Background
Method
Study design and sample
13 steps by van Lent | Application of the steps in this study |
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1 Determine what to benchmark | Comprehensive cancer care, structured through the domains of the BENCH-CAN framework such as People, Process, Product & Services, and Efficient (step 6). |
2 Form a benchmarking team | International consortium existing of representatives from cancer centers, health R&D organisation, biomedical innovations consultancy company, and OECI. |
3 Choose benchmarking partners | Cancer centers in Europe. |
4 Define and verify the main characteristics of the partners | A mapping exercise of the external environment in which the cancer centers are located was performed. |
5 Identify stakeholders | Four stakeholder groups were identified: patients, management, clinicians and researchers. |
6 Construct a framework to structure the indicators | |
7 Develop relevant and comparable indicators | Indicators were retrieved from literature [14] and expert opinion. |
8 Stakeholders select indicators | Stakeholders from the BENCH-CAN project and other experts from cancer centers provided feedback on the indicators. |
9 Measure the set of performance indicators | Indicators were first pre-piloted in three centers to check clarity of the definitions and whether indicators would yield interesting information. Data collection phase was three months. Next, the three month during data collection phase was repeated for the other centers. A team performed a center visit to each pilot center to verify the data, to grasp the context and clarify any questions arising from the provided data. |
10 Analyse performance indicators | The researchers compared the performance of the pilot cancer centers. Reports of this comparison were checked by the other members of the center visit team. |
11 Take action: results are presented in a report and recommendations are given | For each participating cancer centre, a report was made containing the outcomes of the benchmark for all centers. Data was anonymized. Improvement recommendations were sent in a separate document. |
12 Develop relevant plans | Pilot centers were asked to develop improvement plans for recommendations that they agreed with. |
13 Implement the improvement plans | Outside the scope of this study. |
Framework and indicators
Reliability and validity
Indicator refinement and measurement
Analysis
Step | Action |
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1 | Read through the benchmark data (transcripts) and make notes |
2 | Go through the notes and list the different types of information found |
3 | Read through the list and categorize each item (domains of the framework were used as main categories) |
4 | Repeat the first three stages again for each data transcript |
5 | Collect all of the categories or themes and examine each in detail and consider it’s fit and its relevance |
6 | Categorize all data (all transcripts together) into minor and major categories/themes |
7 | Review all categories and ascertain whether some categories can be merged or sub-categorized |
8 | Return to original transcripts and ensure that all the information has been categorized |
Improvement suggestions
Results
Reliability and validity
Performance differences between centers
Topic | Center | |||||||
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A | B | C | D | E | F | G | H | |
Type of center | Comprehensive CC | Comprehensive CC | Clinical CC | Comprehensive CC | x | Comprehensive CC | Comprehensive CC | Comprehensive CC |
Effective | ||||||||
Survival/mortality registration | Gross mortality ratios (2.08%)per tumor type and -stage are published on the website. | Gross mortality ratio per number of discharges is registered (9,5%) and Risk-Adjusted Mortality (e.g.age, sex, tumor etc.) (0,8836) | Gross mortality rate is registered | Gross inpatients mortality ratio (2.0%) is registered. | Gross mortality ratio is registered | Mortality ratios are collected only for patients who had surgery | Mortality ratios are registered by the National Cancer Registry, published on the website. | Not recorded at institutional level |
Colo-rectal surgery mortality (within 30 days) | 0 | Not registered | Not registered | 0 | Unknown | Unknown | Not registered | Unknown |
Innovative technology and therapies | Budgets are not keeping up with the developments in technology’s and therapies and the increase in costs that comes with this | Targeted biological treatments are not covered. New therapies will lead to a negative balance. This will cause a big challenge in the future. | It is hard to introduce the latest technologies because they are not reimbursed. It might take 2–3 years to arrange reimbursement. | - New treatments are very expensive, not always paid for by insurance - Healthcare services are not able to provide state of the art treatment to all patients | Not foreseen as a major challenge. | Biosimilar, and generics are a challenge. Several expensive drugs come to the market. Need for biomarkers | All drugs are reimbursed, but there is a 6 month wait before the reimbursement comes. The national system is slower. ESMO guidelines are followed. | Unknown |
Safe | ||||||||
Risk management | - Quality, Occupational health and environment service - Prospective risk assessments by MDT - Staff training - Dedicated emergency managers, available at the institute 24/7. | - Occupational health and Overall Risk Management Service - Risk management system: general risk management and clinical risk management | - Annual risk factors analysis and prevention action plan. - Evaluation of implementation end each year. | - Several protocols for risk management - New employees undergo a thorough medical examination to decide if they are fit for employment. - Emergency Assessments - External Risk Assessments | -Department for prevention and control of nosocomial infections. - Staff involved is formally trained and informed about the regulations | - Health and Safety function deals with prevention and management of staff safety - The medical physics unit manages the prevention and control of radioactive risks for patients and staff. | - Strategy and program measurements are part of the institute and available on the website | - Risk management plan overseeing clinical management and risk -Medical Directorate coordinates all activities of preventive medicine and environmental health - Protection and Prevention Service. |
Adverse events | - Safe incident reporting system - Every employee of the institute has access to this system and can report incidents - Incidents are analyzed by relevant departments and feedback is given to the detector and an advice for improvement measures to the manager - Patient safety committee monitors hospital-wide | - Everybody is allowed to make a notification of an adverse event - Form allows notifier to make recommendations to prevent this situation - All adverse events are collected by the CG service - Quarterly reports on website | - Every staff member can inform the head of clinical department about potential threats. - Medical staff fill a Report of discrepancies or adverse event and inform Head department - Risk and prevention factors evaluation group prepare annual Risk factors and prevention actions plan for the Institute | - Adverse events and near misses reported on departmental level and institutional level - Radiotherapy department has an IT system for reporting irregularities and adverse events - Analysis of irregularities is reported on the shared drive and as well as patient complaints analysis | - Patient incidents are reported to the complaints registry thereafter addressed to the Management, and after evaluation addressed to the Ethics Council. - Every incident is electronically recorded and sent to the public health authorities quarterly. - In every department there is a local registry for incidents, reporting on paper. - Medical errors: if nurse is involved she reports it to the doctor, if the doctor finds it serious, sends it to the medical committee. Nurses cannot report an incident directly. | - Institutional Incident Reporting program. The events are reported on a voluntary and not-anonymous base; - Summary report is annually shared with the strategic directorate. - Reporting usually on paper, but some departments have it electronically - Patients can report incidents as well | System that registers and generates reports for patient satisfaction, patient safety, patient complaints. | - The “incident reporting module” is available for staff in the institutional intranet and a counseling service is available. - Sheets are anonymous. - In practice only the actual events are reported. |
Patient centered | ||||||||
Case manager | Case managers for head and neck cancer, breast cancer and melanoma - Case manager usually nurse specialist or physician assistant - Contact person for questions about their treatment etc. - Case managers redirects patients to supportive services - All patient receive leaflet with all information on how to reach their case manager. | The patient can contact: The physician at an appointment; - A member from the nursing staff that follows the patient; - The social worker and/ or the psychologist that follows the patient - An administrative office that is called “Patient Support Office” | - Patients are informed by treating physicians - Nurses are also indicated as contact persons | - Contact person for each patient, by law, is their responsible specialized MD - a designated Case Manager exists at the Same Day Surgery Unit - Tasks of the Case Manager: - Schedule procedure and inform patient in writing - Collect the necessary paperwork and provide them to the anesthesiologist - Provide patients with discharge records | The contact person for each patient is the physician (medical oncologist, surgeon etc.). The discharge letter contains all the information the patient needs, including a telephone number for the doctor in charge of the case, and in some cases, the number of the nurse of the day hospital clinic. | There is a contact person/team – usually nurses - for each person. A contact number and all the needed pieces of information are given to the patient before discharge. In the breast unit there is one case manager to act as a contact person. | - “personal support nurse” there in practice, not officially - when needed there is option contact physician in charge | Basically there is a physician as contact person for patients but a specific case manager is not appointed for each patient. In clinical trials a case manager, often a research nurse, is appointed to coordinate appointments (exams, visits, follow-up) as primary contact for patients. |
Patient involve-ment (care) | - Patient portal: access to their full medical file - Patients can choose their own doctor - Patient participation in decision-making regarding treatment depends on type of health insurance. Not all treatments covered by all types of health insurance | - Patients participate in the multidisciplinary appointments - Physician discusses alternative treatments with the patient - Patients can choose their own doctor | - Patients receive information about their diagnostic and treatment processes and must sign Statement of Faith. - Information to patients and other entities is provided according to procedure - Patients can choose their own doctor | - Patients can choose their own doctor - Patients have the right to a Patient Representative - Patients have the right to review their patient documentation and pose any questions | - Patients are explained the purpose of every diagnostic or therapeutic procedure and alternatives where available. The patient signs informed consent forms at every major step of the care pathway. - Patients have the right to review their patient documentation and pose any questions - Patients can choose their own doctor | - Oncologist and/or the multidisciplinary team propose the diagnostic and treatment processes. If the patient decides to accept the proposal, he/she has to sign the informed consent. -Patients have the right to review their patient documentation and pose any questions | - MDT makes a recommendation, and physician decides with the patient. Patient receives most of the patient documentation automatically (and largely in e-format). - All patients (citizens) have access to their own patient records | - Patients are involved in the discussion of their diagnostic and treatment plan during visits performed by physicians. Signature of the informed consent is intended as the acceptance of the patient to the proposed treatment. |
Patient involvement (strategy) | - Patients are represented by the Patient Advisory Board (PAB). - PAB promotes the common interests of patients and gives solicited and unsolicited advice to the Board of Directors | - Patient Support Office to establish connection between users and Board and streamline communication of the patient and the professionals | - Patient representatives are not involved that much due to the lack of legislation and to the fact that representatives are not very active. | - The Patient Representative participates in the Board of Directors’ meeting each week and communicates directly with the Board. | - Patients can participate in the institute through offering suggestions or filing complaints/suggestions during their care in the institute. | - Patients’ representatives are part of the Patient Education working group and proactively propose improvements to services | - For some brochures patients are asked for opinion on design. - Patient Advisory Board, heavily involved in developing services and care. - There is a good relationship with the national Cancer Society. | - Collaboration with external patient organizations that address patients’ priorities and needs. |
Survivors | - The institute offers multidisciplinary rehabilitation - General rehabilitation and special rehabilitation program for patients with head and neck cancer. - % Annual budget for survivorship programmes: 0.6% | - Website under development: “I Have Cancer” -Groups related with the institute that give support to patients. - % Annual budget for survivorship programmes: 0 | -Rehabilitation treatment -Cancer Information Center -Patient’s school -Social services and other rehabilitation services. - % Annual budget for survivorship programmes: 0 | - The survivorship programs are organized in collaboration with the League Against Cancer. - % Annual budget for survivorship programmes: 0 | - Psychological support is available in the Institute for patients and their families. - Follow up program for survivors - % Annual budget for survivorship programmes: 0 | - The institute has a specific clinic for long term cancer survivors and cancer-free patients and a dedicated patient organization. - % Annual budget for survivorship programmes: 0 | - Support unit. - Physiotherapy, Psychosocial support, Nutrition, Peer support, Sexuality, social support, support for families with children - % Annual budget for survivorship programmes: 0.4% | - Chaplain and/or social workers and/or psychologists -Multidisciplinary collaborations to support cancer patients and survivors - % Annual budget for survivorship programmes: 0 |
Timely | ||||||||
Waiting and throughput registration | - Access and throughput standards (maximum times) set by government - Dashboard quality and safety reports quarterly on waiting times - Waiting times published on website - Pass standards entry level requirement for negotiations with insurance companies | - Maximum set by government. - Reported in annual report | - Maximum waiting times - Waiting times are available in Institute information board. | - Waiting times are kept according to government decree | - Maximum set by government. - There are currently no standard means of measuring waiting and throughput times. | - The center records waiting times at two institutional levels: 1- Regional: 2- National: Ministry of Health oversight. | -Waiting times on the website for several tumors: breast, prostate and bowel cancers (more to be added). | - Waiting and throughput times are recorded and published on website, -Regional level maximum waiting times. -No consequences regarding reimbursement. |
Average overall waiting time before first visit | 9.1 days | 1.54 days | 12 days | 7 days | not available | 21.8 days | Unknown | 9.6 days |
Average waiting time from first visit to diagnosis | 9.1 days. | Majority patients already have a diagnosis when they come to the first visit. | 20 days | 14 days | Average not available, depends on pathology result (availability for pathology result is established by law and is maximum 30 days). | Not available | Not available. | Not available |
Average waiting time diagnosis-start treatment | Not available | 6.53 days | Not available | 7 days | Not available | 19.7 days | 14 days | 12.6 days |
Effective
Efficient
Safe
Patient-centered
Timely
Improvement suggestions
Suggestions | Institute/Agreement | Comments | Actions to be taken identified by pilot centers |
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Case managers for (all) patients/all tumor types | A/ Agree | “This is important but requires specialized staff, currently shortage of this specialized staff.” | Currently there are official case managers for 5 tumor types, development of case managers for other tumor types will follow these examples |
B/ Agree | “Case managers are an important tool in patient treatment so we want to improve this area.” | Already part of the strategic vision so no extra actions need to be taken | |
C/ Agree | “It would be good to have case manager-the process has to be more organized, more patient oriented.” | Educate the right staff and dedicate them as case-manager | |
F/ Agree | “A case manager for each pathway will be formally identified.” | Define clear role and responsibility for the case manager for each pathway/tumor type | |
Develop more support for survivors | B/ Agree | “With the increase of the survival rates in cancer patients we recognize that this is an area that we must improve.” | A website where survivors can exchange information and experiences was already launched. A portal for survivors, amongst others, is under development. |
D/ Agree | “Survivorship programs are provided mostly by the patient organizations.” | Develop own survivorship program for the institute and further formalize the collaboration with patient organizations in survivorship programs. | |
Increase patient participation in the care process | B/ Agree | “We are already working in this area.” | An area on the website is under development were patient can access: future appointments, exams results and requisitions, among other clinical and administrative information. The portal that is under development will have one tab containing the patients targeted information. |
Improve patient participation in the organization/strategy development | C/ Partially agree | “Patients have to be involved. However not all patients want to be involved.” | All patients have to pass the MDT. And after discussion-take a decision on whether to participate. This participation has to be organized. |
Develop a structured, institute wide adverse events analysis system | C/ Agree | “It is absolutely necessary to check and register these events. Important for the quality of care.” | Depends on the staff. Sometimes they hide the information |
Measure staff satisfaction | C/ Agree | “Staff has to be honest and not just provide the socially accepted answers.” | Regular discussions with staff, improve existing questionnaires |
Central complication registry may be useful | A/ Partially agree | “Complication registration is mainly useful for healthcare professionals, current registration system allows health professionals to see the data important for them, per discipline. Central registration could be useful to annually analyze the results and look at the trends compared to trends in for example new patients. The national institute for Clinical Auditing registers complications as well on a national level.” | Create system that can extract data from existing system or develop new registration system |
Implement Computerized Physician Order Entry | E/ Agree | Electronic prescriptions are currently being implemented: in the short term there will be 2 pilot actions for 2 departments. It is currently planned to include treatment details (chemotherapy data), transfusions and clinical trial participation. | |
F/ Partially agree | “This is an important and urgent objective, but unfortunately due to regional restrictions the institute cannot be proactively proceed. ” | ||
Improve patient transition protocol | H/ Agree | “We should improve the network with other hospitals/institutes, care facilities and general practitioners (GPs) as well.” | Improvement of the electronic chart (e-chart): at regional level, the first attempt has been made within the region |
Assess and improve inpatient bed utilization | H/ Partially agree | “Inpatient bed utilization is planned and regulated at regional level.” |