3 Projects to Improve Patient Care at Your Facility

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• 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
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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

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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

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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.

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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
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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

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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

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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

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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.

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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

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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

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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

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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
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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
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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
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Review 3 Examples of Quality Improvement

• Colon cancer and lymph node dissection
• Colon cancer and adjuvant chemotherapy
• Breast conserving surgery and radiation

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At least 12 regional lymph nodes are removed and
pathologically examined for resected colon
cancer.

• Colon Measure Endorsed by NQF

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Colon Cancer - Quality Improvement

• Who is involved- Surgeons and Pathologists
• How can we spark their interests
• Insurance carriers
• Pay for performance

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Colon Cancer - Quality Improvement

• Educate the surgeons
• Educate the pathologists
• Measure the results
• Concurrent data
• Allows others projects

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Evaluate historical data (NCDB) for baseline,
accuracy, process problems
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Verify accuracy and completeness
Compliant cases
List of cases can be edited in real time.
Non-compliant cases
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• 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

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Prompt feedback to surgeons and pathologists
Example of e-mail distribution to surgeons on
monthly basis
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Intervention began
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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

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

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

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Breast Cancer Quality Improvement

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

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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

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Breast e-QuIP
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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)

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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

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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