Quality of Care

1. Quality of Care Steven B. Clauser, Ph.D. Chief, Outcomes Research Branch, NCI Applied Research Program Division of Cancer Control and Population Sciences NCCCP “Kick off” Meeting June 25, 2007

2. Steven Clauser, PhD (co-chair) Arnie Potosky, PhD (co-chair) Ted Trimble, MD, MPH (co-chair) Tanya Agurs-Collins, PhD Neeraj Arora, PhD Rachel Ballard-Barbash, MD, MPH Martin Brown, PhD Andrea Denicoff, RN Brenda Edwards, PhD Paul Han, MD Diana Jeffrey, PhD Joseph Kelaghan, PhD Jon Kerner, PhD Sarah Kobrin, PhD Lenora Johnson, MPH Holly Massett, PhD Helen Meissner, PhD Cherie Nichols, PhD Julia Rowland, PhD Stephen Taplin, MD, MPH Emmanuel Taylor, PhD Cynthia Vinson, MA NCI Cancer Care Delivery and Outcomes Group

3. Quality of Care Relates to Several Other NCCCP Components InformationTechnologies Survivorshipand PalliativeCare Clinical Trials Quality of Care Multi- DisciplinaryPractice Disparities

4. The degree to which health services for patients and populations -increase the likelihood of desired health outcomes, Are consistent with current professional knowledge, and Provide coordination and continuity of care throughout the entire cancer experience What is quality? Knowledge-based Patient-Centered Systems-minded

5. To what extent is NCCCP cancer care knowledge-based? PreventionDetection DiagnosisTreatmentSurvivorshipEnd of Life • Primary - Screening - Imaging - Local - Monitor health - Treatments - Prognostic - SystemicandHRQOL- Palliation Biomarkers - Trials - Recurrence - Hospice - Testing - Second - Biopsy Primary • Identify evidence-based guidelines • Compare treatment delivered to guidelines • Evaluate degree of guideline adherence

6. To what extent is NCCCP cancer care patient centered? • “Global” definition centers around provider-patient relationship and communication—understanding patient as a “whole person” • Global metrics include all outcomes of interest to patient – survival, satisfaction with care, and health-related quality of life • Picker Institute defines patient-centered care more broadly:·        fast access to reliable health advice ·         effective treatment delivered by staff you can trust ·         involvement in decisions and respect for patients' preferences ·        clear, comprehensible information and support for self-care ·         physical comfort and a clean, safe environment ·         empathy and emotional support ·         involvement of family and friends and support for careers ·        continuity of care and smooth transitions

7. Is NCCCP cancer care systems-minded? Detection Diagnosis Risk Assessment Cancer or Precursor Treatment Long-term Intermediate Organize Follow-up Clarify survivorship resources and support Clarify Diagnostic Evaluation Clarify referral process and education Organize screening Identify and characterize population Recruit Outreach & Inreach Organize Screening Clarify Treatment resources POTENTIAL for improvement at TRANSITIONS ( ) or DURING TYPES of CARE DELIVERY ( ) Process of Care OUTCOMES

8. A.NATIONALNCI expectations and leadership, Public Policy/Regulations, Purchaser Requirements/changes, Professional Group Standards/Accreditation B. COMMUNITYLeadership, Advocacy Groups’ expectations, Population affluence, Insurance coverage, Geographic and public resources/access barriers, Market pressures; Care delivery/management practices • PILOT GRANTEELeadership, Resources, Structure, Procedures, Systems, Culture ENCOUNTERS INTERACTIONS CONTACTS PATIENT ADHERENCE CLINICIAN/TEAM CHARACTERISTICS PATIENT (and family) CHARACTERISTICS NCCCP quality of care is affected by multiple levels of influence Information Systems OUTCOME Patient: Health Status Satisfaction Quality of Life System: Efficiency Equity Effectiveness Information Systems Delivery Site: Leadership, Systems, Organization

9. Strategic Approach • Changing health care systems is the process of moving from the complex to the obvious in time consuming and expensive steps • NCCCP proposed interventions therefore need to emphasize “off the shelf” and turn key solutions with high potential yield to both NCI and the pilot sites • Also, need pilot site champions for buy-in and to move initiatives forward

10. QoC Workgroup Program Principles • Assess sites needs for internal program quality improvement • Complements external program focus on health disparities • Complement whenever possible NCCCP quality-related initiatives in clinical trials and survivorship • Create infrastructure for sustained and ongoing quality improvement to support clinical and patient-centered performance • Enhanced multi-disciplinary QI teams • Enhanced patient support programs based on patient perspective of needs • Measurement, intervention, feedback on select initiatives • Compare results to pilot, NCCCP program, and national program trends

11. Key Quality of Care Program Components • Baseline Assessments of Quality Improvement (QI) Resources/Capabilities • Enhance NCCCP infrastructure to support and maintain QI activities • Focus on select opportunities linked to national or NCI initiatives • QI Initiatives to Improve Evidence-based Care and Patients’ Satisfaction and Experience • Sites select opportunities and improvement goals within broad NCI framework • Baseline and Follow-up Assessments of both Process and Outcome improvement • Compare when possible to site baseline, NCCCP program experience, and similar national programs

12. Specific Research Questions • Have the multi-disciplinary QI teams enhanced performance on systems-based measures? • Referral for adjuvant therapy • Provision of treatment summaries to patients • Have the quality improvement initiatives increased adherence to evidence-based practice? • Is there consistent improvement across sites? • How does their improvement in clinical care compare to similar national providers or programs? • Are tailored patient education/support programs associated with improved patient experience and quality of life?