In June 2011, the staff of the NCCN Opportunities for Improvement (OFI) project reviewed Massachusetts General Hospital’s (MGH) concordance with breast cancer quality measures. This review revealed that a small proportion of patients with breast cancer started chemotherapy more than 120 days after diagnosis, which is considered suboptimal care.1-3 Similarly, data from the NCCN Oncology Outcomes Database showed a small proportion of patients with breast cancer who started adjuvant chemotherapy more than 12 weeks from last definitive surgery (Figure 1). As might be expected, failing to reach the target of chemotherapy sooner than 12 weeks from surgery was more commonly seen in patients who underwent initial surgery outside of the MGH Cancer Center but opted to receive chemotherapy at MGH. Although the total number of cases discordant with this quality measure was small, the research team at MGH saw an opportunity for improvement, especially given the anticipated and continued growth of the MGH Breast Oncology Program.
Therefore, the goal of this project was to increase the percentage of concordance at the MGH Cancer Center with the ASCO quality measure that time to treatment should be less than 120 days from diagnosis (measure 3) and to achieve a decrease in the weeks from last definitive surgery to first adjuvant chemotherapy by 2014.1 Deliverables included concordance reporting to breast cancer teams, reporting of nonconcordant cases to individual providers, and incorporating a discussion of cases that violate the 120-day deadline at multidisciplinary tumor boards.
Project
Project participants included medical, surgical, and radiation oncologists; clinic administrative staff; new patient access nurses; and call center operators. Stakeholders included patients and referring clinicians from MGH affiliates and outside institutions. This project occurred concurrently with a larger cancer center-wide initiative of providing an oncologic consultation to any new patient within 10 days of a patient’s first request. Other hospital-wide initiatives that were leveraged included a quality incentive program and the creation of a quality dashboard.
Weeks from LDS to AC from 2009 to 2011.
Abbreviations: AC, adjuvant chemotherapy; LDS, last definitive surgery; MGHCC, Massachusetts General Hospital Cancer Center.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 12, suppl_1; 10.6004/jnccn.2014.0210
Weeks from LDS to AC from 2009 to 2011.
Abbreviations: AC, adjuvant chemotherapy; LDS, last definitive surgery; MGHCC, Massachusetts General Hospital Cancer Center.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 12, suppl_1; 10.6004/jnccn.2014.0210
Weeks from LDS to AC from 2009 to 2011.
Abbreviations: AC, adjuvant chemotherapy; LDS, last definitive surgery; MGHCC, Massachusetts General Hospital Cancer Center.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 12, suppl_1; 10.6004/jnccn.2014.0210
Success was defined by 4 metrics. The first metric was to decrease time to first appointment for new patients; the second was to improve timing measures (provided by NCCN), including time from last definitive surgery to adjuvant chemotherapy; and the third was to improve documentation and awareness by oncology providers regarding measure collection. Finally, the project sought to improve multidisciplinary tumor board review by MGH and affiliate faculty.
Improving Time to First Appointment
Several efforts were pursued to improve time to first appointment. The team recognized that the new-patient access nurses needed more assistance in infrastructure to expedite new patient appointments. They were educated regarding the goals of this project, provided with pagers, and paged by call center operators if a new patient sought a consultation. They were required to call patients back within 15 minutes of receiving the page to make the appointment.
Recognizing that availability of physician appointments was a barrier to new consultation appointments, the cancer center recruited 3 new medical oncologists. A second medical oncologist was assigned to the busiest multidisciplinary clinic to ensure that enough medical oncology appointment slots were available.
Providers were required to present cases at the multidisciplinary tumor board that violated the goal of less than 120 days from diagnosis to chemotherapy initiation. This was in addition to a new requirement of presenting any patients admitted to the hospital for nonroutine reasons. To enhance tumor board attendance among MGH and affiliate providers, the series was accredited by Harvard Medical School to offer continuing medical education credits.
Other efforts included improvements and enhancements to an Intranet portal to facilitate internal referrals within MGH to the breast oncology clinic. Furthermore, given the increased volume seen at the infusion unit, the breast program decanted chemotherapy infusions to an affiliate practice in the North Shore of Massachusetts for patient convenience and to improve capacity.
Results
Average wait days to new appointments improved from 17 days to 14 days from fiscal year 2009 to fiscal year 2013 (Figure 2). The score for a patient satisfaction survey item regarding scheduling a visit improved by 2.7 percentage points from fiscal year 2010 to fiscal year 2013. Patient “time-since” items are discussed in the context of tumor boards, and affiliate practice oncologists have been incorporated into routine breast oncology conferences at MGH.
Discussion
The OFI project improved time to new patient appointments and increased quality measurement awareness for all members of the care team. Results include improved documentation of reasons for nonconcordance by medical providers, which improved staff ability to discern the reasons for nonconcordant care and whether that care was in fact appropriate for the patient. The research team also identified opportunities to prioritize new patient appointments based on time from surgery. Special attention to the timing of new patient appointments and surgical dates has become routine in the evaluation and care of patients with breast cancer. The MGH Breast Oncology Program’s next initiative is a comprehensive care redesign project focusing on optimizing outpatient breast cancer survivorship visits and improving clinic efficiencies in an effort to improve the quality of care and further improve access to care for new patients with breast cancer.
Average wait days to new patient appointments at Massachusetts General Hospital Breast Center.
Abbreviation: FY, fiscal year.
aData available only for first 9 months.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 12, suppl_1; 10.6004/jnccn.2014.0210
Average wait days to new patient appointments at Massachusetts General Hospital Breast Center.
Abbreviation: FY, fiscal year.
aData available only for first 9 months.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 12, suppl_1; 10.6004/jnccn.2014.0210
Average wait days to new patient appointments at Massachusetts General Hospital Breast Center.
Abbreviation: FY, fiscal year.
aData available only for first 9 months.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 12, suppl_1; 10.6004/jnccn.2014.0210
References
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Vandergrift JL, Niland JC, Theriault RL et al.. Time to adjuvant chemotherapy for breast cancer in National Comprehensive Cancer Network institutions. J Natl Cancer Inst 2013;105:104–112.
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Burstein HJ. Quality measures, clinical practice, NCCN, and McAllen, Texas. J Natl Compr Canc Netw 2009;7:695.
