Prevention to Palliation: Applying Lessons from Chronic Disease Management to Transform Cancer Care IHI 23 rd Annual National Forum on Quality Improvement in Health Care December 6, 2011 Göran Henriks Chief Executive of Learning and Innovation, The County Council of Jönköping Amy Compton-Phillips, MD Associate Medical Director of Quality, The Permanente Federation, Kaiser Permanente Susan E. Kutner, MD Chair, Interregional Breast Care Leaders Group, Kaiser Permanente Joanne Schottinger, MD Assistant Medical Director for Quality, Kaiser Permanente Regional Quality and Risk Management Session Objectives After this session, participants will be able to: Define how the care process in terms of prevention, early detection, diagnosis, care, treatment, and palliation must be the best every time in order to remove unwanted variation Describe the importance of patient involvement and value-based improvements Demonstrate effective screening methods, highlighting a populationcare approach Disclosures The presenters have nothing to disclose. 1
A patient's perspective Urban and the power of positive deviance Can unlikely patients become our innovators to solve tough problems? When to use positive deviance Positive deviance should be considered as a possible appproach when a concrete problem meets the following criteria: The problem is not exclusevly technical and requires behavorial or/and social change The problem is intractable other solutions have not worked Positive deviants are thought to exist There is sponsorship and local leadership commitment to address the issues See the individual every time Safe care is for me... -Knowledgeable -Meet with professional people and feel that I'm welcome -To have a key relationship -Be seen for who I am -A personal approach -Have a linkage to life Book: A Taste of Water A 2
Population Approach to Cancer Care: Prevention and Screening Amy Compton-Phillips, MD Associate Executive Director, Quality The Permanente Federation Kaiser Permanente CMI Cancer Care Initiative The Patient Journey Backdrop throughout the journey of: Total Health Wellness Slide 8 Why Environmental Stewardship at KP? Prevention It s about health. 3
Safer Chemicals KP s Guideline: We aim to advance an economy where the production and use of chemicals are not harmful for humans as well as for our global environment. Safer Chemicals through the Supply Chain Sustainability Scorecard Supplier disclosure required 10 questions specific to chemicals in each product $10 billion impact (and growing) KP is leading the way for the entire health care sector Kaiser Permanente Complete Care Functions & Systems Screening 4
Goal of Proactive Encounter Improve consistency and quality of patient care experience care by: Activating ALL members of the health care team in providing a proactive patient care experience, Embedding processes to support preventive and chronic care needs into standard workflows, and Utilizing information technology tools for identification of patient care gaps and their resolution at the time of the office visit Making the Business Case for Specialty POE Opportunities for Breast Cancer Screening in Adult Primary Care Test Needing Mammogram Total Seen in Primary Care % 47,294 18,222 38% Approximately 60% of members seen in Specialty Care Mary Gonzales Story 5
Breast Cancer Screening Kaiser Permanente Programwide Combined Rate HEDIS 2007-HEDIS2011 HEDIS KP Programwide Results HEDIS National 90th Percentile HEDIS National 75th Percentile HEDIS National 50th Percentile 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% HEDIS 2007 (PY 06) HEDIS 2008 (PY 07) HEDIS 2009 (PY 08) HEDIS 2010 (PY 09) HEDIS 2011 (PY 10) Breast Cancer Diagnosis A Patient Centered Approach Susan E. Kutner, M.D. Chair, Interregional Breast Care Leaders Group Kaiser Permanente Vision For Optimal Breast Cancer Diagnosis Coordinated, Comprehensive Evaluation Same Day Access to all Diagnostic Services Communicating, Risks, Benefits and need for additional interventions Creating Clear Accountability for Care and Communication with the Patient of Results Minimize Sleepless Nights 6
Typical Story: Screening Mammogram Diagnostic Imaging Breast Biopsy 0 7.0 16.1 26.4 Average Days The Permanente Medical Group, Inc. Supported by Quality and Operations Support, (12/6/2011) 19 Screening to Biopsy Process Map Start See next slide End The Permanente Medical Group, Inc. Supported by Quality and Operations Support, (12/6/2011) 20 Expanded Process Map: Diagnostic through Biopsy Start Screening 1. Clinical breast exam Palpable mass Breast clinic at mammogram Yes Yes 2. Mammogram/Ultrasound detected? medical center? performed 3. Breast biopsy if needed No Normal or abnormal? Abnormal Normal Appropriate follow-up arranged and reviewed with patient Radiologist recommends modality for diagnostic exam Woman notified & asked to return for follow-up exam Woman scheduled for Dx exam(s) based on Appt/ Radiologist availability Mammogram Ultrasound MRI? Modalities based on clinical need. Exams may be scheduled for the same day or different days Variation in who notifies patient and information provided Variation in who notifies patient and information provided Diagnostic exam completed and read by radiologist No Diagnostic results suspicious? Yes Woman notified of results Woman contacted to schedule biopsy -Stereotactic -Ultrasound -Surgical (core or excisional) Biopsy completed and sent to lab for results Benign? Patient notified of No results; hand off to surgery Yes The Permanente Medical Group, Inc. Supported by Quality and Operations Support, (12/6/2011) Patient notified of results; hand off to PCP End21 7
Five Critical Moves to Same Day Access 1. Patient notification, preparation and education 2. Coordination of Services from Imaging to Surgery 3. Access to technology and OR 4. Flexibility of scheduling and operations 5. Capacity modeling and metrics The Permanente Medical Group, Inc. Supported by Quality and Operations Support, () 22 Destination: Timely, Convenient, Hassle Free Diagnostic Evaluation Achieving our destination of timely, convenient, hassle free Imaging Care requires that we accomplish the following: Offer Same Day Imaging Study Read Studies Same Day Adequate Capacity Consistent Processes Patient Centric Service Attitude Measure of Results Perform Same Day Biopsy *out of QOS Scope The Permanente Medical Group, Inc. Supported by Quality and Operations Support, (12/6/2011) 23 Typical Story: Screening Mammo Diagnostic Imaging & Breast Biopsy 0 7.0 16.1 26.4 Average Days The Permanente Medical Group, Inc. Supported by Quality and Operations Support, (12/6/2011) 24 8
Multidisciplinary Treatment Decision Support What To Do if Cancer is Found It Takes a Village Along the Patient Journey of Cancer Care: What we learned from video ethnography In order to get from knowing they have cancer to starting to taking therapeutic action, patients must complete these steps. Diagnosis Learn I have Cancer Understand my Treatment Options Weigh My Options Choose Initial Treatment Make a Plan and Schedule Next Steps Treatment Fitting it together:a Map of how clinic tactics meet patient needs across journey Patient Needs: Empower me with Information and Options Include me and my family in decisions Help me move forward swiftly and seamlessly Build confidence with a compassionate and coordinated team of experts Learn I have Cancer Tell me about Clinic as a next step Ask me to bring a person Clinic meets weekly Meet Care Coordinator Understand Treatment Options Video is concrete and starts to set expectations Chance to ask some initial questions Family learns along with me Because I may still be in shock, my home team often asks questions and clarifies with and for me Tumor board gets all my doctors on the same page quickly While I orient, experts in my clinical team discuss my case Patient steps from diagnosis to treatment Weigh My Options Back-to-back sessions help me and my family process iteratively in one place Getting familiar with the people on the path Choose Initial Treatment Doctors offer most relevant choices for me, answer my questions, & build on education iteratively My personal preferences and family needs can be considered in the moment Meeting doctors in one session, and having them coordinate in realtime, saves visits Doctors and other Clinic team are aligned and work together in the Central RN Station to continue team care Make a Plan and Schedule Next Steps My personalized packet gives me info to review at home Family who will likely take care of me are with me as we plan together Treatments, Labs, ordered in one shot immediately Care Coordinator follows up to make sure I do too 9
Multidisciplinary Breast Care Center Visit Patient and family attend educational session and materials distributed Physician Team review each case-at time that patients are undergoing educational session Patient Visit-one on one with Breast and Plastic Surgeon, Medical and Radiation Oncologist Scheduling-additional imaging and pretreatment tests, surgical scheduling Why Reorganize Operations- Gap Analysis Complexity of Care is increasing Need for Personalized Treatment Improving Patient Education about potential side effects and length of treatment Improve Service, Access and Outcomes Metrics Time from Biopsy to Treatment Time from Consultation to Surgery Patient Satisfaction Re-Excision Rates Use of Neoadjuvant Chemotherapy Accrual to Clinical Trials 10
Breast Cancer Treatment, Survivorship, and Palliation Joanne Schottinger, MD Assistant Medical Director for Quality Kaiser Permanente Regional Quality and Risk Management CMI Cancer Care Initiative The Patient Journey Backdrop throughout the journey of: Thrive Wellness Survivorship Palliative support Survivorship Treatment Prevention Screening Diagnosis End of Life Palliation Adjuvant Hormonal Therapy (AHT) AHT given after primary Breast Cancer treatment Tamoxifen used for >30 yrs to treat early-stage, as well as metastatic Breast Cancer Among the 75-80% of patients with early cancer who have ER+ disease, Tamoxifen immediately reduces local, contralateral, and distant recurrence by 50% and reduces breast cancer mortality by 31% (Early Breast Cancer Trialist Cooperative Group, 2005, 1988) 11
EBCTCG Endocrine therapy Recurrence (n = 10,386) Breast Cancer Mortality KP SCAL 10,000 women AHT discontinuation by year of therapy Cumulative Discontinuation by Number of Treatment Years Tam Only AI Only Tam to AI 30% 25% 20% 15% 10% 5% 0% Within 1 Year Within 2 Years Within 3 Years Within 4 Years Within 5 Years AHT Utilization in KPNC A recent study conducted in KPNC found only 49% of women took AHT for the full duration at the optimal dose Hershman and Kushi et al. J Clin Oncol. 2010 Sep 20;28(27):4120-8. Epub 2010 Jun 28. Adjusting for clinical and demographic variables, both early discontinuation (HR 1.26, 95% CI 1.09-1.46) and nonadherence (HR 1.49, 95% CI 1.23-1.81) among those who continued were independent predictors of mortality Hershman, Shao and Kushi et al. Breast Cancer Res Treat. 2011 Apr;126(2):529-37. Epub 2010 Aug 28. 12
Interventions Regional outreach letter 71% response IVR calls with letters Patient education handouts EMR medication adherence tool Smart phrases for after visit summaries Kaiser Permanente HealthConnect Beacon Over 40,000 cancer patients treated with over 250,000 regimens annually Prior to 2008, over 1400 chemo protocols in a paper system No decision support for safety Chemo administration data not reliably available for quality/utilization review 2008- Beacon deployment with about 400 nationally built protocols by the collaborative group of oncologists/nurses/pharmacists representing over 700 KP providers nationally Protocols designed to include the supportive therapy, labs, imaging studies, hydration, anti-emetics, dose modifications, intent of chemo, and literature references Kaiser Permanente HealthConnect Beacon Benefits Universally accessible and legible record Treatment plan and information for patient Common pathology staging system Integrated lab and pathology through modules integration Simplified referral to clinical trials Quality reporting and improvement enabled Assessment of practice patterns Signal detection for treatment harms provided Improved ability to handle shortages and recalls 13
Kaiser Permanente HealthConnect Beacon Results Decreased variation 86% protocol adherence, non-modified No increase patient safety events Rapid response to drug withdrawals from market or chemo shortages Docetaxel-Cyclophosphamide study in breast cancer Simple Complicated Complex Komplicerad Enkel Komplex Om så, Ja/Nej? Kanske då Kända delar Delar är möjliga att känna till Resultat kan Resultat kan i stor förutspås utsträckning förutspås Checklistor kan Algorithmer/riktlinjer användas kan användas Coloskopi ska Om spridning så ska genomföras etc följande behandling ges Låg autonomi Varierande autonomi för utföraren för utföranren Mål: tillförlitlighet Mål: tillförlitlighet Önskvärd riktning Delar är endast delvis kända, men de kan förändras I stor utsträckning ej förutsägbar Bygger på gemensam målsättning, relationer Andra sjukdomar som påverkar, social situation etc Hög autonomi (självständighet) hos utföraren Mål: Återhämtningsförmåga/flexibilitet Glouberman & Zimmerman, 2002 ACTIVITIES Diet? Physical activity? Risk assessment? Screening? Pt. education? Pre-diagnosis Colonoscopy? Biopsy? Staging? Surgery? Colostomy? Radiation? Chemotherapy? Pt. education? Shared decision-making? Diagnosis & treatment Zone of greatest historic attention Colostomy care? Cancer activity? Pt. education? Shared decisionmaking? Follow-up & monitoring Palliative care? Pt. education? Shared decisionmaking? End of life care Screening policy? Screening events? Prevalence? Pt. awareness? Stage at diagnosis? Treatment algorithm? Complications? Pt. understanding, satisfaction? Q,S,V measures? Survival length? Recurrence? Activities of daily living? Survivorship algorithm? Complications? Pt. understanding, satisfaction? Pain control? Good death? Family help? MEASURES Jan, 2010 pbb 14
Primary care & Public Health Home & palliative care Pre-diagnosis Diagnosis & treatment Follow-up & monitoring End of life care Specialty care Jan, 2010 pbb Promises by the board of the Regional Cancer Center South East WE PROMISE THAT: GOAL GOAL 2012b You do not have to wait more than Contact with healthcare 4 weeks the most before investigation - diagnosis 2 weeks and adequate treatment for cancer Diagnosis treatment 2 weeks You are offered diagnostic and treatment for your cancer according to best practice You are well informed / taking part in the whole care chain We must have Care program (CP) for 90 % of tomours. T ½ T ½ T ½ T ½ Commitment to the CP we have 80% Time schedule to next step shall be 80 % offered at every healthcare contact You who are in the end of life will h have the same good care where ever you live in the region No difference between different inhabitant groups in the region when getting cancer Health care prioritizes patient close research within the area cancer. Access to palliative care. 24 hours after breakpoint Smoking reduced in youth groups Coverage screening program X % Share/part of cancer patients that will enter into research projects T ½ T ½ T ½ T ½ T½= Halving the gap from to day s result to the goal. E.g. current status 30 d, goal14 d. T½ = 22 days before Dec. 31th 2012. Ref:Caroline Fruberg 15
4,8 4,4 4,8 4 5 5 5,7 5,7 5,8 6 4,5 5,1 5,1 5,1 5,1 5,7 5,3 5 5,8 4,5 4,5 5,7 6 5,7 6,2 7 5,2 6,3 5,1 5,1 4,7 5,8 4,1 6 5,9 6 4,6 5,1 Multi discipline Team Design the process with everybody involved Patient s diary Start data analysis for the owners A public health atlas... transparency risk perspective can show how we work with prevention for better dialogues and improvement work from a geographic standpoint show: Un health What factors are important risk health show us patterns variation and high risk areas What we understand so far Low levels of D-vitamin Obesity Diabetes Lower risk : acetylsalicylsyra (not recommended) Hormon treatment (are not recommended) Leaving habits Physical inactivity Smoking Alcohol Low intake of folsyra Low intake of calcium/milk products Too much red meat Western food 16
What we are trying to accomplish? Referrals for Physical activities as a complement to medication treatment Non Smoking Therapy Tobacco free before operation Obesity programs Nutrition support Motivation dialogues Amount of New Colon cancer cases per year in 3 Counties Koloncancer, antal nya fall per år 2000-2009 Antal nya fall 300 250 200 150 100 50 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Jönköping Kalmar Östergötland Incidents in colon cancer, age standardized 75 Åldersstandardiserad incidens koloncancer Heldragen linje=kvinnor Prickad linje = män 50 25 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Jönköpings län Kalmar län Östergötlands län 17
Age at which the diagnosis is given Three Counties 2000-2009 Koloncanc er Kön Antal P 25 Median P 75 Samtliga Kvinnor 2457 67 76 83 Avled under Män 2369 66 74 81 Kvinnor 1190 71 79 84 perioden Män 1145 70 78 83 Levde vid Kvinnor 1267 63 73 80 periodens slut Män 1224 63 71 78 No age differneces between the counties Early detection of colorectal cancer in Primary Care Bakgrund Förslag till triage via telefon eller besök Alltför många patienter med kolorektalcancer får sin diagnos sent trots att man sökt sjukvård. Detta kan bero på att symtomen ofta är varierande och diffusa men det beror också på brister i handläggningen i primärvården och långa väntetider på utredning och behandling på sjukhus. En arbetsgrupp med telefonrådgivningssjuksköterskor och distriktsläkare har gått igenom tillgänglig evidens, internationella och nationella riktlinjer och utformat nedanstående förslag på handläggning i syfte att minska tiden från att patienten kontaktar vårdcentralen till diagnos och behandling på sjukhus. Vi har valt att fokusera på att patienter med symtom talande för hög risk för kolo-rektalcancer får snabb handläggning. Dessa patienter (grupp 1.) identifieras och handläggs skyndsamt både på vårdcentral och sjukhus enl. nedanstående förslag. Övriga patienter (grupp 2.) utreds enl. sedvanliga rutiner om misstanke om kolo-rektalcancer uppkommer. Grupp 1 - Snabb utredning om 2 poäng eller mer enl. Stålhammars score* Starka symtom >50 år (2 poäng per symtom) - Rektal blödning utan anala symtom**, infektion m.m. (ssk, läk) - Subileussymtom*** (ssk, läk) Svaga symtom >50 år (1 poäng per symtom) - Järnbristanemi utan rimlig förklaring (läk) - Hereditär belastning oavsett ålder (2 eller fler 1:a, 2:a-gradssläktingar****) (ssk, läk) - Ändrade avföringsvanor (förstoppning, ökad frekvens, svårt att tömma, diarré, slem, trängningar) >2 veckor utan rimlig förklaring (ssk, läk) - Pos F-Hb (läk) - Rektal blödning med anala symtom (ssk, läk) - Avmagring, aptitlöshet, trötthet >1 månad utan rimlig förklaring (ssk, läk) - Ulcerös colit med 8-15 års duration beroende på lokalisation***** (ssk, läk) Skyndsam utredning på VC - Läkartid inom 3 arbetsdagar, förberedd för rektoskopi - Prov för F-Hb medtages till besöket enl. instruktion av ssk (ej om blödning) - Provtagning (Blodstatus, krea, längd, vikt m.m.) - Remiss skickas samma dag till till kir.klin. för utvidgad utredning. Skyndsam utredning på sjukhus - Kir.klin. koordinerar utredningen och konverterar till lämplig diagnostisk utredning om coloskopi inte bedöms lämplig. Grupp 2 - Sedvanlig utredning Patienter som inte uppfyller kriterier enl. Grupp 1. men där misstanke om kolo-rektalcancer uppkommer utreds enl. sedvanlig rutin. * Efter Peter Stålhammar, distriktsläkare, Sävsjö ** klåda, värk, smärta vid avföring *** intermittenta buksmärtor, uppdriven buk, illamående, tilltagande avföringsproblem **** föräldrar, syskon, barn, morbror/faster, syskonbarn, far/mor-föräldrar ***** ingen risk om enbart i sigmoideum/rectum Förslag från primärvårdsgrupp i Jönköping 2011-08-25, reviderat 2011-10-28 och 2011-11-07 Kjell Lindström, Jönköping, Eva Ellbrant, Huskvarna, Staffan Ekedahl, Jönköping, Annika Bergdahl, Jönköping, Peter Stålhammar, Sävsjö, Helene Sigfridsson, Sävsjö, Per Hauschildt, Skillingaryd och Marie-Louise Claesson, Skillingaryd Multidisciplinary teams and conferences Patient s coordinator Regional network established National partnership Competence needs defined Local team connection MDK how to develop and increase the use of the process Ref Marie Lagerfelt 18
Matchmaking Best care for each patient Same need? Same situation? Same individual choice? Ref Per-Anders Heedman Using modern technology? For the patient and the employers Ref: Stefan Johnsson, PhD, chefsfysiker LKL Samtal till vårdcentral Besök på vårdcentral Remiss till specialister Koloscopi Operation Diagnossamtal/ vårdplanering Datortomografi Cytostatica Palliativ Vård Process navigation From diagnosing to treatment, step by step Ref Eva Lindholm LtJ 19
Samtal till vårdcentral Besök på vårdcentral Remiss till specialister Koloscopi Operation Diagnossamtal/ vårdplanering Datortomografi Cytostatica Palliativ Vård Palliativ vård Om det visar sig att du har en så pass spridd cancer att olika former av behandlingar inte kan hjälpa till att bromsa den kan du bli erbjuden palliativ vård som står för vård i livets slutskede. Du får då medicins hjälp med att lindra symtomen från sjukdomen. Du blir också erbjuden psykosocialt stöd för dig och din familj. Intressanta Länkar Kris och sorg: http://www.1177.se/tema/cancer/kris-och-sorg/ Psykosocialt stöd: http://www.1177.se/tema/cancer/hjalp-ochstod/psykologiskt-stod/psykosocialt-stod-ochrehabilitering/ Swedish Palliative Registers Where Do Patients Die? Var avlider cancerpatienten? (Q1 2011, n=522) 100% 17 2 15 36 80% 20 65 13 60% 58 12 17 Basal hemsjukvård Avancerad hemsjukvård Palliativ slutenvårdsenhet 40% 46 30 Sjukhus Korttidsboende SÄBO 38 30 20% 18 37 26 42 0% Jönköpings län Kalmar län Östergötlands län Ref: Per-Anders Heedman 20
ACTIVITIES Di et? Ri sk assessment? Sc reening? Pt. educat ion? Pre-diagnosis Sc reening events? Prev alence? Pt. awareness? MEASURES Colonosc opy? Biopsy? Staging? Surgery? Colostomy? Radiat ion? Chemot herapy? Pt. education? Shared dec ision-making? Diagnosis & treatment Stage at diagnos is? Treatment algorithm? Complicat ions? Pt. underst anding, sat isfaction? Q,S, V measures? Zone of greatest attention Colost omy care? Cancer ac tivity? Pt. educ ation? Shared decisionmak ing? Follow-up & monitoring Surviv al length? Act ivities of daily living? Monitoring algorithm? Complications? Pt. unders tanding, satisf act ion? Palliative care? Pt. education? Shared dec isionmaking? End of life care P ain control? Good deat h? Family help? Patient/kund upplevda behov Patient/kund upplevda Resultatmått behov 1, 2, 3 Resultatmått 1, 2, 3 Processmått Processmått Indikator Målvärde (%) Resultat (%) Brytpunktssamtal patient/ PP talk 100? Brytpunktssamtal närstående/releatives plan Efterlevandesamtal/ Talk after patients death 100? 100? Smärtskattning/Pain evaluation 100? Avsaknad av trycksår/reduction of Ulcers 90? Närvaro/Professions are at the right place 90? Valfrihet vårdplats/ind choice of place 100? Munhälsa/ Mouth health 100? Måluppfyllelse (resultat/målvärde) Results 780? Same Care, Different Municipalities? Lika god vård i livets slutskede för cancerpatienter oavsett bostadsort? (Sydöstra sjukvårdsregionen, Q1 2011, n=493) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% K1 K2 K3 K4 K5 K6 K7 K8 K9 K10 K11 K12 K13 K14 K15 K16 K17 K18 K19 K20 K21 K22 K23 K24 K25 K26 K27 K28 K29 K30 K31 K32 K33 K34 K35 K36 Patientinvolvering Tidig upptäckt Utredning Palliation Tvärprofessionellt och tvärfunktionellt i samverkan Prevention Background information Incidens Health status Age/Gender Process measures Leadi times Using guidelines Result measures Patient satisfaction Functional Clinical Resources Ref peter Kammerlind et al 21
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 1 00% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Täckn ingsgrad INCA kolo rektal-registret u r k olor ekta lr eg istre t ma j 20 11, sydös tra sjukvå rds reg ione n 2 01 0-201 1 Q 4 2010 Q 1 2011 Q2 2011 Q 3 2011 Q4 2011 Andel patienter utan rapporterad postoperativ komplikation u r INCA kolo rekta lreg ist ret Sydöst ra sju kvård sreg io nen ant al 12 10 8 6 4 2 0 Q1 2010 Q2 2010 Q3 2010 Q4 2010 Q1 2011 Q2 2011 Q3 2011 Q4 2011 2 010-20 11 Kom pl ikat io ner i sam band m ed kolo ncancer ur I NCA k olor ek t al regis tr et Sy dös t ra s juk v årds regionen 2010-2011 K a r d i o v a sk u l ä r a P n e u mo n i S e p si s S å r i n f e k t io n A n as to mos in s u f f. In tr a b d. in f. S t o m i k o mp l. S å r up tu r K A D v i d u t s k r B l öd n in g Ö v r ig a ko mp l ik a t io ne r Jönköping K almar Östergötland Q 1 2010 Q 2 2010 Q3 2010 Q 4 2010 Q 1 2011 Q2 2011 Q 3 2011 Q 4 2011 Andel patienter med stadium 0 eller X (ej spridd sjukdom) vid diagnos ur INCA kol orek talregis tret Sy döstra sjukv årds regionen 2010-2011 Jön köp ing Kalma r Öste rgö tlan d Q1 2010 Q2 2010 Q3 2010 Q4 2010 Q1 2011 Q2 2011 Q3 2011 Q4 2011 Andel patient med <=30 dagar från remissbeslut/diagnos - behandlingsstart ur INCA kolorektalregi stret Sydöstra sjukvårdsregi onen 2010-2011 J önköping Ka lm ar Ös tergötla nd J önköping Ka lmar Ö ste rgöt land Q1 2 010 Q2 20 10 Q3 2 010 Q4 201 0 Q 1 20 11 Q2 2011 Q3 20 11 Q4 2 011 tkr 6000 5000 4000 3000 2000 1000 0 Unders ök ni ngsk os tnad DT-k olon Sydöstra sjukvår dsregionen 2008-2012 Jön köpings län 35 Kalmar län Öster götland 0 2008 2009 2010 2011 2012 30 25 20 15 10 5 20 1 0-01 - 04 201 0-01- 12 2010-01-26 2010-02- 08 20 1 0-02-15 2010-02- 27 2010-03-02 2010-03- 07 2010-03-15 2010-04- 08 2010-04-26 201 0-04- 29 2010-05-04 2010-06- 03 Vård tid i s amb an d med k olo nca nce ro pe rat ion Landstingeti Jönköpings län 2010 2010-06-10 201 0-06- 16 2010-06-24 201 0-0 6-30 2010-07-06 2010-07- 13 m ede l= 9,6 da gar 2010-07-20 2 01 0-0 7-29 2010-08-10 201 0-08- 17 2010-08-19 2 01 0-0 8-31 201 0-09-02 201 0-0 9-14 2010-09-21 201 0-09- 28 2010-10-05 2 01 0-1 0-07 201 0-10- 1 3 201 0-1 0-19 2010-11-02 2 01 0-11 - 04 201 0-11- 0 9 2 01 0-1 1-16 201 0-11- 2 3 20 1 0-12 - 02 201 0-12- 07 2 01 0-12 - 16 2010-12- 2 1 A ntal per 100 000 inv 12 10 8 6 4 2 0 An tal/p ro fessi on m ed s pecia lkom pet ens k opp lat t ill ko lonc ancer pe r 10 0 000 inv Syd östra sjukvår dsregion en maj 20 11 Jön köp ing K almar Ö st erg ötla nd Radiolog Kir urger Patologer Value Compass Colon Cancer Functional health status/ Livskvalitet Oro/ångest Aptit Huvudsakliga aktiviteter Clinical status Täckningsgrad Patientperceptive needs God vård koloncancer Bemötande Komplikationer Delaktighet Stadium vid diagnos Resources/Cost Utredningskostnad Vårdtider Kompetens Information Ledtider Time from Diagnosis to Operation per Hospital Sjukhus Median 80:e perc. Linköping 49 64 Norrköping 27 40 Jönköping 35 44 Eksjö 21 43 Värnamo 15 33 Västervik 21 58 Kalmar 30 44 Sydöstra regionen 29 48 Koloncancer Diagnosår 2010 Källa: Kvalitetsregister för kolorektalcancer - INCA Multidisciplinary Conferences per hospital Källa: http://www.lj.se/koloncancer Källa: Kvalitetsregister för kolorektalcancer - INCA Koloncancer Diagnosår 2010 22
How the Aims are Reached Diskuteras i MDT-konferens Tid från diagnos till operation Koloncancer Diagnosår 2010 Källa: Kvalitetsregister för kolorektalcancer - INCA Studying records with GTT and PPP Global Trigger Tool (GTT) Complications and harm Patient perspective protocol (PPP) Waiting times, amount of doctor contacts and how the information works. Ref Rune Sjödahl Best Practice Amount of complications increased after operation in colorectal cancer when some of the 15 most key points in best practice were not done. If all key points were done 7% of the patients got complications, the complications increased for each missed key point. When 4 or more key points in best practice were missed 42 % of the patiens got complications. Arriaga et al. Annals Surg 2009 23
ERAS Mission statement: Enhancing Recovery After Surgery The mission of the Society is to develop perioperative care and to improve recovery through research, audit, education and implementation of evidence based practice. Ref Olle Ljungkvist What Are We Trying to Achieve? Patient back to preoperative function Normal gastrointestinal function Normal food intake Bowel movement Pain control Mobility No complication What is ERAS? Standardized protocol for perioperative care Reduce stress Support function Evidence based care Integrated view Standards Follow up audit 24
Peri-op fluid management Epidural Anaesthesia Remifentanyl Early mobilisation DVT prophylaxis Pre-op councelling Perioperative Nutrition Bairhugger Oral analgesics/ NSAID s ERAS Prevention of ileus/ prokinetics No - premed No bowel prep CHO - loading/ no fasting Incisions No NG tubes Early removal of catheters/drains Lassen et al, Arch Surg, 2009 Peri-op fluid management Epidural Anaesthesia Remifentanyl Early mobilisation DVT prophylaxis Pre-op councelling Perioperative Nutrition Bairhugger Oral analgesics/ NSAID s ERAS Prevention of ileus/ prokinetics No - premed No bowel prep CHO - loading/ no fasting Incisions No NG tubes Early removal of catheters/drains Lassen et al, Arch Surg, 2009 ERAS: The Patient s Journey Audit compliance and outcome Patients journey C l i n i c Preop Surgery Anesthesia H D U Ward Recovery Home Audit compliance & outcomes 25
Degree of Compliance to ERAS Protocol Andel med följsamhet till ERAS-protokoll Landstinget i Jönköpings län 2011 n=13 (alla från Jönköpings sjukvårdsområde 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Preoperativ information Premedicinering Preoperativ kolhydratrik dryck Tarmstimulerande läkemedel Kostregistrering Mobilisering enligt PM dag 3 Epidural Uppfölj tel 2-3 dgr efter hemgång Perioperativ vätsketillförsel Mobilisering enligt PM dag 2 Hemgång inom 6 dagar Mobilisering enligt PM dag 1 Laxering Time from Operation to PAD Answer Kolorektalcancer tid från operation till PAD-svar patologi, medicinsk diagnostik, Landstinget i Jönköpings län 2010-2011 35 Preanalys (skickat till ankomst reg) Dgr fr op till PADsvar 30 25 Antal dagar 20 15 10 5 0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 2010 2011 26
Onkogenetik Individual screening and prevention in Breast cancer Extra mammography Prophylactic treatments Ref: Marie Stenmarker Askmalm Integration Doing Everything at the Same Time Improvement projects Process redesign System transformation Measurement Will Analyzes Ideas Actions Execution 27
Lau Tzu Learn from the people Plan with the people Begin with what they have Build on what they know Of the best leaders When the task is accomplished The people all remark We have done it ourselves 28