Global tools for metrics and performance advance quality improvement efforts worldwide

Beginnings can be daunting. From a writer facing a blank page to a painter contemplating an empty canvas, taking the first step can be challenging. When the stakes for making a change are much higher, such as for hospitals caring for children with cancer around the world who seek to improve themselves, taking that first step can be stressful and at times confusing. The St. Jude Global Metrics and Performance Transversal program offers help to these hospitals, especially those with limited resources. With a suite of tools designed to assess current capability, hospitals can better determine where to start their quality improvement journey.

“We’re committed to helping reduce the survival gap between children in highly resourced countries and those in resource-limited countries,” said Paola Friedrich, MD, MPH, St. Jude Global Metrics and Performance Unit director. “Around the globe, factors unrelated to the biology of the disease drive a large part of the survival gap; we help institutions understand and categorize these factors so they can define or redefine the steps they want to take towards meaningful action to address them in a targeted way.”

“What we do is develop tools that help institutions assess how they are providing care to patients and how they could improve care delivery,” adds Miriam Gonzalez-Guzman, MD, MSc, St. Jude Metrics and Performance Clinical Research Scientist II. “Then, we help them address those identified challenges using robust quality improvement and implementation science methods.”

PrOFILE gives hospitals a place to start their quality improvement efforts

The program’s flagship tool is the Pediatric Oncology Facility Integrated Local Evaluation (PrOFILE). PrOFILE is a 600-question, 360-degree assessment of an institution that includes voices beyond just physicians, such as nurses, radiologists, nutritionists and other allied health staff. During and after the process of completing PrOFILE, the Metrics and Performance Unit guides hospitals on how to interpret the collected data and plan changes.

“PrOFILE helps health care teams and institutions start a quality improvement journey,” said Melissa Vickers, Metrics and Performance program coordinator, who manages the Full Version of PrOFILE. “You have to know where you are to know where you are going. PrOFILE provides ready-made documentation of what could be improved and detailed plans to define an institution’s unique improvement goals.”

Collaborators who use PrOFILE often identify very different needs. One institution may need to focus on nursing education, another may need to engage with primary care clinics in their catchment area to improve early diagnosis and a third may need to strengthen their ability to use data for improvement. The St. Jude program uses PrOFILE as a starting place to find these needs, then offers help to hospitals planning targeted actions addressing their specific problems. While the Full Version of PrOFILE often gives detailed insights into potential improvement opportunities within an institution, it takes a significant amount of time and engagement and does not provide a real-time comparison to other hospitals, creating a need for an alternative.

Abbreviated PrOFILE provides an accessible alternative guide to quality improvement

“Unlike Full PrOFILE, the Abbreviated Version is a look across institutions rather than within them,” explained Alyana Alvarez, St. Jude Global Metrics and Performance program coordinator, who manages PrOFILE’s Abbreviated Version. “At least three institutions from a country need to participate, and they all work and produce an improvement strategy together.”

As indicated by its name, the Abbreviated Version of PrOFILE is a more concise version of its counterpart, designed to maximize impact while minimizing administrative burden. Instead of requiring a large team of up to 30 people, this version only requires one to three dedicated team members per institution and has half the questions. The tradeoff is the depth of analysis and less intensive support from the St. Jude Global Metrics team, which meets weekly with the teams participating in the Full Version of PrOFILE.

Regardless of the PrOFILE type, each tool is accompanied by a Post-PrOFILE journey, which Alvarez also supports. Post-PrOFILE is an effort to sustain the momentum generated during the PrOFILE process. The Metrics and Performance Unit coaches and guides participants through quality improvement education focused on a single project or area of opportunity identified during the PrOFILE journey and connects participants with relevant peers.

Global Packages co-design solutions to improve health care worldwide

In addition to PrOFILE, the Metrics and Performance Unit created Global Packages, a suite of topic-specific, evidence-based protocols and interventions that address commonly found improvement opportunities shared by their collaborators in resource-limited countries.

“Global Packages are meant to close the gap between what the science shows is best for patients and what happens in actual practice,” said Yawen Zheng, Metrics and Performance, who coordinates the Global Packages projects. “We use implementation science and model-for-improvement methodology to co-design interventions that address common improvement opportunities encountered by our collaborators in these countries, finding how to pilot evidence-based practices to identify what works globally, what needs local adaptation and how to meet Alliance members’ needs while preserving the core of the Package.”

The program has already begun implementing several Packages aimed at improving care for children with cancer by targeting these shared issues. In tandem with the Palliative Care Transversal Program, they have deployed the Global Comfort Promise, an effort to reduce the number and pain of needlesticks children with cancer experience to increase adherence to care, and they are piloting HEAL, a package to improve end-of-life care for children with cancer. 

When a child with cancer develops a fever during active treatment, receiving antibiotics within an hour of reaching the emergency room can prevent sepsis and save lives. Therefore, the Metric and Performance team co-created the Golden Hour package with the Mexico Regional Program and the Institute for Healthcare Improvement (IHI), with input from the Infectious Diseases Transversal Program. The package helps institutions build the capacity to identify patients at risk of or presenting with active infections and treat them rapidly. 

In addition to the packages in deployment, the program is beginning to create more, such as one tackling how to best handle mucositis, a major side effect of some pediatric cancer treatments, which could help increase therapy adherence and reduce patient pain, a package to improve early referral and diagnostic timeliness, and a package addressing treatment continuity. 

Partnering with other global health improvement experts

To supplement the Metrics and Performance team’s expertise in quality improvement science, they ally with external experts through the St. Jude Global and Institute for Healthcare Improvement (SJG–IHI) Strategic Partnership. IHI is a nonprofit dedicated to applying evidence-based quality improvement to health care settings around the world. IHI’s general expertise in applying improvement methods to hospitals in diverse, real-world settings, paired with the St. Jude–specific expertise in pediatric cancer treatment, creates a powerful alliance to improve patient care.

“With IHI, we have been co-designing the Global Quality Improvement Collaborative, focusing on survival, quality of care and experience of care for children being treated for cancer,” Gonzalez-Guzman said. “Together, we are hoping our combined expertise can accelerate progress in improving pediatric survival rates to meet the Global Initiative for Childhood Cancer 2030 goals.”

The Global Initiative, launched by the World Health Organization (WHO) in 2018, seeks to raise global survival rates for pediatric cancer to 60% by 2030. It is an ambitious goal, but one that is within reach, due in part to the work of the St. Jude Global Metrics and Performance Unit and IHI, as well as the commitment of pediatric oncologists worldwide.

“Using our tools, our collaborators have found highly actionable, high-impact opportunities to make a difference,” Friedrich said. “We help them find a starting point, but they are the heroes; they adopt tools, help refine them and implement the solutions that meet their needs, leading to measurable improvement in patient survival and less measurable but equally tangible improvements in team dynamics and the culture of improvement at their institution. The Metrics and Performance Unit helps them see where they are and connect with other institutions with similar challenges. Then, we empower them to set a path and do our best to support them as they make patients’ lives better.”