What s in This Issue? Oncology Public Reporting of Outcomes. A Note from the Oncology Services Director. Our Cancer Committee Members

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1 2017 Oncology Public Reporting of Outcomes CLARK REGIONAL WITH UK MARKEY CANCER CENTER AFFILIATE NETWORK AT GEORGE ROGERS CLARK HIGH SCHOOL What s in This Issue? A Note from the Oncology Services Director Our Cancer Committee Members 2017 Major Accomplishments 2017 Community Prevention and Screening Events Who we serve How is cancer impacting our community? 2017 Quality Improvements

2 A Note from the Oncology Services Director ONCOLOGY SERVICES DIRECTOR Dear community, friends, family and patients, I would like to start by saying that it is my pleasure to serve in my role. Being from a small town myself, it is very important to me that my encounters with people feel warm and welcome. I take great pride in creating an environment that not only strives and accomplishes high quality care, but helps to make Clark Regional Medical Center a place patients want to receive care. Cancer is a word that most all of us can relate to on some level. We know that a diagnosis of cancer, big or small, is a very scary and overwhelming time. We do our best to take great care of the whole picture, not to only treat your disease but to treat you as a person. Throughout the journey of cancer treatment at Clark Regional, we take pride in multidisciplinary individualized care. Our standards are set forth by the Commission on Cancer, which you will learn more about in this issue. Also we partner with the UK Markey Cancer Center Affiliate Network to broaden our capabilities, knowledge, and resources to achieve the best possible outcomes for our patients. Deanna Wells has been with Clark Regional Medical Center for nearly 5 years. She has been leading the way for improvement in the care of infusion and cancer patients. We are always open to questions whether you receive your care with us or with other organizations. We are here to serve our community and surrounding counties any way we can. Thank you for trusting your care in us, Deanna Wells RN, MSN, VA-BC

3 Clark Regional Cancer Committee Members Cancer Committee is a group of Doctors, Nurses and other professionals who ensure Quality Care is a continued focus and Commission on Cancer Standards are being followed. In this committee we discuss issues that need improvement and celebrate accomplishments. Cancer Liaison Physician and Cancer Committee Chair: Dr. Stephen Anderson, Oncologist/Hematologist Cancer Program Administrator: Deanna Wells RN General Surgeon: Dr. Rebecca Bartee Radiologist: Dr. Jeffery Settles and Dr. Benjamin McQuaide Pathologist: Dr. Edward Tanous Cancer Conference Coordinator: Deanna Wells RN Cancer Registry Quality Coordinator: Tracy Mabry CTR Clinical Trials Coordinator: Mandy Mills RN Quality Improvement Coordinator: Kelly Stratton RN and Barbara Kinder RN Community Outreach Coordinator: Roni-Anne Denham Psychosocial Services Coordinator: Dr. Latonia Sweet Psychiatrist and Cheryl Slone Rehabilitation: Justen Hinerman PT Dietitian: Lyndsey Dixon RD

4 Clark Regional Medical Center Receives Commission on Cancer Bronze Level Accreditation On June 6, 2017 Clark Regional Medical Center was surveyed by the American College of Surgeons Commission on Cancer. The Commission on Cancer is a consortium of profession organizations dedicated to improving survival and quality of life for cancer patients through standards set forth that promotes cancer prevention, research, education, and monitoring of comprehensive quality care. We were very pleased to receive a bronze level accreditation without noted deficiencies. Every three years the Cancer Committee and program will be surveyed to continue this level of excellence. Clark Regional Joins UK Healthcare s University of Kentucky Healthcare s Markey Cancer Center Affiliate Network After successfully completing the Commission on Cancer Accreditation, Clark Regional joined the UK Markey Cancer Center Affiliate Network (MCCAN). The MCCAN assists doctors, nurses, pharmacists and other medical staff at local hospitals that provide excellent care in their communities. When patients need care that is not available locally, they can be referred to the Markey Cancer Center in Lexington. When that happens, Markey doctors work with community doctors and oncologists to minimize travel for patients and their families.

5 2017 Community Prevention and Screening Events In 2017 Clark Regional hosted and participated in numerous health events and 10 screening or prevention events focused on cancer. For more information on our events planned for 2018 please contact us. Inflatable Colon to increase awareness and educate on colonoscopies and colon cancer. Above are members of Clark Regional s mammogram team. They are responsible for 3647 screenings as of October 26, This team offers Mammo Mondays with late hours and Saturday appointments at special times throughout the year to help better encourage breast screening and health. Lyndsey Dixon, Dietician, dedicates time to our cancer committee, health fairs, and prevention events to educate our patients about how their diet can prevent illness and increase success of healing.

6 Who We Serve Clark Regional Medical Center Diagnosis Rate per County verses Total per County based off the Kentucky Cancer Registry Data. We are on track to diagnose a total of 175 cancer cases in 2017.

7 Cancer and Clark County- How is it impacting our community? Our top 5 cancers in 2016 were breast, lung, colon, prostate and bladder. In 2014 Clark Regional introduced Dr. Stephen Anderson Oncologist/Hematologist to our team. During this time, we have enhanced cancer care through surgery, chemotherapy, Cancer Committee, Tumor Boards, obtaining our Commission on Cancer Accreditation and UK Markey Cancer Center Affiliate Network Status. Through continued education and increased service lines we hope to impact cancer in Clark County in a positive way by providing high quality cancer care close to home Cases to Currently Abstracted

8 2017 QUALITY IMPROVEMENTS Our Cancer Committee members work together each year to determine areas that we could improve our quality of care. Throughout the process of developing quality improvements, studies are conducted either on our own data and compared to national standards or based off studies completed and published by other entities. Quality Improvement #1 In an effort to prevent a delay in diagnosing and treatment of possible liver and kidney masses or metastatic evaluation, a CT protocol for scanning with contrast or without contrast and delayed images were built and implemented. This protocol will help us avoid the need to rescan for different images. When there is a concern that cancer has metastasized, it may have spread to multiple places in the body. Prior to treatment, it is important to know what stage the cancer is in order to determine the best treatment. These images assist in the staging process. Our radiologists voiced their concern that sometimes with kidney and liver masses there may difficulty with differentiating masses on images performed with/without scanning. By adding the delayed scanning there is better view for our radiologist to assist in diagnosis and staging. This protocol was implemented in September 2017 and is available for physicians to order. Quality Improvement #2 Based on a study performed in our hospital we found that there was a significant percentage of no-show and cancelations for colonoscopies. For the year of 2017, the cancellation rates from January to November ranged from 32.3% to 23.5%. With this information we determined the need for pre-admission testing to include call reminders versus automated reminders. There was also an additional afternoon nurse added to this role in order to enhance the process. Cancellation rates have continued to trend down with the change in process.

9 Thank you for your continued support and allowing us to serve you! If you have any questions, comments or concerns please contact us. Deanna Wells RN, BSN, VA-BC 175 Hospital Dr. Winchester, KY Phone: Fax: