I. MOQC UPDATE Douglas Blayney, MD Jeffrey Smerage, MD, PhD Physician Leads, MOQC

SESSION OBJECTIVE By the end of this session, participants should be able to: Identify at least one QOPI targeted area of improvement Identify at least one QOPI improvement strategy

Today’s Agenda: I. Aim- MOQC 2011/2 Goals II. Measure A.Results of National Assessment B.MOQC Fall 2011 Performance C.New MOQC Oral Measures III. Change/ Improvements Palliative Care Demonstration Project IV. Next Steps

1. AIM: MOQC Goals 2011/2 A. Improve QOPI participation in Michigan including achievement of QOPI Certification B. Improve Michigan performance on QOPI Symptom Management measures C. Improve Michigan performance on QOPI End of Life measures

II. Measure A.Comparison with 5 years of National QOPI Data B.MOQC Fall 2011 Performance C.New MOQC Oral Measures (see oral chemotherapy section)

Analytic Data Set

MOQC Performance Comparison Fall 2011Study

MOQC Pain Initiative

III. Change / Improvements: Palliative Care Demonstration Project ◦ Collaborative Overview ◦ Palliative Care- Key Concepts ◦ Quality Improvement Model ◦ Experience of Participants

Palliative Care Demonstration Project Participants Toledo Clinic Cancer Centers Sparrow Cancer Center Cancer and Hematology Centers of Western Michigan Marquette General Hematology Oncology Center of Cancer Care & Blood Disorders Karmanos Cancer Center IHA Hematology & Oncology Consultants University of Michigan Comprehensive Cancer Center

PALLIATIVE CARE CONSTRUCTS J. Cameron Muir, MD, FAAHPM EVP, Quality and Access, Capital Caring Clinical Scholar, Georgetown Center for Bioethics Assistant Clinical Professor, Johns Hopkins Oncology Past President, Am. Academy of Hospice and Palliative Medicine

Framework: Integrated Palliative Care Palliative Care Disease Modifying Treatments Hospice Diagnosis Treatments to Relieve Suffering/Improve QOL 6MoDeath Bereavement

Measures: ASCO QOPI “Palliative Subset” (Core Measures) Pain Assessment ◦ 3. Pain assessed by the second office visit (%) ◦ 4. Pain intensity quantified by the second office visit (%) ◦ 5. For patients with moderate to severe pain, documentation that pain was addressed (%) Narcotic analgesic assessment ◦ 7. Effectiveness of pain medication assessed on visit following new narcotic prescription (%) ◦ 8. Constipation assessed at time of or at first visit following new narcotic analgesic prescription (%) ◦ Psychosocial support (Test) ◦ 21. Chart documents patient’s emotional well-being was assessed by second office visit (%) ◦ 22. For patients identified with a problem with emotional well-being, the chart documents that action was taken by second office visit (%) 19

Measures: ASCO QOPI “Palliative Subset” (Care at End of Life Measures) Pain assessed and documented near the end of life ◦ 35. Pain assessed on the second to last or last visit before death (%) ◦ 36. Pain intensity quantified on second to last or last visit before death (%) ◦ 37. Plan of care for patients with moderate to severe pain documented on either last 2 visits ◦ Dyspnea assessed near the end of life ◦ 37. Dyspnea assessed on second to last or last office visit before death (%) ◦ 38. Action taken to ease dyspnea on second to last or last office visit before death (%) Timing of hospice enrollment ◦ 39. Patient enrolled in hospice before death (%) ◦ 40. Patient enrolled in hospice/referred for palliative care services before death (%) ◦ 41. Patient enrolled in hospice within 3 days of death (%) (Lower Score - Better) ◦ 42. Patient enrolled in hospice within 1 week of death (%) (Lower Score - Better) ◦ 43. For patients not referred in last 2 months of life, hospice/palliative care discussed (%) Timing of chemotherapy administration before death ◦ 44. Chemotherapy administered within the last two weeks of life (%) (Lower Score -Better) 20

QUALITY IMPROVEMENT CONSTRUCTS Kevin DeHority Lean Coach University of Michigan Health System

Adoptd from: Langley GL, Nolan KM, Nolan TW, Norman CL, and Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. Jossey-Bass, Institute for Healthcare Improvement (IHI) web site, “How to Improve,”

Rules of Thumb Basic pointers to encourage participant along the way… What can we do by next Tuesday? Keep it simple, and get it started Set stretch goals that will make it worthwhile Go for the low-hanging fruit by starting with easier changes You can only fix what you can measure If we keep doing what we have been doing, we will keep getting what we have been getting. To get something better, we have to start doing something differently

Change Management The following activities were recommended as a part of this collaborative… Use of the IHI Change Packet Concept ◦ Defines Aim- Measures –Changes ◦ Details process flow, accountabilities and due dates Visually Display Performance Tracking System in work area ◦ Create a visual presence of your goals and metrics ◦ Allow folks to be thinking and documenting issues and ideas in between meetings Update Performance Tracking System every 1-2 weeks ◦ Create responsibility and cadence for updating the metrics

SHARING BEST PRACTICES Center of Cancer Care & Blood Disorders Tallat Mahmood, MD Helen Shock

Center for Cancer Care and Blood Disorders 1540 Lake Lansing Rd Lansing, MI

About Our Practice 3 Physicians 2 Physician Assistants 4 Registered Nurses 3 Medical Assistants Offices in Lansing and Owosso Chemotherapy, supportive care, iron, provide infusion care for PCP Multi-Specialty physician owned practice Celina Windnagle PA-CEman Issawi PA-C

Palliative Care Demonstration Dr. Tallat Mahmood ◦ Physician Team Leader Patty Morley RN ◦ Clinical Manager Helen Shock ◦ Patient Financial and Billing Specialist Dr. Dan Williams Dr. Tallat Mahmood Dr. Shalini Thoutreddy

MMP Team Goal Clarify the roles of primary oncologist versus palliative care team ◦ Differences in clinical/disease management Streamline process to address symptom control Utilize a tool for ongoing evaluation of symptoms Research treatment options for symptom management Supportive Care Conference Annually ◦ Education for oncology team

Center of Cancer Care & Blood Disorders ESAS Tool Integrated into EMR as Flowsheet

Center of Cancer Care & Blood Disorders EMR- Ability to Trend Symptoms Over Time

Center of Cancer Care & Blood Disorders: Lessons Learned Patients: ESAS-r tool relatively easy to complete; patient instructions should be available from the start Physicians: ESAS-r facilitates targeted discussion of symptoms with patient saving time; trending results are helpful but manual process too difficult to complete on each patient encounter

Center of Cancer Care & Blood Disorders: Lessons Learned Implementation Process: ◦ Limited number of patients in target population can cause confusion for staff determining who should get the form ◦ Incremental improvement/ change is helpful so not to get too overwhelmed ◦ Visible tracking performance and issues is helpful for the team

MOQC Next Steps: Palliative Care Demonstration Project: Spread best practices/lessons learned including standardize use of ESAS QOPI Certification: MOQC Lunch & Learn Webinar I –Getting Started January 31, pm (for details: MOQC Lunch & Learn Webinar II – Self Assessment February 21, pm (for details: Mock Surveys