Achieving Regular Multi-Centre Performance Reporting Within A

Achieving Regular Multi-Centre Performance Reporting
Within A Stroke Region
Louise MacRae; Rhonda Whiteman; Linda Gould and Erin Kelleher
On behalf of the Central South (Ontario) Regional Stroke Measuring and Evaluation Committee:
Louise MacRae, Linda Gould, Rhonda Whiteman, Rebecca Fleck, Stefan Pagliuso, Erin Kelleher, Barb Ansley, Lisa Fronzi, Casey Scholl, Leanne Hammond, Colleen Bishop,
Amanda Plozzer, Mariam Hassan, Michelle Bott, Amy deHueck, Boyan Kovic, Donna Johnson , Kim Hallman, Dana Khan, Arsalan Afzal
Methods
Background
The Central South (CS) Ontario Stroke Region encompasses 2 Local Health
Integration Networks (LHINs) and 16 Hospital organizations with 30 sites, serving
approximately 2.5 million residents (Figure 1). The CS Regional Stroke Steering
Committee (RSSC) has used the annual Ontario Stroke Network (OSN) and LHIN
Stroke Report Card as instruments to implement significant changes in stroke care in
CS and to monitor performance across the region. These annual reports combine
information from administrative data sets and extensive chart audits to produce a
comprehensive report card.
In order to inform services and practice, the Regional Stroke Steering Committee
(RSSC) tasked the CS Regional Stroke Measuring and Evaluation Committee
(RSMEC) to produce:
a) Site specific breakdowns of the Ontario Stroke Report Card indicators for partner
organizations;
a) Quarterly ongoing reports from local data sets to provide ongoing measuring and
monitoring of the readily available Ontario Stroke Report Card indicators.
All member organizations agreed to share individual organization
results with regional stakeholders to monitor ongoing stroke care
performance and to share strategies and quality improvement
approaches used by organizations to improve performance.
Results
Using the methodology from the OSN Annual Report Cards, the CS RSMEC determined which
indicators were accessible through standard administrative databases using the OSN definitions.
A total of 7 of the 20 indicators were readily available though these data sets. Upon further review,
another 5 indicators could be reported with minor changes to the definitions of the indicators
(Table 1).
The CS RSMEC developed:
1. Common definitions numerators and denominators
2. Queries and expressions used in the reports and to allow stakeholder organizations to pull
from their own quarterly reports
3. A template based on the OSN Report card (Figure 2)
4. Where available, a quarterly Hamilton Niagara Brant Haldimand (HNHB) LHIN report card
using data from the Integrated Decision Support (IDS) tool , based out of Hamilton Health
Sciences (HHS).
At the direction of the CS RSSC, reports are shared at RSSC at the end of Fiscal
Quarter 2, 3 and 4. Each organization reviews their performance prior to sharing and
highlights areas of success and notes any changes and challenges within their
organization. The ABC Methodology utilized by the Stroke Evaluation and Quality
Committee is utilized to identify site performance compared the Ontario Benchmark.
Significant changes in care delivery such as the opening of a stroke unit are easily
identified in these reports. Individual as well as region wide initiatives are tracked.
Top performers within the Region are identified semi-annually to support quality
improvement.
Figure 2. Report Template
Poor performance1
Acceptable performance2
Exemplary performance3
The RSMEC uses the ABC Methodology, utilized by the Stroke Evaluation and Quality Committee,
to compare site performance to the Ontario Benchmark on a quarterly basis. Performance and
lessons learned are 3 times a year with RSSC for action planning and shared decision making.
Indicator
No.
1
2
A key enabler to development of the local, LHIN and Regional Quarterly Stroke Report Cards is
the Integrated Decision Support Tool (IDS) which is a collaborative data warehouse which allows
for reporting on the stroke cohort as a whole at a LHIN and Regional level. All partner
organizations either are currently contributing to the IDS or will be this fiscal year.
3b
4a
4b
5
6a
6b
7a
7b
*8
9
Table 1. Comparison of OSN Indicators vs. Central South Adapted Indicators
Domain
Public Awareness and
NOT
REPORTED Patient Education
Prevention of Stroke
2
NOT
REPORTED
Prevention of Stroke
3
1
Figure 1. Map of Central South Stroke Region
4
5
Prevention of Stroke
Prevention of Stroke
NOT
REPORTED
6
Acute Stroke
Management
7
Acute Stroke
Management
*8
Acute Stroke
Management
Acute Stroke
NOT
REPORTED Management
9
10
11
12
13
14
15
Acute Stroke
Management
Acute Stroke
Management
Stroke Rehabilitation
NOT
REPORTED
Stroke Rehabilitation
Stroke Rehabilitation
NOT
REPORTED
Stroke Rehabilitation
16
Stroke Rehabilitation
17
Stroke Rehabilitation
NOT
REPORTED
18
Stroke Rehabilitation
19
Re-integration
*20
RE-INTEGRATION
Original OSN Indicator Definition
Proportion of patients who arrived at ED less than 3.5 hours from
stroke symptom onset.
Annual age- and sex-adjusted inpatient admission rate for
stroke/TIA (per 1,000 population).
Risk Adjusted stroke/TIA mortality rate at 30 days (per 100
patients).
Proportion of ischemic stroke/TIA patients with atrial fibrillation
prescribed or recommended anticoagulant therapy on discharge
from acute care.
Proportion of ischemic stroke patients without atrial fibrillation
who received carotid imaging prior to hospital discharge.
AGE- AND SEX-ADJUSTED READMISSION RATE AT 30 DAYS FOR
PATIENTS WITH STROKE/TIA FOR ALL DIAGNOSES (per 100
patients).
*11
12
13
14
(Source Changes in Red)
15
16
Stroke/TIA mortality rate at 30 days (per 100 patients).
Public
Awareness and
Prevention of
Stroke
Prevention of
Stroke
Prevention of
Stroke
Prevention of
Stroke
Prevention of
Stroke
Prevention of
Stroke
Acute Stroke
Management
Acute Stroke
Management
Acute Stroke
Management
Acute Stroke
Management
ACUTE STROKE
MANAGEMENT
Acute Stroke
Management
Acute Stroke
Management
ACUTE STROKE
MANAGEMENT
Stroke
Rehabilitation
Stroke
Rehabilitation
Stroke
Stroke
Rehabilitation
Stroke
Rehabilitation
18
19 a
Re-integration
19 b
Re-integration
19 c
Re-integration
REINTEGRATION
REINTEGRATION
*20
*20b)
1
Care Continuum
Category
Stroke
Rehabilitation
Stroke
Rehabilitation
17
Indicator 5
Proportion of patients who arrived at ED less than 3.5 hours from stroke
symptom onset.
Annual age- and sex-adjusted inpatient admission rate for stroke/TIA (per
1,000 population).
Risk Adjusted stroke/TIA mortality rate at 30 days (per 100 patients).
Risk-adjusted stroke/TIA mortality rate at 30 days (per 100 patients).
Proportion of ischemic stroke/TIA patients with atrial fibrillation prescribed
or recommended anticoagulant therapy on discharge from acute care.
Proportion of ischemic stroke/TIA patients with atrial fibrillation prescribed
antithrombotics therapy on discharge from acute care. (340 data)
Proportion of ischemic stroke patients without atrial fibrillation who
received carotid imaging prior to hospital discharge.
Proportion of suspected stroke/TIA patients who received a brain CT/MRI
within 24 hours of arrival at ED.
Proportion of suspected stroke/TIA patients who received a brain CT/MRI
within 24 hours of arrival at ED (340 data)
Proportion of ischemic stroke patients who arrived at ED less than 3.5 hours
from symptom onset and received acute thrombolytic therapy (tPA)
(excluding contraindications).
Proportion of ischemic stroke patients who arrived at ED less than 3.5 hours
from symptom onset and received acute thrombolytic therapy (tPA)
PROPORTION OF STROKE/TIA PATIENTS TREATED ON A STROKE UNIT AT
ANY TIME DURING THEIR INPATIENT STAY.
Proportion of stroke (excluding TIA) patients with a documented initial
dysphagia screening performed during admission to acute care.
Proportion of ALC days to total length of stay in acute care.
PROPORTION OF ACUTE STROKE (excluding TIA) PATIENTS DISCHARGED
FROM ACUTE CARE AND ADMITTED TO INPATIENT REHABILITATION.
Proportion of stroke (excluding TIA) patients discharged from acute care
who received a referral for outpatient rehabilitation.
Median number of days between stroke (excluding TIA) onset and admission
to stroke inpatient rehabilitation (RCG-1 and RCG-2).
Rehabilitation therapy staff/bed ratio for inpatient stroke rehabilitation.
Proportion of ALC days to total length of stay in inpatient rehabilitation
(Active+ALC) (RCG-1).
Median FIM Efficiency for moderate stroke in inpatient rehabilitation (RCG1).
HNHB LHIN Rep HNHB LHIN Q4
11/12 (10/11)
FY
ON FY 11- 12
(10-11)
42.3%
-40.9
1.3 (1.6)
1.4 (1.5)
14.3
11.2 (15.8)
*(62.6%)
72.1%
*(66.9%)
78.7%
*(87.2%)
89.6%
*(31.8%)
32.4%
*(25.4%)
38.3%
*(58.4%)
27.7%
(35.9%)
31.0%
(32.6%)
64.8%
23.6%
(32.5%)
31.0%
(30.7%)
*(6.2)
5.9%
(11) 11
10.3 (10.0)
--
4.5%
(5.4%)
6.3%
0.8
0.8 (0.9)
Mean number of CCAC visits provided to stroke/TIA patients in 2008/09 and
2009/10.
-5.5
Proportion of patients admitted to inpatient rehabilitation with severe
38.0%
strokes (RPG= 1100 or 1110) (RCG-1).
(35.5%)
Proportion of stroke/TIA patients discharged from acute care to LTC/CCC
11.9%
(excluding patients originating from LTC/CCC).
(12.1%)
Proportion of stroke/TIA patients discharged from acute care to CCC
12/13
(excluding patients originating from CCC/LTC only ).
14.5%
Proportion of stroke/TIA patients discharged from acute care to LTC
(excluding patients originating from CCC/LTC only) .
AGE- AND SEX-ADJUSTED READMISSION RATE AT 30 DAYS FOR PATIENTS
WITH STROKE/TIA FOR ALL DIAGNOSES (per 100 patients).
7.9(7.5)
AGE- AND SEX-ADJUSTED READMISSION RATE AT 30 DAYS FOR PATIENTS
WITH STROKE/TIA FOR ALL DIAGNOSES (per 100 patients). Host Site only
6.1
29.8%
(31.2%)
8.3%
(9.8%)
Provincial
Benchmark6
52.0%
1.1 (1.1)
12.2(14.3)
86.0%
92.8%
97.7%
61.2%
87.5%
83.7%
14.6%
(14%)
42.6%
(42.3%)
12.1%
6.5 (7.0)
-5.2% (6.3%)
1.1 (1.1)
6.8
48.6%
(46.9%)
3.7% (4.7%)
8.0
8.0
8.0
8.0
Poor Performance = Below 50th percentile
Acceptable Performance = At or above 50th percentile and > 5% absolute/relative difference from benchmark
Exemplary Performance = Benchmark achieved or within 5% absolute/relative difference from benchmark
4
Data not available or benchmark under development
5
Facility based analysis (excluding indicators 1, 2,11, 12 and 19) for patients aged 18 to 108. Indicators 1, 4 - 9, 12 are based on FY1011 (FY0809 displayed in brackets) OSA data otherwise CIHI databases.
(Low rates are desired for indicators # 2, 3, 10, 13, 15, 19 and 20.)
2
3
6
Provincial benchmarks were calculated using the ABC methodology, except for indicators 3, 15 and 20 where the provincial rate was used. For benchmarking methodology, see Weissman et al. J Eval Clin Pract. 1999; 5(3):269-81.
High performing acute sites include high volume institutes (those that treat more than 100 strokes per year) and high performing rehab sites include sites with moderate volumes (those that admit more than 42 stroke patients per year).
* Hospital Service Accountability Agreement indicators, 2010/11
-- data not available
7
Proportion of suspected stroke/TIA patients who received a brain Proportion of suspected stroke/TIA patients who received a brain
CT/MRI within 24 hours of arrival at ED. (OSA Chart Audit)
CT/MRI within 24 hours of arrival at ED (CIHI Stroke Special Project
340 data)
Proportion of ischemic stroke patients who arrived at ED less than Proportion of ischemic stroke patients received acute thrombolytic
3.5 hours from symptom onset and received acute thrombolytic therapy (tPA)
therapy (tPA) (excluding contraindications).
PROPORTION OF STROKE/TIA PATIENTS TREATED ON A STROKE Unchanged
UNIT AT ANY TIME DURING THEIR INPATIENT STAY.
Proportion of stroke (excluding TIA) patients with a documented
initial dysphagia screening performed during admission to acute
care.
Proportion of ALC days to total length of stay in acute care.
Unchanged
PROPORTION OF ACUTE STROKE (excluding TIA) PATIENTS
DISCHARGED FROM ACUTE CARE AND ADMITTED TO INPATIENT
REHABILITATION.
Proportion of stroke (excluding TIA) patients discharged from
acute care who received a referral for outpatient rehabilitation.
Median number of days between stroke (excluding TIA) onset and
admission to stroke inpatient rehabilitation (RCG-1 + RCG-2).
Rehabilitation therapy staff/bed ratio for inpatient stroke
rehabilitation.
Proportion of ALC days to total length of stay in inpatient
rehabilitation (Active + ALC) (RCG-1).
Median FIM Efficiency for moderate stroke in inpatient
rehabilitation (RCG-1).
Mean number of CCAC visits provided to stroke/TIA patients in
2008/09 and 2009/10.
Proportion of patients admitted to inpatient rehabilitation with
severe strokes (RPG= 1100 or 1110) (RCG-1).
Proportion of stroke/TIA patients discharged from acute care to
LTC/CCC (excluding patients originating from LTC/CCC).
10
Revised Central South Indicator Definition
Proportion of ischemic stroke/TIA patients with atrial fibrillation
prescribed antithrombotic therapy on discharge from acute care.
(CIHI Stroke Special Project 340 data)
Total Strokes
Benchmark not available4
3a
Status
LHIN Report Card for Stroke Indicators - Fiscal 2013/14 Q4 (April-Mar)
ALL HNHB
Unchanged
Conclusions
Timely and frequent performance monitoring is achievable with planning and
cooperation among partner organizations. The commitment of stroke care provider
organizations to openly share their data, allows for sharing of successes and
identification of common challenges. Regular reporting is sustainable through the
use of standardized templates and reporting queries. Having the Integrated Decision
Support (IDS) Tool has facilitated ongoing quarterly LHIN level reporting.
Unchanged
Unchanged
Unchanged
Unchanged
Proportion of stroke/TIA patients discharged from acute care to
LTC/CCC (excluding patients originating from LTC/CCC).
Proportion of stroke/TIA patients discharged from acute care to
CCC (excluding patients originating from CCC only).
Proportion of stroke/TIA patients discharged from acute care to
LTC (excluding patients originating from LTC only).
READMISSION RATE AT 30 DAYS FOR PATIENTS WITH STROKE/TIA
FOR ALL DIAGNOSES (per 100 patients). Host Site only
Next Steps
 Expansion of the IDS Tool across the Waterloo Wellington LHIN which will allow
development of a Regional Quarterly Report Card
 Development of local data collection mechanisms for carotid ultrasound and
dysphagia screening to allow for measuring and performance monitoring to
support quality improvement initiatives
 Development of a Community Stroke Report Card reflecting care outside of
traditional hospital based organizations
 Development of a quarterly Regional Stroke Prevention Clinic Report Card

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