In my last column, I described how a convergence of factors are building the quality movement into a “perfect storm.” Several reports from the Institute of Medicine are critical of the quality of cancer care; Congress is considering legislation on the quality of cancer care; payers and employers are increasingly insisting on value (cost and need) as well as medical excellence; ASCO has mounted two programs to assess and improve cancer care; and advocates for quality cancer care grow in influence.
These forces are primed to make big waves across oncology.
I believe this movement will have a profound impact on oncologists and on the operation and economics of their practices. I urged oncologists to take leadership in the quality arena because if they don't, someone else will.
But more important, because an evidence-based, systematic process of self-examination that promotes excellent cancer care is the right thing to do.
Before providing examples of how one might proceed to develop a quality program in one's practice, let's dispense with several issues that might bog one down.
First, I am not suggesting yet another formal academic study of quality; there are more than enough practice guidelines, documented standards of care, and widely accepted “common sense” standards available for use. Rather, I suggest a modest, but practical and systematic, program suitable for community and academic oncologists.
Second, I will not argue over the definitions of quality or how many qualities will fit on the head of a pin. One may choose from a wide variety of standards.
My own benchmarks of quality care are simple:
- ▪ Care I would want my family to have.
- ▪ Care given with skill, sensitivity, efficiency, and economy.
- ▪ Care based on peer-reviewed data or validated experience.
- ▪ Care given in a serious learning environment that includes clinical trials.
- ▪ Care recorded fully and accurately.
Objections & Rejoinders
And third, many oncologists view guidelines as an infringement on their judgment, so let's deal directly with specific objections to starting a quality initiative, followed by my rejoinder to each.
- ▪ “I already give quality care.” Show me the data!
- ▪ “I am too busy.” Would you say that if the patient were your mother or son?
- ▪ “It will cost money, staff time, and more paperwork.” Yes it will, more in the short run.
- ▪ “I have no say in what quality is or what measures will be used.” You can learn and choose your own, or join an ongoing program.
- ▪ “I fear the inappropriate use of the data by the public, competitors, or the government, with the possible loss of income.” Join colleagues in a quality program that controls its own data.
How to Start?
So how does one start? It is useful to think of quality measures as falling into one of three classes: structure, process, or outcomes.
An example of structure might be to include the pathology report or a chemotherapy flow sheet in the patient's chart. Process might be to ask every patient in relapse and record at each visit whether he/she has pain. Outcome could be length of remission, toxicity, or patient satisfaction.
Depending on the size and site of the practice, chart rounds and tumor boards can help control quality, but objective, data-driven measures are essential to enable the tracking of progress, or lack of it.
One might select guidelines like those published by ASCO concerning the use of erythropoietin or other growth factors and regularly review a number of unselected charts to see whether one's practice complies, and if not, why not. One could do the same with NCCN guidelines for chemotherapy, pain control or the sequencing of therapy.
Whatever one chooses, it must be done systematically, perhaps with new measures every four to six months and the repetition of older measures annually.
For some, it may be easiest to join an ongoing program at a hospital or neighboring practice. Sometime in the spring of 2004, ASCO's practitioner-driven quality program should be open to any willing volunteers.
In addition to being led by actively practicing oncologists under the aegis of the Health Services Committee, the program has several virtues that may make it an attractive option. The quality measures are devised and tested by a group of seven practices of different sizes and from all parts of the country, known as the Alpha Group. The user-friendly data collection system set up by the ASCO information technology department uses a slick electronic data entry system to collect and collate the de-identified data. This allows one to compare one's practice to many other unidentified practices from around the country. (In the spirit of full disclosure, I participate in the development of this program.)
Other professional organizations such as the American College of Surgeons and the American Society of Therapeutic Radiology and Oncology also have quality improvement programs. Information is available on their Web sites.
The precise form of a quality program is less important than the result one hopes to achieve: that oncologists take leadership, embrace guidelines, and use quality and outcome measures to create a culture of self-examination to promote excellence in care; in short, to create a practice environment that we would want for our family and ourselves if one of us were the patient.