The Quality Improvement in Colorectal Cancer in Local Health Integration Network 4 (LHIN4) Project (QICC-L4)
The QICC-L4 is designed to optimize colorectal cancer surgical care in all LHIN4 hospitals by creating interventions that support surgeons at key points of care.
A recent audit of data from LHIN4 hospitals demonstrated that for rectal cancer specimens the rate of positive radial margins was an incredibly low 3.6%.
Collaborative Cancer Conferences, involving surgeon-to-surgeon review of patient information and radiology images through secure internet applications, results in changes from initial to final treatment recommendations in the 20-60% range.
More effective methods are needed to leverage the experiences, expertise and decision making ability latent in groups of surgeons in a hospital or region.
The QICC-L4 Project was launched in the fall of 2006 with LHIN4 surgeons, and is designed to optimize the surgical care delivered to patients with colorectal cancer. It is region-based to avoid local excellence and regional mediocrity; it focuses on surgeons as valuable resources to be supported rather than expending energy identifying ‘bad apple’ surgeons; and, it is non-coercive, iterative, and sustained. It is also an example of ‘integrated knowledge translation’ – LHIN4 surgeons are involved in all aspects of the project including the selection through consensus of markers of quality, and, interventions to improve selected markers. From 2009 to 2011 the QICC-L4 project was supported by a Hamilton Academic Health Sciences Organization AFP Innovation Grant. Since 2011 we have further developed QICC-L4 interventions, including annual audits of relevant chart data from all LHIN4 hospitals; annual workshops to review audited data, and to select additional quality markers and interventions; and, Collaborative Cancer Conferences. We continue to observe improvements in LIHN4 quality marker scores. On our last audit for rectal cancer specimens the rate of positive radial margins was an incredibly low 3.6% – the rate that cancer cells were seen by pathologists at the cut edge of the surgical specimen, a key risk factor for local tumour recurrence. Collaborative Cancer Conferences involve surgeon-to-surgeon reviews of patient information and radiology images, which are available through secure internet applications. Collaborative Cancer Conferences are done pre-operatively; referring surgeons provide initial treatment recommendations; and, the key goal is to achieve consensus on pre- and intra-operative treatment recommendations. We have observed consistent changes from initial to final treatment recommendations in 20-60% of cases, depending on venue and surgeons involved. These rates suggest the need for such reviews to occur for all patients – something not occurring in LHIN4 or elsewhere. Related to a CIHR-funded study evaluating the impact of the QICC-L4, interviews with key stakeholders across Ontario demonstrate that only two LHINs, including LHIN4, are engaged in formal LIHN-level quality improvement efforts in colorectal cancer surgery.