What do end-users want to know about managing the performance of healthcare delivery systems? Co-designing a context-specific and practice-relevant research agenda.

BACKGROUND: Despite increasing interest in joint research priority-setting, few studies engage end-user groups in setting research priorities at the intersection of the healthcare and management disciplines. With health systems increasingly establishing performance management programmes to account for and incentivize performance, it is important to conduct research that is actionable by the end-users involved with or impacted by these programmes. The aim of this study was to co-design a research agenda on healthcare performance management with and for end-users in a specific jurisdictional and policy context. METHODS: We undertook a rapid review of the literature on healthcare performance management (n = 115) and conducted end-user interviews (n = 156) that included a quantitative ranking exercise to prioritize five directions for future research. The quantitative rankings were analysed using four methods: mean, median, frequency ranked first or second, and frequency ranked fifth. The interview transcripts were coded inductively and analysed thematically to identify common patterns across participant responses. RESULTS: Seventy-three individual and group interviews were conducted with 156 end-users representing diverse end-user groups, including administrators, clinicians and patients, among others. End-user groups prioritized different research directions based on their experiences and information needs. Despite this variation, the research direction on motivating performance improvement had the highest overall mean ranking and was most often ranked first or second and least often ranked fifth. The research direction was modified based on end-user feedback to include an explicit behaviour change lens and stronger consideration for the influence of context. CONCLUSIONS: Joint research priority-setting resulted in a practice-driven research agenda capable of generating results to inform policy and management practice in healthcare as well as contribute to the literature. The results suggest that end-users are keen to open the "black box" of performance management to explore more nuanced questions beyond "does performance management work?" End-users want to know how, when and why performance management contributes to behaviour change (or fails to) among front-line care providers.

Toward a Common Goal: Improving Safety of Oral Chemotherapy Prescribing Practices at a Jurisdictional Level.

PURPOSE: Extending the safety agenda from parenteral to oral chemotherapy was identified as a provincial improvement priority in the 2014-2019 Cancer Care Ontario (CCO) Systemic Treatment Provincial Plan. Elimination of handwritten prescriptions for oral chemotherapy was one of the specific goals and led to a provincial quality improvement (QI) initiative involving systemic treatment facilities across 14 regional cancer programs. METHODS: The initiative was centrally organized by CCO but locally implemented by the regional partners. CCO provided templates and tools, such as preprinted orders (PPOs), project charters, and an evaluation plan, and facilitated cross-jurisdictional knowledge sharing and exchange. Regions had flexibility in determining their local implementation strategies and were responsible for conducting chart audits to evaluate implementation success. Each participating hospital completed 3 audits-at baseline, immediately after implementation (audit 1), and 1 year later (audit 2)-using either a clinic-based or an outpatient pharmacy-based assessment. RESULTS: Thirty-five facilities providing systemic treatment participated. At baseline, the provincial average for the use of computerized physician order entry (CPOE) or PPOs for prescribing oral chemotherapy was 71%. After implementation of the QI initiative, the provincial average for the use of CPOE or PPO increased to 91% at audit 1 and 95% at audit 2. CONCLUSION: Although not all facilities met the goal of 100% CPOE or PPO compliance, the QI initiative led to improvement in safe prescribing practices for oral chemotherapy. A coordinated QI approach between a central decision maker and local partners can be an effective strategy to encourage high-quality cancer care and promote a culture of safety across a jurisdiction.

From Measurement to Improvement in Ontario's Cancer System: Analyzing the Performance of 28 Provincial Indicators over 15 Years.

Over the past 15 years, Cancer Care Ontario has used a robust performance management approach to drive improvements in care. Each year, priority indicators and targets are selected or retained, and performance is reviewed quarterly with each of Ontario's Regional Cancer Programs. Improvement support and encouragement are provided, such as data analysis, program ranking, communities of practice, consultations, action plan requests and certificates. This article analyzes data on 28 indicators prioritized over these years and demonstrates that 25 have shown sustained improvement over time. The performance management approach, lessons learned and gaps in knowledge are described to inform future research and practice.

Using Data From Ontario's Episode-Based Funding Model to Assess Quality of Chemotherapy.

INTRODUCTION: A new episode-based funding model for ambulatory systemic therapy was implemented in Ontario, Canada on April 1, 2014, after a comprehensive knowledge transfer and exchange strategy with providers and administrators. An analysis of the data from the first year of the new funding model provided an opportunity to assess the quality of chemotherapy, which was not possible under the old funding model. MATERIALS AND METHODS: Options for chemotherapy regimens given with adjuvant/curative intent or palliative intent were informed by input from disease site groups. Bundles were developed and priced to enable evidence-informed best practice. Analysis of systemic therapy utilization after model implementation was performed to assess the concordance rate of the treatments chosen with recommended practice. The actual number of cycles of treatment delivered was also compared with expert recommendations. RESULTS: Significant improvement compared with baseline was seen in the proportion of adjuvant/curative regimens that aligned with disease site group-recommended options (98% v 90%). Similar improvement was seen for palliative regimens (94% v 89%). However, overall, the number of cycles of adjuvant/curative therapy delivered was lower than recommended best practice in 57.5% of patients. There was significant variation by disease site and between facilities. CONCLUSION: Linking funding to quality, supported by knowledge transfer and exchange, resulted in a rapid improvement in the quality of systemic treatment in Ontario. This analysis has also identified further opportunities for improvement and the need for model refinement.

Oral chemotherapy practices at Ontario cancer centres.

PURPOSE: The use of oral chemotherapy agents in cancer treatment is increasing. To better understand issues affecting the optimal use of these agents, Cancer Care Ontario conducted an environmental scan of current practices in Ontario related to prescribing, dispensing, patient education, and supporting regimen adherence. METHODS: A series of semi-structured interviews were conducted either by phone (11 regions) or via email (two regions) with Ontario's Regional Cancer Centres over a 3-month period in 2012. A questionnaire was pre-circulated to the regions to guide the discussions. RESULTS: Responses were received from 13 of 14 regions. Considerable variation in practice was found. Of 13 responding regions, 12 (92%) lacked formal procedures or processes for the prescription of oral chemotherapy. Ten regions (77%) reported using either handwritten prescriptions or a mixture of methods with only three regions routinely using computerized order entry systems for oral chemotherapy prescribing. Oral chemotherapy was reported to be labeled as "chemotherapy" in 46% of the regions. Twenty-three percent indicated that they provide extensive patient education through a multi-disciplinary approach. A number of tools were used to encourage patient adherence in different regions. Patient education was identified as an area where more work could be done. CONCLUSION: Results indicate a lack of formal policies and variable practices across all aspects of oral chemotherapy in many regions. However, some regions have developed and implemented successful initiatives. The results from this review are informing provincial priorities and being shared between regions to support collaborative learning.

Using breakthrough series collaborative methodology to improve safe delivery of chemotherapy in Ontario.

PURPOSE: Chemotherapy delivery is complex, involving multiple providers across settings to deliver safe, effective care. Cancer Care Ontario initiated a provincial breakthrough series collaborative, based on methodology from the Institute for Healthcare Improvement (IHI), to improve the safe delivery of chemotherapy, from ordering through preparation and administration. METHODS: Over the 1-year period of the collaborative, three in-person sessions educated participants on improvement methodology. Twenty teams tested and implemented elements of a predefined change package in their local systems. Monthly teleconferences supplemented the education while encouraging a culture of knowledge sharing. Teams completed monthly self-assessment surveys that evaluated their progress using a 6-point scale, where 1 indicated no evidence of improvement and 5 indicated achievement of all goals and improvement objectives. RESULTS: Monthly self-assessment surveys revealed that over time, scores improved from 1 to 4, indicating significant progress. Moreover, 100% of participants reported in an exit survey that the collaborative had improved the culture of safety in their organizations. The gains of the collaborative have been sustained through development of a practice community and provision of ongoing coaching through the IHI Open School. CONCLUSION: Participation in the collaborative enabled local interdisciplinary teams to develop processes and structures to support ongoing quality improvement, including formation of a sustainable structure for knowledge translation and exchange. However, lack of a shared provincial target limited overall evaluation. Other lessons learned included providing adequate time for planning and clearly defining roles and responsibilities of involved teams and project sponsors.