Tim Shaw

Sarah York

Nicole Rankin

Deborah McGregor

Sanchia Aranda

Kahren White

Jane Young

Shelley Rushton

Deb Baker

Megan Varlow

Tina Chen

Tracey Flanagan

Background

CI NSW looking to develop Key Performance Indicators to measure coordinated care

University of Sydney Commissioned to undertake a consultative approach to develop and prioritise success factors as first step

Cancer care workshop

Scoping lit review

Stakeholder survey

Consumer input

Small group refinement and testing

20 success factors for coordinated care

Priority setting workshops

Priority factors

CI NSW develop KPIs

Coordinated Cancer Care Success Factors

Success Factors - relatively broad statements which collectively describe successfully coordinated care from a systems, practitioner and patient POV.

A number of indicators could sit under each success factor

Example

Success Factor: Patients receive timely & appropriate care on the pathway from first presentation to diagnosis and to commencement of treatment.

Indicator: Time from first presentation to treatment is recorded and meets recognised tumour specific benchmark

Indicator: Patient survey indicates time to treatment acceptable'

Coordinated Cancer Care - Success Factors

1. Patients receive best practice care defined by clinical practice guidelines or a clinical pathway for each tumour group.

2. Patients receive timely and appropriate care on the pathway from first presentation to diagnosis and to commencement of treatment.

3. Patient care takes into account patient and carer needs and preferences (e.g. service locations).

4. Patients at elevated risk of disjointed care and poorer outcomes (e.g. CALD, Aboriginal & Torres Strait Islander) are identified and systems are in place to ensure care is appropriately managed and coordinated.

5. All patients have a comprehensive care plan that is created jointly by patients, family and health professionals and that is documented, accessible by relevant care providers and patients and maintained over the course of their care.

6. Transition of patients across each point of the care trajectory (e.g. from diagnosis to treatment) is well managed and takes into consideration the patient’s physical, social and emotional needs.

Coordinated Cancer Care - Success Factors 7. Transfer of patient information (e.g. test results) between members of the

multidisciplinary team is timely and well managed at each transition point.

8. Patients, families and carers receive timely, relevant and appropriate information at key points along their care trajectory; this may include their diagnosis, prognosis and intention of treatment (e.g. curative/palliative), depending on cultural appropriateness

9. Patients have timely referral and allocation to a key contact person to assist with the coordination of their care.

10. Transfer of information and care between primary and community care providers and specialist services is timely and appropriate.

11. Patients, carers and families know who to contact for information at different stages during their care trajectory.

12. All patients are considered for discussion at an MDT meeting in a timely manner and exclusions are guided by protocols

13. All appropriate team members from core disciplines (including diagnostic, oncology clinicians, GPs, allied health and supportive care) attend and contribute at weekly/fortnightly MDT meetings.

Coordinated Cancer Care - Success Factors

14. MDT meeting members are made aware of patient concerns, preferences and social circumstances and MDT meeting discussions consider a patient’s medical and supportive care needs.

15. The roles and responsibilities of all health care professionals involved in patients care are communicated and understood.

16. Side effects of disease and treatment are managed in a timely and appropriate manner by the care team to reduce unnecessary visits to ED and hospital admissions.

17. Patients are routinely screened for physical, psychological and supportive care needs using validated tools and referred to required services in an appropriate and timely manner.

18. Patients are aware of and have access to practical assistance and financial entitlements as appropriate (e.g. transport and accommodation).

19. Patients receive clear follow-up care plans according to tumour specific guidelines and appropriate survivorship information.

20. Patients receive timely screening and referral to palliative care services.

Priority Setting Workshop

Implement a process of selecting the most significant and measurable success factors for future KPI development

Based on Sydney Catalyst Methodology

Individual Matrix ActivitySignificance Measurability

Transfer of information and care between primary and community care providers and specialist services is timely and appropriate.

Patients receive timely screening and referral to palliative care services.

Success Factor

Criteria

Agree Least

Agree Most

1 2 3 4 5

Priority Setting Criteria

Significance Measurability

Most likely to impact on patient outcomes

Could a KPI be developed that could be feasibly measured and reported on across the board?

Current data point or system in place to allow for data collection (or soon to be)

Data sources- Electronic database (OMIS/RIS)-Patient Reported

‘Dotmocracy’

Identified Priorities

Next steps..4 x priority setting workshops with

care coordinators

1 x priority setting workshop with Cancer Council NSW consumer group

Develop initial set of indicators built around success factors

ConclusionFirst time success factors have been

identified

Good agreement on priorities across workshops to date

Approach represents a constructive way to begin to measure improvement across the cancer system in NSW'