key: cord-0976530-0dzzpbxy authors: Lorenz, K.A.; Mickelsen, J.; Vallath, N.; Bhatnagar, S.; Spruyt, O.; Rabow, M.; Agar, M.; Dy, S.M.; Anderson, K.; Deodhar, J.; Digamurti, L.; Palat, G.; Rayala, S.; Sunilkumar, M.M.; Viswanath, V.; Warrier, J.J.; Gosh-Laskar, S.; Harman, S.M.; Giannitrapani, K.G.; Satija, A.; DeNatale, M. title: The Palliative Care – Promoting Assessment and Improvement of the Cancer Experience (PC-PAICE) Project: A Multi-Site International Quality Improvement Collaborative date: 2020-08-25 journal: J Pain Symptom Manage DOI: 10.1016/j.jpainsymman.2020.08.025 sha: 03362c7380f025ee68564bdba9ce80010eeb737a doc_id: 976530 cord_uid: 0dzzpbxy Mentors at seven United States and Australian academic institutions partnered with seven leading Indian academic palliative care and cancer centers to undertake a program combining remote and in-person mentorship, didactic instruction, and project-based learning in quality improvement. From its inception in 2017 to 2020, the Promoting Assessment and Improvement of the Cancer Experience (PC-PAICE) Program conducted three cohorts for capacity building of 22 Indian palliative care and cancer programs. Indian leadership established a Mumbai training hub in 2019 with philanthropic support, Quality Improvement Hub (e.g., QI-Hub) India. In 2020 the project which now focuses on both palliative care and cancer teams as EQuIP-India. EQuIP now leads ongoing Indian national collaboratives and training in quality improvement and is integrated into India’s National Cancer Grid. PC-PAICE demonstrates a feasible model of international collaboration and capacity building in palliative care and cancer quality improvement. It is one of several networked, blended learning approaches with potential for rapid scaling of evidence-based practices. Chronic disease has become the most rapidly growing health scourge, and an important underlying risk for aging adults worldwide, as demonstrated more recently by the impact of the COVD-19 pandemic. Non-communicable disease account for most of the global disease burden with the number of persons affected by non-communicable diseases continuing to grow. Chronic illnesses particularly impact older adults, causing extensive human suffering and burdening health systems. Globally in 2015, the Lancet Commission found that about 61 million person were living with and 25 million persons died with conditions for which palliative care may be helpful, and that palliative care can relieve suffering at a generally acceptable social cost. (1) India faces one of the largest global challenges in responding to these unmet needs for palliative services and supports for older adults. With s population of nearly 1.5 billion, 103.8 million are currently over 65 years of age, of whom 8% are bed or housebound. India has more older adults than any country other than China, a total that is projected to grow to over 300 million in 2050 (2-4) Population aging will be accompanied by more Indians living with cancer and other serious conditions. By 2020, Indian population-based cancer registries project an increase of about 400,000 new cases to nearly 1.7 million incident cancer cases annually (5) The COVID-19 outbreak demonstrates high mortality in age and disease risk groups, underscoring the urgency of meeting supportive needs in older, sicker persons (6) The human toll on older Indian adults and families is substantial (7). Among middle class Indians, healthcare use at the end of life appears to be increasing, and is often associated with financial hardship. Despite increasing national wealth, only Nigeria has a greater number of citizens than India living on less than $1.25 / day, the global standard for extreme poverty. (8) Nearly 20% of all Indian suicides are associated with serious illness (9) Opioid availability remains very constrained despite reforms to India's J o u r n a l P r e -p r o o f major opioid control law in 2014. (10) In addition to pain management, this raises concern about currently available palliation for dyspnea. The Indian health system relies on both public and private payment, and services for aging adults, including palliative care, are in short supply in both private and government sectors. Access to healthcare is exacerbated by barriers to accessing free government care; out-of-pocket costs comprises nearly 70% of Indian healthcare spending. (3) Palliative care services are concentrated in population centers, and less than 1% of India's population has geographic access to palliative care. (11, 12) Nearly two-thirds of palliative care services are located in the state of Kerala where only 3% of India's population resides. (13) However, in India, there is increasing attention to the need for palliative care, particularly among cancer patients. (4) India recently established a National Cancer Grid in 2012 to encourage standards for uniform service delivery and promote high quality oncology care. (14) A recent national universal health insurance scheme (i.e., "Ayushman Bharat") promises modest support for the provision of palliative care. This report describes the development and conduct of PC-PAICE in the context of cohort 1, and progress and changes instituted for subsequent cohorts. The Palliative Care -Promoting Assessment and Improvement of the Cancer Experience (PC-PAICE) The PC-PAICE Project originated following discussion with palliative care leaders gathered in Coimbatore, India, for the 2017 Indian Palliative Care Conference (IAPCON 2017). We developed PC-J o u r n a l P r e -p r o o f PAICE to foster collaborative learning and quality improvement (QI) education among an initial cohort of seven leading Indian palliative care programs based in major academic and community centers. Each Indian team partnered with one or more coaches at peer institutions with palliative care cancer services in the United States or Australia. (Table 1: There were specific criteria for PC-PAICE participation at the outset. Each Indian QI team identified a clinical leader and an organizational partner who could facilitate the time, resources, and other contextual factors necessary to undertake a QI project and act as local champions. Both the Indian teams and international coaches participated monthly in an hour long, large group call for didactic instruction and problem solving. Indian sites and coaches scheduled at least one monthly individualized session for additional learning and problem solving. Almost all teams adhered to this schedule, and some teams met more frequently. Indian teams represented institutions with established palliative care clinical services and academics. Indian team leaders of this pilot QI program were pioneers in the field of palliative care in India. PC-PAICE coaches included multidisciplinary palliative care physicians, nurses, and a pharmacist who had leadership roles in palliative care programs and experience working with cancer patients in academic J o u r n a l P r e -p r o o f cancer centers in the United States and Australia. All coaches were knowledgeable about QI methods and had led QI at local, regional, or national levels. The coaches contributed diverse perspectives on working successfully in complex healthcare organizations. Many coaches had conducted research in or taught quality measurement and QI methods, and this abetted our approach of melding QI with evidence where possible. The Approach, Resources, and Curriculum of PC-PAICE Our educational approach was rooted in regular team interactions and structured to engage managers, frontline clinicians, and staff with relevant content to build sustainable skills in QI. We reviewed project progress using a structured cadence, paralleling the didactic content and instruction used in general problem-solving methods (16) Although there is mixed evidence supporting the collaborative model of QI (17) , the fundamental characteristics of PC-PAICE including its team structure, didactic elements, user-driven access to resources, and practical, project focus are aligned broadly with adult learning principles and the lessons learned from collaboratives in diverse international contexts. (18) PC-PAICE expanded on general collaborative principles by embracing the concept of evidence-based quality improvement (EBQI). Whereas typical effectiveness studies focus on intervention and ignore context, and many QI approaches (e.g., PDSA) emphasize naturalistic methods, EBQI engages evidence along the steps of a QI process. EBQI has been used to spread evidence-based practices for depression management, pressure ulcer reduction, and to improve antipsychotic prescribing. (19) (20) (21) Limited resources prevented fully operationalizing an EBQI approach in our initial cohort; however, we emphasized context, stakeholder dialogue in team building and engaged clinician researchers as coaches. Our communication platform for PC-PAICE allowed flexible access to resources, facilitated team and group communications, and could be coordinated across the diverse time zones of participants. All J o u r n a l P r e -p r o o f participants were given free access to file-sharing accounts at the outset. This allowed uploading and sharing core documents, agendas, meeting notes, supplementary articles and instructional materials. We used a videoconference line for large group team meetings. This allowed the use of slides and screen sharing for didactics. Many team members used the video feature which we perceived to strengthen interpersonal interactions. To track and manage QI projects in PC-PAICE, we used the A3 Template derived from industrial LEAN management. The term "A3" generally connotes the paper size (11.7" x 16.5") and is used as a shorthand term for a problem solving guide that typically includes the sections of Project Title, Problem Statement, Background, Target State (SMART Goal), Current State Identify Target / Actual / Gap, Analysis, Key Drivers, Interventions / Countermeasures, and Sustain Plan. In a broad sense, the A3 template aligned with both the curriculum and the project goals stressed over the course of PC-PAICE. Our project goal over 6 months was for each team to complete one mentored QI cycle in the course of their didactic instruction. To mitigate distance challenges, we included a mid-course, all day workshop which was held for cohort 1 in New Delhi during the national palliative care (IAPCON2018) meeting. The workshop reinforced relationships between coaches and QI sites. We reviewed lessons learned, focused on problems solving, offered one-on-one mentorship from the leadership team, and emphasized the transition between understanding root causes and intervention. We also pruned the formal curriculum and meetings to the most essential content, adapted curriculum to emerging learner needs, and minimized the frequency and inconvenience of meetings to early or late in the workday which the project's vast geographic scale required. (Table 2 : PC-PAICE Curriculum Overview) Conducting an International Quality Improvement Collaborative J o u r n a l P r e -p r o o f The QI curriculum and tools were taught alongside projects. The timing of the content, offered in largegroup didactics and individual team coaching sessions, was based on the sequential project challenges teams would be facing. During the first few months, teams were taught the importance of data collection and scoping their problem realistically. We emphasized a common QI language by using the A3 structure for problem solving. We taught standard tools such as key driver diagrams, run chart templates, and cause and effect diagrams to facilitate quick understanding of projects' current states and challenges. During final months, topics such as intervention reliability and sustain plans were discussed to assist teams in overcoming the common vulnerabilities of QI work such as interventions ceasing when team members move on (20) . With regard to our large group monthly calls, following introductions and roll call, we prioritized team case presentation and problem solving for 1-2 teams during each call. We followed this with compressed didactic instruction using slides that were archived and remotely accessible to allow PC-PAICE participants (including those who missed specific calls) to subsequently view or review the materials. We With regard to rating the contribution of specific resources used throughout the collaborative to facilitate learning, the in-person workshop and monthly large group and individual team meetings were regarded as essential by more than half of respondents; whereas, access to Stanford Box resources and RITE videos J o u r n a l P r e -p r o o f on YouTube were essential to a minority of respondents. Highly regarded elements of the curriculum all reflected modes of didactic instruction and problem-solving, whereas, less regarded resources reflected those that required self-directed effort. Notably, current versions of RITE videos that are archived on YouTube use examples that are most applicable to Western learners (e.g., solving a QI problem at a bakery), but are culturally less relevant to India. (Table 3 : Participant Ratings of PC-PAICE Elements "Essential" to Learning) PC-PAICE has demonstrated the feasibility of remotely conducting an interventional educational collaborative to support international learning and experience with quality improvement in palliative care. Results suggested that we were also successful in fostering improvement in access to and the quality of palliative care in major Indian cancer and palliative care centers. . Our most important goal was fostering organizational capability for improvement, and participants reported a generally positive learning experience with many of the aspects and curricular elements of PC-PAICE. Several Indian team leaders from PC-PAICE cohort have continued to participate as volunteer QI coaches for cohorts 2 and 3. Australian coaching sites. Projects focused on topics which hold international relevance, such as promoting earlier palliative referral, more effective allocation of scarce palliative care team resources, and improving documentation and coordination of goals of care communication (see also At the end of the first cohort, we received a grant from the Conquer Cancer Foundation (PI, Dr. Sushma Bhatnagar, All India Institute of Medical Sciences) that allowed us to collect approximately 45 hours of interviews to evaluate the PC-PAICE program in depth, and also to evaluate the context for implementing palliative care and performance improvements in India. We interviewed PC-PAICE participants, as well as clinical and organizational team members and leaders at the 7 geographically diverse sites that participated in cohort 1. This third cohort broadened its focus and includes projects from both oncology and palliative care. Although the EQuIP-India program remains grounded in the Stanford QI curriculum, with additional, culture-nuanced structure, processes, contents and evaluations, EQuiP-India is rapidly and fully transitioning into a program developing and led from Mumbai, India, and has developed its in-house capacity for mentoring. The QI Hub has its own web-page on the NCG main site and the EQuIP program uses the E-learning portal of the NCG to support the projects of participating teams. Each QI Project team has a national QI mentor paired with an international mentor to strengthen coaching capacity. The Project ECHO-India platform supports all-hands educational meetings. The third cohort graduated in June 2020. Change is a constant in healthcare, and this is particularly true in India where the National Cancer Grid was established in 2012, and a massive expansion of national health insurance is currently underway. Capacity building in quality improvement is particularly important in this context, contributing The PC-PAICE collaborative shows that through applying the most practical aspects of improvement science, coupled with contextual factors that influence change such as mentorship, stakeholder engagement, and empowered teams, learning and improvement can be accomplished in complex J o u r n a l P r e -p r o o f *all sessions were remote, and an all day workshop at IAPCON is held at approximately month 2-3 to reinforce and expand on early learnings, foster team building, and engage in problem solving. 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A systematic review The Impact of Project ECHO on Participant and Patient Outcomes: A Systematic Review EQuIP is supported by a grant from the Tata Trusts. The Tata Trusts had no role in the writing or submission of this publication.