Post on 31-May-2020
NEMICS GOVERNANCE CHAIR: Adj./ Prof Linda Mellors DIRECTOR NEMICS: A/Prof Paul Mitchell PROGRAM MANAGER NEMICS: Katherine Simons
SIGNATURE: SIGNATURE: SIGNATURE:
1.PROBLEM STATEMENT
Summary of the problem pertaining to identified priority areas
Focus Area 1: Access/timeliness Problem statement:
Patients referred for (suspected) lung cancer investigation
experience delays in receiving their first specialist appointment (FSA)
and subsequently in commencing their initial treatment.
Optimal state goal:
The time from referral to FSA should be ≤ 14 days.
The time from referral to initial treatment should be ≤ 42 days.
Baseline state:
Health service
FSA ≤14 days of referral
1st treatment ≤42 days of referral
New state:
Eastern Health
100% of patients have FSA ≤ 14 days.
83% of patients commence treatment ≤ 42 days.
Austin Health (VLCR) 62% 45%
Eastern Health (local data) 19% 24%
Northern Health (local data) 68% 39%
Focus Area 2: Process/Quality Problem statement:
Culturally and linguistically diverse (CALD) lung cancer patients have
higher mortality rates than Anglo-Australian patients. The reasons
why are unclear.
Optimal state goal:
Australian data that describes the cultural barriers that influence
pathways to care for lung cancer patients exists.
Baseline state:
No Australian data that examines the barriers along the lung cancer
pathway from symptom appraisal to treatment in CALD populations
exists.
Update:
The LEAD study, which examines barriers to care is underway.
The final report is due in December 2018
Focus Area 3: Process/Quality Problem statement:
Not all complex lung surgery takes place in a facility that meets
Cancer Institute of NSW minimum caseload requirements.
Optimal state goal:
Monitor volumes of complex lung cancer surgeries to ensure case
numbers meet Cancer Institute of NSW recommended minimum
caseload volumes of 18 procedures p.a.
Baseline state:
Small volumes of lung cancer surgery (<10 procedures p.a.) are
being performed at Northern Health.
Update:
Lung surgery volumes remain lower than recommended. Working
with lung team to monitor performance outcomes. NEMICS
position statement and NH Cancer plan being developed. Service
expansion likely over time.
EXECUTIVE SUMMARY Background, executive comments and key project findings
Background and Executive comments Public health services in Victoria manage approximately 76% of all patients with a lung cancer diagnosis. In 2015-16, NEMICS public
health services managed about 21% of these public patient admissions, admitting 3530 patients with lung cancer across three major
health services (Austin Health - 52%, Eastern Health – 30% and Northern Health - 18%).
In Australia approximately 80% of lung cancer patients are diagnosed at a late stage. Early diagnosis has been identified as a key
factor in improving outcomes for these patients. In 2014, the Victorian Lung Cancer Summit working party finalised a list of
recommendations to optimise lung cancer care and improve outcomes for lung cancer patients. A recent analysis of NEMICS lung
cancer data supported the assertion that considerable potential exists to improve the timeliness of diagnosis and treatment for lung
cancer patients. Local data described care that was often not well co-ordinated and contained many inefficiencies.
The potential for improving care for lung cancer patients in the NEMICS region clearly lay in designing solutions to hasten presentation,
streamline triage of referrals, formalise referral pathways to enable rapid diagnosis and ensure treatment can be initiated without
unnecessary delay. Most patients with lung cancer present with late stage disease and as a result experience poor outcomes.
Facilitating presentation and eliminating unnecessary delay in care is an active step towards reducing patient distress and improving
the overall experience of care.
Key Project Findings
0
20
40
60
80
Austin Health EasternHealth
NorthernHealth
Nu
mb
er
of
pro
ced
ure
s
Primary lung cancer surgical admissions 2015/16 Pneumonectomy
Lobectomy of lung
Partial resection oflung
C.I NSW min.caseload vol
Primary lung cancer admissions NEMICS public health services
Anglo-AustralianItalian
Greek
Arabic
Vietnamese
Chinese
Other
2a) ACCESS/TIMELINESS. SOLUTION IMPLEMENTATION: (in more detail) Focus
Area
Focus Area by OCP
Step & descriptor
Item
no
List the Solutions selected to address each focus
area
Describe the REACH List the measures used to assess
EFFECTIVENESS
Rating
icon
List the INTERVENTION activities associated with
specific initiatives
Results/Outcomes (as MEASURES
where appropriate
1 OCP Step 2
Care point 2.2
Eastern Health
(VLCRP Tier 1 site)
1a.1 Streamline referral and triage process at health
service (HS)
Lung MDT, GPs, clinic
admin, patients, EMPHN,
redesign unit
≤14 days from referral to FSA.
Clinician interviews.
GP and patient satisfaction surveys.
Triage guidelines developed.
‘Suspected lung cancer’ e-triage point created.
Triage responsibilities and leave cover formalised
100% achieve FSA in <14days.
Clinicians, GPs and patients satisfied
with process.
1a.2 Document and communicate optimal
outpatient(OP) management pathway for lung
cancer to GPs(develop Health Pathway)
GPs, GPLO, EMPHN, Health
Pathways team, lung MDT
OP pathway appears on HS website.
Health Pathway documented.
GP and referrer satisfaction survey.
‘Rapid access lung lesion clinic’ webpage
developed. Health pathway documented. Various
methods of GP communication undertaken.
Web page available.
Lung Health pathway created.
GPs & referrers satisfied.
1a.3 Establish priority booking to allow rapid availability
of OP clinic appointments
GPs, lung MDT, clinic admin,
patients
≤14 days from referral to FSA.
Clinician interviews, patient surveys Rapid priority booking developed for patients
referred with suspected or known lung cancer.
Time to FSA ≤ 14 days (100%)
Clinicians & patients satisfied
1a.4 Develop efficient OP process to ensure rapid
completion of investigations
Lung cancer and diagnostic
clinicians, booking staff
Referral to diagnosis < 28 days.
≤42 days from referral to first treatment Expedite investigations - slips stamped ‘Urgent
appointment <48hrs, Rapid Access Lung Lesion’,
Information added to registrar training manuals.
89% achieve diagnosis < 28d.
83% start treatment in < 42 d
1a.5 Formalise referral pathway for patients requiring
external EBUS/CPET testing
Lung clinicians, patients,
external providers
External referral pathway formalised.
Clinician survey/interviews. Referral pathway established with new external
provider. Equipment purchase being considered.
Clinicians satisfied.
1a.6 All newly diagnosed lung cancer patients
presented at MDM to ensure co-ordinated and
efficient treatment pathway
MDM clinicians, registrars % patients with MDM documentation.
File audit of MDM documentation quality.
Clinician interviews.
All newly diagnosed cases listed on MDM agenda.
MDM referral process formalised & terms of
reference updated. MDM dashboard developed.
90% patients requiring active
treatment discussed at MDM.
Clinicians satisfied with process
Northern Health 1b.1 Participate in extension of VLCRP Referral admin, lung cancer
clinicians, redesign,
operational managers
Project Steering Committee convened Improvement team convened and initial data
analysis underway.
PO commenced May 2017
Rapid Improvement Event (RIE) 21/9/17.
-
1b.2 Analyse VLCR and local data Baseline data collected & analysed Initial gaps/problems identified.
1b.3 Conduct a rapid improvement workshop Gaps/problems identified Solution design phase underway.
Austin Health
(VLCRP tier 2 site)
1c.1 Participation in extended Lung Redesign project Cancer Services Exec &
Austin Redesign
Recruitment of PO
Presence of a documented implementation plan. ~ PO commenced 21/9/2017.
Data collection & analysis via VLCR
Prepare phase initiated – Steering
committee & RIE planning started.
* RATING ICONS: Fully Achieved: √ Partially achieved: ~ Not achieved: × Not commenced: 0
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2b) PROCESS/QUALITY (only if represented previously in SOLUTION DESIGN ) Adoption of Process/ Quality Strategies Unintended Outcomes
What were the overall quality objectives of the local project activity What were the priority interventions i.e. Flagship activity What secondary objectives of the interventions were achieved 1. Gather local data around the cultural barriers that exist to lung cancer care from symptom
appraisal to treatment for culturally and linguistically diverse (CALD) lung cancer patients.
2. Ensure all complex lung cancer surgeries are performed in health services that meet minimum
recommended caseload and capability guidelines (adherence to NEMICS position statement).
3. To disseminate Lung OCP resources to patients and carers.
1. Participation in a multi-site study co-ordinated by Monash University; LEAD – Lung cancer
diagnostic and treatment pathways: A comparison between CALD and Anglo-Australian patients.
2. Initiating a review of Northern Health lung cancer surgery volumes and engaging clinicians and
operational managers in service review discussion. Local clinical audit of all lung surgical cases, and
credentialing of surgeons.
3. Provide local lung cancer support group ‘Love and Light’ with OCP brochures for patient/carer
information packs and provide support to hold lung cancer information forum.
1. Knowledge of length of time (>8mths) and process required to apply for
multi-site research governance approval. Applicable for future work of this
nature.
2. A valuable partnership with Northern Health has been reinforced and has
fostered a willingness to collaborate on future lung service expansion work.
3. Understanding that work conducted with support groups needs to be in-step with the health and wellbeing of its volunteers.
EVALUATE/SUSTAIN
Focus of Work: Implementing LUNG Optimal Care Pathway - Page 1
EVALUATE/SUSTAIN
Focus of Work: Implementing LUNG Optimal Care Pathway - Page 2
3. Self -Assessment of Project Process What was the level of engagement, leadership, participation and uptake
Environment: The focus on OCPs with their common language and inclusion in the Cancer Plan as a major piece of work did serve to focus efforts and link together a number of programs within NEMICS. For lung in particular the VLCRP grants stimulated local review of timeliness of care. Generally, health services have seen OCP related activity as one of opportunity and support to meet other reporting requirements such as SOP and Quality Accounts.
Capacity & Capability: Lung clinicians had variable exposure to health service redesign activities prior to the grants program, and have been positive about the experience in all 3 health services. Locally clinicians do not view this as an OCP implementation but a local redesign/service improvement activity. Governance structures both a health service and ICS level are aware of how these fit into the broader OCP implementation.
Participation: The OCPs have been accepted as a standard of care in-line with individuals’ area of work: e.g. clinical work & outcomes; quality & safety performance; efficiency / effectiveness; supportive & survivorship care. The OCPs are used as a rationale in applications to funding rounds for service improvement and professional development. The specific focus on a tumour type, supported engagement with local support groups and individual MDTs and clinical units.
Embedded into care: Lung OCP is embedded into the pathway of care at sites that have undertaken the redesign work concerned with care pathways. Broad engagement that allows multiple teams to be involved in redesign of care pathways facilitates a greater organisational interest in contributing to change.
4.Evaluation of the ICS Program Outcomes What level of impact on experience and outcomes (High Level Only)
OCP Program approach: Provided a common language and reference point for communication, activities, funding rounds and engagement strategies with the sector. Renewed focus on specific tumour types rather than on common areas of multidisciplinary, supportive & coordinated care.
The extent of improvement in cancer care: timely access to diagnosis and treatment improved with redesign approach. Consumer OCP disseminated more broadly through the Love & Light Support Group.
Barriers & Enablers: Implementing the same projects; LCRP & LEAD across 3 health services streamlined efforts, and supported relationships between the hospitals. Some delays with engaging NH who did not put in an application to LCRP. HREC processes delayed projects by 3-6 months.
Focus for service improvement: EH LCRP – met all objectives. AH & NH just commenced but are likely to meet all objectives. Time frame for large scale projects too short to measure impact.
Patient experience: measures limited to specific aspects or locations of care, e.g. DOU. Findings rest with local Q&S Committees to address. Short life expectancy in lung cancer limits opportunities to monitor direct impact of redesign projects. In a ‘before’ patient survey feedback was all positive so difficult to measure change in this way. Patients who experienced the redesigned lung cancer care were difficult to follow up due to illness and reduced life span.
5. Building Capability and Capacity At High Level (Health Service/Cancer Units) At Local Level Future Proofing capability for next OCPs to be implemented (Prostate and OG)
Organisational Readiness: Each health service has a redesign team and mechanism for prioritising and redesign activities within the health service. All 3 health services have had significant change in the leadership and internal organisational structures over the project term which led to some delays with expanding the VLCRP to Austin & Northern Health. The untimely death of a key member of all 3 Lung MDTs also impacted.
Presentations: on overall and specific aspects of OCPs to health services, PHN GPs & community groups. Feedback forms at educational events.
Stakeholder engagement: Closer proximity & alignment between the Summits and OCP adoption has improved clinical engagement, detailed baseline data and defining the scope of activities. Many stakeholders already identified through the summits. Community & consumer groups identified and approached about findings from summits and upcoming OCP work to identify common ideas / issues.
Transfer of knowledge: Redesign activities have been run via the health services to support ownership. Local networking between sites & ICS secretariat to support problem solving.
Lung redesign has specific COP – widely attended.
Project & health service staff attend OCP COP when agenda applicable to their responsibility.
Solution transferability The concepts used to redesign referral pathways, triage and access to diagnostic testing should be transferable to the following tranche.
Benefits/challenges to cancer units. OCP program has supported health services to demonstrate improvement under the National Standards and Quality Accounts. Cancer i
OCP activities & progress reported to NEMICS Consumer RG Activities and approach co-designed by NEMICS & health service teams.
Lessons learnt: Ensuring all relevant units are represented in project working groups, separating gap and solution development in rapid imp workshops, if ethics required need 6-8months of lead in time to begin project, changeability of organisational readiness and its effect on project timelines
Sharing improvement activity experience. Newsletters sent during implementation, presentations at conferences/annual forum/quality & redesign meetings. Progress towards timeliness targets presented monthly to MDM
OCP activities presented via newsletters, conferences, education events. Redesign projects presented by participating health services. When all complete the overall regional impact will be reported.
Project governance: Program governance processes both within NEMICS and individual health services will be maintained for the next tranche of OCPs. New NEMICS Cancer Plan Committee to be formed including tumour specific leads to support implementation activities. Local project committees to support ownership & sustainability of specific projects. Importance of local units understanding the gaps in their service, developing solutions and owning the improvement project – ICS to be there to provide support but not visibly manage the change.
6. SUSTAIN Outcome area Focus Area 1 Focus Area 2 Focus Area 3
Sustainability factors Victorian Lung Cancer redesign Project – Eastern Health (Austin and Northern Health are in implementation) LEAD study – Monash University NH surgical volume review Responsibility Head of Cancer Services and the Cancer Quality and Strategic Projects Manager. Principal investigators and research site
co-ordinator. CEO & Director Surgical Services. NEMICS Governance Committee
Accountability Program Director of Specialty Medicine or equivalent Monash University research team and local research ethics offices.
CEO & Director Surgical Services NH Cancer Services Plan
Measurement Outcomes monitored via regular VLCR (AH & EH) reporting; NH considering joining the VCLR. MDM activity dashboard reports and DHHS Cancer Service Performance Indicator (CSPI) audits.
The final report will communicate research findings.
Volumes reported 6/12 at Cancer Governance Committee (30 / 90 / 365 mortality)
Improvement Target Improvement targets are set by OCP timeliness measures. These targets have been built into the MDM software (CANMAP) reporting dashboard for ongoing reference.
N/A >10 procedures p.a. (NSW: 18 per institution p.a./ NICE UK: 20 therapeutic procedures p.a.)
Reporting structure inclusive of future Governance arrangements
Outcomes will be regularly reported to the Cancer Services Quality and Strategy committee for review and continued activity on working towards set targets. When all 3 sites have completed their implementation region-wide data will be presented.
Outcomes will be reported to Cancer Council Australia (as the grant provider)
CEO & Director Surgical Services Cancer Governance Committee
Documentation & resources Referral guidelines and triage processes documented (Health Pathways, Rapid Access Lung lesion clinic webpage), a virtual ‘Suspected Lung Cancer clinic’ created to manage and monitor wait times, roles and responsibilities of MDM participants documented in the Lung MDM terms of reference and registrar training manuals updated.
Publications will be drafted over the project period and submitted to relevant journals.
NEMICS Position Statement on low-volume surgery.
Ongoing training and education The referral and triage process is reinforced/communicated to all referring GPs (sent as attachment to patient correspondence from the Lung MDM), a Lung MDM GP webinar has been produced and will be available as a podcast for ongoing GP education through the EMPHN, GP liaison newsletters continue to provide referral information to GPs. New registrars receive referral/triage education during initial orientation training.
N/A N/A
Attachment 1: OCP Evaluation Framework (using RE-AIM platform) – Lung cancer
RE-AIM FACTOR Progress
REACH
Promotion of the OCPs
Substantial efforts have been made to raise awareness and understanding of the role and benefits of the OCPs, including:
Clinical/medical unit meetings Austin Health – Oncology unit meeting (May 2016), Grand Round (July 2016) Eastern Health – Oncology unit meeting (Aug & Nov 2016)
Community groups via the NEMICS Community Ambassador program (Aug & Nov 2016, Feb 2017) Primary health meetings - EMPHN (Mar 2016), GP network (Nov 2016), GP forums (AH, May 2017) and NH Webinar development and presentation collaboration with EMPHN HealthPathways lung cancer pages are now available and include both clinician and consumer versions of the OCP ‘Love and Light’ Lung cancer advocacy & support group (AH, June 2016) VICS conference (May 2017) NEMICS Consumer reference group – (Aug 2016) ‘My Cancer Care Record’ (My CCR) (public and private health service presentations) Redesign unit presentations
Eastern Health (May 2016) Austin Health (Aug 2016)
MDM chairman and leadership group (EH, Dec 2016) What to expect available on the EH Rapid Access Clinic webpage OCPs printed for support groups My CCR folders for oncology patients, including those on clinical trials OCPs disseminated via kiosks, information lounges and clinic waiting rooms
Engaging stakeholders in activities stemming from the OCPs
Consumers and clinicians are engaged in planning and activities related to OCP adoption and application, including:
Victorian Lung Cancer Redesign Project - steering committee (EH) Lung Cancer Service Redesign – reference group (NH) Cancer clinical service units – operational staff Rapid Improvement Event with 35 attending (EH, Sept 2016) Rapid Improvement Workshop (NH, Sept 2017) LEAD study – site coordinator and working group meetings (monthly) My CCR advisory & implementation group Individual clinician interviews: Palliative care NUM (AH, Aug 2016), Geneticist (AH, June 2016), VLCRP grant applicant (AH, June 2016)
RE-AIM FACTOR Progress
Individual interviews with health service Quality Managers (NH, AH, MHW) NEMICS Consumer Reference Group updates VLCRP newsletters Patient Experience Surveys - Day Oncology and Inpatient oncology wards (includes private hospitals in region) VLCRP stakeholder surveys and interviews (lung cancer & diagnostic clinicians, GPs, GP liaison, patients, operational managers, admin staff) 2016 NEMICS Annual Forum theme of OCPs, with approx. 80 attending
Integration of OCPs to care processes and other projects:
The OCPs now underpin the strategic engagement, planning, communication and quality monitoring for the NEMICS region. Some specific examples are:
‘A Common Path’ cancer support videos (focus group discussion and video content production) Patient experience surveys – Day Oncology and Inpatient oncology wards Tumour Summits program, including newsletters Health Services – Cancer Services plans (AH, EH and NH) MDM performance monitoring data (EH) HealthPathways lung cancer pages are now available and include both clinician and consumer versions of the OCP
EFFECTIVENESS
Expenditure on OCP activities
Reported separately
Resourcing sufficient to deliver outcomes
EH Lung redesign PO required contract extension (10 weeks) to complete project Suggested solution to develop multidisciplinary lung cancer clinic not feasible with resources Solution to create lung cancer coordinator position not feasible within project budget
Number of projects delivered within budget Projects within budget but not all completed at this stage AH and NH project officers appointed and have commenced local lung cancer redesign projects Victorian Lung Cancer Registry (VLCR) data format caused delayed commencement of redesign project at AH
Alignment of local activities with identified priorities
Lung redesign project aligned with lung summit priorities NH and AH were supported to align with VLCRP
RE-AIM FACTOR Progress
Extent local/individual projects achieved their objectives
Streamlined referral and triage process [Reduced time from referral to first specialist appointment (FSA), process for referral documented and communicated to GPs/specialists, referral points rationalized and clearly communicated]
Improved outpatient management (Rapid access clinic, all cases presented to MDM, rapid access to testing) Time to complete diagnostic testing reduced Referrals generated within MDM rapidly actioned (reduced time to treatment) Lung Health pathway developed and rapid access lung lesion clinic webpage available Triage guidelines developed Alert process (stamp) created for urgent testing request slips (CT biopsy/EBUS and CPET) ‘Registrar huddle’ post MDM to confirm all patients requiring referral are actioned Formalised external referral process for testing
Effective problem solving (differences between planned and actual implementation)
Original idea to group investigations – not feasible developed rapid investigation process (alert stamp on request slips) Triaging of referrals originally was to be performed by consultants not a viable solution now referrals triaged by registrars
Project learnings – lessons learned, risks mitigated
Head of Respiratory not on steering committee (more thought into clinical champions and decision makers required to achieve project outcomes) Rapid improvement event covered gaps and solutions on one day (succession too rapid – better to separate workshop into gaps and solutions on another
day)
Consumers report care in line with OCP Post implementation survey difficult to complete as patients either too unwell or now deceased. Reporting of quality measures aligned with OCPs including benchmark data
Process for routine MDM monitoring developed against OCP measures
Patient experience survey planned
MDM monitoring ‘dashboard’ developed
ADOPTION
Number of agencies and settings willing to initiate a program of work The following groups were identified as clearly engaged and active in the program of work:
Lung MDM participants across NEMICS Health service operational staff Admin/booking triage staff AH and EH GP liaison and medical specialists – HealthPathways team Thoracic surgeons – remain engaged and initiate a conversation to explore possibility of multidisciplinary clinic 6 GPs have referred directly to the Rapid Access Clinic (using the webpage)
RE-AIM FACTOR Progress
Medical imaging clinicians – collaborated to develop idea of 48-hour turnaround for patients identified by an alert stamp requiring rapid access to investigations
Monash University researchers– LEAD project Northern Health lung cancer clinicians and operational managers for lung redesign/low volume high complex surgery project Austin Health lung cancer clinicians and operational managers for lung cancer redesign project
Spread of common initiatives to multiple sites - new partnerships / collaborations
New collaborations arising within Eastern health that will be replicated within the Austin and Northern redesign projects:
Lung cancer HealthPathway (developed in conjunction with EMPHN for GPs to refer to acute health service) Rapid Access Lung Lesion Clinic webpage (used by GPs and acute health service) Rapid Investigation alert process for urgent testing/investigations (lung cancer specialists, medical imaging and pathology providers) Triage guidelines developed in conjunction with different specialties – oncology, respiratory, thoracic surgery units.
IMPLEMENTATION
At the NEMICS level
The following reflections relating to lessons learnt were prompted by the difference between the planned projects and timelines versus what actually happened Organisational readiness is of vital importance – AH and NH both experienced restructures during the project period, causing delays in commencement Cross-sectoral collaborations can significantly increase complexity – the issues related to the format of data from the Victorian Lung Cancer Registry added
to the delays for the VLCRPs Stakeholder management would have been improved at EH VLCRP with the inclusion of key clinical leadership Although the rapid improvement event for EH VLVRP was productive of good engagement and solution ideas, having two, shorter events separated in time
would have created a clearer understanding of the current gaps
MAINTENANCE
Policy & Practice
Lung MDM terms of reference at EH have been updated to reflect the change in processes and responsibilities
Medical registrar handbooks have been updated to document new roles and responsibilities
Outcomes
VLCRP solutions still being implemented and embedded at EH
Monthly MDM monitoring ‘dashboard’ audit and presentation of results to EH Lung MDM
Yearly presentation to Head of Cancer Services EH – to retain focus, re-iterate solutions and work towards targets