Quality of Care

Steven B. Clauser, Ph.D. Chief, Outcomes Research Branch, NCI

Applied Research Program

Division of Cancer Control and Population Sciences

NCCCP “Kick off” Meeting

June 25, 2007

NCI Cancer Care Delivery and Outcomes Group

• Steven Clauser, PhD (co-chair)• Arnie Potosky, PhD (co-chair) • Ted Trimble, MD, MPH (co-chair) • Tanya Agurs-Collins, PhD• Neeraj Arora, PhD• Rachel Ballard-Barbash, MD, MPH• Martin Brown, PhD• Andrea Denicoff, RN• Brenda Edwards, PhD • Paul Han, MD • Diana Jeffrey, PhD

• Joseph Kelaghan, PhD • Jon Kerner, PhD• Sarah Kobrin, PhD• Lenora Johnson, MPH• Holly Massett, PhD• Helen Meissner, PhD • Cherie Nichols, PhD• Julia Rowland, PhD• Stephen Taplin, MD, MPH• Emmanuel Taylor, PhD• Cynthia Vinson, MA

Quality of Care Relates to Several Other NCCCP Components

InformationTechnologies

Quality of

Care

Survivorshipand

PalliativeCare

Multi-Disciplinary

Practice

Disparities

Clinical Trials

• The degree to which health services for patients and populations

• -increase the likelihood of desired health outcomes,

• Are consistent with current professional knowledge, and

• Provide coordination and continuity of care throughout the entire cancer experience

Knowledge-based

Patient-Centered

Systems-minded

What is quality?

To what extent is NCCCP cancer care

knowledge-based?

Prevention Detection Diagnosis Treatment Survivorship End of Life - Primary - Screening - Imaging - Local - Monitor health - Treatments

- Prognostic - Systemic and HRQOL - Palliation

Biomarkers - Trials - Recurrence - Hospice

- Testing - Second - Biopsy Primary

• Identify evidence-based guidelines• Compare treatment delivered to guidelines• Evaluate degree of guideline adherence

To what extent is NCCCP cancer care patient centered?

• “Global” definition centers around provider-patient relationship and communication—understanding patient as a “whole person”– Global metrics include all outcomes of interest to patient – survival,

satisfaction with care, and health-related quality of life

• Picker Institute defines patient-centered care more broadly:· fast access to reliable health advice· effective treatment delivered by staff you can trust · involvement in decisions and respect for patients' preferences · clear, comprehensible information and support for self-care · physical comfort and a clean, safe environment · empathy and emotional support · involvement of family and friends and support for careers· continuity of care and smooth transitions

Is NCCCP cancer care systems-minded?

Process of Care OUTCOMES

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Risk Assessment

Diagnosis

Cancer or Precursor Treatment

Detection

Intermediate

Long-term

POTENTIAL for improvement at TRANSITIONS ( ) or DURING TYPES of CARE DELIVERY ( )

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NCCCP quality of care is affected by multiple levels of influence

B. COMMUNITY Leadership, Advocacy Groups’ expectations, Population affluence, Insurance coverage, Geographic and public resources/access barriers, Market pressures; Care delivery/management practices

A. NATIONAL NCI expectations and leadership, Public Policy/Regulations, Purchaser Requirements/changes, Professional Group Standards/Accreditation

C. PILOT GRANTEE Leadership, Resources, Structure, Procedures, Systems, Culture

OUTCOME

Patient: Health Status Satisfaction Quality of Life System: Efficiency Equity Effectiveness

Information S

ystems

PATIENT (and family)

CHARACTERISTICS

ENCOUNTERS

INTERACTIONS

CONTACTS

PATIENT ADHERENCE

CLINICIAN/TEAM CHARACTERISTICS

Delivery Site: Leadership, Systems, Organization

Information Systems

Strategic Approach

• Changing health care systems is the process of moving from the complex to the obvious in time consuming and expensive steps

• NCCCP proposed interventions therefore need to emphasize “off the shelf” and turn key solutions with high potential yield to both NCI and the pilot sites

• Also, need pilot site champions for buy-in and to move initiatives forward

QoC Workgroup Program Principles

• Assess sites needs for internal program quality improvement – Complements external program focus on health disparities – Complement whenever possible NCCCP quality-related initiatives in

clinical trials and survivorship • Create infrastructure for sustained and ongoing quality

improvement to support clinical and patient-centered performance – Enhanced multi-disciplinary QI teams – Enhanced patient support programs based on patient perspective of

needs – Measurement, intervention, feedback on select initiatives

• Compare results to pilot, NCCCP program, and national program trends

Key Quality of Care Program Components

• Baseline Assessments of Quality Improvement (QI) Resources/Capabilities – Enhance NCCCP infrastructure to support and maintain QI activities – Focus on select opportunities linked to national or NCI initiatives

• QI Initiatives to Improve Evidence-based Care and Patients’ Satisfaction and Experience – Sites select opportunities and improvement goals within broad NCI

framework • Baseline and Follow-up Assessments of both

Process and Outcome improvement – Compare when possible to site baseline, NCCCP program

experience, and similar national programs

Specific Research Questions

• Have the multi-disciplinary QI teams enhanced performance on systems-based measures?– Referral for adjuvant therapy – Provision of treatment summaries to patients

• Have the quality improvement initiatives increased adherence to evidence-based practice? – Is there consistent improvement across sites? – How does their improvement in clinical care compare to

similar national providers or programs?• Are tailored patient education/support programs

associated with improved patient experience and quality of life?