Building Quality Improvement Partnerships in the VA: The Colorectal Cancer Care Collaborative

1
Building Quality Improvement Partnerships in the
VAThe Colorectal Cancer Care Collaborative

• QUERI National Meeting
• Phoenix, AZ
• December 2008
• George L. Jackson, Ph.D., MHA Leah L. Zullig,
  MPH
• Adam A. Powell, Ph.D., MBA Diana L. Ordin, MD,
  MPH Dawn T. Provenzale, MD, MS

2
C4 Colorectal Cancer Care Collaborative

• Began in 2005
• To assess and improve the quality of colorectal
  cancer care from screening and diagnosis through
  treatment

3
Time Line
4
Todays Workshop

• How did we get started on the collaboration?
• Overview of Colorectal Cancer Care Collaborative
• Measurement challenges
• Building a measurement system
• Spreading lessons to the VA
• Lessens for QUERI investigators

5
Why C4?

• Initiated in 2005
• Earlier CMO study suggested timeliness problems
• QUERI research results demonstrated gaps in
  colorectal cancer diagnosis and treatment
• OIG report
• Congressionally-mandated review of cancer care
  (GPRA Government Performance and Results Act)
• Colorectal, breast, lung, prostate, hematologic

6
Colorectal Cancer

• Second leading cause of cancer death
• Third most common type of cancer among men and
  women in the United States
• 11 of all new cancer cases
• 90 five-year survival when diagnosed at stage I
• 5 five-year survival when diagnoses at stage IV
• Source VA Colorectal Cancer QUERI Fact Sheet,
  January 2006

Source VA Colorectal Cancer QUERI Fact Sheet,
Jan. 2006
7
CRC Continuum
8
Follow-Up Positive FOBT
9
Modifiable Risk Factors for Advanced CRC

• 549 patients
• 43 presented with late stage (stage III or IV)
  colorectal cancer
• The only factor associated with presenting with
  late stage was not having a usual source of
  health care
• Median patient delay 9 weeks
• Median physician delay 6 weeks
• Stage at presentation was not associated with
  either patient or physician delay

Fisher DA, Martin C, Galanko J, Sandler RS, Noble
MD, Provenzale D. Risk factors for advanced
disease in colorectal cancer. Am J Gastroenterol
2004992019-2024.
10
Modifiable Risk Factors for Advanced CRC

• Median patient delay 9 weeks
• Median physician delay 6 weeks
• Stage at presentation was not associated with
  either patient or physician delay

Fisher DA, Martin C, Galanko J, Sandler RS, Noble
MD, Provenzale D. Risk factors for advanced
disease in colorectal cancer. Am J Gastroenterol
2004992019-2024.
11
OIG Report CRC Detection and Management in VHA
Facilities Feb. 2006

• Metrics to evaluate and improve CRC dx timeliness
• Prioritization process for dx c-scopes
• Directive addressing timeframes
• Pt notification of screening results within 7
  working days
• Consistent notification and documentation
  requirement for dx testing

12
OQP Vision

• Measures and measurement tool development
  (QUERI/HSRD)
• Pilot collaborative project to identify and
  develop improvement strategies/tools (OQP/SR)
• National dissemination of project (SR/OQP)
• Monitors or Performance Measures to create pull
  for improvement
• Ongoing support to facilitate sharing,
  identification of additional effective
  strategies/tools

13
OQP Vision

• Partnership among OQP, researchers, PCS, Advanced
  Clinical Access/Systems Redesign
• Strong, ongoing evaluation component

14
Anticipated Challenges

• Measurement challenges
• Improvement challenges
• Dissemination challenges
• Two phases diagnosis and treatment
• Project infrastructure
• New partnership model
• Just-in-time planning
• Pace and design of project
• Sense of urgency
• Cultural clashes
• Research vs. operations
• Anecdote vs. evidence

15
Anticipated Outcomes and Products

• Measurement
• Standardized facility-level approaches for QI
  measures
• Real-time measurement tools
• Documentation of barriers to national measurement
• Improvement tools/strategies
• Dissemination mechanism
• Improvement before external review published
• Lessons on how to do this better next time
• Project organization and partner roles
• C4-type collaborative

16
The Partnership

• Quality Enhancement Research Initiative (QUERI)
• CRC expertise in measurement and improvement
• Office of Quality and Performance (OQP)
• Performance measurement expertise
• Quality improvement expertise
• Systems Redesign
• Expertise in delay reduction
• National infrastructure, experience, and tools
• Patient Care Services
• Clinical expertise
• Link to VA clinical constituencies

17
C4 Planning Committee

• Organizes the collaborative
• Includes representatives from all partner
  organizations and other VA collaborative experts
• Subcommittees
• Measurement Issues
• Collaborative Operations
• Dissemination

18
Optimizing the Partnership

• Dialogue is critical!
• Initial QUERI-provided measures were critiqued by
  the field
• C4 works with the field to develop better
  measures
• Some may inform national data systems and some
  may remain local improvement tools
• OQP, DUSHOM and VISN CMOs provide continued
  support

19
Changing Systems
20
C4 Learning Collaboratives

• 21 volunteer facilities (one per VISN) in
  diagnosis collaborative
• 28 volunteer facilities (at least one per VISN)
  in treatment collaborative
• Collaborative structured, sharing with rapid
  cycle improvement
• Planning and facilitation by partner
  organizations with the involvement of many VA
  stakeholders

21
Diagnosis Collaborative21 Improvement Teams
VISN 1 Providence VISN 2 Buffalo VISN 3 New
Jersey VISN 4 Pittsburgh VISN 5 Washington

• VISN 6 Beckley, WV
• VISN 7 Columbia, SC
• VISN 8 San Juan
• VISN 9 Lexington, KY
• VISN 10Columbus
• VISN 11Northern Indiana

• VISN 20 Portland
• VISN 21 San Francisco
• VISN 22 Loma Linda
• VISN 23 Black Hills, SD

VISN 12 Chicago (Hines) VISN 15 St. Louis VISN
16 Houston VISN 17 Temple VISN 18 West
Texas VISN 19 Salt Lake City
22
Treatment Collaborative28 Improvement Teams
VISN 1 Providence VA
Connecticut VISN 2 Buffalo VISN 3 New Jersey VISN
4 Pittsburgh Lebanon, PA VISN 5
Washington

• VISN 6 Beckley, WV
• Salisbury, NC
• VISN 7 Columbia, SC
• VISN 8 Gainesville
• VISN 9 Lexington, KY
• VISN 10Dayton
• VISN 11Northern Indiana

• VISN 20 Portland
• Puget Sound
• VISN 21 San Francisco
• VISN 22 Loma Linda
• San Diego
• VISN 23 Black Hills, SD
• Nebraska/W. Iowa

VISN 12 Chicago (Hines) VISN 15 St. Louis VISN
16 Houston VISN 17 Temple VISN 18 West Texas
Albuquerque VISN 19 Salt Lake City
23
C4 Learning Collaborative Process

• Flow-mapping and initial data collection
• QUERI measurement using CPRS data
• Local measurement
• Setting aims
• Plan-Do-Study-Act (PDSA) cycles
• Coaches aid in the improvement process
• Collaborative sharing via in-person meetings,
  monthly national calls, monthly reports to
  coaches and senior leaders, updates to VA
  leadership, website, and listserv

24
Collaborative Process
Team selection and commitment
In-Person Meeting -Flow mapping -Baseline
measures -Aim setting
Plan-Do-Study-Act (changes and measurement)
Structured sharing (e.g national calls)
Reports to C4 and leadership
PDSA
Dissemination
25
C4 Team Composition

• Facility Management
• Facilities volunteered for the collaborative
• Applications signed by the medical center
  director, chief of staff, and nursing executive
• Sites chosen to provide size, complexity,
  geographic diversity
• Team Formation
• Teams include physicians, nurses, and other
  representatives from the involved clinical
  services
• Designated project manager
• Information technology representative

26
C4 Team Activities

• Flow-mapping and initial data collection
• Setting aims
• Plan-Do-Study-Act (PDSA) cycles
• Coaches aid in the improvement process
• Collaborative sharing via in-person meetings,
  monthly national calls, monthly reports to
  coaches and senior leaders, updates to VA
  leadership, website, and listserv

27
Model for ImprovementPDSA Rapid Cycle
Improvement
What are we trying to accomplish? How will we
know that a change is an improvement? What
changes can we make that will result in an
improvement?
PDSA slides courtesy of Jim Schlosser, MD, MBA
28
The PDSA Cycle for Learning and Improvement
29
Examples of PDSA Cycles
Improved access
Data
Cycle 5 Implement standards and monitor their
use
Cycle 4 Standardize appointment types and test
their use
Cycle 3 Test the types with 1-3 providers
patients
Reduction of appointment types will increase
appointment availability
Cycle 2 Compare requests for the types for one
week
Cycle 1 Define a small number of appointment
types and test

with staff
30
Overall Aim improve timeliness, reliability and
patient focus of CRC treatment
Improve pathology reporting
Shorten staging work-up

Improve treatment concordance
Improve patient education
Testing Multiple Changes
31
Systems Redesign/Advanced Clinic Access

• Scientifically based principles
• System/process redesign
• Everything improves
• Requires measurement
• Delay elimination
• http//srd.vssc.med.va.gov

32
High Leverage Changes to Eliminate Delay

• Office Efficiency
• Balance supply demand for non-appointment work
• Synchronize patient, provider, information
• Predict anticipate patient needs
• Optimize rooms equipment
• Manage constraints

• Access
• Match supply demand daily
• Reduce the backlog
• Decrease appointment types
• Develop contingency plans
• Reduce demand
• Increase supply/ Optimize the team

33
Service Agreements

• Purpose
• Specialists cant do everything best
• PC cant do everything best
• Best utilization of resources
• Elements
• Define the work.
• It is not NO work
• It is not ALL work
• It is the work that only I can do (colonoscopy)
• 2. The sender agrees to send the right work
  packaged the right way.
• Referral templates
• Guideline driven
• All the information to safely complete the
  procedure
• 3. The receiver agrees to do the work right away

34
CRC Screening ProcessProblems All Along the Path
35
CRC Dx Improvement Strategies

• Decrease inappropriate screening
• Strengthen service agreements/consult templates
• Improve patient colonoscopy prep
• Track positive screens to ensure follow-up
• Fee-base or contract to get rid of backlog
• Add permanent staff
• Other (LOTS!!!)

36
CRC Tx Improvement Strategies

• CPRS enhancements (clinical reminders, quick
  orders, templates) are useful to ensure guideline
  reliability/timeliness
• Cancer care coordinators streamline process for
  patients, monitor care, and can maintain contact
  for lengthy surveillance

37
C4 Data Collection

• Phase I
• Baseline data
• Two process evaluation surveys
• Qualitative interviews with site team leaders
• Outcome data (to be collected)
• Phase I Spread
• National facility survey
• National success case method interviews
• Monitor data
• Phase II
• CCQMS dataset
• Pre-intervention assessmentOrganizational
  readiness to change
• Process Evaluation Survey

38
Process Change
N 128 to 131 Facilities Fully Implemented In Process of Implementing Not Implementing
Strategies to decrease cancellations/no shows 82 12 6
Create/revise of PC/GI service agreement 64 22 14
Consult template revision 59 25 16
Track colonoscopy supply and demand 56 28 16
Form an multidisciplinary improvement team 56 22 22
Revise colonoscopy prep ed and/or protocols 54 21 25
Participate in an improvement collaborative 51 21 28
Initiate/increase use of fee-based colonoscopies 44 16 40
Revise CRC screening clinical reminder 43 31 26
Create system for tracking FOBT patients 42 38 20
Track number of inappropriate FOBTs 33 28 39
Hire additional nurses/other staff for colonoscopies 29 33 38
Track number of incomplete colonoscopies 28 20 52
Hire additional colonoscopists 23 35 42
Add additional endoscopy suites 15 27 58
Contract additional onsite colonoscopists 15 18 67
- Process Improvement - QI Infrastructure - GI Capacity Building
39
What have been the most significant barriers to
improvement?
40
Measurement Challenges

• Develop a timely measure of timeliness
• Establishing a reasonably short hurdle (
  receiving follow-up in 60 days) better than
  mean/median time to follow-up
• Ideally the same measure(s) will be useful both
  within facilities (QI) and between facilities
  (evaluation)

41
Local FOBT Tracking Tool

• Features
• Ease of input
• Tracks most relevant indicators of improvement
• Generates run charts
• Adaptable to evolving data needs
• Facilitates reporting of FOBT Follow-up monitor
  data

42
FOBT Follow-up Monitor

• Self-reported
• Currently lack of standardization within VistA
  across facilities makes centralized collection of
  monitor data difficult
• Tradeoff between rigor and data collection burden
  on sites
• Generated from local QI tracking system(Most use
  nationally developed FOBT Tracking tool)
• Evolving as definitional issues encountered

43
FOBT Follow-up Monitor

• Which FOBTs should be included?
• Inappropriate screening? (e.g. recently
  screened, limited life expectancy)
• Patient refusals?
• Patients going outside of VA for follow-up?

44
FY09 FOBT Follow-up Monitor

• Proportion of patients with a positive colorectal
  cancer (CRC) screening FOBT with diagnostic
  colonoscopy lt 60 days after the positive
  screening FOBT.
• Numerator Those in denominator who had complete
  diagnostic colonoscopy lt 60 days after a positive
  CRC screening FOBT
• Denominator Number of patients with a positive
  CRC screening FOBT in the measurement month
• Exclusions
• Patients who refuse follow-up colonoscopy
• Patients who choose to have follow-up colonoscopy
  outside (i.e., neither performed nor paid for by)
  the VA
• Patients determined to be clinically
  inappropriate for colonoscopy
• Patients who have had a previous positive FOBT in
  the FY09
• Patients whose FOBT was not performed as a CRC
  screening FOBT.

45
Monitor Validation

• Planned independent assessments
• C4 Post-intervention Evaluation
• Partin grantDETECT Determinants of Timely
  Evaluation Colonoscopy for crc screening Tests
• Powell CDA manual chart review project
• EPRP abstraction

46
Colorectal Cancer Care Measurement System

• These measures, when mapped to NCCN
• Guidelines, will
• Identify facility level gaps in care to patients
• Identify facility level deviations from
  established standards of patient care
• Identify systemwide gaps in care to patients
• Identify systemwide deviations from established
  standards of patient care

47
CCQMS Development Process

• Solicited input from VA constituencies
• Office of Patient Care Services
• Oncology Field Advisory Committee
• Team of members at participating sites
• Developed specific quality indicators and
  measures
• Sample quality indicator proportion of patients
  with resected colon cancer with 12 lymph nodes
  examined by pathology
• Indicators and measures form the basis for
  computerized measurement and analyses tools

48
CCQMS Development Process

• Facilities collect measurement data from VA
  computer systems
• Information to C4 participants
• During the improvement collaborative, facility
  and VA-wide reports are being produced
• A goal is to increase data extraction
  capabilities during the time of the collaborative
• Potential to serve as a model for other cancer
  care quality measurement efforts

49
CCQMS Operational Design
50
CCQMS Data Entry
51
CCQMS Reporting Feature

• Immediate feedback on concordance with NCCN
  guidelines and their progress in meeting the
  quality indicators
• Displays facility de-identified data for
  reference and comparison

52
CCQMS Quality Indicator Reports
3
53
CCQMS Quality Indicator Reports
54
CCQMS Timeliness Reports
55
Colorectal Cancer Care QualityMeasurement System

• Next Steps
• Discussions with VA leadership regarding national
  dissemination of the tool
• Partnership with Department of Defense
• Collaborators at Walter Reed Army Medical Center
• Survey Component
• University of Minnesota
• Patient/Family Experiences
• Explore options for use in private health care
  systems

56
Working with the Teams

• Collaborative work is different than traditional
  research
• Considerable people-factor in dealing with
  multidisciplinary groups
• Communication and flexibility are key
• Balance between rapid cycle improvement and rigor
  of data collection
• End goal is impact improvement rather than
  publication

57
National Dissemination

• DUSHOM Monitor
• Local measurement tool
• Quarterly feedback of aggregate results (FOBT
  measure)
• Provide baseline data (CRC treatment)
• Improvement facilitation
• Improvement guide from collaborative
• Monthly phone calls
• Listserv
• Coaching (not yet available)

58
FOBT Follow-Up Monitor

• Year 1 (FY2007)
• Q1 flow map
• Q4 FOBT-positive patients with follow-up
  within 60 days improvement progress report
• Year 2 (FY2008)
• Q2-Q4 FOBT-positive patients with follow-up
  within 60 days (revised) improvement
  self-assessment
• Year 3 (FY2009)
• Q2-Q4 FOBT-positive patients with follow-up
  within 60 days (revised)
• Q4 improvement self-assessment

59
DUSHOM FY2009 CRC Diagnosis and Treatment Monitor

• Opportunity to spread improvement nationally
• Facilities begin to look at their processes for
  colorectal cancer care
• Medical centers identify improvement
  opportunities, collect data on an indicator in
  their area of opportunity, begin improvement work
• Tools/lessons available from the collaborative

60
CRC Treatment Monitor FY2009

• Q2 team, aim, flow map to SR POC
• Q3 improvement plans for targeted area,
  including measures to SR POC
• Measures menu and tool available
• Q4 improvement progress report

61
C4 Products

• Models for improving cancer treatment
• Measurement systems
• Models for developing surveys
• Protocols for collaborative development
• National dissemination of cancer dianosis and
  care improvment

62
Research Working with Operations C4 Lessons

• Learning who is who in the VA
• Central Office, VISNs, facilities
• Integrating C4 and changes into facility workflow
• Tremendous differences among VA facilities
• Organization of care, information technology,
  services provided
• Managers at different levels have different needs
• Information technology changes must be considered

63
Comparing Research Operations

• Research
• Primary goal is to improve the care of veterans
  and others
• Focus on generalizable knowledge
• Pressure to publish and get grants
• Generally smaller number of players

• Operations
• Primary goal is to improve the care of veterans
  and others
• Focus on implantation in real time
• Pressure to respond to organizational demands and
  stakeholders
• Huge number of players

64
Lessons for Investigators

• Wonderful opportunity to make a difference in
  patient care
• Allows for an extensive network to be built
• Can take up a great deal of time
• Often responding to the needs of many different
  stakeholders
• Researchers have different career goals than
  collaborators
• Can require creativity to get academic products
• Can still take a longer time than usual

65
C4 Planning Committee

• Jacki Bebb, BSB/M
• Hanna E. Bloomfield, MD, MPH
• Deborah Cortez, MPH, CHES
• Cody Couch
• Michael Davies, MD
• Carrie Dekorte, PharmD
• Jill Edwards, NP
• Fabiane Erb, BA
• David Haggstrum, MD, MAS
• Theresa Hellings, RD
• Janis Hersh, MBA
• John Inadomi, MD
• George L. Jackson, Ph.D., MHA
• Michael Kelley, MD
• Laura Kochevar, Ph.D.

• Nancy Koets, PsyD
• Odette Levesque, RN, MBA
• Heidi L. Martin, MPH
• Irrma McCaffrey, BA
• Peter Mills, Ph.D., MS
• Jeffrey Murawsky, MD
• RimaAnn O. Nelson, RN, MPH
• Dede Ordin, MD, MPH
• Renee Parlier, RN, MPA
• George Ponte, Ph.D.
• Adam A. Powell, Ph.D., MBA
• Dawn T. Provenzale, MD, MS
• James Schlosser, MD, MBA
• Leah L. Zullig, MPH

66
CCQMS Financial Support

• HSRD grant (CRT 05-338)
• VA CDA (MRP 05-312)
• NCI-VA IAAs (Y1-PC-8218-01 V246S-00054)
• Sole Source Contract (HHSN261200800504P)

67
CCQMS Development Team

• Durham VAMC, Center for Health Services Research
  in Primary Care
• (HSRD)
• Dawn T. Provenzale, MD, MS Principal
  Investigator
• George L. Jackson, PhD, MHA Co-Investigator
  Project Director
• Leah L. Zullig, MPH Project Manager
• Bryan Paynter, BS Lead Programmer
• Radhika Khwaja, MD Clinical Coordinator
• Adam Powell, PhD, MBA Evaluation Coordinator
• Yousuf Zafar, MD Medical Oncologist
• Ziad Gellad, MD, MPH Gastroenterology Fellow
• Melissa Garrett, MD Gastroenterology Fellow
• Natia Hamilton, BA Research Assistant
• Chris Newlin, MPH Research Assistant
• Michelle van Ryn, PhD Co-Investigator
  Survey Component
• Minneapolis VAMC, Center for Chronic Disease
  Outcomes Research (HSRD)

68
Contact Information

• George Jackson - george.l.jackson_at_duke.edu
• Leah Zullig leah.zullig_at_va.gov
• Adam Powell adam.powell_at_va.gov
• Dede Ordin diana.ordin_at_va.gov
• Dawn Provenzale prov002_at_mc.duke.edu