Quality Training Program Research Articles

Addressing risk of financial toxicity in an ambulatory oncology practice: Our institutional experience with the ASCO Quality Training Program.

114 Background: Due to escalating cost of cancer care, patients (PTs) with cancer are at increased risk for financial toxicity (FTOX) that can exacerbate disparities in care and lead to clinically relevant adverse PT outcomes; including quality of life; symptom burden; adherence; and survival. A review of our informed consent (IC) process demonstrated that PTs were not routinely informed of financial risks of high-cost (HC) cancer therapies at the time of IC. Methods: A multidisciplinary team was formed to conduct a rapid-cycle quality improvement project with the aim of reducing FTOX through improvement in patient education at the time of IC. Because of HC and increased utilization, the initial pilot focused on treatment with immune checkpoint inhibitors (ICI). A cause and effect diagram identified the potential causes that FTOX was not addressed during the IC process. Diagnostic data were obtained through staff surveys and querying our EMR from June to August, 2016. A Pareto chart identified lack of educational (ED) tools at the time of IC and a poorly understood prior authorization (PA) process as the most common causes for not addressing risk of FTOX during IC. Plan-do-study-act (PDSA) #1 began with development of a PT ED tool to be used during IC. The tool was approved by the Patient Advisory Board. Staff from clinical teams utilizing ICI for approved indication completed training on its use and a pilot study was initiated. PDSA#2 focused on optimizing the PA process and PDSA#3 focused on PT distress and FTOX monitoring through the NCCN distress and a validated patient-reported-outcome tools (COST), respectively. Results: The utilization of the PT ED tool reached the project aim (administer to > 65% of pts during IC) during initial phase of PDSA#1, although accrual is ongoing. A revised PA process (PDSA#2) was developed, staff were educated and the updated PA process was initiated. Work on PDSA#3 is ongoing. Conclusions: This QI project suggests that it is feasible to address FTOX through PT ED during IC for HC cancer therapies. However, the impact of this intervention on PT distress, overall FTOX and treatment disparities will need to be monitored closely.

A Review of the 21st Century Skills in Technical Vocational Education and Training (TVET)

Efforts must be made to improve the skills of the 21st century to produce graduates of quality Technical Vocational Education and Training (TVET) program employability in this country. The effect of the change of program that often occurs have an impact on students and teachers because of the quality of the produced graduates who cannot meet the current needs of the job market. In Blueprint 2015-2025 launched on 7 April 2015, it has been stated that efforts have be made in order to ensure surge reached the fourth and seventh rally of TVET. Graduates quality and innovation ecosystems can be achieved through increased technological innovation skills among TVET graduates. Thus the model of Technological Pedagogical and Content Knowledge (TPACK) and elements of the 21st century skills are suitable for use in helping to increase knowledge and skills of TVET graduates.

The Impact of Delivering Quality Improvement Education and Training Program for Nurses to Improve Patient Care with Intra Vascular Access Lines

Multicultural phenomena require nursing students to have cultural competence. Nursing students who are culturally competent can understand more about patients’ issues with regard to cultural diversity and equality when delivering culturally sensitive care. This study aims to identify cultural competence across educational levels.This study involves 164 students of a second-semester professional program and an eighth-semester academic program. This study employs a cross-sectional design and a stratified random-sampling technique. The questionnaire used is modified from related concepts and theories of culture care and cultural competence.The results show that the average cultural-competence scores of second-semester professional students and eighth-semester academic students are 60.0 and 59.0, respectively (p = 0.283; alpha = 0.05).Based on the results of the statistical tests, there was no significant statistical difference in cultural competence between second-semester professional students and eight-semester academic students. Further research is needed to examine the factors affecting cultural competence of students.

Transitioning to Academic Quality-Improvement Work Within the Field of Oncology: Opportunities and Challenges.

Quality improvement is an integral component of cancer care. In 1999, the Institute of Medicine (IOM) published “Ensuring Quality Cancer Care,” a seminal report on the state of cancer care in the United States. The IOM found that patients with cancer do not always receive effective care, and there has been little study of the reasons for this variation. The IOM reiterated these concerns in a 2013 report entitled “Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis.” The IOM highlighted that cancer care in the United States is in a state of crisis; treatment decisions are often not based on scientific evidence, and symptoms and adverse effects are sometimes overlooked. The findings of the IOM highlight that it is imperative for cancer specialists (ie, medical, radiation, and surgical oncologists) to improve delivery of cancer care. Ideally, this work should have an academic focus to ensure that projects are rigorously designed and the results are relevant to a wider audience. There is limited evidence, however, that cancer specialists are pursuing academic quality-improvement work. A systematic review by Coory et al found that between 1990 and 2012, there were only 12 published studies of quality-improvement interventions targeted at cancer specialists. These authors concluded that although there has been much work to describe quality problems in cancer care, more research is needed on the impact of qualityimprovement interventions. Since the review by Coory et al, there have been several more reports of quality-improvement work in the cancer literature. For example, Newcomer et al conducted a 3-year study of five medical oncology groups and found that a program which rewarded quality care reduced medical costs by 34%. ASCO’s Quality Oncology Practice Initiative has also had a positive effect on participating practices, and ASCO’s Quality Training Program holds similar promise. Yet, despite these favorable trends, there continues to be a relative dearth of publications on quality-improvement efforts in oncology. Such publications may not only identify best practices in delivering cancer care, but also improve adoption of evidence-based care by cancer specialists. Although cancer specialists are well poised to engage in academic qualityimprovement work, they require guidance in making this transition. Table 1 outlines a framework for understanding the key barriers to pursuing academic qualityimprovement work. The framework is on the basis of this author’s experience in leading quality-improvement efforts, as well as themes from the literature.

The Effectiveness of Promoting Iranians’ Marital Quality Training Program in Marital Quality Among Couples Referring to Health Centers

The Effectiveness of Promoting Iranians’ Marital Quality Training Program in Marital Quality Among Couples Referring to Health Centers

Strategies for Promoting Girls’ Education in Jammu and Kashmir

The purpose of this study to discuss the different strategies that promotes the female education in Jammu & Kashmir. These strategies are important for female education. These strategies includes quality education and training program, expansion of schools, awareness of the community on girl‟s education, early childhood gender awareness and knowledge, encouragement of students, teachers and education leaders etc. have been discussed.

PTH-124 Regional ERCP Structure – Are We Able to Train Within A High Quality Service?

Introduction ERCP services have traditionally developed dependent on local facilities and expertise. Recognising concerns regarding ERCP training and service provision, there have been efforts to describe the features of a high quality ERCP service and training program. Greater procedural volume leads to improved outcomes but there is no consensus on the effect this has on current ERCP service and training structure. We have reviewed how current regional practice fits into a suggested optimal service model and how training fits within this. Methods All ERCP endoscopists and trainees within the NorthWestern deanery were invited to complete an electronic survey of their routine practice. Results All 29 ERCP endoscopists, and 35 (79.5%) trainees, from 12 hospitals responded. All units fulfilled criteria for a high quality service with access to multidisciplinary meetings and interventional radiology facilities and audit protocol. However, there was no standard approach to assessment or management of common diagnoses. Half were confident that CBD stones 7 of 9 units offering ERCP training provided training in the previous 12 months but there was no standardised approach, and no structure to allow exposure to higher case volume and complexity as training progressed. 54.2% of trainees declared an interest in ERCP training, with 37.1% currently training. All trainees had encountered difficulty obtaining training. 87.5% did not expect to be competent at CCT. Conclusion The current structure of this regional ERCP service fulfils suggested criteria for high quality service. This demonstrates that the current endoscopists are working with sufficient volume of cases to maintain expertise, and also have access to services to ensure appropriate and safe patient selection. However, there is no organisation of training. A high proportion of trainees are receiving limited training, and there is universal concern regarding availability. To optimise training within the region, we suggest that trainee numbers should be limited and a standardised training program developed. This would allow effective monitoring of training progression with the aim of producing a cohort of endoscopists who are near to or at a level of competence at the time of their CCT to start independent practice as a consultant or continue supervised practice as a post CCT fellow. Disclosure of Interest None Declared

Integrated post-surgical colon cancer care planning at the Rutgers Cancer Institute of New Jersey and Robert Wood Johnson University Hospital.

75 Background: Colorectal cancer is the second leading cause of cancer death in the United States each year. The use of adjuvant chemotherapy after surgical resection of colon cancer has been associated with a survival benefit. Timely initiation of adjuvant chemotherapy has been shown to have an effect on overall and disease-free survival. There is no integrated post-surgical colon cancer care planning for patients who have surgery at our institution. Poor understanding on the part of patients and ancillary providers regarding appropriate follow up may cause delay in time to adjuvant chemotherapy initiation. Methods: Baseline data was obtained for the ASCO Quality Training Program. Chart review was conducted on patients with stage III colorectal cancer that were treated at the Cancer Institute of New Jersey and Robert Wood Johnson University Hospital to identify average time to adjuvant chemotherapy initiation and factors which were thought to have a strong influence on chemotherapy initiation. Time to initiation of adjuvant chemotherapy, pathology report resulting, central access obtainment, and outpatient medical oncology appointment was abstracted from patient charts. Other factors including the presence of intraoperative or postoperative complications, type of surgeon, academic versus private medical oncologist, and the presence of an inpatient medical oncology consult were also identified and reviewed. Results: 128 patient charts were reviewed. Mean number of days from surgery to adjuvant chemotherapy (n = 79) was 49.6, to pathology report resulting (n = 70) was 4.92, to central access obtainment (n = 49) was 40, and to outpatient medical oncology appointment (n = 38) was 30. The presence of intraoperative (p < 0.059) and postoperative complications (p < 0.0155) was found to have a statistically significant effect on time to initiation of adjuvant chemotherapy. Conclusions: While there are some uncontrollable factors like operative complications that delay time to initiation of chemotherapy, engaging the patient may help decrease the time to adjuvant chemotherapy by increasing patient awareness of the importance of seeking aggressive postoperative care.

Reducing patient wait time on an inpatient hematology and transplant unit.

87 Background: The University of Wisconsin Hematology and Bone Marrow Transplant services admit 250 patients per year for scheduled treatment. Time from patient arrival to chemotherapy initiation averages 7 hours. This long time leads to patient dissatisfaction and prolonged length of stay. Chemotherapy often begins in the evening when physicians and pharmacists are not on site to clarify treatment questions. Methods: A multidisciplinary team was formed in April 2015 as part of the ASCO Quality Training Program. The team developed the aim to reduce time from 7 hours to 5 hours to allow for more daytime nursing shift chemotherapy starts. The group created a process map and an Ishikawa diagram to identify causes of treatment delays. The team observed that treatment orders were often written and signed after hospital admission, though the plan of care was available prior to admission. Using a prioritized list, the initial process change was to have physicians write and sign chemotherapy treatment plans prior to admission. The process measure was the percentage of orders signed before admission. The outcome measure was time from arrival to chemotherapy start. Balance measures included narrative comments from physician and nursing staff about the process change. Data were obtained from EHR time stamps. Physicians were asked to begin making signed treatment plans available after August 1, 2015. Results: Data from 55 patients prior to the change (May 1-July 31) and 52 patients post-change (August 1-October 16) were analyzed. The number of treatment plans signed prior to admission increased from 27% to 58% (p = 0.0018). Mean time from admission to treatment pre-process change was 404 minutes and 383 minutes post-change. When plotted on a control chart, a sustained shift in the process was not apparent. Feedback from physician and nursing staff did not identify efficiency or safety concerns with the new process. Conclusions: Though the percentage of orders signed prior to admission increased, there was no improvement in the time from patient admission to treatment initiation with this change. Future PDSA cycles will include increasing the percentage of orders signed prior to admission as well as address other sources of delay identified in the process map.

Making steps to decrease emergency room visits in patients with cancer: Our experience after participating in the ASCO Quality Training Program.

51 Background: Overutilization of emergency room services by oncology patients is a known problem associated with increased admission rates and health care expenditure. A review of our oncology patients’ emergency room (ER) visits from January to May 2015 demonstrated that 48% of ER visits happened during office hours. Consequently a rapid cycle quality improvement project was developed with an aim to decrease ER visits by 30% by September 2015. Methods: A multidisciplinary team completed an action plan, starting with a project charter and definition of aim statement. A process map for patient scheduling/triage was created. A cause and effect diagram helped identify potential causes patient utilization of the ER. Diagnostic data were obtained querying our EMR (EPIC) for ER visits from January to May 2015. A Pareto chart identified Breast, Hematology and GI malignancies as main diagnosis utilizing the ER. Plan-do-study-act (PDSA) #1 began with development of a protocol to guide the handling of patients' calls that could previously resulted in an ER visit. Staff from the patient access center (PAC), a telephone operator service, and physicians’ offices were trained on its application. PDSA #2 focused on patient education to the importance of contacting the PAC for any concern or symptom related to active chemotherapy treatment. Results: The implementation of a triage system at our PAC resulted in a 60% decrease in the number of patients utilizing the ER, which met our goal. Patients’ calls to the PAC have increased. Two new materials were developed: a telephone triage form categorizing the patient’s complaint and the resulting action by our PAC center staff, and a patient Clinical Intervention Triage Tracking Log which allowed for the tracking of all patients triaged, their data, and the responsible team member. Conclusions: This study suggests that the development of a tool to properly identify and address emergent chemotherapy symptoms without utilizing the ER during working hours resulted in an intervention that positively affected the pre-specified endpoint.

Systematic development of a a breast cancer survivorship program at a small independent oncology practice.

52 Background: It is widely accepted that providing survivorship care plans leads to improvements in outcomes for cancer survivors. Treatment summaries are now part of ASCO and NCCN survivorship guidelines. We faced a unique challenge of implementing the survivorship care plan at the Jones Clinic as a small independent practice. The Jones Clinic consists of three full time physicians and two full time nurse practitioners. We see approximately 850 new patients per year. Methods: As a part of ASCO’s quality training program, we focused on the stage I – III (early stage) breast cancer patients who completed their initial therapy. We formed a team, identified the barriers, created a flow diagram of the process, assigned roles for each individual member and finally implemented the process. Results: The major issues identified were lack of provision in the electronic medical record (EMR) system for survivorship and lack of standardized data entry process. We created a system in the EMR for survivorship data entry and extraction of such data in a document. Since July 2015, one hundred percent of breast cancer patients completing adjuvant therapy at the Jones Clinic have received a survivorship treatment summary and a plan of care. The care plan is also shared with their primary care provider. Importantly, creating a survivorship document required less than 10 minutes of the provider’s time. Conclusions: We are now able to provide our patients with a survivorship care plan and address survivorship issues within thirty days of completion of therapy. Creating the care plan requires minimal time from the providers. Our new process meets ASCO guidelines for survivorship care plans and no additional staffing was needed. We now plan to provide a survivorship care plan to all oncology patients treated with curative intent.

Reduction of Inappropriate Prophylactic Pegylated Granulocyte Colony-Stimulating Factor Use for Patients With Non-Small-Cell Lung Cancer Who Receive Chemotherapy: An ASCO Quality Training Program Project of the Cleveland Clinic Taussig Cancer Institute.

Routine prophylactic pegylated granulocyte colony-stimulating factor (pGCSF) administration for patients receiving chemotherapy regimens associated with low risk (< 10%) for neutropenic fever (LRNF) is not recommended. Inappropriate use of pGCSF increases patient morbidity and health care costs. A multidisciplinary team reviewed the charts of patients with non-small-cell lung cancer (NSCLC) at the Taussig Cancer Institute in whom a new chemotherapy regimen was initiated from April through November 2013. pGCSF use was identified and deemed appropriate if prescribed for chemotherapy associated with high risk of neutropenic fever (> 20%) or intermediate risk (10% to 20%) if other risk factors for neutropenic fever were present. Use with LRNF chemotherapy was recorded as inappropriate. One hundred eighty patients with NSCLC received a new chemotherapy regimen during the specified time period. Thirty-four of 119 patients (28%) treated with LRNF chemotherapy received pGCSF. Each patient received an average of 2.6 doses of pGCSF (total, 89 doses). We implemented three plan-do-study-act cycles: education of providers, development of Taussig Cancer Institute consensus guidelines for pGCSF in NSCLC, and removal of standing pGCSF orders from LRNF chemotherapy in the electronic medical record. Analysis during the change period revealed 4% of patients with NSCLC treated with LRNF chemotherapy received pGCSF. Cost analysis showed an 84% decrease in billed charges per month. No increase in neutropenic fever admissions was found. pGCSF was excessively prescribed for patients with NSCLC. Factors contributing to inappropriate use included provider lack of familiarity with guidelines and knowledge with regard to the risk of neutropenic fever for individual chemotherapy regimens, and electronic medical record chemotherapy templates that contain standing GCSF orders. Interventions to address these gaps quickly produced improved compliance with guidelines and led to significant cost savings.

ReCAP: Feasibility and Effectiveness of a Pilot Program to Facilitate Quality Improvement Learning in Oncology: Experience of the American Society of Clinical Oncology Quality Training Program.

Studies have demonstrated that structured training programs can improve health professionals' skills in performing clinical care or research. We sought to develop and test a novel quality training program (QTP) tailored to oncology clinicians. The American Society of Clinical Oncology QTP consisted of three in-person learning sessions and four phases: prework, planning, implementation, and sustain and spread. We measured two primary outcomes: program feasibility and effectiveness. Feasibility was evaluated by recording participation. Effectiveness was measured using the Kirkpatrick model, which evaluates four outcomes: reaction, learning, behavior, and results. We collected qualitative feedback through a focus group of participants and mixed quantitative–qualitative results from a 6-month follow-up evaluation survey. Results are presented using descriptive statistics. We received feedback from of 80% of participants who took part in 92% of in-person program days. QTP deliverables were completed by 100% of teams; none withdrew from the program. Regarding reaction, 100% of respondents expressed interest in actively contributing to future QTP courses. For learning, most teams continued to use the core methodology tools (eg, project charter, aims statements) after the program. Regarding behavior, when asked about intention to serve as a local quality improvement leader, a majority said they “definitely will” serve as: team leader on a specific project (75%), project champion or sponsor (75%), or teacher or trainer for others (64%). In evaluating outcomes, 50% reported applying learned methodology to new projects at their local institution. We demonstrate one of the first feasible and effective training programs to facilitate quality improvement learning for oncology clinicians.

Improving adherence with oral antiemetic agents in patients with breast cancer receiving chemotherapy.

In this small breast cancer-dedicated solo practice, a retrospective medical record review disclosed the following: significant rate of chemotherapy-related nausea and vomiting and discordance between patient-reported compliance with prescribed antiemetics and medical record documentation of compliance. As part of the curriculum for the American Society of Clinical Oncology (ASCO) Quality Training Program, a quality improvement project was developed to improve adherence to oral antiemetics in our patients with breast cancer receiving highly emetogenic chemotherapy. The following steps were undertaken in plan-do-study-act cycles to improve adherence: enhanced patient education at time of chemotherapy consent, implementation of standardized in-person or e-mail contact with our patients receiving chemotherapy, and improvement of our electronic health record documentation of adherence to oral antiemetics. A run chart was generated to analyze our data. After our interventions, the percentage of patients who took their antiemetics as prescribed rose from a baseline of 49% to 79%. Significant improvement in adherence to oral antiemetics among patients with breast cancer receiving chemotherapy was achieved and sustained in this small-practice setting using the framework provided by participation in the ASCO Quality Training Program.

Public and Private School Distinction, Regional Development Differences, and Other Factors Influencing the Success of Primary School Students in Turkey

AbstractThis study investigates the factors influencing the success of students in primary schools in Turkey. TIMSS 2011 data for Turkey, measuring the success of eighth-grade students in the field of mathematics, were used in an econometric analysis, performed using classical linear regression models. Two hundred thirty-nine schools participated in the TIMSS 2011 study for Turkey, and the sample size comprised 6,928 students. The results of our regression analyses revealed that regional differences, in particular, significantly impacted the success of students. Greater success in mathematics was achieved by students who live in urban areas and in socioeconomically more developed regions. Furthermore, math success rates of private school pupils were higher than those of public school students. The economic status of students' families, as well as their surroundings, sex, the educational background of their fathers, and educational instruments owned are substantial factors affecting the students' performance. We found that students whose fathers have a low level of education, who come from socioeconomically disadvantaged groups, and who live in poorly developed areas have lower performance.Keywords: Student Success * TIMSS * Socioeconomic Factors * Regional Differences * Private Schools * Public Schools.Education accelerates a country's economic development by ensuring personal growth and social progress. Assuring the spread of community-specific values among generations, education is one of most basic elements of human capital. A country's investments in education produce valuable future savings. Educational policies adopted in any country, and resources directed towards education, in either public or private sectors, are very important for education.Quality in education is only possible through educational plans and training programs, implemented in an efficient and equal manner. A quality training program meets the requirements of its time, closely follows the development of information and communication technologies, and pursues equality of opportunity and facility. The success of a country's educational policies can be measured by its students' success. Many studies, at the national level, conducted especially in recent years, assess the training efficiency of schools, in relation to students' academic success. In addition, programs continuously determine countries' comparative academic success versus other countries. Studies such as the Trends in International Mathematics and Science Study (TIMSS), Program for International Student Assessment (PISA), and Progress in International Reading Literacy Study (PIRLS) compare the success of students in international platforms. By providing preliminary information for researchers, for those who prepare school curricula, and for educational politicians regarding the operation of educational systems, these studies, repeated at certain intervals, become guides for criticism, assessment of educational systems, and required regulations.International examinations cause large reactions in many countries. Many countries try to improve their performances on these exams, as a strong relation exists between student success and economic development (Barro, 2013). Following the inputs or outputs of an educational system closely, determining shortcomings and stop points, and implementing proper policies is extremely important for national economies. Using data from TIMSS 2011, an international success evaluation program, this study investigates the factors affecting the mathematical success of eighth-grade students in Turkey. The findings of this study, in which the impact of a large number of variables concerning the socioeconomic status of students, regional differences, and school types upon success are comprehensively examined, will uncover required preliminary information for those preparing training programs. The study will further provide the required feedback for policy makers who shape the educational system, while answering the question: what kind of an educational system should it be? …

Infrastructure to improve together: Fostering palliative care (PC) and quality improvement (QI) learning in oncology through a virtual learning collaborative (VLC).

20 Background: PC and oncology teams can most effectively improve patient experience during cancer when the specialties improve care processes together through collaborative QI activities. To support collaboration ASCO, the American Academy of Hospice and Palliative Medicine, and Duke University developed a partnership to pilot the ASCO VLC. This pilot will develop and test a scalable model for quality improvement and dissemination of best practices, focused on improving palliative care in oncology. Methods: The ASCO VLC integrates lessons learned through the Breakthrough Series, ASCO Quality Training Program, and others. An Advisory Committee representing expertise in medical oncology, palliative care, geriatrics, nursing, social work, survivorship, health services research, and quality improvement oversees the pilot project. Content in the VLC website was refined based on feedback gathered through a needs assessment survey of pilot participants. Results: The online collaborative and learning platform went live in June 2014. The site houses live and recorded educational sessions covering PC and QI topics, includes discussion boards to foster interactions between practices, supports sharing of tools and resources, and allows practices to submit their problems and aims statements, and results of their work for peer review and feedback. 24 practices were recruited to participate; 73% from community/private practice sites. In response to the needs assessment, 85% of participants responded with a high sense of comfort with PC; yet, only 33% had similar comfort with QI. When asked to rank their top preference, respondents were most interested in learning about pain and symptom management (44%), or advance care planning (22%). Ongoing mixed qualitative and quantitative assessments through Spring 2015 will assess feasibility and acceptability of the ASCO VLC model. Conclusions: We are creating an online virtual learning collaborative as a sustainable infrastructure to support and foster clinician education and dissemination of PC best practices in oncology.

Improving prophylactic growth factor (pGCSF) use in non-small cell lung cancer (NSCLC) patients (pts) receiving chemotherapy (CT) at the Cleveland Clinic Taussig Cancer Institute (TCI).

83 Background: Per guidelines (ASCO, NCCN, EORTC), pGCSF is not recommended for pts receiving CT regimens with low risk (&lt; 10%) for febrile neutropenia (FN). Inappropriate use of pGCSF increases pt morbidity and healthcare costs. In the current healthcare environment, it is critical to maximize value via alignment with accepted care standards and elimination of unnecessary costs. Methods: A multidisciplinary team was created to perform a quality improvement (QI) project under ASCO’s Quality Training Program. We reviewed all NSCLC pts at TCI who initiated a new CT regimen from April to November 2013. First-cycle pGCSF use was identified and deemed appropriate if prescribed for CT associated with high risk of FN (&gt;20%) or intermediate risk (10-20%) if other risk factors for FN were present (age, gender, performance status, renal/hepatic function, prior treatment with radiation or CT, and pre-existing neutropenia, wounds, or infection). Use with low-risk CT was recorded as inappropriate. Results: 179 NSCLC pts received a new CT regimen during the specified time period. 22/90 pts (24%) treated with low-risk CT received pGCSF. Each pt received an average of 3 doses with 69 total doses administered. In all other instances pGCSF was prescribed in accordance with guidelines. Using QI strategies, we identified and implemented three PDSA cycles: education of NSCLC providers, development of TCI Consensus Guidelines for the use of pGCSF in NSCLC, and removal of standing pGCSF orders from low-risk CT regimens in the EMR. Cost analysis shows the potential to save 1.6 million dollars in charges over 1 year when pGCSF is not administered to NSCLC pts receiving low risk CT. Conclusions: pGCSF was excessively prescribed for NSCLC pts at a tertiary care academic medical center. Factors contributing to inappropriate pGCSF use included providers’ lack of familiarity with guidelines and the risk of FN for CT regimens as well as EMR CT templates with standing pGCSF. Appropriate pGCSF administration leads to significant cost savings without adverse impact on pt outcomes. Re-measurement is in progress and will be presented at the time of the meeting.

Improve optimal treatment in head and neck cancer patients (HNCA).

227 Background: Since 2011, 50% of HNCA patients receiving concurrent chemoradiation with Cisplatin (CIS/XRT) have not been able to complete their therapy per protocol (dose over time interval) leading to suboptimal therapy. Based on historical data, the non-completion rate for patients HNCA receiving radiation/ high dose Cisplatin was 15%. We aim to improve this in our patients. Methods: A chart review of patients on CIS/XRT conducted and, using a Pareto Chart, the data indicated Acute Kidney Iinjury as the major cause for failure of completion. Using methodology from ASCO’s Quality Training Program, a process map for patients on treatment was created and an Ishikawa diagram (cause and effect) assisted in pinpointing breaks in processes. A telephone survey of surviving patients further clarified inadequacies. Using the Plan, Do, Study, Act (PDSA) improvement cycle, inadequacies were identified. Results: Chart review showed that significant side effects from treatment began around the 2nd cycle of Cisplatin in spite of adequate IV hydration following chemotherapy. Inadequate documentation of dietary and speech pathology consultations, patient weight and serum creatinine levels during treatment were noted. Patients reported minimal PEG tube education and infrequent use of PEG tube for hydration. Analysis of post treatment weight and creatinine level revealed a significant change in creatinine clearance. Checking daily weights, speech pathology and dietary consult prior to initiation of therapy, added hydration instructions to EPIC PEG tube instruction sheet, and nurse practitioner education and follow-up in symptom management clinic were part of the PDSA cycle interventions. If 2lb. weight loss, patients were brought in for repeat lab and IV hydration. Conclusions: Patients with advanced head and neck cancer are frail and subject to acute toxicity from chemotherapy. Change in Creatinine Clearance is a sensitive measure of renal damage/likely predictor of non-completion. Post-intervention patients had fewer unplanned admissions leading to lower costs. PDSA helped identify inadequacies in our education and monitoring processes. More post intervention data are needed to determine if true improvement in patient outcomes exist.

Reduction of emergency department utilization via access to outpatient cancer care.

128 Background: Emergency department (ED) utilization for non-emergent medical problems is an inefficient use of medical resources. During calendar year 2013, 224 RIH adult cancer patients presented to the RIH ED. Retrospective review indicated up to 50% of these ED visits were avoidable. Methods: This project was developed for the ASCO Quality Training Program. A multidisciplinary team was assembled to address ED utilization. Retrospective chart review of ED visits included time and reason for visit and primary tumor site. The team selected the Lung Cancer as the target group, developed a cause-and-effect analysis for ED visits, administered a patient survey, and implemented a series of Plan-Do-Study-Act (PDSA) cycles. The team implemented a patient education process of nurse sick-line symptom management and same-day sick visits at RIH CCC as well as developing a single-page patient “sick-line tool” with oncology nurse sick-line contact telephone numbers. A patient navigator introduced the sick-line tool at the first visit and its usage was reinforced at subsequent visits. Results: For RIH CCC lung cancer patients, a standardized symptom-control education process correlated with 30% decrease in ED visits for any presenting complaint (42 visits vs. 60 visits) and 32% decrease in ED visits with presenting complaint of pain (13 visits vs. 19 visits) during January/February 2014 compared to January/February 2013. We did not find significant differences between the proportion of ED visits during Cancer Center business hours, evenings, or weekends. Sick-line calls were found to increase by 53% during January 2014 compared to December 2013 with an additional 35% increase in February 2014. Conclusions: A standardized patient education process resulted in a significant decrease in ED visits, concurrent with an increase in outpatient sick-line utilization. This may reflect an improvement in efficiency of outpatient cancer patient care in a single-institution setting. Given other reports of increased ED utilization by lung cancer patients for similar presenting reasons, these improvements may be generalizable to other institutions.

The ASCO Quality Training Program: designing and implementing a medical specialty society-based quality improvement training program.

The mission of ASCO”s Quality Training Program is “to teach oncology providers to engage in successful quality improvement activities in their practice settings and to train oncologists to assume quality leadership positions and champion quality initiatives.”