Improving the Patient Experience and Health Outcomes Collaborative Project Name: Prepared by: Improving the Patient Experience and Health Outcomes Collaborative Alyssa Macedo Date (MM/DD/YYYY): 29/10/2015 1. Introduction Improving Patient Experience and Health Outcomes Collaborative (ipehoc) is a multi-site 3 year initiative led by CPAC and CCO to facilitate the uptake of standardized PROMS and PREMS and their meaningful use in clinical practice. The project aim is to reduce symptom burden and improve the patient experience of cancer. The goal is to develop a common and sustainable experience measurement system that can be used across Canada. Defining elements of this project include: 1. Routine administration of disease-specific PROMS including: pain (Brief Pain Inventory; BPI), fatigue (Cancer Fatigue Scale; CFS), anxiety (Generalized Anxiety Disorder; GAD-7), and depression (Patient Health Questionnaire; PHQ-9). 2. Strategic KT approach to effect clinical practice change including adoption of PROMS and linkage to actions for symptom management and patient self-management. 3. An evaluation framework to determine change and to stimulate quality of care improvement through feedback to clinical teams. 4. Knowledge exchange between sites with sensitivity to cultural diversity for national expansion. 2. Project Sponsor and Governance The Canadian Partnership Against Cancer (CPAC) has granted Cancer Care Ontario (CCO) and partnering hospitals $1,000,000 in funding to carry out this 3-year project (ending in Jan 2017). ipehoc is a quality improvement initiative implemented as part of routine clinical care in cancer patients. The executive sponsor is Cancer Care Ontario and the site sponsor is Terri Stuart McEwan, Director Of Ambulatory Care. The Princess Margaret (PM) IPEHOC approval body is the Lung Operations Committee. Updates and approvals of changes to Distress Assessment and Response Tool (DART) will require approval by the DART Operations Committee. See Appendix A PM PROs Governance Structure. 3. Project Objectives Objectives: This study aims to develop and field test the ipehoc patient experience measurement system and evaluate its impact on patients, health care providers and the health care system. Aim 1: Engage health care providers in the design of PROM implementation, including tool selection for fatigue, pain, anxiety and depression, output design/decision-making tools, and oncology team educational needs.
3. Project Objectives Continued Aim 2: Aim 3: Aim 4: Aim 5: Engage patients in the design of PROM and PREM implementation, including survey utility testing/acceptability, and strategies to support patient activation for self-management. Implement routine PROM and PREM administration in cancer centres at varying stages of readiness to identify key approaches and elements for successful clinical utilization of these data. Determine the impact on patient experience and health outcomes, health care provider satisfaction and teamwork, and health care utilization. Use active knowledge exchange methods to facilitate pan-canadian uptake of the ipehoc measurement system. 4. Rationale for the Change Princess Margaret (PM) is the largest comprehensive cancer centre in Canada with 15 disease sites, over 3000 staff and approximately 1000 patients seen per day. The ambulatory care vision is to provide exemplary patient centred care experiences. To achieve this vision and to become partners with our patients, PM has embedded DART as a standard of care. DART is an electronic screening tool which detects physical symptoms, emotional distress and practical difficulties. Within all 15 disease sites DART is available electronically on 70 ipads and 30 kiosks distributed in each disease site. The average screening rate across all clinics in PM is 73% with the vast majority of screening occurring electronically via the kiosks/ipads. Although screening rates have remained high, evidence from the chart audits (annual CCO deliverable) indicate that an area to improve is documentation of assessment and response to distress. Recent chart audits in Lung 2013/14 completed on 70 patients (10 charts for each of the 7 ESAS symptoms) with patients with ESAS 4 indicate that documentation of assessment and intervention for physical symptoms (pain and fatigue) is higher than depression and anxiety and overall improvements are required in responding to distress. CCO Annual Deliverable -Lung Chart Audit 2013/14 We also know from our Quarterly Symptom Prevalence Update reports that these symptoms occur frequently in Lung clinics with the prevalence of pain being 21%, anxiety 24%, depression 21% and fatigue 44%. Therefore these are very common symptoms for the Lung Site, as well pain is the most common symptom for the Sarcoma site.
Symptom Prevalence Update Report (Q1 Apr- June 2014) Prevalence of ESAS Tiredness Source: ecancer database, PM All Disease Sites, All Entries Q1 Apr- June 2014 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% No Tiredness (0) Mild Tiredness (1-3) Mod Tiredness (4-6) Sev Tiredness (7-10) These symptoms are very prevalent and they are also persistent. Recent analysis of these symptoms, indicate that pain persistence was the highest in the Lung Site, compared to all other sites. Therefore the patients had the highest level of repeated high ESAS scores >=4 based on all data examined from 2014; Change in mean pain scores across second and first visits (based on paper by Follwell 2009) Persistent of Distress (ESAS Pain) Therefore there is a need to shift attention away from screening and to focus on engaging clinicians to
respond to symptom distress. There has not been much case based adult education for clinicians on how to respond to patient reported outcomes in busy clinic settings. As well the role of the patient in PROs has also not been maximized. The Lung and Sarcoma sites would benefit from this new patient experience system to ensure that clinicians are supported to provide evidence based assessment and response and to improve the symptom experience for patients. 4. Change Objectives and Principles The IPEHOC initiative builds on the work of DART and fills some of the gaps with implementation. Mainly IPEHOC at PM will focus on four main gaps; 1) Addition of patient reported outcomes for pain and fatigue with the Brief Pain Inventory (BPI) and the Cancer Fatigue Scale (CFS) respectively 2) Provision of additional case base education on management of the 4 symptoms based on symptom management guidelines 3) Provision of education on patient activation and self-management to better support patients outside of clinic hours 4) Facilitation of quality response to PROMs use in the clinical encounter through use of specific KT strategies. Therefore, the objective of IPEHOC change management initiative is to raise awareness and response to the most commonly reported cancer symptoms anxiety, depression, fatigue and pain. Using ADKAR principles a plan will be described below that highlights how we will improve awareness, ability and response to these symptoms and how we will reinforce this change in practice. 5. Key Change Messages DART is a standard of care for all patients Electronic screening is the preferred mode to allow for additional patient reported outcomes Lung patients have the highest symptom burden, with the highest level of pain persistence High symptom burden is linked with emergency room visits Many of these emergency room visits are preventable with early interventions and symptom management
IPEHOC is an effective way to partner with patients Case based education and role modeling will provide opportunities for practice change for oncology nurses Data will be used to support this change and to feedback to staff process improvements Evaluation has been embedded throughout this process to ensure we are achieving our objectives. 6. Readiness for Change The Lung site was chosen as our primary site for IPEHOC implementation with Sarcoma as our secondary site due to the high prevalence of these symptoms and gap in documented response. The Lung and Sarcoma sites were also chosen because of several enablers inclusive of significant site leadership, multiple PROs champions, and alignment with new clinic processes with optimization. Both sites have very high engagement in DART as seen by consistently high screening rates; 86% in Lung and 100% in Sarcoma as of August 2015. Please refer to our previously submitted readiness assessment for details. 7. Development Change Plan Organizational readiness with the current use of DART as a standard of care will be maximized to launch IPEHOC. CLINIC PROCESS: In January 2015, 12 DART ipads were rolled out as part of standard care in both the Lung and Sarcoma sites. The rationale, in part, was to allow for patients and staff to become accustomed to the new process of using ipads as electronic screening devices. The DART-iPEHOC tool will be piloted in smaller site champion clinics. The DART-iPEHOC will undergo usability testing and the IT programming will be finalized (by end of October 2015). After a few weeks of testing, site based education will be rolled out with a site launch in November 2015. All Lung and Sarcoma patients will check in and be advised to complete DART-iPEHOC using ipads. The Patient Flow Coordinators (PFCs) will introduce DART and provide the ipads. The project co-ordinator will be onsite in clinics to assist patients as needed. The project co-ordinator will also take the lead with all evaluations that need to be completed. Summary reports (Please see Appendix B DART-iPEHOC Summary Report) will be printed to a dedicated DART network printer and then placed on patient charts by PFCs (or sometimes the clinic volunteers). Summary reports will also be available in EPR (patient review). Clinicians will review the reports in real time. In the Lung site, nursing staff will complete further assessments/ interventions on patients who receive 3 or more additional PROs (pain, fatigue, anxiety and depression) based on ESAS cut-off scores, and will consult the attending physician as required. In the Sarcoma site, nursing staff will complete further assessments/ interventions on patients who receive all 4 additional PROs based on ESAS cut-off scores, and will consult the attending physician as required. Please see Appendix C- Clinic Flow Diagram.
As part of ipehoc s process and health outcomes evaluation, patient paper-based surveys will also be distributed in both the Lung and Sarcoma clinics by the project co-ordinator. This will take place at various time points (baseline, mid-point, and post). Survey distribution will be staggered to lessen the impact on clinic flow. Collection rates will be recorded in daily clinic logs and entered into a database. Additionally, completed patient survey data will be entered into an Access Database. As part of the evaluation framework, a staff contact list for both Lung and Sarcoma will be compiled. At various project time points, clinicians will be sent a fluid survey link by an ambulatory manager (via email) requesting voluntary participation. Two subsequent email reminders will be sent one week apart. TECHNOLOGY: Stakeholders were engaged to assist in the development of the electronic ipehoc tool (Fall-Winter 2014). Site champions were involved to ensure their input was integrated into the process early on. All technical specs were provided to the Health Informatics team in June 2015. IT programming within the DART platform was completed in July 2015. Intelligent programming will be tested and fully integrated into DART as part of standard care (end of October 2015). The full roll out of the intelligently programmed DART-iPEHOC tool will occur in November 2015. Aggregate data will be collected in the DART ecancer database and access will be provided via the DART Lead. EDUCATION: Education sessions and slide decks will be provided to all inter-professional staff (RNs, MDs, volunteers, and PFCs) involved prior to the study launch, interim and post study. Prior to the October 2015 launch, there will be several education blitzes, including a formal kick-off event delivered to both participating sites as well as presentations at MCC rounds. At the kick-off event, staff will be provided with an overview of ipehoc and how ipehoc will be implemented in clinic. Staff will also be provided with a toolkit, which includes the PRO measures and a Staff FAQ handout (Please see Appendix D Inter-Professional FAQ Handout). Prior to launch, there will be a series of clinician education sessions consisting of a pre-launch global education session followed by three PROs symptom specific education training sessions (pain, fatigue, and anxiety/depression). These sessions will be delivered by an education lead using a standard PowerPoint slide deck. The global education session will focus on the following topics: PROs and benefits, how to interpret summary report/ scores, how to integrate PROs data in the clinical encounter, person-centered communication and patient engagement, clinical decision making and symptom management guidelines. A cluster symptom case scenario video will also be presented. The three targeted PRO symptom education sessions will provide a more in depth nursing focused discussion which will highlight best practices/guidelines in symptom management, action planning/ goal setting engagement, and patient activation for self-management. For each PRO symptom specific education session, there will be a symptom specific case scenario video. A large extent of the session will involve discussion/ reflection on current practice.
Each education session (both global and PROs symptom specific) will be 1 hour in length. The PROs symptom specific training sessions will be staggered at on-two week intervals after the initial global education session. Webinars will be created based on the above mentioned education sessions and circulated to interprofessional staff. The global education modules are expected to be completed by January 2016. Ongoing education will also be implemented after these initial education sessions are delivered. After every education debrief sessions will be held where clinicians will to bring complex cases to discuss. Knowledge Translation Strategies and Education Educational toolkits Educational outreach via ongoing case based workshops/ lectures Web-based courses Facilitation of practice change via simulated practice and case discussion Training/ symptom videos Small media (e.g., poster/ongoing email communication/ FAQs) Audit and feedback of responses to PROMs PDSA cycles 8. Reinforcement Change will be reinforced in many different formats; 1. Newsletters will be prepared monthly with screening rates, chart audits, PDSA cycles and patient feedback. The IPEHOC newsletter will be an informative way to feedback status updates to the site. (See Sample Newsletter Appendix E). 2. Change will also be reinforced with huddles in clinics about process and response. 3. Education will also be reinforced with opportunities for debriefs with staff on regular bases to review case studies and complex cases based on IEPHOC reviews. 9. Evaluation EVALUATION: Evaluations will take place according to the specified timeframe (baseline, mid-point and post) starting September 2015 until May 2016. Evaluations to include (but will not be limited to): Patient Perspective: PROMs (ESAS-r, PHQ-9, GAD-7, BPI, and CFS; Patient Acceptability of Routine Symptom Reporting
Survey (PAS) PREMs to assess patient activation in self-managing care (Perception of Care Survey (PCS); Ambulatory Oncology Patient Satisfaction Survey (AOPSS) Focus groups Clinician Perspective: Measures of teamwork and communication (Collaborative Practive Assessment Tool (CPAT) Chart audits to assess clinical uptake Surveys (Clinician Satisfaction with Patient-Reported Outcome Measures) Focus groups Quality improvement processes will be embedded throughout the process with PDSA cycles and audit and feedback. See appendix F: Evaluation Framework. 10. Communication Plan COMMUNICATION: All materials will be collected and linked to the DART intranet website. Project updates will be provided at the Lung and Sarcoma Site Business Meetings as well as Tumor Board meetings. Staff will be provided with FAQ documents, one-on-one feedback, newsletters, project emails, and monthly progress reports which will include screening rates, chart audits, symptom prevalence, and quality improvement indicators. For patients, signage will be present in clinics and patient education 1 pagers/pamphlets will be available. For volunteers, a DART training video will be developed to highlight the role of the volunteer in clinic.
Appendix A: Governance
Appendix B: Clinic Flow
Appendix C: Summary Report
Appendix D: FAQ For Staff
Appendix E: IPEHOC Monthly Progress Report
Appendix F: Evaluation Framework