NEMICS GOVERNANCE CHAIR: Adj./ Prof Linda Mellors DIRECTOR NEMICS: A/Prof Paul Mitchell PROGRAM MANAGER NEMICS: Katherine Simons

SIGNATURE: SIGNATURE: SIGNATURE:

1.PROBLEM STATEMENT

Summary of the problem pertaining to identified priority areas

Focus Area 1: Access/timeliness Problem statement:

Patients referred for (suspected) lung cancer investigation

experience delays in receiving their first specialist appointment (FSA)

and subsequently in commencing their initial treatment.

Optimal state goal:

The time from referral to FSA should be ≤ 14 days.

The time from referral to initial treatment should be ≤ 42 days.

Baseline state:

Health service

FSA ≤14 days of referral

1st treatment ≤42 days of referral

New state:

Eastern Health

100% of patients have FSA ≤ 14 days.

83% of patients commence treatment ≤ 42 days.

Austin Health (VLCR) 62% 45%

Eastern Health (local data) 19% 24%

Northern Health (local data) 68% 39%

Focus Area 2: Process/Quality Problem statement:

Culturally and linguistically diverse (CALD) lung cancer patients have

higher mortality rates than Anglo-Australian patients. The reasons

why are unclear.

Optimal state goal:

Australian data that describes the cultural barriers that influence

pathways to care for lung cancer patients exists.

Baseline state:

No Australian data that examines the barriers along the lung cancer

pathway from symptom appraisal to treatment in CALD populations

exists.

Update:

The LEAD study, which examines barriers to care is underway.

The final report is due in December 2018

Focus Area 3: Process/Quality Problem statement:

Not all complex lung surgery takes place in a facility that meets

Cancer Institute of NSW minimum caseload requirements.

Optimal state goal:

Monitor volumes of complex lung cancer surgeries to ensure case

numbers meet Cancer Institute of NSW recommended minimum

caseload volumes of 18 procedures p.a.

Baseline state:

Small volumes of lung cancer surgery (<10 procedures p.a.) are

being performed at Northern Health.

Update:

Lung surgery volumes remain lower than recommended. Working

with lung team to monitor performance outcomes. NEMICS

position statement and NH Cancer plan being developed. Service

expansion likely over time.

EXECUTIVE SUMMARY Background, executive comments and key project findings

Background and Executive comments Public health services in Victoria manage approximately 76% of all patients with a lung cancer diagnosis. In 2015-16, NEMICS public

health services managed about 21% of these public patient admissions, admitting 3530 patients with lung cancer across three major

health services (Austin Health - 52%, Eastern Health – 30% and Northern Health - 18%).

In Australia approximately 80% of lung cancer patients are diagnosed at a late stage. Early diagnosis has been identified as a key

factor in improving outcomes for these patients. In 2014, the Victorian Lung Cancer Summit working party finalised a list of

recommendations to optimise lung cancer care and improve outcomes for lung cancer patients. A recent analysis of NEMICS lung

cancer data supported the assertion that considerable potential exists to improve the timeliness of diagnosis and treatment for lung

cancer patients. Local data described care that was often not well co-ordinated and contained many inefficiencies.

The potential for improving care for lung cancer patients in the NEMICS region clearly lay in designing solutions to hasten presentation,

streamline triage of referrals, formalise referral pathways to enable rapid diagnosis and ensure treatment can be initiated without

unnecessary delay. Most patients with lung cancer present with late stage disease and as a result experience poor outcomes.

Facilitating presentation and eliminating unnecessary delay in care is an active step towards reducing patient distress and improving

the overall experience of care.

Key Project Findings

0

20

40

60

80

Austin Health EasternHealth

NorthernHealth

Nu

mb

er

of

pro

ced

ure

s

Primary lung cancer surgical admissions 2015/16 Pneumonectomy

Lobectomy of lung

Partial resection oflung

C.I NSW min.caseload vol

Primary lung cancer admissions NEMICS public health services

Anglo-AustralianItalian

Greek

Arabic

Vietnamese

Chinese

Other

2a) ACCESS/TIMELINESS. SOLUTION IMPLEMENTATION: (in more detail) Focus

Area

Focus Area by OCP

Step & descriptor

Item

no

List the Solutions selected to address each focus

area

Describe the REACH List the measures used to assess

EFFECTIVENESS

Rating

icon

List the INTERVENTION activities associated with

specific initiatives

Results/Outcomes (as MEASURES

where appropriate

1 OCP Step 2

Care point 2.2

Eastern Health

(VLCRP Tier 1 site)

1a.1 Streamline referral and triage process at health

service (HS)

Lung MDT, GPs, clinic

admin, patients, EMPHN,

redesign unit

≤14 days from referral to FSA.

Clinician interviews.

GP and patient satisfaction surveys.

Triage guidelines developed.

‘Suspected lung cancer’ e-triage point created.

Triage responsibilities and leave cover formalised

100% achieve FSA in <14days.

Clinicians, GPs and patients satisfied

with process.

1a.2 Document and communicate optimal

outpatient(OP) management pathway for lung

cancer to GPs(develop Health Pathway)

GPs, GPLO, EMPHN, Health

Pathways team, lung MDT

OP pathway appears on HS website.

Health Pathway documented.

GP and referrer satisfaction survey.

‘Rapid access lung lesion clinic’ webpage

developed. Health pathway documented. Various

methods of GP communication undertaken.

Web page available.

Lung Health pathway created.

GPs & referrers satisfied.

1a.3 Establish priority booking to allow rapid availability

of OP clinic appointments

GPs, lung MDT, clinic admin,

patients

≤14 days from referral to FSA.

Clinician interviews, patient surveys Rapid priority booking developed for patients

referred with suspected or known lung cancer.

Time to FSA ≤ 14 days (100%)

Clinicians & patients satisfied

1a.4 Develop efficient OP process to ensure rapid

completion of investigations

Lung cancer and diagnostic

clinicians, booking staff

Referral to diagnosis < 28 days.

≤42 days from referral to first treatment Expedite investigations - slips stamped ‘Urgent

appointment <48hrs, Rapid Access Lung Lesion’,

Information added to registrar training manuals.

89% achieve diagnosis < 28d.

83% start treatment in < 42 d

1a.5 Formalise referral pathway for patients requiring

external EBUS/CPET testing

Lung clinicians, patients,

external providers

External referral pathway formalised.

Clinician survey/interviews. Referral pathway established with new external

provider. Equipment purchase being considered.

Clinicians satisfied.

1a.6 All newly diagnosed lung cancer patients

presented at MDM to ensure co-ordinated and

efficient treatment pathway

MDM clinicians, registrars % patients with MDM documentation.

File audit of MDM documentation quality.

Clinician interviews.

All newly diagnosed cases listed on MDM agenda.

MDM referral process formalised & terms of

reference updated. MDM dashboard developed.

90% patients requiring active

treatment discussed at MDM.

Clinicians satisfied with process

Northern Health 1b.1 Participate in extension of VLCRP Referral admin, lung cancer

clinicians, redesign,

operational managers

Project Steering Committee convened Improvement team convened and initial data

analysis underway.

PO commenced May 2017

Rapid Improvement Event (RIE) 21/9/17.

-

1b.2 Analyse VLCR and local data Baseline data collected & analysed Initial gaps/problems identified.

1b.3 Conduct a rapid improvement workshop Gaps/problems identified Solution design phase underway.

Austin Health

(VLCRP tier 2 site)

1c.1 Participation in extended Lung Redesign project Cancer Services Exec &

Austin Redesign

Recruitment of PO

Presence of a documented implementation plan. ~ PO commenced 21/9/2017.

Data collection & analysis via VLCR

Prepare phase initiated – Steering

committee & RIE planning started.

* RATING ICONS: Fully Achieved: √ Partially achieved: ~ Not achieved: × Not commenced: 0

kkk

2b) PROCESS/QUALITY (only if represented previously in SOLUTION DESIGN ) Adoption of Process/ Quality Strategies Unintended Outcomes

What were the overall quality objectives of the local project activity What were the priority interventions i.e. Flagship activity What secondary objectives of the interventions were achieved 1. Gather local data around the cultural barriers that exist to lung cancer care from symptom

appraisal to treatment for culturally and linguistically diverse (CALD) lung cancer patients.

2. Ensure all complex lung cancer surgeries are performed in health services that meet minimum

recommended caseload and capability guidelines (adherence to NEMICS position statement).

3. To disseminate Lung OCP resources to patients and carers.

1. Participation in a multi-site study co-ordinated by Monash University; LEAD – Lung cancer

diagnostic and treatment pathways: A comparison between CALD and Anglo-Australian patients.

2. Initiating a review of Northern Health lung cancer surgery volumes and engaging clinicians and

operational managers in service review discussion. Local clinical audit of all lung surgical cases, and

credentialing of surgeons.

3. Provide local lung cancer support group ‘Love and Light’ with OCP brochures for patient/carer

information packs and provide support to hold lung cancer information forum.

1. Knowledge of length of time (>8mths) and process required to apply for

multi-site research governance approval. Applicable for future work of this

nature.

2. A valuable partnership with Northern Health has been reinforced and has

fostered a willingness to collaborate on future lung service expansion work.

3. Understanding that work conducted with support groups needs to be in-step with the health and wellbeing of its volunteers.

EVALUATE/SUSTAIN

Focus of Work: Implementing LUNG Optimal Care Pathway - Page 1

EVALUATE/SUSTAIN

Focus of Work: Implementing LUNG Optimal Care Pathway - Page 2

3. Self -Assessment of Project Process What was the level of engagement, leadership, participation and uptake

Environment: The focus on OCPs with their common language and inclusion in the Cancer Plan as a major piece of work did serve to focus efforts and link together a number of programs within NEMICS. For lung in particular the VLCRP grants stimulated local review of timeliness of care. Generally, health services have seen OCP related activity as one of opportunity and support to meet other reporting requirements such as SOP and Quality Accounts.

Capacity & Capability: Lung clinicians had variable exposure to health service redesign activities prior to the grants program, and have been positive about the experience in all 3 health services. Locally clinicians do not view this as an OCP implementation but a local redesign/service improvement activity. Governance structures both a health service and ICS level are aware of how these fit into the broader OCP implementation.

Participation: The OCPs have been accepted as a standard of care in-line with individuals’ area of work: e.g. clinical work & outcomes; quality & safety performance; efficiency / effectiveness; supportive & survivorship care. The OCPs are used as a rationale in applications to funding rounds for service improvement and professional development. The specific focus on a tumour type, supported engagement with local support groups and individual MDTs and clinical units.

Embedded into care: Lung OCP is embedded into the pathway of care at sites that have undertaken the redesign work concerned with care pathways. Broad engagement that allows multiple teams to be involved in redesign of care pathways facilitates a greater organisational interest in contributing to change.

4.Evaluation of the ICS Program Outcomes What level of impact on experience and outcomes (High Level Only)

OCP Program approach: Provided a common language and reference point for communication, activities, funding rounds and engagement strategies with the sector. Renewed focus on specific tumour types rather than on common areas of multidisciplinary, supportive & coordinated care.

The extent of improvement in cancer care: timely access to diagnosis and treatment improved with redesign approach. Consumer OCP disseminated more broadly through the Love & Light Support Group.

Barriers & Enablers: Implementing the same projects; LCRP & LEAD across 3 health services streamlined efforts, and supported relationships between the hospitals. Some delays with engaging NH who did not put in an application to LCRP. HREC processes delayed projects by 3-6 months.

Focus for service improvement: EH LCRP – met all objectives. AH & NH just commenced but are likely to meet all objectives. Time frame for large scale projects too short to measure impact.

Patient experience: measures limited to specific aspects or locations of care, e.g. DOU. Findings rest with local Q&S Committees to address. Short life expectancy in lung cancer limits opportunities to monitor direct impact of redesign projects. In a ‘before’ patient survey feedback was all positive so difficult to measure change in this way. Patients who experienced the redesigned lung cancer care were difficult to follow up due to illness and reduced life span.

5. Building Capability and Capacity At High Level (Health Service/Cancer Units) At Local Level Future Proofing capability for next OCPs to be implemented (Prostate and OG)

Organisational Readiness: Each health service has a redesign team and mechanism for prioritising and redesign activities within the health service. All 3 health services have had significant change in the leadership and internal organisational structures over the project term which led to some delays with expanding the VLCRP to Austin & Northern Health. The untimely death of a key member of all 3 Lung MDTs also impacted.

Presentations: on overall and specific aspects of OCPs to health services, PHN GPs & community groups. Feedback forms at educational events.

Stakeholder engagement: Closer proximity & alignment between the Summits and OCP adoption has improved clinical engagement, detailed baseline data and defining the scope of activities. Many stakeholders already identified through the summits. Community & consumer groups identified and approached about findings from summits and upcoming OCP work to identify common ideas / issues.

Transfer of knowledge: Redesign activities have been run via the health services to support ownership. Local networking between sites & ICS secretariat to support problem solving.

Lung redesign has specific COP – widely attended.

Project & health service staff attend OCP COP when agenda applicable to their responsibility.

Solution transferability The concepts used to redesign referral pathways, triage and access to diagnostic testing should be transferable to the following tranche.

Benefits/challenges to cancer units. OCP program has supported health services to demonstrate improvement under the National Standards and Quality Accounts. Cancer i

OCP activities & progress reported to NEMICS Consumer RG Activities and approach co-designed by NEMICS & health service teams.

Lessons learnt: Ensuring all relevant units are represented in project working groups, separating gap and solution development in rapid imp workshops, if ethics required need 6-8months of lead in time to begin project, changeability of organisational readiness and its effect on project timelines

Sharing improvement activity experience. Newsletters sent during implementation, presentations at conferences/annual forum/quality & redesign meetings. Progress towards timeliness targets presented monthly to MDM

OCP activities presented via newsletters, conferences, education events. Redesign projects presented by participating health services. When all complete the overall regional impact will be reported.

Project governance: Program governance processes both within NEMICS and individual health services will be maintained for the next tranche of OCPs. New NEMICS Cancer Plan Committee to be formed including tumour specific leads to support implementation activities. Local project committees to support ownership & sustainability of specific projects. Importance of local units understanding the gaps in their service, developing solutions and owning the improvement project – ICS to be there to provide support but not visibly manage the change.

6. SUSTAIN Outcome area Focus Area 1 Focus Area 2 Focus Area 3

Sustainability factors Victorian Lung Cancer redesign Project – Eastern Health (Austin and Northern Health are in implementation) LEAD study – Monash University NH surgical volume review Responsibility Head of Cancer Services and the Cancer Quality and Strategic Projects Manager. Principal investigators and research site

co-ordinator. CEO & Director Surgical Services. NEMICS Governance Committee

Accountability Program Director of Specialty Medicine or equivalent Monash University research team and local research ethics offices.

CEO & Director Surgical Services NH Cancer Services Plan

Measurement Outcomes monitored via regular VLCR (AH & EH) reporting; NH considering joining the VCLR. MDM activity dashboard reports and DHHS Cancer Service Performance Indicator (CSPI) audits.

The final report will communicate research findings.

Volumes reported 6/12 at Cancer Governance Committee (30 / 90 / 365 mortality)

Improvement Target Improvement targets are set by OCP timeliness measures. These targets have been built into the MDM software (CANMAP) reporting dashboard for ongoing reference.

N/A >10 procedures p.a. (NSW: 18 per institution p.a./ NICE UK: 20 therapeutic procedures p.a.)

Reporting structure inclusive of future Governance arrangements

Outcomes will be regularly reported to the Cancer Services Quality and Strategy committee for review and continued activity on working towards set targets. When all 3 sites have completed their implementation region-wide data will be presented.

Outcomes will be reported to Cancer Council Australia (as the grant provider)

CEO & Director Surgical Services Cancer Governance Committee

Documentation & resources Referral guidelines and triage processes documented (Health Pathways, Rapid Access Lung lesion clinic webpage), a virtual ‘Suspected Lung Cancer clinic’ created to manage and monitor wait times, roles and responsibilities of MDM participants documented in the Lung MDM terms of reference and registrar training manuals updated.

Publications will be drafted over the project period and submitted to relevant journals.

NEMICS Position Statement on low-volume surgery.

Ongoing training and education The referral and triage process is reinforced/communicated to all referring GPs (sent as attachment to patient correspondence from the Lung MDM), a Lung MDM GP webinar has been produced and will be available as a podcast for ongoing GP education through the EMPHN, GP liaison newsletters continue to provide referral information to GPs. New registrars receive referral/triage education during initial orientation training.

N/A N/A

Attachment 1: OCP Evaluation Framework (using RE-AIM platform) – Lung cancer

RE-AIM FACTOR Progress

REACH

Promotion of the OCPs

Substantial efforts have been made to raise awareness and understanding of the role and benefits of the OCPs, including:

Clinical/medical unit meetings Austin Health – Oncology unit meeting (May 2016), Grand Round (July 2016) Eastern Health – Oncology unit meeting (Aug & Nov 2016)

Community groups via the NEMICS Community Ambassador program (Aug & Nov 2016, Feb 2017) Primary health meetings - EMPHN (Mar 2016), GP network (Nov 2016), GP forums (AH, May 2017) and NH Webinar development and presentation collaboration with EMPHN HealthPathways lung cancer pages are now available and include both clinician and consumer versions of the OCP ‘Love and Light’ Lung cancer advocacy & support group (AH, June 2016) VICS conference (May 2017) NEMICS Consumer reference group – (Aug 2016) ‘My Cancer Care Record’ (My CCR) (public and private health service presentations) Redesign unit presentations

Eastern Health (May 2016) Austin Health (Aug 2016)

MDM chairman and leadership group (EH, Dec 2016) What to expect available on the EH Rapid Access Clinic webpage OCPs printed for support groups My CCR folders for oncology patients, including those on clinical trials OCPs disseminated via kiosks, information lounges and clinic waiting rooms

Engaging stakeholders in activities stemming from the OCPs

Consumers and clinicians are engaged in planning and activities related to OCP adoption and application, including:

Victorian Lung Cancer Redesign Project - steering committee (EH) Lung Cancer Service Redesign – reference group (NH) Cancer clinical service units – operational staff Rapid Improvement Event with 35 attending (EH, Sept 2016) Rapid Improvement Workshop (NH, Sept 2017) LEAD study – site coordinator and working group meetings (monthly) My CCR advisory & implementation group Individual clinician interviews: Palliative care NUM (AH, Aug 2016), Geneticist (AH, June 2016), VLCRP grant applicant (AH, June 2016)

RE-AIM FACTOR Progress

Individual interviews with health service Quality Managers (NH, AH, MHW) NEMICS Consumer Reference Group updates VLCRP newsletters Patient Experience Surveys - Day Oncology and Inpatient oncology wards (includes private hospitals in region) VLCRP stakeholder surveys and interviews (lung cancer & diagnostic clinicians, GPs, GP liaison, patients, operational managers, admin staff) 2016 NEMICS Annual Forum theme of OCPs, with approx. 80 attending

Integration of OCPs to care processes and other projects:

The OCPs now underpin the strategic engagement, planning, communication and quality monitoring for the NEMICS region. Some specific examples are:

‘A Common Path’ cancer support videos (focus group discussion and video content production) Patient experience surveys – Day Oncology and Inpatient oncology wards Tumour Summits program, including newsletters Health Services – Cancer Services plans (AH, EH and NH) MDM performance monitoring data (EH) HealthPathways lung cancer pages are now available and include both clinician and consumer versions of the OCP

EFFECTIVENESS

Expenditure on OCP activities

Reported separately

Resourcing sufficient to deliver outcomes

EH Lung redesign PO required contract extension (10 weeks) to complete project Suggested solution to develop multidisciplinary lung cancer clinic not feasible with resources Solution to create lung cancer coordinator position not feasible within project budget

Number of projects delivered within budget Projects within budget but not all completed at this stage AH and NH project officers appointed and have commenced local lung cancer redesign projects Victorian Lung Cancer Registry (VLCR) data format caused delayed commencement of redesign project at AH

Alignment of local activities with identified priorities

Lung redesign project aligned with lung summit priorities NH and AH were supported to align with VLCRP

RE-AIM FACTOR Progress

Extent local/individual projects achieved their objectives

Streamlined referral and triage process [Reduced time from referral to first specialist appointment (FSA), process for referral documented and communicated to GPs/specialists, referral points rationalized and clearly communicated]

Improved outpatient management (Rapid access clinic, all cases presented to MDM, rapid access to testing) Time to complete diagnostic testing reduced Referrals generated within MDM rapidly actioned (reduced time to treatment) Lung Health pathway developed and rapid access lung lesion clinic webpage available Triage guidelines developed Alert process (stamp) created for urgent testing request slips (CT biopsy/EBUS and CPET) ‘Registrar huddle’ post MDM to confirm all patients requiring referral are actioned Formalised external referral process for testing

Effective problem solving (differences between planned and actual implementation)

Original idea to group investigations – not feasible developed rapid investigation process (alert stamp on request slips) Triaging of referrals originally was to be performed by consultants not a viable solution now referrals triaged by registrars

Project learnings – lessons learned, risks mitigated

Head of Respiratory not on steering committee (more thought into clinical champions and decision makers required to achieve project outcomes) Rapid improvement event covered gaps and solutions on one day (succession too rapid – better to separate workshop into gaps and solutions on another

day)

Consumers report care in line with OCP Post implementation survey difficult to complete as patients either too unwell or now deceased. Reporting of quality measures aligned with OCPs including benchmark data

Process for routine MDM monitoring developed against OCP measures

Patient experience survey planned

MDM monitoring ‘dashboard’ developed

ADOPTION

Number of agencies and settings willing to initiate a program of work The following groups were identified as clearly engaged and active in the program of work:

Lung MDM participants across NEMICS Health service operational staff Admin/booking triage staff AH and EH GP liaison and medical specialists – HealthPathways team Thoracic surgeons – remain engaged and initiate a conversation to explore possibility of multidisciplinary clinic 6 GPs have referred directly to the Rapid Access Clinic (using the webpage)

RE-AIM FACTOR Progress

Medical imaging clinicians – collaborated to develop idea of 48-hour turnaround for patients identified by an alert stamp requiring rapid access to investigations

Monash University researchers– LEAD project Northern Health lung cancer clinicians and operational managers for lung redesign/low volume high complex surgery project Austin Health lung cancer clinicians and operational managers for lung cancer redesign project

Spread of common initiatives to multiple sites - new partnerships / collaborations

New collaborations arising within Eastern health that will be replicated within the Austin and Northern redesign projects:

Lung cancer HealthPathway (developed in conjunction with EMPHN for GPs to refer to acute health service) Rapid Access Lung Lesion Clinic webpage (used by GPs and acute health service) Rapid Investigation alert process for urgent testing/investigations (lung cancer specialists, medical imaging and pathology providers) Triage guidelines developed in conjunction with different specialties – oncology, respiratory, thoracic surgery units.

IMPLEMENTATION

At the NEMICS level

The following reflections relating to lessons learnt were prompted by the difference between the planned projects and timelines versus what actually happened Organisational readiness is of vital importance – AH and NH both experienced restructures during the project period, causing delays in commencement Cross-sectoral collaborations can significantly increase complexity – the issues related to the format of data from the Victorian Lung Cancer Registry added

to the delays for the VLCRPs Stakeholder management would have been improved at EH VLCRP with the inclusion of key clinical leadership Although the rapid improvement event for EH VLVRP was productive of good engagement and solution ideas, having two, shorter events separated in time

would have created a clearer understanding of the current gaps

MAINTENANCE

Policy & Practice

Lung MDM terms of reference at EH have been updated to reflect the change in processes and responsibilities

Medical registrar handbooks have been updated to document new roles and responsibilities

Outcomes

VLCRP solutions still being implemented and embedded at EH

Monthly MDM monitoring ‘dashboard’ audit and presentation of results to EH Lung MDM

Yearly presentation to Head of Cancer Services EH – to retain focus, re-iterate solutions and work towards targets