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

www.HQOntario.ca

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

www.HQOntario.ca

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

www.HQOntario.ca

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?

www.HQOntario.ca

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

www.HQOntario.ca

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

13

Following the patient after discharge from acute care:The post-acute episode model

14

Bringing it all together:A combined acute / post-acute model for COPD

Recommendations in QBP Clinical Handbook

15www.HQOntario.ca

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

www.HQOntario.ca

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

www.HQOntario.ca 18

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

www.HQOntario.ca

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

24

Each quality standard comprises

the following products

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Quality Standards Clinical Guide

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www.HQOntario.ca 26

The Quality Statement

The Audience Statements

The Quality Indicators

The Definitions

Quality Standards Clinical Guide

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Quality Standards Patient Reference Guide

27

Quality Standards Adoption

Recommendations and Resources to

Support

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Quality Standards Information and Data Brief

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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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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www.HQOntario.ca

- 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

www.HQOntario.ca

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

www.HQOntario.ca

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

www.HQOntario.ca

www.HQOntario.ca

Email: sue.jones@hqontario.ca

FOLLOW@HQOntario

Questions?

Contact:

Sarah Burke Dimitrova, Lead COPD Quality Standard

Sarah.BurkeDimitrova@hqontario.ca