ANNUAL REPORT. Public Reporting of Outcomes

Transcription

1 2016 ANNUAL REPORT Public Reporting of Outcomes

2 The Merle M. Mahr Cancer Center at Baptist Health Madisonville continues our long-standing history of providing quality cancer treatment to our Western Kentucky service area. Our interdisciplinary team approach to care provides an empowering experience for our patients because it allows them to become an essential partner in their own care plan. At Baptist Health Madisonville, we recognize the need to care for the emotional as well as the physical needs of each patient. This is reflected in our mission, vision and values as we offer evidence-based medicine in a faith-based environment to those we are honored to serve. Epic Baptist Health s new electronic health record system In May, the Baptist Health Board of Directors approved one of the most important initiatives to Baptist Health s future that it s ever been undertaken Epic, an award-winning electronic health record solution for its system. The decision signaled a commitment to Baptist Health s patients, employees, physicians and the community that it The 2016 Annual Report showcases the quality of our program, our efforts to expand our services and our commitment to caring for our communities. It reviews the current state of cancer care and compares our local expertise to state and national standards. The Merle M. Mahr Cancer Center is equipped with the latest advances in technology, advanced diagnostics, early detection programs, nurse navigation, and support programs for our patients during and long after treatment ends. By improving access to medical care and expanding our care team with the addition of Dr. Modi and Dr. Triplett, we proudly provide comprehensive care right here at home. is advancing our goals of providing not only excellent patient care, but also enhancing the health of its communities. All Baptist Health Medical Group practices in Kentucky are now live with Epic, along with Baptist Health Corbin, La Grange, Lexington, Louisville and Paducah. Baptist Health Madisonville and Baptist Health Richmond will launch Jan. 21, Baptist Health Floyd and its urgent care facilities have plans underway for implementation early next year with launches scheduled for Baptist Health Madisonville and the Merle M. Mahr Cancer Center team are committed to walking the journey to wellness with each patient by providing high quality, compassionate care. Robert Ramey President, Baptist Health Madisonville completion in August Each launch provides Baptist s patients with an opportunity to sign up to MyChart. The new patient portal helps them better managing their health and also helps Baptist Health s physicians and clinicians maximize their efforts to BaptistHealthMadisonville.com keep patients well. 2

3 ABOUT THE CANCER PROGRAM AT BAPTIST HEALTH Our Vision Justin Sedlak, MD Chairman/Pathologist As a member of the Baptist Health Oncology Network, we continue to provide high quality care to residents of Western Kentucky, both locally, and as a region partnering with Baptist Health Paducah. From early detection programs, advanced diagnostic The vision of Baptist Health Cancer Network of Kentucky is to be the leader among cancer programs offering the most comprehensive, integrated, quality driven, and patient-centered care in community-based settings. testing, multidisciplinary surgical, chemotherapy and radiation therapy treatment options to support programs, the Cancer Program truly provides comprehensive care close to home and all under one roof. Darren Chapman, MD, FACS General Surgery/ Cancer Liaison Physician The cancer program has been continuously accredited by the American College of Surgeon s Commission on Cancer since Since 80% of all cancer patients are diagnosed and treated at ACoS accredited programs, this participation allows our cancer program to compare our experiences and trends with that of the nation through the data submissions to the National Cancer Data Base and participation in the Cancer Program Practice Profile Reports (CP3R). Diana Jackson, MSN, RN, OCN Cancer Program Administrator Baptist Health Madisonville is part of the Baptist Health Cancer Network delivering high quality cancer care across Kentucky. BaptistHealthMadisonville.com 3

4 Jeffrey Triplett, MD Radiation Oncology Jeffrey Triplett, MD, earned a medical degree from East Tennessee State University, Quillen College of Medicine. He completed a radiation oncology residency at the University of Kentucky, where he was chief resident during his final year. Prior to joining Baptist Health Merle M. Mahr Cancer Center, Dr. Triplett practiced for seven years at Baptist Health Paducah. Tejas Modi, MD Hematology/Oncology Tejas Modi, MD, earned a medical degree from Smt. NHL Municipal Medical College in India. He completed a chief fellowship in hematology and oncology at New York Medical College, and a fellowship in hematology and oncology at Seton Hall University. Dr. Modi is a fellow of the American Society of Clinical Oncology and the American Society of Hematology. He is board certified in internal medicine. How Our Cancer Program Utilizes Cancer Registry Data Cancer registrars are highly trained data information specialists who collect and code patient-level data for cancer registries. Essential information is provided to state and national cancer registries to assist cancer programs to accurately determine cancer patient populations, measure outcomes of treatment and survival, and formulate plans for improvement. The cancer registry database is a computerized data center, which provides a broad range of demographic, diagnostic, therapeutic and lifetime follow-up information about cancer and some benign neoplasms diagnosed at Baptist Health Madisonville, Merle M. Mahr Cancer Center, and Baptist Health Medical Group. The networked computer system in the registry allows for direct data entry supporting the paperless system. Data from the registry enables the medical staff, as well as other health care professionals, to analyze the results of their efforts. The addition of Rapid Quality Reporting has added another layer to our multi-disciplinary approach to Oncology care. The real-time accession of our most frequently reported cases provides additional monitoring of our patient s course of treatment and adherence to National Treatment Guidelines. As a Commission on Cancer accredited facility, this is one of many standards the cancer registry maintains that reflects Baptist Health Madisonville s commitment to provide high quality Oncology care. In 2015, approximately 350 new cancer cases were accessioned into the cancer registry database. The cancer registry is part of the Kentucky Cancer Registry s Cancer Patient Data Management System (CPDMS.net) using a modern data encryption system with patient confidentiality and data security a top priority. Our cancer registry continually exceeds all expectations of data quality as evidenced by audits performed by the Kentucky Cancer Registry, Surveillance Epidemiology and End Results Program (SEER), National Cancer Database (NCDB), and American College of Surgeons, Commission on Cancer (CoC). For questions concerning Cancer Registry, please contact Susan Knight BS, RT, (T), CTR at , or by at susan.knight@bhsi.com BaptistHealthMadisonville.com 4

5 Quality of Care Cancer Program Practice Profile Reports (CP3R) The Cancer Committee ensures and monitors that patients treated at Baptist Health receive care according to nationally accepted measures. The Commission on Cancer measures compliance with current CoC quality reporting tools the Cancer Program Practice Profile Reports. We are proud that our program consistently meets or exceeds the required performance expectations within the 95% confidence interval of the Commission on Cancer, and all Kentucky and CoC approved programs. Benchmark Radiation therapy is administered within 1 year (365 days) of diagnosis for women under age 70 receiving breast conserving surgery for breast cancer. [BCS/RT] Baptist Health Madisonville 90% 89.0% Kentucky 94.9% 93.7% 92% All CoC Approved Programs 92.4% 91.8% 91% Combination chemotherapy is considered or administered within 4 months (120 days) of diagnosis for women under 70 with AJCC T1c N0 M0, or Stage IB -III hormone receptor negative breast cancer. [MAC] Baptist Health Madisonville 90% Kentucky 94.9% 93.5% 95% All CoC Approved Programs 92.1% 92.5% 92% Tamoxifen or third generation aromatase inhibitor is considered or administered within 1 year (365 days) of diagnosis for women with AJCC T1c N0 M0, or Stage IB- III hormone receptor positive breast cancer [HT] Baptist Health Madisonville 90% 95.0% 100% Kentucky 95.0% 95.1% 93% All CoC Approved Programs 91.5% 91.6% 90% Radiation therapy is considered or administered within 1 year (365 days) of diagnosis for women undergoing mastectomy for breast cancer with 4 or more positive regional lymph nodes [MASTRT] Baptist Health Madisonville 90% n/a 50%* Kentucky 87.7% 86.5% 87% All CoC Approved Programs 89.2% 88.3% 84% Needle/core biopsy is performed to establish diagnosis prior to surgical treatment of breast cancer [nbx ] Baptist Health Madisonville 80% Kentucky 90.3% 89.5% 91% All CoC Approved Programs 89.9% 90.5% 90% Breast conservation surgery rate for women with AJCC Clinical Stage 0, 1 or 2 breast cancer [BCS] Baptist Health Madisonville N/A 68.2% 75.0% 97% Kentucky 55.8% 55.0% 61% All CoC Approved Programs 62.6% 62.6% 65% *Patient Refused Treatment BaptistHealthMadisonville.com 5

6 Adjuvant chemotherapy is considered or administered within 4 months (120 days) of diagnosis for patients under the age of 80 with AJCC Stage III (lymph node positive) colon cancer. [ACT] Baptist Health Madisonville 90% 100% Kentucky 95.3% 93.5% 92% All CoC Approved Programs 89.8% 89.5% 87% At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer. [12RLN] Baptist Health Madisonville 85% 88.0% 96.0% 95% Kentucky 87.0% 89.2% 87% All CoC Approved Programs 88.2% 90.0% 91% Systemic chemotherapy is administered within 4 months to day preoperatively or day of surgery to 6 months postoperatively or it is considered for surgically resected cases with pathological lymph node-positive (pn1) and (pn2) NSCLC [LCT] Baptist Health Madisonville N/A n/a 100% Kentucky 88.9% 88.5% 88% All CoC Approved Programs 90.7% 90.0% 89% At least 10 regional lymph nodes are removed and pathologically examined for AJCC stage IA, IIA, IIB resected NSCLC [10RLN] Baptist Health Madisonville N/A 50.0% 43.0% 40% Kentucky 32.7% 33.2% 30% All CoC Approved Programs 39.7% 41.0% 42% At least 15 regional lymph nodes are removed and pathologically examined for resected gastric cancer [G15LN] Baptist Health Madisonville N/A n/a n/a n/a Kentucky 42.9% 52.9% n/a All CoC Approved Programs 53.1% 54.4% n/a FIT Kit Screening Results General Community Capstone Project 2016 Distributed Returned Positive 11 8 Percent Positive 39% 28% Partnering with Baptist Health Madisonville, Colorectal Cancer (CRC) educational sessions and free screening opportunities were provided for 193 City of Madisonville, Kentucky employees. CRC knowledge was assessed before and after the educational session with the Sanchez Knowledge Assessment Survey (Sanchez et al., 2913). A paired t-test indicated that mean CRC knowledge scores improved significantly following the educational sessions (t (181) = , p <.0001). Over half of the participants (130/193) elected to take home a fecal immunochemical test (FIT) screening kits. The final analysis of screening results yielded 29 participants submitting their screening kits for evaluation; 8 have been positive for colon cancer indictors. All participants have been notified of their screening results; those with positive results have received referral recommendations. The community-based CRC project was effective in improving CRC knowledge and screening participation. Please note the table above for the comparison of general community screenings versus this project with deliberate education BaptistHealthMadisonville.com 6

7 Patient Navigation Baptist Health offers patient navigators for any type of cancer. An oncologycertified nurse provides assistance for patients and families from the point of screening or a suspicious finding through diagnosis, treatment and survivorship. A Licensed Certified Social Worker and a Financial Advocate assist the Nurse Navigator to meet the complex needs of patients. The patient navigators provide the following services: Heather Tow, RN, OCN Patient Navigation Team Judy Blue, LCSW Clinical Social Worker l Coordinate care and streamline appointments, allowing for more timely treatment l Identify and assist with potential barriers to cancer care - educational needs, financial concerns, transportation, language or cultural issues, emotional and social needs - of patients and family members Survivorship In 2005, the IOM and National Research Council report, From Cancer Patient to Cancer Survivor: Lost in Transition, recommended patients with cancer who are completing the first course of treatment be provided a comprehensive care summary and follow up plan. Enormous strides are continually being made in cancer treatment, and these cancer survivors require medical care and support services tailored to meet their unique needs. This includes but is not limited to: l Survivorship care plans and treatment summaries l Screening for other cancers l Counseling for family members and caregivers l Risk assessments l Maintaining a long-term patient/ physician relationship l Information on new treatments and therapies l Provide one-on-one education to help patients and families understand diagnosis and treatment options l Link patients, families and caregivers to community resources to address specific needs during the cancer treatment experience l Lead and facilitate support groups for patients and their families In 2016, our team enhanced the focus on Survivorship Care Plans by adding radiation patients of curative intent. Each patient at first follow-up after their treatment is completed receives an in depth Survivorship Care plan that assists them in moving forward in their lives as a cancer survivor. BaptistHealthMadisonville.com 7

8 Public Reporting of Outcomes: Prevention and Screening 2016 Community Outreach Events Event Date Focus Outcome Plan to be Tobacco Free January-October Cancer Prevention Tobacco Cessation 20 referred; 9 completed Kick It January-October Cancer Prevention Tobacco Cessation 11 attendees; 3 completed Tobacco Education January-November Cancer Prevention Tobacco Education Hopkins County Schools Colon Cancer Screening/ Giant Inflatable Colon March 15, 2016 Colon cancer awareness 250+ attendees West KY Lifestyle Expo April 16, 2016 Senior Community Health Fair April 20, 2016 Cancer prevention and detection for adults tobacco cessation Cancer prevention and detection for adults tobacco cessation 300+ attendees 48 attendees Medical Fitness Week April 23-30, 2016 Prevention 600 signed up; 235 completed Bike Safety Day May 7, 2016 Prevention 120 children Carhart Health Fair June 17, 2016 Prevention and Education 280 attendees Dust Bowl August 6, 2016 Prevention and Education 200 attendees Think Pink October 22, 2016 Breast cancer screening, education and awareness 63 attendees Lung Cancer Screening Dec 15 - Nov 16 Detection 22 participants Kentucky LEADS Despite focused efforts to educate the community, a recent community assessment shows smoking cessation to be a top priority for all Baptist Health Madisonville counties served. In an effort to make an impact, our facility has joined a statewide initiative to reduce lung cancer in Kentucky. The Kentucky LEADS Collaborative (LEADS = Lung Cancer Education, Awareness, Detection, and Survivorship) entails three key components and an administrative core, committed to reducing the burden of lung cancer in Kentucky. The Mission of The Kentucky LEADS Collaborative is dedicated to reducing the burden of lung cancer in Kentucky and beyond through development, evaluation, and dissemination of novel, community-based interventions to promote provider education, survivorship care, and prevention and early detection regarding lung cancer. BaptistHealthMadisonville.com 8

9 The Merle M. Mahr Cancer Center will participate in the second component, Survivorship Care, which will develop and evaluate a lung cancer-specific survivorship program for individuals diagnosed with lung cancer as well as their caregivers. This component will also develop a training program to facilitate dissemination of the lung cancer survivorship care program that will target lung cancer navigators and mental health providers. Heather Tow, RN, OCN, Nurse Navigator, Jenifer Miller RN, OCN, Clinical Trial Data Manager, and Judy Blue LCSW, Oncology Social Worker have all received the formal training required to participate in the LEADS initiative. And most recently, the University of Kentucky s Institutional Review Board approved the Kentucky Leads Collaborative Survivorship Care study protocol, so we are one step closer to participating in the state wide initiative to reduce the burden of lung cancer in Kentucky! Our Services Our cancer team is committed to treating the whole patient and providing individualized care. Given our commitment to Commission on Cancer Accreditation and a growing focus on results, research that demonstrates increased patient satisfaction, and cancer outcomes, our tumor board currently meets the 1st and 3rd Wednesdays of each month. These multidisciplinary conferences involve surgeons, medical oncologists, radiation oncologists, pathologists, radiologists, nurses, clinical research staff, nurse navigator, and ancillary support staff. These conferences bring cancer care specialists together to discuss management of patient care, and review national treatment guidelines and the latest research findings, in order to create the best treatment plan or management plan for individual patients. Radiation Therapy The Merle M. Mahr Cancer Center incorporates innovative technology with an experienced and dedicated team trained to provide radiation treatment with compassion. A Continuing Quality Improvement Program is in place to meet the high standards of the American College of Surgeons accreditation as well as standards set forth by the American College of Radiology. Program members coordinate efforts to ensure continuous improvements of patient care and outcomes. Our Radiation Team has been working toward a goal of replacing both Linear Accelerators (treatment machines) with a state of the art Varian TrueBeam Linear Accelerator. This technology further expands the capability of providing radiation treatments that are the most current and available in a community hospital setting. We are excited to see this project coming to fruition as construction planning is already underway. TrueBeam from Varian Medical Systems is an advanced radiotherapy system that opens up treatment options for some of the most complex cancers in areas such as the head and neck, lung, breast, abdomen and liver. The TrueBeam system s advanced imaging and powerful treatment modes allow doctors to tailor treatments specific to a particular cancer. Treatments with Varian s TrueBeam are fast. Most can be given within just minutes a day. Treatments that once took 10 to 30 minutes can now be completed in less than two minutes. In addition to enabling a more comfortable experience for the patient with less time on the treatment table, faster delivery also allows for reduced chances of tumor motion during treatment, which helps protect nearby healthy tissue and critical organs. Before and at any point during a treatment, the TrueBeam system can generate the three-dimensional images used to fine-tune tumor targeting in much less time (and with less X-rays) than was possible with earlier Varian technologies. These images can be used to fine-tune a patient s position prior to and during the treatment process. BaptistHealthMadisonville.com 9

10 TrueBeam was also designed to enhance the patient experience. Thanks to an advanced communications system, the therapist running the system can be in constant contact with the patient. It s almost as if they are there in the treatment room with the patient. In short: TrueBeam is a powerful system that opens up treatment options for complex cancers TrueBeam is fast and precise TrueBeam was developed to address patient comfort The Radiation Oncologist will determine if TrueBeam treatment is right for each patient. Outpatient Chemotherapy Nationally certified oncology nurses provide highly individualized, quality care in a convenient setting at the Merle M. Mahr Cancer Center. These highly skilled nurses provide the compassionate care and support that only someone like family can provide, and our goal is to treat you like family. Each chemotherapy plan is the product of commitment to the gold standard in cancer care developed by the National Comprehensive Cancer Network will be a very exciting year as we move to the EPIC electronic health record, and Oncologists will have at their fingertips distinctly designed chemotherapy plans for every diagnosis and every treatment regimen. A team of professionals within the BH oncology network team spent more than a year building these treatment plans in order to provide patients with an individualized treatment plan. Inpatient Cancer Care 4West is the dedicated inpatient oncology unit at Baptist Health where nurses are trained to care for cancer patients and provide chemotherapy. This group of caring nurses is committed to maintaining the strong skill set that is required for cancer patients and to infuse chemotherapy. To meet this commitment, staff education is provided by the Merle M. Mahr Cancer Center Oncology certified nurse s annually and more often when indicated. This team effort provides a smooth transition for patients who may need to be admitted to the hospital for their care. Non-Oncology Infusion Services Many patients have infusion or injection needs that can t be managed in a clinic, yet are not appropriate for admission to the hospital. To meet the needs of those patients, infusion services are coordinated by the Merle M. Mahr Cancer Center team. Additional treatment services included blood transfusions, and non-oncology infusions such as antibiotics, and other intravenous medications including but not limited to drugs for rheumatoid arthritis, osteoporosis and cardiac issues. Infusions may be administered in the cancer center or the ambulatory care unit. In addition, all patients have available to them a Licensed Certified Social Worker, Dietician, and Spiritual Support. Smoking Cessation Baptist Health offers a smoking cessation class called Kick It, free to both employees and community members. This five week program consists of 30 minute group sessions, once a week. These sessions provide the education, tools, and resources to aid in quitting successfully. A pharmacist provides nicotine replacement and medication education. Classes are offered online starting on the first Tuesday of every month at 7:30CST. Quarterly classes are also offered onsite at Baptist Health Madisonville. BaptistHealthMadisonville.com 10

11 Treatment and Emotional Support American Cancer Society Information Center Trained specialists assist cancer patients, their families and the public 24/7, 365 days a year, at the American Cancer Society s toll-free number: Specialists provide current information on housing, financial assistance, support groups, American Cancer Society programs and other local resources. Cancer information is also available online at cancer.org. Personal Health Manager The American Cancer Society is pleased to provide newly diagnosed cancer patients with a Personal Health Manager (PHM). The Personal Health Manager is an organizational portfolio containing tailored information relevant to their type of cancer that will empower patients to make educated health decisions and connect them to local resources and services. Additionally, the portfolio helps patients keep track of critical medical information provided by their healthcare team. There are multiple tabbed folders in the organizer which provide a tool for patients to organize information, write down questions, track appointments and record prescription information. In addition to the folders, the Personal Health Manager comes with a standard set of information, including a series of documents written in an easily understood format. Look Good Feel Better The American Cancer Society s Look Good Feel Better is a beauty program for women who are going through or recently completed treatment. Look Good Feel Better empowers patients by teaching techniques to help with skin, nails, makeup and hair loss concerns from treatment. The program is available to female patients in a number of ways: through DVDs at home, through one on one personal consultation with ACS-trained volunteer cosmetologists, through group sessions led by volunteer cosmetologists in which the patient receives cosmetic samples for practice, and through a virtual class online at lookgoodfeelbetter.org in which interactive makeover tools are used. To register, call Local Cancer Resource Guide The Kentucky Cancer Program publishes the PATHFINDER, a local cancer resource guide for cancer patients and their families. The guide is available at Baptist Health Madisonville and Baptist Health Paducah or by calling the Kentucky Cancer Program at You also may view online at kycancerprogram.org/publications. National Cancer Institutes (NCI) Cancer Information Center NCI s central Web site, cancer.gov, has extensive information on cancer prevention, diagnosis, treatments, statistics, research, clinical trials and news, as well as links to other NCI Web sites. Trained cancer control specialists are available at the toll-free hotline ( CANCER) to answer questions and provide cancer education materials. Reach to Recovery The American Cancer Society volunteer visitation program matches breast cancer survivors with those concerned about breast cancer. Whether the person has been diagnosed with breast cancer, had surgery or found a suspicious lump, a Reach volunteer lends an ear, shares resources and offers emotional support. To schedule a visit, call Road to Recovery Through this program, the American Cancer Society provides cancer patients with transportation to and from medical facilities for treatment. Volunteer drivers help keep them on their regular treatment schedule. To schedule a ride, call BaptistHealthMadisonville.com 11

12 Baptist Health Madisonville 2016 Cancer Committee Members Chairman/Pathologist* Justin Sedlak, MD*** Diagnostic Radiologist* General Surgery/ ACoS Cancer Liaison Physician Radiation Oncologist* Medical Oncologist* ENT Surgeon Pathology* Cancer Program Administrator Oncology Nurse (Inpatient) Oncology Nurse Navigator Clinical Social Worker** Cancer Registry Coordinator PI Quality Improvement Clinical Trial Research Associate** Radiation Oncology Chaplain Pharmacy Community Outreach Coordinator ACS Representative Hospice Care Rehabilitation Care Neal Rosner, MD Darren Chapman, MD, FACS*** Satish Shah, MD Jeffrey Triplett, MD Ali Kanbar, MD/ Tejas Modi, MD William A. Logan, MD, FACS Richard Bauer, MD Diana Jackson, MSN, RN, OCN Angie Bland, RN Heather Tow, RN, OCN Judy Blue, LCSW Susan Knight, BS RT (R)(T) Denise Dunn BSN, RN, CPHQ Jenifer Miller, RN, OCN Danette Brown RT(T) Rev. Bill McCann Margo Ashby, PharmD Ava Lomache RN Ellen Schroeder Cyndi Clark BSN, RN Andrea Ramsey Oncology Dietician Executive Team Cardiothoracic Surgery Family Practice Residency Faculty West Area Health Education Sheila Baker, RD Tiffany Cabibbo, MSN, BSN, RN, CENP Joan Lang, MBA - Ky. Cancer Program Ad Hoc Members Medical Library T. Mark Stanfield, MD, FACS William Crump, MD Jamie Knight Teresa Ruddell, CTR * Required Physician Members ** Required Non- Physician Members *** Registry Advisors BaptistHealthMadisonville.com 12

13 Hospital Drive l Madisonville, KY BaptistHealthMadisonville.com