Cancer Imaging Program

The Quality Agenda

J. Dobranowski MD FRCPC

MITT 2013

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Cancer Imaging ProgramCancer Care Ontario

No conflicts of interest to disclose ( i.e. no industry funding received or other commercial relationships)

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Agenda

• About CCO• About CIP• Why Quality Improvement• Priorities• The CIP Quality Journey• Access to Care

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Who is Cancer Care Ontario?• Directs and oversees more than $1 billion to hospitals and other cancer care providers to

deliver high quality, timely cancer, kidney and other healthcare services

• Uses information technology/management, informatics, project management and clinical expertise to execute provincial strategies

CancerCCO’s core mandate since 1943 as mandated by the

provincial Cancer Act

Chronic Kidney Disease Ontario Renal Network

launched June 2009

Access to CareBuilding on Ontario’s Wait Times Strategy

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CCO’s Evolution

Cancer Act passed;

Ontario Cancer Treatment Research

Foundation (OCTRF) born

1940

THE EVOLUTION

Ontario Renal Network

Access to Care

Today

Specialized Cancer

Services

Cancer Care Ontario

Ontario Cancer Registry

transferred to OCTRF

Ontario Breast Cancer

Screening Program launched

CCO launches under new name to promote better

integration of cancer services

Cancer Quality Council of

Ontario created to measure

system performance

CCO implements Wait Times Information

System public reporting of wait

times

Ontario Renal Network

created

Specialized cancer services

(i.e., Bone Marrow

Transplant)

1970

1990

1997

2002

2004/5

2009

2010

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Our Core Competencies

Performance Management and

Management Cycle

Performance Management and

Management Cycle

Standards and Guidelines

Standards and Guidelines

Public Reporting and Transparency

Public Reporting and Transparency

IM/ITIM/IT

Health System Policy Expertise

Health System Policy Expertise

Clinical Engagement and Alignment

Regional Partnerships

Clinical Engagement and Alignment

Regional Partnerships

Cancer

As mandated

by the Cancer Act;

Ontario Cancer Plan

III

Access to Care

Building on Ontario’s Wait Time Strategy

Chronic Kidney Disease

Ontario Renal

Network launched

June 2009

Driving performance and quality

Mandated Service Core Competencies

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Performance Management

Data/Information

Knowledge

Transfer

Our Performance Improvement CycleQuality and its continuous improvement is a critical goal across the health care system.

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Vision and Mission

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Areas of Focus

Patient-Centred Care

Prevention of Chronic Disease

Integrated Care

Value for Money

Knowledge Sharing & Support

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Presented by: Michael Sherar, President & CEO

April 8,2011

Ontario Cancer Plan2011-20152011-2015Patient-centered, quality driven cancer care

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1. Develop and implement a focused approach to cancer risk reduction

2. Implement integrated cancer screening

3. Continue to improve patient outcomes through accessible, safe, high quality care

4. Continue to assess and improve the patient experience

5. Develop and implement innovative models of care delivery

6. Expand our efforts in personalized medicine

Six strategic priorities in Ontario Cancer Plan III

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Why Imaging?

Prevention

Screening

Diagnosis

Treatment

Recovery

End-of-Life Care

IMAGING

2009

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Cancer Imaging Program

Cancer Imaging Program•Regional Leadership•Provincial Priorities

PET Scans Ontario•PET Steering Committee•Operations

• Reimbursement• PET Access

•Evidence building• PEBC review• Registry/Access• Clinical Trials

•Communication

SETTING PRIORITIES

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Safe EffectiveAccessible/

Timely

Patient Centred/

Responsive Equitable Integrated Efficient

Prevention

Screening

Diagnosis

Treatment

Recovery

End-of-Life Care

Cancer Imaging Program-Opportunities

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Cancer Imaging Program – Priorities

Four priority areas:• Appropriateness• Timely Access to Imaging• Standardized/Synoptic Reporting• Development and Fostering of Imaging

Communities of Practice

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Appropriateness

Ensure patients are being referred for tests that would benefit them. Optimize safety and system resources by avoiding tests that won’t.

How:• Endorsement guidelines One-stop decision support for appropriate

use of cancer imaging• Collation of existing guidance, packaged into a useable form

• Topic-specific guideline development• Often target areas of emerging technology (breast MRI,

suggesting prostate MRI)

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CIP Guideline Endorsement - Methods

Review Lung Cancer Diagnosis

DPM

• Disease Pathway Maps (DPMs) • comprehensive pathways of disease-specific cancer

journey’s

• The CIP worked with the DPM team to create a radiology cut of the pathway

• Critical imaging nodes identified in pathway

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CIP Guideline Endorsement - Methods

Guideline selection and

review

•Guidelines were screened for relevance by lead author• All relevant guidelines reviewed by other members of the

working group.

•Selected relevant guidelines assessed for quality • Using the AGREE II scores available through the SAGE database

• Lung cancer imaging guidelines identified by internet search using:• The Program in Evidence Based Care preferred list of guideline developers

• Guideline directories of Canadian and international health organizations

• The National Guidelines Clearinghouse

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CIP Guideline Endorsement - Methods

Recommendations compiled

• Recommendations relevant to the decision identified through DPM complied and reviewed by the working group as candidates for endorsement

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CIP Guideline Endorsement - Methods

Endorsed recommendations

externally reviewed

• Endorsed recommendations were reviewed:• Internally by CIP Clinical leads• Externally by a group of health

professionals including radiologists and other imaging professionals, medical oncologists, radiation oncologists, surgeons

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Timely Access to Cancer Imaging

To support and ensure timely, equitable access to quality imaging across the province.

But first, we need data….

• Wait times – Interventional Radiology Initial, then ongoing survey of wait times for priority (high-volume, high impact) procedures• Report in preparation

• Wait times – ‘Cancer Flag’ Leverage ATC CT/MRI wait time data collection – addition of cancer flag • Improving clarity regarding use

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IR Wait Time Collection - Methods

• Priority procedures identified via consensus• Selected based on volume and impact to patient care

• PICC (peripherally inserted central catheter) lines, portacaths and CT-guided lung biopsies (CTBx))

Data Collection

• Participating hospitals emailed 1x per month and asked to submit first and second available appointments for each procedure

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IR Wait Time Collection - Methods

• Data collected between Apr 2012 to Jan 2013 analyzed to determine:• Median wait times • 90th percentiles; and• Variance for each procedure

• Target timelines identified through consensus to aid interpretation of results:

• 7 Days• 14 Days• 28 Days

Data Limitations:• High level data, non-patient level• Does not capture all possible PICC line and poratcath insertions• Assumes referral is complete and procedure occurs on given date

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IR Wait Time Collection – PICC Line Results

*LHIN Numbers removed and data placed in random sequence for anonymity

Number/percentage of hospitals meeting timeline

(number of participating hospitals = 36)

   

1st Available Appointment 2nd Available Appointment

Value n (%) Value n (%)

Within 7 days 29 (81%) 24 (67%)

Within 14 days 35 (97 %) 35 (97%)

Within 28 days 36 (100%) 36 (100%)

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IR Wait Time Collection – CTBx Results

Number/percentage of hospitals meeting timeline

(number of participating hospitals = 35)

   

1st Available Appointment 2nd Available Appointment

Value n (%) Value n (%)

Within 7 days 13 (37%) 7 (20%)

Within 14 days 26 (74%) 21 (60%)

Within 28 days 35 (100%) 35 (100%)

*LHIN Numbers removed and data placed in random sequence for anonymity

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Timely Access to MRI/CT - ATC

Cancer Surgery

Expansion to major Surgical Areas

Cataract Surgery

Hip & Knee Replacement

MRI & CT Scans

Cardiac Procedures

Perioperative Efficiencies (SETP)

Key Health Services Targeted

Ontario’s Wait Time Strategy was introduced by the Ministry of Health and Long-Term Care in November 2004. The Wait Time Strategy was developed to improve access to five key health services by reducing wait times, and then expanded to include wait time data for major surgeries as well as perioperative efficiencies.

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MRI CT Approach

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Ontario MRI CT Targets 2005

• MRI 62 per 1000• CT 114 per 1000• P1- 4 targets

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96 CT scanners hospitals 4 CT in IHF’s

ATC- CT

81 day P4 wait

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CT 2005 How did we compare? (OECD)(CIHI)

CT Scan Rate per 1,000 population 2005 2006 2007

Ontario 79.4

Canada 101.6

Australia 88.6

France 111.1

United States 194.8

Denmark 71.4

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Provincial Wait Time Trend: CT

• CT wait time has been relatively stable since late 2010 at just above the 28 days priority 4 target.

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CT scans ordered and completed by Fiscal Year

171 scanners (base 94)

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CT scan rates per 1,000 population

• Data Source: • 2008-2011 – Wait Time Information System, Cancer Care Ontario

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CT Scan Rate per 1,000 population –

comparison (OECD)(ATC)

CT Scan Rate per 1,000 population

2007 2008 2009 2010 2011

Ontario --- 78.3 81.5 79.7 78.5

Canada --- 119.0 125.4 --- ---

Australia 88.6 93.4 93.9 --- ---

France 120.3 130 138.7 --- ---

United States 227.9 --- --- --- ---

Denmark 73.6 83.8 --- --- ---

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CT what changed?

• Capacity- bulk buy• incremental funding• Demand-

Completed Scan Volume

YEAR CT Population

2008 1,012,868 12,919,572

2009 1,065,470 13,050,754

2010 1,053,540 13,193,809

2011 1,050,597 13,349,125

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CT- 2013 current wait time P4

• February 2013 – P4 Wait time 90 percentile = 28 days

• Increased capacity• Improved efficiencies• Stable or decreasing demand

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ATC- MRI

• 52 MRI scanners in hospitals

• 5 MRI in IHF’s• 257,042 total scans

120 day P4 wait

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MRI 2005 How did we compare? (OEDC) (CIHI)

MRI Scan Rate per 1,000 population 2005 2006 2007

Ontario 27.4

Canada 30.7

Australia 20.2

France 38.2

United States 84.3

Denmark 27

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Provincial Wait Time Trend: MRI

• Wait time for MRI scans peaked on October 2010 at 127

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Comparison of MRI Orders Received & Scans Completed

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MRI scan rates per 1,000 population

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MRI Scan Rate per 1,000 population –

comparison (OECD)(ATC)

MRI Scan Rate per 1,000 population

2007 2008 2009 2010 2011

Ontario --- 38.7 41.2 43.7 47.5

Canada --- 40.6 43.0 --- ---

Australia 20.2 21.4 23.3 --- ---

France 44.2 48.4 55.2 --- ---

United States 91.2 --- --- --- ---

Denmark 36 37.8 --- --- ---

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Removing variability

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Provincial Wait Time Trend: MRI and CT

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Backlog

demand capacity time

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Looking at the MRI backlog

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Backlog management- The Blitz

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MRI Blitz: Impact on Overall Provincial Wait Times

Participating hospitals were notified of their additional volume allocations in November 2010, December 2010, January 2011

Provincial wait times closely followed wait times for blitz hospitals

Participating hospitals reached the lowest wait time of 93 days in June 2011, 3 months after receipt of funding

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MRI – System improvement

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Data Captured in Weekly Performance Dashboards by MRI-PIP Hospitals

Outcome Indicators

1.MRI Wait Times

Time between requisition received and exam completed •By priority•By body division•By hospital site (for multi-site facilities)•By contrast/non-contrast

1.MRI Report Turnaround Times Time between exam completed and report verified

1.MRI Exams RequestedNumber of exams requested (i.e. demand)•By priority•By body division

1.MRI Volumes Performed

Number of exams completed •By priority•By body division•By hospital site (for multi-site facilities)•By contrast/non-contrast

1.Planned Operating Hours Utilization

[Sum of actual scanning time for pre-booked patients/Sum of operating hours dedicated to pre-booked patients] *100

1.Unplanned Operating Hours Utilization

[Sum of actual scanning time for unscheduled patients (e.g. inpatients and emergency) /Sum of operating hours dedicated to unscheduled patients] *100

PIP Outcome Indicators

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Process Indicators

1.Requisition Completeness [Number of complete requisitions / Number of requisitions received] * 100

2.Booking Turnaround Time Time between requisition received and appointment booked

3.Booking Volumes Number of appointments booked

4.Booked Time Utilization [Sum of hours planned time of booked exams/Sum of operating hours available to be booked] *100

3.Requisitions Received Relative to Time Allocated

[Sum of hours of incoming requests/Sum of hours in scheduling template] *100•By priority•By body division•By contrast/non-contrast

3.Actual Hours Performed Relative to Time Allocated

[Sum of actual scanning time/Sum of hours in scheduling template] *100•By priority•By body division•By contrast/non-contrast

3.Protocolling Turnaround Time Time between requisition sent for and received from protocolling

3.No Show Rate [Number of no shows / Number of appointments booked] * 100

3.No Shows Filled [Number of no shows filled / Number of no shows] * 100

3.On-Time Scan Starts [Number of early and on-time exams / Number of exams completed] * 100

3.Patient Prep Time Time between registration and scan start

3.Room Turnaround Time Time between patient 1 exiting scan room to patient 2 entering

3.Planned Scan Time AccuracyPlanned scan time – Actual scan time•By procedure

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MRI PIP Wait Times Improve in London

Patients Getting Needed MRIs SoonerThe London Free Press. Aug 2010

The improvements mean 780 more patients can be scanned each year with MRI at St. Joseph’s, said Glen Kearns, integrated vice president, clinical support services and information technology services at St. Joe’s and London Health Sciences Centre (LHSC).

As part of a project with Ontario’s Health Ministry, St. Joe’s dissected every MRI process, assessed what worked and what could be tweaked, then put the process back together more effectively for patients and staff.

The results:•An average 50 days’ wait for semi-urgent patients (down from 104 days a year ago) and 60 days (down from 149) for non-urgent patients; •212 MRI exams each week, or 15 more a week than a year ago.

LHSC is in the middle of a similar process, one made more complex by the wider range and type of MRI services offered for inpatients and outpatients. So far, the waits there have dropped to an average 86 days, from 150 as recently as six months ago. That pace of improvement means 1,000 more patients can be scanned each year, he said.

MRI PIP

MRI PIP

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MRI PIP Wait Times Improve in Ottawa

Improving Equitable Access to ImagingJ American College of Radiology. Aug 2010

The Ottawa Hospital Rapid Improvement Event team was assembled and completed a 4-day review of the booking process and scheduling in MRI. They then delineated additional steps that could be initiated to potentially reduce wait times. This was undertaken using Lean methodology brought forth by the Ontario government to evaluate process improvement and patient throughput at all stages of navigation through the system . Some of the main goals and strategies of the Lean project include the following:

•Improving efficiency of each scan•Improving patient flow and throughput •Improving booking process •Evaluating the patterns of unfilled spots and adjusting the schedule commensurately •Reducing physicians’ redundant ordering of diagnostic imaging tests through education on appropriate indications MRI PIP

MRI PIP

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MRI- 2013 current wait time P4

• February 2013 – P4 Wait time 90 percentile = 60 days

• Increased capacity• Improved efficiencies

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Future considerations

If no significant wait time…

Then are we doing enough or are others doing too much?

?Over or Underutilization

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Standardized/Synoptic Reporting

Collect uniform and complete data to improve the information available to referring clinicians for diagnosis and treatment planning

How:• Champion rectal cancer MRI template

• Developed by SOP to ensure surgeons get information needed, distributed in part by Leads and working towards implementation

• Multi-disciplinary Expert Panel • To determine minimum standards needed in synoptic reports, identify

disease sites of focus, recommend development and maintenance framework

• Roadmap • To guide provincial deployment

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May 20, 1896

Dear Dr Stieglitz:

The X ray shows plainly that there is no stone of an appreciable size in the kidney. The hip bones are shown & the lower ribs and lumbar vertebrae, but no calculus. The region of the kidneys is uniformly penetrated by the X ray & there is no sign of an interception by any foreign body.

I only got the negative today and could not therefore report earlier. I will have a print made tomorrow. The picture is not so strong as I would like, but it is strong enough to differentiate the parts.

Yours very sincerely

W.J. Morton

Synoptic reporting

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PET/CT

1999 OANM - Request for Provincial funding for PET2000 ICES- Review of Evidence2001 ICES- Report- Health Technology Assessment of PET

“despite the availability of PET scanning for almost three decades, the number of methodologically high quality studies (and the numbers of patients within these studies) is distressingly small.”

Institute for Clinical Evaluative Sciences. 2001 (May) Health Technology Assessment of Positron Emission Tomography (PET) – A Systematic Review. An ICES Investigative Report.

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Program Objective:

Introduce and use PET according to high-quality evidence, insuring availability of PET for appropriate indications on a timely basis

2004Ministry of Health in Ontario (MOH) takes evidence-based

approach to the introduction of PET imaging

2009MOH insured nine indications, and transitioned oversight of

a continuing evaluative program for new indications to Cancer Care Ontario (CCO)

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PET (Positron Emission Tomography)

Ensure PET/CT scans are available to Ontario patients for appropriate indications on a timely basis.

What is appropriate?• Use of PET scanning where there is evidence that the scan has the

potential to impact patient management

How? • Access• Evidence• Advice• Communication

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Evaluative Program Elements:

PET Steering CommitteeExpert advisors to MOH

PET RegistryField evaluation of promising indications

Clinical TrialsTesting diagnostic accuracy and impact to patient management

PET Access ProgramCase-by-case review for patients not meeting other eligibility criteria

Evidence ReviewContinuous review, ensuring recommendations are current

CommunicationOngoing promotion of equitable access across Ontario

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PET Scans Ontario• www.petscansontario.ca

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Measuring

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Questions/Discussion