In the new performance category of Improvement Activities for 2017, CMS rewards clinicians for care focused on care coordination, beneficiary engagement, and patient safety. 

Below are links to 40 projects completed in the Quality Training Program to share expertise and provide ideas for others seeking to improve quality of patient care. All the project presentations use the same framework, stating

  • the name of the organization and the individuals completing the work,
  • the project problem statement and aim (goal),
  • interventions, and
  • baseline data and results (where available).

In this list, each project has been assigned a primary category (such as Care Coordination or Patient Safety) and secondary categories as appropriate. 

Are you ready for MACRA? A List of CMS Improvement Activities That Can Be Crosswalked to ASCO Quality Programs

Care Coordination 

Project: Creation of a Cross Functional Care Team to Develop Individualized Care Plans in High Utilize Oncology PatientsCleveland Clinic Foundation, Cleveland, OH, 2016

Subcategory: Hospital Readmission Prevention

Problem Statement: With growing attention to quality in health care, readmission have gained much of the national focus. At our institution, it has become clear that a small portion of our patient population drive a significant burden of our readmission rates and resource utilization  In fact, just 6% of all discharged patients account for a staggering 41% of all readmissions. However, patients who are most frequently readmitted have complex psychosocial barriers that no general intervention is likely to address

 

Project: Wilmot Cancer Institute Ambulatory Treatment Handoff Project, Wilmot Cancer Institute, Rochester, NY, 2016

Subcategory: Patient Safety

Problem Statement: Fifty-nine percent of reported medication events for patients receiving anti-cancer treatments at WCI Infusion Center on the same day as clinic visits from 7/24/2014 to 6/30/2016 were due to ineffective handoff communication. The completion rate of the WCI handoff tool from 10/1/2015 to 6/30/2016 for patients treated with anticancer therapy on the same day as a clinic visit is 32% (based on 25 audits per month, or 5% of patients.

 

Project: Reducing Emergency Room Visits in Patients Receiving IV Chemotherapy Using Care Coordination, Tennessee Oncology, Chattanooga, TN, 2016

Problem Statement: From January to June 2016, 96 patients receiving IV chemotherapy at the Memorial office had an Emergency Room visit. This results in emotional, psychosocial, and physical burden for patients and is a preventable cost for patients and the healthcare system. 


Patient Safety 

Project: Improvement of Treatment Toxicity Grading According to the Common Terminology Criteria for Adverse Events (CTCAE)Contemporary Oncology Team, Athens, Greece, 2016

Subcategory: Treatment Toxicity, Documentation Improvement

Problem Statement: During the evaluation for QOPI® Certification in Spring 2016 it was noted that toxicity assessment was rarely graded according to the Common Terminology Criteria for Adverse Events (CTCAE) in the files of patients receiving treatment and this could hinder appropriate treatment dose modification. After collecting baseline data we determined that toxicity was graded according to CTCAE only in 26% of the patients receiving chemotherapy with epirubicin/cyclophosphamide and nab-paclitaxel and immunotherapy with nivolumab*. *Represents approximately 5-7% of the COT patient population under iv treatment. 

 

Project: Reduction of Invasive Fungal Infections in Patients with Acute Myeloid Leukemia Undergoing Induction or Re-induction Chemotherapy, University of Virginia Health System- Mohammed A Naeem, MD, PhD, Charlottesville, VA, 2016

Problem Statement: 21.7% of patients with AML undergoing induction or re-induction chemotherapy at UVA medical center had a proven/probable invasive fungal infection (IFI) leading to increased morbidity as evidenced by increased number of medical emergency team (MET) calls.


Oral Chemotherapy

Project: Improving Oral Chemotherapy Fulfillment Processes and Implementation of a Pharmacist-Managed Oral Chemotherapy Follow-Up ProgramCone Health Cancer Center at Alamance Regional, Burlington, NC, 2015

Subcategory: On-time Treatment Delivery

Problem Statement: Development of oral chemotherapy agents is expanding. Concerns regarding access and adherence to oral chemotherapy treatment have arisen. Process of initiating a patient on oral chemotherapy varies significantly among institutions.

– Hospital vs. specialty pharmacy

– Delay in prescription fulfillment affects treatment adherence and potentially patient outcomes if treatment is postponed for days to weeks

 

Project: Oral Anticancer Medication Adherence, Grady Health System, Atlanta, GA, 2016

Subcategory: Treatment Adherence

Problem Statement: A retrospective review of 30 patients during 2013-2016 demonstrated a 30% adherence to oral anticancer medications (OAM). Adherence*: Drug available ≥ 80% to < 120% of days evaluated. *Adherence was calculated using the “days covered” method. 

 


Documentation Improvement

Project: Improving Plan of Care Documentation in Pain Management, JPS Health Network Center for Cancer Care, Fort Worth, TX, 2016

Subcategory: Pain Management

Problem Statement: Results for the Spring 2016 QOPI data submission identified ‘Plan of care for moderate/severe pain documented’ measure at 0%, compared with 70.94% for the QOPI average benchmark. This area was prioritized as an improvement opportunity due in part to the frequently cited relationship between effective pain management and improved patient satisfaction and outcomes, as well as decreased ER and unscheduled clinic visits.

 

Project: Improving Oral Chemotherapy Documentation in the Breast Medical Oncology Outpatient Practice, Icahn School of Medicine at Mount Sinai, New York, NY, 2016

Subcategory: Oral Chemotherapy 

Problem Statement: 0 % of Breast Oncology patients have complete or easily found documentation of an oral chemotherapy care plan as per QOPI standards, resulting in clinical providers spending an inordinate amount of time trying to find answers to patient phone calls regarding dosage, adverse effects and follow up schedule 

 

Project: Providing Treatment Summary and Survivorship Care Plan to Early-Stage Breast Cancer Patients Beyond Their Initial Therapy in a Smaller Community-based Practice Set-upThe Jones Cancer Clinic, Germantown, TN, 2015

Subcategory: Patient Education

Problem Statement: Breast cancer survivors at the Jones Clinic currently do not receive a written summary of their treatment plan. It has been recognized in the area of oncology that this information is important to improve quality of care for survivors as they move beyond their cancer.

 

Project: Improving the Consenting and Education Process for Patients Starting on Oral Oncology MedicationsMary Bird Perkins – Our Lady of the Lake Cancer Center, Baton Rouge, LA, 2015

Subcategory: Patient Education, Patient Safety, Oral Chemotherapy, Treatment Adherence       

Problem Statement: Oral oncology medication prescribing is on the rise within the Mary Bird Perkins - Our Lady of the Lake Cancer Center Medical Oncology Clinic. Given that these medications are self-administered, drug compliance is a concern. Appropriate patient education directly impacts drug adherence. Currently, there is implied consent while educating patients on side effects and written informed consent is obtained 0% of the time. This creates a patient safety and risk management problem. 

        

Project Title: Improving Documentation of Pain Management at MedStar Washington Cancer Institute, MedStar Washington Cancer Institute,  Washington, D.C., 2013/2014

Subcategory: Pain Management

Problem Statement: Twenty five percent of MedStar Washington Cancer Institute hematology oncology clinic outpatients with pain ≥ 4 did not have documented plan of care for pain, potentially resulting in inadequate pain control. This was evidenced in Quarter II 2013 data.

 

Project: MD Epic Documentation for Colon Cancer, Palo Alto Medical Foundation, Palo Alto, CA, 2013/2014

Problem Statement: 100% of oncology providers document in Epic using a free-form style, hindering timely, accurate, and sustainable clinical data collection, analysis and reporting. Without data, quality improvement in patient care is uninformed, anecdotal and progress cannot be measured. Value cannot be determined.

 

Project: Improving Advance Care Planning and Documentation for UICC Patients, University of Illinois Cancer Center, Chicago, IL, 2013/2014

Subcategory: Patient Experience, Advance Care Planning

Problem Statement: WHAT: Advance care planning discussions in the ambulatory care setting are poorly documented. – 23% of patients currently receive advance care planning in the ambulatory care setting as documented in the last two clinic visits – 9% of our metastatic solid tumor patients are receiving advance care planning discussion in the ambulatory care setting documented by the 3rd visit. 5

• WHO: Metastatic solid tumor patients • WHERE: Oncology clinic setting

• WHEN: Within 2 months or by the 3rd visit whichever is first

• WHY: Prevent medically futile care at end of life – Improve communication about prognosis and goals of care early on – Increase hospice utilization and referrals from ambulatory setting – Promote aggressive symptom direct care for improved quality of life

 

Project: Improving Advanced Directive Discussion and Documentation in Thoracic Oncology Patients, The Laura and Isaac Perlmutter Cancer Center at  New York University Langone, New York, NY, 2013/2014

Subcategory: Patient Experience, Advance Care Planning

Problem Statement: 99% of NYU Cancer Center patients do not have an Advance Directive (AD) discussed and documented in their electronic medical records, during all phases of their cancer care. Research indicates that this may contribute to :

• A high rate of hospitalizations and readmissions (Dartmouth 1,2)

• Increase in ICU utilization (Dartmouth 1,2) • Increased healthcare costs (Dartmouth 1,2)

• Decreased palliative care utilization (Dartmouth 1,2)

• Increased patient and family suffering (Support Trial)

• Decreased patient satisfaction (Support Trial)

 

Project: Improving Documentation for Oral Chemotherapy at Trillium Health Partners, Trillium Health Partners, Toronto, Ontario, Canada, 2013

Subcategory: Oral Chemotherapy, Patient Safety

Problem Statement: During observations of 24 charts in October 2013 at Trillium Health Partners – Queensway Site, only 67% (8/12) of the components of an oral chemotherapy plan (as defined by ASCO‐ONS) were documented in the medical record. This represents a potential safety risk as complete information regarding the oral chemotherapy plan was not readily accessible to all health team

 

Project: Improving Phone Triage System for Oncology Outpatients, University of Pennsylvania Abramson Cancer Center, Philadelphia, PA, 2013/2014

Problem Statement:  Abramson Cancer Center outpatients are dissatisfied with the management of their phone correspondences to the oncology practices. Delays in symptom and medication management result in frequent patient complaints and low Press Ganey access ranking.

 

Project: Implementation of a Written Chemotherapy Consent from Zero to Compliant in 6 Months, West Virginia University & Mary Babb Randolph Cancer Center, Morgantown, WV, 2013/2014

Subcategory: Patient Safety, Patient Experience

Problem Statement: Original consent process: Recording of verbal acknowledgement of patient consent in clinic note

• Not in a easily retrievable location in the medical record.

• Inconsistencies in communication of risk / benefit between clinicians

• Lack of documentation of communication of treatment goals

• Lack of written chemotherapy consent may lead to patient dissatisfaction in care, poor communication and other adverse events.

Patients at WVU/MBRCC do not have written chemotherapy consent in the medical record prior to the start of therapy. Implementation of written consent will result in improved patient safety, education, understanding, and ensure proper communication.

1) Storm C, et al. Informed Consent for Chemotherapy: ASCO Member Resources: JOP November 2008 2) Treleaven J, et al. Obtaining Consent for Chemotherapy: British Society for Haematology 2005. 3) Michels D, Cahill, M. Informed Consent and Chemotherapy: JOP September 2005 

 

Project: Oral Capecitabine Documentation in the Electronic Medical Record Flow sheet, Yolanda G. Barco Oncology Institute, Meadville, PA, 2013/2014

Subcategory: Oral Chemotherapy, Patient Safety

Problem Statement: Patients at Yolanda G. Barco Oncology Institute (YGBOI) are often prescribed oral anti-neoplastic agents such as Capecitabine (Xeloda ®). There is no standardized documentation of the dose prescribed, dosage adjustments, or dose administered per cycle (dose intensity) in the current EMR flow sheet making tracking of chemotherapy toxicities, dose intensities, and therapy adjustments time consuming, cumbersome, and potentially dangerous to patients.

 


Process Improvement

Project: Increasing on Time Treatment Time Delivery In Radiation Medicine, Oregon Health and Science University, Portland, OR, 2016

Subcategory: On-time Treatment Delivery, Radiation Therapy

Problem Statement: Sixty-two percent of final Physics Quality Assurance (PQA) approvals for treatment plans (including3D/IMRT/Arc/SBRT/SRS plans) are not completed by 8:00 am the day prior to the patient’s first treatment appointment. 

 


Patient Access

Project: Improving New Patient Access by Decreasing Missed Appointments to First Visit, Parkland Hospital and Health Systems, Dallas, TX, 2016

Subcategory: Process Improvement

Problem Statement: Analysis of the new appointments scheduled for newly diagnosed cancer patients had a 39% incomplete rate for the first scheduled appointment. 

- 61% Completion

- 27% Cancelled

- 13% No Show

Analysis includes medical/surgical oncology and GYN oncology clinics • Evaluation period May 01 – Jul 31, 2016 

 


Patient Education

Project: Decreasing the Risk of Financial Toxicity in an Ambulatory Oncology Practice, NorthShore University HealthSystem, Kellogg Cancer Center, Highland Park, IL, 2016

Subcategory: Drug Costs

Problem Statement: 0% of NorthShore University HealthSystem Kellogg Cancer Center patients routinely receive information on financial risks of high cost cancer therapies, as well as available financial support services, resulting in significant financial and overall distress and compromised informed decision making. 

 

Project: Improve Optimal Treatment in Head & Neck Cancer Patients, Feist-Weiller Cancer Center, Shreveport, LA, 2013/2014

Subcategory: Process Improvement, Symptom Management

Problem Statement: Since 2011 in Feist-Weiller Cancer Center, 50% of Head and Neck cancer patients receiving Cisplatin 100mg/m2 day 1 and every 21 days (total 3 doses) with concurrent radiation, 35 fractions (CIS/XRT) have not been able to complete their therapy as per protocol (dose over time interval) leading to suboptimal therapy. Based on 2003 ECOG Study article, An Intergroup Phase III Comparison of Standard Radiation Therapy and Two Schedules of Concurrent Chemoradiotherapy in Patients With Unresectable Squamous Cell Head and Neck Cancer, by DJ Adelstein et al, the non-completion rate was 15%.

 


Supportive Care

Project: Incorporating Emotional Distress Tool for Cancer Treatment Patients Ralph Lauren Center for Cancer Care, Harlem, NY, 2016

Subcategory: Emotional Distress, Documentation Improvement, Distress Screening Tool

Problem Statement: Distress screening is a proven method to timely assess and manage common symptoms and stressors of chemotherapy patients. RLCCC shows 0% compliance by not utilizing standardized methods to assess distress in its patient population which historically has high levels of distress. 

 

Project: Improving Adherence With Oral Antiemetic Agents in Breast Cancer Patients Receiving Chemotherapy, Center for Breast Health, Bethesda, MD, 2013/2014

Problem Statement: Only 59% of breast cancer patients are compliant with medication prescribed for chemotherapy‐ induced nausea and vomiting (CINV), leading to:

  • Increased nausea and vomiting during chemotherapy
  • Decreased ability to perform normal activities
  • Additional office visits for hydration and parenteral antiemetics
  • Aversion to subsequent cycles of chemotherapy
  • Poor patient experience

 

Project: Improving the use of Pegfilgrastim in Lung Cancer Patients at the Taussig Cancer Institute of the Cleveland Clinic, Cleveland Clinic, Cleveland, OH, 2013/2014

Subcategory: Process Improvement

Problem Statement: 20% of lung cancer patients treated at the Taussig Cancer Institute of the Cleveland Clinic Foundation, are administered prophylactic pegfilgrastim.

– The inappropriate use of prophylactic growth factors increases morbidity and unnecessary cost to health care organizations.

– In the current healthcare market, it is critical to eliminate waste and unnecessary treatments for our patients.

– Each dose of pegfilgrastim causes increased cost to the health care system and our patients:

     • $15,090 charged for each dose patient. $3,253 reimbursed per dose for CMS patients.

– The national guidelines for prophylactic growth factors are inconsistent.

 


ER Visit Reduction

Project: Reduction of Oncology Patients Visits to The Emergency Room, Memorial Cancer Institute, Hollywood, FL, 2015

Subcategory: Process Improvement

Problem Statement: 48% of Memorial Cancer Institute patients’ E.R. visits occur during business hours causing an over utilization of E.R. services, in lieu of our physicians’ practices. 

 

Project: Patient Centered Cancer Care Assess & Reduce Preventable Emergency Department Visits,The Comprehensive Cancer Center of Rhode Island Hospital, Providence, RI, 2013/2014

Subcategory: Patient Education, Process Improvement

Problem Statement: During calendar year 2013, 224 Rhode Island Hospital (RIH) adult cancer patients presented to the RIH Emergency Department (ED). Retrospective review indicates up to 50% of these ED visits were avoidable. In our resource restricted environment we must focus resources to avoid costly ED visits for “non-emergent” care.

 

Project: Reducing Emergency Room Visits in Patients Receiving IV Chemotherapy Using Care Coordination, Tennessee Oncology, Chattanooga, TN, 2016

Subcategory: Care Coordination

Problem Statement: From January to June 2016, 96 patients receiving IV chemotherapy at the Memorial office had an Emergency Room visit. This results in emotional, psychosocial, and physical burden for patients and is a preventable cost for patients and the healthcare system. 


Patient Experience

Project: A Multidisciplinary Effort to Decrease Time from Admission to Chemotherapy on an Inpatient Oncology Unit, University of Virginia Health System-Louise Man, MD,Charlottesville, VA, 2016

Subcategory: On-time Treatment Delivery

Problem Statement: Many oncology patients at the University of Virginia are admitted for scheduled inpatient chemotherapy (chemo) administration for established diagnoses. These patients frequently experience delays in starting chemo after their arrival on the inpatient oncology unit. Delays are made known by patient complaints and also directly observed by physicians, nurses, and clinical pharmacists. These delays negatively impact healthcare resource utilization, length of stay, and may delay other patients’ admissions. 

 

Project: Reducing the Percent of ICU Deaths of Patients With Advanced Cancer at Stanford Health Care, Stanford Cancer Center, Palo Alto, CA, 2015

Subcategory: Process Improvement, Decrease in ICU deaths

Problem Statement: In 2014, 40.4% of patients with solid tumors admitted to the Stanford Healthcare ICU died with advanced stage disease.  This compromised the patients’ quality of life and resulted in excessive costs for patients and their families.

 

Project: Total Lab TimesClearview Cancer Institute, Huntsville, AL, 2013/2014

Subcategory: Patient Experience, Process Improvement

Problem Statement: Over the past 6 months, patient wait times are continually increasing in the lab with a current average of 55% of patients having greater than a 20 minute total lab time. Increased total lab times lead to increased delays to see the Providers and receive treatment. Several factors have contributed to this:

- In the last four years we have not increased the number of phlebotomist, however, we have grown by 9-11% annually in patient volume.

- Over scheduling patients in am slots.

- Lab only draws not being scheduled in appropriate time slots.

- Employees’ work and lunch schedules.

- Stocking Times.


Telephone Triage

Project: Redesign the Triage Workflow to Align With the RN Role by Redirecting Non-Triage Calls, New Mexico Cancer Care/CHRISTUS St Vincent Regional Cancer Center, Santa Fe, New Mexico, 2015

Subcategory: Process Improvement

Problem Statement: In a five week period between June 22, 2015 and July 24, 2015 Triage received 2149 calls.

• Data review indicates that 950 (44%) of these calls were unrelated to symptom management and the patient’s treatment plan.

• We must redirect the calls to the appropriate area/staff members, and reassign the medication refills, so the RNs can focus their efforts on managing patient care and related issues.

 

Project: Utilizing a Case Management System to Reduce the Response Time for Symptom Management Calls, Tennessee Oncology, 2015

Subcategory: Process Improvement, Patient Safety, Patient Experience

Problem Statement:The Saint Thomas West clinic receives on average 500 calls daily. There is not an effective process for appropriately categorizing or prioritizing incoming patient phone calls, or to address symptom management calls according to evidencebased protocols. Additionally, there is neither a system to track symptom management calls, nor a procedure to determine whether they are being handled correctly and on a timely basis. 

 

Project: Outpatient Oncology Office Telephone System Improvement Project, Regional Cancer Care Associates: Central Jersey Division, 2013/2014

Subcategory: Patient Experience

Problem Statement: Telephone access for patients is their primary mode of communication with a doctor’s office; ineffective phone systems results in patient low satisfaction rates. 30% of RCCA-CJ Division’s patients in November 2013 perceived a call wait time longer than 5 minutes, 30% did not have their call reason resolved and 42% expressed dissatisfaction with the phone system.


On-time Treatment Delivery

Project: Treatment of Febrile Neutropenia at the University of Virginia, University of Virginia, Emily Couric Cancer Center, Charlottesville, VA , 2015

Subcategory: Patient Safety

Problem Statement: Febrile neutropenia is a common complication in oncology patients and is associated with significant morbidity and mortality if untreated. Both national and international guidelines recommend the administration of appropriate antibiotics within one hour of a febrile neutropenic episode. Upon review of time-to antibiotic administration for febrile neutropenia events at our institution, a significant percentage (~55% in 2012) were not administered antibiotics within 1-hour of event.

 

Project: Reduction of Time from Admission to Initiation of Chemotherapy on Inpatient Hematology and Bone Marrow Transplant Services, University of Wisconsin Carbone Cancer Center, Madison, WI, 2015

Subcategory: Patient Safety, Patient Experience

Problem Statement: Patients admitted to the hematology and bone marrow transplant service for scheduled chemotherapy average 7 hours between arriving on the B6/6 inpatient unit and starting chemotherapy. This delay results in later chemotherapy start times leading to decreased patient satisfaction and prolonged hospitalization. Moreover, this lag also leads to a disproportionate amount of chemotherapy assigned to the evening shift. During these hours there is decreased pharmacy staffing and fewer clinicians readily available to clarify treatment orders. All of these factors affect patient safety and may result in increased chemotherapy related errors.


Emotional Distress

Project: Incorporating Distress Screening Tool in an Oncology Office Setting, University Oncology, Augusta, GA, 2015

Subcategory: Distress Screening Tool, Documentation Improvement, Supportive Care

Problem Statement: Identifying and addressing all of the stressors within the relationship-centered care process of our practice will enhance our ability to better relieve or lessen distress, hopefully improving outcomes. The integration of the ambulatory and hospital based services also offers the ability to impact admissions and hospital length of stay, both impacted by psychosocial issues that can severely compound symptoms related to the primary disease and its treatment. An effective process may, therefore, reduce the overall cost of care while maximizing outcomes and patient outcomes and patient satisfaction.

 

Project: Emotional Distress Assessment and Management Initiative, Smilow Cancer Hospital at Yale-New Haven, New Haven, CT, 2013/2014

Subcategory: Distress Screening Tool

Problem Statement: In Spring 2012 QOPI abstraction results, 49% (217/445) of Smilow Cancer Hospital patients had documented assessment of “emotional well-being assessed by the second office visit” identifying a barrier to addressing patient emotional needs. – Compliance in 2 of our 10 cancer care centers identified for improvement pilot was below 12% Note: QOPI data based on physician documentation in paper chart