Cancer Program Annual Outcomes Report 2015

1. Cancer Program Annual Outcomes Report 2016 Cancer Program Annual Outcomes Report 2015

2. National Recognition

3. Vision • Advocate Vision: To be a faith-based system providing the safest environment and best health outcomes, while building lifelong relationships with the people we serve. • Good Samaritan Hospital’s core competency: Building Loyal Relationships

4. Table of Contents: Quality MeasuresStudies of QualityCancer Committee

5. Quality MeasuresCancer Program Practice Profile Reports (CP3R)2014 Outcome Analysis

6. Quality MeasuresCancer 2014 CP3R Outcome Analysis

7. Quality MeasuresCancer 2014 CP3R Outcome Analysis

8. Quality MeasuresCancer 2014 CP3R Outcome Analysis

9. Quality MeasuresCancer 2014 CP3R Outcome Analysis

10. Quality MeasuresCancer 2014 CP3R Outcome Analysis

11. Quality MeasuresCancer 2014 CP3R Outcome Analysis

12. Quality MeasuresCancer 2014 CP3R Outcome Analysis

13. Quality MeasuresCancer 2014 CP3R Outcome Analysis

14. Quality MeasuresCancer 2014 CP3R Outcome Analysis

15. Quality MeasuresCancer 2014 CP3R Outcome Analysis

16. Quality MeasuresCancer 2014 CP3R Outcome Analysis

17. Quality MeasuresCancer 2014 CP3R Outcome Analysis

18. Quality MeasuresCancer 2014 CP3R Outcome Analysis

19. Quality MeasuresCancer 2014 CP3R Outcome Analysis

20. Quality MeasuresCancer 2014 CP3R Outcome Analysis

21. Quality MeasuresCancer 2014 CP3R Outcome Analysis

22. Program Profile Reports – CP3RCancer 2014 NCDS Submission Outcome Analysis

23. Program Profile Reports – CP3RCancer 2014 NCDS Submission Outcome Analysis

24. Quality MeasuresCancer 2014 CP3R Outcome Analysis

25. Quality MeasuresCancer 2014 CP3R Outcome Analysis

26. Studies of QualityThe Cancer Committee at Good Samaritan Hospital designs and completes studies to evaluate whether patients are being evaluated and treated in conformance with evidence-based national treatment guidelines and to review our patient’s outcomes.

27. Colon Cancer Surveillance Are NCCN colon cancer surveillance guidelines for colonoscopy, CEA and CT being followed for patients diagnosed with Stage II and III (T2 & T3) cancer in 2012 – 2013 who survived without reoccurrence for 3 years past initial diagnosis? Conclusions: • CEA ordered within 4 months of curative resection for colorectal cancer - GSAM = 97% • CT every 6-12 months - GSAM = 88% • Colonoscopy within 12 months of curative resection or adjuvant chemotherapy – GSAM = 88% (average performance = 14% after 14 months from Oncology Roundtable 2016 Cancer Quality Dashboard pg. 17)

28. Colon Cancer Surveillance Notes • CEA: 1 of 32 non-compliant, did not follow-up with MD (GI) • CT: 4 of 32 non-compliant • 2 did not follow-up with MDs (GI & PCP) • 1 with 2nd cancer primary under active treatment, CT deferred • 1 received treatment at another facility and the facility was unable to provide surveillance information • Colonoscopy: 4 of 32 non-compliant • 2 did not follow-up with MDs (GI & PCP) • 1 with 2nd cancer primary under active treatment, colonoscopy deferred • 1 received treatment at another facility and they were unable to provide surveillance information

29. Use of Deep Breath Hold in Radiation Therapy to Decrease Cardiac Dose Does the use of deep inspiratory breath hold (DIBH) for L sided breast radiation therapy patients decrease the mean heart dose and Lung V20 scores in comparison to maximum targets established by RTOG and NCCN? • Conclusions: Patients treated with DIBH in 2014 – 2015 received an average mean heart dose of 108 cGy for 2 fields and 205.4 cGy for 4 fields, both significantly better than the maximum target dose of 400 cGy. Patients treated with DIBH in 2014 – 2015 scored 11.9% Lung V20 for 2 fields and 28.7% for 4 fields of treatment, significantly better than the maximum target dose of 35% cGy.

30. Breast and Ovarian Cancer Are patients diagnosed with breast cancer being referred for cancer genetic counseling in compliance with the NCCN criteria? • Conclusion: 125 patients diagnosed with breast or ovarian cancer in 2014 were reviewed. 54.2% met the National Comprehensive Cancer Network (NCCN) criteria and were referred for cancer genetic counseling. Based on the Oncology Roundtable Cancer Quality Dashboard, the best observed result nationally is 75%.

31. Safe Administration of Chemotherapy A 12 month review of near misses and safety events related to chemotherapy concluded: IV pump settings were the most common cause of chemotherapy administration related safety events/near misses. The RN verification process contributed to treatment delays.

32. Safe Administration of Chemotherapy (cont.) Based on these findings: • the standard RN verification process was modified to include independent review and verification of patient, drug, dose, IV pump settings and IV line reconciliation. • The RN order verification process was revised to occur upon receipt of orders. Following these improvements, the near miss/safety event rate related to chemotherapy administration decreased from 5/year (2013) to 1/year (2014).

33. Lung Cancer Are patients diagnosed with non-small cell lung cancer receiving timely treatment? • Conclusion: For patients initially diagnosed with non-small cell lung cancer between July 2012 and June 2013, the average time from diagnosis to treatment was 16.8 days, which places Good Samaritan Hospital in the top quartile of hospitals based on the Oncology Roundtable Cancer Quality Dashboard (mean = 33 days, top quartile = 20 days).

34. Breast Cancer Are breast cancer patients undergoing mastectomy with four or more positive regional lymph nodes being considered for or receiving radiation therapy within one year of diagnosis? • Conclusion: After reviewing all breast cancer patients undergoing mastectomy with four or more positive regional lymph nodes in 2010 and 2011, 100% were considered for or received radiation therapy within one year of diagnosis.

35. Prostate Cancer Are prostate patients being screened using an American Urological Association (AUA) approved form to assess urinary, sexual and bowel function prior to initiation of treatment? • Conclusion: For men treated in 2012, 100% were assessed prior to treatment using an AUA approved form. Are patients at high risk of recurrence who were prescribed adjuvant hormone therapy receiving external beam radiation therapy? • Conclusion: 100% of high risk men treated in 2012 receiving external beam radiation therapy were prescribed adjuvant hormone therapy.

36. Prostate Cancer (cont.) Are patients a low risk of recurrence who receive interstitial brachytherapy or external beam radiation therapy or radical prostatectomy having a bone scan done after diagnosis? (Note: bone scan is not indicated and results in an unnecessarily exposure to radiation) • Conclusion: 0% of low risk men treated in 2012 were given a bone scan after diagnosis.

37. 2016 Cancer Committee Membership

38. Cancer Committee Membership 2016

39. Cancer Committee Membership 2016

40. Resources • Advocate Good Samaritan Hospital Cancer Registry Statistical Data • National Cancer Database • Cancer Quality Dashboards: Metrics, Definitions, and Benchmarks Spanning the Cancer Care Continuum, 2015 The Advisory Board Company Oncology Roundtable