Quality Improvement Initiatives in Cancer Care

COC / NAPBC / NAPRC Tracy Paulus, CTR Goshen Center for Cancer Care / Goshen Health ICRA President

I am not an expert. I have nothing else to disclose. DISCLAIMER

COC Commission on Cancer

What is the intent of this standard? What do you need? STD. 7.3 QUALITY IMPROVEMENT INITIATIVE What is the end game? Important notes: ~If you already know the cause of the problem, it will not qualify ~You can t do a study to see if a problem exists .one must already be known

STD. 7.3 EXAMPLES FROM CANSWER FORUM Chart audit revealed low percentage of women at childbearing age undergoing chemotherapy had documented discussion of fertility options and resources This does seem to meet the standard; however, we cannot pre-approve quality initiatives 1. Initiating new QI for Covid Vaccination on Oncology population. Plans for inpatient administration and scheduling outpatients for when the clinic is open. Potentially good QI; however, we cannot pre-approve quality initiatives 2. Delay in treatment for patients receiving concurrent chemoradiation Could be considered a problem statement that needs to be studied 3. Patients who have surgical treatment only and are not seen by medical and/or radiation oncology are not always staged If you have a problem statement around surgical treatment only and problems with missing stage, this could be a reasonable topic. 4. 1. https://cancerbulletin.facs.org/forums/forum/commission-on-cancer-coc-2020-standards/chapter-7-quality-improvement/standard-7-3-quality- improvement-initiative/119732-qi 2. https://cancerbulletin.facs.org/forums/forum/commission-on-cancer-coc-2020-standards/chapter-7-quality-improvement/standard-7-3-quality- improvement-initiative/117753-potential-qi-initiative 3. https://cancerbulletin.facs.org/forums/forum/commission-on-cancer-coc-2020-standards/chapter-7-quality-improvement/standard-7-3-quality- improvement-initiative/117479-std-7-3-qi-project 4. https://cancerbulletin.facs.org/forums/forum/commission-on-cancer-coc-2020-standards/chapter-7-quality-improvement/standard-7-3-quality- improvement-initiative/117430-surgical-staging

What is the intent of this standard? What do you need? What is the end game? STD. 7.4 CANCER PROGRAM GOAL Important Notes: ~Must fit the CoC template ~Cannot duplicate requirements from another standard

STD. 7.4 EXAMPLES FROM CANSWER FORUM Implement a telepathology program Develop and implement an art therapy program for cancer center patients and family members Create policies and procedures to verify accuracy of chemo administration Evaluate current patient education materials/services and implement improvements to patient education where needed Increase rate of completion of Medical Orders for Life Sustaining Treatments for cancer patients with an inpatient Do-Not-Resuscitate order Remodel current cancer center to add new patient registration area for cancer services https://cancerbulletin.facs.org/forums/forum/commission-on-cancer-coc-2020-standards/chapter-7-quality-improvement/standard-7-4-cancer-program- goal/121354-ca-committee-approved-smart-goal

STD. 7.4 EXAMPLES FROM CANSWER FORUM 1. Using SMART, discussing the purchase/installation of a new nuclear medicine camera to improve cancer related studies, particularly bone imaging Appears to be appropriate; however, we do not pre-approve goals 2. Development and Implementation of a Health Literacy Program to help with non- compliance We do not pre-approve goals. Make sure all elements are there and write in SMART format. 3. Can we consider the hiring process of a new Radiation Oncology as a goal? It would involve the hiring process, documentation of need for the physician and timeline of the process to maintain continuity of services. The CoC cannot pre-approve standard compliance. However, this could be an acceptable goal provided all requirements are met. 1. https://cancerbulletin.facs.org/forums/forum/commission-on-cancer-coc-2020-standards/chapter-7-quality-improvement/standard-7-4-cancer-program- goal/118707-new-equipment 2. https://cancerbulletin.facs.org/forums/forum/commission-on-cancer-coc-2020-standards/chapter-7-quality-improvement/standard-7-4-cancer-program- goal/116598-health-literacy-program 3. https://cancerbulletin.facs.org/forums/forum/commission-on-cancer-coc-2020-standards/chapter-7-quality-improvement/standard-7-4-cancer-program- goal/113619-hiring-new-physician-as-program-goal

What is the intent of this standard? What do you need? STD. 8.1 ADDRESSING BARRIERS TO CARE What is the end game? Important Notes: ~Could possibly be related to other standards, as long as what you use is not a part of the required criteria

STD. 8.1 EXAMPLES FROM CANSWER FORUM 1. Help with reducing delays to treatment Yes, delays to treatment can be a barrier Other Ideas . 1. Fear of Lost Wages / Returning to Work; Developed educational materials for staff on topics and terminology related to the disability programs available to workers so they could better have those conversations with patients and a more defining guideline of when to refer patients to social work for further assistance. - Jessi Beth Colby, Facebook 2. Goshen: English to Spanish documents; Transportation; Housing 1. https://cancerbulletin.facs.org/forums/forum/commission-on-cancer-coc-2020-standards/chapter-8-education-professional-and-community- outreach/standard-8-1-addressing-barriers-to-care/111068-delay-in-care

NAPBC National Accreditation Program for Breast Centers

What is the intent of this standard? What do you need? STD. 2.20 SURVIVORSHIP What is the end game? Important Notes: ~The 50% requirement is temporarily suspended due to the pandemic. Make sure to document on the COVID-19 Accreditation Tracker.

STD. 2.20 CANSWER FORUM 1. SCP Delivery Clarification Treatment Completed Elsewhere Your program provided a portion of curative treatment so if you cannot provide the full SCP, you should provide an SCP based on what your center provided. 2. SCP in Person or Telephone Follow-up Mailing is not the preferred method. In person and calls should be tried before sending through the mail. If mailing, there should be a follow-up call to see if the patient wants to discuss or has questions. It should be documented that it was mailed. 3. SCP Numbers Calculations Denominator (Final Reported) = the number of eligible patients who finished treatment in the target year Numerator = the number of Survivorship Care Plans delivered for the target year 1. https://cancerbulletin.facs.org/forums/forum/napbc/chapter-2-clinical-management/s2-20-breast-cancer-survivorship-care/120261-scp-delivery- clarification-treatment-completed-elsewhere 2. https://cancerbulletin.facs.org/forums/forum/napbc/chapter-2-clinical-management/s2-20-breast-cancer-survivorship-care/117088-scp-in-person-or- telephone-follow-up 3. https://cancerbulletin.facs.org/forums/forum/napbc/chapter-2-clinical-management/s2-20-breast-cancer-survivorship-care/112135-scp-numbers- calculations

What is the intent of this standard? What do you need? What is the end game? STD. 6.1 QUALITY AND OUTCOMES Important Notes: ~A study cannot be conducted for the purpose to meeting a standard. However, a study could aim to enhance upon how you meet the requirements. ~The same study can be used for both NAPBC and the CoC, just make sure the study meets the requirements for both

STD. 8.1 EXAMPLES FROM CANSWER FORUM 1. One of our CY21 studies found an issue during analysis: patients not being appropriately referred to our high-risk breast clinic. Issue impacts about 20 patient per year. Would it meet criteria knowing the number of patients affected is relatively small? Yes, this will meet the standard as long as all other criteria are met and the topic is relevant to your center 2. Can you clarify what we need to report to our BPLC to count QOPI as one of our studies? For compliance, a summary of the data over the past year or time of study must be presented to the BPLC 3. My facility is located in an under served area where the number of patients receiving screening mammograms is low. Our social worker is looking to conduct a survey using a questionnaire given to the surrounding community members in order to identify some of the major barriers leading to a lack of screening mammograms, such as transportation, insurance, religious beliefs, etc. Would this be something that we could utilize as a quality study for 2020?? Yes, based on the above information, it sounds like it would meet criteria for a quality study. Make sure there is a good analysis performed on the information collected 1. https://cancerbulletin.facs.org/forums/forum/napbc/chapter-6-quality-improvement/s6-1-quality-and-outcomes/121398-small-number-of-patients- impacted-for-a-possible-study 2. https://cancerbulletin.facs.org/forums/forum/napbc/chapter-6-quality-improvement/s6-1-quality-and-outcomes/109846-qopi-for-qi 3. https://cancerbulletin.facs.org/forums/forum/napbc/chapter-6-quality-improvement/s6-1-quality-and-outcomes/99138-possible-2020-study

NAPRC National Accreditation Program for Rectal Cancer

Patients that ARE included: ICD-0-3 Site Code: 20.9 (rectal) Adenocarcinoma & Metastatic, Stage IV, disease Patients receiving first course treatment for a new diagnosis Patients receiving palliative care for first course therapy Surgery only patients (neoadjuvant & adjuvant therapy elsewhere) PATIENT SELECTION Patients that are NOT included: ICD-0-3 Site Code: 19.9 (rectosigmoid) In-Situ; Squamous; Carcinoid histology; Neuroendocrine Tumor; Rectal GIST Patients with a recurrence Follow-up Only (NED & all first course treatment elsewhere) NOTES: Patients not having definitive surgical resection are not included in the denominator for Std. 5.11 but would be included for Stds. 5.1, 5.5, & 5.6. Emergency patients are included in Stds. 5.9-5.13

THIS IS HOW WE DO IT. Agenda AGENDA Attendance Minutes Spreadsheet ATTENDANCE & MINUTES SPREADSHEET Attendance Minutes Spreadsheet

OPEN DISCUSSION Thoughts? Comments? Questions?

MY INFO Tracy Paulus, CTR Goshen Center for Cancer Care Phone: 574-364-2894 E-mail: tpaulus2@goshenhealth.com