Priorities in Quality Care

Bolwell, Brian J. MD, FACP

doi: 10.1097/01.COT.0000515936.00539.de
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Everybody sets priorities all of the time. This morning, for example, is it more important to get to work early, or to sleep a bit more? Tonight—more important to watch your calories, or to enjoy that piece of pie that looks so delicious? Your next vacation—spend money on entertainment, meals, or a great hotel? The point is that setting priorities happens every day. One of my jobs as chair of a large cancer center is to set priorities about a wide variety of things. It is a challenge, because we have many initiatives that are all important. Some of the more challenging things to prioritize are quality and patient satisfaction metrics.

Those of us with gray hair know cancer medicine today is quite different than it was 25 years ago. The good news is that knowledge about genomics and immunologic therapy has led to significant clinical improvement for many patients. On the other hand, there are several differences today that lead to significant physician (and nurse) job dissatisfaction. Among these challenges is the fact that modern medical practice is quantified and measured, producing innumerable metrics on which we are judged, and this leads to many “priorities” for docs that swell annually.

If you search “hospital quality metrics” in the U.S. Department of Health and Human Services Agency for Healthcare Research and Quality, considered an authority on the topic, you will find a menu of a total of 2,284 measure summaries, of which over 2,000 measure clinical quality. I have no idea what all of these metrics are, or why there are so many, but such a massive number of metrics seems absurd.

Nevertheless, some of these metrics directly affect reimbursement, so they become part of our daily lives. Most hospitals want us to focus on dozens of these, such as readmission rates, catheter-related urinary tract infections, and observed to expected mortality. The question is, how do you prioritize among so many metrics, and how do you measure that what you prioritized led to a good outcome?

This issue of priorities always reminds me of a scene in a movie called “Grand Canyon.” A father (played by Kevin Kline) is teaching his 16-year-old son how to drive. They are in Los Angeles, there is a lot of traffic, the son is overconfident, and within a minute he almost has two accidents. As he pulls to a stop on the side of the road the shaken son looks up to his father who says “Rule No. 1—Do not hit a person!” It's a funny scene from an excellent movie.

So how does this story translate in to prioritizing quality metrics? I think if we focus on a few VERY important priorities, and do them well, we will likely excel on many additional measures. Therefore, we have decided to focus on these fundamental issues.

Number 1. Do not cause catastrophic harm with the delivery of chemotherapy or radiation therapy.

Obviously, this addresses quality and safety, but this is a priority that has been with me for decades. I led our bone marrow transplant (BMT) program for many years, and I still remember an incident about 30 years ago when another institution had two massive, fatal overdoses of a chemotherapy BMT preparative regimen. We decided to require five (yes, five) signatures to sign off on the doses of every BMT chemotherapy order. I realize that was a bit of overkill, but the point is that catastrophic errors of chemotherapy or radiation must not occur.

To try to eliminate serious chemotherapy adverse events, 5 years ago we instituted two new procedures. We have a “time out” before chemotherapy administration (we stop and verbally verify the patient identity and the chemotherapy regimen) and we require two nurses sign off on the dose. Since then, we have had zero serious adverse events with chemotherapy. It takes a bit of time to execute but the outcomes speak for themselves. I believe safety must be a primary priority.

Number 2. Talk to patients, and treat all staff with courtesy and respect.

This addresses physician communication, but mostly addresses culture. It is very important to establish a culture of empathy in a cancer center. Step one is to recruit people with emotional intelligence. Next is to support your team. Then, one must emphasize the importance of interpersonal interactions with patients and staff. There is no metric that can accurately measure culture, but I think the metric used for physician communication is a reasonable culture barometer. It has three domains—Doctors Explain, Doctors Listen, and Respect from Doctors. Our institution has a mandatory communication program for staff physicians, and we also have mini sessions with residents before their oncology inpatient rotations. If we are scoring well with physician communication, then it is likely that our overall culture is also positive.

Number 3. Access is a very big deal.

Those of you in private practice already know this, as referrals are everything for you. If you get a new consult, you will see the patient right away. For some reason, in many academic cancer centers, access is frequently not only unimportant, but it is basically ignored. Excuses abound for poor access—physician travel, no openings, no appropriate trials...whatever. If a referring doc is asking for our help with a cancer patient, it is our job to provide that help. More importantly, if a cancer patient wants to see one of our docs, undoubtedly they are filled with fear, and the best way to address that fear is to see the patient quickly and come up with a plan, even if the plan is simply a discussion about the reality of the given clinical situation. Access is key to all of our most important priorities: growth, patient satisfaction, reducing time to treat, and many others. We measure access in two ways: a metric called “appointment when wanted” and a metric that measures the number of days for a new patient to be seen, with a goal of 7 days. We do very well with both. I believe access is a surrogate marker for culture. Good access translates into a culture of people who “get it.” Patients with cancer are scared, and they are asking for help—we need to see them, and see them rapidly.

So when you are prioritizing—whether planning a vacation, or dealing with all of the metrics that exist for a big cancer center—consider starting with a very important rule about learning to drive: Do not hit a person!

BRIAN J. BOLWELL, MD, FACP, is Chairman of the Taussig Cancer Institute and Professor of Medicine at the Cleveland Clinic Lerner School of Medicine. Cleveland Clinic is a top 10 cancer hospital according to U.S. News & World Report.

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