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Measuring Oncology Quality through QOPI: A Growing Industry Standard

July 2012, Vol 2, No 4
Dawn Holcombe, MBA, FACMPE, ACHE
President, DGH Consulting, South Windsor, CT

Chicago, IL—The question of how to define and measure quality in oncology is one of the hottest topics in oncology care today. At the 2012 annual conference of the American College of Oncology Administrators in Chicago this past June, a keynote panel discussed how they are meeting that challenge. Robert Hauser, PharmD, PhD, the new Senior Director of Quality and Guidelines at the American Society of Clinical Oncology (ASCO), joined Beth Hayden, RN, BSN, MBA, OCN, Director of Oncology Services at the OSF Saint Anthony Medical Center, Rockford, IL, and Jenna VanGilder, RN, BSN, OCN, Director of Cancer Services at Edward Hospital, Naperville, IL, in describing the national ASCO Quality Oncology Practice Initiative (QOPI), and how it is being adapted across the country and in their own centers.

The QOPI Program

Practices not only have the ability to voluntarily participate in the QOPI program but also to obtain certification under the QOPI certification program. Conference attendees very much appreciated the chance to better understand the program itself and also to listen to 2 real-world examples of colleague institutions adapting the program and its processes to their daily lives—at the OSF Saint Anthony Medical Center and the Edward Hospital Cancer Services.

ASCO launched the QOPI pilot program in 2002, and expanded the program to all members in 2006. After a period of measure and content expansion, the QOPI certification program was launched in 2010. Practices have the option to participate in 2 chart review programs each year, and by spring 2012, more than 6700 individual charts have now been reviewed in almost 300 participating practices. More than one third of participating QOPI practices (approximately 130) have now also achieved QOPI certification. More than 100 measures are now actively being tracked, and expansion is planned for measures such as pediatric oncology, gynecologic cancer, urology/prostate cancer, cost of care, and efficiency.

Quality Measures

In 2012, oncology practices and payers are struggling to find universally acceptable measures that reflect quality in cancer care. In the absence of universal measures, it could be too easy to focus solely on the cost of treatment, without enough attention paid to how that treatment is being delivered. The QOPI program offers not only universal measures but also a way to track and benchmark success against those measures in practices and cancer centers of all sizes and types, even though much of the needed information is still buried in the patient’s medical chart.

This helps payers and practices to change their negotiations from a claims-based discussion to more of a quality initiative–based discussion. ASCO does not release individual practice information or scores, but it does encourage practices and payers to recognize the value of QOPI participation and certification.

Program Participation

Participation in the QOPI program itself is fairly straightforward. If a cancer center desires physicianlevel reporting, it will be necessary to review and submit findings for a minimum of 24 charts for each of 2 or more modules. ASCO offers significant support through a help desk, training videos, and teleconferences as practices prepare for the chart review process. As increasing numbers of practices implement electronic medical records (EMRs), many are finding it easier to extract QOPI-related data this way rather than by manual review.

ASCO suggests the following 4-step process for practices planning to participate in the QOPI program:

  1. Gaining access to the system and setting up the needed accounts and any restrictions on access for staff at different locations, depending on patient and program privacy expectations
  2. Getting familiar with the tools and methods of the program, including the forms and the questions
  3. Getting prepared, that is, defining passwords, training staff, getting ready for the 5-week period of participation and submission
  4. Participating (which entails identifying eligible charts no more than 1 week before the actual data collection) and completing submissions within the 5-week allotted time frame for each data collection session.

OSF Saint Anthony Medical Center

Two participating cancer centers offered great insight into what participation actually entailed for their programs.

Ms Hayden, from OSF Saint Anthony Medical Center, reported that the key to successful participation and eventual certification under the QOPI program was to create a solid base of support and visibility for the program. She and her colleagues made participation in QOPI a 2011-2012 oncology service line goal, as well as a cancer committee programmatic goal. They solicited a physician champion to shepherd the program through internal discussions, as well as the support of the oncology medical director. They also assigned resources to the program in the form of a QOPI resource/audit team.

The first time Ms Hayden and her colleagues tried to participate, they started late and were unable to finish within the designated 5-week period, but once they became active in later sessions, they found that they loved the participation. Ms Hayden noted that the data collection covers a 2-year window—if the data are related to initial visits and you were not following those measures at the time, the previous lack of measures will still be reflected in lower measure scores. Because active participation in the program, with attention to individual measures, evolves, the scores will improve as the data time frame catches up with more diligent following of measured data elements over time.

Ms Hayden shared the following strategies that her cancer center implemented to improve outcomes, as a result of participating in the QOPI program:

  • Creating and implementing a standardized physician progress note
  • Incorporating specific questions into dictation templates that address the areas that need improvement
  • Discussing indicators at weekly physician meetings
  • Incorporating specific QOPI indicators into the oncology service line scorecard.

For illustrative purposes, Ms Hayden also shared the following measures, for which she and her colleagues at the center extracted data and participated:

Core measures module. Under this module, the cancer center staff extracted data and received benchmarking for several measures, including:

  1. Pain addressed appropriately
  2. Documented plan for chemotherapy, including doses, route, and time intervals
  3. Chemotherapy intent (curative vs palliative) documented
  4. Cigarette-smoking status documented by the second office visit
  5. Patient emotional well-being assessed by the second office visit.

Breast cancer measures module. Under this module, some of the data extractions covered the following:

  1. Combination chemotherapy received within 4 months of diagnosis by women aged <70 years with American Joint Committee on Cancer (AJCC) stage I (T1c) to stage III estrogen receptor (ER-negative/progesterone receptor (PR)-negative breast cancer
  2. Test for HER2/neu gene over expression
  3. Trastuzumab not received when HER2/neu status is negative or undocumented
  4. Trastuzumab received by patients with AJCC stage I (T1c) to stage III HER2/neu-positive breast cancer
  5. Tamoxifen or aromatase inhib itor received within 1 year of diagnosis of patients with AJCC stage I (T1c) to stage III ER-positive or PR-positive breast cancer.

Colon/rectal cancer measures module. Under this module, the data collection included the following:

  1. Carcinoembryonic antigen test within 4 months of curative resection for colorectal cancer
  2. Adjuvant chemotherapy received within 4 months of diagnosis by patients with AJCC stage III col on cancer
  3. Adjuvant chemotherapy received within 9 months of diagnosis by patients with AJCC stage II or stage III rectal cancer
  4. Colonoscopy before or within 6 months of curative colorectal resection or completion of primary adjuvant chemotherapy.

Ms Hayden expressed extreme satisfaction with the process and the potential value of their center’s QOPI certification. She noted that the ability to benchmark and focus on quality initiatives that were more clinically driven and cancer specific helped with the standardization of the process and even with some other certification and accreditation processes they needed to follow.

Edward Hospital Cancer Center

Ms VanGilder from Edward Hospital stated that the center was already accredited by the Commission on Cancer, and the center’s leadership decided to seek QOPI certification as well, after their first very successful QOPI participation session.

Ms VanGilder shared much of the preparation and the process they instituted for the certification-related QOPI site visit. She noted that much of the program seems to reside in the responsibilities of the nurses, and that she found it was appropriate to spend much upfront time preparing internally for the certification process and the site visit.

The QOPI program has very specific expectations for a certification site visit, including:

  • Introduction/tour of the facility
  • Observation of 2 to 3 patients scheduled for chemotherapy (QOPI randomly selected)
  • Observation of the preparation, delivery, and administration of chemotherapy
  • Observation of how ASCO/Oncology Nursing Society safety standards are implemented
  • Review of chart documentation of patients who are observed
  • Policy and procedure review
  • Review of policies related to QOPI selected standards
  • Interview of 2 to 3 nurses, 1 pharmacist, 1 administrator, and 1 educator
  • Exit interview.

Ms VanGilder shared the process that her cancer center created internally to prepare for the site visit. Some of the materials were available through the ASCO resources and help desk, and others were created internally by Ms VanGilder and her staff.

All of the cancer center staff were required to attend a QOPI certification update and a presentation to introduce them to the QOPI and give them an overview of the program. The presentation reviewed what the staff could expect during the certification visit. All policies and procedures related to the 17 QOPI standards specific to the preparation and administration of chemotherapy were organized in a binder, which was made readily available for the nurses to review.

The staff was educated on the QOPI standards, and the evidence to meet different criteria was reviewed and shown to them in the EMRs. Demonstrations were also made on how they would talk about the evidence, with the surveyor utilizing the EMRs. Most important, practice interviews were done with staff members when they were preparing to give chemotherapy and during its administration to make them more comfortable with the questions that would most likely be asked by the surveyor.

Ms VanGilder noted that no matter how experienced or skilled the staff was in delivering cancer care, not everyone was prepared at first to clearly describe what they were doing and how those actions were consistent with the QOPI care standards; therefore, a good deal of time was spent in adding those skills to the skill sets of all their staff, in preparation for the site review.

Part of the constant preparation process for the site visit included using a clinical educator to observe clinical practice in action and conduct mock interviews of staff; safety standards were also reviewed on a one-on-one basis with the key individuals who would be present in the infusion clinic during the site visit. By creating an internal binder with all the policies and procedures, Ms VanGilder and her staff also found that there was a need for, and a value in, a standardized orientation process for the staff in general. The center has also added a quality coordinator to follow through with consistency in the process and training at the center, a direct benefit and result of preparing for the QOPI certification.

Ms VanGilder also shared some of the recommendations she and her staff received as a result of their participation in the QOPI program. One recommendation was to have all the physicians become certified in CPR (cardiopulmonary resuscitation). Another was that depression (ie, the psychosocial effects of treatment) was a huge issue that they were addressing inconsistently. A third recommendation involved the clarification of cancelled appointments versus “no shows” in their records.

The time required to participate in the data extraction has shrunk measurably with ongoing program participation, according to Ms VanGilder. When she first started, the process took a while, even when she used her EMRs as much as possible; it now takes approximately 15 to 20 minutes per patient. There is a learning curve involved with knowing what the questions are—the more you do it, the easier it becomes.

What Does a QOPI Certification Entail?

Practices or cancer centers have to participate in the QOPI program to become certified, but certification is a full program on its own.

The QOPI certification process entails abstracting and scoring certain levels for all modules of QOPI participation, as well as attestation to meeting all 17 chemotherapy preparation and administration safety standards, submitting policies and documentation for safety standards, and random (personal health information de-identified) medical records for validation. A majority of practices seeking certification will also participate in an onsite review by advanced-degree oncology nurses. Findings and results for the measures and standards scoring and the onsite visit are evaluated for qualification for a QOPI certification.

The certification standards center on staffing, treatment planning and chart documentation, informed consent, chemotherapy orders, drug preparation, chemotherapy administration, patient monitoring and assessment, and preparedness for emergency situations. Once certification is awarded, the certification is valid for a period of 3 years, after which recertification is expected.

QOPI certification is one of the few certification programs available to private cancer practices, and it fully complements cancer center certifications by the Commission on Cancer and other hospital-based accreditation programs.

Increasingly, payers will be asking for evidence of such certification participation as a mark of quality, making participation almost a necessity for providing cancer services. Another value to such certification programs is that they set the bar for care delivery very high clinically and may reduce the risk of nonphysicianor hospital-based programs seeking to deliver cancer care services in alternative treatment models.

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