Improving Quality Care in Community Oncology Settings
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Findings from 3 quality improvement initiatives presented at the ACCC National Oncology Conference shed light on the feasibility and importance of these projects at the community level.
Quality improvement plays an important role in medical practices as a methodical approach to enhancing patient care and ultimately improving outcomes. Key areas of focus include patient safety and satisfaction, clinical outcomes, and efficiency.
Implementing quality improvement initiatives with buy-in from all members of a practice can lead to improved outcomes for patients, better staff morale, and stronger practice reputation. At this year’s Association of Cancer Care Centers (ACCC) National Oncology Conference, 2 presentations focused on quality improvement initiatives in community-based cancer centers.
Using Lean Six Sigma to Improve Cancer Staging
One such initiative was the implementation of Lean Six Sigma methodology at the Oncology and Hematology Care (OHC) in Cincinnati, Ohio, spearheaded by David M. Waterhouse, MD, MPH, medical oncologist/hematologist and director of early phase clinical trials at OHC, and Molly Mendenhall, MBOE, LSSBB, BSN, RN, director of quality and compliance at OHC.1
The principles of Lean Six Sigma are to eliminate waste by identifying and removing unnecessary steps and activities that don’t add value to the process, reduce variation by minimizing inconsistencies, improve flow by streamlining processes, and focus on delivering products that meet or exceed expectations.2
Molly Mendenhall, MBOE, LSSBB, BSN, RN
“Lean Six Sigma is something that OHC deploys to look at quality improvement projects—basically using that process as structured approach to identify and often eliminate inefficiencies,” said Mendenhall in an interview with Targeted OncologyTM. “Our staging process looks at defining the problem and how are we measuring baseline to find the gap to the goal? How do we analyze root causes? Then, when can we implement those targeted strategies and interventions to move it to that controlled phase where we can sustain that improvement over time?”
Waterhouse and Mendenhall’s initiative used a Lean Six Sigma tool known as DMAIC—define, measure, analyze, improve, control—to improve the rates of cancer staging at OHC. The issues with staging were initially identified in non–small cell lung cancer (NSCLC), but Waterhouse correctly suspected that the issue was not limited to cancer type.
“We noticed a problem with staging that, although doctors’ notes had staged patients largely correctly, and the patients were getting the appropriate treatment, the staging was not making it into structured fields. As a result of that, it was very difficult to measure what we were looking for, because if you cannot find the patient, you cannot do these kinds of improvements,” said Waterhouse in an interview with Targeted OncologyTM.
Identifying the right tool to begin the initiative was the first part, according to Mendenhall. “There are a lot of great Lean Six Sigma tools out there, and that is part of it. The culture and physician buy-in is that second part,” she explained.
David M. Waterhouse, MD, MPHDavid M. Waterhouse, MD, MPH
“We knew, at least in the non–small cell lung group, what our baseline was. We then sought to establish our baseline by basically manual chart auditing. We then developed processes for that. That process of auditing, then reporting to the doctors, creating dashboards for them to understand where their staging was,” Waterhouse said.
Mendenhall noted that OHC used value stream mapping, a visual tool to identify and analyze the flow of materials and information, along with process mapping to assess gaps and the root cause of issues. Pareto charts were also used to pinpoint specific breakdowns in the process, whether related to a certain diagnosis or core components of staging.
However, asking staff to repeatedly fix their mistakes was not effective enough. To improve buy-in, OHC’s compensation structure was leveraged.
“Built into our compensation system at OHC, a portion of our compensation is dependent upon meeting various quality metrics, dependent upon whether you are a medical oncologist, a radiation oncologist, a gynecologic oncologist, or something that is appropriate to everybody. We put this as a metric which would be linked to their compensation. It was a zero-sum game. If everybody met their metrics, everybody got paid the same, but if you did not meet the metrics, then you were hurting the rest of the population. You did not get paid on that metric, and the rest of your partners took that money and divided it up,” Waterhouse explained.
“All of those tools and combinations are what drove the success behind the project, along with those visual managements or scorecard pieces and financial metrics at the end,” Mendenhall added.
Aiming for Better Biomarker Testing in Lung Cancer
Another quality improvement initiative presented at the ACCC meeting included one from Matthew Smeltzer, PhD, MStat. Here, a survey of over 100 providers across 3 community cancer centers was conducted to identify quality gaps in early-stage NSCLC.3
Matthew Smeltzer, PhD, MStat
“This is part of a greater initiative to help identify quality gaps in community cancer care and find solutions and ways for improvement, and then to disseminate the findings in order to help improve care and create content for cancer centers to learn from and to utilize tools and different types of content that maybe can help someone improve their care,” said Smeltzer, associate professor of epidemiology and biostatistics at the University of Memphis School of Public Health, in an interview with Targeted OncologyTM.
The survey assessed quality metrics and issues within the care environment. The survey identified issues including suboptimal evidence-based treatment planning due to a lack of multidisciplinary teams and biomarker testing in early-stage NSCLC.
“Biomarker testing may not be ideal in early-stage lung cancer and in early-stage surgically resected lung cancer. EGFR, ALK, and PD-L1 testing are 3 biomarkers we need on most patients, and probably all patients. In general, we think all 3 of those need to be tested at an early stage,” Smeltzer explained. “If you look at the [National Comprehensive Cancer Network (NCCN)] guidelines for early-stage lung cancer, they recommend testing for these. This is one thing that we figured would be a hot topic for these projects. When we recruited and got the sites signed on for this project, all 3 sites wanted to address biomarker testing.”
Biomarker testing serves crucial purposes in lung cancer, specifically regarding personalizing treatment. However, several barriers can halt optimal biomarker testing. Smeltzer identified these barriers as lack of awareness, lack of streamlined processes within the clinical workflow, and prohibitive costs to patients.
According to Smeltzer, reflex testing was the solution implemented at one site to automate the process of biomarker testing.
“The way they were able to do that is to work together with the pathologists, the medical oncologists, and the surgeons to decide a group were going to do this, and then figuring it out the barriers to making this happen with the hospital administration,” Smeltzer said. “They were able to implement and put the reflex testing in place, in which the pathologist will automatically do it, and there is essentially a standing order from one of the other physicians. That sometimes is another issue about who is ordering the test, depending on how [the institution is] structured.”
The implementation required buy-in from everyone at the institution, in addition to direct collaboration with the testing company to minimize excess costs.
“It was not all solved in one day, but by getting everybody in the same room to find solutions, they were able to put this in place. We do not have the final results yet, but I understand that it is going well. I am looking forward to seeing how good their testing rates are at the end of the day,” Smeltzer added.
Practical Implementation of Quality Improvement Initiatives
Waterhouse stressed that quality improvement initiatives can take place at any institution, regardless of size.
“Quality should be an aspiration of everybody, whether you are a solo practitioner or you're working at the Mayo Clinic. For quality work, you are never going to meet all your goals, because, as with any process, you keep finding other places where you could do better,” he said.
“I think from my perspective, whether it is community-based or hospital-based, I think the key lesson here is the importance of a standardized process as you are basically using that as the power behind that continuous quality improvement mentality with techniques like Lean Six Sigma, but also that value of incentives to drive that compliance piece home with providers,” Mendenhall added.
Mendenhall also noted that it is not necessary to have a Lean Six Sigma background to take on projects like the one at OHC.
“Not every tool is meant for every project, but what is great is you can pull in experts from all areas of your facility, and you do not necessarily need to have somebody with a Lean Six Sigma background. Pulling in physician champions like Dr. Waterhouse is a great example of getting that buy-in on the front lines,” she explained.
Smeltzer emphasized the importance of awareness when it comes to identifying new goals and implementing projects.
“Awareness is a major piece of good quality care. Guidelines are changing so frequently, and cancer care is evolving so rapidly that it is important that we are all up to date on best practices and finding solutions. We can all agree that things should happen, but sometimes there is this process level that must be implemented to make it happen,” he said.
Waterhouse noted that there is always room for improvement at every practice.
“The hard part is not coming up with ideas. The hard part is prioritizing the ideas. If you cannot look at your practice and figure out where you could do better, something is wrong with you. All of us can do that every single day,” Waterhouse said. “It is an ongoing process. It will always be an ongoing process. We want every single person in our group to be doing this.”
