Quality & Value Matter
The MaineHealth Cancer Care Network has chosen three quality metrics for our 2024/2025 quality improvement initiatives. Included are the metric definitions, targets, and expectations. Click below to learn more.
Epic TNM Staging Tobacco Screening & Referrals
Epic Staging: Clinical Staging
Clinical Epic Staging Rates
Data per month runs two months behind
Location: MMPMH SP/San/Brun, LMP Med Onc Damariscotta, WCGH Oncology
Goal: Complete clinical or pathological staging in Epic within 60 days of all new patient visits
Target: >= 80%
Diagnoses Exclusions: Patients with Brain Cancer & Neoplasms, Waldenstrom Macroglobulinemia, Leukemia, Mylodysplatic syndrome, or Monoclonal gammopathy
Epic Staging: ERAS Surgeons
ERAS Fiscal Year Trended Staging
% Staged Target
Data per month runs two months behind
Location: ERAS Surgeons
Goal: Complete clinical or pathological staging in Epic within 60 days of all new patient visits
Target: >= 65%
Diagnoses Exclusions: Patients with Brain Cancer & Neoplasms, Waldenstrom Macroglobulinemia, Leukemia, Mylodysplatic syndrome, or Monoclonal gammopathy
Epic Staging: GynOnc Surgeons
GynOnc Fiscal Year Trended Staging
Location: GynOnc Surgeons
Goal: Complete Pathological staging in Epic within 31 days of their surgical date for all new surgical cancer patient visits
Target: >= 30%
Diagnoses Exclusions: Benign Cases
Epic Staging: Thoracic Surgeons
TOC Fiscal Year Trended Staging % Staged Target
Location: Thoracic Surgeons
Goal: Complete pathological TNM staging in Epic within 31 days of their surgical date for all new surgical cancer patient visits
Target: >= 95%
Diagnoses Exclusions: All Non-Lung Diagnosis (Primary Site C34 only included)
Tobacco Screening –“Just Ask”
MHCCN Tobacco Screening - "Just Ask"
% Screened Target
Location: Breast, Thoracic, MMPMH SP/San/Brun, MMP
SurgOnc, MMP GynOnc
QI Initiative: American College of Surgeons Just ASK
Goal: Complete Tobacco Screening within 4-weeks of initial cancer consult
Target: >= 90%
Dashboard Link:
Oncology - Tobacco Screening And Referrals - Power BI Report Server (mehealth.org)
Cessation Referrals –“Beyond Ask”
Location: Breast, Thoracic, MMPMH SP/San/Brun, MMP
SurgOnc, MMP GynOnc
QI Initiative: American College of Surgeons – Beyond ASK
Goal: Tobacco Hotline Referral within 6-months of tobacco screening