Implementation and evaluation of a national quality improvement initiative in cancer surgery.

BACKGROUND: In 2017, the Canadian Partnership Against Cancer, a Canadian federally sponsored organisation, initiated a national multijurisdictional quality improvement (QI) initiative to maximise the use of synoptic data to drive cancer system improvements, known as the Evidence for Surgical Synoptic Quality Improvement Programme. The goal of our study was to evaluate the outcomes, determinants and learning of this nationally led initiative across six jurisdictions in Canada, integrating a mix of cancer surgery disease sites and clinicians. METHODS: A mixed-methods evaluation (surveys, semistructured interviews and focus groups) of this initiative was focused on the ability of each jurisdiction to use synoptic reporting data to successfully implement and sustain QI projects to beyond the completion of the initiative and the lessons learnt in the process. Resources provided to the jurisdictions included operational funding, training in QI methodology, national forums, expert coaches, and ad hoc monitoring and support. The programme emphasised foundational concepts of the QI process including data literacy, audit and feedback reports, communities of practice (CoP) and positive deviance methodology. RESULTS: 101 CoP meetings were held and 337 clinicians received feedback reports. There were 23 projects, and 22 of 23 (95%) showed improvements with 15 of 23 (65%) achieving the proposed targets. Enablers of effective data utilisation/feedback reports for QI included the need for clinicians to trust the data, have comparative data for feedback, and the engagement of both data scientists and clinicians in designing feedback reports. Enablers of sustainability of QI within each jurisdiction included QI training for clinicians, the ability to continue CoP meetings, executive and broad stakeholder engagement, and the ability to use pre-existing organisational infrastructures and processes. Barriers to continue QI work included lack of funding for core team members, lack of automated data collection processes and lack of clinician incentives (financial and other). CONCLUSION: Success and sustainability in data-driven QI in cancer surgery require skills in QI methodology, data literacy and feedback, dedicated supportive personnel and an environment that promotes the process of collective learning and shared accountability. Building these capabilities in jurisdictional teams, tailoring interventions to facility contexts and strong leadership engagement will create the capacity for continued success in QI for cancer surgery.

Data that makes a difference in quality improvements in primary health care: approaches through a pan-Canadian voluntary electronic medical record source.

Primary Health Care (PHC) is the most common health care experienced by Canadians and is an important source of chronic disease prevention and management; however, PHC providers say they have little information about their patient populations, especially groups of patients with multiple conditions. The Canadian Institute for Health Information in collaboration with 50 PHC providers examined the ability to extract and use a subset of PHC EMR data from four disparate environments in an agreed and privacy sensitive manner. Findings describing the feasibility of clinician engagement, EMR data extraction, EMR content standards and data utility gaps, information system requirements, and systemic enablers and barriers are described in this paper. Ability to collect and use discrete and standardized clinical and administrative information is fundamental to improving practice efficiency, optimal use of information, and patient quality of care. Improving quality of EMR data captured at the point of service will considerably enable our ability to measure and understand PHC across Canada; promote dialogue to identify priority information needs; and support health system information uses for clinical program and health system management, research, and population surveillance.

Development of electronic medical record content standards to collect pan-Canadian Primary Health Care indicator data.

In 2006 the Canadian Institute for Health Information (CIHI) released a set of 105 pan-Canadian Primary Health Care (PHC) indicators. This was followed by an assessment of data gaps, which prevented the calculation of the indicators, and the data collection options available to close the gaps. A quality review of Electronic Medical Record (EMR) data indicated a requirement for content standards. In order to assist the provinces as they developed requests for proposal for PHC-based EMRs, the EMR content standards project was born. Considerable effort was made to identify standards for the Electronic Health Record (EHR) including existing national and international EHR content. As well, CIHI attempted to align the content standards with those of other projects such as the Physician Office System Requirements (POSR). The outcome of this project was a set of EMR content standards for 12 pan-Canadian PHC indicators. The standards will be used to develop a prototype of a PHC reporting system that collects and analyzes data to generate clinical quality indicators for regional and longitudinal comparisons. In late 2008, CIHI will release the pan-Canadian PHC Core Reporting Data Set. This project has developed EMR content standards to better understand PHC in Canada.

Accountability and primary healthcare.

This paper examines the accountability structures within primary healthcare (PHC) in Ontario; in particular, who is accountable for what and to whom, and the policy tools being used. Ontario has implemented a series of incremental reforms, using expenditure policy instruments, enforced through contractual agreements to provide a defined set of publicly financed services that are privately delivered, most often by family physicians. The findings indicate that reporting, funding, evaluation and governance accountability requirements vary across service provider models. Accountability to the funder and patients is most common. Agreements, incentives and compensation tools have been used but may be insufficient to ensure parties are being held responsible for their activities related to stated goals. Clear definitions of various governance structures, a cohesive approach to monitoring critical performance indicators and associated improvement strategies are important elements in operationalizing accountability and determining whether goals are being met.

Role of obesity on the risk for total hip or knee arthroplasty.

We asked whether there was an association between obesity levels and subsequent THA or TKA using data from 54,406 THA and TKA patients entered into the Canadian Joint Replacement Registry. We compared these patients with a sample of the Canadian population using the Canadian Community Health Survey of 2006. We analyzed information from the Canadian Joint Replacement Registry to quantify the relative risk for THA or TKA in Canada for specific body mass index categories. In reference to the acceptable weight category of body mass index less than 25 kg/m2, the risk for TKA and THA was 3.20- and 1.92-fold higher, respectively, for overweight individuals (body mass index 25-29.9 kg/m2); 8.53- (TKA) and 3.42-fold (THA) higher for those in the obese Class I (body mass index 30-34.9 kg/m2) category; 18.73- (TKA) and 5.24-fold (THA) higher for those identified in obese Class II (body mass index 35-39.9 kg/m2); and 32.73- (TKA) and 8.56-fold (THA) higher for people in obese Class III group (body mass index > 40 kg/m2). Thus, our data support an association between obesity and subsequent THA and TKA.