Cancer Care Collaborative Approach to Optimize Clinical Care

For each of the 3 CCC phases, VA-CASE IEs facilitated the development of standardized measurement and tracking tools for each cancer type. The tools identified key timeliness and quality measures as a function of entered patient data (eAppendixes 4-7, available at fedprac.com/AVAHO). 

Quality Improvement Toolkit Series

The Quality Improvement Toolkit Series (QITS) was created for VA clinical managers and policy makers to improve diagnosis, treatment, and patient outcomes for high-priority conditions. The goal of the QITS is to serve as the cancer care improvement resource guide to produce and disseminate the National Quality Improvement Toolkit resource.

Each tool included in the QITS is matched to 1 or more metrics of the OQP (such as a performance measure or quality indicator). For example, the types of tools include CPRS order sets and templates, enhanced registries and patient databases, service agreements, and care process flow maps. Each toolkit served as a resource for improving facility performance on a specific set of established performance measures and/or quality indicators. Toolkits that helped VA facilities improve performance on OQP quality indicators and performance measures were based on the VA-TAMMCS model and continuous improvement that was tailored to the structure and needs of the VA system. The VA-CASE staff provided guidance on the criteria for inclusion in the toolkits to promote best practice and quality in clinical practice. The criteria used by a condition-specific expert panel were based on whether or not it was (1) not already part of VA routine care nationwide; (2) can be matched to 1 or more VA quality metrics/indicators; and (3) currently in use at a health care facility (innovative VA colleagues nationwide and by non-VA health care organizations).

Evaluation

After each LS, VA CCC evaluation data were collected using standardized 5-point Likert scale questions.

Results

Industrial engineers provided > 1,200 days of on-site support across the 60 teams and built 63 flow maps and 47 customized tools based on the team’s requests throughout the implementation period. Throughout the 3-phase CCC, the IEs developed standardized measurement and tracking tools for each cancer type (lung, colorectal, prostate, head and neck, and HCC). Outcomes included the sharing of best practices that spread across programs (uploaded to the national QITS site, available only to VA employees); as well as enterprisewide development of the special interest group (eg, VHA survivorship), which led to a national survivorship toolkit.

The table illustrates the overall collaborative impact across the CCC. In phase 1, 78% of the 64 aims (breast, CRC, lung, prostate) were met at 18 facilities. In phase 2, 72% of the 94 aims (CRC; HCC; and head and neck, lung, and prostate cancers) were met at 21 facilities. In phase 3, 47% of the 64 aims for head and neck and lung cancer were met at 11 facilities. The difference in the percentage of aims met during each phase was due to the variations in complexity of cancer types as well as additional logistic barriers at each institution.

Discussion

Overall, the CCC had a positive impact that improved timeliness, accessibility, and quality of the cancer care process in participating VAMCs. The majority of VAMCs focused on optimizing the lung cancer care process in all the phases of the collaborative, given that lung cancer suspicion-to-treatment process is highly complex, requiring multiple departments to coordinate workup and care, leading to the greatest room for improvement.

Industrial engineers introduced a variety of approaches to improvement to the collaborative teams, and they were integral to the development of standardized measurement and tracking tools for each type of cancer, introducing advanced SR methods for specific aims and performing appropriate data analysis. The ability of the VA system to recognize where improvements were needed was complemented by the efforts of VA clinicians and administration with direction from VERC IEs and their toolkits. Improvements were made, sometimes decreasing time from diagnosis to treatment by 50%. The VA facilities were encouraged to sustain this improvement using the toolkits with continued data gathering and implementation. In phase 1, lung cancer improvements included (1) establishing the multidisciplinary clinic, multidisciplinary rounds, and improved communication among key service lines; (2) developing a database (measurement tool) to prospectively track all cancer patients; (3) scheduling weekly multidisciplinary meetings to provide a mechanism to rapidly review patients and triage to appropriate pathways in the treatment algorithm; and (4) increasing physician participation, including oncologists, surgeons, radiologists, and radiation oncologists, to identify methods and process
changes that could eliminate wasteful steps and improve access for expediting diagnosis and treatment of patients with lung cancer who require surgery, chemotherapy, and/or radiation. The overall impact on time from abnormal CT to lung cancer surgery was reduced by > 5 months from 180 to 20 days. Substantial improvements were made in timeliness and reliability in caring for veterans with lung cancer.¹²

Groundbreaking work and exceptional results continued in the second phase for lung cancer care. In addition, the creation of a prostate cancer care web-based clinical measurement tool helped to improve the ability to proactively manage patients. The tool included same-day scheduling of biopsy and urology appointments for veterans with possible prostate cancer and the development of a protocol for expedited high-risk patients with metastatic disease. Ultimately, the wait time from urology consult to diagnosis was cut from 96 to 46 days for veterans with prostate cancer (Figure 4).