www.HQOntario.ca
Health Quality OntarioThe provincial advisor on the quality of health care in Ontario
Supporting Best Practice for
COPD Care Across the System
May 3, 2017
1
Overview
• Health Quality Ontario background
• QBP overview
• Quality Standards overview
– Program background
– Development process
– Measurement
– Adoption
• COPD Quality Standard
– Timeline
– Scope
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www.HQOntario.ca 2
Develop
Evidence
Based
Guidance
Support
Quality
Improvement
and Adoption
Monitor and
Report on the
Quality of the
System
Strategic Partnerships and Patient Engagement
The quality standards program is part of our
legislated mandate
www.HQOntario.ca 3
(c) to promote health care that is supported by
the best available scientific evidence by,
(i) making recommendations to health care
organizations and other entities on
clinical care standards
(i) making recommendations to the Minister
concerning,
A. the Government of Ontario’s
provision of funding for health care
services and medical devices, and
A. clinical care standards and
performance measures relating to
topics or areas that the Minister may
specify
4
Variation in hysterectomy rates is just one
example that shows why we need standards
Little variation in
hysterectomies
performed for
cancer
Little
variation in
treatment of
fibroids and
prolapse
10-fold
variation in
hysterectomy
rate for heavy
menstrual
bleeding across
LHINs
5
Time and Regional Crude Rates for Patients Hospitalized with COPD, FY
2013-2014:2015-2016
-North East LHIN had the highest rates overall across all three years, but ended the reporting period at
their lowest.
-North East and South East LHINs had the two highest rates for COPD in 2015-2016 FY
www.HQOntario.ca
0
200
400
600
800
1,000
1,200
1,400
Rat
e p
er 1
00
,00
0
2013-2014 2014-2015 2015-2016
Data Source: Discharge Abstract Database, provided by the Ministry of Health and Long-
term Care (using the QBP Methodology)
www.HQOntario.ca 6
COPD Emergency Visits Admitted into Inpatient bed by LHIN Region, Fiscal
Year 2015-2016Toronto Central LHIN had the highest proportion of emergency department visits admitted into
acute inpatient care
Data Source: Quality Based Procedures Cohort using Discharge Abstract Database and
National Ambulatory Care Reporting System
39% 37% 36% 33% 33% 33% 32% 30% 28% 27% 24% 24% 23% 22%
0
10
20
30
40
50
60
70
80
90
100
TorontoCentral
Central West MississaugaHalton
Central HamiltonNiagara
HaldimandBrant
Central East WaterlooWellington
Champlain South East NorthSimcoe
Muskoka
South West Erie St. Clair North West North East
Percent All COPD Emergency Visits Admitted to Inpatient Bed
7
Patients who Received Follow-up Care 7 days Post Hospital
Discharge by LHIN Regions
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0%
10%
20%
30%
40%
50%
60%2011 2012 2013 2014 2015
Data Source: Quality Based Procedures Cohort using Discharge Abstract Database and
Registered Person Database, provided by the Ministry of Health and Long-term Care
8
Health Equity Lens
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Health equity allows people to reach their full health
potential and receive high-quality care that is fair
and appropriate to them and their needs, no matter
where they live, what they have or who they are.
• What can the quality standard do to mitigate variations in
access, experience and outcomes that may be related to
patient or community characteristics such as race/ethnicity,
income, and geographic location?
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Quality Standards and QBPs: A short history
• 19 Quality-Based Procedures Clinical
Handbooks developed
• Handbooks are 80+ pages with 50+
recommendations of varying importance and
evidentiary support
• Quality Standards is a new program that
addresses “Where should I start? What are the
top 5 + things I should focus on?”
• Quality Standard recommendations (“quality
statements”) focus on areas where there are
gaps between current Ontario practice and best
practice according to evidence
9
Example of how a QBP Pathway and a
QS could intersect
www.HQOntario.ca 10 HQO QBP COPD, 2015
Sample
Quality
Statement:
Access to
pulmonary
rehabilitation
Sample
Quality
statement:
Follow up
after
discharge
Sample
Quality
Statement:
Comprehensive
assessment
11
Acute episode(completed Winter 2012)
Post-acute episode (completed Summer 2014)
Integration & update(completed Fall 2014)
HQO’s COPD QBP journey
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12
Patient presents with
suspected exacerbation
of COPD
Usual medical
care (inpatient)
Usual medical
care (in ED /
outpatient)
NPPV
IMV
Go to usual
medical care
(inpatient)
Go to ventilation
(NPPV or IMV)
Severe Level of care
Usual medical
care (inpatient)
Go to IMV
End of life care
Wean
from IMVDecision on
ventilation
modality or
palliative care
Treatment fails
Recovers
Treatment fails
Assess recovery
ModerateLevel of care
MildLevel of care
Assess recovery
Assess recovery
Assess recovery
Discharge planning
& full clinical
assessment
Assess
level of care
required
Home
Home
Home
Home
Recovers
Recovers
Recovers
Treatment fails
Treatment fails
Discharge planning
& full clinical
assessment
Discharge planning
& full clinical
assessment
Usual medical
care (inpatient)
Discharge planning
& full clinical
assessment
N = 43,215P = 1.0
N = 19,337P = 0.447
N = 22,054P = 0.511
N = 1,824P = .042
N = 773P = .018
N = 1051P = .024
Legend
Care module
Assessment node
Episode endpoint
Death
The episode of care model for COPD in acute care
16
COPD QBP Indicator Recommendations
Patient presents with
suspected exacerbation
of COPD
Usual medical
care (in ED /
outpatient)
NPPV
IMV
Go to usual
medical care
(inpatient)
Go to ventilation
(NPPV or IMV)
Severe Level of care
Usual medical
care (inpatient)
Go to IMV
End of life care
Wean
from IMVDecision on
ventilation
modality or
palliative care
Treatment fails
Recovers
Treatment fails
Assess recovery
ModerateLevel of care
MildLevel of care
Assess recovery
Assess recovery
Assess recovery
Discharge planning
& full clinical
assessment
Assess
level of care
required
Home
Home
Home
Home
Recovers
Recovers
Recovers
Treatment fails
Treatment fails
Discharge planning
& full clinical
assessment
Discharge planning
& full clinical
assessment
Usual medical
care (inpatient)
Discharge planning
& full clinical
assessment
N = 43,215Pr = 1.0
N = 19,337Pr = 0.447
N = 22,054Pr = 0.511
N = 1,824P = .042
N = 773P = .018
N = 1051Pr = .024
Legend
Care module
Assessment node
Episode endpoint
Death
Usual medical
care (inpatient)
Length of stay
In-hospital mortality
30-day readmissions
In-hospital mortality
Post-discharge physician follow-up
? % referred to pulmonary rehab
Admission rate
Use of NPPV
? % received recommended in-hospital pharmacotherapy
? % had diagnosis confirmed with spirometry
LEGEND
Indicators that are in current use
Indicators that are potentially feasible with currently available data
? Indicators that are not feasible with currently available data
17
What about the QBP Clinical Handbooks?Changing the approach to
Clinical Handbook development
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Quality then funding
• HQO’s mandate is to make recommendations based on evidence, support quality improvement, and report on the quality of care
• MOHLTC determines funding
• Advisory committee’s objective is to define quality care (quality statements and indicators) for the patient population (which is defined using clinical criteria)
Example: Order Sets, EMR
• Core content for
inclusion in order
sets
• Embed evidence in
systems that
support care
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19
Adoption Supports for QBPs
www.HQOntario.ca
http://www.hqontario.ca/Quality-Improvement/Our-Programs/QBP-Connect
20www.HQOntario.ca
Care in hospitals
and long-term care
homes
Care in all
settings
Care in
hospitals
We have released 3 quality standards…
21
Quality Standards StatusFinalized
(board approved)
In Development
(late phase)
In Development
(early phase)
Pre-Development
(topic approved)
Major depression Diabetic Foot Ulcers(post-consultation)
*Summer 2017
Dementia Care
(community)*Fall 2017
Transitions in Care
Behavioural
Symptoms of
Dementia
Venous Leg Ulcers(post-consultation)
*Summer 2017
Opioid Use Disorder*Winter 2018
Lower Back Pain
Schizophrenia Pressure Injuries(post-consultation)
*Summer 2017
Prescribing opioids
for pain*Winter 2018
Heart Failure
Hip Fracture Vaginal birth after C-
section(post-consultation)
*Summer 2017
Schizophrenia Care
(community)*Winter 2018
Heavy Menstrual
Bleeding
Palliative Care*Spring 2018
Osteoarthritis
COPD
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Quality Standards: Development Process
www.HQOntario.ca 22
1. Scoping and planning
(~4 months)
Determine scope, initiate and plan project, engage partners,
stakeholders and establish QSAC
• Open Call for advisory committee (QSAC) members and co-chairs
• Identification of key stakeholders and potential partners
• Scoping options and background analysis
• Data analysis
2. Development
(~6-7 months)
Develop quality statements and indicators with AC; plan for adoption
• 3-4 QSAC meetings
• Draft quality standard documents (clinical guide and the patient reference guide)
• Develop Information and Data Brief
• Recommendations for adoption
3. Finalization/launch
(~6-7 months)
Finalize Quality Standard and HQO Board approval.
Adoption supports available for use by the field.
• Internal Approvals
• Post draft for public feedback;
• Finalize Quality Standard
• Adoption begins
Topic selection and
Prioritization
Feasibility analysis,
stakeholder engagement;
apply prioritization criteria
Pre-Standard:
23
Quality Standards Process
www.HQOntario.ca
* Patient and public engagement incorporated throughout
Topic selection and prioritization
Content development and
production
Development of Quality Standard
Recommendations for Adoption
Monitoring and
evaluation
• Topic
identification
via scans,
partners,
MOHLTC
• Prioritization
using criteria
and a matrix
• Range of adoption tools and
supports developed/disseminated
• Engage areas of system to use the
standard, and quality improvement
approaches to change practice
where needed
• Evaluation of uptake
• Assess need to update
standards
• QSAC
recruitment and
formation
• QSAC meetings
• Public
consultation
• Standards
finalized,
approved by
HQO Board, and
published on
HQO website
• Broad
engagement and
input
• Initiated when
draft standard is
available
• Plan is approved
and published
Development Adoption
Take actions to support adoption and
quality improvement
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The Quality Statement
The Audience Statements
The Quality Indicators
The Definitions
Quality Standards Clinical Guide
30
Measuring Adoption of Quality Standards
“If you can’t measure it, you can’t manage it”
- Peter Drucker
• One of the tools that is needed to facilitate adoption of the standard
and each statement through quality improvement methods is
measurement
• In creating and supporting this standard, we would like to provide
users with a set of measures that can be used to track improvements
in the quality of care of patients with COPD
• These set of measures, called indicators, can be used to assess the
successful adoption of each statement and the standard overall
• There are 3 types of indicators: structural, process and outcome
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31
Quality
Statement
Outcome 2
Outcome 3
Outcome 4
Outcome 1
Outcome 5
Quality
statements
Quality indicators Statement-specific quality indicators help
measure progress and success adopting
specific statements
Outcomes for the
standardOutcome indicators help measure
success overall (3-5 in total)
Relationship between quality statements, statement-specific indicators
and outcomes for the standard
Note: Diagram for illustrative purposes only
Quality
Statement
Quality
Statement
Quality
Statement
Process / Structural /
Outcome Indicators
Process / Structural /
Outcome Indicators
Process / Structural /
Outcome Indicators
Process / Structural /
Outcome Indicators
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32
How We Will Measure Our Success
• A limited number of overarching outcomes are set for each
quality standard; these guide measurement of the successful
adoption of each quality standard as a whole
• Criteria for these overarching outcomes:
• Can be influenced by adopting the standard
• Important to patients and the system
• At least some of the outcomes should be currently
measureable
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- Know that the quality standard exists
- Know where to access it
- Use the quality standard
- Know what to anticipate
- Feel empowered by it
- Know that the quality standard exists
- Share and use the quality standard with their patients
- Embed quality standards into their practice
- Actively shares and promotes quality standards
- Incorporates the quality standard into professional education
- Requests new quality standard topics
- Uses quality standards:
- For monitoring & reporting
- To guide QI initiatives
- For funding decisions
Patient and Caregivers
Providers
Health System
What will Successful Adoption Look Like?
33
34
Quality Standards Adoption
• Two major activities for each standard:
• Recommendations will be unique though consider common elements required for successful
adoption. Reflects a system-level approach for what is needed to support the adoption of the
quality standard
• Informed by the Quality Standards Advisory Committee, key stakeholders/potential partners
(including MOHLTC), targeted structured interviews with front line providers, relevant evidence
• Source for ‘recommendations’ of the Ontario Quality Standards Committee
• Resources to support adoption initiated in parallel and/or expected within the timeline indicated
in the recommendations
Develop Quality Standard Adoption Recommendations
Resources to support adoption & improvement
1
2
Adoption Approaches
Develop the Adoption
Recommendations
• Readiness assessment including
regional context
• Policy or regulatory implications
• Use of levers (contracts, QIP)
• Identified needs for clinical tools
• Proposed Quality Improvement
strategies
• Partners (specific to each of
above)
• Resources / costs
• Expectations on timing (what can
start immediately or is longer term)
• Monitoring and evaluation plan
Resources to support adoption
and Improvement
• Getting started guide
Other examples of tools and QI:
• Clinical pathways
• Decision aids
• Order sets, methods to embed in
systems of care
• Audit & feedback
• Education / training
*appropriate partners and existing
programs where they exist
35
1 2
36
COPD Quality Standard Timeline
Spring to Fall 2017:
Development and adoption meetings
Fall 2017:
Public consultation and stakeholder engagement
Winter 2017-18:
Finalizing quality standard products
Winter 2018:
Approval by HQO Board and Ontario Quality Standards Committee
Spring 2018:
Quality Standard launch and adoption
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37
COPD Quality Standard Scope
• Inclusion:
– Adults who have or are suspected of having COPD,
including people with complex health needs or comorbidities
– All settings, with focus on primary care and community care
– Diagnosis and management of COPD (stable and acute
exacerbations)
• Exclusion:
– Management of specific COPD comorbidities
– Lung surgery
– End-of-life and palliative care
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38
24 Members COPD
Quality Standard Advisory
Committee
Lived Experience
Advisors
Physicians: primary care &
respirology
Physical & Occupational
Therapists
Pharmacist
Administrators
Psychologist
Nurse practitioners
Respiratory Therapists
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39
Prioritizing outcomes and areas for
improvement for people living with COPD
www.HQOntario.ca
Diagnosis and comprehensive
assessment
Education and self-
management
Pulmonary rehabilitation
Pharmacologic management of stable COPD &
AECOPD
Transitions in care
Multidisciplinary care / Primary care / Referral to specialized care
Improved
Quality of
Life &
ADL
Reduced
hospitalizations
Reduced
ED visits
Early
identification
of COPD
Reduced
rates of
AECOPD
Improved
access to
PR
Improved
follow-up
Increased
smoking
cessation
40
Your Role in this Process
• Opportunities for engagement:
– Town Hall – June 12th
– Public consultation - October
• Share your:
– Tools, templates and innovative practices
– Learnings and progress
– Existing programs and initiatives that can support adoption
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www.HQOntario.ca
Email: [email protected]
FOLLOW@HQOntario
Questions?
Contact:
Sarah Burke Dimitrova, Lead COPD Quality Standard
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