quality management partnership - university of toronto · 2017-03-20 · 2015-11-12 3 5 quality...

2015-11-12

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Quality Management Partnership: Pathology Quality Management Program U of T Pathology Update November 13, 2015 Dr. Kathy Chorneyko, Clinical Lead, Pathology, Quality Management Partnership

2 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

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In March 2013, the Ministry announced a formal partnership between CCO and CPSO to develop

provincial quality management programs for colonoscopy, mammography and pathology

WHAT IS THE QUALITY MANAGEMENT PARTNERSHIP?


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

WHAT ARE THE DRIVERS?

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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


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

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ALIGNING ACROSS THE SYSTEM

Quality Management Partnership

MOHLTC Initiatives

CPSO Peer & Facility

Assessments

Local Facility Structures

Health System Organizations

Existing Evidence & Standards

CCO Programs


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

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QUALITY MANAGEMENT MODEL


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

QMP Facility Leads

Pathologists

Working groups (e.g., pediatrics)

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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


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

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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


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

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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


EARLY QUALITY INITIATIVES (EQIS)

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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


PRIORITIZATION OF STANDARDS AND INDICATORS

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PRIORITIZATION OF QMP RECOMMENDATIONS

Process: ! 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


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)

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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)


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.

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PROPOSED PRIORITIZED FACILITY LEVEL INDICATORS FOR 16/17

S2Q Category

Indicator Definition

Turnaround Time Turnaround Time

•  Average facility time from specimen receipt to case sign out for professional group overall for all surgical pathology cases

Intra-operative Consultation

Intra-operative Consultation Deferral Rate

•  Number of deferred intra-operative consultations for the professional group/ total cases for the professional group

Intra-operative Consultation

Intra-operative Consultation Accuracy Rate

•  Number of accurate intra-operative consultations for the professional group/ total cases for the professional group


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

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TIMELINE OF KEY IMPLEMENTATION ACTIVITIES

Stakeholder engagement, consultation, communications and change management

2015/16

•  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

2016/17


CONTACTS AND INFORMATION

•  Dr. Kathy Chorneyko, Clinical Lead, Pathology, Quality Management Partnership [email protected]

•  Annette Ellenor, Manager, Pathology, Quality Management Partnership [email protected]

•  www.qmpontario.ca

quality management partnership - university of toronto · 2017-03-20 · 2015-11-12 3 5 quality...

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