ASCO’s Quality Training Program Project Title: Incorporating Distress Screening Tool in an Oncology Office Setting Presenter’s Name: Caroline Usry, RN, BSN, OCN Laura Holder, Pharm.D. Jennifer Lamneck Heaberlin DO, MPH Institution: University Oncology, Augusta, Georgia Date: 10/08/2015 Storyboard for Session 2 will be the slides up to and including the Baseline Data slide. ASCO will be providing other versions of this PPT that provide an example and tips on adding content to your Storyboard and Presentation.

Institutional Overview University Oncology is a hospital based hematology oncology practice We have two locations: Augusta, Georgia and Aiken, South Carolina The practice has 6 physicians providers and one physician assistant. The practice caters to an average of 1200 new patients a year Include basic demographic information about your practice/ institution. E.g. location, patient volume, practice setting (community, academic), # of oncologists, etc.

Problem Statement Identifying and addressing all of the stressors within the relationship-centered care process of our practice will enhance our ability to better relieve or lessen distress, hopefully improving outcomes. The integration of the ambulatory and hospital based services also offers the ability to impact admissions and hospital length of stay, both impacted by psychosocial issues that can severely compound symptoms related to the primary disease and its treatment. An effective process may, therefore, reduce the overall cost of care while maximizing outcomes and patient outcomes and patient satisfaction. Describes the concern or opportunity objectively. Describes the extent of the problem. Describes the impact of the problem. Example: Medication lists are often inaccurate which compromises patient care. It is challenging to fit medication reconciliation into 15-20 minute multi-issue visits. Providers often rely on EMR medication lists rather than patient history. No clear policy on who “owns” the list and who is “allowed” to modify and no standard process exists across the institution.

Team Members Job Function Role Name Team Sponsor Kim Taylor Chief Operating Officer Team Leader Jennifer Lamneck Physician Core Team Members Meg Harmon Laura Holder Caroline Usry Cancer Liaison Pharmacist Charge Nurse Other Team Members Anu Batra Alan Faulkner Chaplain Advisor Michael Shlaer Use information from the project charter. Project Leaders: You! Team Members: have “fundamental knowledge” of the process you are addressing (e.g. frontline workers) Project Sponsors: accountable for your overall effort, provides your team with direction and support, assists you with implementation when appropriate, and ensures that key stakeholders have appropriate involvement. Be sure to specify the role/discipline and contribution for each member (frontline knowledge, influencer, etc) Example: Jane Smith, Floor nurse Dr. John Doe, Physician Dr. Mary Last, Chief, Dept of Med

Process Map Yes No No Yes >= 5 0-4 Patient arrives at the front desk Form scanned in patient’s chart Form Filled out Patient is given the new patient packet to be filed out with NCCN distress thermometer New Patient Form given to Chaplain Yes No No Yes MD visit PA visit RN eval Lab draw only Distress score >= 5 0-4 Form scanned in patient’s chart Referred to Cancer Liaison Financial Assistant Chaplain Patient Advocate MD

Cause & Effect Diagram Patient Material Staff Resources Workflow Do not want to share Not a priority at the time of appointment Language barrier Illiteracy Don’t want to be held up Cultural Perceived lack of resources Educationally appropriate for alll Is it working..the form Unwilling to ask Time/efficiency Don’t know how to response Staffing ratios Another office process Who should address Low screening Not enough time to fill out form Already under stress of referral Overwhelmed with forms Privacy Stress level is multifacttorial and varies constantly Lack of training to detect stress Lack of training to implement program Lack of standardization in asking questions When is the right time / How often Instructions not given initially on why this is I mportant Lack of resources Who should follow up No outpatient psychiatrist No outpatient dietician Lack of referral resources Resources Workflow Environment

Diagnostic Data We have not had consistent process of documenting distress We have previously documented spiritual and emotional distress using part of the NCCN tool, but comprehensive distress assessment has not been carried out. We found only 45% of responders marked the distress thermometer. Links directly to the measurement implied in your primary aim statement Example: % of Accurate Lists One Week Post Annual Visit (p-chart) UCL Mean % accurate lists LCL Week

Common Barriers to Screening Time versus efficiency among staff Instructions not clearly given Lack of referral resources once distress identified Any observations, tally sheet data, interviews, that helped you understand your process, prioritize opportunities, etc. Displayed in a Pareto chart, frequency distribution, run chart, etc. Demonstrates how you identified your opportunities for improvement and how you prioritized your specific area of focus that will relate to your aim statement.

Aim Statement By September 30, 2015, incorporate a comprehensive assessment tool and increase the documentation of physical, practical, emotional and spiritual problems for new oncology patients being seen in University Oncology’s office to 75% at the time of their initial visit. Defines the team’s specific improvement objective – what you are trying to accomplish. AIM statements should be SMART - specific, measurable, attainable, relevant and time bound. Example: By June 30, 2011, increase the accuracy of medication lists one week after physical exams and chronic disease visits to 90% by providing physicians with accurate patient generated medication lists during the targeted visit at XYZ clinic.

Measures Measure: Percentage of new patients screened for distress Patient population: New patients Exclusions (if any): Calculation methodology: Numerator : Number of patients with screening tool documented Denominator (if applicable): Number of new patients Data source: New Patient Packet Data collection frequency: weekly Data quality (any limitations) Incomplete filling out of forms Describe your outcome, process or balance measures which you will present as your baseline data and change data. If you have more than one measure you will want to create a slide for each measure. Describe the measure and note whether it is your outcome, process or balance measure. Include the patient population (who is included and any exclusions). Specify the calculation methodology (specify the numerator, denominator if applicable). Describe the data source, data collection frequency, quality of data (any limitations). Measures should be directly related to your AIM statement. Can also show off your data collection tools that you developed.

Baseline Data % of Accurate Lists One Week Post Annual Visit Example: Should be one of the measures outlined on the measurement slide which is directly related to your aim statement. Annotate chart to identify when intervention/PDSA cycles began, label the x and y axis, and indicate the type of chart used. Note if rules of special cause are present indicating improvement is significant. Example: % of Accurate Lists One Week Post Annual Visit UCL Mean % accurate lists LCL Intervention Started Week 8 Week

Prioritized List of Changes (Priority/Pay-Off Matrix) Ease of Implementation High Low Easy Difficult Impact Self screening tool provided to patients as a part of the new patient packet which is later scanned into our system Education of front desk staff about importance of form and making sure it is completed Change format of the form to 2 pages to help ensure patients fill out both parts of the tool Tool filled out by MD/RN with questions directly asked to the patient No standardized tool Review of distress by providers and Nurses Filling out the tool at each visit and reviewing with MD/RN Describe process of idea generation (brainstorming, etc) Highlight ideas selected for this PDSA cycle 12 12

PDSA Plan (Tests of Change) Date of PDSA cycle Description of intervention Results Action steps 4/18/2015 - 5/5/2015 Identification of tool Workflow NCCN Distress thermometer Educated MD’s, Nurses, Staff in the practice regarding implementation 5/5/2015 – 7/1/2015 Pilot Implementation of tool Development of data collection plan Low screening not meeting goals Plan to educate the front desk to reinforce the importance of form to the patient 8/1/2015- 9/30/2015 Changed the format of the distress tool Educated the front desk on administration of the tool and asking patients to fill it out. Overall percentage of pts filling out the form completely is improved. Plan to continue distress screening tool and start to find ways to better address stressors in patient’s lives. Describe your test plan – briefly summarize PDSA cycles or multiple PDSA cycles. Could include stakeholder analysis or communication plan if relevant.

Materials Developed E.g. patient education materials; visual of tools to test as part of tests of change. This slide is optional for a team to include. If your team did not develop any materials related to your project (e.g. patient education tools; survey), you may delete this slide.

Materials Developed

Change Data – P Chart % of Accurate Lists One Week Post Annual Visit Should be one of the measures outlined on the measurement slide which is directly related to your aim statement. Annotate chart to identify when intervention/PDSA cycles began, label the x and y axis, and indicate the type of chart used. Note if rules of special cause are present indicating improvement is significant. Example: % of Accurate Lists One Week Post Annual Visit UCL Mean % accurate lists LCL Intervention Started Week 8 Week

Conclusions Our p chart does not show specific cause as we don’t have enough data points since the intervention We did see a trend toward a change and achieving our aim of having at least 75% of new patients filling out the form completely.   Conclusions should be directly related to your change data. Describe whether or not you saw improvement or if you met your aim. This is different than lessons learned.

Next Steps/Plan for Sustainability Continue to collect data on if patients are filling out the form completely to evaluate our intervention Explore resources so we can address the concerns appropriately on the distress screening which was the original plan for project before we realized that patients were not using the form correctly. Meet with social worker, chaplain and team to develop a plan on how to find better ways to address the stressors that we are identifying in the patients. Continue with staff education. Continue to meet on weekly basis Describe additional tests of change, how intervention will be incorporated into standard work flow, etc. Example: Increase and measure reliability of process elements of our intervention Continue to measure post encounter medication list accuracy to evaluate intervention Collaborate with IT to develop system fixes (e.g end date for antibiotics) Explore utility of patient portal for inter-visit medrec

Name, credentials, job title Entity Project Title Incorporating Distress Screening Tool in an oncology office setting TEAM: Physician : Jennifer Lamneck Nursing : Caroline Usry Pharmacy : Laura Holder Social Work : Meg Harmon PROJECT SPONSORS: Kim Taylor AIM: BySeptember 1,2015, incorporate a comprehensive assessment tool and increase the documentation of physical, practical, emotional and spiritual problems for new oncology patients being seen in University Oncology’s office by 75% at the time of their initial visit. INTERVENTION: Introduction of the NCC RESULTS: Should be related to your AIM statement. Be sure to title the graph, identify the SPC chart used, label the x & y axis, include a legend CONCLUSIONS: Should summarize the data in the results section, state whether or not the AIM was met. Conclusions are different than lessons learned. NEXT STEPS: Graph title Once a team has completed their final presentation for the Quality Training Program, they may wish to display it in their institution or at conferences. The content can be displayed in a poster format, similar to this. This is a sample template slide for a poster presentation or summary of your work. Insert graph