I. MOQC UPDATEI. MOQC UPDATE

Douglas Blayney, MDJeffrey Smerage, MD, PhDPhysician Leads, MOQC

SESSION OBJECTIVESESSION OBJECTIVE

By the end of this session, participants should be able to:Identify at least one QOPI targeted area of improvementIdentify at least one QOPI improvement strategy

Today’s Agenda:Today’s Agenda:

I. Aim- MOQC 2011/2 GoalsII. Measure

A. Results of National AssessmentB. MOQC Fall 2011 PerformanceC. New MOQC Oral Measures

III. Change/ Improvements Palliative Care Demonstration

Project

IV. Next Steps

1. AIM: MOQC Goals 1. AIM: MOQC Goals 2011/22011/2A. Improve QOPI participation in

Michigan including achievement of QOPI Certification

B. Improve Michigan performance on QOPI Symptom Management measures

C. Improve Michigan performance on QOPI End of Life measures

II. MeasureII. Measure

A. Comparison with 5 years of National QOPI Data

B. MOQC Fall 2011 PerformanceC. New MOQC Oral Measures (see

oral chemotherapy section)

Analytic Data SetAnalytic Data Set

Table 2.2 Mean score of Indicators by incident participation by Domain

Domain Non-MOQCN

(practices)N (charts

abstracted) MOQCN

(practices)N (charts

abstracted) Diff (1-2)

P-value (Satterthwaite)

Breast Cancer 0.92 136 688 0.95 20 63 -0.03 0.18

Care at End of Life 0.73 136 316 0.73 20 110 0.00 0.94

Colon and Rectal Cancers 0.90 136 356 0.85 20 23 0.05 0.32

Core 0.77 136 1,392 0.77 20 299 0.00 1.00

Lung Cancer (non-small cell) 0.65 136 161 0.71 20 9 -0.07 0.67

Non-Hodgkin's Lymphoma 0.75 136 147 0.53 20 10 0.21 0.07

Symptom/ Toxicity Management 0.67 136 337 0.56 20 43 0.12 0.07

Mean of scores

Note: Inclus ion cri teria for medica l practices are 30+ new patients , Not fel lowship programs, US based, participated 2+ rounds

MOQC Performance Comparison Fall 2011Study

Table 3. Results for Fixed Effects Estimates 95 % Confidence Interval

Variable Variable values Odds Ratios P-Value Lower Bound Upper BoundIntercept 2.05 0.28 0.56 7.52Practice-level variablesSpecialty Multi-specialty 1.05 0.82 0.71 1.54

Oncology only ref .missing 1.06 0.90 0.41 2.78

Affi liation Employee 2.20 0.04 1.03 4.70

Private independent 1.52 0.22 0.78 2.98

Private with academic affiliation 2.77 0.02 1.15 6.66

missing 0.44 0.36 0.08 2.51

Academic full time ref .

Number of patients 500 to 1500 0.72 0.17 0.46 1.15More than 1500 0.77 0.38 0.42 1.39Fewer than 500 ref .

Number of physicians 5 to 10 1.37 0.25 0.80 2.32More than 10 1.05 0.87 0.60 1.83Fewer than 4 ref .

missing 1.53 0.54 0.40 5.80US Region Midwest 1.08 0.78 0.64 1.82

Northeast 1.00 1.00 0.54 1.88South 1.38 0.23 0.82 2.35West ref .

MOQC Status Yes 1.63 0.12 0.88 2.99No ref .

Measure-level variablesLevel of Evidence High 1.83 0.29 0.59 5.68

Medium 0.71 0.56 0.22 2.30Low ref .

Documentation Yes 0.70 0.52 0.23 2.09No ref .

Instituted New Practice Yes 0.01 <.0001 0.00 0.05No ref .

Time related variablesAbstraction Round 1.09 <.0001 1.07 1.12Interaction of Abstraction Round & Instituted New Practice

Instituted New Practice1.40 <.0001 1.36 1.43

Not ref .Note1: Inclus ion cri teria for medica l practices are 30+ new patients , Not fel lowship programs, US based, participated 2+ rounds

MOQC Pain Initiative

MOQC Pain Initiative

III. Change / Improvements:III. Change / Improvements:Palliative Care Demonstration Palliative Care Demonstration ProjectProject

◦Collaborative Overview◦Palliative Care- Key Concepts◦Quality Improvement Model◦Experience of Participants

Palliative Care Palliative Care Demonstration Project Demonstration Project ParticipantsParticipants

Toledo Clinic Cancer Centers

Sparrow Cancer Center

Cancer and Hematology Centers of Western Michigan

Marquette General Hematology Oncology

Center of Cancer Care & Blood Disorders

Karmanos Cancer Center

IHA Hematology & Oncology Consultants

University of Michigan Comprehensive Cancer Center

PALLIATIVE CAREPALLIATIVE CARECONSTRUCTSCONSTRUCTS

J. Cameron Muir, MD, FAAHPM

EVP, Quality and Access, Capital Caring

Clinical Scholar, Georgetown Center for Bioethics

Assistant Clinical Professor, Johns Hopkins Oncology

Past President, Am. Academy of Hospice and Palliative

Medicine

Framework: Integrated Framework: Integrated Palliative CarePalliative Care

Palliative Care

Disease Modifying Treatments

Hospice

DiagnosisTreatments to Relieve Suffering/Improve QOL

6Mo Death

Bereavement

Measures: ASCO QOPI “Palliative Measures: ASCO QOPI “Palliative Subset” (Core Measures)Subset” (Core Measures)

Pain Assessment◦ 3. Pain assessed by the second office visit (%)◦ 4. Pain intensity quantified by the second office visit (%)◦ 5. For patients with moderate to severe pain, documentation

that pain was addressed (%) Narcotic analgesic assessment◦ 7. Effectiveness of pain medication assessed on visit following

new narcotic prescription (%)◦ 8. Constipation assessed at time of or at first visit following

new narcotic analgesic prescription (%)◦ Psychosocial support (Test)◦ 21. Chart documents patient’s emotional well-being was

assessed by second office visit (%)◦ 22. For patients identified with a problem with emotional well-

being, the chart documents that action was taken by second office visit (%)

19

Measures: ASCO QOPI “Palliative Measures: ASCO QOPI “Palliative Subset” Subset” (Care at End of Life Measures)(Care at End of Life Measures)

Pain assessed and documented near the end of life

◦ 35. Pain assessed on the second to last or last visit before death (%)

◦ 36. Pain intensity quantified on second to last or last visit before death (%)◦ 37. Plan of care for patients with moderate to severe pain documented on either last 2

visits

◦ Dyspnea assessed near the end of life

◦ 37. Dyspnea assessed on second to last or last office visit before death (%)

◦ 38. Action taken to ease dyspnea on second to last or last office visit before death (%)

Timing of hospice enrollment

◦ 39. Patient enrolled in hospice before death (%)

◦ 40. Patient enrolled in hospice/referred for palliative care services before death (%)

◦ 41. Patient enrolled in hospice within 3 days of death (%) (Lower Score - Better)

◦ 42. Patient enrolled in hospice within 1 week of death (%) (Lower Score - Better)

◦ 43. For patients not referred in last 2 months of life, hospice/palliative care discussed (%)

Timing of chemotherapy administration before death

◦ 44. Chemotherapy administered within the last two weeks of life (%) (Lower Score -Better) 20

QUALITY IMPROVEMENT QUALITY IMPROVEMENT CONSTRUCTSCONSTRUCTS

Kevin DeHorityLean Coach

University of Michigan Health System

Adoptd from: Langley GL, Nolan KM, Nolan TW, Norman CL, and Provost LP. The

Improvement Guide: A Practical Approach to Enhancing

Organizational Performance. Jossey-Bass, 1996.

• Institute for Healthcare Improvement (IHI) web site, “How to Improve,”

Rules of ThumbRules of ThumbBasic pointers to encourage participant along the way…

What can we do by next Tuesday? Keep it simple, and get it startedSet stretch goals that will make it worthwhileGo for the low-hanging fruit by starting with easier changes You can only fix what you can measureIf we keep doing what we have been doing, we will keep getting what we have been getting.To get something better, we have to start doing something differently

Change ManagementChange Management

The following activities were recommended as a part of this collaborative…Use of the IHI Change Packet Concept

◦ Defines Aim- Measures –Changes◦ Details process flow, accountabilities and due dates

Visually Display Performance Tracking System in work area◦ Create a visual presence of your goals and metrics◦ Allow folks to be thinking and documenting issues and ideas in between

meetings

Update Performance Tracking System every 1-2 weeks◦ Create responsibility and cadence for updating the metrics

SHARING BEST SHARING BEST PRACTICESPRACTICES

Center of Cancer Care & Blood DisordersTallat Mahmood, MD

Helen Shock

Center for Cancer Care and Center for Cancer Care and Blood DisordersBlood Disorders

1540 Lake Lansing Rd Lansing, MI

About Our PracticeAbout Our Practice

3 Physicians 2 Physician

Assistants 4 Registered Nurses 3 Medical Assistants Offices in Lansing

and Owosso Chemotherapy,

supportive care, iron, provide infusion care for PCP

Multi-Specialty physician owned practice

Celina Windnagle PA-C

Eman Issawi PA-C

Palliative Care Palliative Care DemonstrationDemonstration

Dr. Tallat Mahmood◦Physician Team

Leader

Patty Morley RN ◦Clinical Manager

Helen Shock◦Patient Financial

and Billing Specialist

Dr. Dan Williams

Dr. Tallat Mahmood

Dr. Shalini Thoutreddy

MMP Team GoalMMP Team GoalClarify the roles of primary oncologist

versus palliative care team◦ Differences in clinical/disease management

Streamline process to address symptom control

Utilize a tool for ongoing evaluation of symptoms

Research treatment options for symptom management

Supportive Care Conference Annually ◦ Education for oncology team

Center of Cancer Care & Blood DisordersESAS Tool Integrated into EMR as Flowsheet

Center of Cancer Care & Blood DisordersEMR- Ability to Trend Symptoms Over Time

Center of Cancer Care & Blood Center of Cancer Care & Blood Disorders:Disorders:Lessons LearnedLessons Learned

Patients: ESAS-r tool relatively easy to complete; patient instructions should be available from the start

Physicians: ESAS-r facilitates targeted discussion of symptoms with patient saving time; trending results are helpful but manual process too difficult to complete on each patient encounter

Center of Cancer Care & Blood Disorders:Center of Cancer Care & Blood Disorders:Lessons LearnedLessons Learned

Implementation Process:◦Limited number of patients in target

population can cause confusion for staff determining who should get the form

◦Incremental improvement/ change is helpful so not to get too overwhelmed

◦Visible tracking performance and issues is helpful for the team

MOQC Next Steps:MOQC Next Steps:

Palliative Care Demonstration Project: Spread best practices/lessons learned including standardize use of ESAS

QOPI Certification: MOQC Lunch & Learn Webinar I –Getting Started

January 31, 2012 12 -1pm (for details: http://moqc.org)

MOQC Lunch & Learn Webinar II – Self Assessment February 21, 2012 12 -1pm (for details: http://moqc.org)

Mock Surveys