Title: 3 Projects to Improve Patient Care at Your Facility
1- 3 Projects to Improve Patient Care at Your
Facility
John Kennedy, MD, FACS Chair, Quality Integration
Committee Richard Anderson, MD, FACS Illinois
State Chair Greer Gay, PhD, RN, MPH Manager,
Research Unit, National Cancer Data Base
2Objectives
- To understand the meaning and importance of
quality improvement in cancer care at the local
level - To understand your role to drive and support
quality improvement - To learn three methods for evaluating areas of
your cancer program - To develop the skills to become a proactive user
of NCDB data to improve patient care
3Why Quality Improvement in Healthcare is
Essential
- Benefits associated with Quality Improvement
- ? Patient satisfaction
- ? Physician and staff satisfaction
- ? Patient survival
- ? Continuity of care
- ? Profitability
- ? Costs
- McLaughlin and Kaluzny
4CLP Role in Quality Improvement
- Serve as a physician champion, and identify
others as well - Identify strengths/weaknesses in delivery of
care. - Take advantage of e-QuIPs and CP3R for
benchmarking and quality improvement plans. - Identify key areas for improvements.
- Develop a plan of action, timeline, and
assignment of activities. - Collaboration with facility administration.
- Continually assess the impact of improvement
projects, and revise as necessary.
5Traditional v. Improvement-Based
- Traditional QA
- What is hospitals expected v. actual practice
relative to radiation after breast conservation
surgery (BCS)? - Which physician has referred fewer women for
radiation after BCS?
- Improvement-Based
- How can we increase compliance with radiation
after BCS? - What elements of process have greatest impact
receipt of radiation post BCS? - What information is needed to manage process
better?
ISIS
6Key Success Factors
- Keep purpose of quality improvement in forefront
- Core group of physicians to do planning,
analyses, implementation - Clinical Champion at the local level
- Team accountability and Ownership
- Multi-disciplinary participation
- Available resources for education, support, data
collection/analyses - Systematic evaluation/modification
- Open communication
-
7Quality Measures Provided to CoC-Accredited
Programs
- Provide feedback on performance through Web
reports - Cancer Program Practice Profile Reports (CP3R)
- Electronic-Quality Improvement Packets (e-QuIP)
- Hospital Comparison Benchmark Reports
- Survival Reports
8Electronic Quality Improvement Packet
- Web-based application offering estimated
performance rates based upon concordance with
widely accepted, nationally recognized standard
of care guidelines - Retrospective case review 2003 and 2004 data
presented based upon submission to NCDB - Interactive online reconciliation tool to update
case information - Subsequent years added annually
- Feedback reports designed to allow cancer
committee review quality of - Registry data
- Physician charting
- Quality of cancer patient care
9Benefits of e-QuIP
- Emphasizes the importance of the entire cancer
programs role in quality data - Highlights collaborative, multidisciplinary
efforts. - Moves responsibility beyond registry staff.
- Links all departments of the cancer program.
- Call to action for cooperation within and between
cancer programs and providers for data capture
and follow-up. - Only CoC Approved Programs receive information.
- Should help programs prepare for anticipated Pay
for Performance for federal and private plans.
10Cancer Program Practice Profile Report (CP3R)
- Web-based application providing local providers
with comparative information to assess their
local utilization of adjuvant chemotherapy (ACT)
following the resection of Stage III cancers of
the colon - Years reported 1998 to 2005
- Based upon data submission to NCDB
- Provides a benchmark of performance relative to
- State
- ACS Division
- CoC Approvals Category
11Cancer Program Practice Profile Reports (CP3R)
- Provides a program the ability to
- Evaluate their practice relative to
evidenced-based guidelines - Compare their practice to program performance in
their - State
- ACS division
- Other similar program types
12Benefits of Hospital Benchmarks
- Analyze your cancer program relative to 59
different cancers by - Demographics
- Insurance status
- Stage at entry
- First course of treatment
- First course surgery type
- Radiation therapy
- Systemic therapy
- Histology
- Behavior
13Breast Measures Endorsed by NQF
- Radiation therapy is administered within 1 year
(365 days) of diagnosis for women under age 70
receiving breast conserving surgery for breast
cancer. - Combination chemotherapy is considered or
administered within 4 months (120 days) of
diagnosis for women under 70 with AJCC T1c, or
Stage II or III hormone receptor negative breast
cancer. - Tamoxifen or third generation aromatase inhibitor
is considered or administered within 1 year (365
days) of diagnosis for women with AJCC T1c or
Stage II or III hormone receptor positive breast
cancer.
Measures, as stated, harmonized with ASCO/NCCN
14Colon Measure Endorsed by NQF
- Adjuvant chemotherapy is considered or
administered within 4 months (120 days) of
diagnosis for patients under the age of 80 with
AJCC Stage III (lymph node positive) colon
cancer. - At least 12 regional lymph nodes are removed and
pathologically examined for resected colon
cancer.
Measures, as stated, harmonized with ASCO/NCCN
15Rectal Measure Developed by CoC, ASCO and NCCN
- Radiation therapy is considered or administered
within 6 months (180 days) of diagnosis for
patients under the age of 80 of with clinical or
pathologic AJCC T4N0M0 or Stage III receiving
surgical resection for rectal cancer.
Measures, as stated, harmonized with ASCO/NCCN
16Review 3 Examples of Quality Improvement
- Colon cancer and lymph node dissection
- Colon cancer and adjuvant chemotherapy
- Breast conserving surgery and radiation
17At least 12 regional lymph nodes are removed and
pathologically examined for resected colon
cancer.
- Colon Measure Endorsed by NQF
18Colon Cancer - Quality Improvement
- Who is involved- Surgeons and Pathologists
- How can we spark their interests
- Insurance carriers
- Pay for performance
19Colon Cancer - Quality Improvement
- Educate the surgeons
- Educate the pathologists
- Measure the results
- Concurrent data
- Allows others projects
20Evaluate historical data (NCDB) for baseline,
accuracy, process problems
21Verify accuracy and completeness
Compliant cases
List of cases can be edited in real time.
Non-compliant cases
22- Implement methodology for prospective
identification of cases (path reports) - Manual tracking vs. software solution (E-Path,
other) - Allows for prompt (within one month) assessment
of compliance - Establish standardized policy for pathologic
assessment - Requires buy-in by pathologists
- Algorithm for a re-exam of specimen if lt 12 nodes
are found
23Prompt feedback to surgeons and pathologists
Example of e-mail distribution to surgeons on
monthly basis
24Intervention began
25Adjuvant chemotherapy is considered or
administered within 4 months (120 days) of
diagnosis for patients under the age of 80 with
AJCC Stage III (lymph node positive) colon
cancer.
- Colon Measure Endorsed by NQF
26Evaluate historical data for baseline, accuracy,
process problems.
Comparison with other centers in state
27Evaluate historical data for baseline, accuracy,
process problems
Data can be trended annually
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30Implement methodology for prospective
identification of Stage III cases
- Utilize pathology reports to identify patients
with N disease (Stage III) - Identify physician champion (colorectal surgeon?)
to oversee data - Document post-operative referral to oncologist,
and subsequent administration (and completion) of
chemotherapy, or patient refusal.
31Document referral to oncologist, and the
recommendation and administration of
chemotherapy-
32Radiation therapy is administered within 1 year
(365 days) of diagnosis for women under age 70
receiving breast conserving surgery for breast
cancer.
- Breast Measure Endorsed by NQF
33Breast Cancer Quality Improvement
- E-QuIP in 2/5/07 performance rate 65.6
- Who is Involved-Breast Surgeons, Radiation
Oncology, and Oncology
34Breast Cancer Quality Improvement
- Look at the data
- Look at problem
- Incorrectly labeling patient
- Data collection error
- Performance Rate 95.6
- Concurrent Data able to correct
- MAC-considered for combination chemotherapy
- HT- considered for hormone therapy
35Breast e-QuIP
36CP3R/E-QuIP
- Currently are retrospective tools only
- Improvement limited to improving accuracy of
documentation and identification of opportunities
for improvement - Potential for decreasing delay in data entry
which will increase utility in QI (RQRS)
37NCDB of the Future
- Rapid Quality Reporting System (RQRS)
- Will be piloted this spring
- Selected subset of data points to be entered
close to time of diagnosis (breast and colon
cancers) - Increase and improve realtime interactivity
- Automated reminders for pertinent data entry
relating to clinical indicators
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39Conclusions
- NCDB provides a variety of tools for data
evaluation, including eQuIP, CP3R, Survival and
Benchmarking reports - QI projects can objectively improve the quality
of care we provide to our patients - Physicians and other enlightened professionals,
including disease registries, can and should
champion ongoing quality improvement - NCDB is evolving to a more timely and interactive
quality measurement tool