Kadlec Regional Medical Center Cancer Committee November 10 th, 2016

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1 Kadlec Regional Medical Center Cancer Committee November 10 th, 2016 Public Reporting of Outcomes As part of Kadlec Regional Medical Center s mission to provide quality health care for every patient, the Cancer Committee finds it vital to be open and transparent in our goals to improve the oncology program. The committee is a multidisciplinary group of providers and healthcare professionals that come together to identify barriers within our community and our health care system in order to find ways to eliminate, or minimize, them and improve access to and quality of, cancer care within our region. Chaired by Dr. Basir Haque, MD at Kadlec Hematology and Oncology with close collaboration with physicians and staff of the Tri-Cities Cancer Center, the cancer committee adheres to evidence based standards that improve quality and outcomes for our patients outlined by the American College of Surgeon s Commission on Cancer. This is a three-year accreditation process that ensures ongoing progress of our program and one we at Kadlec Regional Medical Center are proud to be a part of. We would like to thank the community for all of its support in our endeavors and most importantly, it is an honor and a privilege to provide care to our community thru prevention, screening, treatment, and survivorship. The following pages are an example of some of the commitment to quality care we here at Kadlec strive for our community. Dr. Basir Haque s annual report on adherence to evidence based practice in our treatments is provided first followed by Dr. Brian Staley s analysis of Breast Cancer treatments provided by the Kadlec Health System in 2013 and 2014 (2015 is unavailable at this time). Our community outreach report provided, in collaboration, by the Tri-City Cancer Center outlines classes, cancer screening activities in the community, as well as programs for cancer prevention such as smoking cessation. Finally, the cancer committee s 2016 goals for quality improvement are provided. These goals are determined by identifying barriers for our patients within the program through quality studies followed by subcommittees created to collaborate across departments to eliminate or minimize these barriers. Thank you for allowing this organization to be a part of this community; it truly is an honor and a privilege. We strive for excellence because it is something our region deserves and we look forward to another year of growth where we can continue to provide quality health care for every patient. Sincerely, Robert Nelson, BSN, RN, OCN Cancer Care Program Manager Kadlec Regional Medical Center

2 Kadlec Regional Medical Center Monitoring Compliance with Evidence-Based Guidelines Presented by Dr. Basir Haque, MD Cancer Committee Chairman November 10 th, 2016 Standard 4.6: Each calendar year, the cancer committee designates a physician member to complete an in-depth analysis to assess and verify that cancer program patients are evaluated and treated according to evidence-based national treatment guidelines. Study Populations: Patients within the Kadlec Regional Medical Center (KRMC) system that were diagnosed with diffuse large B-cell lymphoma (DLBCL) and received 1 st line therapy in 2015 Total 2014 Non-Hodgkin s Lymphoma (NHL) cases both nationally and within KRMC 1 st line therapy NCCN Guidelines for DLBCL:

3 Percent Data Presented for Analysis: Using the Cancer Registry database, twenty patients were counted as being treated for DLBCL in After chart review it was determined that 15 (75%) were given R-CHOP and 3 (15%) were given EPOCH + R as a first line therapy. One (5%) patient received R-CVP (without Gemcitabine) and one (5%) patient refused treatment. Treatment Type Number of Patients Percentage R-CHOP EPOCH+R 3 15 R-CVP 1 5 Refused 1 5 Total nodal Non-Hodgkin s Lymphoma (NHL) data (2015 data unavailable at this time) using the National Cancer Database (NCDB) was gathered using the hospital comparison reporting tool thru the Commission on Cancer (CoC) datalinks website. Of nodal NHL cases, KRMC had 30 cases with 22 (73.33%) receiving systemic therapy and 8 (26.67%) received no systemic treatment. NCDB nodal DLBCL cases totaled cases with (70.76%) receiving systemic therapy and 9380 (29.24%) received no treatment with 7192 (22.43%) having variations of other treatments. Nodal NCDB Comparison Type of Therapy KRMC NCDB KRMC % NCDB % No Systemic Therapy Received Systemic Therapy Other Col. TOTAL KRMC and NCDB 2014 Systemic Treatment Rates in Nodal NHL No Systemic Therapy Received Systemic Therapy KRMC (30 Cases) Other NCDB (32077)

4 Analysis and Results: To determine how the Oncology Program at Kadlec Regional Medical Center (KRMC) is managing patients with Non-Hodgkin s Lymphoma (NHL), specifically diffuse large B-cell lymphoma (DLBCL), clinical cases from 2015 with the aforementioned diagnosis were analyzed as well as overall NHL cases treated in When examining the percentage of DLBCL patients that have received initial treatments following national standards, it is evident that the KRMC Oncology program continues to provide excellent, evidence based treatments to its patients. Analysis of cases reported to the National Cancer Database (NCDB) also suggests excellence in comparison to other reporting hospitals within the nation. Of the twenty patients beginning treatment in 2015, 95% of patients (100% if excluding the patient who refused treatment) received a first line treatment that followed national guidelines established by the National Comprehensive Cancer Network. National guidelines for treatments are linked to improving overall outcomes so are therefore vital for the care of our oncology patients. When comparing KRMC with other reporting hospitals it is evident that we are treating more patients (73.33% vs 70.76%) rather than them receiving no treatment (26.67% vs 29.24). In conclusion, no gaps have been found within this study on NHL and, specifically, DLBCL. KRMC continues to provide high-quality care to its patients and meets the national standard of care within this metric. For the best possible treatment for our patients, continued diligence is needed as we continue to adapt and follow national standards in our therapy regimens. Respectfully Submitted, Dr. Basir Haque, MD KRMC Cancer Committee Chair

5 Kadlec Regional Medical Center CLP Report on Accountability and Improvement Measures Presented by Dr. Brian Staley, MD Cancer Liaison Physician November 10 th, 2016

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13 Kadlec Regional Medical Center Cancer Committee November 10 th, 2016 Standard 1.5/4.8: Quality Improvement Goals for Goal #1: Develop and improve the process for stomal/wound consults prior to surgery that show a 50% improvement. Ad hoc team: Progress: Jessica Lukson, RN Clinical Manager of KCHO; Craig Jameson Director of Kadlec Clinic Wound Healing Center; Marcia Vondruska, RN Colorectal Nurse Navigator; Lisa Bartholomew, RN Wound and Ostomy Certified Nurse; and Robert Nelson, RN Cancer Care Program Manager. The team met to solidify the goal: To improve pre-operative site marking and preoperative ostomy education by 50% prior to surgery. Barriers Identified: 1. Patient confusion regarding the need of two visits 2. Access to services due to a small window (one week) for pre-op marking Proposed solutions: I. Start education to promote the importance of the two visits by: 1. Creating a patient teaching pamphlet to be given to patient once the referral for ostomy teaching and marking is made. This pamphlet will be brief but clearly state the importance of the two visit process and what to expect during those visits 2. At the time of referral to the ostomy nurse, the colorectal providers and the colorectal nurse navigator will emphasize the need for this teaching and marking prior to surgery. II. Increase the window of stomal site marking to two weeks versus one week prior to surgery 1. The Ostomy nurses will use a surgical pen as the standard of practice to mark the site as it is harder to wash off than a sharpie. 2. A picture of the site will be taken at the time of marking and uploaded to the media tab Update: On track. We will be completing the pamphlet soon and sending it to Providence for approval. They also added another ostomy nurse certified for outpatient and that will help to expand availability when needed.

14 Kadlec Regional Medical Center Cancer Committee November 10 th, 2016 Standard 1.5/4.8: Quality Improvement Goals for Goal #2: Develop a process to ensure that patients with suspected breast cancer will have a biopsy 98%, of the time prior to lumpectomy or excisional biopsy. Ad hoc team: Krista McManus, Manager of Breast Imaging Services; Heather Johansen, Manager of Research; Pam Steeber of Blue Mountain Oncology Program; Jessica Lukson, RN Clinical Manager of Kadlec Clinic Hematology and Oncology. Progress: Data from the Blue Mountain Oncology Program was pulled for evaluation of this quality improvement study. 731 analytical cases for Kadlec Health System, between 2011 and 2015, were reviewed and 42 patients were identified as having excisional biopsies/lumpectomies without a diagnostic biopsy attempted. Those charts were audited to see if the biopsies could be found. We were able to find 25 of the cases that did have a wire, core, or stereotactic biopsies first. That left 17 cases with no biopsy prior to a lumpectomy or excisional biopsy. These cases are broken down below by years: cases out of 130 = 3.8% cases out of 116 = 1.7% cases out of 132 = 3.0% cases out of 152 = 1.9% cases out of 201 = 1.5% Total = 2.3% average over 5 years Barriers Identified: Timely referrals for biopsy after suspicious mammogram. Lack of education from the primary care providers. Labor intensive process. Proposed solutions: Reflex pathways, monitoring by the FDA-MQSA. Primary care provider education on the urgency of entering the referral order to radiology for the diagnostic PNB before referral to surgery. Clarification: The biopsy we are referring to are Percutaneous Needle Biopsies prior to surgery. Rationale: Per Calhoun, KE and Anderson, BO, Percutaneous needle biopsy (PNB) for breast tissue diagnosis has emerged as a quality metric for breast disease management. In 2003, the National Comprehensive Cancer Network identified needle biopsy as preferred over

15 surgical excision for breast diagnosis. In 2005, a multidisciplinary international consensus conference concluded that PNB is the optimal initial tissue-acquisition method and the procedure of choice for image-detected breast abnormalities. More recently, the National Accreditation Program for Breast Centers established palpationguided or image-guided needle biopsy as the initial diagnostic approach rather than open biopsy as one of 19 clinical management standards by which breast centers are measured. Thus, PNB represents an important transition in breast cancer management of specific interest to surgeons. Update: Krista McManus, Manager of Breast Imaging Services and Dr. Meadows, the Medical Director of Kadlec Clinics, developed a pathway for Self-Referred Screening Mammography for patients that can lead to a recommendation for biopsy. They also developed a Breast Image-guided reflex order to help initiate a biopsy prior to a surgical consult. 1) When an abnormal mammogram occurs, the PCP is sent a copy of the report. The patient is also sent a letter with the results (as mandated by FDA-MQSA). If a patient is self-referred for her screening mammogram and does not list a PCP, she is sent a letter with the results. We recommend that she establish care with a physician as we cannot perform any diagnostic studies without a physician s order. If the patient s results are alarming and they do not have a physician, the team works with the patient to help her find one. Dr. Droesch, the breast surgeon has been helping with these cases and acting as a referring physician to maintain best practice. 2) The radiologist is a Breast Imaging Specialist and cannot order the needle biopsies. This must come from the PCP. 3) Typically, if a radiologist recommends an open biopsy it is for good reason (too thin of a breast to do needle biopsy, large vessels, etc.). Usually the radiologist will discuss with the surgeon in these cases and will dictate in the report. 4) There are no absolute contraindications to PNB however the following may exclude the patient: 1. Significant coagulopathy that cannot be adequately corrected. 2. Severely compromised cardiopulmonary function or hemodynamic instability. 3. Lack of a safe pathway to the lesion. 4. Inability of the patient to cooperate with, or to be positioned for, the procedure. 5. Pregnancy in cases when imaging guidance involves ionizing radiation. a. All imaging facilities should have policies and procedures to reasonably attempt to identify pregnant patients before the performance of any examination involving ionizing radiation. If the patient is known to be pregnant, the potential risk to the fetus and clinical benefits of the procedure should be considered before proceeding with this study, per ACR Resolution 1a (established in 1995, revised in 2005). 5) For the Breast Imaging Department: They are mandated by the FDA-MQSA to track everything from our department, which will monitor if we are having fallout.

16 Continued Progress: In May 2016, they added another radiologist to the breast imaging program bringing their numbers to two. Krista also added a 3 rd ultrasound technologist, and they no longer have any back logs for diagnostics or Ultrasound biopsies due to these changes. However, they now have an issue of a backlog of 3D needle biopsies as they only have 2 mammography machines. Krista is now working to acquire another 3D mammography machine so that they can do all the procedures on that machine and instead of interrupting their daily screening and diagnostic schedules. This most likely will not happen until at least References: Calhoun, K.E. & Anderson, B.O. Needle Biopsy for Breast Cancer Diagnosis: A Quality Metric for Breast Surgical Practice. Journal of Clinical Oncology, Vol 32, No 21 (July 20), 2014: pp