An integrated system-wide strategy for quality improvement in cancer surgery

It is a paradox, at a time of remarkable advance in technology and understanding of the mechanisms of disease, that the best of modern surgical treatment may be difficult to access or inappropriately applied, and that hospitals can be dangerous places. Different countries have adopted different strategies to address this issue. The Surgical Colleges in the UK and Australia have been leaders in continuing professional development and surgical audit. In Sweden, the Netherlands and Finland the emphasis has been on surgeon education and mentoring1. In the USA the National Surgical Quality Improvement Program has been successful in reducing surgical morbidity and mortality in the Veterans Administration system2, and the Institute for Healthcare Improvement's ‘100 000 Lives’ initiative has shown promising early results3. There is no shortage of information about best surgical practices, but there is wide variation in how these practices are applied. This paper outlines what has been done in Ontario, Canada, to develop a more integrated and systematic approach to improving the quality of cancer surgery. It relies on surgical standards and guidelines, publicly reported indicators, and knowledge transfer strategies targeted at practitioners, hospital administrators and regional leaders in specialty-specific ‘communities of practice’. Canadian healthcare is a single payer, tax-funded, system in which each province administers its healthcare programmes. The Ontario hospitals receive a global budget annually from the provincial government, and most physicians are remunerated on a ‘fee-for-service’ basis. Radiation oncology and most systemic therapy are centralized in each of the 14 health regions in either university or community hospitals. Cancer surgery is largely dispersed throughout the province's hospitals. Cancer Care Ontario (CCO) is an agency of the provincial government and its principal advisor on cancer services, including prevention, screening, diagnostic services, active treatment, and supportive and palliative care. CCO's Program in Evidence-based Care has developed clinical guidelines, mostly directed at systemic or radiation therapy, that are widely used in Ontario and elsewhere4. Expert panels of relevant professionals, hospital administrators and regional cancer planners review and discuss bodies of literature. Draft guidelines and standards are then sent to a large sample of practitioners and administrators across Ontario for feedback5. Thus begins the creation of a commitment to implement guidelines. Formal implementation uses knowledge transfer tools directed at surgeons, hospital administrators and planners. These include mail, e-mail and web-based communications, presentations at professional meetings, and informal communications among the ‘communities of practice’ that are developing in individual specialties. Incentives to adopt guidelines and improve practice include public reporting of regional performance data on the Cancer System Quality Index (CSQI)6, and providing hospitals and surgeons with hospital-specific data. In 2001, CCO created the Surgical Oncology Program (SOP) to coordinate the delivery of cancer surgery and improve its quality. Building on the concept of integrated regional cancer programmes, the SOP proposed that regional networks be developed in which common, uncomplicated operations are performed in most hospitals, whereas complex, uncommon procedures are provided in a few specialized centres. CCO's Program in Evidence-based Care focuses on developing guidelines and standards to support this goal and two examples will be provided to illustrate the impact of this quality improvement strategy. According to a National Cancer Institute guideline, at least 12 regional nodes should be removed and examined for proper staging of curable colonic cancer7. A review of pathology reports in Ontario between 1997 and 2000 revealed that only 27 per cent of patients had adequate node sampling8. A multidisciplinary knowledge transfer intervention was developed in one of the Ontario cancer centres and this improved retrieval from a median of seven nodes to 17 nodes9. This intervention was then piloted in 16 hospitals across the province to examine the role of local ‘opinion leaders’. One early adopter community hospital reported an increase in compliance with the guideline from 46 to 92 per cent, 2 years after the intervention. When CCO included this compliance indicator on its public CSQI (Cancer System Quality Index), awareness of this issue increased as did the participation of surgeons in remedial measures. The provincial mean compliance with the guideline has increased from 27 per cent in 1997–2000 to 69 per cent in 20056. In 1997, wide variations in postoperative mortality, and an inverse relationship between hospital volume and mortality, were recognized in Ontario for major pancreatic resection for neoplasm10. When hospital mortality rates were released publicly, there was anxiety and discussion in the professional community that focused attention on the standards being developed by a CCO pancreatic surgery taskforce. ‘Criteria for the Delivery of Pancreatic Cancer Surgery’ recommended both training requirements for surgeons and hospital requirements, including resources, organization of diagnostic and treatment services, and annual case volumes of at least ten major pancreatic resections and 25 major hepatic, pancreatic and biliary tract resections per annum. In 2005, a retrospective review revealed an increase in the proportion of pancreatic resections being performed in high-volume centres after 1999, and a decrease in the provincial crude 30-day mortality rate from 10·2 to 4·5 per cent6. Although fewer surgeons and hospitals were performing these operations in 2005, many hospitals still continued to perform small volumes of major pancreatic surgery with excessive mortality rates. In 2006, CCO developed new standards that increased hospital requirements and accountability, and recommended volumes of 20 pancreatic resections and 50 total hepatopancreaticobiliary resections per annum. This document is guiding the development of regional networks of care and is expected to centralize hepatopancreaticobiliary surgery further. The SOP strategy is based on four factors: reliable and current information systems, quality improvement tools (standards, guidelines and indicators), networks of surgeons and other providers, and incentives. As quality improvement ultimately takes place at local level, it is essential to gain the trust and cooperation of clinicians and hospital managers locally to create that local change. The support of regional leaders and payers (the Ontario government) is also needed to develop an integrated system of care. The SOP has been in place for just over 4 years and has begun to improve the practice of cancer surgery in Ontario. There is considerable support for its quality initiatives and voluntary participation in developing its goals. CCO's role as advisor on the allocation of resources has been crucial in persuading hospitals to adopt the quality improvement initiatives. Incremental funding to reduce waiting times for surgery has been an important incentive in changing practice, as have support for upgrading skills and continuing professional development activities, and quality performance feedback information. Ontario's cancer surgery success story has generated much outside interest and has created an environment in which further beneficial change is increasingly possible. Recognizing quality as the primary objective is the key. There is, however, more to do and considerably more to learn about the best way in which to do it. This article is based on the European Surgical Association (ESA) lecture, sponsored by the BJS Society and delivered by Professor B. Langer during the 13th Annual Meeting of the ESA, Zurich, Switzerland, April 2006.

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