Histopathology National QI Programme Annual Workshop · Histopathology National QI Programme...
Transcript of Histopathology National QI Programme Annual Workshop · Histopathology National QI Programme...
Histopathology National QI
Programme – Introduction & Update
Dr Niall Swan, Chair Histopathology QI Programme Working
Group
10 May 2016
Vision of National QI Programme
A patient centred Quality Improvement framework within each department, which facilitates their
routine review of performance and drives improvement, in key quality areas against
intelligent targets.
Development Stage of Programme
Initiation
Engagement
Stakeholders
Design:
Guidelines
Data Collection –LIS
Data Recording
NQAIS
Roll-out
Conducting
Recording
Reporting on NQAIS
Measure
Data analysis
Target Setting Methodology
Control
Targets set
4
Framework set up :•Guidelines•Quality Data Collection•Quality Data Reporting•Intelligent Targets set
Radiology programme39 Sites collecting Quality Data
GI Endoscopy34 sites collecting & recording data on NQAIS
Histopathology programme32 sites - public & private conducting, collecting & reporting on NQAIS
08/06/2016
Ongoing Stage of ProgrammeReview by units of their own data on a regular
basis against intelligent targets and appropriate
learning and actions
Annual review of Guidelines, documents,
Indicators, intelligent targets, support for
quality improvement and learning
Quality Improvement by units and shared learning
6
•Relevant national framework •Specialists can review their own data and act •Opportunity to share learning on improvements•Improved patient care
Histopathology programme32 sites public and private conducting, collecting and reporting on NQAIS
08/06/2016
Current Status of Histopathology Programme• 32 labs conducting quality activity and recording data
• First data report only included 15 labs
• Targets set for 22 out of 50 key quality indicators (minimum 12 months data required)
• National Aggregate Data Reports 2014, 2015 & 2016
• What the hospital sees?• Laboratory
• Hospital management
• What the programme sees?
• What difference has it made?
• Challenges
• Opportunities e.g. RCQPS research collaborative, improvements, publications…
Data improvements• The timeliness, volume and accuracy of data is improving
– see compliance slides.
• Completion of Memorandums of Understanding by hospital management seems to support departments overall.
• Sharing of reports and data in context outside laboratories with Clinical Directors, hospital management, etc– increases profile of histopathology
– facilitates further quality improvement.
• Help to share learning through the programme and hospital groups
– Areas for development
– Areas of best practice
Cancer centre (C) submission rates – 6 May 2016
= Uploaded months
= new uploads since last Steering Committee Compliance Report
= not applicable/Hospital inactive
= Upload requested for Dec 15
= months behind
Overall status – improved
32 sites
8 private, 28 public– Including 8 cancer centers.
All have uploaded December data, 28 have uploaded January data.
Remaining sites have been reminded & are working through issues.
23 sites have also uploaded February 2016 data, which was due on
the 1st May.
centertype
Oct
2014
Nov
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Dec
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Jan
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Feb
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Mar
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Apr
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May
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Jun
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Jul
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Aug
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Sep
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Oct
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Nov
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Dec
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Jan
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Feb
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2016
Upload
statusMonths
behind
cc3 new upload 2M 1
cc7 new upload 1M 0
cc4 new upload 1M 1
cc1 new upload 1M 0
cc5 new upload 1M 0
cc6 new upload 2M 0
cc2 new upload 1M 1
cc8 new upload 1M 0
Total arrears in months (all labs combined) 3
General centre (NC) Submission rates – 6 May 2016
centertype
Oct
2014
Nov
2014
Dec
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Jan
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Feb
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Mar
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Apr
2015
May
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Jun
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Jul
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Aug
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Sep
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Oct
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Nov
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Dec
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Jan
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Feb
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Mar
2016Upload status
Months
behind
nc1 new upload 1M 0
nc2 new upload 2M 0
nc3 new upload 2M 0
nc4 new upload 3M 0
nc5 new upload 2M 0
nc6 new upload 1M 0
nc7 new upload 2M 1
nc8 new upload 2M 0
nc9 new upload 1M 1
nc10 new upload 2M 0
nc11 new upload 1M 0
nc12 new upload 1M 0
nc13 new upload 2M 0
nc14 2
nc16 1
nc17 new upload 2M 0
nc18 new upload 1M 0
nc19 new upload 1M 0
nc20 new upload 1M 0
nc21 new upload 1M 1
nc22 new upload 1M 0
nc23 2
nc24 2
nc25 new upload 2M 0
Total arrears in months (all labs combined) 10
Summary of Histopathology GuidelinesKey Quality Area (Monitor) Key Quality Indicators #, measure
Workload Total no of cases
1a Inter-institutional consultation – Cases referred externally for review 2: % Cases referred, % Agreement
1b Inter-institutional consultation – Received internally for review 2: % Cases received, % Agreement
1c Inter-institutional consultation – Cases referred externally for opinion 1: % Agreement
2 Intradepartmental Consultation 3: 3-5 % Cases for Histo & Cyto FNA, 7-9% Cyto Exfoliative,
3 Frozen Section Correlation 3: 97% Concordance, 5% Deferral rate >10% needs review
4 Frozen Section TAT 85% TAT < 20 minutes
5 Cytological/histological correlation 3: % Discordant, % False positive, % False negative
6a Retrospective review (Focused real time) 1: % Agreement
6b Retrospective review (report completeness)
1: % Completeness (POS approach – cancers of Endometrium & pancreas)
7 Multi disciplinary Team meetings - By P-Code 2: % Agreement, % of total cases discussed - By P-Code
8 Non-conformance reporting 2: No. of non-conformances, Clinical impact
9 External Quality Assessment 2: List of Schemes, results
1108/06/2016Blue – potential target/recommendation
Dark red – Quality Improvement activityYellow – discussing today
Green – targets set
Summary of Histopathology GuidelinesKey Quality Area (Monitor) Key Quality Indicators #, measure
10 Turnaround Time (TAT)
6 areas 1 indicator: TAT by case type 80% day 5 i. P01 Small Biopsy ii. P02 GI Endoscopic Biopsy
80% day 7 Non Biopsy iii. P03 Cancer resection, P04 Other
80% day 5 Non gynae cytology – v. P06 FNA vi.P07 Exfoliative
11 Addendum Reports 3: Quantity, Error classification, Clinical impact
12 Critical Diagnosis/Value reporting 1: No. of cases reported directly to clinician (audit in progress)
13 Adult Autopsy – Intradepartmental Consultation 1: 2% all cases
14 Adult autopsy case review 1: % of total cases reviewed
15 Adult autopsy turnaround time 1: TAT by autopsy case type
16 Paediatric Autopsy extra departmental
consultation
1: % of total cases reviewed at M&M
17 Paediatric autopsy retrospective review 1: % of total cases reviewed
18 Paediatric turnaround Time 1: TAT by paediatric turnaround time
19 Quality / Discrepancy Meetings participation Possible addition – learning opportunities
1208/06/2016
Blue – potential target/recommendation
Dark red – Quality Improvement activityYellow – discussing today
Green – targets set
Targets setSet Monitor Target & Key Indicators
Round 1
Round 2Intradepartmental
Consultation
3- 5 % All Cases (round 1)
3-5% Histo cases (retain)
3-5% Cytology Exfoliative (retain)
7- 9% Cytology FNA
Round 1
Round 2Frozen Section 97% Concordance
5 % Deferral rate, >10% <1% needs review,
85% TAT < 20 minutes
Round 1 Turn around Time TAT by case type
i. P01 Small Biopsy – 80% day 5
ii. P02 GI Endoscopic Biopsy – 80% day 5
iii. P03 Non Biopsy – Cancer resection – 80% day 7
iv. P04 Non Biopsy – Other – 80% day 7
v. P06 Non gynae cytology – FNA – 80% day 5
vi. P07 Non gynae cytology - Exfoliative – 80% day 5
Round 2 Intradepartmental
Consultation
2% Adult Autopsy All cases
10/02/2015 13
QA to QI – Lloyd Provost
Ref: ‘The Health Care Data Guide, learning from data for improvement’. Lloyd P. Provost & Sandra Murray. Jossey Bass
• Group 1 follows rounds 1 and 2 methodology where measures are
defined and data is appropriate for national target setting.
• Group 2 includes quality areas where definitions are agreed but no
national data has been collected. Future targets are settable but only
when sufficient data is available for review. A minimum of 12 months data
will be collected.
• Group 3 comprises quality areas where the type of data being recorded
is not applicable for national target setting as agreed definitions for these
KQIs are not currently achievable. A recommendation only is being
suggested for local quality improvement activity.
• Group 4 consists of quality areas where insufficient national data is being
collected through the QI programme. Some of these quality areas are
captured through other routes e.g. INAB and EQA. The updated
guidelines will reflect this.
• Group 5 sets out new key quality areas following refinement of initial
measure and maturing of the data. Recommended codes will be
circulated and data collected prior to any potential target setting.
National developments - 2015• Award winning – Excellence in
Healthcare Management (from 18)
• L – R: Sarah Treleaven RCPI, Maureen Flynn
HSE QID, Philip Ryan RCPI, Dr Jennifer Martin
HSE QID ( Steering Committee Chair), Prof
Conor O’Keane Faculty of Pathology, Dr Ann
O’Shaughnessy RCPI, Dr Niall Swan
Faculty of Pathology (Working Group Chair).
Missing from photo, Dr Julie McCarthy, Dr Sine Phelan, Prof Kieran Sheahan, Dr Ann
Treacy (Working Group members) Mairead Guinan RCPI Programme Manager
• Memorandum of Understanding with participating hospitals
• Health Information and Patient Safety Bill – due for publication in
2017
1. Employ more effective teamwork in the diagnostic
process (DP)
2. Enhance healthcare professional education and
training in the DP
3. Ensure health IT supports patients & HCP in the DP
4. Develop and deploy approaches to identify, learn
from, and reduce diagnostic errors and near misses
in clinical practice
5. Establish a work system and culture that supports
the diagnostic process and improvements in
diagnostic performance
6. Develop a reporting environment and medical
liability system that facilitates improved diagnosis
through learning from diagnostic errors and near
misses
7. Design a payment system and care delivery
environment that supports the DP
8. Provide dedicated funding for research on the DP
and diagnostic errors
8 Goals from
Institute of Medicine
Communications• Presentations - International
– “Implementation of a national patient-centred clinician-led Histopathology National
Quality Improvement (QI) Programme to enhance patient care and safety”, March
2015, Grand Rounds, Dept of Pathology & Laboratory Medicine, Boston Medical
Centre & Boston University School of Medicine, USA
– “Jurisdictional Quality plans & indicators in Interpretative Pathology: experience in
Canada and abroad: Implementation of a national patient-centred clinician-led
Histopathology National Quality Improvement (QI) Programme to enhance patient
care and safety”, Canadian Laboratory Medicine Congress (CLMC), Canadian
Association of Pathologists, CAP-ACP Annual Meeting Jun 2015
– “An Innovative System for Histopathology Quality Improvement / Assurance”, Jun
2015 Meeting, UEMS Specialist Section of Pathology, European Pathology Board
– “Set up and Implementation of a Patient-centred Clinician-led Histopathology
National Quality Improvement (QI) Programme” Pathsoc/BDIAP joint meeting, Jun
2015
– “Dissemination, stakeholder engagement and endorsement – the Irish Experience”
Quality Initiative in Interpretive Pathology (QIIP) Meeting, Canada Jun 2015
– “Metric development & implementation for a patient-centred clinician-led
Histopathology National Quality Improvement (QI) Programme”, QIIP Workshop
Communications• Presentations - National
– “Implementation of a patient-centred clinician-led National
Quality Assurance (QA) Programme in Histopathology to
enhance patient care and safety”, National Patient Safety
Conference, Dublin November 2014 (12 selected from 1,07l
abstracts) submitted
– “Histopathology Quality Improvement Programme – an update”,
Radiology QI Programme Annual Workshop, June 2015
– “Specialty Quality Improvement Programmes, current status and
future developments”, Clinical Directors Masterclass, September
2015
Communications• Posters - National
– “Implementation of a patient-centred clinician-led Histopathology
National QI Programme”, National Office of Clinical Audit, Inaugural
Annual Conference, Dublin, May 2015
– “Implementation of a patient-centred clinician-led National QI
Programme in Histopathology”, Irish Society of Surgical Pathology,
Kildare, October 2015
• Posters - International
– “Implementing a National Quality Assurance Programme in
Histopathology”, USCAP, Seattle, USA, March 2016
– “Impact of Intradepartmental Consultation on Amended Report Rate:
Findings from the Irish National Quality Improvement Programme in
Histopathology”, USCAP, Seattle, USA, March 2016
– “Communication with Clinicians in Anatomical Pathology”, USCAP,
Seattle, USA, March 2016
International developments – 2015/2016
• Maintaining programme in Ireland is top priority.
• Ireland remains a world leader, as the only country to
collect this data nationally across public and private
sector.
• Other countries very interested in the Irish approach
– Canada, QIIP review in 2016
– Presentation of three posters at USCAP meetings over past 3
years
– BDIAP / Path Soc (8th Joint Meeting) - differing approach in the
UK- individual poor performance focus on EQA schemes
– UEMS - Opportunities for consultation with Hungary and
Germany
Opportunities for participating sites
• RCQPS – research collaborative HSE QID /HRB / RCPI,
opportunity to access funds fore research relating to quality
and patient safety.
• Up to €280,000 over 2 years.
• Research question – link with academic researchers,
competitive rounds of funding, submit May, final decision
Sept.
• Think about topics – next round May 2017.
• Current topic is LEAN via Bill Bennett –
‘Can LEAN Six Sigma Methodology be used to develop
integrated software tools to improve patient care in surgical
pathology?’
Opportunities for participating sites
• Clinical audit – easy access to information
via NQAIS
• Build up CME points
• Use your data in more detail – publications
• Application – Team ,Diploma in Healthcare
Management & Quality Improvement (link)
• National data – Prof Sheahan
AcknowledgementsProgramme Team: Ms. Mairéad Guinan, Mr. Philip
Ryan, Ms Sarah Treleaven,
Working Group: Dr. Julie McCarthy, Prof J. Conor
O’Keane, Dr Sine Phelan, Prof. Kieran Sheahan,
Dr Ann Treacy
Dr. Jennifer Martin - HSE QID (current funder)
Mr. Seamus Butler & Mr. Brian Dunne - HSE OCIO
Mr. Mel McIntyre & Mr. Pawel Starawz - OpenApp
Dr. Howard Johnson HSE HII,
Dr. Mary Hynes – NCCP (initial funder),
Mr. Leo Kearns & Ms. Louise Casey - RCPI