Physicians as Champions for Quality Improvement
Quality improvement is front and center in health care—a continuous mission requiring the efforts of everyone on the health-care team.
—Joseph Jacobson, MD
Interest in quality measurement and improvement was once primarily a concern of regulators, insurers, and consumer advocates. Today, quality improvement is front and center in health care—a continuous mission requiring the efforts of everyone on the health-care team. At the recent ASCO Quality Care Symposium held in Phoenix, more than 600 oncologists and cancer care providers gathered to exchange new ideas and strategies to improve the quality of care in oncology. The Symposium is the only meeting dedicated to the science and practice of quality improvement in caring for these types of patients.
A key takeaway from this year’s meeting was that the oncology field as a whole must bring the same brand of rigor to quality improvement as is brought to clinical research. As physicians, we are committed to delivering the highest quality care to our patients.
Joseph Jacobson, MD
Physicians are eager to test innovative ways to reduce errors, improve patient safety, enhance the patient experience, reduce inefficiencies, and achieve better outcomes. Yet, if not harnessed carefully and conscientiously, this eagerness can lead clinicians to inadvertently overlook critical details. Care teams may initiate steps to improve quality before identifying the factors that will influence their success; they may become too focused on one aspect of quality care; or the project may not be designed with the kind of methodologic rigor that would be needed to produce durable and sustainable results or knowledge that others can apply.
Four Key Elements
At the Symposium, participants voiced a wide range of perspectives on how we can bring about collective action and agreed on four key elements and guiding points for designing and implementing effective quality-improvement projects.
1. Thoughtful project selection and design: Initial planning for projects should unambiguously define the problem to be solved. By understanding what is to be accomplished, the correct approach can be selected. This may range from a simple unit-based plan-do-study-act test of change to a multi-institutional improvement project that requires quasi-experimental design.
Independent of the design of the project, implementation of the intervention should be informed by an understanding of program theory. Teams should give ample thought to why they expect their intervention to be effective, along with how success will be assessed.
2. Attention to human factors: Understanding the environment in which the project is planned, including the setting of care and the local culture, is essential. Is the culture prepared to tackle change? What must be done in advance of the intervention to ensure that human-human and human-machine interactions are fully understood and optimized?
Trying to impose an improvement project on an overtaxed staff with low morale will almost certainly fail. Even when the culture is right, an intervention that does not fit the existing workflow or that does not respectfully engage those who will be most affected will face stiff resistance.
Researchers from the University of Nebraska Medical Center shared their experience at this year’s Symposium.1 They found that a less-than-optimal work environment worsened by high staff turnover was resulting in low-quality nursing care, and that was adversely affecting patient care. The organization took steps to transform the culture by developing updated professional guidelines, collecting and incorporating staff feedback through regular focus groups, and increasing engagement from its leadership. As a result of these changes, the organization was able to create an environment that was better suited to provide quality patient care, and patients reported much higher rates of satisfaction with their care.
3. Careful integration of health information technology: Technology is now ubiquitous in health care, and more and more data are available for routine care delivery and improvement. Clinical workflow has been markedly altered by the need for the provider to interface with electronic health records, order entry systems, billing systems, and others.
The availability of patient-derived data is growing rapidly through an array of smartphone applications and Internet and office-based portals. Patient-reported outcomes, in particular, provide an opportunity for enormous learning about the patient experience outside of the clinical encounter.
These technologies must be thoughtfully harnessed to enhance, rather than obscure, communication between patient and provider and among providers. The potential to greatly improve quality of care is vast.
For example, at this year’s Symposium, researchers from the Group Health Research Institute in Seattle presented findings that a new online tool can help oncologists navigate the thorny issue of the cost of cancer care.2 Consisting of worksheets that include pricing information for the 50 most commonly ordered treatment protocols and are easily accessed from patients’ electronic health records, this tool helped physicians and patients determine whether the patient can afford the out-of-pocket costs of a certain treatment.
4. Meaningful, ongoing patient engagement: Finally, the Symposium highlighted the urgent need to engage the patient in all aspects of quality improvement. The era of paternalistic medicine is over: Patients want and need to understand how their cancer care can be optimized. As the direct recipients in care, they are uniquely positioned to provide advice around project prioritization, scope, and testing of interventions.
Cancer Care Ontario, which has been at the vanguard of cancer care guideline development, included patients on the working group of a project focused on person-centered adult cancer care.3 The faculty of the ASCO Quality Training Program strongly encourages the inclusion of a patient or patient advocate on team-based improvement project teams.
Improving quality and efficiency in cancer care is a top priority for ASCO. In addition to sponsoring the Symposium, ASCO has undertaken several major quality initiatives that are designed to help physicians monitor and improve patient care.
ASCO’s Quality Oncology Practice Initiative (QOPI®), in which any oncology practice or physician may participate, collects and compares data on more than 100 quality measures against national benchmarks to make sure a practice is providing the best care possible to patients. ASCO also is leading the development of CancerLinQ™, which harnesses big data technology and is expected to be integrated into electronic medical records to provide real-time quality feedback to providers. Finally, PracticeNET is a learning collaboration that allows oncology practices to share information about ways to enhance quality while also reducing costs. I encourage you to take advantage of these resources.
I am already looking forward to next year’s Symposium, which will take place in Orlando from March 3 to 4, and I hope you will consider joining us. The discussion and ideas generated there will help chart a path forward for future research and practice and will help challenge us to continually raise the bar on what it means to deliver high-quality care to our patients. ■
Disclosure: Dr. Jacobson reported no potential conflicts of interest.
Dr. Jacobson is Chief Quality Officer, Dana-Farber Cancer Institute, and was Chair of the 2016 ASCO Quality Care Symposium Planning Committee.
Disclaimer: This commentary represents the views of the author and may not necessarily reflect the views of ASCO.
3. Moody L, Nicholls B, Shamji H, et al: Bringing person-centered care to practice with CCO’s guideline for person-centered care in adult oncology services. 2016 Quality Care Symposium. Abstract 65. Presented February 26, 2016.