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'
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