How a Canadian federal organization integrated synoptic reporting and quality improvement tools to drive a national learning health system in cancer surgery

Abstract

Accurate and complete surgical and pathology reports are the cornerstone of treatment decisions and cancer care excellence. Synoptic reporting is a process for reporting specific data elements in a specific format in surgical and pathology reports. Since 2007, the Canadian Partnership Against Cancer has led the implementation of synoptic reporting mechanisms across multiple cancer disease sites and jurisdictions across Canada. While the implementation of synoptic reporting has been successful, its use to drive improvements in the quality of cancer care delivery has been lacking. Here we describe the 4-year, national multi-jurisdictional quality improvement initiative to catalyse the use synoptic data to drive cancer system improvements. Resources provided to the jurisdictions included operational funding, training in quality improvement methodology, national forums, expert coaches, and ad hoc monitoring and support. The program emphasized foundational concepts including data literacy, audit and feedback reports, communities of practice, and positive deviance methodology.

Introduction

The challenge

Every patient with suspected or confirmed cancer requires accurate diagnosis and staging to guide treatment planning and to make informed patient care decisions. Traditionally, pathologists and surgeons have recorded findings from investigative tests, surgical procedures, and examination of tumour specimens in dictated reports. These reports are typically free-text and characterized as highly narrative, making them prone to omission of necessary data and inconsistencies in formatting.¹ Synoptic reporting is a process for reporting specific data elements in a specific format in surgical and pathology reports. Synoptic reporting is not only a means of standardizing cancer reporting but also ensures that all reports contain all necessary data elements, thereby improving the availability and quality of information capture and exchange. In 2020, the Commission on Cancer (CoC) launched six new accreditation standards known as the CoC Operative Standards (Standards 5.3 through 5.8).^2,3 Four of these standards (Standards 5.3 through 5.6) have required cancer programs across the United States to include certain data elements in their operative reports in a synoptic format rather than the traditional narrative format.⁴ This new requirement has been endorsed by the Cancer Surgery Standards Program (CSSP) of the American College of Surgeons,^4,5 who have now implemented educational programs and processes to help comply with the synoptic operative reporting requirements.

Since 2007, the Canadian Partnership Against Cancer (known as “the Partnership”) has led the implementation of synoptic reporting mechanisms across Canada via its Cancer Guidelines Action Group’s Synoptic Reporting Tools Project.^6,7 The Partnership is a federally sponsored organization whose mandate is to accelerate action on cancer control for all Canadians. It works with partners to support uptake of the knowledge emerging from cancer research and best practices in order to optimize cancer control planning and drive improvements in quality of practice across the country. Partners include provincial and territorial cancer programs; federal organizations and agencies; national health and patient organizations; and individual experts who provide strategic cancer control insight and advice from both patient and professional perspectives. The Partnership has supported the use of electronic synoptic reporting tools for pathology and surgical data for eight cancer disease sites (breast, colon, rectal, lung, endometrial, ovarian, thyroid, and prostate), and across multiple cancer jurisdictions and organizations in Canada (Alberta, Manitoba, Ontario, Prince Edward Island, Nova Scotia, British Columbia, and Newfoundland and Labrador). It was thought that because synoptic reports capture consistent information in a standardized way and facilitates easier retrieval of information, data would be used to not only improve communication between members of the healthcare team to provide effective treatment plans but also for Quality Monitoring and Improvement (QI) initiatives at multiple levels.

Ten years later, an evaluation of cancer jurisdictions across the country showed that synoptic data-driven QI initiatives were happening in a very minimal level. Reasons for this included the difficulty clinicians found to access synoptic data, insufficient mechanisms to translate raw data into QI projects, lack of human and organizational infrastructure to facilitate QI projects, lack of comparative benchmarks and targets to monitor quality of care, compare across jurisdictions, or make national system-level improvements. To this end, the Partnership recognized an opportunity to initiate a national multi-jurisdictional QI initiative to maximize the use synoptic data to drive cancer system improvements across Canada, known as the Evidence for Surgical Synoptic Quality Improvement (ESSQUI) initiative. How does one achieve systems change through local jurisdictional impact? The ESSQUI initiative would be the first Canadian national QI initiative to integrate multiple jurisdictions and the diverse cancer surgery disciplines under a single umbrella.

The goal

The ESSQUI initiative aimed to invest in solutions and mechanisms that would catalyse the use of synoptic data reports to drive cancer surgery quality across Canada. The objectives were to use synoptic surgery and pathology data to (1) engage clinicians in self-reflection, peer-to-peer audit and feedback in practice behaviour and outcomes, (2) identify opportunities to improve the quality of surgical cancer care delivered, (3) implement QI initiatives to address those opportunities, and (4) build capacity and sustain local QI efforts in cancer surgery, across the country.

The execution

A national call for proposals was conducted,⁶ and six jurisdictions across Canada were selected with a mix of cancer disease sites (breast, colorectal, endometrial, ovary, prostate, thoracic, and thyroid cancer). From December 2017 to December 2021, the Partnership led the teams through a roadmap (Figure 1) and provided a range of supports including:

1. Flexible funding: ranged from $100,000 to $723,000 CDN per jurisdiction over the 5 years. Teams used the funding for clinical stipends, meetings, travel, supplies, digital technology, and staff salaries to support the project (project managers, analysts, and programmers).

2. National forum: Six 1-2 day national forums were held over 5 years, initially every 6 months at the beginning of the initiative. These forums invited project teams and were either in-person (prior to the COVID pandemic) or virtual and provided opportunities for education on QI processes, exchange of ideas, and updates on the progress of all the projects from each of the jurisdictional teams.

3. Training in QI process and tools: The Partnership recognized that the foundation for any initiative’s success is having the tools to carry out the work and having the knowledge through training to support continuous learning. As such, project team members were supported with an accredited QI course (https://www.ideasontario.ca/foundations-of-quality-improvement/) within the national forums, to train team members in data fluency, PDSA methodology, process optimization, root-cause diagrams, and change management skills. These investments ensure team members share common QI methodology and have access to tools for success.

4. Regular monitoring and ad hoc support: The Partnership held monthly status calls with team leads to review and address emerging barriers to progress. Teams also submitted annual reports on their progress and budget used. Status calls with the Partnership helped teams move their projects forward, discuss and troubleshoot challenges, and collect and submit project documentation. Calls helped teams feel supported throughout project implementation. Teams especially appreciated the additional support and flexibility offered by the Partnership throughout the COVID-19 pandemic.

5. Expert coaches: A group of six coaches with expertise in QI, audit and feedback,^8,9 data presentation and literacy,¹⁰ physician engagement,¹¹ Communities of Practice (CoP),^11-13 positive deviance methodology,^14-16 change management, and implementation science were provided to all teams to help with their projects on a regular and as needed basis. The expert coaches also provided one-on-one consultation to the practice champions or facilitated group discussions with the practice care team during the national forums. Many clinicians needed assistance with translating new or evolving evidence-based research into their everyday practice. Specifically, the coaches helped each team with:

• Development of QI teams: Each project was led by an implementation team that includes clinician lead(s), project managers, coordinators, and data analysts. Project meetings along with periodic status calls between the individual teams and Partnership staff have helped to share learning, identify issues, and monitor progress.

• Data management, dashboards, and audit and feedback reports: Project team analysts were guided by coaches that had expertise in turning raw data into actionable and concise information that can be easily understood by front line clinicians. Coaches provided suggestions on the format of data presentations on dashboards and the design of audit and feedback reports that were to be provided to participating surgeons and pathologists of each jurisdiction; with the goal of promoting physician awareness of their individual performance on one or more metrics, relative to their peers or a normative standard, to support improvements in care. Examples of feedback reports are shown in Figure 2.

• Development of quality measures: Project teams were assisted with the development of structure, process, or outcome measures to align with the project QI goals. Traditionally, clinicians are more interested outcome measures, or the effects of effects of healthcare on the patient or the system. However, not all outcome measures were feasible within the data collected. As such, suggestions for specific structural (measures focus on attributes and facilities of healthcare) and process measures (focus on the specific steps that lead to a particular outcome) were undertaken. These measures were not only used to develop benchmarks but also to assess variation across individual clinicians and participating institutions with a goal of standardization. In addition, they were used to identify evidence-to-practice gaps to be targets for knowledge translation and further inform QI initiatives.

Figure 1.

The 4-year roadmap for the six jurisdictions involved in the ESSQUI initiative. CoP: Communities of Practice.

Figure 2.

Example of audit and feedback report provided to clinician. (A) Provincial feedback report from the British Columbia Provincial Services Authority. (B) Feedback report documenting adverse events from the Canadian Association of Thoracic Surgeons.

As part of the initiative, all teams had to engage in regular CoP meetings every 1-3 months. CoP meetings brought clinicians together to discuss where to focus QI efforts and how to use data to assess their progress. Teams used these meetings to revise synoptic templates and/or feedback reports to improve their accuracy and clinical relevance, review anonymized individual- and site-level disease-specific data formats in a collaborative, non-punitive environment, and openly discuss ways to improve and standardize clinical care across individual clinicians and regions. Any concerns related to privacy and liability were acknowledged and addressed. In addition, to foster broad engagement, other multidisciplinary health professionals, including those in administration, nursing, and allied health, were invited to help with QI implementation. Using positive deviance methodology and peer-to-peer modelling, practice clinician “superstars” discussed best practices and ways to help others perform similarly. All teams had to go through key foundational activities that the Partnership help implement.

The team

The team from the Canadian Partnership Against Cancer provided oversight, managerial, and operational duties of the ESSQUI initiative. The chief executive officer of the Partnership was present at the national forums to re-iterate the goal of the initiative to all participating jurisdictions. The director, manager, and analyst of the diagnosis and clinical care portfolio of the Partnership were responsible for the day-to-day operations and the setup of partner meetings, national forums, continuous monitoring, and ad hoc calls. They worked with a physician lead and six expert coaches in implementing the goals and evaluation strategy. The team also comprised of a specialist in performance measurement, evaluation, and impact reporting. Collectively, the coaches were a combination of physicians and senior scientists/researchers.

Metrics

The Partnership worked collaboratively with project partners (coaches and jurisdictional teams) to design a coordinated evaluation approach for the initiative. The evaluation used a collaborative, mixed method approach, combining data from qualitative and quantitative sources. For quantitative data, we looked at performance metrics for specific QI projects towards the last 6 months of the 4-year initiative in 2021, as well as a clinician survey. Qualitative data included semi-structured interviews with 18 project team leads and 37 participants across the jurisdictional teams where they reflected on their experience, enablers, and barriers of using synoptic data reports to drive QI efforts.

There were 23 QI projects with 221 participating clinicians. 101 CoP meetings were held where clinicians from different disciplines came together to review synoptic data, discuss what the data meant, and decide where to focus their QI efforts. A survey of clinicians (response rate 79/221) demonstrated the following:

• 76% of clinicians trusted the date in the feedback reports.

• 95% of clinicians were likely to use data for continued patient care.

• 89% of clinicians were likely to use synoptic data for discussing care gaps with their peers.

• 90% of clinicians felt that they could speak openly in CoP meetings without fear of negative consequence.

• 95% of clinicians felt that the QI projects they participated in were worthwhile.

• 89% of clinicians supported one another in adopting new practices.

• 83% of clinicians saw positive impacts on how they practice cancer care.

• 77% of clinicians saw positive impacts on cancer care delivery in their organization.

Overall, 22/23 (95%) showed improvements with 15/23 (65%) achieving their proposed target benchmarks (Figure 3, Table 1):

• 18 increased the use of high-value practices in pathology assessment (e.g., faster turnaround time and better documentation), pre-surgical treatment (neoadjuvant chemotherapy and use of preoperative staging tests), or surgery (decreased positive margins, increase lymph node retrieval, increase in immediate breast reconstruction, and increase in laparoscopic technique).

• 3 improved post-operative outcomes (e.g., reducing adverse events or shortening length of stay).

• 2 reduced low benefit practices (e.g., reduce unnecessary use of deep vein thrombosis).

Figure 3.

Characteristics of each of the 6 jurisdictions involved in the ESSQUI initiative and their changes in cancer care delivery as a result of the initiative.

Table 1.

Summary of all QI projects, their aims, and target values for measurement. *Only projects with at least 1 year of measurement data were included.

Jurisdiction	Cancer site	Project aim	Baseline value	Final value	Target value	Met target?
British Columbia Provincial Health Services Authority	Breast	Increase in documentation assessment of response to neoadjuvant treatment on pathology reports by 33%	77%	99%	100%	No
British Columbia Provincial Health Services Authority	Prostate	Decrease number of cases of positive margins in organ-confined prostatectomies to <20%	24%	21%	20%	No
Alberta Health Services	Breast	Decrease retrieval of only 1 sentinel lymph node retrieved by 10%	38%	30%	34%	Yes
	Colorectal	Increase composite preoperative staging by 10%	89%	89.5%	98%	No
	Thyroid	Increase patients receiving preoperative ultrasound lymph node assessment by 10%	65%	92%	71.5%	Yes
	Thyroid	Reduce patients who receive deep vein thrombosis prophylaxis prior to thyroid surgery by 10%	20%	15%	18%	Yes
	Breast	Decrease reports with only 1 sentinel lymph node retrieved by 10%	38%	30%	34%	Yes
	Colorectal	Increase composite preoperative staging by 10%	89%	89.5%	98%	Yes
Cancer Care Manitoba	Breast	Increase immediate reconstruction for rural breast cancer patients by 5%	55%	61%	58%	Yes
		Decrease axillary clearance by 5%	6.5%	4.0%	5.8%	Yes
	Colorectal	Increase laparoscopic colon surgery by 10%	36%	40%	40%	Yes
	Ovarian	Increase perioperative antibiotic usage to 95%	67%	75%	95%	No
Health PEI	Breast	Increase breast surgical specimen orientation to 100%	91%	99%	100%	No
	Colorectal	Increase identification of lymphovascular invasion in pathology reports	17%	20%	30%	No
	Endometrial	Reduce the turnaround time for send outs of endometrial biopsy specimens to offsite to ≤48 hours	8.8 days	1.3 days	2 days	Yes
Newfoundland Eastern Health Authority	Breast	Increase neoadjuvant chemotherapy usage by 10%	4.8%	7.1%	5.3%	Yes
Canadian Association of Thoracic Surgeons	Lung	Reduce prolonged air leak after sublobar resection by 10%	6.9%	6.5%	6.2%	Yes
		Reduce prolonged air leak after lobectomy by 10%	13.2%	13.7%	11.9%	No
		Reduce atrial fibrillation after sublobar resection/lobectomy by 10%	2.0%	1.6%	1.8%	Yes
		Reduce atrial fibrillation after lobectomy by 10%	6.2%	5.2%	5.6%	Yes
		Reduce length of stay after lobectomy by 1 day	90^th percentile LOS: 9	90^th percentile LOS: 8	90^th percentile LOS: 8	Yes
	Oesophagus	Reduce anastomotic leak after oesophagectomy by 10%	14.1%	13.0%	12.7%	No
	Oesophagus	Reduce length of stay after oesophagectomy by 1 day	90^th percentile LOS: 62.4	90^th percentile LOS: 24.8	90^th percentile LOS: 61.4	Yes

Experience and learnings by jurisdictional teams

Overall, it was felt that data-driven QI in healthcare requires specific skills, time, and intentionality on the part of the clinicians; dedicated supportive personnel; broad stakeholder engagement; and an environment/means that promote continued learning and improving. Harnessing data for QI requires competency in data literacy, management, analytics, integration (with hospital emergency medical records), and delivery in such a way that is conducive to reflection, audit, and feedback by clinicians. To achieve this competency, team members felt that they benefitted not only from formal QI training to learn the language, tools, and methodology of QI but also from continued expert coaching and monitoring along the way. Additionally, teams stressed the importance of formal (dedicated personnel such as data analysts and project managers) and informal supports (clinician peers motivating each other) within the process. Teams varied in the amount of executive level support from hospital administration/leadership and provincial cancer agencies. Teams where health system leaders were engaged saw increased capacity for QI work (with support from hospital information technology in the data collection and synoptic reports and connections with other stakeholders). Senior leadership was more likely to be engaged when the QI priorities were aligned with organizational strategic priorities and/or demonstrated value (economic, political, and strategic) to the organization. Few teams also recognized that other stakeholders including nurses, allied health, and managers can also influence patient outcomes and invited them to the CoP meetings to participate in the QI projects. This resulted in greater interest and discussion and broadened support for QI work among health system stakeholders.

Sample Quotation #1: “We have been doing synoptic reporting for a decade, but not the feedback loops.”

Clinical lead (source: Project Team Focus Group)

Sample Quotation #2: “I don’t think we would have done these directed feedback reports looking at variation or specific outcomes without [the partner meetings]. We would have continued doing what we were doing… this more focused approach was completely invigorated by the Partnership.”

Team lead (source: Project Team Interview)

Sample Quotation #3: “The Partnership gave us ideas that we didn’t even know were out there. Meetings with coaches and touch-base meetings with the Partnership were helpful for moving us along. We are updating one of our feedback reports based on interactions with a coach.”

Team lead (source: Project Team Interview)

Emergence of a culture change

Within the CoP meetings, clinicians could see the utility of data for QI, discuss adverse events without fear of reprimand, identify areas for improvement, speak a common language about QI, and collaborate to meet their QI goals. Clinical champions led culture change, while senior leadership sustained it by making organizational commitments for continued use of synoptic data and audit and feedback reports. Actively engaging frontline staff, working with hospital administrators, and adoption of a clear rhythm-of-performance measurement and communication via CoP meetings were all found to be enablers to enhancing this culture. Routinely entering data about adverse events and incorporating QI interventions into routine workflow has reminded clinicians that QI is part of patient care. Clinicians became comfortable about looking at data objectively and having collaborative discussions about how to work together to improve patient care within a culture of shared responsibility. Clinicians felt that seeing and discussing data about care discrepancies has impacted surgical techniques and post-operative care. Team members reported that identifying issues, discussing solutions, and implementing even small changes had a big impact on patient care. Some teams even started to engage residents and housestaff in QI projects, teaching them the language and how to conduct QI. In addition, using data to guide patient care did spread beyond the cancer focused projects in many institutions. For example, there was more surgeon buy-in for other data-driven pathways such as enhanced recovery after surgery programs.

Sample Quotation #1: “You can feel the drive and energy. [Clinicians] are more comfortable with QI. They don’t seem so nervous about getting their data back.”

Team lead (source: Project Team Interview)

Sample Quotation #2: “I think the power is showing what our colleagues are doing in a semi-anonymized non-threatening way. I think that’s actually the best way to change behaviour.”

Participating clinician (source: Project Team Focus Group)

Hurdles

Designing effective feedback reports

Feedback reports must provide accurate and clinically meaningful information for the QI process to work. Designing effective feedback reports is an iterative process that requires a nuanced understanding of the data, user, and healthcare context. Several teams engaged additional external data scientists to help them design and implement the feedback reports. They found that it was important for the data scientists to understand the users’ needs and clinical context, as well as the data and IT systems. Clinicians also needed to be engaged to validate the data. Understanding where the raw data was coming from and participating in the methodology of data collection helped validate the data and therefore its interpretation. The data (and the data source) need to be seen as credible by clinicians, so several teams did pause their clinical QI work intermittently to identify and address data quality concerns. This validation process often led to changes in synoptic reporting templates. Some teams used manual chart audits at the beginning to ensure that automated data extraction processes could be trusted. Many teams took the time to invest in foundational work to ensure everyone agreed with what the synoptic data represented and how it related to their clinical work, although one team noticed that too many iterations of reviewing data validity led to disengagement of some clinicians. Typically, these feedback reports provided benchmark goals, comparison points (to other physicians, sites, or jurisdictions), some level of interpretation of the data, and trends in performance. Suggestions were also made on how to ensure data alignment with QI strategies, promotion of clinician ownership of data, and emphasis of presenting data that clinicians have control over. To automate data extraction from hospital electronic medical records, teams needed access to specialized information technology support, which needed organizational buy-in. Software used to produce the feedback reports included Synoptec, Microsoft SQL, TSQIC and REDCap, and RStudio.

Sample Quotation #1: “When we started getting the feedback and looking at the data, some of it didn’t actually make sense. We had to go back and look at how we were pulling it out and classifying it. It required some tweaking and reorganization. We had gotten some interesting discussion within the group about, ‘Do we do this? And if we’re not, how can we capture the data to reflect what is truly happening?’

Clinical lead (source: Project Team Focus Group)

Sample Quotation #2: “There’s been various iterations of [synoptic reporting] systems. There’s been burnout and we’ve lost people through that.”

Team lead (source: Project Team Focus Group)

Getting busy clinicians into the same room to discuss QI

As busy clinicians have many competing demands on their time, it can be hard to bring them together in the same room. Several strategies were used to address this, including emphasizing that the process was not about data but about improving care delivery and patient outcomes. In order to facilitate attendance, many teams leveraged pre-existing meeting slots (multidisciplinary tumour boards, morbidity, and mortality rounds) or national meetings and forums for clinicians. During the initiative, teams saw that virtual meetings improved accessibility for busy or remote clinicians, but in-person interactions had the benefit or strengthening relationships between clinicians and other stakeholders and helped establish trust. Many teams provided physicians with Continuing Medical Education (CME) or Continuing Professional Development (CPD) credits for CoP attendance or reviewing feedback reports. Getting buy-in from leadership made engagement of clinicians easier, improving both participation levels and outcomes, especially from clinicians who were reluctant to participate. Additionally, it was important to have enthusiastic clinician champion(s). Seeing their peers engaged and witnessing even small improvements in patient care encouraged other clinicians to participate.

Clinician incentives and payment models

While the emphasis on QI projects was to improve patient care, many clinicians felt that funding and remuneration models that incentivized QI work would be needed for sustainability. Fee-for-service clinicians’ function was not compensated to participate in meetings or undertake QI work. In contrast, salaried clinicians had a more collectivist attitude and felt incentivized to participate in QI projects. Even with CPD or CME accreditation for CoP attendance or reviewing feedback reports, many teams felt that it was difficult to sustain a clinical champion to lead QI projects without financial remuneration. Clinical champions are often clinical leaders that are also have multiple other responsibilities such as managing the department and clinical services and would benefit from administrative support and remuneration such that they can reduce their workload elsewhere.

“I think [clinicians] were all somewhat interested, but nobody was the leader. Nobody was saying, ‘I’m the champion of this and we need to get it done.’ In their defense, they don’t get administrative time or support to lead projects.”

Team lead (source: Project Team Focus Group)

Pandemic disruption

Although QI projects continued in all jurisdictions during COVID-19 pandemic, although some momentum was lost as information technology staff, clinicians, and project team members were intermittently diverted to pandemic-related work. These effects were felt more acutely in smaller jurisdictions. CoP meetings were converted to virtual events, and data analyses were delayed in some jurisdictions. The COVID-19 pandemic reduced the number of cancer surgeries in most jurisdictions, which affected QI project implementation and lowered the number of surgeries included in the final measure. In addition, the restriction of elective surgeries to those most critical altered the volume and characteristics of patients undergoing surgery, which may explain a failure of achieving proposed targets.

Where to start

For teams looking to introduce synoptic data-driven QI, it is important to secure resources for success early on in the initiative; resources such as leadership engagement and supportive personnel (project managers and data scientists). Team members would benefit from gaining skills in QI methodology, data management, and delivery in such a way that is conducive to reflection, audit, and feedback by clinicians. CoP meetings can be a good environment to promote the process of collective learning and shared accountability. Teams should start with small projects to learn from initially and to gain momentum and confidence after “quick wins.” The ultimate goal of QI is for it to be a continuously embedded in workflows and an integral part of care delivery.

For organizations looking to support multi-institutional synoptic data-driven QI efforts, it is important to recognize that institutions have different starting points in terms of their synoptic reporting, skills, and capacity for QI, with varied levels of information technology support, organizational commitment and culture, as well as leadership involvement. A “readiness assessment” can be undertaken examining each organization’s readiness for change overall, its current infrastructure, how the mission and vision tie into its goal for QI, the revenue streams, how decisions are made, and supportive resources (such as information technology). A multifaceted approach with various formats (funding, educational workshops, coaches, and monitoring) and intensity allows tailoring for each institution to avoid a “one size fits all” approach. It is also important to have clear expectations and goals for each team. Core elements and activities can be defined early in the process and initial status calls should be used to clarify expectations from supported teams. Engaging teams with coaches at the beginning of the initiative allows for help with anticipated and unanticipated needs to keep the momentum going. Finally, while learning is inherent within a CoP group, profound insights can be also be insights that can also be gleaned across diverse CoP groups, spanning various subject matters and fields of practice. The unique opportunity of a multi-jurisdictional initiative under one umbrella demonstrated that inter-CoP group learning is also valuable for shared processes, such as methodologies for crafting feedback reports and engaging clinicians, transcending disciplinary boundaries, and enriching collective knowledge.

Next steps

While the COVID-19 pandemic remains a threat and continues to demand attention, the ESSQUI initiative has come to an end and efforts have been made by the Partnership along the way to help teams plan for sustainability of their QI culture and successes. Many teams have plans to distribute feedback reports or present data on a regular basis (quarterly, twice a year, or annually), continue to work on refining the report templates, and attract more clinicians. Some teams have attracted other cancer disease site teams interested in participating in synoptic data collection and their own CoP. Two teams have secured funding to continue QI work (from their provincial health system or through private-sector partnerships). One of these teams aims to build an integrated data warehouse with linked data from synoptic templates, the provincial cancer registry, and the National Surgical Quality Improvement Program (NSQIP), which will provide more robust data for QI. The other team plans to build a permanent national database that they can use to collect data for clinical trials and publications. Whereas the last decade has marked a transition from paper to electronic health records, the next decade will see an evolution of how clinicians generate, share, and use high-quality clinical data to improve the care they deliver to their patients. By leveraging the benefits synoptic reporting, clinicians can realize an ideal “future state” in which surgeons have an efficient mechanism for documentation that allows all the benefits of synoptic operative reports for fellow clinicians, quality improvement teams, and healthcare researchers.

Takeaways

Passive presentation of synoptic data does not translate into its use to improve care delivery

Clinicians need mechanisms, skills, and solutions to be able to capture the relevant data that can be meaningfully interpreted in a way that results in self-reflection, peer-peer learning, and practice change. Clinicians require time, effort, and intentionality to use synoptic data for QI, which can be a challenge in a healthcare context where there are so many competing priorities.

Use a comprehensive, multifaceted approach to support teams in synoptic data-driven QI work. The following elements helped our national led initiative:

• Operational funding for the teams.

• National and local CoP meetings.

• Formal QI training for clinicians.

• Support from expert QI coaches.

• Regular status update meetings, calls, and support to navigate ongoing challenges/barriers.

Have clear expectations and goals

Ensure teams know from the outset what they are collectively working toward (positive QI culture to improve patient care) and what is expected of them. Define core elements and activities early in the process and use initial status calls early to clarify expectations.

Understand each team’s readiness for QI

Teams begin with different capacities for QI and have different levels of information technology support, organizational and leadership engagement, and dedicated staff involvement. Understanding each team’s context and starting point is important for tailoring timelines, expectations, and supports.

Leverage the expertise of QI coaches and advisors

Coaches and advisors can provide training to all teams as well as ad hoc support to individual teams as needed (identified through status calls). Suggestions for success:

• Assign a small core group of coaches from the beginning of the large scale initiative.

• Watch for unanticipated needs that emerge (selecting data/reporting platforms) and source an advisor or coach with expertise in those areas.

• Try different ways to connect teams with coaches (coaches holding “office hours” at in-person events and inviting coaches to status calls).

Help teams plan for sustainability of continuing synoptic data-driven QI work once national initiative supports end

Leveraging (a) the culture that has been created, where QI is integrated into daily practices and decision-making processes and (b) existing resources and partnerships developed during this project, including the interdisciplinary team and data analytics infrastructure, can sustain QI efforts in the face of evolving organizational challenges and priorities.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Partenariat Canadien Contre Le Cancer.

Ethical approval

Institutional Review Board approval was not required.

ORCID iD

Angel Arnaout

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