"Development of a Practice Improvement Plan for a New Radiation Oncology Department"

1. "Development of a Practice Improvement Plan for a New Radiation OncologyDepartment" Molly Gabel, M.D. Associate Professor Radiation Oncology Robert Wood Johnson University Hospital

2. Resources for Quality Improvement • Agency for Healthcare Research and Quality • Institute for Healthcare Improvement • National Association for Healthcare Quality • Joint Commission on Accreditation of Healthcare Organizations • Institute of Medicine

3. Quality Assurance Quality Improvement Clinical Value Compass : Sorted Monitors Functional Health Status: Physical function Mental function Pain/Symptom Relief Quality of life Satisfaction: Patient, staff, Referring MD Access to care Respect, trust “I got what I want and need when I wanted it and needed it” Clinical Outcomes: Morbidity Mortality Safety Survival Costs: Direct medical Indirect/social Market share and volume Insurance carriers

4. Quality Improvement circa 2000 • Compass encouraged multifaceted quality improvement • Outcomes data encouraged • Success defined as 5-10% improvement over baseline

5. Quality Improvement after 2001 • Result of the Institute of Medicine’s report “Crossing the Quality Chasm: A New Health System for the 21st Century (2001)” • Health care industry should hold itself to same standards as other industries • Recommended complete redesign of delivery systems, based on data • Zero defects, “perfect care”

6. Ten “Simple” Rules for Redesign of Care Adapted by Donald M. Berwick, MD, from IOM, Crossing the Quality Chasm, 2001 Old Way 1. Care is based primarily on visits. 2. Professional autonomy drives variability. 3. Professionals control care. 4. Information is a record. 5. Decision making is based on training and experience. New Rules 1. Care is based on continuous healing relationships. 2. Care is customized according to patient needs and values. 3. The patient is the source of control. 4. Knowledge is shared freely. 5. Decision-making is evidence-based.

7. Ten “Simple” Rules for Redesign of Care Adapted by Donald M. Berwick, MD, from IOM, Crossing the Quality Chasm, 2001 Old Way 6. “Do no harm” is an individual responsibility. 7. Secrecy is necessary. 8. The system reacts to needs. 9. Cost reduction is sought. 10. Preference is given to professional roles over the system. New Rules 6.Safety is a system property. 7. Transparency is necessary. 8. Needs are anticipated. 9. Waste is continuously decreased. 10. Cooperation among clinicians is expected.

8. 2001: Raising the Bar for Healthcare Quality: Pursuing Perfection InitiativeJoint Grant Process with RWJF and IHIchallenging health care systems to aim for zero defects • Six Aims For Improvement that evolved from those rules: • 1. Safe • Avoids injuries to patients from care that should help • 2. Effective • Matches science to care, avoids overuse of ineffective, under-use of effective care • 3. Efficient • Continually reduces waste • 4. Timely • Involves less waiting, for patients and for providers • 5. Patient-centered • Honors individual preferences and values, respects choice • 6. Equitable • Closes gaps based on race-ethnicity and other demographic variables

9. Pursuing Perfection: Process of Outcome Measurement • Define “perfect” care • Absolute value (e.g., zero defects, 100% accessibility) • Best possible level (specific non-zero target) • Define baseline performance • Define timeline for “perfect” - 24 months • Set ambitious interim targets • Define between end goal and “current” performance • Close gap by half every six months

10. Brand new department No chart rounds (physician peer review) No M&M No tracking of timeliness No documentation in chart of pain management No documentation of treatment variances No documentation of multi-tiered patient education No documentation of staging, performance status or fall risk No standardized satisfaction survey No clinic enhancements planned RWJUH Department of Radiation Oncology First Performance Improvement Meeting

11. Access to care: time to initial consultation Treatment Variances Physician peer review Done within one week Recommendations acted upon ECOG, fall risk, pain all documented, followed and acted upon in chart Extensive patient education documented in chart Translation of teaching materials to Spanish Written discharge instructions upon completion Documentation/update of medications throughout treatment Development of unique satisfaction survey Timely care Safety Safety Safety Effective, patient-centered Patient-centered Effective, efficient, patient-centered Effective, patient-centered, safety Patient-centered Performance Improvement Plan :Simple Example RWJUH Initiatives Correlation with Six P.P. Aims

12. RESULTS Timeliness of consultation Safety: Treatment Variances

13. Safety: Physician Peer Review for each new field Safety, Efficacy: Performance status, pain and risk of fall documented in consult and on-treatment visit notes

14. Efficacy, Patient-Centered, Efficiency: Multi-tiered education documented in chart (at consult and in separate post-simulation teaching session by nurses) Effective, Patient-Centered: Written discharge instructions ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ Thank you for taking the time to complete this survey. Your answers will be used to improve the experience for future patients. Rev. 1/15/05 Comments: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Thank you for taking the time to complete this survey. Your answers will be used to improve the experience for future patients. Comments: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Comments: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

15. A More Complex Example….. Pursuing Perfection in Prostate Cancer Care: Transforming a Healthcare System • From the six aims, we (40 physicians) made enhancements to our prostate cancer practice: • Multidisciplinary prostate cancer clinic • Educational DVD co-written by urologists and radiation oncologists, post –test at end • Clinic note via EMR to all providers, same day • Patient follow up card • Patient advisory board • Rigorous patient follow up (comprehension, treatment, satisfaction, morbidity and status) Note: above with the assistance of a very robust electronic medical record

16. Pursuing Perfection in Prostate Cancer Care:Results Fig. V.8: Patients Treated According to NCCN Guidelines 100 99 98 97 Percent 96 95 94 Baseline 4Q01 1Q02 2Q02 3Q02 4Q02 1Q03 All Patients PCOP Patients Target 4Q01 results due to 2 patients’ mortality (>75 undergoing surgery)

17. Pursuing Perfection in Prostate Cancer Care:Results

18. Pursuing Perfection in Prostate Cancer Care:Results - Administered 6 months post-treatment - >80% response rate Coded by race: No variation

19. M.O.C. Guidelines • May be easier for physicians in hospital-based department (with Performance Improvement policy and reporting in place) • But…….RWJUH experience gives example of simplified version of practice improvement easily translated to smaller practice setting • Offer consultation/training on national level • Consider incorporating practice improvement into residency training