Cancer Care Ontario's experience with implementation of routine physical and psychological symptom distress screening.

OBJECTIVE: In late 2006, Cancer Care Ontario launched a quality improvement initiative to implement routine screening with the Edmonton Symptom Assessment System (ESAS) for cancer patients seen in fourteen Regional Cancer Centres throughout the province. METHODS: A central team: created a provincial project plan and management and evaluation framework; developed common tools and provided expert coaching and guidance, provincial data analysis, progress reporting and program evaluation. Regional Steering Committees and Improvement teams were accountable for planning and coordination within each region and supported by a funded Regional Improvement Coordinator. A hybrid model for quality improvement facilitated process improvements and uptake of screening. RESULTS: Challenges to implementation included: lack of consensus on the chosen screening tool, lack of guidance for assessment or management of high scores, concern of inadequate time or resources to address issues identified by the screening, data entry was labour intensive, resistance to change and challenges to the traditional care model. Essential components for success were: centralized project management, a person dedicated to implementation of the project locally, clinical champions, clearly identified aims, monthly regional data reporting and implementation of quality improvement methodologies with expectations for performance. To achieve screening aims many centres engaged all members of the team, examined the roles of the different members and reorganized workflow and responsibilities and changed booking times. In March 2010, approximately 25,000 ESAS's were completed in the regional cancer centres across Ontario, with 60% of lung cancer patients and almost 40% of all other cancer patients who visited the Regional Cancer Centres screened. CONCLUSION: Routine physical and psychological distress screening is possible within regional cancer centres. Although considerable effort and investment is required, it is worthwhile as it helps create a culture that is more patient-centered.

Determining resource intensity weights in ambulatory chemotherapy related to nursing workload.

Ontario cancer programs aim to deliver high-quality nursing care and treatment that is safe for patients and staff. The reality of health care is that financial constraints, inherent in the delivery of care, require that funding mechanisms count not only the cost of drugs, but factors such as pharmacy and nursing human resource costs. While some organizations have developed patient classification systems to measure nursing intensity and workload, these systems apply primarily to inpatient populations, and are fraught with numerous challenges, such as the need for nurses to document to justify the workload required for care. The purpose of this paper is to outline the methodology and engagement of nurses to develop regimen-based resource intensity weights that can be applied to ambulatory chemotherapy suites. The methodology included determination of workload related to nursing time to prepare, teach, counsel and assess patients, as well as time to gather supplies, access lines, monitor, manage adverse reactions, manage symptoms and document care. Resource intensity weights provide better measures of the complexity of care required by cancer patients in ambulatory settings.

Ontario, Canada: using networks to integrate palliative care province-wide.

Ontario, a Canadian province, identified the lack of coordination, integration, and consistency of end-of-life care services as barriers to quality palliative care. To address these barriers, various governmental, organizational, and community-level initiatives were implemented. The Ministry of Health and Long-Term Care enacted an End-of-Life Care Strategy in 2005 aimed at shifting care from acute settings to appropriate alternate settings of care; enhancing client-centered and interdisciplinary service capacity; and improving access, coordination, and consistency of services. Crucial to accomplishing the strategy was the establishment of End-of-Life Networks within health care planning regions. The networks were instrumental in developing end-of-life care service delivery models in the various regions, bringing key stakeholders together toward a common vision, and building strong collaborations across providers and settings. Cancer Care Ontario, an organization dedicated to improving cancer care at the regional and provincial levels, also leads improvements in palliative care through the implementation of a palliative strategy for cancer patients aimed at improved measurement of quality indicators, increased use of evidence and standards, and increased efficiency and access to care. A regional network of organizations in Southeastern Ontario created a quality improvement project, the Palliative Care Integration Project (PCIP), which disseminated common symptom assessment tools, collaborative care plans, and evidence-based guidelines across the continuum of care. The PCIP was embraced by key stakeholders across the province as a model intervention to better coordinate, integrate, and standardize palliative care service delivery, and is currently being spread across all regions of the province.

Quality councils as health system performance and accountability mechanisms: the Cancer Quality Council of Ontario experience.

Recent national and provincial reviews on the status of healthcare in Canada have recommended the establishment of quality councils to guide quality improvement efforts. The emergence of quality councils, such as the Health Quality Council of Alberta, the Saskatchewan Health Quality Council, the Cancer Quality Council of Ontario and the Health Council of Canada, reflect new but largely unscrutinized models for improving quality of care. We discuss the varying mandates of these new quality councils, their fit with evolving governance and accountability structures and the credibility and legitimacy of their role as perceived by other health system organizations. To further illustrate these issues, we present insiders' perspectives on the Cancer Quality Council of Ontario's activities over its first three years, including the initial agenda, critical success factors and the nature of evolving relationships with other organizations in Ontario's healthcare system. While current Canadian quality councils represent an eclectic mix of methods for achieving improvements in quality of care, it is not entirely clear how quality councils will stimulate sustained and significant improvements in quality of care where other models have failed. However, these new Canadian quality councils represent natural experiments in motion from which much needs to be learned.

Transforming cancer services in Ontario: a work in progress.

Cancer Care Ontario (CCO) is the largest provincial cancer agency in Canada, with a long and rich history as a specialized service entity within a generic delivery system in Ontario. CCO's evolution has been well characterized by Hayter (1998), and described by us previously (Sullivan et al. 2003, 2004). Once criticized as a very inward-looking body with a mixed record in solving a series of radiation waiting-time crises, CCO has reinvented itself over the past three years in ways that are very similar to the transformation of the Veterans Health Administration.

Can better care for complex patients transform the health system?

The idea that a health system can recover significant value by focusing on better care management for a relatively small cohort of high needs patients has taken flight. Given a poor fiscal outlook, and anticipating the growing number of people who will come to rely on the healthcare delivery system, health system leaders are keen to seize opportunities to find greater value within the existing health system investment. This paper discusses what it means to be a so-called "high cost user," and how health systems have approached improving care and services for this population. It also describes Ontario's particular experience in launching the Health Links initiative as a "ground game" for health system transformation.

Quality improvement in cancer symptom assessment and control: the Provincial Palliative Care Integration Project (PPCIP).

CONTEXT: The Provincial Palliative Care Integration Project (PPCIP) was implemented in Ontario, Canada, to enhance the quality of palliative care delivery. The PPCIP promoted collaboration and integration across service sectors to improve screening and assessment, palliative care processes, as well as clinician practice and outcomes for cancer patients. OBJECTIVES: The project involved 1) implementation of the Edmonton Symptom Assessment System (ESAS) for symptom screening, 2) use of "rapid-cycle change" quality improvement processes to improve screening and symptom management, and 3) improvements in integration and access to palliative care services. METHODS: Symptom scores were collected and made accessible to the care team through a web-based tool and kiosk technology, which helped patients enter their ESAS scores at each visit to the regional cancer center or at home with their nurse. Symptom response data were gathered through clinical chart audits. RESULTS: Within one year of implementation, regional cancer centers saw improvements in symptom screening (54% of lung cancer patients), symptom control (69% of patients with pain scores and 31% of patients with dyspnea scores seven or more were reduced to six or less within 72 hours), and functional assessment (23% of all patients and 64% of palliative care clinic patients). ESAS screening rates reached 29%, and functional assessment reached 26% of targeted home care patients. CONCLUSION: The PPCIP demonstrated that significant strides in symptom screening and response can be achieved within a year using rapid-cycle change and collaborative approaches. It showed that both short- and long-term improvement require ongoing facilitation to embed the changes in system design and change the culture of clinical practice.

Development of a set of strategy-based system-level cancer care performance indicators in Ontario, Canada.

OBJECTIVES: To develop a set of scientifically sound and managerially useful system-level cancer care performance indicators for public reporting in Ontario, Canada. IMPLEMENTATION: Using a modified Delphi panel method, comprising a systematic literature review and multiple rounds of structured feedback from 34 experts, the Cancer Quality Council of Ontario developed a set of quality indicators spanning cancer prevention through to end-of-life care. To be useful to decision-makers and providers, indicator selection criteria included a clear focus on the cancer system, relevance to a diversity of cancer providers, a strong link to the mission and strategic objectives of the cancer system, clear directionality of indicator results, presence of targets and/or benchmarks, feasibility of populating the indicator, and credibility of the measure as an indicator of quality. To ensure that the selected indicators would measure progress over time against specific and widely accepted goals, we created a strategy map based on the five strategic objectives of the Ontario cancer system: (i) to improve the measurement and reporting of cancer quality, (ii) to increase the use of evidence and innovation in decision-making, (iii) to improve access to cancer services and reduce waiting times, (iv) to increase efficiency across the system, (v) to reduce the burden of cancer. An analysis of the mean indicator ratings by experts, and the strategy mapping exercise resulted in the identification of 36 indicators deemed suitable for routine performance measurement of the Ontario cancer system. LESSONS LEARNED: The resulting instrument incorporates a credible evidence basis for performance measurement aligned to the five strategic goals for the Ontario cancer system. It represents the integrating of a management culture, focused on the implementation of a new strategic direction for the cancer system, with the underlying evidence-based culture of clinicians.