1. Quality Standard for Schizophrenia One Year Later
Phil Klassen MD FRCPC
Vice-President, Medical Affairs
Ontario Shores Centre for Mental Health Sciences
Assistant Professor, University of Toronto
With thanks to Terri Irwin, and HQO

2. Introduction Overview of the schizophrenia Quality Standard
Ontario Shores’ approach to implementation
Results of our gap analysis

3. 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

4. What Quality Standards mean to our key audiences
Patients, caregivers and the public can use Quality Standards to understand what excellent care looks like and what they should expect from their health care providers
Health care professionals can use Quality Standards to evaluate their practice, identify areas for personal and organizational quality improvement and incorporate them into professional education
Provider organizations can use Quality Standards to audit their quality of care, identify gaps, guide organizational improvement strategies and inform clinical program investments
LHINs and disease agencies can use Quality Standards to inform regional improvement strategies and monitor the care provided by health service providers
Government can use Quality Standards to identify provincial priority areas, inform new data collection and reporting initiatives, and design performance indicators and funding incentives

5. Quality Standards: The Elements
The Statement
The Indicators
The Audience Statements
Defintions

6. Quality Standard foR SCHIZOPHRENIA

7. Schizophrenia: Population and Scope
Adults aged suffering from schizophrenia
From the ER/hospital admission to discharge
Community treatment for next iteration
In Scope
Adolescents and the elderly
Not specifically about first episode psychosis
Not specifically about concurrent disorders
Out of Scope

8. Quality Standard for Schizophrenia: Content

9. Steps to Implementation
Select the guideline
Develop the algorithm
Undertake a gap analysis
Create the governance structure
Select the process adherence and outcome measures
Create the project charter
Utilize informatics
Realign therapeutic services
Monitor and support adherence
Physician transparency
Use of a physician assistant
Academic detailing
Performance appraisals

10. Quality Standards - Lessons we are learning
The are numerous statement and many indicators
You need to decide where to spend your energy
You need to decide how many indicators, and for what purpose
Change can be managed by creating three “buckets”
Things we are doing already and may not measure
Eg comprehensive assessment
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
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

11. Gap Analysis & Level of Difficulty Rating Overview
Schizophrenia Quality Statements
Clinical Gap
Data Gap
1 – Screening for Substance Use
2 – Comprehensive, Interprofessional Assessment
3 – Physical Health Assessment
*adjustment of the indicators would change this rating
4 – Promoting Physical Activity and Health Eating
5 – Promoting Smoking Cessation
6 – Treatment with Clozapine
7 – Treatment with Long-Acting Injectable Antipsychotic Medication
8 – Cognitive Behavioural Therapy
9 – Family Intervention
9 – Follow-Up Appointment After Discharge
10 – Transition of Care
Highlights:
70% of the quality statements assessed as routine clinical practice
Discussion around creating a schizophrenia template to capture applicable data elements for reporting on the identified indicators.

12. 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).
Recommendation to provide feedback to HQO on these indicators.
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.

13. Quality Statements
Implementation Plan Summary
Comprehensive Assessment
Comprehensive assessments considered routine practice, with the exception of the requirement for a physical examination
Referral process updates:
Inclusion of requirement to complete PHQ-9 (a validated assessment tool for assessing severity) to confirm suspected severity
Updates to priority setting standardization to include suspected severity
Meditech changes:
Ability for psychiatrists and clinicians to complete the PHQ-9 at assessment, and thereafter, to track progress.
Prompts to include recommendation to complete a physical health assessment as part of consult (if not already completed)
Suicide Risk Assessment and Intervention
Assessed as routine clinical practice already.
Leverage PHQ-9 results to trigger the addition of a suicide risk assessment to worklist as applicable
Shared Decision-Making
Development of decision aid for use with patients
Provide decision aid resource and record use of decision aid with patients
Treatment After Initial Diagnosis
New depression treatment note, including checks to record initiation of medication and/or psychotherapy as applicable.
Adjunct Therapies and Self-Management
Assessed as routine clinical practice already (although not recorded as discrete data)
Queries added to record that this information was shared with the patient.
Monitoring for Treatment Adherence and Response
New depression progress note, with queries to capture treatment adherence & response, as well as remission
Optimizing, Switching, or Adding Therapies
New depression progress note, with specific queries record offering of a different or additional antidepressant, psychotherapy, or a combination, if they have not responded to their antidepressant medication after 8 weeks.
Continuation of Antidepressant Medication
Assessed as routine practice already (although not recorded as discrete data).
Queries added to record that this requirement is being completed.
Electroconvulsive Therapy
Assessed as routine practice already (although not capturing when it was offered as discrete data)
Query added to capture when ECT is offered
Assessment and Treatment for Recurrent Episodes
Same implementation plan as outlined in quality statement #1.
Education and Support
Queries added to record that this was offered
Transitions in Care
Assessed as routine clinical practice for inpatients being discharged
Replace current outpatient physician discharge summary note with a shorter outpatient physician D/C report with diagnosis template and add query to clinician depression note to identify as a final note, ability to add receiving provider contact information and notice to HIM to send report.

14. Physician Workflow in the EHR

15. Estimating psychotherapy needs
We went to our clinicians, and DS
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 HER
Short-stay: inpatient continued as outpatient or deferred
Long-stay: inpatient

16. 15%-30% time conversion

17. Clinical Decision Support: Physician Admission Assessment
PRESENTER: Nander Stevens

18. Clinical Practice Guidelines: Dashboard

19. CBT for Psychosis Referrals (Comparison with Pre-Implementation Baseline)
Desired direction
CPG Implementation
Note – April 2013 – October 2013 data is not showing any referrals so it has not been included in this graph.

20. Progression over time www.HQOntario.ca Measure
Median (pre-implementation)
Mean (pre-implementation)
Median
Mean
Median
Mean
March Snapshot (March 31, 2016)
Polypharmacy (excluding clozapine)
46.5%
46.25%
40.2%
41.52%
41.7%
40.1%
30.2%
Metabolic Monitoring
76.8%
77.1%
79.5%
79.28%
80.9%
82%
89.6%
CBT-Psychosis Referral 5%
5.6% *calculated with data from Nov-13-Mar- 14. No referrals shown in the reports from Apr-13 – Oct-14
7.85%
9.2%
16.9%
25%
52.2%
Voc. Services Referral
37.5%
37.67%
41.39%
43.6%
45.3%
57.2%

21. July 2016

22. Indicators chosen Process (annual audit for the remainder) Tracking
Percent screened for CBTp
Percent referred for CBTp
Percent received family intervention
Percent care plan within 7 days
Percent appointment within 7 days
Outcome
Improvement in positive symptoms between admission and discharge

23. CPGs - Lessons Learned Recommendations need to be evidence-based
Implementation needs to be led by physicians/clinicians
Choices need to be transparent and justifiable
Structured templates/order sets/automated decision-support help promote adherence: reflex orders (can be built on paper if EMR is not available)
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 rates
Data push
On-unit champions

24. Conclusions These quality standards will go “live” in 2017-2018
It is not clear yet if, or how, they will be linked to funding
They are iterative; expect updates
The next mental health and addiction standard is for community treatment of schizophrenia.