Rex Cancer Center: Integrating Quality Improvement Standards

Neil Canavan

July 2012, Vol 2, No 4 - Quality Care


Baltimore, MD—Quality reporting is one of the cornerstones of the healthcare reform. Now is the time to integrate quality improvement mechanisms at your cancer center, suggested Cynthia Jones, BSHA, CPHQ, Quality Program Coordinator at Rex Cancer Center, NC, at the 2012 Association of Community Cancer Centers meeting.

Rex Cancer Center—with practices in Wakefield and in Raleigh, NC—consists of 2 hematology/oncology sites with infusion suites, and 4 radiation oncology sites. The center employs more than 1100 medical personnel and treats an average of 150 new patients monthly.

In 2008, 2009, and 2011, Rex Cancer Center’s Hematology/Oncology Associates re ceived national recognition as one of the best national outpatient cancer programs for patient satisfaction by Professional Research Consultants, as well as the highest score in the national Outpatient Oncology Service Line database.

“So, given these accolades,” said Ms Jones, “why would Rex hire someone to do quality assessments?” The center is growing, treating more patients, becoming organizationally more complex, and facing increasing competition.

Getting Started: Assessing the Problem

Ms Jones’ first day at Rex Cancer Center was in February 2011. “The staff was somewhat frightened about having someone there who works for the director and is coming out to be her eyes and ears,” she recalled. “It was unsettling for them. So, my first task was to engage them and to make it clear that I was there for the greater good,” not only for the patient, but also to find ways to protect and maintain the staff that had already earned such high recognition.

Ms Jones set out to communicate to the directors that she was not interested in “mission values that hang on the wall,” as much as in discovering what was going on in the treatment areas.

“I first needed to know what we do really well,” which would (1) clarify how the awards for excellence were earned, and (2) show the staff an appreciation of skills and talents that were already contributing to the center’s success, to foster cooperation rather than blame.

Ms Jones started with an assessment of high-risk activities, including chemotherapy administration (740 bags mixed monthly) and blood products (150 blood/blood products transfused monthly).

“There was already a variance reporting system at Rex—most acute care centers have a risk management reporting system,” said Ms Jones. They had quantitative data, but they were missing any qualitative component. “The problem was that the reporting was not detailed enough to explain why anything happened.”

She started to spend time in the wards. “My goal was not to put Band-Aids on what goes wrong, but to identify the problem as it occurs, and as it will likely occur again.” She wanted to fix the workflow, which required more information.

Improving the Communication Procedures

“Initially, nurses said, ‘I don’t have time for detailed reports.’ They just jot a brief note. But when you’re reporting events, you want to know the key facts that led to the event. You should be able to do that in 3 lines or less,” Ms Jones said. The new process seemed like a huge culture change initially, but within weeks it began to bear fruit. “We have a robust reporting system now that includes the details I need to identify how a process is not working.”

For example, “We were seeing medical events that were tied to ordering,” she said. By going to the wards and talking to all the players—the nurses, the pharmacists, and the physicians—she established that there were basic miscommunications that were directly related to the order form.

Yet, everyone was wedded to that form, because they were used to it. “I had to convince them to revise it, because it did not communicate well with anyone.”A simple revision to the document’s formatting, to how it looked and read, improved its performance. “It became a much improved communication tool,” Ms Jones said. Errors and events were reduced.

Gaining the qualitative information was key to addressing treatment variance, which involved the right attitude to ensure the staff that the goal was not punitive, as well as patience, because, Ms Jones said, “at first you hear complaints. You need to deescalate the complaint, and then try to get at the facts.”

These facts were entered into an Excel spreadsheet, with the events down the x-axis and the reasons for the events across the y-axis.

Identifying Breakdowns in the Process: Improving Care Quality

Ms Jones then addressed the problem of chemotherapy waste. “Again, the reporting was there, but there was no detail about the waste,” she said. She asked the pharmacists how they get through their busy day, to get a clearer picture of what was going on. Once the information was collected, trends emerged.

“Again, I could see communication breakdowns,” Ms Jones said, outlining the following problems:

  • Laboratory results were not assessed before the mixing of chemotherapies
  • Orders were mixed before the time the drugs were needed
  • There were port/intravenous problems that the pharmacists did not know about.

“This information helped my group go from complaining to seeing how waste could be prevented. This new insight was not just on the part of the pharmacists, but the nurses and the doctors as well,” she said.

The proposed changes were not monumental. “I would estimate that we can prevent 75% of these events by changing just a few things about how we do what we do,” Ms Jones suggested.

She then assessed the radiation oncology services, using the same process in gathering data. The main complaint from radiology was about treatment delays. The assessment revealed the main culprits:

  • The treatment plan was not approved in either of the oncology management systems software programs (ie, Impac and ADAC)
  • Additional information was required by the treating physician
  • Miscommunications were common.

“I mapped it all out, and then even broke it down by diagnosis,” Ms Jones explained. She determined that patients with head and neck cancers were experiencing the most delays at the center. “We needed to recognize that treating these patients took more time, involved more variables, and therefore had more delaycausing complexities.”

This approach was focused on understanding the breakdowns in the process rather than on finger pointing.

This is just one example, and the story at your institution may be different, Ms Jones said, but to tell the story, and to change how the story ends, you need the qualitative data.