Dr. Mary Dixon-Woods kicked off the recent ASCO Quality Care Symposium with a rousing introductory lecture asking “Why is quality improvement so hard?” She outlined several barriers to quality cancer care, highlighting the role of operational defects. Oncology care is composed of “multiple interacting microsystems” that are complex and tightly coupled. A defect in one process along the system can propagate risks throughout the entire care chain. As an example, she cited outpatient chemotherapy where successful delivery is dependent on multiple factors, including production and precise dosing, on-time drug delivery, timely lab work, and successful coping with less predictable patient adverse reactions to treatment. In this high-risk clinical setting, nurses are frequently spending their time in “rescuing situations” and working around operational failures rather than being involved in a standardized work flow.
Poorly functioning systems stress providers, generating negative team dynamics, and ultimately impacting patient care.
Unfortunately, these system defects are not easily repaired. Reforms must be reality tested. Like parents who insist that their baby is the loveliest and eschew criticism, practitioners will often insist on the success of their intervention without submitting it to rigorous, independent analysis. There is a lack of attention to how the intervention will result in the desired outcome. Dr. Dixon-Woods urged that, as in other areas of medicine, quality improvement proposals require a theory that links the intervention to an outcome.
Furthermore, every problem should not be treated as something unique with the development of a local solution; rather there should be widespread adoption of successful interventions. “Standards are like tooth brushes, everyone has one, nobody wants to use anyone else’s,” she said.
The proliferation of local solutions degrades system safety. There is only a limited amount of organizational attention and the proliferation of forms and rules erodes the success of quality improvement interventions.
Dr. Dixon-Woods concluded that there is a way forward for quality improvement in oncology care. She emphasized the importance of highly functioning teams and collective competence to achieve quality improvement goals and of moving away from no blame to fostering a moral community and individual accountability. She also noted the importance of focusing on positive deviance, replicating the success of organizations that are doing quality improvement well. Finally, many of the issues underlying quality are “big and hairy,” and these, she states, require structural changes and must be confronted at the sector level through organizations such as ASCO.
Lung cancer management
Dr. Michael Fung-Kee-Fung followed Dr. Dixon-Woods with a discussion on improving lung cancer care and described how his team’s intervention at the Ottawa Hospital demonstrated how quality improvement in care delivery can be made in a complex and large cancer system.
Dr. Fung-Kee-Fung and his associates evaluated the journey of the lung cancer patient from suspicion of cancer to initial treatment. The researchers had noted that there was variable access to treatment depending on which specialty provider a patient with suspected lung cancer sees. Taking a systems-based approach, their goal was to get “the right patient to the right providers with the right information and tests to make the right treatment decision.”
The methodology involved a systems-wide view of the patient journey and standardizing it across the region, building collaboration between communities of providers and involving patient partnerships in redesigning patient flow, and, finally, “hard-wiring” these changes through technological solutions. After the development of their care platform, there was a 48% reduction in cumulative wait times from referral to initial treatment as well as increased patient satisfaction with coordination of care.
Dr. Ray Osarogiagbon also discussed the issue of quality improvement in lung cancer care delivery focusing on this issue of highly functioning teams and collective competence. His team examined the question of “quick, efficient, accurate triage into the treatment pathway most likely to provide the best possible outcome within the bounds of patient preference” and focused on the multidisciplinary care model. The researchers assembled diverse stakeholders (patients, caregivers, clinicians, hospital leaders, health insurance executives) to provide input on the characteristics of optimal care delivery. The stakeholders agreed that the benefits of multidisciplinary care include collaboration, coordination of care, concordance with guidelines, and timely care. They saw concerns, however, with conflicting treatment opinions, scheduling conflicts, and financial disincentives. They have now initiated a matched cohort comparative effectiveness study to compare multidisciplinary care against conventional serial care. Outcomes include timeliness of care, stage-confirmation rates, stage-appropriate treatment rates, patient reported outcomes, and survival. This study is currently ongoing, but it demonstrated the rigorous approach to quality improvement advocated by Dr. Dixon-Woods.
The future of quality improvement in the setting of payment reform
Dr. Deborah Schrag put much of the research in context in her abstract discussion on oncology practice innovators. She advocated that the Gertner Model of Analytics should be employed in oncology quality of care research with the adoption of prescriptive analytics, to “make good care happen consistently, every time.” This model has been applied to other industries and must be considered in the oncology space, especially in the setting of payment reform. These reforms will call for a proactive care system with, as Dr. Schrag points out, care delivered not just in offices but through phone calls, navigators, and nurses to keep patients well, outside the traditional office visit, and to avoid adverse events. She notes that clearly ER visits and hospitalizations will continue to happen but the key question will be the percentage that are avoidable.
As an example, our own research from the University of Chicago Medicine presented at the symposium evaluated this question of “avoidability” with respect to terminal oncology ICU hospitalizations. It is estimated that 8% of oncology patients die in the ICU. These terminal ICU hospitalizations come at high cost and are associated with a reduced quality of life for patients and families. Using our Cancer Registry, we identified patients who died in our ICU in fiscal year 2013. Each of these hospitalizations was reviewed by an oncologist, intensivist, and hospitalist to determine the clinical avoidability of the terminal hospitalization. Physicians identified 47% of these terminal hospitalizations as clinically avoidable with different medical management. Dr. Schrag notes that the Centers for Medicare & Medicaid Services’ goal is to move quickly from a pay for volume to a pay for value system within the next few years. There will thus be increasing pressure on providers to design interventions to prevent these avoidable adverse outcomes.
Conclusion: Paragons of quality excellence
Forward motion in quality improvement will be delivered in part by focusing on positive deviance, those organizations that have succeeded in delivering high-quality care. The symposium ended with a presentation of exemplars in quality. Dr. Randall Holcombe and Dr. Robert Siegel discussed delivering quality care at a large academic, urban institution and in the community setting respectively. Dr. Holcombe and Dr. Siegel both emphasized the need for the institution to have an openness to quality improvement interventions. Dr. Holcombe noted that engagement and ethos are critical to quality improvement, and Dr. Seigel emphasized the need for a culture of innovation that was open to change and novel approaches. The conference wrapped up with attendees excited for the symposium next year and with an enthusiasm for confronting the quality improvement challenges of lovely babies and tooth brushes with rigorously tested, innovative interventions that enhance the value of care delivered to cancer patients.
Dr. Daly is the chief fellow in the section of hematology/oncology at the University of Chicago Medicine. He also serves as a director of Quadrant Holdings Corporation and receives compensation from this entity. Frontline Medical Communications is a subsidiary of Quadrant Holdings Corporation.
