1. Implementing Health Quality Ontario’s (HQO) Quality Standards

2. 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

3. 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.

4. 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.

5. 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

6. 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

7. 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.

8. 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.

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

12. 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.

13. 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

14. 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.

15. 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.

16. 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.

17. Step 5: Informatics Depression Treatment Note Example

18. 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.

19. 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.

20. 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.

21. 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.

22. Step 7: Monitor and Support Adherence Physician-Specific Scorecards

23. Outcomes

24. 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.

25. 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. 

26. Schizophrenia Annual Audit Results

27. 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

28. 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 

29. 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.

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

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

32. 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

33. 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)

34. Major Depression – Timely Access to Assessment

35. Major Depression – Timely Access to Treatment

36. Major Depression Audit Results

37. Quality Improvement, Monitoring & Sustainability

38.
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

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

40. Thanks!