Building a Quality Plan for a Blood and Marrow Transplant Program: Quality Framework and Indicator Development

Introduction: Quality of care is a priority among patients, providers, and accreditors in blood and marrow transplantation (BMT), and has resulted in the need to develop quality management systems.  BMT programs can apply quality frameworks such as the Model for Improvement, which guide programs to set quality goals, and to develop quality measurement and reporting strategies to ensure progress toward those goals. We report on the systematic, end-user-informed development of a set of quality indicators, to be monitored and reported on in the context of a quality framework at the Princess Margaret Cancer Centre BMT program.

Methods: This involved three phases: 1) Evidence Review (database and grey literature search for quality indicators used in BMT); 2) Modified Delphi process, in which identified indicator concepts were discussed to generate a list of broad clinical categories, then prioritized via a staff survey; and 3) investigation of the published literature for data standards for these indicators.

Results: Evidence review generated 214 indicators, which were categorized as Clinical (n=139), Management-level (n=40), or Hospital-wide (n=35). Only the Clinical indicators were deemed meaningful for staff prioritization. By merging like concepts, the 139 indicators were reduced to 22 for inclusion in the prioritization exercise. Prioritization was achieved through an online survey sent to 152 clinical BMT staff. Respondents ranked indicators based on their perceived clinical value as quality measures. Respondents ranked “Survival” and “Treatment-related mortality” most frequently in their top 3 choices. However, a low survey response rate (35 of 152, or 23%) suggested a lack of staff awareness of quality measurement, and a need to coordinate staff education and creation of a quality improvement culture to ensure success of such initiatives in the future. Next, Management-level indicators were pared down through discussion and consensus, generating 12 indicators to be developed for future reporting. The Hospital-wide indicators, which were non-BMT-specific but could be adapted for use in BMT quality measurement, were mapped to corresponding Management-level and Clinical indicators. Their existing measurement structures may be useful in developing measurement strategies for our BMT-specific quality indicators. Finally, working toward eventual implementation, all indicators were assessed for any data standards mentioned in the literature. Our findings revealed a paucity of published data standards for BMT quality indicators, highlighting a need for more research in this field.

Conclusions:  Quality indicator development in BMT can be undertaken systematically, but requires a concerted effort from staff engagement to informatics infrastructure. Currently, this area is challenged by a lack of published development standards and implementation studies.