Quality Management Partnership: Pathology Quality Management Program U of T Pathology Update November 13, 2015 Dr. Kathy Chorneyko, Clinical Lead, Pathology, Quality Management Partnership OBJECTIVES Overview of the Quality Management Partnership Highlight the importance of engaging patients/ caregivers Review of the Quality Management Model Update on the Early Quality Initiatives Proposed Prioritized Standards and Indicators Timelines 2 QUALITY MANAGEMENT PARTNERSHIP 1
WHAT IS THE QUALITY MANAGEMENT PARTNERSHIP? In March 2013, the Ministry announced a formal partnership between CCO and CPSO to develop provincial quality management programs for colonoscopy, mammography and pathology 3 QUALITY MANAGEMENT PARTNERSHIP WHAT ARE THE DRIVERS? Past quality and patient safety incidents Variation in quality of care in hospitals and community Variation in processes to proactively identify quality concerns Ontario s Action Plan for Healthcare and focus on quality 4 QUALITY MANAGEMENT PARTNERSHIP 2
WHAT ARE OUR GOALS? Increase the quality of care and improve patient safety Increase the consistency in the quality of care provided across facilities Improve public confidence by increasing accountability and transparency 5 QUALITY MANAGEMENT PARTNERSHIP QUALITY MANAGEMENT PROGRAM FRAMEWORK Introduction of standards and guidelines to improve the consistency of care provided across facilities Quality reporting at the provincial, regional, facility and provider levels A supportive three-tiered clinical leadership structure Resources and opportunities to support quality improvement 6 QUALITY MANAGEMENT PARTNERSHIP 3
ALIGNING ACROSS THE SYSTEM MOHLTC Initiatives CCO Programs CPSO Peer & Facility Assessments Quality Management Partnership Existing Evidence & Standards Local Facility Structures Health System Organizations 7 QUALITY MANAGEMENT PARTNERSHIP STATUS UPDATE: WHERE WE ARE WE NOW? Phase 2 Report: Contains design recommendations for colonoscopy, mammography and pathology quality management programs (QMPs) Was submitted to the Ministry of Health and Long- Term Care in March 2015; positive feedback on the report was received at preliminary meetings with MOHLTC Deputy Minister Distributed to key stakeholders Will be circulated more broadly upon receipt of formal approval 8 QUALITY MANAGEMENT PARTNERSHIP 4
QUALITY MANAGEMENT MODEL 9 QUALITY MANAGEMENT PARTNERSHIP PATHOLOGY QUALITY MANAGEMENT MODEL Pathology QMP Provincial Lead QMP Pathology Provincial Committee Provincial Lead, QMP Regional leads representing academic, community and private laboratories Representation from CCO (i.e. PLMP), CPSO, IQMH, Path2Quality Working groups (e.g., pediatrics) QMP Facility Leads Pathologists 10 QUALITY MANAGEMENT PARTNERSHIP 5
PROPOSED REGIONAL MODEL! Modelled on CCO s LHIN-based regional structure for pathology! Private labs will have a Regional Lead who will represent the six private surgical pathology labs across the province Regional Structure 14 Regional Leads representing hospital labs, aligned with LHIN structure LHIN 1 LHIN 8 LHIN 2 LHIN 9 LHIN 3 LHIN 10 LHIN 4 LHIN 11 LHIN 5 / 6 LHIN 12 LHIN 7 North LHIN 13 LHIN 7 South LHIN 14 1 Regional Lead who will represent private labs Total = 15 Regional Leads 11 QUALITY MANAGEMENT PARTNERSHIP PROVINCIAL AND REGIONAL LEAD ROLES (1/2) Provincial Lead Currently in final stages of recruitment Role: Provide clinical leadership for the pathology quality management program at the provincial level Lead the development and implementation of a strategy to standardize clinical quality across the province Chair the QMP pathology provincial committee 12 QUALITY MANAGEMENT PARTNERSHIP 6
PROVINCIAL AND REGIONAL LEAD ROLES (2/2) Regional Leads Need to be Facility Leads and will be selected through a procurement process Expected procurement timeline: January - May 2016 (approximately) Role: Support facilities to implement the pathology QMP Work with the local facilities and the QMP provincial lead to identify opportunities for quality improvement and mechanisms to share best practices across the province and to provide a supportive network of clinical resources 13 QUALITY MANAGEMENT PARTNERSHIP FACILITY LEADS AND PROVINCIAL QMP COMMITTEE (1/2) Facility Leads Will be practicing pathologists identified by the facility who are the Laboratory Director / Medical Director or identified delegate Expected appointment timeline: October - February 2016 (approximately) Role: Will provide and monitor data and oversee quality at the local level Are responsible to the QMP provincial and regional leads and accountable to their local facility 14 QUALITY MANAGEMENT PARTNERSHIP 7
FACILITY LEADS AND PROVINCIAL QMP COMMITTEE (2/2) Pathology Provincial Committee Will consist of QMP provincial and regional leads and other relevant clinical leads, non-physician providers, patients/service users and subject matter experts, as required Expected timeline: Spring 2016 (approximately) Role: Provide guidance and leadership for the pathology QMP Advise on program priorities, recommendation refinement and future areas of expansion Provide recommendations for improvement opportunities Support change management and knowledge translation and exchange across the province 15 QUALITY MANAGEMENT PARTNERSHIP EARLY QUALITY INITIATIVES (EQIS) 16 QUALITY MANAGEMENT PARTNERSHIP 8
EQIs: Status Update Baseline Pathology Survey: Results will be used to describe the current landscape of quality in pathology and inform the development of the Pathology QMP Preliminary results will be reported in the fall 2015 quality report Recommendations to improve communication and pathology diagnostic reporting on polypectomies: Developed preliminary list of recommendations Engaging stakeholders for feedback on the draft recommendations Recommendations to inform practices related to tissue exemption and tissue release: Legislative scan complete Current state assessment is currently being reviewed 17 QUALITY MANAGEMENT PARTNERSHIP PRIORITIZATION OF STANDARDS AND INDICATORS 18 QUALITY MANAGEMENT PARTNERSHIP 9
Process: PRIORITIZATION OF QMP RECOMMENDATIONS! Recommendations were prioritized using a prioritization matrix based on Lean 6 methodology! Leveraged preliminary results from the Baseline Survey! Pathology Expert Advisory Working Group provided input 19 QUALITY MANAGEMENT PARTNERSHIP PROPOSED PRIORITIZED STANDARDS (1 /3) Foundational Elements: Laboratories must have: A pathology professional quality management committee. (70.51% implemented / 11.54% in progress) A pathology professional quality management plan. (79.49% implemented / 8.94% in progress) A guideline for classification of report defects, discrepancies, discordances and errors, and a policy for their investigation and resolution. (79.5% implemented / 14.29% in progress) 20 QUALITY MANAGEMENT PARTNERSHIP 10
PROPOSED PRIORITIZED STANDARDS (2 / 3) External Review: A policy that outlines the processes for handling requests for review of cases by an external source, including the documentation and review of those results (83.33% implemented / 6.41% in progress) Turnaround Times: A policy that outlines the processes for monitoring of turnaround times on a regular basis. (92.31% implemented / 2.56% in progress) Collect and review data on turnaround times, for the professional group. (Data collection: 87.18% have implemented. Data review: 73.53% review cancer and non-cancer reports; 14.71% review cancer reports only) 21 QUALITY MANAGEMENT PARTNERSHIP PROPOSED PRIORITIZED STANDARDS (3 / 3) Intra-operative Consultation: A policy that outlines the processes for, and the documentation of, the comparison of intra-operative consultation results with final diagnoses. (74.36% implemented / 10.26% in progress) All laboratories must collect and review data on the accuracy of intra-operative consults and deferral rates, for the professional group. (74.36% implemented data collection for both accuracy and deferral rates / 28.17% have implemented for accuracy only) Monitoring/ Maintenance: Standards and best practice guidelines for internal quality assurance must be maintained and monitored. 22 QUALITY MANAGEMENT PARTNERSHIP 11
PROPOSED PRIORITIZED FACILITY LEVEL INDICATORS FOR 16/17 S2Q Category Indicator Definition Turnaround Time Intra-operative Consultation Intra-operative Consultation Turnaround Time Intra-operative Consultation Deferral Rate Intra-operative Consultation Accuracy Rate Average facility time from specimen receipt to case sign out for professional group overall for all surgical pathology cases Number of deferred intra-operative consultations for the professional group/ total cases for the professional group Number of accurate intraoperative consultations for the professional group/ total cases for the professional group 23 QUALITY MANAGEMENT PARTNERSHIP IMPLEMENTATION CONSIDERATIONS Prioritizing standards that have strong stakeholder support, good alignment with existing initiatives and adequate resources for execution Developing supports for facilities to implement prioritized standards (e.g. sharing templates and best practices) Focusing initially on a subset of facility indicators; provider-level reporting out of scope for now 24 QUALITY MANAGEMENT PARTNERSHIP 12
TIMELINE OF KEY IMPLEMENTATION ACTIVITIES 2015/16 2016/17 An inaugural report on quality (Building on Strong Foundations: Inaugural Report on Quality in Colonoscopy, Mammography and Pathology) will be released Begin to establish Quality Management Model clinical leadership structure (provincial, regional, and facility leads) Early Quality Initiatives complete Finalize Quality Management Model clinical leadership structure First release of QMP reports at the facility, regional, and provincial level Stakeholder engagement, consultation, communications and change management 25 QUALITY MANAGEMENT PARTNERSHIP CONTACTS AND INFORMATION Dr. Kathy Chorneyko, Clinical Lead, Pathology, Quality Management Partnership katherine.chorneyko@bchsys.org Annette Ellenor, Manager, Pathology, Quality Management Partnership annette.ellenor@cancercare.on.ca www.qmpontario.ca 26 QUALITY MANAGEMENT PARTNERSHIP 13