Together, we bring the full power of our collective expertise to provide the
best possible care to our patients, our people, and our communities.
Dartmouth Health’s strategic plan promises to draw on the expertise of clinical teams, researchers, educators, administrators, patients, families, and communities in an approach that sets DH apart from other health systems. To deliver on this promise, DH has partnered with The Dartmouth Institute for Health Policy and Clinical Practice and the Dartmouth Cancer Center to pilot a Learning Health System based on principles of coproduction. Lessons from this initiative will inform the adaptation and expansion of the model as we grow and collectively work toward delivering on The Promise across the health system.
Promise Partnership Publications
Anna N. A. Tosteson, ScD; Kathryn B. Kirkland, MD; Megan M. Holthoff, MSHS; Aricca D. Van Citters, MS; Gabriel A. Brooks, MD, MPH; Amelia M. Cullinan, MD; Miriam C. Dowling-Schmitt, MS, RN, CPPS, CPHQ; Anne B. Holmes, BA; Kenneth R. Meehan, MD; Brant J. Oliver, PhD; Garrett T. Wasp, MD; Matthew M. Wilson, MD; Eugene C. Nelson, DSc, MPH
Abstract: The coproduction learning health system (CLHS) model extends the definition of a learning health system to explicitly bring together patients and care partners, health care teams, administrators, and scientists to share the work of optimizing health outcomes, improving care value, and generating new knowledge. The CLHS model highlights a partnership for coproduction that is supported by data that can be used to support individual patient care, quality improvement, and research. We provide a case study that describes the application of this model to transform care within an oncology program at an academic medical center.
Citation: Tosteson ANA, Kirkland KB, Holthoff MM, Van Citters AD, Brooks GA, Cullinan AM, Dowling-Schmitt MC, Holmes AB, Meehan KR, Oliver BJ, Wasp GT, Wilson MM, Nelson EC. Harnessing the Collective Expertise of Patients, Care Partners, Clinical Teams, and Researchers Through a Coproduction Learning Health System: A Case Study of the Dartmouth Health Promise Partnership. J Ambul Care Manage. 2023 Apr-Jun 01;46(2):127-138. doi: 10.1097/JAC.0000000000000460. PMID: 36820633.
Garrett T Wasp, Amelia M Cullinan, Catherine P Anton, Andy Williams, James J Perry, Megan M Holthoff, Madge E Buus-Frank
Purpose: We aimed to increase Serious Illness Conversations (SIC) from a baseline of, at or near, zero to 25% of eligible patients by December 31, 2020.
Methods: We assembled an interdisciplinary team inclusive of a family partner and used the Model for Improvement as our quality improvement framework. The team developed a SMART Aim, key driver diagram, and SIC workflow. Standardized screening for SIC eligibility was implemented using the 2-year surprise question. Team members were trained in SIC communication skills by a trained facilitator and received ongoing coaching in quality improvement. We performed Plan-Do-Study-Act cycles and used audit-feedback data in weekly team meetings to inform iterative Plan-Do-Study-Act cycles. The primary outcome was the percent of eligible patients with documented SIC.
Results: Over 18 months, three clinics identified 63 eligible patients; of these, 32 (51%) were diagnosed with head and neck cancer and 31 (49%) with sarcoma. The SIC increased from a baseline near zero to 43 of 63 (70%) patients demonstrating three shifts in the median (95% CI). Conversations were interdisciplinary with 25 (57%) by oncology MD, six (14%) by advanced practice registered nurse, and 13 (30%) by specialty palliative care. We targeted four key drivers: (1) standardized work, (2) engaged interdisciplinary team, (3) engaged patients and families, and (4) system-level support.
Conclusion: Our approach was successful in its documentation of end points and required resource investment (training and time) to embed into team workflows. Future work will evaluate scaling the approach across multiple clinics, the patient experience, and outcomes of care associated with oncology clinician-led SIC.
Citation: Wasp GT, Cullinan AM, Anton CP, Williams A, Perry JJ, Holthoff MM, Buus-Frank ME. Interdisciplinary Approach and Patient/Family Partners to Improve Serious Illness Conversations in Outpatient Oncology. JCO Oncol Pract. 2022 Jul 20:OP2200086. doi: 10.1200/OP.22.00086. Epub ahead of print. PMID: 35858156.
Prioritizing Measures That Matter Within a Person-Centered Oncology Learning Health System
Aricca D. Van Citters, MS , Alice M. Kennedy, MPH, Kathryn B. Kirkland, MD, Konstantin H. Dragnev, MD, Steven D. Leach, MD, Madge E. Buus-Frank, DNP, ARNP-BC, FAAN, Elissa F. Malcolm, MS, Megan M. Holthoff, MSHS, Anne B. Holmes, Eugene C. Nelson, DSc, MPH, Susan A. Reeves, EdD, RN, Anna N. A. Tosteson, ScD; on behalf of the Promise Partnership Delphi Panel
Background: Despite progress in developing learning health systems (LHS) and associated metrics of success, a gap remains in identifying measures to guide the implementation and assessment of the impact of an oncology LHS. Our aim was to identify a balanced set of measures to guide a person-centered oncology LHS.
Methods: A modified Delphi process and clinical value compass framework were used to prioritize measures for tracking LHS performance. A multidisciplinary group of 77 stakeholders, including people with cancer and family members, participated in 3 rounds of online voting followed by 50-minute discussions. Participants rated metrics on perceived importance to the LHS and discussed priorities.
Results: Voting was completed by 94% of participants and prioritized 22 measures within 8 domains. Patient and caregiver factors included clinical health (Eastern Cooperative Oncology Group Performance Status, survival by cancer type and stage), functional health and quality of life (Patient Reported Outcomes Measurement Information System [PROMIS] Global-10, Distress Thermometer, Modified Caregiver Strain Index), experience of care (advance care planning, collaboRATE, PROMIS Self-Efficacy Scale, access to care, experience of care, end-of-life quality measures), and cost and resource use (avoidance and delay in accessing care and medications, financial hardship, total cost of care). Contextual factors included team well-being (Well-being Index; voluntary staff turnover); learning culture (Improvement Readiness, compliance with Commission on Cancer quality of care measures); scholarly engagement and productivity (institutional commitment and support for research, academic productivity index); and diversity, equity, inclusion, and belonging (screening and follow-up for social determinants of health, inclusivity of staff and patients).
Conclusions: The person-centered LHS value compass provides a balanced set of measures that oncology practices can use to monitor and evaluate improvement across multiple domains.
Citation: Van Citters AD, Kennedy AM, Kirkland KB, Dragnev KH, Leach SD, Buus-Frank ME, Malcolm EF, Holthoff MM, Holmes AB, Nelson EC, Reeves SA, Tosteson ANA; Promise Partnership Delphi Panel. Prioritizing Measures That Matter Within a Person-Centered Oncology Learning Health System. JNCI Cancer Spectr. 2022 May 2;6(3):pkac037. doi: 10.1093/jncics/pkac037. PMID: 35736219; PMCID: PMC9219163.
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