Ten best-practice measures identified by a multidisciplinary team at the Norris Cotton Cancer Center (NCCC) at the Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire, were used to improve the care provided to patients with glioma during the perioperative period. “Using a plan-do-study-act framework,” the team assessed current process performance, developed and implemented improvement interventions, and created a plan for sustaining the new process, Natalie B. V. Riblet, MD, MPH, and colleagues explained in the Journal of Oncology Practice.
The specific aims of the multiphase quality improvement project are to improve the quality of care for patients with glioma, reduce process variation, and maximize patient safety. The current report covers the first phase, which focuses on the time from initial diagnosis to entry into the surgical pathway and first visit with neuro-oncology to establish care.
The multidisciplinary team included physicians, a physician’s assistant, nursing staff, schedulers, and a social worker, with members representing disciplines such as neuro-oncology, neurosurgery, radiation oncology, and care management as well as cancer center leadership. The team was organized into three groups: entry into the neuro-oncology microsystem, surgical care, and postoperative care.
“Before beginning this quality improvement work, we reviewed the literature, and except for guidelines directing chemotherapy, surgery, and radiation treatment, we found limited information on which measures are associated with improved outcomes in the glioma population,” the team members explained. “On the basis of scant evidence and brainstorming, we proposed 10 objective measures that reflected timely and comprehensive care.”
10 Best-Practice Measures
The 10 best practices follow: (1) The Neuro-Oncology Program is notified preoperatively of new admissions by the neurosurgery service; (2) The Neuro-Oncology Program evaluates a patient during hospital admission; (3) Standard postoperative orders are used; (4) Appropriate use of corticosteroids; (5) Appropriate use of antiepileptic drugs; (6) Patients are evaluated by the social worker within 2 weeks of admission; (7) Follow-up appointment is scheduled with neuro-oncology prior to hospital discharge; (8) Patients are evaluated by radiation-oncology within 2 weeks of discharge; (9) Patients are presented at tumor board; (10) Tumor board within 2 weeks of surgery.
During the retrospective assessment phase of the quality improvement project, a manual medical record review for 43 patients with a diagnosis of glioma showed that compliance with 10 best-practice measures ranged from 23% to 100%. “Several factors contributed to less-than-ideal process performance, including poor communication among disciplines and lack of familiarity with the larger system of care,” the authors noted. “After implementing improvement interventions, performance was measured in 96 consecutive patients with glioma. The proportion of patients who met criteria for the 10 practice measures significantly improved (pre-quality improvement work, 63%; post-quality improvement work, 85%; P = .003). The largest improvement was observed in the measure assessing for preoperative notification of the neuro-oncology program (pre-quality improvement work, 39%; post-quality improvement work, 97%; P < .001).”
The team members concluded that “the timeliness and consistency of care provided to patients with glioma in the perioperative period can be improved through the use of quality improvement principles. Involving clinical leaders, developing a system for ongoing measurement, and reporting of system performance are important for sustaining the gains of quality improvement work.” The next phase of the quality improvement initiative is currently underway and focuses on the delivery of acute care. The final phase will be to examine and postulate best-practice measurements for the chronic and palliative care of patients with glioma. ■