The Cancer Registrar: Facilitator in Quality Improvement

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The Cancer RegistrarFacilitator in Quality
Improvement

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What is Continuous Quality Improvement (CQI)?

• is a structured organizational process for
  involving personnel in planning and executing a
  continuous flow of improvements to provide
  quality health care that meets or exceeds
  expectations.
• -McLaughlin and Kaluzny

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What is CQI?

• Healthcare delivery is a system that is composed
  of thousands of interlinked processes
  
• Quality improvement is the science of process
  management
  
• James, MD 1996

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Characteristics of CQI -McLaughlin and Kaluzny

• Staff support for process analysis and redesign
• Personnel policies that motivate and support
  staff participation in process improvement
  
• Based on changing environments and requirements
• Research
• Clinical care
• Clinical and administrative staffing and
  philosophies
  
• Patient needs and choices
• ONE SIZE DOES NOT FIT ALL
• Why?

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Characteristics of CQI -McLaughlin and Kaluzny

• Links to the organizations strategic plan
• Mission, vision and values
• Involves top leadership, multidisciplinary in
  nature
  
• CLP, CCC, CP administrator
• Training/educational programs for staff
• NCRA, ONS, Clinical Congress, ASCO, SSO, etc.
• Methods and mechanisms for selecting improvement
  opportunities
  
• Tumor board, cancer conferences
• Formation of process improvement teams
• Led by clinical champion from cancer committee

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A Word About Systems

• Systems thinking is a discipline for seeing
  wholes. It is a framework for seeing
  interrelationships, rather than things, for
  seeing patterns of change rather than static
  snapshots
• Senge, 1990

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Systems

• The facility is a system
• It has its own culture
• It behaves its own way
• It learns its own way
• It takes everyone coming together to improve the
  care of one patient
  
• Kelly, 2004

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Organizational Culture
Other Clinical Staff
Nurses
Research
Physicians
Administration/Board
System
Registrars
Patients
Services
Technology
Facility
Resources
Community/Political Environment
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Avedis Donabedian, MD, MPH

• Three ways to measure components of quality
• Structure
• Process
• Outcomes

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Structure

• the relatively stable characteristics of the
  providers of caretools and resourcesphysical
  and organizational settingsincreases or
  decreases the probability of good performance
• Examples
• Number/credentials of cancer program staff
• Medical oncology reporting system
• Relationship with chemo treatment
  facilities/offices
  
• Registry workload
• Formalized support programs
• Transportation
• Support groups

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Process

• a set of activities that go on within and
  between practitioners and patientselements of
  the process of care do not signify quality until
  their relationship to desirable health status has
  been established.
• Examples
• Use of cancer committee for treatment protocol
  discussion
  
• Surgeon-oncologist communication, documentation
• Administration of adjuvant chemotherapeutic
  agent
  
• Physician-patient communication
• Appropriate registry abstraction

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Outcomes

• a change in a patients current and future
  health status that can be attributed to
  antecedent health care.
  
• Example
• Increasing proportion of patients being treated
  according to Stage III colon cancer guidelines
  i.e., patients having surgery and receiving
  adjuvant chemotherapy
• Improving survival of Stage III colon cancer
  patients

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Structure, Process Outcome are Interconnected

• Outcomes can indirectly give information on
  process
  
• In this instance, measuring the proportion of
  Stage III colon cancer patients receiving
  adjuvant chemotherapy
  
• Outcomes can guide monitoring activities
• Surgeon referrals
• Medical oncologist documentation
• Registrar activity
• Donabedian, MD, 1980, p. 121-122

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• Outcome oriented methods can lead to corrective
  action in process
  
• Donabedian, MD 1980, p. 121-122
• CQI sees problems as opportunities for
  improvement.
  

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Why bother with QI in Healthcare? -McLaughlin
and Kaluzny

• Benefits associated with QI
• ? Customer satisfaction
• ? Employee satisfaction
• ? Profitability
• ? Patient survival
• ? Costs
• ? Continuity of care

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Why do registrars have a role in QI?
-McLaughlin and Kaluzny

• Fundamental concept of QI
• Multidisciplinary teams must participate in
• Data collection
• What data should be collected
• Administrative data
• Clinical data
• Actual data collection
• Data may come from a variety of sources
• Analysis of process and outcomes related data
• Actions necessary to make improvements

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Why do registrars have a role in QI?

• Registrars must help to identify and work with a
  QI champion to foster acceptance and future
  change
  
• Physician
• In touch with clinical care
• Understands registry data
• May also include
• Oncology Nurses and Nurse Administrators
• Cancer Program/Hospital Administrators

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Why do registrars have a role in QI?
-McLaughlin and Kaluzny

• CQI in complex organizations is
• Data intensive
• Information intensive
• DYNAMIC
• Over time, gain new customers
• Involves change in staff at various times
• New questions to be answered
• Thus, more time
• More action

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Why do registrars have a role in QI?
-McLaughlin and Kaluzny

• Done correctly, CQI increases organizational
  demands for
  
• Data requests
• Information
• Knowledge

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Why do registrars have a role in QI?
-McLaughlin and Kaluzny

• Organizational leaders must be ready to guide the
  organization level of expertise with information
  management and technology
  

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Registrars in the Data to Action Cycle
-McLaughlin and Kaluzny
Requires training Ideally, data collection occu
rs as healthcare is delivered Performance improv
ement decisions guide data collection in the
future Improves feedback between data and decisi
ons
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Data to Action Cycle

• Data
• Data are facts alone, they have no meaning
• Registrars are responsible for putting clinical
  facts into the registry
  
• Accurate
• Accessible
• Registrars responsible for formatting,
  organization and storage (with IT)
  
• Data that are accurate and structured properly
  can be easily retrieved and combined with other
  data elements for analysis
  
• Data of poor quality are difficult to find and
  become useless
  

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Data to Action Cycle

• Information
• Data that has become meaningful
• Registrars assemble data to answer clinicians
  and administrations questions
  
• Registrars can work with management to
• Properly frame questions
• Identify sources of data necessary to answer
  questions
  
• Select and combine data to provide answers
• COMMUNICATE findings to interested parties to aid
  decision making processes
  

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Data to Action Cycle

• Knowledge
• Knowledge implies prediction
• Management must predict to control future
  performance of care processes
  
• Registrars map data over time to uncover trends
  in
  
• Diagnosis
• Care
• Treatment
• Survival
• Registrars must work collaboratively with
  clinicians to determine
  
• If trend is predictable
• If intervention should be considered
• If so, what kind?

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Data to Action Cycle

• Knowledge and Prediction
• May include use of statistical process control
  methods, benchmarking, etc.
  
• May help to uncover causes of variation
• May provide knowledge about appropriateness of
  specific treatments for patients/populations
  
• May identify at-risk populations

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Data to Action Cycle

• Decisions lead to ACTION or INACTION
• Registrars provide feedback marking actual past
  patterns of care
  
• Based on knowledge of process and systems
• This feedback is the best possible resource for
• Motivating change
• Improving communications
• Goal is to improve the SYSTEM, rather than
  focusing on an individual(s)
  

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Action

• May include
• Physician care processes
• Physician interactions
• Physician charting
• Registry abstraction
• Administration/physician interactions
• Ultimate Goal
• IMPROVE PATIENT OUTCOMES

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What the CoC is Doing

• Several CoC Approvals standards focus on quality
  improvement, data quality, and quality assurance
  activities
  
• Survey and approvals process key to creating
  awareness
  
• Utilize Cancer Liaison Physicians to promote
  awareness, need for change
  
• Education through communication
• Quality Integration Committee helps CoC/NCDB
  determine whether there is compelling evidence to
  support a particular pattern of care
  
• Changes are monitored via the NCDB/data
  submission process

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Examples Using NCDB Data

• Cancer Program Practice Profile Reports (CP3R)
• NCDB Benchmark Reports

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Web-based Reports Tools-CP3R

• Case Reporting Summary
• Comparison Report (table figure)
• Ranking Report (table figure)
• On-Line Adjuvant Therapy Reconciliation Tool

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Assessment and Monitoring

• Assessment (short-term)
• Monitoring (long-term)

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Quality Care MeasuresStage III Colon Cancer

• Adjuvant chemotherapy is administered to patients
  with lymph node positive colon cancer
  
• Concordant if programs ranked in the upper
  quartile
  
• Non-concordant if ranked otherwise

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CONCORDANT

• Facilities documented appropriate treatment
  (surgery adjuvant chemotherapy) to Stage III
  Colon Cancer patients
  

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NON-CONCORDANT

• Facility documented a lack of appropriate
  treatment (surgery adjuvant chemotherapy) to
  Stage III Colon Cancer patients
  

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Shows weighted average across data submission
years 1998-2002
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Improvement in later years
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Case Detail Screen

• Review case specific information
• Data describing non-surgical treatment can be
  modified
  

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Making Changes At The Local Level

• Structure and process
• What works
• Cancer committee study

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Use of Available Tools

• Fishbone Diagram

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Stage III Colon Cancer Adjuvant Therapy
Follow-up Request Form

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Stage III Colon Cancer Adjuvant Therapy
Follow-up Request Form
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NCDB Benchmarks-Public
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NCDB Benchmarks-Public
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NCDB Benchmarks-Public
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NCDB Benchmarks-Public
Age Perhaps Not a Factor?
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NCDB Benchmarks-Public
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NCDB Benchmarks-Public
Race a Factor?
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NCDB Hospital Comparison Benchmark Reports
https//web.facs.org/datalinks
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Type of Report
Geography
Hospital Type/System
My Hospital
Dx year
Variable
Display
Primary Site
Case Type
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NCDB Hospital Comparison Benchmark Reports
Stage
Race
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NCDB Hospital Comparison Benchmark Reports-AL
More AL patients have private insurance, fewer
are on managed care, and more have Med/Sup. Does
this account for the variations in care?
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My Hospital
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Survival Reports
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Using Benchmarks Allows

• State Cancer Planning
• Evaluation of Care at the Hospital Level
• Definition of Cancer Care Priorities
• Outreach Through Prevention/Early Detection
• Treatment
• Advocacy/Policy Development
• Formulate Study Questions
• Manuscript Development
• Clinical Trial Development
• IMPROVE QUALITY OF CARE AT THE LOCAL LEVEL

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Questions?

• ncdb_at_facs.org
• Lina Patel-Parekh, MHA, CHE
• American College of Surgeons
• Commission on Cancer
• 633 N. St. Clair
• Chicago, IL 60611
• 312-202-5401
• lpatel-parekh_at_facs.org