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3 Projects to Improve Patient Care at Your Facility

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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
2
Objectives
  • 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

3
Why 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

4
CLP 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.

5
Traditional 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
6
Key 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

7
Quality 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

8
Electronic 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

9
Benefits 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.

10
Cancer 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

11
Cancer 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

12
Benefits 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

13
Breast 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
14
Colon 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
15
Rectal 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
16
Review 3 Examples of Quality Improvement
  • Colon cancer and lymph node dissection
  • Colon cancer and adjuvant chemotherapy
  • Breast conserving surgery and radiation

17
At least 12 regional lymph nodes are removed and
pathologically examined for resected colon
cancer.
  • Colon Measure Endorsed by NQF

18
Colon Cancer - Quality Improvement
  • Who is involved- Surgeons and Pathologists
  • How can we spark their interests
  • Insurance carriers
  • Pay for performance

19
Colon Cancer - Quality Improvement
  • Educate the surgeons
  • Educate the pathologists
  • Measure the results
  • Concurrent data
  • Allows others projects

20
Evaluate historical data (NCDB) for baseline,
accuracy, process problems
21
Verify 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

23
Prompt feedback to surgeons and pathologists
Example of e-mail distribution to surgeons on
monthly basis
24
Intervention began
25
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.
  • Colon Measure Endorsed by NQF

26
Evaluate historical data for baseline, accuracy,
process problems.
Comparison with other centers in state
27
Evaluate historical data for baseline, accuracy,
process problems
Data can be trended annually
28
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30
Implement 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.

31
Document referral to oncologist, and the
recommendation and administration of
chemotherapy-
32
Radiation 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

33
Breast Cancer Quality Improvement
  • E-QuIP in 2/5/07 performance rate 65.6
  • Who is Involved-Breast Surgeons, Radiation
    Oncology, and Oncology

34
Breast 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

35
Breast e-QuIP
36
CP3R/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)

37
NCDB 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

38
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39
Conclusions
  • 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
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