Successful healthcare systems simultaneously improve the patient experience of care, advance the health of populations and reduce the per capita costs of healthcare. Despite the growing burden of cardiovascular disease on Canadians and healthcare budgets, Canada lacks a coherent strategy to provide ongoing measurement and management of the quality and value of cardiovascular care. The CCS Quality Project is working to address this important gap.
Driven by the tremendous support and dedication of its members, the Quality Project is an initiative working to bring together key stakeholders for national reporting on cardiovascular care towards evidence-based practice change. Through the Quality Project, the CCS has developed a Data Dictionary and Quality Indicator E-Catalogue to improve standardization and evaluation of cardiovascular care across Canada.
The CCS Quality Project calculates and reports on quality of care nationally through clinician-identified quality indicators. Quality indicators (QIs) are increasingly being used in many health systems in Canada and internationally, to improve accountability and to provide quantitative measures of value.
Identifying optimal cardiovascular care practices and quantifying the quality of care through adherence to certain recognized benchmarks can serve to drive significant improvements in terms of quality of care, and ensure a sustainable health system.
Through funding from the Public Health Agency of Canada (PHAC) (2010-2016), the CCS completed and published six sets of pan-Canadian cardiovascular care quality indicators. Notably, they have been voluntarily adopted by some provinces, with select indicators also now supported at a national level through the Canadian Institute for Health Information.
Through ongoing advocacy efforts, the CCS is seeking to secure government funding and support for the implementation of a sustainable national measurement and quality reporting system.
Development of CCS Quality Indicators
The Canadian Heart Health Strategy and Action Plan recommended that the CCS lead the development of pan-Canadian data definitions and QIs for evaluating cardiovascular care in Canada. In developing its cardiovascular QIs, the CCS followed a rigorous, best practice methodology that measures overall quality based on indicators related to optimal structure, process and outcomes, such as:
• Type and quality of resources used for programs and services (e.g. procedural wait times);
• Activities undertaken in patient care (i.e. evidence-based treatment); and
• Effects of care on patient outcomes (i.e. mortality rate and quality of life)
The resulting methodology of the CCS Best Practices for Developing Cardiovascular Quality Indicators identifies three main phases of QI development.
Phase 1: Plan and Organize the QI Development Initiative
This phase involves selecting the focus area for the indicators, defining the intended use, users and target populations for the QIs, and selecting a QI working group that includes relevant stakeholders in the development process
Phase 2: Develop and Select the QIs
QIs are formulated based on the highest level of available scientific evidence and knowledge. The proposed set of indicators is selected by applying formal rating criteria and a group consensus strategy.
Phase 3: Operationalize the QIs
Operationalizing QIs encompasses four key steps: Develop final technical specifications for the QIs for use in their application; conduct indicator review and testing; develop an indicator updating process; obtain CCS approval and endorsement and implement a knowledge translation strategy.
CCS National Quality Reports are intended to help hospitals engage in quality improvement strategies; enable provinces to monitor and improve quality of care in a consistent, evidence-based way; and build patient confidence in the cardiovascular health system.
In 2016, the CCS released its ground-breaking National Quality Report: TAVI, the first study of its kind to describe the quality of Transcatheter Aortic Valve Implantation (TAVI) at the national level, and demonstrate the feasibility and importance of a collaborative, pan-Canadian effort to improve patient care.
Recognizing the historical difficulties in pooling patient-level data across jurisdictions, the CCS TAVI Quality Working Group developed a set of nine quality indicators for TAVI, and has identified the need to further evaluate the drivers of hospital readmission and interventions, to mitigate risk for patients.
In developing the report, a number of data quality issues were identified – specifically, that many sites did not collect key quality indicators; inconsistent definitions were utilized for several variables; and substantial data was missing for some of the structural and process indicators. These issues indicate critical regional variation in care across the country.
Our Partners and Stakeholders
All programs, policies and quality improvement initiatives are clinician-driven, and led by our Quality Project Steering Committee and associated Expert Working Groups, which are engaged with representatives from a number of national societies and organizations, including:
• Alberta Health Services
• Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH)
• Canadian Association of Cardiovascular Prevention and Rehabilitation (CACPR)
• Canadian Association of Interventional Cardiology (CAIC)
• Cardiac Care Network of Ontario
• Canadian Heart Rhythm Society (CHRS)
• Canadian Institute for Health Information (CIHI)
• Canadian Society of Cardiac Surgeons (CSCS)
• Cardiac Services BC
• Cardiovascular Health Nova Scotia
• Health Canada
• Heart and Stroke Foundation
• Institute for Clinical Evaluative Sciences (ICES)
• L’institut national d’excellence en santé et en services sociaux (INESSS)
• Public Health Agency of Canada (PHAC)
• Statistics Canada
• National Cardiovascular Data Registry (NCDR)
• National Institute for Cardiovascular Outcome Research (NICOR)
Expert Working Groups
Following the direction of the Quality Project Steering Committee, CCS Quality Indicators Working Groups oversee the development and implementation of reports and measures in their specialized area of cardiovascular care; organize and lead national efforts in actionable cardiovascular care quality enhancements; and lead education in quality process management in cardiovascular care through Continuing Professional Development programs.
Below is a list of all active CCS Working Groups, and their associated chairs/vice-chairs:
Heart Failure (HF) Working Group
Chair: Robert McKelvie, Western University; Vice-Chair: George Heckman, University of Waterloo
Percutaneous Coronary Intervention (PCI) Working Group
Chair: Ata ur Rehman Quraishi, Dalhousie University; Vice-Chair: Robert Welsh, University of Alberta
Cardiac Surgery (CS) Working Group
Chair: James Abel, Providence Health Care, St. Paul’s Hospital; Vice-Chair: Ansar Hassan, New Brunswick Heart Centre
Atrial Fibrillation (AFIB) Working Group
Chair: Jafna Cox, Cardiovascular Health Nova Scotia; Vice-Chair: D. George Wyse, Libin Cardiovascular Institute of Alberta and University of Calgary
Cardiac Rehab (CR) Working Group
Chair: Sherry Grace, York University and University Health Network; Vice-Chair: Neville Suskin, London Health Sciences Centre
Transcatheter Aortic Valve Implantation (TAVI) Working Group
Chair: Anita Asgar, Montreal Heart Institute
Data Definitions and Quality Indicators
Atrial Fibrillation Atrial Fibrillation/Flutter Data Elements and Definitions Data Elements and Definitions Atrial Fibrillation Quality Indicators for Atrial Fibrillation/Flutter Quality Indicators CAD/ACS Acute Coronary Syndrome Data Elements and Definitions Data Elements and Definitions CAD/ACS Coronary Angiography/Revascularization Data Elements and Definitions Data Elements and Definitions Cardiovascular/Heart Disease Quality Indicators for Transcatheter Aortic Valve Implantation Quality Indicators Cardiovascular/Heart Disease Transcatheter Aortic Valve Implantation Data Elements and Definitions (in development) Data Elements and Definitions Cardiovascular/Heart Disease Cardiac Surgery Data Elements and Definitions (in development) Data Elements and Definitions Cardiovascular/Heart Disease Quality Indicators for Cardiac Surgery Quality Indicators Cardiovascular/Heart Disease Percutaneous Coronary Intervention Data Elements and Definitions (in development) Data Elements and Definitions Cardiovascular/Heart Disease Quality Indicators for Percutaneous Coronary Intervention Quality Indicators Miscellaneous Core Elements and Demographics Data Elements and Definitions Data Elements and Definitions Heart Failure Heart Failure Data Elements and Definitions Data Elements and Definitions Heart Failure Quality Indicators for Heart Failure Quality Indicators Rehabilitation Cardiac Rehabilitation and Secondary Prevention Data Elements and Definitions (in development) Data Elements and Definitions Rehabilitation Quality Indicators for Cardiac Rehabilitation and Secondary Prevention Quality Indicators
Cardiovascular/Heart Disease Cardiac Care Quality Indicators Report Quality Report