Cancer Program Practice Profile Reports (CP3R) Accountability Measures/Quality Improvement Measures
A requirement for Commission on Cancer (CoC) Accredited cancer programs is to monitor compliance with evidence-based treatment guidelines. In addition to performing site-specific studies to assess compliance with evidence-based national treatment guidelines, we are required to monitor compliance with evidence-based guidelines by utilization of the CoC quality reporting tools of the Cancer Program Practice Profile Reports (CP3R).
The cancer committee reviewed National Cancer Database (NCDB) benchmark reports for Beaumont for breast cancer and colon cancer stage and treatment. We are consistent with first course of treatment benchmarks comparing to both national and Michigan hospitals. Beaumont diagnoses and treats about 17% of breast cancer cases and about 10% of colorectal cases in Michigan. In order to best track the treatment process of our patients and position ourselves for commendable status with Commission on Cancer Rapid Quality Reporting System standards, we are analyzing breast and colorectal cases on a concurrent basis.
The CP3R has been implemented by the CoC for the purpose of fostering quality improvement at cancer programs awarded CoC Accreditation by utilization of quality of care measures. Facilitated by the National Quality Forum (NQF), CoC, American Society
for Clinical Oncology (ASCO) and National Comprehensive Cancer Network (NCCN) agreed to synchronize their developed measures for breast and colorectal cancer to ensure that a unified set of quality of care measures were put forth to the public. Each year the cancer committee is required to review the quality of patient care using the CP3R to evaluate care within and across disciplines, to discuss successful processes and to evaluate how processes can be improved to promote evidencebased practice. An accountability measure is the standard of care based on clinical trial evidence. A quality improvement (QI) measure is one that demonstrates good practice but is not based on clinical trial evidence. In 2018, we evaluated issues with obtaining all first course of therapy information to comply with documentation for standards of care. We have made good progress in gaining access to ongoing treatment that takes place in our private practice physician’s offices or that are referred elsewhere to complete their first course of therapy. For the CoC evaluation of accountability measures and quality improvement measures compared to other hospitals, Beaumont quality measure reports for breast cancer demonstrate a higher rate of compliance with standards of care for all accountability, quality improvement and surveillance measures compared to state, census region, American Cancer Society (ACS) division, CoC program type and all CoC programs. We demonstrated diagnosis of breast cancer cases at an earlier stage than in all hospitals in all states.
We have a very robust early detection program at Beaumont. Review of the performance measures for colon cancer also demonstrated a higher rate of compliance with standards of care. Beaumont exceeds the performance rates/benchmarks specified by the CoC for quality improvement measures. As outlined above, the cancer committee reviewed the comparison of all breast cancer and colorectal cancer CP3R measures and Beaumont rates significantly higher than other hospitals measured in the National Cancer Database and exceeds national benchmarks. We have also worked with our physician’s offices to obtain treatment documentation to demonstrate our patients have a higher compliance with national standards of care.
Rapid Quality Reporting System (RQRS)
In January 2014, Beaumont began participation in the Rapid Quality Reporting System (RQRS) which was developed to assist CoC-accredited cancer program in promoting evidence-based cancer care at the local level. Eligible cases are submitted monthly for all performance measures. It is a web-based, systematic data collection and reporting system that advances evidencebased treatment through a prospective alert system for anticipated care that supports care coordination required for breast and colorectal cancer patients at participating cancer programs. The 2016 CoC Standards require that cancer cases for breast and colorectal be RQRS submitted within three months of date of first contact for the cancer program to be recognized for commendable performance. We have performed concurrent
abstracting of breast and colorectal cases for submission to RQRS within three months as required for commendable recognition. This provides further opportunity to identify cases and monitor and update their first course of treatment in real-time.
Continuous Quality Improvement (CQIP) Reports
The cancer committee also reviewed the Continuous Quality Improvement (CQIP) reports. CQIP reports are a CoC summary of our activity compared to national benchmarks. Cancer Committee review of the many major points outlined were consistent with our understanding of our program and our expectations. We did not identify any discrepancies where we could implement an intervention for the improvement of quality of cancer care. With the use of RQRS, concurrent analysis/ abstracting of breast and colorectal cases, and CP3R review, any potential issues are already identified and addressed. CQIP report findings are shared at all of the facility and corporate meetings.
Monitoring Compliance with Evidence-Based Guidelines
Sayee Kiran, M.D., reported on the review of compliance with evidenced-based guidelines, NCCN, for HER2 Positive Breast Cancer in Beaumont’s Integrated Network Cancer Program (INCP). Review of cases for 2016 demonstrated that our INCP was 100% compliant with evidence-based national guidelines for Herceptin for adjuvant or neoadjuvant treatment.
2018 STUDIES OF QUALITY AND QUALITY IMPROVEMENTS
Decrease medical oncology mortality
Areas of focus identified to reduce medical oncology mortality were:
• improving documentation
• proper patient evaluation
• increase palliative and hospice consultations
• provide palliative care consultations at earlier stages of care
• increase hospice utilization
The Joint Commission Journal on Quality and Patient Safety published a study from the Mortality Review Committee identifying a number of opportunities patient care could be improved including mortality rates. Through the use of a mortality review committee a number of opportunities were identified to improve mortality. These included a medical records query process and rapid response team for the hospice program. Regular review of mortality cases will help identify trends in patient documentation and focusing on hospice initiatives to improve patient access will help increase utilization.
The Journal of Oncology Practice published a study from the Icahn School of Medicine at Mount Sinai, New York that concluded early palliative care consultations increased hospice utilization and reduced the probability of dying in a hospital. This consultation included advanced care planning, establishing goals of care, transition planning, and symptom assessment. With early intervention, the idea of utilizing hospice was less daunting to patients with advanced cancers.
The Health Research and Educational Trust and the American Hospital Association published Health Care Leaders Action Guide: Hospital Strategies for Reducing Preventable Mortality in 2011 as part of their 2011-2013 strategic plan. Their recommendations were to start by reviewing data and setting SMART goals for reducing mortality. This included establishing an organized process to review mortality. Using a structured review process, Issues in care and documentation improvement opportunities can be identified.
• Design a corrective action plan based on evaluation of the data.
1. Identify and initiate a documentation specialist to review oncology patient documentation and report their findings to the medical oncologists.
2. Identify observed cases where documentation could have been improved; expected mortality did not match observed.
3. Initiate discussion in the monthly oncology department meetings regarding mortality rate and review patient documentation that was identified using the steps outlined.
4. Establish a peer review committee.
5. Provide palliative care consults and advanced care planning information.
6. Identify paths to increase hospice consults and admits.
Establish follow-up steps to monitor the actions implemented.
Possible next steps:
1. Continue to review documentation with medical oncologist, oncology administration and the documentation specialist.
2. Increase medical oncology education and engagement through department meeting discussion.
3. Develop a peer review committee process for medical oncology.
4. Develop strategies to improve hospice consults/admits.
5. Monitor monthly quality data.
• Outcomes
Improved Medical Oncology Mortality Score. Documentation specialist involved in improved documentation review and care, mortality case evaluation and utilization of hospice services for appropriate patients. Also increased patient and family education through the use of advanced care planning videos and all available options. This initiates consultations and increased hospice utilization. Medical Oncology mortality rates decreased significantly in 2018 and trended lower than target.
Text Messaging Appointment Reminders to Decrease Patient Cancellations and No Shows
The objective of this quality improvement project was to develop a way to decrease no-show rates in the breast care center. From January to July of 2016, no-show rates in the breast care center have consistently been between 26-32 percent. Oncology administration and breast care center staff determined using other points of contact, other than a phone call reminder, to remind patients of their appointments may help decrease the number of no-call, no-show patient visits.
The number of missed appointments and monthly rate of no-shows were reviewed. Follow-up with these patients was conducted to identify what led to each occurrence. Additionally, we worked to identify patients who miss more than one appointment without notifying the breast care center. Then we reviewed options that we could implement to remind patients of their appointments.
Documenting missed appointments and identifying barriers that led to no-shows allows oncology leadership to determine better appointment reminder methods. Upon review, many patients forgot about their appointment. They either missed their call reminder and never listened to the voicemail or ignored it. Based off this finding, administration was able to evaluate patient preferences for appointment reminders and identify more effective measures.
Columbia University Mailman School of Public Health surveyed 161 patients and found those who send text messages every day preferred reminders by text. Those who did not preferred a phone call. While their analysis revealed most patients preferred a phone call reminder above other forms of communication, patients who were sent text messages every day had a higher level of responsiveness to a text reminder.
The Ohio State Medical Center offers patients the option to choose text message reminders in place of reminder phone calls. If the patient opts for text reminders, they receive the text reminder three days before and one day prior to their scheduled appointment.
This effort resulted in plans for implementing a text message appointment reminder:
1. continue to monitor no-show rates in the breast care center
2. once text reminders are implemented, track missed appointments for comparison
3. follow-up with patients who opt in for text reminders and track their perception of effectiveness
4. approval to move on with the project
5. finalization from IT, legal and compliance
6. approval text wording
7. give patients the option to opt in for the service
8. pilot within the breast care center
This project is ongoing and outcomes to be reviewed.
Increase Dissemination of Breast Cancer Survivorship Care Plans (SCP)
The Commission on Cancer (CoC) and National Accreditation Program for Breast Cancers (NAPBC) have currently set a 50% minimum for survivorship care plan delivery to patients with breast cancer. SCP delivery percentage for eligible patients of the Comprehensive Breast Care Center at Beaumont, Royal Oak in 2017 was 58%. This percentage reflects the patients who were given SCPs at the time of their surgical follow-up 6-12 months after diagnosis.
In an effort to improve our SCP delivery percentage, the Breast Care Center implemented a new process to increase the number of care plans that were delivered. For patients who did not return to follow up appointment with the surgeon, the nurse navigators began calling these patients to discuss their SCP over the phone. Following the phone call, patients were mailed a copy of their SCP. This process was implemented on April 3, 2018.
The SCP delivery percentage for the period between January 1, 2018, and April 2, 2018, (PRE) was compared to the SCP delivery percentage following the change in the delivery process, April 3, 2018, through November 8, 2018 (POST).
Summary of Findings:
There was a 5.9% increase in the number of SCPs that were delivered as a result of the process change. Both the PRE and POST SCP delivery percentages were greater than the 50% benchmark set by the CoC and NAPBC, but the process change has gotten us closer to the anticipated increased threshold of 75% in 2020. This measure will continue to be tracked to assess sustainability throughout 2019.
2018 Community Outreach Activities
The community outreach coordinator shared the 2018 summary of outreach activities with the cancer committee. The total number of participants in Health Fairs with prevention and/or screening programs was 2,692. Patients referred for oncology services and screenings were 383 and the number referred for other health and medical needs were 537.
Beaumont sponsored a Men’s Health Event in September of 2018 focused on prevention based on behavioral changes and risk reduction strategies. There were 250+ participants. Patients were educated and informed around colorectal cancer and 165 eligible participants received Colorectal FIT Kits as well as 60 ECHOS and 200 EKGs. Education included nutrition, exercise, dietary, other types of cancers, and one-on-one referrals for individual needs. A survey was administered to gauge overall understanding
of cancer screening guidelines, and current practices. Participants were given resources and assistance to seek further medical care.
These community outreach activities include components and elements from all national agencies utilized with emphasis on American Cancer Society materials and resources.
• Agency for Healthcare Research and Quality; ahrq.gov
• American Cancer Society
• cancer.org/professional
• Cancer Control P.L.A.N.E.T; cancercontrolplanet.cancer.gov
• Centers for Disease Control and Prevention; cdc.gov
• National Cancer Institute; cancer.gov
• National Institutes of Health