Implementing Health Quality Ontario’s (HQO) Quality Standards

Quality Standards for Mental Health: Implementation at Ontario Shores Centre for Mental Health Sciences Phil Klassen MD FRCPC Vice-President, Medical Affairs Ontario Shores Centre for Mental Health Sciences Assistant Professor, University of Toronto Sanaz Riahi, PhD Vice-President, Academics and CNE With thanks to Ilan Fischler, MD, Elizabeth Coleman, MD, Marsha Bryan, Sarah Kipping, Bethany Holeschek, Kelly Delaney, Terence Hedley, Jeff MacDonald, Susan Wei and Terri Irwin, and HQO

Introduction Ontario Shores’ approach to implementation Results of our gap analysis Key challenges and outcomes Next steps I will give a brief overview of the process, and the standards, but focus on implementation.

Implementation: Clinical Practice Guidelines at Ontario Shores Implementing CPGs yearly was part of the 5-year strategic plan Board support for development and implementation Opportunity to be a data-driven organization, using clinical measures to drive quality improvement and better patient outcomes We are a HIMSS Stage 7 hospital; a good technology platform is an important enabler.

CPGs - Lessons Learned Implementation needs to be led by physicians/clinicians Choices need to be transparent and justifiable Structured templates/order sets/reflex orders/automated decision-support help promote adherence Many factors outside of physician behaviour affect adherence (interprofessional team, patient choices) Need to pay attention to data quality and have a mechanism for sharing data with the clinicians Medical Directors incentivized to deliver adherence Data push On-unit champions/role pf practice

Quality Standards – what are they? Concise sets of 5-15 strong (“must do”), measurable, evidence-based statements guiding care in a topic area Developed in topic areas identified as having high potential for better quality care in Ontario Each quality statement accompanied by quality indicator(s) Every quality standard will be accompanied by a plain language summary for patients and caregivers Strong emphasis on implementation through a variety of vehicles (monitoring/reporting, QBPs, Quality Improvement Plans, etc.) Strong emphasis on partnerships to support development and implementation

Quality Standards - the elements The Statement The Indicators The Audience Statements Definition There is meat in the definition. Two have been derived largely from NICE. There are 89 indicators.

Why Quality Standards? There is marked variability of practice Likely reflects local factors more than true patient variability Lack of a measurement based culture Likely affects quality There is a long gap from emergence of clinical evidence to its routine application at the service user level Patients and families need to know what they should expect The HQO Quality Standards are largely built off the NICE guidance, the most authoritative evidence-based guidance (AGREE II) Local variability as a driver has been shown in utilization in mental health. The Royal Society of Medicine, citing work done between 2005 and 2010, reported a 17 year evidence lag, published in 2011. 55 billion dollars per year in biomedical research; we get a 39% return.

In all, there are 37 statements, and 89 indicators.

Steps to Implementation Select the Standard(s)/statements We implemented all statements Create the governance structure/team/partnerships Undertake a gap analysis/es Select the process adherence and outcome measures Based on the gap analysis Utilize informatics Align therapeutic services Monitor and support adherence Physician transparency Interprofessional engagement Use of a physician assistant Academic detailing Performance appraisals Use of technology Communicate, communicate, communicate Pick what you feel you can do, initially. This is a lot of work. Consider partnerships with other organizations. Include physicians, clinicians, and IT, and DS. We picked measure frequency in accordance with the anticipated implementation challenges.

Implementation Phase (2016-2017): The “Three Buckets” Strategy to implement the three mental health Quality Standards in order to close any gaps identified between our previous Clinical Practice Guideline work and the new Quality Standards. Things we were doing already but not documenting in a way to easily measure (e.g. comprehensive assessment) 1. Measurement Changes Things that we were not doing consistently but technology and forcing functions helped to drive the solution, with some measurement (e.g. EHR prompts to explain why not an LAI; focus on exception handling) 2. Technology Enablers Things that represented a very significant change in our business model, and required resource re-allocation, technology, change management and staff training or partnerships to accomplish (e.g. CBT for psychosis) 3. Service Changes Measurement Changes Things we are doing already but may not yet measure Eg comprehensive assessment Technology Enablers Things that we are not doing consistently but technology and forcing functions can drive the solution, with some measurement Eg EHR prompts to explain why not an LAI Focus on exception handling Service Changes Things that represent a very significant change in our business model, and will require resource re-allocation, technology, change management and staff training or partnerships to accomplish Eg CBT for psychosis

Step 3: Gap Analysis Through the Lens of the Three Buckets Quality Statement Clinical Gap Data Gap 1. Screening for Substance Use No gap (although capacity levels for provision of service may need to be reviewed) Need to be able to identify if the patient had a referral to concurrent disorders treatment (prior to admission) and are awaiting that service 3. Physical Health Assessment No gap Unable to currently identify if a patient had a comprehensive physical assessment, including metabolic work-up, in the past year (prior to admission). 4. Promoting Physical Activity and Health Eating Need to be able to identify when patients received interventions that promoted physical activity and/or healthy eating 6. Treatment with Clozapine Need to be able to identify when a patient was offered clozapine 7. Treatment with Long-Acting Injectable Antipsychotic Medications Potential gap in clinical practice with regards to whether this is always offered. Need to be able to identify when a patient was offered a long-acting injectable antipsychotic medication. 8. Cognitive-Behavioural Therapy Clinical gap with provision of individual CBT for psychosis. 9. Family Intervention Clinical gap with provision of family intervention as specified in this quality statement Need to way to identify if consent was provided for family involvement, who is receiving family intervention services during admission or arranged in discharged plan 10. Follow-up Appointment After Discharge Need to look into approach to report on follow-up appointment timing with other service providers. 11. Transitions of Care Need to confirm if any additional details are required to report on patients discharged to homelessness with shelter arrangements or without shelter arrangements. This is an example of a gap analysis. This will vary from setting to setting.

Step 5: Utilize Informatics Physician Workflow in the EHR Put the needed material on one page to make it easier for the ordering clinician to complete what is needed.

Step 5: Informatics Use of the EHR (“Bucket 2”) CBTp screening tool embedded in clinical workflow with orders for 1:1 CBTp automatically triggered for completion by the clinician based on screening results. System automation leveraged to support Quality Standards. E.g. If all three questions in the CBTp screening tool are answered as “yes”, an automatic order for 1:1 CBTp is triggered for completion by the clinician. This is an example of a bucket 2 item: using technology to drive adherence, in the form of reflex orders.

Step 5: Informatics Depression Treatment Note Example

Step 6: Align Therapeutic Services (“Bucket 3”) Schizophrenia CBT for psychosis Family therapy Dementia Few Major depression Time frames for assessment and treatment Psychotherapy capacity This is specific to our hospital. Depression assessments must come with a measure. This needs to be verified clinically, as to enhance prospects of referral many distressed consumers will generate high scores. Diagnostic acumen is needed; depression is among the most unreliable of the DSM-5 diagnoses, according to the field trials.

Step 8: Align Therapeutic Services; Schizophrenia Where do we need to focus attention? Interventions Received Concurrent Disorder Services Smoking Cessation Supports Treatment with Clozapine Treatment with Long-Acting Injectable Antipsychotic Medication Cognitive Behavioural Therapy for Psychosis Family Intervention Interventions Ordered Interventions Offered Screening for Interventions Substance Use Smoking Offered and ordered and received should all be measured. Knowing where the gaps are will drive quality improvement efforts.

Enablers & Sustainability Supports Step 8: Align Therapeutic Services; Schizophrenia Psychotherapy Capacity Assessment & Implementation Planning Manual Selection Identification of Trained Resources Current Capacity Estimates Anticipated Demand Estimates Capacity Analysis Delivery location (inpatient vs. outpatient, by program) Clinicians to support delivery (social workers, OTs, psychologists, etc.) Training requirements Program and senior leadership approval Resource Plan EMR Note Templates (based on the manual) Training approach for new resources Clinical supervision & consultation approach Measurement/ evaluation plan Enablers & Sustainability Supports This is a very granular process that will reach deep into an organization, and potentially challenge the historical autonomy of practice of clinicians. Templates in the EHR are important to manage consistent application of a model, as if supervision or consultation.

Step 8: Align Therapeutic Services; Schizophrenia Estimating Psychotherapy Needs We went to our clinicians, and decision support How many patients carry schizophrenia as a principal diagnosis? How many patients are screened in/accept/complete therapy? Used the following equation 100% x .5 (screened in) x .5 (accepted) x.5 (completed) We calculated hours per treatment x patient numbers x available resources Looked at training/supervision gap Ascertained manuals Material into EHR Short-stay: inpatient continued as outpatient or deferred Long-stay: inpatient 15%-30% staff time conversion from unstructured to structured interventions; no operational cost increase, only one-time costs for training and supervision Conversion of unstructured to structured interventions shoud produce a better outcome.

Step 7: Monitor and Support Adherence Physician-Specific Scorecards

Outcomes

Priority Indicators Chosen: Schizophrenia Process (annual audit for the remainder) Tracking Percent screened for CBTp Percent referred for CBTp Percent received family intervention training (FIT) Percent care plans shared with receiving providers within 7 days Percent follow-up appointments within 7 days of discharge Outcome Improvement in RAI-MH Positive Symptom Scale between admission and discharge We are auditing annually for some statements, but monthly for the most at-risk statements.

CBTp & FIT Screening/Referral Targets 95% or greater of all patients in scope for the Schizophrenia Quality Standard are screened for CBTp and FIT 90% or greater of all patients screened as candidates for CBTp and/or FIT are referred for service. 

Schizophrenia Annual Audit Results

Schizophrenia Outcome Primary outcome measure is the RAI-MH Positive Symptoms Scale Moved from nursing to medicine completion Concerns about accuracy We were running about 60% of patients improved; lacked face validity With physician data input, approximately 90% of patients show improvement, but Given the change in approach to measurement, we don’t have a trend to demonstrate

Priority Indicators: Depression The Access Challenge % of people with suspected severe major depression, identified by a health care provider, who receive a comprehensive assessment within 7 days of initial contact; % of people with suspected mild to moderate major depression, identified by a health care professional, who receive a comprehensive assessment within 4 weeks of initial contact; % of people with severe major depression who receive a combination of medications and psychotherapy within 7 days of their assessment; % of people with mild to moderate major depression who receive medications or psychotherapy within 4 weeks of their assessment; % of people with severe major depression in full remission who receive a comprehensive assessment within 7 days after experiencing symptoms of relapse % of people with major depression who show an improvement in depressive symptoms during an inpatient stay 

Meeting the Access Challenge: Major Depression Time frames for assessment a challenge (7 and 28 days) How can we screen more effectively? (MDD) Psychotherapy capacity; need to offer within 7 and 28 days Just enough therapy in the right time frame Applications? E-therapy? Group or individual? We don’t want to use resources treating mood disorders or presentations that are not major depression, with this algorithm. Getting the diagnosis right is important. We will need to innovate in terms of psychotherapy, to close the treatment access gap.

DSM Field Trials: Diagnostic reliability-adults Diagnostic reliability is even lower in non-English speakers, with an English-speaking clinician.

Depression: co-morbidities complicate diagnosis Determining the primary diagnosis will be essential. This does nor even include persistent depressive disorder, and personality disorders.

Finding True Positives in Major Depression referrals: Our Data Out of 274 primary care referrals with suspected Major Depressive Disorder: 8 (3%) were diagnosed as Major Depressive Disorder (Severe) 60 (22%) were diagnosed as Major Depressive Disorder (Mild/Moderate) Only 25% had a primary diagnosis of depression after psychiatric assessment PHQ-9 almost always high 51 (19%) did not have a diagnosis specified Given mismatch, we have adjusted the filter (to be assessed based on clinical features rather than PHQ-9) Diagnosis not specified – follow-up outside of action plan to help review and address gaps with diagnoses not being entered

Suspected Major Depressive Disorder (Severe) and Diagnosis Match Rates I Clinical Diagnosis of Major Depressive Disorder December – 2 (Prompt) January – 1 (AMD) February – 1 (Prompt)

Major Depression – Timely Access to Assessment

Major Depression – Timely Access to Treatment

Major Depression Audit Results

Quality Improvement, Monitoring & Sustainability

2018-2019 Continue work to monitor and sustain improvements achieved and to realize improvements in areas still not at the desired levels, eg Timely access targets (depression); Psychotherapy wait times. Depression outcome measure Support work on indicators of focus with CAMH, Waypoint and the Royal Explore other opportunities to share knowledge and learnings with hospital and community partners

Key Learnings You learn a lot about your organization when you dive into major change efforts; Mental health facility culture has a long history….

Thanks! Klassenp@ontarioshores.ca riahis@ontarioshores.ca