Cancer Care Collaborative Approach to Optimize Clinical Care
A collaboration between clinicians and industrial engineers resulted in significant improvements in cancer screening, the development of toolkits, and more efficient care for hepatocellular carcinoma and breast, colorectal, lung, head and neck, and prostate cancers.
The phase 3 collaborative was designed for hub and spoke facilities by focusing on current state vs ideal state processes, communication patterns, and care coordination between the hub and spoke facilities. There were 10 facilities in which all teams focused on lung cancer. Each facility was made up of 1 hub and had the ability to send up to 8 participants (from either the hub or the spoke facility) to the CCC workgroup meetings. Participants were specialists, radiologists, primary care providers, pathologists, nurses, nurse practitioners, or physician assistants.
Conceptual Model Deployment
The deployment of the CCC 3-phase conceptual model was based on the Institute for Healthcare Improvement (IHI) Breakthrough Series Collaborative Model.24,25 Implementation was carried out over 3 phases (2005-2011) after proper teaching, coaching, and learning sessions (LS)
Each LS incorporated instruction in basic systems engineering and Lean Six Sigma principles (an approach to quality improvement that focuses on reducing waste and variability) with practical, health care-based examples, case studies, and immediate application of the VA-TAMMCS (vision/analyze, team/aim, map, measure, change, sustain) SR organizational framework (Figure 2), tools, and methodologies to the process under investigation.26 The VA-TAMMCS (eAppendix 2, available at fedprac.com/AVAHO)
The CCC encouraged joint facilitation. A SR clinical coach, a VERC IE, and participating facilities were required to work together intensively (mentor and support) for 10 to 12 months. The mix of clinicians and engineers helped the facilities by bringing in diverse perspectives, which led to better decisions in the improvement of cancer care.28 During the CCC, the IEs partnered with and supported clinicians, using Lean Six Sigma and SR tools and approaches to health care quality improvement to quickly make improvements in efficiency and quality (eAppendix 3a, 3b, and 3c, available at fedprac.com/AVAHO).26,29 
The IEs provided on-site support at all participating VAMCs during all 3 phases by providing the clinical teams with a variety of VA-TAMMCS process improvement tools to support the analysis and improvement of their organizations.
Data Collection
As part of the overall improvement process, the facilities worked on several aim statements in order to improve a primary constraint; such as timeliness and quality of care. An aim statement communicates what you want to do (eg, reduce, improve, or eliminate), by how much, and when. In order to improve timeliness, the CCC focused on measures from first evidence to tissue diagnosis, from diagnosis to treatment, and also intermediate measures, such as time from positron emission tomography scan ordered to completion. While working on overall quality of care unique to cancer, the CCC focused on measures related to documentation compliance and consistency of care provided to patients.
Phase 1
Facilities were to optimize their process (time from initial suspicion to diagnosis). Hence, participating facilities were allowed to simply identify their aim statement and pick and choose the area of focus.
Phases 2 and 3
Timeliness Aims. These aims were addressed through improvements in information technology in the Computerized Patient Record System (CPRS) electronic medical record by creating electronic order sets containing codes that alert providers daily to retrieve and follow up on abnormal test results. Primary care physicians and front desk staff also were educated on the use of these order sets and to schedule a follow-up test or specialist consult within 3 to 7 days.
Aim 1: Reduce to 15 days the time from initial suspicion to diagnosis within 1 year.
Aim 2: Reduce to 30 days the time from diagnosis to start of treatment within 1 year.
Quality Aim. Improve the compliance rate of identified quality indicators to 100% within 1 year.
Measurement Tools
The Cancer Care Measurement Tools were designed to support the OQP performance metric (Figure 3). The OQP creates and collects data on evidence-based national benchmarks to measure the quality of preventive and therapeutic health care services at the facility, VISN, and national levels. These metrics may be performance measures, performance monitors, quality indicators, and special studies, among other measures, to support clinicians, managers, and employees in improving care to veterans.
