Improving International Quality Standards for Oncology Health Care

Improving International Quality Standards for Oncology Health Care


Dr. Vicente Guillem

Dr. Alfredo Carrato

Dr. Eduardo Diaz-Rubio

Dr. Carlos Camps

Dr. Pere Gascon, credit Olivier Valiente Tous Droits Reservés

Vicente Guillem, MD, PhD; Alfredo Carrato, MD, PhD; Eduardo Diaz-Rubio, MD, PhD; Carlos Camps, MD, PhD; and Pere Gascon, MD, PhD

Article Highlights

  • There is a need to measure quality oncology care at an international level to guarantee analysis, comparison, and continuous improvement.
  • ASCO’s Quality Oncology Practice Initiative (QOPI®) uses evidence-based measurement parameters to assess quality.
  • The ECO Foundation has partnered with Spanish hospitals and institutions to bring QOPI Certification to Spain.
  • The ECO Foundation’s objective is that all oncology services in Spain become part of the QOPI Certification Program and contribute to improvement in quality and health care excellence.

The quality of health care is a high priority for the majority of health services, and there is a growing interest worldwide in achieving a quality standard that guarantees that health problems can be addressed effectively and efficiently, with little variability between different practices and professionals. In oncology, the past few decades have seen significant changes and developments in diagnostic and therapeutic procedures, and a number of clinical guidelines have been developed for the most prevalent types of cancer. These guidelines have provided an important tool for reducing the variability in health care treatment. However, there is a need to measure quality of care, especially on an international level, to guarantee analysis, comparison, and continuous improvement.

The oncology field does not have clearly established tools to assess quality, but one American initiative stands out: the ASCO Quality Oncology Practice Initiative (QOPI®). In 1990, ASCO began involving its members—instead of external professionals—in improving the quality of care and defining the concept of quality in the area of oncologic health care. The pediatric oncologist
Joseph Simone, MD, FASCO, in conjunction with a small group of medical oncologists, developed the QOPI program, which was piloted from 2002 to 2006 and then made available to the public. Step by step, the measurement criteria and content grew, and the QOPI Certification Program (QCP) was launched in 2010.1

QOPI is a voluntary program designed to assess and improve the quality process in oncology practice. QOPI gives you the quality measures that were developed by world-renowned practicing oncologists and quality experts, using clinical guidelines, expert consensus, and published standards, such as the National Initiative on Cancer Care Quality (NICCQ), ASCO/NCCN Quality Measures, and ASTRO/ASCO/AMA PCPI Oncology Measures. QOPI’s aim is to provide an effective and practical tool through which oncology practices can continually evaluate their care provided, thus ensuring that each patient receives the best care possible. QOPI was designed for doctors to use and examine data from their own office and their own patients. Retrospective data are collected from medical records through a structured questionnaire and included in an online-accessible database. The results are quickly obtained, allowing the medical practice to be compared within a particular hospital or with other hospitals.2

The QCP, an affiliate of ASCO, was launched in 2010 to recognize medical oncology and hematology/oncology practices that are committed to delivering the highest quality of cancer care. In addition to achievement of a minimum threshold on a series of performance indicators, ASCO QOPI Certification requires that practices demonstrate adherence to 20 chemotherapy standards involving staff education, chemotherapy planning, preparation and administration, and patient assessment, consent, and education.

In Spain, in this area of quality and oncology, the commitment and effort of the Foundation for Excellence and Quality in Oncology (called the ECO Foundation in Spanish) is worth highlighting. Since the Foundation’s conception, it has led and supported various initiatives to guarantee the quality of cancer care in Spain. The ECO Foundation is a platform of experts that deals with the treatment of patients with cancer and gathers most of the major Spanish hospitals. Its mission is to achieve excellence and quality in oncology by searching for and developing solutions and tools. This network of experts promotes quality in three areas: patient care, specialized medical education, and clinical research. In relation to the quality of patient care, two initiatives being led by the ECO Foundation stand out: the development of quality criteria and how to measure it, and an agreement reached with ASCO to enroll Spanish hospitals in the QCP.

Quality Criteria in Oncology and the ECO Foundation

In May 2012, the ECO Foundation launched the Quality Healthcare Criteria in Medical Oncology project with the ultimate goal of disseminating among the Spanish medical community some quality standards developed with the active participation and professional consensus of a panel of oncology experts. Since its very beginning, the ECO Foundation has ambitiously strived to create a reference tool that would allow for self-assessment of quality and, in a second phase, the quality certification of the health centers in oncology. To do this, the ECO Foundation uses a strict methodology3 based on solid scientific and technical evidence and ensures that the final content complies with a specific collective selection criteria, such as feasibility, the influence on health outcomes, and the ease of implementation in different hospitals in all regions. The ultimate goals are to reduce the unjustified clinical inconsistencies, to better satisfy the true needs of both involved health care professionals and patients, and to change the organizational culture of services to promote continuous improvement and excellence. Quality indicators have been developed in the following areas: general organization, colorectal cancer, breast cancer, lung cancer, prostate cancer, and palliative care.

QCP and the ECO Foundation

The agreement reached with ASCO to involve the Spanish hospitals in the QCP  is further proof of the ECO Foundation’s commitment to quality health care. Spain does not have a national certification program for quality health care in oncology, so this agreement offers Spanish oncologic centers the chance to obtain a highly recognized certification in this field.

Since 2015, the ECO Foundation has offered all Spanish hospitals the possibility of fulfilling the QOPI criteria and obtaining the corresponding results and reports, which would allow them to have an assessment tool for their health care activity at their disposal. So far, there have been four rounds of data collection (fall 2015, spring 2016, fall 2016, and spring 2017). In the first three rounds, 15 hospitals participated; some of those have repeated in two or even three rounds. In autumn 2015, 11 centers participated. In spring 2016, six centers participated, and in autumn 2016, eight centers enrolled. All the hospitals belong to the National Health System and are located in different regions across Spain. The ECO Foundation works with hospitals seeking QOPI certification by facilitating the use of a computer tool, assisting during the recording process and data collection, following the methodology proposed by QOPI, and offering a contract research organization service that supports data abstraction at participating centers.

The global scores obtained (Table) were above 70% in 64% of the practices in the first round, 50% in the second round, and 75% in the third round. It should also be noted that one of the aspects of the QOPI program is the possibility of improving health care practice in oncology services. With regard to the temporal evolution of the scores, four centers have participated in three rounds of data collection, and another two have taken part in the last two rounds. These results are worth reflecting on, as they show an improvement in the global scores in all cases (Fig. 1). These hospitals did not receive training between rounds. All they received was the information about the results obtained in the previous round.

This first set of results is a good starting point for following the implementation of the QOPI program in Spain, providing a structured program for analyzing our health care objectively and implementing an improvement program, both in procedures and in making sure we correctly document what we do with our patients.

The Future of Quality Criteria in Oncology

Without any doubt, up to now, important developments have been made in the area of health care quality, such as certification and accreditation of centers and health care services via the prestigious quality models, such as the International Organization for Standardization (ISO) standards, the Joint International Commission, and the European Foundation for Quality Management Excellence Model (EFQM). However, despite much progress made in the assessment of health care, the same cannot be said when we focus on particular areas of specialization.

Thanks to the QCP, we have an excellent tool for assessing the quality of oncologic health care that can be done in any country, allowing for comparison at an international level and leading to the implementation of improvement procedures and a guarantee of the same quality of service throughout the world. The acceptance of QOPI is facilitated by the fact that it is a program developed by oncologists, using both clinical guidelines based on evidence and global consensus.2 QOPI thus provides a structure for self-assessment that has been widely adopted and shows improvement in practice over time. The absence of improvements in some specific areas demonstrates the opportunity to bridge the gap in quality. The development of new tools to encourage this improvement is clearly the next step to take.4

In addition, this program allows for the comparative analysis of the results between different hospitals in the public and private sectors, as well as between those hospitals with and without ISO, EFQM, or the Joint International Commission Certification. In these latter cases, we hope that the hospitals are well on their way to achieving this documentation, and, therefore, more robust conclusions could be taken with regard to what needs improving: health care practice and procedures or documentation of the procedures.

At the moment, three Spanish centers are undergoing the QOPI Certification process.

To achieve QOPI Certification, a practice must have participated in QOPI and met or exceeded a benchmark score on measures that compared the quality of its care against national standards.  A practice then undergoes an on-site review, which evaluates an individual practice’s performance in areas that affect patient care and safety. The results are peer reviewed by a select team of oncology professionals, such as physicians and nurses. Certification is awarded when a practice meets all QOPI Certification standards.

All three hospitals have taken part in the fall 2016 round and have achieved a score above 75% (the minimum to be eligible for certification). At the time of writing, they are finalizing the application process for certification, and QOPI’s technical/professional team is planning to visit the centers in June to carry out the surveys and audits necessary for granting the QOPI certificate of quality, which is valid for 3 years. The ECO Foundation’s objective is that all oncology services in Spain become part of the QCP and contribute to improvement in quality and health care excellence.

However, if we look deeper into this complex area of health care, we must highlight that the desire for excellence is also a question of attitude. In other words, a prior commitment to quality is required, so a culture of quality must first be established and then consolidated and internalized in the clinical practice. This is the true merit of all the work carried out by the ECO Foundation. It has introduced a culture of quality health care by creating and developing health care quality criteria and consolidating it with participation in QOPI and its certification program for Spanish hospitals. This, without doubt, is a great step toward the introduction and internalization of quality in cancer care.

About the Authors: Dr. Guillem is a medical oncologist and head of the Oncology Department at the Instituto Valenciano de Oncología, in Spain. He is president of the ECO Foundation and past president of the Spanish Society of Medical Oncology. Dr. Carrato is a medical oncologist and head of the Oncology Department at the Hospital Ramón y Cajal, in Madrid. He is vice president of the ECO Foundation, past president of the Spanish Society of Medical Oncology, and associate professor of the Department of Medicine, at the University of Alcalá de Henares. Dr. Diaz-Rubio is a medical oncologist and head of the Oncology Department at the Hospital Clínico San Carlos, in Madrid. He is honorary president of the ECO Foundation, past president of the Spanish Society of Medical Oncology, and associate professor of the Department of Medicine, at the University Complutense of Madrid. Dr. Camps is a medical oncologist and head of the Oncology Department at the Hospital General de València, in Spain. He is the director of academic programs at the ECO Foundation, president of the Spanish Association for Cancer Research, and associate professor of the Department of Medicine at the University of Valencia. Dr. Gascon is a medical oncologist and head of the Translational Research Center at the Hospital Clínic de Barcelona, in Spain. He is director of international affairs at the ECO Foundation, editor-in-chief of Clinical Translational Oncology, and associate professor of the Department of Medicine at the University of Barcelona.