Our philosophy and methodology
Collaborative, reliable processes and systems
At Cancer Treatment Centers of America® (CTCA), quality care does not simply happen, it is built and nurtured. Quality is the outcome of a set of consciously designed, reliable procedures and systems that connect people, processes, knowledge and technology in the delivery of high quality, safe care. The CTCA®quality program is grounded in the following principles:
- Collaborative partnerships across CTCA are essential to individual and collective improvement.
- Improvement and clinical innovation is achieved through the conscious deployment of methodologies, technologies and tools.
- Evidence-informed practice, guidelines and/or expert opinion are central to learning and transferring knowledge.
- Providers and patients alike are empowered to serve as champions for improvement.
CTCA utilizes the six aims of the Institute of Medicine (IOM) as a framework for our definition of quality care. According to these aims, health care should be:
- Safe: Avoid injuries to patients from the care intended to help them.
- Effective: Base patient services on scientific, evidence-informed knowledge of the benefits.
- Patient Centered: Provide care in a respectful manner that is responsive to individual preferences, needs and values.
- Timely: Reduce waits and delays for both those who receive and those who give care.
- Efficient: Avoid waste, including waste of equipment, supplies, ideas and energy.
- Equitable: Be consistent in the quality of care, which should not vary due to individual differences such as gender, age, ace/ethnicity, geographic location or socio-economic status.
Safety, our first commitment
The We ARE (Accountable, Reliable, and Empowered) Safe initiative establishes a framework to create a culture of safety for CTCA patients. As an organization committed to eliminating preventable harm through the detection and correction of system weaknesses, we have implemented high reliability strategies such as selfchecking (Stop-Think-Act-Review), peer checking, communication tools (Situation-Background-Assessment-Recommendation), Leader Rounding and Daily Safety Check-ins. In this effort, CTCA has engaged Healthcare Performance Improvement (HPI), a national leader in patient safety, which works with over 600 hospitals across the U.S. Further, CTCA is committed to the National Patient Safety Goals established by The Joint Commission, which accredits more than 19,000 health care organizations and programs nationally.
To assess our success in establishing a culture committed to patient safety, CTCA hospitals utilize the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on the Culture of Patient Safety, a validated staff survey considered among the top-cited and most well-respected instruments in the country. On average, over 700 hospitals utilize the instrument annually, constituting a comparative data set of over 447,000 responses. Conducting the survey every 18 to 24 months and contributing to the national database, CTCA hospitals’ most recent Patient Safety Grade is presented below in comparison to the AHRQ 2016 national norm.
Ongoing measurement through a quality dashboard
Using robust data from various external and internal sources, information is leveraged across CTCA hospitals to drive performance. Although not an exact match to publicly reported data, more timely internal data creates transparency at all organizational levels and supports real-time improvement. Through a dashboard approach, CTCA continuously monitors and assesses a variety of metrics related to the IOM aims with respect to care outcomes, processes and structures. The list of metrics changes constantly as CTCA views the metrics of interest from multiple angles, including those of our clinicians, the boards of directors of the CTCA hospitals, the employer and payer communities and patients. The following measures are examples of our current focus areas.
The prevention of hospital-acquired infections is a national priority. CTCA conducts Central Line Associated Bloodstream Infection (CLABSI) and Catheter Associated Urinary Tract Infection (CAUTI) surveillance in all inpatient care areas utilizing surveillance definitions from the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN). CTCA has implemented a number of CLABSI and CAUTI prevention efforts to reduce the number of infections and sustain evidence-informed practices for central line and urinary catheter insertion and maintenance as evidenced by our performance.
Inpatient complications, length of stay and safety
CTCA hospitals utilize Crimson Continuum of Care (CCC) software, an industry-leading solution, to aggregate our source system data to produce meaningful metrics, providing visibility into our coded data for purposes of benchmarking and supporting improvement. The CCC database has over 1,000 hospital members and represents approximately one-third of all inpatient admissions in the U.S. The tool uses a severity-adjusted methodology based on the 3M™ All Patients Refined Diagnosis Related Groups (APR DRG) grouper to compare only clinically-relevant cases. The CCC cohort benchmark displayed on the graphs is static to reflect the most recent 27 months of data in the global CCC system.
The inpatient complications of care rate depicts the percentage of inpatient cases with a complication code, excluding complications that were already present on admission (POA) or related to pre-existing conditions upon admission to the hospital. By excluding complications that were POA, this measure provides results that more directly reflect quality of care. These codes are useful for screening for adverse events that patients experience as a result of exposure to the health care system, which are likely amenable to prevention by changes at the system or provider level. CTCA continues to take appropriate action to ensure our patients are provided safe and high quality care at all times.
The average length of stay displays the average length of stay for an inpatient admission. Monitoring trends and improving processes related to management of patients have reduced the number of days our patients stay in the hospital without sacrificing quality or patient safety.
The Patient Safety and Adverse Events Composite, known as PSI 90, is an updated and modified version of the Patient Safety Indicator for Selected Indicators Quality Indicator Composite. This composite score provides an overview of hospital-level quality as it relates to a set of potentially preventable hospital-related events associated with harmful outcomes for patients. Included in this measure are events such as developing a stage 3-4 pressure ulcer, postoperative hemorrhage and postoperative sepsis. Our commitment to safety and eliminating patient harm has led to an overall reduction in our composite score exceeding the external benchmark with a lower score preferred.
Medication management technologies, if implemented effectively, can greatly reduce the likelihood of errors in the prescribing and administering process. Two such methodologies used by CTCA hospitals include Computerized Provider Order Entry (CPOE) and Bar Code Medication Administration (BCMA). The use of a CPOE system can significantly reduce errors related to handwriting or transcription. BCMA by nursing at the point-of-care ensures that patients are receiving the correct medications at the correct time by electronically validating and documenting medications using scanning technology. CTCA monitoring of BCMA includes all locations where medications are administered, with the exception of surgery and interventional radiology, where sterile fields may be in place.
CTCA has established several custom quality metrics reflective of our model of care. Two such metrics focus on nutrition and the appropriate use of probiotics. Malnutrition in cancer patients may go undetected and, if left untreated, may have serious health consequences. Studies demonstrate that the appropriate use of probiotics protects against both antibiotic-associated diarrhea and C. difficile infections.
Quality Oncology Practice Initiative (QOPI)
In response to the IOM report that identified major gaps in both quality and safety of patient care, the American Society of Clinical Oncology (ASCO) created the Quality Oncology Practice Initiative (QOPI) launched in 2006. Developed under the guidance of an expert panel of oncologists, the program provides a process for standardized assessment of care and reliable information to help focus improvement activities. Currently, 1,008 U.S.-based oncology practices are registered in QOPI and 291 are certified. All five CTCA hospitals have achieved and now maintain QOPI certification.
Oncology practices that wish to achieve a three-year certification from QOPI must meet stringent criteria. This begins with an assessment of performance against 26 quality metrics calculating a composite overall score and by submitting data on190+ measures. To achieve QOPI certification, a practice must achieve an overall quality score of 75% or higher and comply with 20 safety standards. QOPI measures fall into the following categories: core, disease-specific and domain-specific. Core measures include areas such as staging, pathology testing and pain. Domain-specific measures include symptom management and care at the end of life. Disease-specific modules include breast, colorectal and non-small cell lung cancer.
The following select key quality metrics shared below reflect the performance of CTCA hospitals in aggregate.
||Plan of care for moderate/severe pain documented on either of the two most recent office visits
||Anti-emetics prescribed or administered appropriately with moderate/high emetic risk antineoplastic treatment (defect-free measure)
||Action taken to address problems with emotional well-being by the second office visit
||Adjuvant chemotherapy recommended for patients with AJCC Stage II or IIIA NSCLC
||Platinum doublet first-line antineoplastic treatment or EGFR-TKI (or other targeted therapy with documented DNA mutation) received by patients with initial AJCC stage IV or distant metastatic NSCLC with performance status of 0-1 without prior history of antineoplastic treatment
Staff did everything to help with pain
||Performance status documented for patients with initial AJCC stage IV or distant metastatic NSCLC
||Anti-EGFR MoAb therapy not received by patients with KRAS and NRAS mutation
||Adjuvant antineoplastic treatment recommended within nine months of diagnosis for patients with AJCC stage II or III rectal cancer
||Adjuvant antineoplastic treatment recommended within four months of diagnosis for patients with AJCC stage III colon cancer
||CEA within four months of curative resection for colorectal cancer
||Trastuzumab recommended for patients with AJCC stage I (T1c) to III Her-2/neu positive breast cancer
||Combination chemotherapy recommended within four months of diagnosis for women under 70 with AJCC Stage IA (T1c) and IB-III ER/PR negative breast cancer
||Tamoxifen or AI recommended within one year of diagnosis for patients with AJCC stage IA (T1c) and 1B - III ER or PR positive breast cancer
||Test for Her-2/neu overexpression or gene amplification
||Complete staging for women with invasive breast cancer (Cancer stage, HER2,and ER/PR status)
This measure is intended to capture that all patients prescribed chemotherapy via any route understand the intent of that therapy and that curative, adjuvant or disease control is documented.
As the use of oral chemotherapy increases so does the need to routinely assess patient adherence following the start of therapy and toxicity. This includes clear documentation of the review of the regimen drug, dose, schedule and tolerance with the patient.
For those patients of child- bearing potential and who have not undergone treatment previously, it is important to discuss the effects of chemotherapy on fertility prior to the administration. Related conversation regarding preservation options should also occur.
Patients who are in end-stage of their disease should be counseled, recognizing it can be extremely emotional and overwhelming. When appropriate, there may come a time for referral into hospice. This measure is intended to ensure appropriate discussion occurs on a timely basis to maximize the benefits of such enrollment.
Including all forms of chemotherapy, this measure is intended to address quality of life concerns for patients at the end of life when aggressive treatment is no longer appropriate.