Mi Professional Issues
Guadalupe R. Palos, RN, LMSW, DrPH— Associate Editor
Transforming Cancer Survivorship Care Through Quality Improvement Initiatives Guadalupe R. Palos, RN, LMSW, DrPH, Fran Zandstra, RN, BSN, OCN®, MBA, Katherine Gilmore, MPH, CCRP, Ludivine Russell, MS, Jacklyn Flores, BS, and Maria Alma Rodriquez, MD
Oncology nurses must become better prepared to conduct quality improvement projects that w ill optimize quality of care and patient safety for long-term cancer survivors. The growing interest in survivorship care has led to the availability of multiple versions of cancer survivorship care plans (SCPs). Despite the availability of SCPs, research is lacking evidence-based processes to evaluate whether providers comply w ith planning and issuing SCPs. In the current article, the authors describe exploratory efforts to m onitor the providers' compliance rate in issuing SCPs in diverse disease-specific clinics. Guadalupe R. Palos, RN, LMSW, DrPH, is a clinical protocol administrator in the Division of Medical Affairs, Fran Zandstra, RN, BSN, OCN®, MBA, is an executive director, Katherine Gilmore, MPH, CCRP, is a project consultant, Ludivine Russell, MS, is an informatics analyst, Jacklyn Flores, BS, is a program coordinator, and Maria Alma Rodriguez, MD, is the vice president in the Division of Medical Affairs, all in the Office of Cancer Survivorship at the University of Texas MD Anderson Cancer Center in Houston. The authors take full responsibility for the content of the article. The study was supported, in part, by a grant (No. CA016672) from the National Institutes of Health. No financial relationships relevant to the content of this article have been disclosed by the editorial staff. Palos can be reached at [email protected], with copy to editor at [email protected]. Key words: quality improvement; survivorship care plans; compliance rates Digital Object Identifier: 10.1188/14.CJON.468-470
ro viding high-quality, safe care to long-term cancer survivors is a growing concern to all healthcare professionals. Recent trends have empha sized the critical need to teach healthcare providers and patients about the design, implementation, and evaluation of such services. Florence Nightingale introduced nurses to quality improvement w hen she uncovered the link the betw een high mor tality and poor hygiene practices (Meyer & Bishop, 2006). Her findings continue to serve as a fundamental tenet em bedded in today’s healthcare systems. A critical com pon en t of adoption of new professional practice in survivorship care is to increase awareness and consensus of the need for quality improvement metrics related to the care of long-term cancer survivors. A grow ing paradigm shift has occurred to include survivorship care as p art of the cancer care continuum (Taplin et al., 2012). The
P
468
2005 Institute of Medicine (IOM) report, From Cancer P atient to Cancer S u rvi vor: Lost in T ransition, acknow ledged that evidence-based practice is necessary to inform clinicians and patients on best care of long-term cancer survivors (Hewitt, Greenfield, & Stovall, 2005). The standards recently issued by the American College of Surgeons Commis sion on C ancer ([COC], 2012) req u ire that, by 2015, all p atien ts com pleting curative trea tm e n t receive a survivor ship care plan (SCP). The COC’s (2012) survivorship standards also stated that a perform ance and com pliance plan will be required and evaluated in every U.S. accredited cancer program. The four-step process calls for plans to monitor, evalu ate, present, and d ocum ent th e actual program plan. A surveyor will conduct an on-site visit and discuss m ethods w ith m em bers of the cancer com m ittee. Then, August 2014
a program will receive a rating of com pli ance or noncom pliance. However, sev eral challenges will have to be addressed before these standards are integrated into routine clinical practice. O ne relates to the lack of evidence dem onstrating that SCPs can be successfully used by clini cians to adapt and standardize survivor ship care. The growing interest in survivorship care has led to the availability of multiple versions of SCPs. Despite the availability, providers face several challenges in plan ning and issuing them, including variation in com pliance rates, lack of knowledge about survivor issues, and lack of consen sus on how to measure the impact of SCPs on survivor outcomes (Dulko et al., 2013; Palmer et al., 2014; Strieker & O ’Brien, 2014). The authors used the template from the American Society of Clinical Oncology ([ASCO], 2014) Quality Oncology Practice Initiative and American Board of Internal Medicine (ABIM) Self-Directed Practice Im provem ent Module. The cu rre n t ar ticle describes exploratory efforts to use elements from the module to monitor the providers’ compliance rate (CR) in issuing SCPs in diverse disease-specific clinics. In this pilot effort, the authors sought to col lect baseline CRs per clinic and compare them with a goal rate of 100%. The authors purposely established a high compliance goal rate to show the im portance of the role of SCPs in survivors’ transitions back to primary care providers.
Methods Survivorship Care Plans Structure and Implementation Process The authors’ institution identified SCPs as an appropriate way to disseminate and im plem ent evidence-based p ractice in
Volume 18, Number 4
Clinical Journal o f Oncology Nursing
survivorship clinical practice and care. The conceptual structure of the SCP (see Figure 1) established a broad perspective for managing long-term survivorship care and summarized relevant tools needed to address the com plex issues of survivor ship. The need for the SCPs was estab lished by recommendations from the IOM (Hewitt et al., 2005). One recom m enda tion proposed that each cancer survivor should receive a treatm ent summ ary and SCP for coordinating his or her care, and another advocated for a change in clinical practice for all healthcare providers. The care plan described in the current article w as in ten ded to address th ese recom mendations. A rigorous literature review of peerreview ed research and en dorsed care plans appropriate for the delivery of sur vivorship care was conducted by a mul tidisciplinary team of ex p ert clinicians, researchers, administrators, and librarians. The review found limited endorsements by statem ents from federal, national, or professional organizations. Given the lim ited availability of a gold standard SCP for diverse cancer sites, the team endorsed th e ir ow n standard fram ew ork to cre ate care plans. The format, perform ance m easures, and desired outcom es w ere critiqued and peer-reviewed by an expert team. A plan to provide feedback to clini cians and monitor the implementation of SCPs was also reviewed and approved by the expert team. The structure served as the standard fo undation for th e developm ent of all SCPs regardless of disease site. Each care plan had tw o m ain parts: a treatm ent sum m ary as w ell as clinical strategies, interventions, procedures, and recom m endations related to surveillance, risk reduction and early detection, monitor ing for late effects, and psychosocial functioning. Contents of th e care plan w ere tailored to m eet the recom m enda tions for specific sites. All SCPs w ere d esigned to provide a visual and w ritte n guide to support providers’ delivery of high-quality care. These tools w ere designed to be easily retrieved, stored, and displayed through institutional clinical inform ation systems and printed sources. Care plans for each specific site w ere accessible in prin t or electro n ic form at. Survivors and th e ir prim ary care providers w ere also able to access th e algorithm s through a portal Clinical Journal of Oncology Nursing
Patient Passport Plan for Health: Head and Neck Patient name:_____________Date of birth:______________ Gender: _ Healthcare provider:____________________________ Allergies:________ ________________________________________ Cancer diagnosis:__________ Stage:___________________ Histology: Past medical history:________________________________________ Surgery:
Yes □
No □
Date
Procedure Primary surgery Neck surgery Reconstruction Dental
Chemotherapy:
Yes □
Date Completed
No □
Treatment Indicated
Radiation Therapy: Date Completed
Drug Name(s)
Yes □
No □
Primary or Postoperative
Late Effects of Treatment/ Signs and Symptoms to Report
Recommended Procedures
Cycles
Doses
Active
Potential
□
□
Last Performed Date and Location
Number of Fractions
Recommended Consults/ Monitoring
Counseled Recommendations
Future Date and Location
TSH, T4 Indirect mirror examination Chest x-ray Computed tomography Gynecologic, cervical, or prostate screening Skin examination Colonoscopy
f
Mammogram Audiogram
..
General Preventive Health Care and Personal Health Behaviors Recommendations General Recommendations 1. Eat a healthy diet.
Specific Recommendations
2. Maintain a healthy weight, and avoid being overweight. 3. Have an active lifestyle. 4. Use sunscreen, and limit time in the sun. 5. Maintain adult vaccinations per recommendations. 6. Do not smoke or chew tobacco. 7. Limit alcohol intake.
FIGURE 1. Example of a Survivorship Care Plan for a Patient With Head and Neck Cancer Note. Form courtesy of University of Texas MD Anderson Cancer Center. Used with permission.
link provided on the survivorship p ro gram w ebsite. O rientation and training sessions for clinicians w orking in the sur vivorship clinics w ere conducted w hen clinics w ere launched and during periods
Volume 18, Number 4
Professional Issues
of staff turnover. Sessions covered how to integrate SCPs into clinical practice, collecting data for SCPs, tailoring SCPs to specific needs, and docum enting out com es of counseling and referrals. 469
Audit of Providers' Compliance Rate An evaluative activity approved by the Quality Improvement Assessment Board at the University of Texas MD Anderson Cancer Center was conducted to assess clinicians’ CR w ith the care plans. In the current article, the authors report the results of a clinical audit to evaluate clinicians’ compliance with issuing SCPs. From December 1, 2011 to May 31, 2012, the authors conducted an exploratory au dit to determine the CRs for issuing SCPs in seven clinics. The four steps were (a) evaluate SCPs issued within a specific sixmonth period, (b) abstract selected mea sures from the electronic care plan issued to each survivor, (c) identify numerators and denominators unique to each clinic, and (d) calculate the number of records to audit based on the number of full-time providers in each clinic. Data for each item to be m easured were collected by staff. The authors fol lowed the template from the ABIM SelfDirected Practice Improvement Module and ASCO’s Quality Oncology Practice Initiative. Ten elements from ASCO’s tem plate were used in this analysis, which in cluded (a) source of data, (b) name and lo cation, (c) time frame for data collection, (d) method used to collect data, (e) target condition (i.e., cancers of the breast, colorectal, endocrine, genitourinary, and gynecologic, as well as melanoma), (0 measure used (i.e., number of SCPs issued), (g) number of patients reviewed (i.e., survivors seen in each clinic), (h) CR (i.e., percent of compliance in issuing a SCP), (i) self-report of the measure’s reli ability, and (j) self-report of whether the results reflected current practice. The care plans issued to survivors in seven disease-specific clinics were the pri mary data sources. Other sources for data abstraction included mined data from insti tutional databases and scheduling systems. Statistical Analysis Simple descriptive statistics (i.e., fre quency and percentage) w ere used to summarize the responses and rates of adherence resulting from the monitoring activities.
Results During the study, 3,274 electronic medi cal records were reviewed, and 40 provid 470
TABLE 1. Summary of Module Elements Collected Per Survivorship Clinic Clinic Launch Date
Providers Per Clinic
Gynecology
Sept. 2008
8
200
129
65
Endocrine (thyroid)
Oct. 2008
2
342
324
95
Genitourinary
Jan. 2009
1
341
284
83
Breast
Sept. 2009
17
1,996
1,717
86
Head and neck
Dec. 2009
1
104
92
89
Colorectal
Jan.2011
8
60
47
78
Melanoma
Nov. 2011
3
231
168
73
40
3,274
2,761
84
Survivorship Clinic
Total
-
EMRs Reviewed
Electronic SCPs Issued
CR (%)
CR— compliance rate; EMR— electronic medical record; SCP— survivorship care plan
ers issued 2,761 electronic SCPs within 30 days of the arrived appointment (see Table 1). To calculate CR, the authors divided the number of care plans issued by number of electronic medical records reviewed. The findings indicated CRs among the seven clinics ranged from 65%-95%, with an average of 84%. The future goal was to improve the CR to at least 90%.
Discussion The uniform approach described in this article offered meaningful guidance to physicians and other clinicians who used the survivorship algorithms. The conclu sions indicated that the ASCO and ABIM process proved to be a systematic and stan dard method for monitoring CRs among providers in diverse clinics. All data were extracted from electronic sources, which increased reliability, reproducibility, and consistency across target conditions and clinics. Clinics w ith low com pliance (less than 75%) will be further assessed to identify barriers and solutions contribut ing to SCP use in routine clinical care. Further examination is warranted to de termine characteristics of clinics present ing high and low CRs and their effect on survivors’ outcomes. The IOM (2003) have also called for a transformation in education to better prepare nurses and other healthcare pro fessionals to provide safe, high-quality care by increasing knowledge, skills, and com petency in providing patientcentered, evidence-based practice, infor matics, and quality improvement. Howev August 2014
er, many nurses lack the knowledge, skills, and competencies needed to understand the nuances of quality improvement and how this concept differs from evidencebased practice or research. In response to gaps in nursing academic curricula and continuing education programs, the Rob ert Wood Johnson Foundation funded the Quality and Safety Education for Nurses Initiative (QSENI) (Cronenwett et al., 2007; QSENI, 2014). Because oncology nurses comprise a large segment of health care providers, it remains clear that they must become better prepared and skilled in conducting quality improvement proj ects that will optimize quality of care and patient safety. Based on the results from this quality improvement effort, the authors demon strated that SCPs can be used as decision tools to help guide and deliver optimal survivorship care. A growing need ex ists to provide academic curricula and practice-based learning, which can help healthcare professionals better under stand the nuances of providing compre hensive survivorship care. A critical com ponent of the adoption of new professional practice in survivorship care is to increase awareness and consensus of the need for quality improvement metrics related to the care of long-term cancer survivors. In the current article, the authors also provided an innovative approach for monitoring efforts for delivery of survivorship care.
Volume 18, Number 4
(Professional Issues continues on page 472.) Clinical Journal o f Oncology Nursing
w h ic h m ay have re su lte d in an o v eresti
in g m e th o d s sh o u ld b e u n d e rta k e n . Re
m ate o f th e effect o f sigm oidoscopy.
searc h e rs should also focus o n ad h e re n c e to sc re e n in g , av ailab le re s o u rc e s, a n d
Research Recommendations A d d itio n a l r e s e a r c h o n m e a s u rin g c o m p lic a tio n s a s s o c ia te d w ith s c r e e n
cost.
Reference H olm e, 0 ., B retth au er, M., F reth eim , A., Odgaard-Jensen ,J., & Hoff, G. (2013). Flex
ible sigm oidoscopy versus faecal occult blood testing for colorectal cancer screen ing in a sy m p to m a tic in d iv id u a ls. Co chrane D atabase o f System atic Reviews, 9, C D 009259. d o i:1 0 .1 0 0 2 /1 4 6 51858 ,CD009259.pub2 For more about the Cochrane Library of system atic reviews, visit www.thecochranelibrary.com.
Safe Sexual Practices During Cancer Treatment (Continued from page 453) O ccupational Safety and H ealth A dm inis tration. (1999). OSHA technical manual. Retrieved from http://L usa.gov/lnZ x8kr Polovich, M., O lsen, M., & LeFebvre, K. (Eds.). (2014). C hem o th era p y a n d b io th era p y g u id e lin e s a n d re c o m m e n d a tio n s f o r P ractice (4th ed.). Pittsburgh, PA: Author. Park, E.R., Norris, R.L., & Bober, S.L. (2009). Sexual h e a lth co m m u n ic a tio n d u rin g c a n c e r care: B arriers and re c o m m e n d a tio n s. C a n c e r J o u r n a l, 15, 74-77. doi:10.1097/PPO.0b013e31819587dc Speroff, L., & D arney, P. (2010). A c lin i ca l g u id e f o r co n tra c e p tio n (5th ed.). P h iladelphia, PA: L ip p in co tt W illiam s and Wilkins.
Taylor, S., & Pereira, A.S. (2001). A ntiret roviral drug concentrations in sem en of HIV-1 infected men. Sexu a lly Transm it ted Infections, 77,4-11. Teva P harm aceuticals. (2012). Paragard® [Package insert]. Retrieved from h ttp :// w w w .paragard .com T russed, J. (2011). C ontraceptive efficacy. In R.A. Hatcher, J. Trussed, A.L. Nelson, W. Cates, D. Kowal, & M.S. Policar (Eds.), C ontraceptive techology (20th ed., pp. 779-863). New York, NY: Ardent Media. Van Dyke, R.B., Connor, J.D., Wyborny, C., Hintz, M., & Keeney, R.E. (1982). Pharma cokinetics of orally administered acyclovir in patients w ith herpes progenitalis. A m er ican J o u rn a l o f Medicine, 73, 172-175.
Wildfeuer, A., Laufen, H., Schmalreck, A.F., Yeates, R.A., & Zim m erm ann, T. (1996). Fluconazole: Comparison of pharm acoki netics, therapy and in vitro susceptibility o f yeasts. M ycoses, J9 (S u p p l.), 51-57. d o i:10.1111/j.1439-0507.1996. tb00529.x W orkow ski, K.A., & B erm an , S. (2010). Sexually transm itted diseases treatm ent guidelines, 2010. M orbidity a n d M ortal ity W eekly Report. R e c o m m e n d a tio n s a n d Reports, 59, 1-110. Yokoe, D., C asper, C., D ubberke, E., Lee, G., M unoz, P., P alm o re , T., . . . D o n nelly, J.P. (2 009). Safe living a fte r h e m atopoietic cell tran sp lan tatio n . B one M arrow Transplantation, 44, 509-519. doi: 10.1038/bmt.2009.262
Professional Issues (Continued from page 470) References A m erican S ociety o f C linical O n c o lo g y (2014). Quality Oncology Practice Initia tive. Retrieved from http://qopi.asco.org C om m ission on C ancer. (2012). C a n cer p r o g r a m s ta n d a r d s 2012: E n s u r in g p a tie n t-c e n te re d care. R etrieved from http://bit.ly/lnCR L9H C ronenw ett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., M itchell P., . . . W arren, J. (2007). Q u a lity and safety education for nurses. N u rsin g O utlook, 55, 122-131. Dulko, D., Pace, C.M., Dittus, K.L., Sprague, B.L., P o llack , L.A., H aw k in s, N.A., & Geller, B.M. (2013). Barriers and facilita tors to implementing cancer survivorship care plans. O ncology N u rsin g F orum , 40, 575-580. doi:10.1188/13.ONF.575-580 Hewitt, M., Greenfield, S., & Stovall, E. (Eds.). (2005). From cancer p a tie n t to cancer survivor: Lost in transition. Washington, DC: National Academies Press. Institute of M edicine. (2003). H ealth p r o 472
fe ssio n s education: A bridge to quality. W ashington, DC: N ational A cadem ies Press. Meyer, B.C., & Bishop D.S. (2006). Florence Nightingale: N ineteenth cen tu ry apostle o f quality. J o u rn a l o f M a n a g em en t H is tory, 13, 240-254. Palm er, S.C., Jacobs, L.A., D eM ichele, A., Risendal, B., Jones, A.F., & Strieker, C.T. (2014). M etrics to ev alu a te tre a tm e n t summaries and survivorship care plans: A scorecard. Supportive Care in Cancer, 22, 1475-1483. doi:10.1007/s00520-013-2107-x Q uality and Safety E ducation for N urses Initiative. (2014). Project overview. Re
trieved from http://qsen.org/about-qsen/ project-overview Strieker, C.T., & O’Brien, M. (2014). Im ple menting the commission on cancer stan dards for survivorship care plans. Clinical J o u rn a l o f Oncology Nursing, LS(SuppL), 15-22. doi: 10.1188/14.CJON.S1.15-22 Taplin, S.H., A nhang Price, R., E dw ards, H.M., Foster, M.K., Breslau, E.S., Chollette, V., . . . Zapka, J. (2012). In troduc tio n : U n d e rsta n d in g an d in flu e n c in g m u ltile v e l fa c to rs a c ro s s th e c a n c e r c a re c o n tin u u m . J o u r n a l o f th e N a tio n a l C ancer In stitu te . M onographs, 44, 2-10.
Do You Have an Interesting Topic to Share? Professional Issues provides readers w ith a b rie f sum m ary o f n o n c lin ic a l issues relevant to onco lo gy nursing. Length should be no m ore th a n 1 ,0 0 0 -1 ,5 0 0 words, exclusive o f tables, figures, insets, and references. If interested, contact Associate Editor Guadalupe R. Palos, RN, LMSW, DrPH, a t gpalos@ m danderson.org.
A u g u s t 2014 * V o lu m e 18, N u m b e r 4 • C linical Journal o f O n co lo g y N ursing
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Guadalupe R. Palos, RN, LMSW, DrPH— Associate Editor
Transforming Cancer Survivorship Care Through Quality Improvement Initiatives Guadalupe R. Palos, RN, LMSW, DrPH, Fran Zandstra, RN, BSN, OCN®, MBA, Katherine Gilmore, MPH, CCRP, Ludivine Russell, MS, Jacklyn Flores, BS, and Maria Alma Rodriquez, MD
Oncology nurses must become better prepared to conduct quality improvement projects that w ill optimize quality of care and patient safety for long-term cancer survivors. The growing interest in survivorship care has led to the availability of multiple versions of cancer survivorship care plans (SCPs). Despite the availability of SCPs, research is lacking evidence-based processes to evaluate whether providers comply w ith planning and issuing SCPs. In the current article, the authors describe exploratory efforts to m onitor the providers' compliance rate in issuing SCPs in diverse disease-specific clinics. Guadalupe R. Palos, RN, LMSW, DrPH, is a clinical protocol administrator in the Division of Medical Affairs, Fran Zandstra, RN, BSN, OCN®, MBA, is an executive director, Katherine Gilmore, MPH, CCRP, is a project consultant, Ludivine Russell, MS, is an informatics analyst, Jacklyn Flores, BS, is a program coordinator, and Maria Alma Rodriguez, MD, is the vice president in the Division of Medical Affairs, all in the Office of Cancer Survivorship at the University of Texas MD Anderson Cancer Center in Houston. The authors take full responsibility for the content of the article. The study was supported, in part, by a grant (No. CA016672) from the National Institutes of Health. No financial relationships relevant to the content of this article have been disclosed by the editorial staff. Palos can be reached at [email protected], with copy to editor at [email protected]. Key words: quality improvement; survivorship care plans; compliance rates Digital Object Identifier: 10.1188/14.CJON.468-470
ro viding high-quality, safe care to long-term cancer survivors is a growing concern to all healthcare professionals. Recent trends have empha sized the critical need to teach healthcare providers and patients about the design, implementation, and evaluation of such services. Florence Nightingale introduced nurses to quality improvement w hen she uncovered the link the betw een high mor tality and poor hygiene practices (Meyer & Bishop, 2006). Her findings continue to serve as a fundamental tenet em bedded in today’s healthcare systems. A critical com pon en t of adoption of new professional practice in survivorship care is to increase awareness and consensus of the need for quality improvement metrics related to the care of long-term cancer survivors. A grow ing paradigm shift has occurred to include survivorship care as p art of the cancer care continuum (Taplin et al., 2012). The
P
468
2005 Institute of Medicine (IOM) report, From Cancer P atient to Cancer S u rvi vor: Lost in T ransition, acknow ledged that evidence-based practice is necessary to inform clinicians and patients on best care of long-term cancer survivors (Hewitt, Greenfield, & Stovall, 2005). The standards recently issued by the American College of Surgeons Commis sion on C ancer ([COC], 2012) req u ire that, by 2015, all p atien ts com pleting curative trea tm e n t receive a survivor ship care plan (SCP). The COC’s (2012) survivorship standards also stated that a perform ance and com pliance plan will be required and evaluated in every U.S. accredited cancer program. The four-step process calls for plans to monitor, evalu ate, present, and d ocum ent th e actual program plan. A surveyor will conduct an on-site visit and discuss m ethods w ith m em bers of the cancer com m ittee. Then, August 2014
a program will receive a rating of com pli ance or noncom pliance. However, sev eral challenges will have to be addressed before these standards are integrated into routine clinical practice. O ne relates to the lack of evidence dem onstrating that SCPs can be successfully used by clini cians to adapt and standardize survivor ship care. The growing interest in survivorship care has led to the availability of multiple versions of SCPs. Despite the availability, providers face several challenges in plan ning and issuing them, including variation in com pliance rates, lack of knowledge about survivor issues, and lack of consen sus on how to measure the impact of SCPs on survivor outcomes (Dulko et al., 2013; Palmer et al., 2014; Strieker & O ’Brien, 2014). The authors used the template from the American Society of Clinical Oncology ([ASCO], 2014) Quality Oncology Practice Initiative and American Board of Internal Medicine (ABIM) Self-Directed Practice Im provem ent Module. The cu rre n t ar ticle describes exploratory efforts to use elements from the module to monitor the providers’ compliance rate (CR) in issuing SCPs in diverse disease-specific clinics. In this pilot effort, the authors sought to col lect baseline CRs per clinic and compare them with a goal rate of 100%. The authors purposely established a high compliance goal rate to show the im portance of the role of SCPs in survivors’ transitions back to primary care providers.
Methods Survivorship Care Plans Structure and Implementation Process The authors’ institution identified SCPs as an appropriate way to disseminate and im plem ent evidence-based p ractice in
Volume 18, Number 4
Clinical Journal o f Oncology Nursing
survivorship clinical practice and care. The conceptual structure of the SCP (see Figure 1) established a broad perspective for managing long-term survivorship care and summarized relevant tools needed to address the com plex issues of survivor ship. The need for the SCPs was estab lished by recommendations from the IOM (Hewitt et al., 2005). One recom m enda tion proposed that each cancer survivor should receive a treatm ent summ ary and SCP for coordinating his or her care, and another advocated for a change in clinical practice for all healthcare providers. The care plan described in the current article w as in ten ded to address th ese recom mendations. A rigorous literature review of peerreview ed research and en dorsed care plans appropriate for the delivery of sur vivorship care was conducted by a mul tidisciplinary team of ex p ert clinicians, researchers, administrators, and librarians. The review found limited endorsements by statem ents from federal, national, or professional organizations. Given the lim ited availability of a gold standard SCP for diverse cancer sites, the team endorsed th e ir ow n standard fram ew ork to cre ate care plans. The format, perform ance m easures, and desired outcom es w ere critiqued and peer-reviewed by an expert team. A plan to provide feedback to clini cians and monitor the implementation of SCPs was also reviewed and approved by the expert team. The structure served as the standard fo undation for th e developm ent of all SCPs regardless of disease site. Each care plan had tw o m ain parts: a treatm ent sum m ary as w ell as clinical strategies, interventions, procedures, and recom m endations related to surveillance, risk reduction and early detection, monitor ing for late effects, and psychosocial functioning. Contents of th e care plan w ere tailored to m eet the recom m enda tions for specific sites. All SCPs w ere d esigned to provide a visual and w ritte n guide to support providers’ delivery of high-quality care. These tools w ere designed to be easily retrieved, stored, and displayed through institutional clinical inform ation systems and printed sources. Care plans for each specific site w ere accessible in prin t or electro n ic form at. Survivors and th e ir prim ary care providers w ere also able to access th e algorithm s through a portal Clinical Journal of Oncology Nursing
Patient Passport Plan for Health: Head and Neck Patient name:_____________Date of birth:______________ Gender: _ Healthcare provider:____________________________ Allergies:________ ________________________________________ Cancer diagnosis:__________ Stage:___________________ Histology: Past medical history:________________________________________ Surgery:
Yes □
No □
Date
Procedure Primary surgery Neck surgery Reconstruction Dental
Chemotherapy:
Yes □
Date Completed
No □
Treatment Indicated
Radiation Therapy: Date Completed
Drug Name(s)
Yes □
No □
Primary or Postoperative
Late Effects of Treatment/ Signs and Symptoms to Report
Recommended Procedures
Cycles
Doses
Active
Potential
□
□
Last Performed Date and Location
Number of Fractions
Recommended Consults/ Monitoring
Counseled Recommendations
Future Date and Location
TSH, T4 Indirect mirror examination Chest x-ray Computed tomography Gynecologic, cervical, or prostate screening Skin examination Colonoscopy
f
Mammogram Audiogram
..
General Preventive Health Care and Personal Health Behaviors Recommendations General Recommendations 1. Eat a healthy diet.
Specific Recommendations
2. Maintain a healthy weight, and avoid being overweight. 3. Have an active lifestyle. 4. Use sunscreen, and limit time in the sun. 5. Maintain adult vaccinations per recommendations. 6. Do not smoke or chew tobacco. 7. Limit alcohol intake.
FIGURE 1. Example of a Survivorship Care Plan for a Patient With Head and Neck Cancer Note. Form courtesy of University of Texas MD Anderson Cancer Center. Used with permission.
link provided on the survivorship p ro gram w ebsite. O rientation and training sessions for clinicians w orking in the sur vivorship clinics w ere conducted w hen clinics w ere launched and during periods
Volume 18, Number 4
Professional Issues
of staff turnover. Sessions covered how to integrate SCPs into clinical practice, collecting data for SCPs, tailoring SCPs to specific needs, and docum enting out com es of counseling and referrals. 469
Audit of Providers' Compliance Rate An evaluative activity approved by the Quality Improvement Assessment Board at the University of Texas MD Anderson Cancer Center was conducted to assess clinicians’ CR w ith the care plans. In the current article, the authors report the results of a clinical audit to evaluate clinicians’ compliance with issuing SCPs. From December 1, 2011 to May 31, 2012, the authors conducted an exploratory au dit to determine the CRs for issuing SCPs in seven clinics. The four steps were (a) evaluate SCPs issued within a specific sixmonth period, (b) abstract selected mea sures from the electronic care plan issued to each survivor, (c) identify numerators and denominators unique to each clinic, and (d) calculate the number of records to audit based on the number of full-time providers in each clinic. Data for each item to be m easured were collected by staff. The authors fol lowed the template from the ABIM SelfDirected Practice Improvement Module and ASCO’s Quality Oncology Practice Initiative. Ten elements from ASCO’s tem plate were used in this analysis, which in cluded (a) source of data, (b) name and lo cation, (c) time frame for data collection, (d) method used to collect data, (e) target condition (i.e., cancers of the breast, colorectal, endocrine, genitourinary, and gynecologic, as well as melanoma), (0 measure used (i.e., number of SCPs issued), (g) number of patients reviewed (i.e., survivors seen in each clinic), (h) CR (i.e., percent of compliance in issuing a SCP), (i) self-report of the measure’s reli ability, and (j) self-report of whether the results reflected current practice. The care plans issued to survivors in seven disease-specific clinics were the pri mary data sources. Other sources for data abstraction included mined data from insti tutional databases and scheduling systems. Statistical Analysis Simple descriptive statistics (i.e., fre quency and percentage) w ere used to summarize the responses and rates of adherence resulting from the monitoring activities.
Results During the study, 3,274 electronic medi cal records were reviewed, and 40 provid 470
TABLE 1. Summary of Module Elements Collected Per Survivorship Clinic Clinic Launch Date
Providers Per Clinic
Gynecology
Sept. 2008
8
200
129
65
Endocrine (thyroid)
Oct. 2008
2
342
324
95
Genitourinary
Jan. 2009
1
341
284
83
Breast
Sept. 2009
17
1,996
1,717
86
Head and neck
Dec. 2009
1
104
92
89
Colorectal
Jan.2011
8
60
47
78
Melanoma
Nov. 2011
3
231
168
73
40
3,274
2,761
84
Survivorship Clinic
Total
-
EMRs Reviewed
Electronic SCPs Issued
CR (%)
CR— compliance rate; EMR— electronic medical record; SCP— survivorship care plan
ers issued 2,761 electronic SCPs within 30 days of the arrived appointment (see Table 1). To calculate CR, the authors divided the number of care plans issued by number of electronic medical records reviewed. The findings indicated CRs among the seven clinics ranged from 65%-95%, with an average of 84%. The future goal was to improve the CR to at least 90%.
Discussion The uniform approach described in this article offered meaningful guidance to physicians and other clinicians who used the survivorship algorithms. The conclu sions indicated that the ASCO and ABIM process proved to be a systematic and stan dard method for monitoring CRs among providers in diverse clinics. All data were extracted from electronic sources, which increased reliability, reproducibility, and consistency across target conditions and clinics. Clinics w ith low com pliance (less than 75%) will be further assessed to identify barriers and solutions contribut ing to SCP use in routine clinical care. Further examination is warranted to de termine characteristics of clinics present ing high and low CRs and their effect on survivors’ outcomes. The IOM (2003) have also called for a transformation in education to better prepare nurses and other healthcare pro fessionals to provide safe, high-quality care by increasing knowledge, skills, and com petency in providing patientcentered, evidence-based practice, infor matics, and quality improvement. Howev August 2014
er, many nurses lack the knowledge, skills, and competencies needed to understand the nuances of quality improvement and how this concept differs from evidencebased practice or research. In response to gaps in nursing academic curricula and continuing education programs, the Rob ert Wood Johnson Foundation funded the Quality and Safety Education for Nurses Initiative (QSENI) (Cronenwett et al., 2007; QSENI, 2014). Because oncology nurses comprise a large segment of health care providers, it remains clear that they must become better prepared and skilled in conducting quality improvement proj ects that will optimize quality of care and patient safety. Based on the results from this quality improvement effort, the authors demon strated that SCPs can be used as decision tools to help guide and deliver optimal survivorship care. A growing need ex ists to provide academic curricula and practice-based learning, which can help healthcare professionals better under stand the nuances of providing compre hensive survivorship care. A critical com ponent of the adoption of new professional practice in survivorship care is to increase awareness and consensus of the need for quality improvement metrics related to the care of long-term cancer survivors. In the current article, the authors also provided an innovative approach for monitoring efforts for delivery of survivorship care.
Volume 18, Number 4
(Professional Issues continues on page 472.) Clinical Journal o f Oncology Nursing
w h ic h m ay have re su lte d in an o v eresti
in g m e th o d s sh o u ld b e u n d e rta k e n . Re
m ate o f th e effect o f sigm oidoscopy.
searc h e rs should also focus o n ad h e re n c e to sc re e n in g , av ailab le re s o u rc e s, a n d
Research Recommendations A d d itio n a l r e s e a r c h o n m e a s u rin g c o m p lic a tio n s a s s o c ia te d w ith s c r e e n
cost.
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