can be derived frm the language f the quality statement itself; additinal parameters (such as a time frame) may als appear in the definitins sectin. In sme cases, a prxy indicatr is prvided that indirectly measures the prcess. Prxy indicatrs are used nly when the actual indicatr cannt be measured using currently available data. While mst quality statements fcus n a single cncept and are linked with a single prcess indicatr, sme statements include tw r mre clsely related cncepts. In these cases, multiple prcess indicatrs can be cnsidered t capture all aspects f the quality statement. Palliative Care Measurement Guide Page 4

Fr example, a quality statement might suggest the need fr a cmprehensive assessment with several cmpnents, and each f thse cmpnents might have a prcess indicatr. Examples f prcess indicatrs include the percentage f patients with hip fracture wh receive surgery within 48 hurs, r the percentage f patients with schizphrenia wh are ffered clzapine after first- and secnd-line antipsychtics have been ineffective. Please refer t the published quality standards fr mre examples. 2.3 Structural Indicatrs Structural indicatrs assess the characteristics and resurces that influence and enable delivery f care. These can include equipment; systems f care; availability f resurces; and teams, prgrams, plicies, prtcls, licences, r certificatins. Structural indicatrs assess whether factrs that are in place are knwn help in achieving the quality statement. Sme quality statements have structural indicatrs assciated with them. Structural indicatrs are binary r categrical and d nt require the definitin f a numeratr and denminatr. Hwever, in sme cases it culd be useful t specify a denminatr defining an rganizatinal unit, such as a hspital, a primary care practice, r a lcal regin. In many cases data fr structural indicatrs are nt readily available using existing administrative data, s lcal data cllectin might be required. This lcal data cllectin might require reginal r prvincial-level data-cllectin systems t be develped. Structural indicatrs shuld be defined fr a quality statement r fr the quality standard as a whle when there is strng evidence that a particular resurce, capacity, r characteristic is imprtant fr enabling the effective delivery f a prcess f care. It shuld be theretically feasible fr these structural elements t be implemented acrss Ontari, even if adptin is aspiratinal in sme cases. In rare instances, a quality statement may have tw r mre assciated structural indicatrs, if the quality standard advisry cmmittee decides that multiple factrs are crucial t the delivery f the quality statement. Examples f structural indicatrs include the availability f a strke unit, the existence f discharge planning prtcls, r access t a specialized behaviural supprt team. Please refer t the published quality standards fr mre examples. 2.4 Outcme Indicatrs Outcme indicatrs assess the end results f the care prvided. They are crucial and are arguably the mst meaningful measures t cllect, but many health utcmes such as mrtality r unplanned hspital readmissins are ften the prduct f a variety f related factrs and cannt be reliably attributed t a single prcess f care. Fr this reasn, althugh relatively few quality statements are directly linked t an utcme indicatr, a set f verall measures including key utcme indicatrs is defined fr the quality standard as a whle, reflecting the cmbined effect f all f the quality statements in the standard. Similar t prcess indicatrs, utcme indicatrs shuld be specified using a defined denminatr and a numeratr that, in mst cases, shuld include a clear time frame. Examples f utcme indicatrs include mrtality rates, imprvement (r decline) in functin, and patients experience f care. Please refer t the published quality standards fr mre examples. Palliative Care Measurement Guide Page 5

3 Lcal Measurement As part f the quality standard Palliative Care, specific measures were identified fr each f the statements t supprt measurement fr quality imprvement. As an early step in yur prject, we suggest that yur team cmplete an initial assessment f the relevant measures in the standard and cme up with a draft measurement plan. Here are sme cncrete next steps: 1. Review the list f identified measures (in the quality standard), and determine which measures yu will use as part f yur adptin planning, given yur knwledge f current gaps in care 2. Determine the availability f data related t the measures yu have chsen 3. Identify a way t cllect lcal data related t yur chsen measures 4. Develp a draft measurement plan The earlier yu cmplete the abve steps, the mre successful yur quality imprvement prject is likely t be. 3.1 Lcal Data Cllectin Lcal data cllectin refers t data cllectin at the health prvider r team level fr indicatrs that cannt be assessed using prvincial administrative databases (such as databases held by the Institute fr Clinical Evaluative Sciences r the Canadian Institute fr Health Infrmatin). Examples include data frm electrnic medical recrds, clinical patient recrds, reginal data cllectin systems, and lcally administered patient surveys. Indicatrs that require lcal data cllectin may signal an pprtunity fr lcal measurement, data advcacy, r imprvement. Lcal data cllectin has many strengths: it is timely, can be tailred t quality imprvement initiatives, and is mdifiable n the basis f currently available data. Hwever, cautin is required when cmparing indicatrs using lcal data cllectin between prviders t ensure cnsistency in definitins, cnsistency in calculatin, and validity acrss patient grups. 3.2 Measurement Principles fr Lcal Data Cllectin Three types f data can be used t cnstruct measures in quality imprvement: cntinuus, classificatin, and cunt data. 3.2.1 Cntinuus Data Cntinuus data can take any numerical value in a range f pssible values. These values can refer t a dimensin, a physical attribute, r a calculated number. Examples include patient weight, number f calendar days, and temperature. 3.2.2 Classificatin Data Classificatin (r categrical) data are recrded in tw r mre categries r classes. Examples include sex, race r ethnicity, and number f patients with depressin versus number f patients withut depressin. In sme cases, yu might chse t cnvert cntinuus data int categries. Fr example, yu culd classify patient weight as underweight, nrmal weight, verweight, r bese. Palliative Care Measurement Guide Page 6

Classificatin data are ften presented as percentages. T calculate a percentage frm classificatin data, yu need a numeratr and a denminatr (a percentage is calculated by dividing the numeratr by the denminatr and multiplying by 100). The numeratr includes the number f bservatins meeting the criteria (e.g., number f patients with depressin), and the denminatr includes the ttal number f bservatins measured (e.g., ttal number f patients in clinic). Nte that the bservatins in the numeratr must als be included in the denminatr (surce ppulatin). Examples f measures that use classificatin data include percentage f patients with a family physician and percentage f patients wh receive therapy. 3.2.3 Cunt Data Cunt data ften fcus n attributes that are unusual r undesirable. Examples include number f falls in a lng-term care hme and number f medicatin errrs. Cunt data are ften presented as a rate, such as the number f events per 100 patient-days r per 1,000 dses. The numeratr f a rate cunts the number f events/nncnfrmities, and the denminatr cunts the number f pprtunities fr an event. It is pssible fr the event t ccur mre than nce per pprtunity (e.g., a lng-term care resident culd fall mre than nce). Rate f 30-day hspital readmissin = N. f hspital readmissins within 30 days f discharge [numeratr] N. f discharges frm hspital [denminatr] 3.2.4 Benefits f Cntinuus Data It is cmmn practice in health care t measure tward a target instead f reprting cntinuus measures in their riginal frm. An example wuld be measuring the number f patients wh saw their primary care physician within 7 days f hspital discharge instead f measuring the number f days between hspital discharge and an appintment with a primary care physician. Targets shuld be evidence-based r based n a high degree f cnsensus acrss clinicians. When a chice exists, cntinuus data smetimes are mre useful than cunt r classificatin data fr learning abut the impact f changes tested. Measures based n cntinuus data are mre respnsive and can capture smaller changes than measures based n cunt r classificatin data; therefre, it is easier and faster t see imprvement with measures based n cntinuus data. This is especially true when the average value fr the cntinuus measure is far frm the target. Cntinuus data are als mre sensitive t change. Fr example, while yu might nt increase the number f peple wh are seen within 7 days, yu might reduce hw lng peple wait. 3.3 Benchmarks and Targets Benchmarks are markers f excellence t which rganizatins can aspire. Benchmarks shuld be evidence-based r based n a high degree f cnsensus acrss clinicians. At this time, Health Quality Ontari des nt develp benchmarks fr the indicatrs. Users f these standards have variable practices, resurces, and patient ppulatins, s ne benchmark might nt be practical fr the entire prvince. Palliative Care Measurement Guide Page 7

Targets are gals fr care that are ften develped in the cntext f the lcal care envirnment. Prviders, teams, and rganizatins are encuraged t develp their wn targets apprpriate t their patient ppulatins and their quality imprvement wrk. Organizatins that include a quality standard indicatr in their quality imprvement plans are asked t use a target that reflects imprvement. Time frame targets, like the number f peple seen within 7 days, are typically prvided with prcess indicatrs intended t guide quality imprvement. In many cases, achieving 100% n an indicatr will nt be pssible. This is why it is imprtant t track these indicatrs ver time, t cmpare results against thse f clleagues, t track prgress, and t aim fr the successful implementatin f the standard. Fr guidance n setting benchmarks and targets at a lcal level, refer t: Appraches t Setting Targets fr Quality Imprvement Plans Lng-Term Care Benchmarking Resurce Guide Palliative Care Measurement Guide Page 8

4 Prvincial Measurement In its quality standards, Health Quality Ontari strives t incrprate measurement that is standardized, reliable, and cmparable acrss prviders t assess the impact f the standards prvincially. Where pssible, indicatrs shuld be measurable using prvince-wide data surces. Hwever, in many instances data are unavailable fr indicatr measurement. In these cases, the surce is described as lcal data cllectin. Fr mre infrmatin n the data surces referenced in this standard, please see the appendix. 4.1 Accessing Prvincially Measurable Data Prvincial platfrms are available t create custm analyses t help yu calculate results fr identified measures f success. Examples f these platfrms include IntelliHealth, ereprts, and Query. 4.1.1 IntelliHealth Ministry f Health and Lng Term Care IntelliHealth is a knwledge repsitry that cntains clinical and administrative data cllected frm varius sectrs f the Ontari health care system. IntelliHealth enables users t create queries and run reprts thrugh easy web-based access t high quality, well rganized, integrated data. 4.1.2 ereprts Canadian Institute fr Health Infrmatin Quick Reprts ffer at-a-glance cmparisns fr the rganizatins yu chse. The tl als prvides sme ways t manipulate the pre-frmatted lk and feel f the reprts. Flexible r Organizatin Reprts ffer yu many chices t cmpare yur rganizatin s data with thse f ther rganizatins. With these custmizable reprts, yu can view data by different attributes and fr multiple rganizatins. Bth reprt types allw trending ver time and prvide a cmparisn f rganizatins with regins, prvinces r territries, r the entire database. 4.1.3 Query Public Health Ontari Query is a dynamic tl that allws public health prfessinals t instantly explre, manipulate, and analyze health data using pre-defined reprts and variables. Query tls are available fr reprtable infectius disease data (ID Query) and health care-assciated infectin data (HAI Query). Palliative Care Measurement Guide Page 9

5 Hw Success Can Be Measured fr This Quality Standard This measurement guide accmpanies Health Quality Ontari s quality standard Palliative Care. Early in the develpment f each quality standard, a few perfrmance indicatrs are chsen t measure the success f the entire standard. These indicatrs guide the develpment f the quality standard s that every statement within the standard aids in achieving the standard s verall gals. This measurement guide includes infrmatin n the definitins and technical details f the indicatrs listed belw: Percentage f peple wh receive care in their last 12 mnths, 3 mnths, and 1 mnth f life: Hme care services (any hme care and palliative-specific hme care) Health care prvider hme visits (currently nly physician hme visits are measurable) Hspice care (lcally measurable) Percentage f peple wh had 1 r mre unplanned emergency department visits in their last 12 mnths, 3 mnths, and 1 mnth f life Percentage f deaths that ccurred in: Hspitals In-patient care Emergency department Cmplex cntinuing care Palliative care beds (lcally measurable) Lng-term care hmes The cmmunity (may include hme, hspice residence, retirement hme, r assisted-living hme) Percentage f peple wh receive palliative care (r their caregivers) wh rated verall care received in their last 12 mnths, 3 mnths, and 1 mnth f life as excellent Example f a questin frm the CaregiverVice Survey: Overall, and taking all services in all settings int accunt, hw wuld yu rate his/her care in the last 3 mnths f life? (Respnse ptins: Excellent, Very gd, Fair, Gd, Dn t knw ) Nte: as f 2017, 25 hspice residences in Ontari have adpted the CaregiverVice Survey, and abut 11 f 14 lcal health integratin netwrks have adpted this survey fr patients as end-f-life hme care clients This guide includes data surces fr indicatrs that can be cnsistently measured acrss prviders, acrss the sectrs f health care, and acrss the prvince. Palliative Care Measurement Guide Page 10

Indicatrs are categrized as: Prvincially measurable (the indicatr is well defined and validated) r Lcally measurable (the indicatr is nt well defined, and data surces d nt currently exist t measure it cnsistently acrss prviders and at the system level) Fr mre infrmatin n statement-specific indicatrs, please refer t the quality standard. 5.1 Quality Standard Scpe This quality standard addresses care fr adults with a prgressive, life-limiting illness, and fr their family and caregivers. It fcuses n palliative care in all health settings, fr all health disciplines, and in all health sectrs. It includes infrmatin abut general palliative care that applies t all health cnditins. Palliative care can benefit individuals and their caregivers as early as at the time f diagnsis f a prgressive, life-limiting illness thrugh the end f life and bereavement. This quality standard includes 13 quality statements. They address areas identified by Health Quality Ontari s Palliative Care Quality Standard Advisry Cmmittee as having high ptential fr imprving the quality f care in Ontari fr peple with a prgressive, life-limiting illness. Cnditin-specific palliative care may be addressed in ther quality standards. Althugh this quality standard includes infrmatin that culd apply t infants, children, and yuth, a separate quality standard is being cnsidered fr these ppulatins. 5.2 Chrt Identificatin The chrt fr the quality standard Palliative Care is peple with a prgressive, life-limiting illness, and their family and caregivers. Hwever, because f a lack f data surces and existing methdlgy t identify this ppulatin, the indicatrs selected t measure verall success are calculated amng peple wh died in a selected reprting perid (e.g., a fiscal year). Sme indicatrs are measured in bereaved caregivers (see details in technical templates). The indicatrs that accmpany statements t guide the measurement f quality imprvement are fcused mstly in peple identified with palliative care needs r thse wh receive palliative care services. The chrt f peple identified with palliative care needs is currently nt measurable at the prvincial level; lcal data cllectin may be required. Palliative Care Measurement Guide Page 11

5.3 Hw Success Can Be Measured Prvincially The Palliative Care Quality Standard Advisry Cmmittee identified a small number f verarching gals fr this quality standard. These have been mapped t indicatrs that may be used t assess quality f care prvincially. The fllwing indicatrs are currently measurable in Ontari s health care system: Percentage f peple wh receive care in their last 12 mnths, 3 mnths, and 1 mnth f life: Hme care services (any hme care and palliative-specific hme care) Health care prvider hme visits (currently nly physician hme visits are measurable) Hspice care (lcally measurable) Percentage f peple wh had ne r mre unplanned emergency department visits in their last 12 mnths, 3 mnths, and 1 mnth f life Percentage f deaths that ccurred in: Hspitals In-patient care Emergency department Cmplex cntinuing care Palliative care beds (lcally measurable) Lng-term care hmes The cmmunity (may include hme, hspice residence, retirement hme, r assisted-living hme) Percentage f peple wh receive palliative care (r their caregivers) wh rated verall care received in their last 12 mnths, 3 mnths, and 1 mnth f life as excellent Example f a questin frm the CaregiverVice Survey: Overall, and taking all services in all settings int accunt, hw wuld yu rate his/her care in the last 3 mnths f life? (Respnse ptins: Excellent, Very gd, Fair, Gd, Dn t knw ) Nte: as f 2017, 25 hspice residences in Ontari have adpted the CaregiverVice Survey, and abut 11 f 14 lcal health integratin netwrks have adpted this survey fr patients as end-f-life hme care clients Methdlgic details are described in the tables belw. Palliative Care Measurement Guide Page 12

Table 1: Percentage f peple wh receive care in their last 30 days f life: hme care services (any hme care and palliative-specific hme care); health care prvider hme visits (currently nly physician hme visits are measurable); hspice care GENERAL DESCRIPTION DEFINITION & SOURCE INFORMATION Indicatr descriptin Measurability Dimensins f quality Calculatin: General This indicatr measures the percentage f peple wh lived in the cmmunity during their last 30 days f life and wh received at least ne: Hme care (any hme care and palliative-specific hme care) Physician hme visits Hspice care a Directinality: A higher percentage is better Measurable at the prvincial level Patient-centred Denminatr Number f peple wh died and were in the cmmunity in the last 30 days f their life Exclusins Peple wh spent their last mnth in hspital, lng-term care/cmplex cntinuing care, r an inpatient rehabilitatin facility Numeratr Number f peple in the denminatr wh in their last 30 days f life received: 1. Any hme care (had any f the cdes listed belw) Inclusins Hme Care Database: services variable SERVICE = [1 13, 16 18] SERVICE = Type f service prvided (hme care service) 1 = Nursing Visit 2 = Nursing Shift (Hur) 3 = Respiratry Services 4 = Nutritin/Dietetic 5 = Physitherapy 6 = Occupatinal Therapy 7 = Speech Language Therapy 8 = Scial Wrk 9 = Psychlgy 10 = Case Management 11 = Persnal Services (Hur) 12 = Hmemaking Services (Hur) 13 = Cmbined Persnal Services and Hmemaking Services (Hur) 14 = Placement Services 15 = Respite 16 = Mental Health and Addictin Nursing Visit 17 = Nurse Practitiner Palliative Visit 18 = Rapid Respnse Nursing Visit 99 = Other Palliative Care Measurement Guide Page 13

2. Palliative hme care (any f the cdes belw) HCD: SRC_admissin = 95: Service recipient cde (i.e., classificatin) f end f life n admissin Service_RPC = 95: Service care gal f end f life; patient prvided service under end f life designatin Residence_type = 2000: Staying in hspice r palliative care unit while receiving service SRC_discharge = 95: Service recipient cde f end f life n discharge 3. Physician hme visit (any f the cdes belw) G511: Telephne services t patient receiving palliative care at hme (max 2/week) B966: Travel premium fr palliative care (billed with B998/B996) B998: Hme visit fr palliative care between 07:00 and 24:00 (Sat, Sun, and hlidays) B997: Hme visit fr palliative care between 24:00 and 07:00 A901: General practitiner/family physician huse call B990: Special visit t patient s hme (weekday/daytime) B992: Special visit t patient s hme (weekday/daytime), with sacrifice t ffice hurs B994: Special visit t patient s hme, nn-elective, evenings B996: Special visit t patient s hme, night time, first patient f the night Methd Numeratr divided by the denminatr 100 ADDITIONAL INFORMATION Data surces Cntinuing Care Reprting System, Discharge Abstract Database, Hme Care Database, Natinal Ambulatry Care Reprting System, Natinal Rehabilitatin Reprting System, Ontari Health Insurance Plan Claims Histry Database, Registered Persns Database Limitatins The data d nt shw the details and quality f hme care, health care needs, preferences, r apprpriateness f care The data shw the number f peple wh had at least ne hme care service, which may nt be sufficient There is n evidence f the apprpriate amunt r mix f hme care services t which the data culd be cmpared The data d nt shw whether peple had any ther hme supprt r a caregiver Peple receiving hspice care cannt be identified Hme visits by nn-physician prviders are nt captured Cmments This indicatr aligns with prvincial measurement initiatives This indicatr can be reprted fr different time frames (e.g., a persn s last 12 mnths, 3 mnths) a Peple receiving hspice care can t be identified. Palliative Care Measurement Guide Page 14

Table 2: Percentage f peple wh had ne r mre unplanned emergency department visits in their last 30 days f life GENERAL DESCRIPTION DEFINITION & SOURCE INFORMATION Indicatr descriptin Measurability Dimensins f quality Calculatin: General This indicatr measures the percentage f peple, amng thse wh died, wh had ne r mre unplanned emergency department visits in their last 30 days f life Measurable at the prvincial level Efficient Denminatr Number f peple in Ontari wh died in each year f interest Exclusins: Peple wh spent their last mnth in hspital, cmplex cntinuing care, r an inpatient rehabilitatin facility Numeratr Number f peple wh had at least ne unplanned emergency department visit in their last 30 days f life Inclusins Peple wh had an unplanned emergency department visit in NACRS Unscheduled/unplanned emergency department visits are identified by: NACRS variables VISITTYPE = [1,2,4] r SCHEDEDVISIT = N Exclusins Planned emergency department visits Methd Numeratr divided by the denminatr 100 ADDITIONAL INFORMATION Data surces Cntinuing Care Reprting System, Discharge Abstract Database, Natinal Ambulatry Care Reprting System, Ontari Health Insurance Plan Claims Histry Database, Registered Persns Database Limitatins This indicatr des nt prvide infrmatin abut clinical details, health care needs, preferences, r apprpriateness f the unplanned emergency visits This infrmatin is difficult t interpret, because there are n benchmarks r targets fr the acceptable rate f emergency department visits in this patient ppulatin Cmments This indicatr aligns with prvincial measurement initiatives This indicatr can be reprted fr different time frames (e.g., a persn s last 12 mnths, 3 mnths) Abbreviatins: NACRS, Natinal Ambulatry Care Reprting System. Palliative Care Measurement Guide Page 15

Table 3: Percentage f peple wh died in hspital, lng-term care hmes, and the cmmunity GENERAL DESCRIPTION DEFINITION & SOURCE INFORMATION Indicatr descriptin Measurability Dimensins f quality Calculatin: General This indicatr measures the prprtin f deaths in: Hspital (inpatient, emergency department, cmplex cntinuing care, and inpatient rehabilitatin facilities) Lng-term care Cmmunity (may include hme, residential hspices, retirement hmes, and assisted living hmes) Measurable at the prvincial level Efficient Denminatr Number f peple in Ontari wh died in each year f interest Numeratr Number f peple wh died in each f the fllwing settings: Hspital (in-patient care, emergency department, cmplex cntinuing care, r inpatient rehabilitatin facility) Lng-term care hmes The cmmunity (hme, hspice residence, retirement hme, r assisted-living hme) Inclusins Hspital deaths are identified by the fllwing cdes: In-patient: DAD SDS dischdisp = 07 Emergency department: NACRS visit dispsitin = 10 r 11 Cmplex cntinuing care: CCRS discharge_t_facility_type = 11 Inpatient Rehabilitatin facility: NRS dreasn=8 LTC Lng-term care hmes: CCRS-LTC discharge_t_facility_type = 11 Cmmunity: all ther deaths nt included in any f the abve categries Methd Numeratr divided by the denminatr 100 Data surces Cntinuing Care Reprting System, Discharge Abstract Database, Hme Care Database, Natinal Ambulatry Care Reprting System, Natinal Rehabilitatin Reprting System, Ontari Health Insurance Plan Claims Histry Database, Registered Persns Database Palliative Care Measurement Guide Page 16

ADDITIONAL INFORMATION Limitatins The data shw the lcatin f the death, but nt where care was received befre death (e.g., death may have ccurred in the emergency department, but verall care may have been prvided in a lng-term care hme) N infrmatin n the preferred place f death is prvided Death in palliative care beds are included in verall hspital deaths, but cannt be identified Cmments If there were multiple death recrds with different death dates in each f the abve administrative databases, the last (i.e., the mst recent) death recrd fr each unique health card number was selected If ne health card number appeared in multiple care settings, the fllwing hierarchy based n care intensity was used t assign death setting: acute care, emergency department, cmplex cntinuing care, rehabilitatin facilities, lng-term care hmes. There shuld be nly ne recrd per health card number Abbreviatins: CCRS, Cntinuing Care Reprting System; DAD, Discharge Abstract Database; LTC, lng-term care; NACRS, Natinal Ambulatry Care Reprting System; NRS, Natinal Rehabilitatin Reprting System. Palliative Care Measurement Guide Page 17

Table 4: Percentage f caregivers* wh rated verall care f the patient they cared fr in their last 3 mnths f life as excellent GENERAL DESCRIPTION DEFINITION & SOURCE INFORMATION Indicatr descriptin Measurability Dimensins f quality Calculatin: General This indicatr measures the percentage f caregivers wh rated the verall care f the patient that they cared fr in their last 3 mnths f life as excellent Directinality: a higher percentage is better Measurable at the prvincial level Patient-centred Denminatr All CaregiverVice Survey respndents wh respnded t the survey questin belw. Exclusins Dn t knw respnses Numeratr Survey respndents wh answered excellent t the fllwing questin: Overall, and taking all services in all settings int accunt, hw wuld yu rate his/her care in the last 3 mnths f life? Excellent Very gd Gd Fair Pr Dn t knw Methd Numeratr divided by the denminatr 100 ADDITIONAL INFORMATION Data surce CaregiverVice Survey Limitatins The CaregiverVice Survey reflects the perceptins f nly caregivers f peple wh died in hspices and wh received end-flife hme care in 11 f the 14 lcal health integratin netwrks in Ontari The panel recmmended cllecting data frm patients and caregivers, but this indicatr relies n data frm bereaved caregivers; n data frm the peple wh received palliative care are available Cmment Nte: as f 2017, 25 hspice residences in Ontari have adpted the CaregiverVice Survey, and abut 11 f 14 lcal health integratin netwrks have adpted this survey fr patients as end-flife hme care clients *The panel recmmended that the indicatr measure perceptin amng thse receiving palliative care and their caregivers, but the CaregiverVice Survey reflects the perceptins f caregivers nly. Palliative Care Measurement Guide Page 18

6 Resurces and Questins 6.1 Resurces Several resurces are available fr mre infrmatin: The quality standard prvides infrmatin n the backgrund, definitins f terminlgy, numeratrs and denminatrs fr all statement-specific indicatrs The Getting Started Guide includes quality imprvement tls and resurces fr health care prfessinals, including an actin plan template The infbrief prvides data n why a particular quality standard has been created and the data behind it The data tables prvide data that can be used t examine variatins in indicatr results acrss the prvince 6.2 Questins? Please cntact qualitystandards@hqntari.ca. We wuld be happy t prvide advice n measuring quality standard indicatrs, r put yu in tuch with ther prviders wh have implemented the standards and might have faced similar questins. Health Quality Ontari ffers an nline cmmunity dedicated t imprving the quality f health care acrss Ontari tgether called Qurum. Qurum can supprt yur quality imprvement wrk by allwing yu t: Find and cnnect with thers wrking t imprve health care quality Identify pprtunities t cllabrate Stay infrmed with the latest quality imprvement news Give and receive supprt frm the cmmunity Share what wrks and what desn t See details f cmpleted quality imprvement prjects Learn abut training pprtunities Jin a cmmunity f practice Palliative Care Measurement Guide Page 19

7 Appendix: Data Surces Referenced in This Quality Standard Within this quality standard, there are several data surces used fr prvincial measurement. The data surce(s) fr each indicatr are listed within the individual indicatr specificatins. Mre details n the specific data surces that Health Quality Ontari used t prduce the indicatrs are nted belw. Cntinuing Care Reprting System Canadian Institute fr Health Infrmatin The Canadian Institute fr Health Infrmatin develped the Cntinuing Care Reprting System t enhance the cllectin f standardized infrmatin n facility-based lng-term care and cmplex cntinuing care, fr natinal cmparative reprting. This reprting system cntains demgraphic, administrative, clinical, and resurce use infrmatin n individuals receiving cntinuing care services in hspitals r in lng-term care hmes in Canada. Participating rganizatins als prvide infrmatin n facility characteristics t supprt cmparative reprting. The clinical data are cllected using an internatinally accepted standard, the Resident Assessment Instrument Minimum Data Set Versin 2.0 (RAI-MDS 2.0). Each resident in a lngterm care hme is assessed at admissin and then every 3 mnths, r whenever they experience a significant change in health status. The assessment includes patient-level measures f functin, mental and physical health, scial supprt, and service use. It was mdified by the institute with permissin, fr Canadian use. All lng-term care hmes in Ontari have submitted data t the institute n a quarterly basis since 2009. Discharge Abstract Database Canadian Institute fr Health Infrmatin The Discharge Abstract Database by the Canadian Institute fr Health Infrmatin cntains infrmatin abstracted frm hspital recrds that capture administrative, clinical, and patient demgraphic data n all hspital in-patient separatins, including discharges, deaths, sign-uts, and transfers. The institute receives Ontari data directly frm participating facilities, frm their respective reginal health authrities, r frm the Ministry f Health and Lng-Term Care. The database includes patient-level data fr acute care facilities in Ontari. Data are cllected, maintained, and validated by the institute. The main data elements f this database are patient identifiers (e.g., name, health care number), patient demgraphics (e.g., age, sex, gegraphic lcatin), clinical infrmatin (e.g., diagnses, prcedures), and administrative infrmatin. Hme Care Database Ministry f Health and Lng-Term Care The Hme Care Database is a clinical, patient-centred database that captures all hme care services prvided r crdinated by Ontari s cmmunity care access centres, including gvernment-funded hme and cmmunity services. The Hme Care Database is managed by Health Shared Services Ontari. It includes patient, intake, assessment, and admissin/discharge infrmatin. This infrmatin is used t determine the eligibility f patients and the care crdinatin, care planning, and services that align with their care needs. Clinical data are cllected using standardized interrai tls, including the Resident Assessment Instrument fr Hme Care (RAI-HC). Palliative Care Measurement Guide Page 20

Natinal Ambulatry Care Reprting System Canadian Institute fr Health Infrmatin The Natinal Ambulatry Care Reprting System by the Canadian Institute fr Health Infrmatin cntains data fr all hspital- and cmmunity-based emergency and ambulatry care, including day surgeries, utpatient clinics, and emergency departments. Data are cllected, maintained, and validated by the institute. The institute receives Ontari data directly frm participating facilities, frm their respective reginal health authrities, r frm the Ministry f Health and Lng-Term Care. Data are cllected, maintained, and validated by the institute. Data elements f this reprting system include patient identifiers (e.g., name, health care number), patient demgraphics (e.g., age, sex, gegraphic lcatin), clinical infrmatin (e.g., diagnses, prcedures), and administrative infrmatin. Natinal Rehabilitatin Reprting System Canadian Institute fr Health Infrmatin The Natinal Rehabilitatin Reprting System was develped by the Canadian Institute fr Health Infrmatin in 2001 t supprt data cllectin by hspitals fr inpatient rehabilitatin clients wh are mainly age 18 and lder. The rehabilitatin services are usually prvided in specialized rehabilitatin hspitals and in general hspitals within rehabilitatin units, prgrams, r grups f rehabilitatin beds. The database captures clients with a range f health cnditins, including strkes, rthpedic cnditins, and amputatins. Ontari Health Insurance Plan Ministry f Health and Lng-Term Care The Ontari Health Insurance Plan (OHIP) claims database cvers all reimbursement claims t the ministry made by fee-fr-service physicians, cmmunity-based labratries, and radilgy facilities. The OHIP database at the Institute fr Clinical Evaluative Sciences cntains encrypted patient and physician identifiers, cdes fr services prvided, dates f service, assciated diagnses, and fees paid. Services missing frm OHIP data include sme labratry services, services received in prvincial psychiatric hspitals, services prvided by health service rganizatins and ther alternative prviders, diagnstic prcedures perfrmed n an in-patient basis, and labratry services perfrmed at hspitals (bth in-patient and same day). Als excluded is remuneratin t physicians thrugh alternative funding plans; this culd distrt analyses because f their cncentratin in certain specialties r gegraphic areas. Ontari Mental Health Reprting System Canadian Institute fr Health Infrmatin The Ontari Mental Health Reprting System cllects infrmatin abut peple admitted t designated adult mental health beds in Ontari. It includes infrmatin n admissins and discharges, as well as clinical infrmatin. Clinical data are cllected using the Resident Assessment Instrument fr Mental Health (RAI-MH), a standardized assessment instrument fr in-patient mental health care. It includes infrmatin abut mental and physical health, scial supprt, and service use. Data are cllected n clients frm participating hspitals at admissin, at discharge, and every 3 mnths fr patients with extended stays. Data are available frm Octber 1, 2005, nward. The number f active sites has varied between 65 and 74 since the start f the reprting system in 2005/2006. In its early years, 90% t 98% f active sites submitted at least sme data every quarter. This rate has increased t 100% fr all fur quarters f 2014/2015. As f May 15, 2017, 84 participating facilities had submitted data at least nce. Registered Persns Data Base Ministry f Health and Lng-Term Care The Registered Persns Database is a histrical listing f the unique health numbers issued t each persn eligible fr Ontari health services. This listing includes crrespnding demgraphic infrmatin, such as date f birth, sex, address, and date f death (where applicable). The Institute fr Clinical Evaluative Sciences creates an enriched pstal cde Palliative Care Measurement Guide Page 21

dataset that uses pstal cde and ther administrative data t generate the best-knwn pstal cde n July 1 f each year fr eligible individuals. Palliative Care Measurement Guide Page 22

Health Quality Ontari 130 Blr Street West, 10 th Flr Trnt, Ontari M5S 1N5 Tel: 416-323-6868 Tll Free: 1-866-623-6868 Fax: 416-323-9261 Email: QualityStandards@hqntari.ca Website: www.hqntari.ca ISBN 978-1-4868-1727-6 (PDF) Queen s Printer fr Ontari, 2018 Palliative Care Measurement Guide Page 23