- All five Cancer Treatment Centers of America (CTCA) sites are QOPI certified, and the benefits are significant.
- Participation in the initial data abstraction round taught CTCA about the ever-growing popularity of oral chemotherapeutic agents and best-practice documentation involving patients who self-administer chemotherapy.
- Based on QOPI data, additional enhancements were made and continue to be made within the EHR to make documenting pertinent information as easy as possible for physicians and mid-level practitioners.
- Increased communication between CTCA physicians, nurses, and administrators has been one of the greatest and most evident benefits. QOPI promotes an environment of shared learning, continuous improvement, and collaboration.
Cancer Treatment Centers of America (CTCA) is a national network of five hospitals that serves adult patients with cancer. CTCA offers an integrative approach to care that combines advancements in genomic testing, precision cancer treatment, surgery, radiation, immunotherapy, and chemotherapy with evidence-informed, supportive therapies designed to help patients physically and emotionally by enhancing their quality of life while managing side effects during and after treatment. During the fall of 2013, two of our five sites began the pursuit of ASCO Quality Oncology Practice Initiative (QOPI®) certification. A third site began QOPI certification the spring of 2014, and our remaining two practices followed suit in the spring of 2015. Currently all five CTCA sites are QOPI certified, and the benefits resulting from this pursuit are significant. In this editorial, we share our journey of leading five centers through the QOPI Certification Program™ process, the merits of such intense self-reflection, and why we continue to participate in, maintain, and build upon the virtues of this achievement.
Preparing for QOPI Participation
ASCO advertises QOPI as a practice-based quality-assessment and reporting program offered to all ASCO members (non-members may participate in reporting on quality measures, but each participating practice must have at least one active ASCO member to register with QOPI). QOPI is designed to promote excellence in cancer treatment by helping practices create a culture of self-examination and improvement by providing a process for standardized, routine assessment of care, as well as reliable information in order to meet internal and external reporting requirements.
Once it was determined that QOPI certification would become a network-wide goal, CTCA made strides to centralize the process. With this standardization, we sought both the removal of variability and the advancement of process reliability.
We hired two quality review nurses to spearhead education and data abstraction and to coordinate all activities behind the certification process. These quality review nurses work for the Medicine and Science Division of the Quality Department and, subsequently, have become QOPI subject-matter experts. They are instrumental in the understanding of and adherence to the safe practices promoted under the auspices of this certification program. Consolidating these tasks under the purview of a dedicated team provided an incredible team-building opportunity that has fostered working relationships across all five centers.
Early in the journey, a CTCA QOPI Steering Committee was formed, consisting of each site’s quality director and one other designated QOPI liaison of their choosing. This Committee still functions today. The quality review nurses, with support from their management team, became the point people for receiving and dispensing information and sharing lessons learned, which promotes a group effort and a highly cohesive atmosphere.
QOPI Data Abstraction and Chart Identification
Data submission occurs biannually (spring and fall) based on a rotating schedule to spread out the workflow across centers. Currently, data abstraction is manual. The quality review nurses are responsible for requesting and obtaining patient lists consistent with the chart sampling methodology as set forth by QOPI. The patient lists are generated by the corporate Information Systems Department, and as each data abstraction round passes, the lists become more streamlined, making chart identification efficient and expeditious. A Gantt chart was created to assist the quality review nurses with keeping track of which center was due for data abstraction, and a master planning document was created to house key activities, including when re-certification activities should commence.
What We Do With Our Data
During our first round of data collection, after sharing results with our QOPI Steering Committee, we agreed that we would solicit feedback from various key clinical leaders to choose measures to be monitored on a continual basis. The Quality Improvement Committee, as well as CTCA’s National Consortium for Clinical Excellence Program, filtered requests. The National Consortium for Clinical Excellence is a network-wide program that develops and implements standardized CTCA treatment regimens, advances evaluation pathways, identifies and monitors emerging technologies/therapies, and develops and refines clinical expertise. CTCA physician groups, referred to as Institutes, have been formed around the following tumor types or treatment modalities: breast cancer, lung cancer, female pelvic malignancies, gastrointestinal malignancies, genitourinary malignancies, and hematologic malignancies.
Although the first QOPI data set only included data from two of our five sites, it shed a light on our opportunities for improvement that were relevant for the enterprise as a whole. Collectively, we chose measures for which CTCA scores fell greater than 10% below the QOPI aggregate score or that physicians considered to be the highest risk in terms of impact on patient outcomes. These measures included those that focused on documentation surrounding:
- Chemotherapy intent,
- Oral chemotherapy,
- Risk of infertility associated with chemotherapy,
- Genetic testing in patients with breast cancer,
- Chemotherapy treatment summary, and
- End-of-life care.
We also considered several additional measures that ASCO addressed as key opportunities to improve care and reduce costs in its “Top Five” article.¹ Twenty measures surfaced and were agreed upon. Continuous internal data collection began July 1, 2014, which the quality review nurses conducted to ensure strong inter-reliability for abstraction consistency and QOPI knowledge.
All new patient charts were reviewed, including analytic and nonanalytic, and specific diagnosis dates were imposed to include patients who presented after initial diagnosis or suffered recurrence. We refined the inclusion criteria to be consistent with our belief that the intent behind the metric is applicable to all patients served, not only those diagnosed and or receiving at least part of their initial course of treatment at CTCA. We reported data on a quarterly basis to our QOPI Steering Committee and the Quality Improvement Committee. The quality review nurses worked closely with the sites by identifying opportunities in the documentation, enabling centers to focus their quality-improvement efforts.
Part of the QOPI Certification Program process involves reviewing policies. Review of our policies revealed differences from across sites. The medicine and science quality team worked on standardizing three common core policies: Management of Extravasation, Chemotherapy Verification and Administration, and Informed Consent. After a period of fine-tuning, the policies were completed and distributed to the centers as templates, with the preface of tailoring certain language specifically to each site’s individual practice.
Participation in the initial data abstraction round also taught us about the ever-growing popularity of oral chemotherapeutic agents and best-practice documentation involving patients who self-administer chemotherapy. The opportunities identified lent themselves to a network-wide A3 project, a Lean Six Sigma problem-solving technique used to address the assessment of oral chemotherapy adherence and toxicities. Under the leadership of one quality review nurse, a task force was formed consisting of care management leads from all five sites. This task force worked together to create a policy titled “Assessment and Management of the Patient Receiving Oral Chemotherapy,” which was finalized and distributed to the centers for local adoption. Nursing education was provided, leading to the creation of “acronyms,” a function within our electronic health record (EHR) that the nurse can use to trigger and facilitate the collection of key information from the patient regarding oral chemotherapy medication adherence. Baseline compliance rates for assessing adherence prior to the initiation of the A3 project was determined to be as low as 7.8%. Taking the QOPI aggregate mean into consideration, the goal to obtain a composite score of 60.0% across the sites was set, and a high score of 68.9% was achieved, signifying a more than 783% improvement. We have continued to maintain this high score.
Based on our QOPI data, additional enhancements were made and continue to be made within the EHR to assist physicians and mid-level practitioners to make documenting pertinent information as easy as possible. Structured fields were created in the physician note templates, using checkboxes to facilitate documentation of vital conversations addressing goals of chemotherapy, the effects of chemotherapy on fertility, practitioner assessment of oral chemotherapy adherence, and HER2/neu status in patients with breast cancer.
Lastly, comprehensive evaluations including QOPI data and denials data prompted us to refine the clinical practice of ordering pegfilgrastim to align with best practices. Pegfilgrastim on-body is CTCA’s preferred agent. If a provider intends to change the default from pegfilgrastim on-body to injection, a reason for change is provided via a drop-down menu. Furthermore, febrile neutropenia risk assessment was categorized as high, intermediate, and low. For patients at high risk for febrile neutropenia (> 20%), there is no need for additional documentation beyond the risk level. For patients at intermediate risk (10% to 20%), additional documentation of patient- and/or treatment-related reasons is mandatory for approval. Checkboxes were provided to assist in mandatory documentation for providers who feel pegfilgrastim is needed in the low-risk setting.
The Benefits of QOPI Participation
Quality-improvement efforts directly related to QOPI measures and standards have been in full swing at all five centers since we began our pursuit of QOPI certification. Increased communication between our physicians, nurses, and administration has been one of the greatest and most evident benefits. QOPI-related metrics are reported in multiple different ways and shared with a variety of audiences, each with a goal of casting light—not heat—on the opportunities. Providing sites with breakdowns of their data allows for physician-specific discussion and a steady and consistent nursing education process. It also continues to strengthen the bond as a supporting function between the Medicine and Science Quality Department and our medical community. Policies have been standardized supporting compliance with intended best practices, and the resulting EHR enhancements have increased compliance regarding documentation expectations.
We have now come full circle and have begun the QOPI Certification Program recertification process at those first two centers that led the way for our network. Recertification prompts our centers to carefully review all of our policies that address the 20 QOPI standards, re-evaluate the data we continually collect for trends and line of sight to performance opportunities, and promote open communication between our five centers. In short, it promotes an environment of shared learning, continuous improvement, and collaboration.
About the Authors: Ms. Hepler is a quality review nurse with the Medicine and Science Department Division of Quality, the Cancer Treatment Centers of America. She is a subject-matter expert in QOPI data abstraction. Dr. Markman is president of Medicine and Science at the Cancer Treatment Centers of America. In June 2011, he received the ASCO Statesman Award. Ms. Denny is the vice president of quality, patient safety, and clinical outcomes at the Cancer Treatment Centers of America. She is a certified professional in patient safety and in health care quality. Dr. Crilley is chief of medical oncology and chair of the Department of Medical Oncology at the Cancer Treatment Centers of America. In January, she received the Chairman Award for Innovation in Patient Care.