Gap analysis: a strategy to improve the quality of care of head and neck cancer patients

In the United States, there will be an estimated 49,670 new cases of head and neck cancer for 2017.¹ Head and neck cancer (HNC) is a term used to describe a range of tumors that originate in the area of the body spanning from the lower neck to the upper nasal cavity.² Specifically, they are malignancies arising in the mouth, larynx, nasal cavity, sinuses, tongue, lips, and numerous glands such as the thyroid and salivary.² To clarify, HNC, despite the encompassing name, does not include growths of the bones, teeth, skin, brain parenchyma, and eye; therefore, such tumors will not be addressed in this article.

Patients with HNC often experience fragmented and uncoordinated care that leads to delays in cancer treatment, severe distress in patients and families, and dissatisfaction with care. Literature reports that these patients face numerous stressors including aggressive cancer treatments, severe symptoms, body image concerns, loss of speech, difficulty swallowing, nutritional issues, and respiratory problems that affect their quality of life and ability to function on a day-to-day basis.^3,4In addition, patients with HNC and their families are challenged to navigate the health care system and to overcome the difficulties of accessing services within the context of financial constraints. A multidisciplinary team (MDT) approach is the standard of care for HNC patients, as demonstrated in studies reporting better 5-year survival outcomes, increased completion of adjuvant therapy, and higher compliance with speech-language pathologist (SLP) recommendations.^{5, 6} Furthermore, a recent systematic review of cancer teams concluded that the MDT approach leads to improved clinical outcomes and enhanced communication between the patient and the team.⁷

The Institute of Medicine (IOM) stated in its 2013 report on cancer care that a high-quality care delivery system requires continuing measurement of cancer care and strategies to carry out performance improvement.⁸ Following the IOM premise, the cancer center at an academic medical center in Philadelphia made efforts to improve patient access to multidisciplinary services, first, by creating a multidisciplinary Cancer Appetite and Rehabilitation (CARE)clinic to address the symptoms and nutritional needs of HNC patients,⁹ and second, by using a gap analysis to conduct an assessment of the cancer care services provided to this cancer population. The need to conduct this assessment was generated by the desire to improve access to multidisciplinary care, with the goal of meeting standard benchmarks for completion of treatment while increasing the use of ancillary services. This article describes the process of conducting a gap analysis of cancer services for HNC patients, and includes discussion of the findings, recommendations for improving care, a description of the quality improvement interventions, and a report of the outcomes based on an interval re-assessment 18 months later.

Methods

Methods included a gap analysis, implementation of quality improvement recommendations, and re-assessment of indicators (Figure). A gap analysis “identifies differences between desired and actual practice conditions, including service delivery and quality patient outcomes as measured against evidence-based benchmarks while incorporating key stakeholder concerns and expectations.”¹⁰ The gap analysis of cancer care services offered to HNC patients was achieved through the step-by-step process described hereinafter. The implementation of quality improvement recommendations was accomplished by establishing two task force committees focused respectively on education and transitions in care coordination. Re-assessment of indicators related to timeliness of delivery of cancer treatments and collection of additional baseline data regarding supportive services.

Gap analysis

Identification of the scope of the problem. Members of the HNC multidisciplinary team raised concerns about unintended breaches in care for HNC patients that resulted not only in delay of the patients’ cancer treatments, but also in unnecessary distress for the patients and their families. As a result, the HNC team decided to conduct a gap analysis to identify the barriers in care for HNC patients, and by doing this, to determine possible solutions.

Identification of best practice care indicators. The indicators of best practice care (benchmarks) for HNC patients were identified after exhaustive review of the literature^11-22(Table 1). For this gap analysis, the indicators focused on waiting time to treatment (surgery, chemotherapy, radiation therapy) and to supportive care interventions (nutrition, speech and language pathology) as follows:

• 9.2Futura StdInitial ear-nose-throat (ENT) visit to surgery: <30 days
• Biopsy to start radiation therapy (RT) for nonsurgical patients: 40 days
• Surgery to RT start: 42 days
• Surgery to nutrition consultation (outpatient), start RT to nutrition: Pretreatment
• Surgery to outpatient SLP, initial ENT visit to SLP referral, surgery to SLP referral, RT start to outpatient SLP start: Pretreatment