The Oncology Medical Home: An Oncology Nurse s Dream

Transcription

1 Iside Presidet s Message 2 Educatioal Opportuities 2 PSONS Member Profile 12 Treasurer s Report 15 Vol. 37, No. 1 Sprig 2014 The Ocology Medical Home: A Ocology Nurse s Dream Ted Oko, MBA, Executive Director, Commuity Ocology Alliace Before I get ito the meat of this article, you should kow I have a bias about ocology urses: I m married to oe. I see first-had the hours my wife Susa puts i ad the ivestmet she has i her patiets. So, with all due respect to my ocologist colleagues, I believe that ocology urses are the heart ad soul of cacer care. Ad I believe that there is a especially key role for ocology urses i the Ocology Medical Home. The cost of health care has become part of the atioal dialogue o the fiscal health of the Uited States. Regardless of political ideology, there is a commo belief that the federal govermet the sigle largest purchaser of health care eeds to accomplish two thigs cocurretly: purchase quality ad efficiet health care. The two operative words are quality ad efficiet, the later referrig specifically to cost. Ad private payers have adopted a similar quest i terms of esurig quality health care delivery i a cost-cotaied eviromet. This is certaily true of cacer care, where costs have icreased substatially with ew therapies. Attempts by Medicare ad private payers to cotai costs by cuttig provider reimbursemet have had the uiteded cosequece of cosolidatig the cacer care delivery market. This cosolidatio is creatig patiet access issues, ad is icreasig costs for both patiets ad payers. We also believe that reimbursemet chages are the root cause of the shortages of lowcost ijectable cacer drugs. The medical home model of cacer care that the Commuity Ocology Alliace (COA) is pursuig provides elemets that all primary stakeholders patiets, payers (both primary ad secodary), ad providers wat i esurig quality, efficiet cacer care delivery. We kow this because that is exactly what the stakeholders have commuicated to us. What is a Medical Home? I basic terms, the patiet has a medical home that is the cetral coordiator or gatekeeper of their medical care, ad as importatly becomes a source of hope ad comfort. Typically, the medical home is a primary care physicia who becomes the poit perso for coordiatig the patiet s total care, icludig both primary ad specialty care. The theory is that the medical home model of patiet-cetered care results i importat positive outcomes relatig to the quality, efficiecy, ad cost of patiet care by optimizig care coordiatio. The medical home model has bee aroud for over 40 years ad has bee evolved ad piloted sice its itroductio. What is the Logic of a Ocology- Specific Medical Home? At first glace, it would appear that the cocept of a ocologyspecific medical home flies i the face of reaso by defeatig the purpose of a medical home maaged by the primary care physicia. However, the ratioale is see i the complexity ad severity of cacer treatmet. As all ocology urses well uder- Cotiued o page 3

2 Presidet s Message As PSONS Grows, the Challege is to Meet Our Members Needs Reiko Torgeso, MN, RN, OCN PSONS Presidet It s hard to believe it has bee a year ad my presidecy is comig to a ed. What a icredible year it has bee. I thik the major chage durig this past year has bee the ONS membership model chage. We wet from approximately 300 members to over 700 by the ed of the year. As this orgaizatio cotiues to grow, our challege will be to cotiue to meet the eeds of our members throughout our regio. I ve had a opportuity to Reiko Torgeso meet may of you this past year. I ve talked with may of you i the South Soud, North Soud, Weatchee, Yakima ad other distat areas. PSONS Board realizes there are umet eeds. We wat to hear for you. Please share your thoughts, ideas ad cocers. Joi us at the Board Meetigs via phoe coferecig to hear what we do. I urge you to become ivolved so that we ca effectively meet your eeds. I will cotiue to serve the Board as the Past Presidet for the ext year. It will be i a advisory capacity without votig rights. If your see me out ad about, do t hesitate to talk to me about PSONS. Lastly, I wat to thak the Board for their hard work ad commitmet this past year. There is o possible way I could have led this orgaizatio without all of you. Fodly, Reiko Editor s Notes Explaiig the Ocology Medical Home Cocept Bob Chapma, RN, MN, CCRN Defie patiet-cetered care. I believe that most registered urses would defiitely have some choice words or key phrases to defie patiet-cetered care. However, I woder how may of those defiitios would fit the test of a shared metal model, which are beliefs, ideas, images, ad verbal descriptios that we cosciously or ucosciously form from our experieces ad which (whe formed) guide our thoughts ad actios withi arrow chaels. These represetatios of perceived reality (i.e., these metal models) explai cause ad effect to us, ad lead us to expect certai results, give meaig to evets, ad predispose us to behave i certai ways. Although metal models provide iteral stability i a world of cotiuous chage, they also blid us to facts ad ideas that challege or defy our deeply held beliefs. They are, by their very ature, fuzzy ad icomplete. Ad everyoe has differet metal models (that differ i detail from everyoe else s) of the same cocept or subject, o matter how commo or simple. O your ow, defie patiet-cetered care, the seek out a trusted colleague ad compare your defiitios. Do you share the same metal model? Now, defie The Ocology Medical Home. I suspect this oe may be a bit more challegig. First, the medical home is best described as a model or philosophy of primary care that is patiet-cetered, comprehesive, team-based, coordiated, accessible, ad focused o quality ad safety. Does this soud like the model of excellece we use i ocology today? Secod, the how is The Ocology Medical Home differet whe placed i the cotext of cacer care or i the cotext of patiet-cetered care? I am hoored to brig to you this sprig editio with a focus o The Ocology Medical Home. I have had the privilege of collaboratig with ocology leaders from across the coutry, all of whom are leadig chage i our field. They are o the cuttig-edge of helpig us all to develop a shared metal model of excellece i ocology patiet-cetered care. Follow us o 2 Puget Soud Quarterly Vol. 37, No. 1 PSONS Educatioal Opportuities March 19th Meetig Topic: Legal Issues Impactig Ocology Nursig: Lawsuits ad Licesure Speaker: Kari J. Mitchell RN, JD. Locatio: SCCA April 16th Meetig Topic: Myelofibrosis May 21st Meetig Topic: Cogress Update preseted by PSONS scholarship wiers

3 Ocology Medical Home: Treatmet of Cacer Primary Focus Cotiued from page 1 stad, whe a perso is diagosed with cacer, i the majority of cases, the treatmet of the cacer becomes the primary focus of medical care. Other medical care eeds to be coordiated i the cotext of the primary goal of treatig the cacer. The complexity of the care ad potetial for side effects i treatmet eed to be treated i the cotext of the patiet s overall cacer care. Few primary care physicias have the expertise ad facilities to admiister cacer treatmet. Additioally, primary care physicias are ot traied or comfortable with the itesity of symptom maagemet (e.g., related to pai, ausea/vomitig, europathy, ad blood cout maagemet) typically required i providig cacer treatmet. As such, because treatig the cacer becomes the medical priority, i most cases the ocology provider team fuctios as the patiet s primary medical caregiver durig the phase of active cacer treatmet ad follow-up care. As the medical home for the cacer patiet, the ocology team especially the ocology urse is i the best positio to esure that treatmet is optimized ad that adverse evets are miimized, with a goal of elimiatig them based o process improvemets. These evets iclude treatmet side effects that require additioal care ad, i cases, ca lead to emergecy room (ER) visits ad/or hospitalizatios, which ca be detrimetal to patiet outcomes ad substatially icrease the cost of patiet care. What is the Research Supportig a Medical Home Model i Ocology? There are 2 reports that support the implemetatio of a ocology medical home model. A Istitute of Medicie (IOM) report i 1999, Esurig Quality Cacer Care, idetified specific ways to improve cacer care. The report established that cacer care is optimally delivered i systems whose processes of care provide: Stadardized evidece-based guidelies for prevetio, diagosis, treatmet, ad palliative care Measuremet ad cotiuous moitorig of a core set of quality measures Agreed upo care pla prepared by experieced professioals, outliig the goals of care Access to cliical trials Policies to esure full disclosure to patiets of iformatio about appropriate treatmet optios Mechaisms to coordiate services Quality care at the ed of life Policies to address the barriers to receivig appropriate cacer care i specific segmets of the populatio Aother IOM report, Assessig ad Improvig Value i Cacer Care, focused o the ucertaity of where we are curretly wastig resources (payig for goods ad services of little value) ad where we should be icreasig our resource commitmets (high-value goods ad services that patiets uderutilize). High value services are defied as services that improve results, reduce potetially avoidable complicatios, ad reduce uecessary resource utilizatio. Scott Ramsey, MD, PhD, the Committee Chair of the Plaig Committee, eloquetly poited out that, Nowhere is this issue more cotetious tha i the care of cacer patiets Ulike may areas i health care, the practice of ocology presets uique challeges that make assessig ad improvig the value of care especially complex A practical workig descriptio of value i ocology would beefit may stakeholders ad serve as a useful model for other fields of medicie. The report states that true value i cacer care ca oly be defied by the covergece of perspectives of the patiets, their families, ad payers, ad be based o verifiable data collected at the poit of care. The basic problem is that there is o defied template, approach, or icetive to re-egieer the processes of care withi idividual ocology practices ad to collect data to measure importat edpoits/outcomes. This is exactly what the Ocology Medical Home model that COA is pursuig is iteded to accomplish. What is the Ocology Medical Home Model? The Ocology Medical Home model is about deliverig, esurig, ad measurig quality cacer care. I short, it is a patiet-focused system of deliverig quality cacer care that is coordiated ad efficiet. As such, it will be desiged to meet the eeds of patiets, payers, ad providers. Some of the key aspects of the Ocology Medical Home model are: Cacer care that is coordiated with the cetral focus o the patiet ad their etire medical coditio Cacer care that is optimized based o evidece-based medicie to produce quality outcomes Cacer care that is accessible ad efficiet, with treatmet provided i the highest quality, lowest cost settig for the patiet Cacer care that is delivered i a patiet-cetric, carig eviromet that optimizes patiet satisfactio Cacer care that is cotiuously improved by measurig ad bechmarkig results agaist other facilities providig care so that best practices raise the bar i deliverig care What Does COA Wat to Accomplish by the Developmet ad Evolutio of a Medical Home Model i Ocology? Cotiued o page 4 Puget Soud Quarterly Vol. 37, No. 1 3

4 Ocology Medical Home: COA Proposed Model of Care Cotiued from page 3 COA wats to equip ocology providers with a model of care that will accomplish 2 thigs: Ehace the quality of cacer care while cotrollig overall costs of care i a system where quality ad value are measured ad cotiuously improved. Provide the foudatio for differet reimbursemet models that associate appropriate paymet with results i a eviromet that places the patiet first. Cacer care has evolved dramatically over the past 40 years from academic, i-patiet treatmet to commuitybased, comprehesive, ad coordiated cacer care. I the process, the Uited States has developed the world s best cacer care as documeted by actual outcomes. However, cacer care is i crisis as the system of commuity-based care is cotractig ad drug shortages threate patiet care. The Ocology Medical Home model puts patiet care first while isurig the survival ad viability of the cacer care delivery system. I this model, reimbursemet eeds to be more appropriate, aliged with the quality ad value of cacer care delivered, ad recogize the cogitive services provided by ocologists ad ocology urses. What Are the Nuts ad Bolts of the Ocology Medical Home Model? The COA Ocology Home Model is a 3-step approach that allows ocology providers to move alog a trajectory of icreasig thoroughess towards becomig a medical home. Some of the specific tasks that will be ecessary to accomplish this overall goal are as follows: Defiig a core set of stadardized quality ad value measures to documet performace Developig a bechmark capability that allows providers to compare performace agaist their peers i a systematic ad highly efficiet maer Developig a set of services ad tools icludig iformatio, materials, etc that provide a stepped approach for providers to move alog the trajectory of becomig a fullyfuctioig medical home Establishig a forum of iformatio exchage for practices to cotiually improve processes ad outcomes Developig differet paymet models ad cotracts with Medicare ad private payers to make the medical home a viable model for ocology It is importat to uderstad that the ature of ocology practice is such that providers curretly fuctio aywhere from 75-85% of a medical home, especially i terms of care coordiatio ad reliace o evidece-based medicie. This ad the fact that ocology providers iheretly become the medical home for the cacer patiet, positios most providers well to evolvig ito a fully fuctioig medical home model. What eeds to happe i order to realize that evolutio is practice process chage that accomplishes 2 importat facets of care: Places the patiet clearly at the ceter of care Measures both quality ad value; ad has i place a mechaism for cotiuous improvemet based o measuremets Medicare ad private payers are demadig health care delivery accoutability from providers. COA believes that ocology eeds to take the lead i developig a accoutable model that also justifies appropriate reimbursemet. Without this, the ladscape of cacer care delivery will cotiue to codese, ad patiets will face less accessible ad more expesive care, which also will be bore by patiets ad payers. How is COA Proceedig ad What Has Bee Accomplished to Date? COA established a Steerig Committee to direct the overall efforts of the COA Ocology Medical Home iitiative. The committee is comprised of represetatives from the ocology provider team, private payers, ad patiet groups. The committee is chaired by Bruce Gould, MD, a practicig commuity ocologist with Northwest Georgia Ocology Ceters. To date, the committee has helped defie the model of the Ocology Medical Home, startig with idetifyig the eeds of patiets, providers, ad payers i the delivery of cacer care. This effort the allowed the committee to idetify ad edorse a iitial set of 16 quality ad value measures of cacer care. Additioally, the committee backed the developmet of a patiet satisfactio tool, which is modificatio of the Cosumer Assessmet of Healthcare Providers ad Systems (CAHPS) survey tool. A Implemetatio Team was also formed to idetify the iformatio, tools, software, etc. required to tur ocology ceters ito fully fuctioig Ocology Medical Homes. This team is chaired by Carol Murtaugh, RN, OCN, a practice admiistrator ad ocology urse with Hematology & Ocology Cosultats (Nebraska & Iowa). To date, the team compromised of ocology practice admiistrators has idetified the resources (over 50 ad coutig) ad is workig to pull those together ito a ocology medical home tool kit. The goal is to provide practices accordig to a ocology medical home assessmet a customized set of tools to move alog a path of icreasig sophisticatio. The articles that follow touch o differet facets of the COA Ocology Home Iitiative, icludig a uique Come Home project made possible by a grat from the ewly established Ceter for Medicare & Medicaid Iovatio. I believe that the Ocology Medical Home is a ocology urse s dream i terms of doig what they do so well put the focus o the patiet first! Refereces Natioal Research Coucil. Assessig ad Improvig Value i Cacer Care: Workshop Summary. Washigto, DC: The Natioal Academies Press, (Pages: I the preface to the report) Natioal Research Coucil. Esurig Quality Cacer Care. Washigto, DC: The Natioal Academies Press, Puget Soud Quarterly Vol. 37, No. 1

5 COME HOME: A Ocology Medical Home Pilot Barbara McAey, MD, CEO New Mexico Cacer Ceter Health care costs are placig a icreasig burde o the federal govermet, private payers ad o patiets. Recet attempts to reduce costs to the govermet, icludig Pay for Performace (P4P) have resulted i oly modest savigs to Medicare (0.1% or $7 per beeficiary) (Nelso et al 2012). Health care costs also impact patiets, with 62.1% of bakruptcies i the US resultig from medical bills. Amog those filig bakruptcy due to medical bills, 48% of bills are from hospitals, 18% are medicatios ad 15% are from physicias (MedPAC 2011). We believe that maagig high-cost cacer patiets i a outpatiet settig ca provide sigificat cost savigs to Medicare. Whe patiets visit a physicia office that is part of a hospital s outpatiet departmet, Medicare pays a facility fee to the hospital ad a reduced fee for the physicia s services. The combied fees paid for visits to hospitalbased practices are ofte more tha 50% greater tha rates paid to freestadig practices (MedPAC 2011). There is growig evidece that patiet cetered medical homes (PCMH) ca be successful i achievig the Triple Aim of improved quality, lower cost, ad higher patiet satisfactio. Recet studies have demostrated that medical homes ca sigificatly reduce costly ED visits by 15-50% ad ipatiet admissios by 10-40% i a variety of populatios (Reid et al 2009; Steier et al 2008; Leff et al 2009; Dorr et al 2008). With this i mid, we developed Commuity Ocology Medical HOME (COME HOME), a medical home model for freestadig idepedet ocology practices, focused o ehaced access ad symptom maagemet to prevet the complicatios of cacer ad cacer care. Cacer patiets have eve more to gai from a medical home ifrastructure tha primary care patiets. Ocology practices already have the ifrastructure to do ifusios, labs ad imagig osite so they ca maage coditios that require those therapies outside of a hospital. These practices also have the ability to maage patiets who eed multiple days of itraveous therapy, i.e. atibiotics, as outpatiets rather tha admittig to a hospital. The COME HOME program has erolled seve idepedet commuity ocology practices that have agreed to trasitio from a traditioal FFS model to a ocology medical home by participatig i this study. Those practices are Austi Cacer Ceters (Austi, TX), The Ceter for Cacer ad Blood Disorders (Ft. Worth, TX), Dayto Physicias Network (Dayto, OH), Maie Ceter for Cacer Medicie (Scarborough, ME), New Mexico Cacer Ceter (Albuquerque, NM), Northwest Georgia Ocology Ceter (Marietta, GA), ad Space Coast Cacer Ceter (Titusville, FL). Collectively, these practices treated 2% of all colo, breast ad lug cacers diagosed i The COME HOME model of care delivery builds o the cocept of a patietcetered medical home, icorporatig features specific to the maagemet of cacer ad the symptoms of cacer treatmet, evolvig toward a ocology medical home (OMH) model. COME HOME icludes six features to esure safe, efficiet ad high quality care: best practices care usig cliical pathways, electroic health records, team-based care, active disease maagemet, ehaced access ad fiacial support. The COME HOME participatig practices utilize stadardized, evidecebased pathways for the diagosis ad treatmet of seve cacer types (breast, lug, colo, pacreas, thyroid, melaoma ad lymphoma). Additioally, they icorporate active disease maagemet i the form of symptom maagemet pathways that allow triage urses to quickly assess patiets over the phoe ad determie if they ca be maaged remotely, if they should be scheduled for a same day appoitmet or if emergecy services should be called. The fiacial support of the grat also allows the practices to remai ope (exteded access) at least two extra hours i the eveigs ad at least four hours o the weekeds, so that patiets ca be see same day for acute symptom maagemet. I this way, the COME HOME practices are able to provide care whe the patiet eeds it, rather tha whe it is coveiet for the cliic. Prior to COME HOME, may patiets ow see by a ocologist i eveig or weeked hours were referred to local emergecy departmets (EDs) or urget care ceters. Prior to implemetatio, a task force cosistig of grat staff ad practice represetatives provided educatio to Cotiued o page 9 Puget Soud Quarterly Vol. 37, No. 1 5

6 COME HOME: Implemetatio i Private Practice Steve L. D Amato BSPharm, BCOP Executive Director, Maie Ceter for Cacer Medicie Overview O July 1, 2012, Dr. Barbara McAey ad Iovative Ocology Busiess Solutios (IOBS) were awarded a $19.76 millio grat from the Ceter for Medicare ad Medicaid Iovatio (CMS/CMMI) to develop a commuity ocology medical home model ad implemet that model i seve practices across the coutry. Iovative Ocology Busiess Solutios, Ic is a for-profit corporatio owed by Dr. McAey, ad was created for the purpose of applyig for ad admiisterig the CMMI grat. This award represeted the culmiatio of several years of research ad developmet o the part of Dr. McAey ad her staff at New Mexico Cacer Ceter (NMCC). Several cocepts ad strategies were cosidered, vetted, ad evetually tested for viability at NMCC before iclusio i the proposal. The goal of COME HOME is to improve health outcomes, ehace patiet care experieces ad sigificatly reduce costs of care by keepig patiets out of the emergecy departmet ad hospital as much as possible. The seve practices that were selected had to demostrate the ability to fulfill the requiremets of the grat. The practices participatig i the project are: Austi Cacer Ceter, Austi, TX Ft Worth Ceters for Cacer ad Blood Disorders, Ft. Worth, TX Dayto Physicias Network, Ketterig, OH Maie Ceter for Cacer Medicie, Scarborough, ME New Mexico Cacer Ceter, Albuquerque, NM NW Georgia Ocology Ceters, Marietta, GA 6 Puget Soud Quarterly Vol. 37, No. 1 Space Coast Cacer Ceter, Titusville, FL Project Compoets The first part of the project ivolves the process for a Ocology Medical Home (OMH). The requiremets of a OMH are available from the Commuity Ocology Alliace. The process ivolves Triage Pathways, idetificatio of patiets at high risk for complicatios; same day visits, 24/7 access to the physicias of the practice, ad the ability to actively maage the disease process ad therapy complicatios, ad ehaced electroic medical record with data collectio. Dr. McAey developed proprietary triage pathways for symptom maagemet i ocology that all of the practices are required to implemet. All data from the practices is collected through software developed by Net Dot Orage (NDO), a software compay for patiet data itegratio ad quality of care/pathway compliace trackig. Implemetig this model required the practices to make sigificat chages to their workflow ad staffig patters. They are required to have live first respoders who ca iitially triage calls comig ito the practice ad immediately route them to dedicated triage urses who utilize the triage pathways ad schedule patiets ito the practice immediately for urget care if ecessary. Extedig practice hours, both durig the week ad o weekeds is aother requiremet. Years of experiece suggest that the lack of access to a outpatiet facility i the early eveig ad o weekeds leads to more emergecy room visits ad hospitalizatios. The secod part of COME HOME was to have the practices develop the capability to provide urget care util 8pm o weekdays ad for 3-5 hours o weekeds. Havig this capacity allows patiets to cotact the o-call physicia for referral to the cliic for evaluatio. This ca iclude labs or imagig, hydratio, atibiotics, ad other symptom maagemet medicatios. Providig these services requires additioal staffig ad creative schedulig of physicias ad advaced practice providers. The grat does help pay the practices to hire additioal persoel to provide for exteded hours. The grat does ot pay for services that ca be billed to CMS such as E&M codes, ifusios, lab work, or physicias to take call. The third part of the COME HOME project requires both diagostic ad therapeutic pathways to be developed ad followed i additio to the triage pathways. CMS is iterested i the appropriate use of imagig ad pathology services i ocology. This will result i quality ad cost effective care. The diagostic pathways used will iclude appropriate stagig tests ad ot iclude iappropriate tests (such as PET CT for stage I breast cacer or boe sca for Cotiued o ext page

7 PSA less tha 10 i prostate cacer). Geetic markers are becomig icreasigly importat for the determiatio of appropriate therapy. IOBS has partered with KEW which has a CLIA certified laboratory i Cambridge, MA. KEW has developed CacerPlex; a highly versatile ad comprehesive gee testig pael to evaluate geetic chages i a patiet s tumor to help ocologists effectively maage treatmet optios. The COME HOME practices will have the ability to sed patiet tissue for molecular aalysis to KEW. Each practice dedicated sigificat physicia time workig i committees o the developmet of the pathways. The therapeutic pathways were developed for seve disease states: breast, colo, pacreatic, lug, thyroid, o-hodgki s lymphoma, ad melaoma. The grat provides compesatio for physicia time i the developmet of the pathways. Practice Challeges with Implemetatio To be part of COME HOME requires a great deal of commitmet ad the ability to adapt to workflow chages that are ecessary to fulfill the goals of the project. Our practice, the Maie Ceter for Cacer Medicie (MCCM) faced such challeges. First, participatig i the project requires that all members of the practice embrace the grat, especially leadership. MCCM had to replace its log stadig Director of Nursig because of egativity about the project. This was most ufortuate but ecessary to move the practice forward. The first challege was establishig first respoders. MCCM desigated two staff receptioists as first respoders who would take all calls comig ito the practice, triage them, ad sed the appropriate calls to urse triage. The aswerig service ad calls set to urse mailboxes were elimiated durig the day. The goal was for our patiets to always receive a live perso whe callig i. The secod challege was settig up the urse triage system. MCCM has a primary urse model where we have a physicia, urse, ad secretary team. The primary urses would take their ow calls while workig i the cliic ad this was stopped as we implemeted the triage system. The requiremet of the grat is to have urses dedicated to phoe call triage durig the day. We used our ursig office as a commad ceter where urses were rotated ad dedicated to triage usig the established triage pathways ad documetig the calls ad itervetios i the NDO software package loaded o their computers. This created several problems ad morale issues withi our ursig staff because ursig was takig calls o patiets they did ot kow ad they sesed they were losig cotiuity of care with their patiets. They stated it was takig loger to triage patiets opposed to takig calls o patiets they kow well. To remedy this issue, we provided dual computer screes i the cliic that have NDO ad COME HOME call lists o oe scree ad our EMR (Altos OcoEMR) o the other. This allowed the urses to pick up the calls o their ow patiets. If urses were ot scheduled i the cliic, they were i the ursig office takig triage calls as well. This has worked well ad the urses have bee much happier. Compliace with triage pathways is moitored ad feedback is give back to the practice. The triage pathways have also bee adjusted as practices idetify areas of improvemet. The third challege was extedig our hours of operatio. Traditioally, MCCM paid oe of its urses to take calls o the weeked. This was rotated betwee a few urses who were paid overtime for providig this coverage. To exted hours durig the week ad opeig the cliic o Saturday ad Suday from 9am to 1pm preseted several challeges. We ow had to rotate the whole ursig staff through weeked coverage ad provide a physicia or advaced practice provider (APP) to cover those hours as well. Oe ca imagie this was ot received well iitially ad it required our leadership team to get creative with schedulig ad icetives. First, we approached the physicias ad advaced practice providers. The physicias were compesated with additioal pay out of their bous pool if they worked the weeked ad the advaced practice providers were give a stiped. We eded up with the physicias ad APPs each takig two weekeds per moth. Next was the ursig staff. We had to carefully balace their work hours ad provide time off durig the week if they worked the weeked. At the same time we had to provide them with a pay differetial for workig the weeked. This also applied to the secretaries ad medical assistats that we eeded for the weeked coverage as well. We the discovered that we eeded to have our lab services available, so we developed a rotatio for them as well. Our pharmacy staff would help ursig prepare for the weekeds ad we periodically will have pharmacy voluteer for the weeked to ear additioal pay. Most of this, except for the professioal services, is covered by the grat. What traspired made these chages less of a challege ad embraced by our staff. We ow have patiets ad family members thakig our urses, physicias, ad other staff o the weekeds for beig available immediately to care for them. Goe are the trips to the emergecy room or ocology floor o the weekeds. We ca provide supportive care medicatios, hydratio, ad prevet hospital admissios with this ew model of care. If a patiet does eed to be admitted to the hospital, it ca ow be a direct admit bypassig the emergecy room. We have literally had patiets i tears they are so happy they do ot have to go through that system. It has literally bee fatastic for our patiets ad staff. Data Patiet ad provider satisfactio surveys specific to ocology were developed by the Commuity Ocology Alliace ad are beig used by the practices i the COME HOME project. The grat is providig tablets to the practices to facilitate electroic capture of this data. Data collectio ad aalysis will be obtaied through a iterface with NDO ad will measure compliace with the pathways o a early real-time basis. It will iclude cliical data, pertiet complicatig factors, ad all charges associated with the care of the patiet. Compariso data will be obtaied with the help of CMS from a practice selected locally as the cotrol practice ad by a NCCN hospital system. A dashboard will be created so that data ca be moitored at frequet itervals by IOBS. Dr. McAey ad her team estimate overall Medicare savigs of $4,178 per member per year Cotiued o page 9 Puget Soud Quarterly Vol. 37, No. 1 7

8 Measurig Quality ad Value i Cacer Care Bo Gamble Director of Strategic Practice Iitiatives, Commuity Ocology Alliace The Affordable Health Care for America Act (ACA), which passed November 7, 2009, was the first official legislative attempt to icrease the quality of health care while also reducig the expese. (Traslatio = value.) This represets a radical chage i thikig from the traditioal approach of a health care delivery system that was based simply o utilizatio. If you got sick or had a accidet, you wet to a health care provider/facility ad they would address the problem as they thought best. There has bee miimal accoutability i this model ad the services were paid for with o regard to quality, value or outcomes. The ACA brought the cocept of measurable quality ad value to the forefrot of egotiatios betwee provider ad payer, provider etworks ad geeral paymet reform. (Oe Hudreth Eleveth Cogress, 2010) This has also bee true for cacer care but with far less visibility tha other aspects of healthcare. This is primarily due to the lack of uderstadig of the uiqueess of cacer care by our decisio makers or legislatures. The March 23, 2010 public ACA law metios cacer 14 times withi the 906 pages. The refereces icluded six refereces to cacer hospitals, six refereces to cacer screeig, ad oe referece to the importace of cacer assays. There was oly referece to cacer with regards to paymet reform ad that was i referece to evidece-based medicie (oly). The commuity of cacer care 8 Puget Soud Quarterly Vol. 37, No. 1 providers took this as a wakeup call to orgaize as well as educate ad propose practical solutios for all of cacer care. This ew perspective icludes a focus o quality, value ad outcomes i cacer care ad how paymet ca be wrapped ito the equatio for demostrated achievemet. This process started with the collaboratio ad establishmet of 19 measures very specific to cacer care. These measures, alog with stadardized patiet satisfactio survey for cacer care represet a comprehesive view of what is importat i cacer care ad from key stakeholders. This 18 member team icludes a mid-level provider, pharmacist, patiet (ad a patiet focus group), 2 practice admiistrators, 4 atioally recogized ocologist, 5 medical directors from atioal ad regioal payers, ad represetatio from ASCO, NCCN, NPAF, McKesso ad Iteratioal Ocology Network. Together they have reached cosesus o a set of measures that is Stakeholder drive This team arrowed the selectio of key measures from a startig list of over 200 to 40 to the iitial list of additioal measures have bee subsequetly added. (See for a complete list ad details of these measures.) All of these measures were edorsed with the uderstadig that they are importat to providers, payers ad most importatly.patiets. (OMH Steerig Committee, 2013) Cacer specific These measures are specific to key attributes ad deliverables i cacer care. Ad they are measures that ca be used i ay site of care or ay cacer care delivery model. Ulike some of the geeral or ocology measures withi the Physicia Quality Reportig System (PQRS), all of these measures are relevat, practical ad importat to ay cacer care model. Balaced The etire cotiuum of cacer care is reflected i the set. Measure categories are specific to patiet care, resource utilizatio, survivorship ad ed of life care. The patiet satisfactio survey complimets these measuremets with summary ad detail scores of how the patiet ad family perceive their cacer care throughout their jourey. Ogoig The work of this team ad this effort is ot complete. As the uderstadig of true quality ad value cotiues to evolve, this team will cotiue to evaluate ad edorse measures that will beefit all aspects ad stakeholders i cacer care. The drivers ad motivatio for these measures is a ew paymet model for all of cacer care. We cotiue to see sampligs of this reform through the Ceters for Medicare ad Medicaid Services (CMS) Ceter for Medicare ad Medicaid Iovatio (CMMI) projects, evolvemet ad maturig of ACA models, ad pilot programs from regioal ad atioal isurace carriers. The days of gettig reimbursed simply for providig care are disappearig. It is as if everyoe has take lessos from the grad state of Missouri Cotiued o ext page

9 ad is sayig Show me. Patiets are demadig quatifiable quality, value, ad outcomes i cacer care. Payers, icludig Medicare ad Medicaid, are demostratig that they are willig to pay for these distictios. These cocepts, the recommeded chages to the care process, measuremet, bechmarkig, ad paymet reform are all part of establishig your team as medical home for your patiets ad their families. There are may cacer ceters/practices leadig this effort ad they are beig oticed by employers, payers ad other etities. You ca be champio withi your ow team by acceptig the challege of: a) Trasitioig your thoughts ad deeds to those based o quatifiable improvemet i quality, value ad outcomes. b) Promote your measurable differeces so that your cacer care team is adequately recogized ad rewarded by atioal ad regioal payers ad employers. c) Cotiue to make measurable improvemets to that your patiets receive the best cacer care available. Please joi us i this atioal effort to reshape how cacer care is viewed ad rewarded. Visit to lear more. Refereces OMH Steerig Committee. (2013, 08 07). Ocology Medical Home. Retrieved from Ocology Medical Home: org/coa/bechmarkig.htm Oe Hudreth Eleveth Cogress. (2010, Jauary 5). Goveremt Pritig Office. Retrieved from Govermet Pritig Office: gov/fdsys/pkg/bills-111hr3590er/ pdf/bills-111hr3590er.pdf COME HOME Implemetatio Cotiued from page 7 (PMPY), which represets a savigs rate of approximately 6.276%. Based o a Medicare erollmet of 8,022 patiets over 3 years, the projected Medicare savigs are $33.5 millio ad et savigs of $13.76 millio (after budget costs). The Uiversity of Teessee Health Sciece Ceter will also be a parter for evaluatio ad cost aalysis. The results of Dr. McAey s project could redefie the delivery of cacer care. This is oe of the first projects that could pave the way towards a budled paymet model. If her hypothesis is correct, ad commuity ocology practices provide quality care at a lower cost, that is more coveiet for patiets, the model could be exported to other practices ad payers. Medical Home Pilot: Sigificat Traiig Give to Triage Staff Cotiued from page 5 practice staff, ad recruited voluteers to take part i medical home activities icludig workig exteded hours ad staffig the telephoe triage lies. Sigificat traiig was give to the triage staff to use the ewly developed triage pathways. Physicia exteders were hired by the practices to icrease the available same day appoitmet slots so that patiets who eeded them could be offered same day appoitmets for symptom maagemet. The ehaced access, ehaced care ad active disease maagemet portios of the grat have bee implemeted. This icludes the use of triage pathways for symptom maagemet, exteded hours i the eveigs ad weekeds ad patiet educatio. The fial two phases of implemetatio will iclude roll out of the cliical (diagostic ad therapeutic) pathways, ad applicatio for Ocology Medical Home certificatio. For all phases of implemetatio, we have leveraged iformatio techology to aggregate data across all practices ad coduct mothly data reviews to idetify treds, moitor process measures ad evaluate outcomes, allowig for rapid cycle feedback o the effectiveess of the model. Because ipatiet ad ED care is extremely expesive ad, may times, uecessary for our patiets, we believe that the cost savigs associated with utilizatio reductios i these areas will be sufficiet to more tha offset the cost of this OMH ifrastructure. Oly lookig at the Medicare patiets, the et savigs from COME HOME are projected to be $4,178/patiet per six moth episode of care. These savigs reflect reduced hospitalizatios ($3619), reduced ED visits ($593) ad reduced pharmacy costs ($450). They also reflect icreased physicia outpatiet costs ($484) which are attributed to additioal visits to the ocology practice for acute symptom maagemet. Total savigs for the three year period of the grat are predicted to be approximately $33 Millio. Our fial aalyses will iclude ED visit rate, ipatiet hospitalizatio rate, all-cause mortality ad total cost of care, both logitudially for the COME HOME practices ad i compariso with patiets treated at o-come HOME practices. Refereces Dorr DA, Wilcox AB, Bruker CP, et al. The Effect of Techology-Supported, Multidisease Care Maagemet o the Mortality ad Hospitalizatio of Seiors. J Am Geriatr Soc 2008; 56(12): Leff B, et al. Guided Care ad the Cost of Complex Healthcare: A Prelimiary Report. Am J Maag Care, 2009; 15 (8): MedPAC, Medicare Paymet Policy. Report to Cogress Nelso, Lyle. Lessos from Medicare s demostratio projects o disease maagemet ad care coordiatio. Issue Brief, CB Office, Editor Reid RJ, et al. Patiet-Cetered Medical Home Demostratio: A Prospective, Quasi-Experimetal, Before ad After Evaluatio. Am J Maag Care 2009; 15(9):e71-e87. Steier BD, et al. Commuity Care of North Carolia: Improvig Care through commuity health etworks. A Fam Med 2008; 6: Puget Soud Quarterly Vol. 37, No. 1 9

10 The Ocology Medical Home: What Patiets Wat Remais No Surprise to the Ocology Nurse Scott Parker, Executive Director Northwest Georgia Ocology Ceters, P.C. Whe the Commuity Ocology Alliace (COA) established a Steerig Committee i late 2011 comprised of patiets, payers ad providers, the itet was to develop a blueprit for a model of care that would demostrate quality of care for our patiets, value ad adherece to evidece based guidelies for payers, ad a reductio i bureaucratic hurdles alog with a sustaiable reimbursemet model for our providers ad staff. The patiet is obviously the corerstoe for the COA Ocology Medical Home ad was our iitial focus. Shortly after Dr. Bruce Gould was appoited Chairma of the Steerig Committee Northwest Georgia Ocology Ceters (NGOC) bega egagig its patiets. NGOC was fortuate eough to have bee a early parter i COA s Patiet Advocacy Network (CPAN). As a result of our CPAN participatio we were able to solicit feedback from a group of twety patiets who were active CPAN participats. NGOC paid a outside cosultat to iterview these patiets, ad ask oe questio. As a cacer patiet what s most importat regardig your iteractio with your physicia ad our office staff? Below is a summary of the resposes we received: Best Possible Outcome Best Quality of Life Doctors Ability (educatio), Availability ad Friedliess/Carig Timely Commuicatio of Test Results Friedly, Compassioate, Competet Staff 10 Puget Soud Quarterly Vol. 37, No. 1 Easy/ Timely Access to Staff ad Office Hoesty about Diagosis ad Progosis Educatio ad Egagemet i their Care Pla Coordiatio of Care/Commuicatio with Other Providers & Facilities Least Amout of Pai, ER Visits & Hospitalizatios What Patiets Wat Process Evidece Based Medicie Adherece to atioally recogized guidelies Access to cliical trials Access Urget appoitmets available for ew patiets Same day appoitmet available Structured telephoe triage Patiet Egagemet New patiet orietatio Fiacial couselig Chemotherapy educatio Patiet portal Team Based Care Esure that other providers are iformed Referrals ad appoitmets arraged Patiet Satisfactio Survey Survey used to moitor/improve patiet experiece I m sure most of you are ot surprised by these resposes ad if faced i a similar situatio might respod i a similar maer. A well-costructed Ocology Medical Expectatios Evidece Based Medicie Best quality outcome Best quality of life Least amout of pai, hospitalizatios Access Doctor availability Easy/timely access to staff ad office Coordiatio of care with other provider s facilities Reduced ER visits ad hospitalizatios Timely commuicatio of test results Patiet Egagemet Educatio ad egagemet i care plaig Hoesty about diagosis ad progosis Easy/timely access to staff ad office Team Based Care Coordiatio of care with other provider s facilities Easy/timely access to staff ad office Timely commuicatio of test results Patiet Satisfactio Survey Doctor s ability, availability ad friedliess/ carig Friedly, compassioate, competet staff Easy/timely access to staff ad office Home icorporates processes of care that if implemeted are desiged to meet the expectatios that our patiets are tellig us are importat to them. As the adoptio of the Ocology Medical Home evolves, the idea of patiet cetered care is certaily ot a ew cocept for the ocology urse. I my sevetee plus years at NGOC, I am always humbled by the ever edig level of care ad compassio displayed by our ursig staff. Wheever I have the pleasure of iteractig with patiets there are always usolicited complimets regardig the kidess, persoal touch, ad level of support provided by our ursig staff. Rest assured the team at COA is workig hard to esure that the Ocology Medical Home model succeeds i meetig all stakeholders expectatios ad helps to maitai the viability of Commuity Ocology.

11 Patiet Satisfactio Survey Jourey to Patiet-Cetered Care Marsha DeVita, RN, NP, AOCN Chief Cliical Officer of Medical Ocology Hematology Ocology Associates of Cetral New York Patiet egagemet is cosidered a corerstoe of High Quality Cacer Care. Measuremet of patiet satisfactio with CAHPS based survey questios focused o patiet cetered care is a importat step o the jourey to become a Ocology Medical Home. Hematology Ocology Associates of Cetral New York admiistered the Ocology Medical Home survey to their patiets i 2012 ad 2013 ad used the results to examie ad chage practice process ad improve care There are may reasos why ocologists should be usig a patiet satisfactio survey. Patiets desire a better healthcare experiece ad a greater level of participatio i healthcare decisios. Cacer care is complex. Egagig patiets i their care requires good commuicatio skills. Providers eed to uderstad patiets values ad prefereces as they discuss the diagosis, progosis ad treatmet optios. Measuremet of patiet satisfactio gives us the feedback we eed to esure that we are meetig our patiets eeds ad serves as a useful quality improvemet tool. Favorable patiet satisfactio scores ca differetiate oe healthcare facility from aother. There is a tred toward icreasig trasparecy of quality ad patiet satisfactio scores i healthcare. The Ceter for Medicare ad Medicaid (CMS) publishes hospital quality measure scores ad patiet satisfactio survey results o their Hospital Compare website. It is likely that the Physicia Compare website will follow the same path. Patiet experiece surveys will gai importace i our icreasigly trasparet, competitive marketplace where patiets seek quality, value ad a satisfyig experiece. Hematology Ocology Associates of Cetral New York (HOACNY) is a comprehesive private ambulatory ocology practice with five office locatios servig a six couty area i Cetral New York. We have fourtee medical ocologists, three radiatio ocologists 18 o-physicia providers with a total staff of 260. Treatmet modalities available withi our orgaizatio iclude; medical ocology, radiatio ocology, cyber kife, CT imagig, laboratory, ifusio, dispesig pharmacy, psychosocial care, registered dieticia cosultatio, cacer rehabilitatio, itegrative ocology ad welless. We bega to obtai patiet experiece data with the use of suggestio boxes several years ago. I 2008 we iitiated a mothly patiet satisfactio survey with approximately resposes each moth. We added Cosumer Assessmet of Healthcare Providers ad Systems (CAHPS) based survey questios to the mothly survey i 2011 as a preparatio for aticipated CMS patiet satisfactio reportig requiremets. We admiistered the Commuity Ocology Alliace (COA) Ocology Medical Home (OMH) Patiet Satisfactio Survey for the first time i September The OMH survey is made up of 40 CAHPS based questios, divided amog four categories: Timeliess, Thoroughess, Commuicatios, ad Friedliess-Helpful. Surveys were mailed to 3023 patiets who were see by a provider for a office visit durig a 30-day period. Our respose rate was 46% with 1307 resposes. We were pleased with our overall results ad the ability to bechmark. The OMH survey reportig allowed us to compare our results to other practices withi our state ad atio. We were able to study the survey results by questio, category, locatio ad provider. The ability to sort by questio, provider, ad locatio is helpful i the evaluatio process for quality improvemet. Commuicatio is at the heart of patiet cetered care. The Istitute of Medicie lists six compoets of high quality cacer care ad raks patiet egagemet first (2013). We decided to focus o a questio related to commuicatio ad patiet egagemet for our quality improvemet project. We selected the followig questio. I the last 12 moths, whe this provider ordered a blood test, x-ray, or other test for you, how ofte did someoe from this providers office follow up to give you those results? The patiet is asked to select oe of the followig aswers: ever, sometimes, usually or always. 88.1% of respoders reported that they were usually or always give the results of labs ad other tests. As we bega to look at process we discovered variatio i satisfactio scores by locatio ad idividual providers. We determied that variatio was likely related to several factors icludig: schedulig practices, availability of testig ad turaroud time for results by locatio, the importace providers placed o relayig ormal results, ad cocers about the amout of staff time it would take to call patiets with ormal lab results. Notificatio of lab test results was primarily doe o a eed to kow basis. The defiitio of eed to kow icludes results that are abormal, have some effect o the disease, treatmet, or health ad welless of a patiet. This did ot ecessarily iclude ormal results. The satisfactio survey results prompted us to examie our attitudes, patiet prefereces ad best practices. Studies have show that the majority of patiets wat all test results, icludig ormal results. Providig all test results improves satisfactio ad elists patiets i a safety et for missig tests. (Baldwi et al 2005) Access to laboratory testig with rapid turaroud time varies by office locatio. Our largest site typically produces a chemistry pael result withi a hour while the other locatios sed results to a cetral office for process- Cotiued o page 13 Puget Soud Quarterly Vol. 37, No. 1 11

12 PSONS Member Profile Kari A Felzer, RN, BSN Ifusio Nurse, Seattle Cacer Care Alliace Jody Stroh, MBA 12 Puget Soud Quarterly Vol. 37, No. 1 I the years I have bee writig these profiles, we have ever featured a urse fresh out of school. For the most part we have featured teured, well kow urses ad eve a few advace practice urses. Needless to say, I was tickled whe a request wet out to the Board for profile suggestios ad Kari A s ame came back with a great deal of ethusiasm. Kari A was bor ito a close family i Everett. The oly other idividual i health care was Mom who worked i medical isurace ad billig. Growig up, Kari A, like so may childre, was defiitely afraid of eedles. So oe might woder how she got over that ad selected ursig as a career. Kari A was exposed to cacer at a early age. Whe she was 9, her father was diagosed with a brai tumor. It was a blessig for the family that he was able to survive his cacer for 10 years. Sadly, whe Kari A was 19, her father lost his decade log battle with cacer. Durig the 10 years Kari A ad her family dealt with brai cacer, she was a first had witess to the icredible ursig care her father received. It was a observatio that would steer her ito ursig. She worried that ocology ursig might hit too close to home ad cosidered pediatric ursig as she started her educatio. Her first step was completig her Associate degree i ursig at Edmods Commuity College i Kari A the completed her BSN i August 2012 at Seattle Uiversity. The selectio of Seattle Uiversity for ursig school would ed up beig seredipity for Kari A. Ubekowst to Kari A, the SCCA had bee reachig out to the Uiversity of WA with the idea of creatig a out-patiet cliical rotatio. Whe that could ot be realized, the SCCA tured to Seattle Uiversity who agreed the out-patiet cliical rotatio would be a woderful opportuity for their ursig studets. The SCCA created oly 8 spots for this iaugural opportuity. Kari A applied ad was accepted ito the pilot program. She loved the experiece ad kew she was oto somethig ispiratioal at the Seattle Cacer Care Alliace! Meawhile, Kathlee Shao- Dorcy, RN, PhD was spearheadig a ew opportuity at the SCCA. Kathlee was workig to create a ew graduate ursig residecy program that would be split half time i trasplat (at the SCCA) ad half time i ifusio (at the SCCA). Kathlee did get the program up ad ruig just i time for Kari A to be amog the first participats i this uique opportuity. Kari A spet eight moths i the residecy program ad three moths before it was completed, she accepted a positio at the SCCA as a ifusio urse. I asked Kari A about metors she remembers as beig particularly ifluetial. It is a easy questio for her to aswer. At Seattle Uiversity, Karla Mather, RN, was a first time Cliical Leader ad Istructor. She really stepped up to the plate! says Kari A. Karla worked part time at Virgiia Maso, juggled a family with kids, commuted from Baibridge Islad to work i Seattle, ad ra the SCCA cliical rotatios for Seattle U! The admiratio from Kari A is readily apparet. The other metor Kari A quickly metios is Kathlee Shao-Dorcy, RN, PhD. Durig Kari A s residecy at the SCCA, she had mothly 1 to 1 meetigs with Kathlee as she rolled out the ew program. We were buildig it as we wet alog. Because she was so experieced, Kathlee was like a mother figure to me. She always kew what I was comig up agaist ext, ad could draw me out ad help put thigs back ito perspective. The mutual admiratio betwee Kari Kari A Felzer A ad Kathlee goes both ways so I gave Kathlee the opportuity to iclude some thoughts o Kari A: Kari A has bee a dedicated youg woma to learig about ocology ad implemetig her kowledge ito cliical practice sice we first met. Kari A voluteered to be a participat i the pilot project betwee Seattle Uiversity ad Seattle Cacer Care Alliace where seior Medical/Surgical cliical rotatios could be completed i the Outpatiet Cliic. Kari A was a pioeer i that program which has become a tremedously successful collaboratio betwee SU ad SCCA. Kari A the opted to do her seior practicum with SCCA i the summer term of her seior year. At that time SCCA had formulated the first residecy program for our cliical site ad Kari A was hired ito that role. Throughout all the complex orietatios ad multiple areas of learig, Kari A was a steady committed urse who always seized all opportuities to ehace her professioal growth. Followig her time i residecy, she was the hired ito a positio withi the Ifusio Room at SCCA. It has bee a privilege to have Kari A as a parter i this ew adveture ito workig with ursig studets, developig a residecy program, ad ow hirig a taleted youg dedicated professioal urse. Kari A, a PSONS scholarship re- Cotiued o ext page

13 PSONS Member Profile Cotiued from previous page cipiet for Symposium 2013, says she was t as familiar with ovaria cacer ad she wated to try to icorporate as may extra educatioal opportuities as possible. Ovaria cacer was a area I was t as exposed to so I really leared a lot at Symposium ad I felt way more prepared to care for that patiet populatio says Kari A. She also says ow that school is over ad she has a great ew job (ad a great ew husbad!) that she will defiitely be joiig ONS/ PSONS. I asked Kari A about advice she might give to other ew urses ad she offered somethig I had ot heard before: Most ursig studets ted to go to the hospital ad start i med/surg for a year to get experiece but I broke the mold ad wet ito out-patiet ad directly ito ocology. If you kow what you wat to do, go for it! Clearly it paid off for Kari A. Our Editor, Bob Chapma, RN, posed a questio for Kari A: How do you promote evidece-based practice as a way to improve quality patiet outcomes or improve a quality patiet experiece? She respoded, Durig my time at the SCCA, I have ever bee told We do thigs this way, because it is the way it has always bee doe. Wheever I have iquired why somethig is doe i a particular way, the aswer has always bee based o sciece, research, ad/or best practice stadards. Throughout the residecy program, I was taught how to care for our patiets based o the policy ad procedures of the SCCA, which have all bee created ad implemeted based o sciece, research studies, ad/ or best practice stadards. Evidecebased practice guides the way I care for our patiets every day, ad is what allows me to provide the best quality of care for our patiets. Kari A ad her ew husbad (a Evirometal Studies grad out to save the world! ) have two sweet dogs, a lab Sadie ad a puggle Gaje whom they love to treat to parks ad hikes o the weekeds. The ew couple is also recet homeowers ad busy themselves with lots of yard work ad home projects i their spare time. Somethig you might ot kow about Kari A but wo t be surprised to kow either is that she graduated Summa Cum Laude from Nursig School. It was really hard work she says, but it really paid off. Well I kow a whole group of urses ad patiets who would agree to that! Patiet Satisfactio Survey: Secure Patiet Olie Portal Saves Staff Time Cotiued from page 11 ig. Whe test results take loger, more patiets leave our office without their result. This creates additioal work ad traslates ito more staff time to call patiets ad follow up o results. It also leads to a greater opportuity for lab result commuicatio failure. We explored several optios to esure that ormal lab results ad abormal results are commuicated. We ruled out mailig ad callig ormal results because of the volume ad related staff time. We decided to use our secure patiet portal to deliver lab results to patiets. The process of uploadig the results was automated to save o staff time. We ecourage every patiet who comes ito our office to joi the portal. The secure portal is a great tool to deliver labs ad improves access i other areas. We examied our process of sharig imagig results with patiets. Imagig tests are routiely scheduled so that a provider will see the patiets the same day with a stat imagig result or withi oe or two days followig a test. This eables the provider to have ample time to discuss the result with the patiet. We have rare occasios whe a patiet has a test scheduled without a follow up appoitmet withi a day or two. Whe this occurs, it is up to the physicia ad care team to otify the patiet of the results via telephoe. After review of our processes we were able to use our electroic medical record to develop a trackig system to esure that we relay results to patiets. The imagig test order is liked to a imagig results quality checklist. All imagig is tracked ad remais o the check list util the patiet is give the result. This trackig system is beeficial from a quality stadpoit ad a satisfactio stadpoit. We saw a modest improvemet i our score o this questio whe we repeated the survey i Iitially 88.1% of 1307 respoders stated they usually or always received their test results ad this icreased to 91.4% of 1430 respoders i April We will cotiue to follow the satisfactio survey results, evaluate, ad look for opportuities to improve. Our ext survey will be admiistered i the first quarter of We believe that our trackig system for imagig results ad utilizatio of the patiet portal to relay lab test results will cotiue to improve our satisfactio score ad patiet experiece. May physicias, urses ad other healthcare workers are draw to cacer care i part because of a desire to improve the patiet s jourey. This is a great time to be a part of patiet cetered chages that will positively affect satisfactio, outcomes ad the success of your orgaizatio. Measurig the patiet experiece is a ogoig commitmet to review process, practice style ad beliefs about what patiets wat ad eed. The COA OMH survey is a powerful tool whe used to examie your patiet experiece ad esure that you ca set yourself apart from your competitio by meetig your patiet s eeds. Refereces Baldwi, D, Quitela, J, Duclos, C, Stato, E & Pace, W (2005). Patiet prefereces for otificatio of ormal laboratory test results: A report from the ASIPS collaborative. BiomedCetral Family Practice, 6(11). Retrieved from lm.ih.gov/pmc/articles/pmc555570/ Istitute of Medicie (2013) Deliverig high quality cacer care: Chartig a ew course for a system i crisis. Retrieved from books.ap.edu/opebook.php? record_id=18359&page=5 Puget Soud Quarterly Vol. 37, No. 1 13

14 Radiatio Safety for Nurses i Medical Imagig ad Radiatio Therapy Trag Marquez CNMT, PET, ARRT (CT) 14 Puget Soud Quarterly Vol. 37, No. 1 Radiatio is everywhere. It is aturally foud i our eviromet. It comes from outer space through cosmic rays ad the groud through soil. It is i our food we eat, the water we drik as well as buildig materials used to build homes. I fact, most of our atural exposure comes from rado; a gas released from the earth s crust ito the air we breathe i. All this atural radiatio is called backgroud levels. No adverse health effects have bee foud from these levels of atural radiatio exposure. The average aual exposure from atural radioactive sources is 310 millirem or mrem i the US 1. A millirem is a uit used to measure doses of radiatio. Radiatios from ma-made sources cotribute aother 310 mrem to our aual average radiatio exposure through medical, commercial, ad idustrial evets 1. Cosumer products such as tobacco, fertilizer, exit sigs, ad smoke detectors add more tha 10 mrem to our aual radiatio exposure 1. For radiatio exposures from occupatioal source of radiatio the US Nuclear Regulatory Committee (NRC) ad State Radiatio protectio officers require that all licesed medical facilities that use radioactive materials or machie geerated radiatio to limit occupatioal urse radiatio exposure to 5,000 mrem (50 msv) per year 1. For more iformatio regardig state ad federal regulatios ad radiatio exposure limits ca be foud o the NRC website i Title 10 of the Code of Federal Regulatios, Part 20 or Washigto State Office of Radiatio Protectio s website. Natural ad ma-made radiatio exposure affects us all i the same way, causig ios to be formed i cells. The huma body has mechaisms to repair damage to livig cells caused by radiatio. The biological effects of radiatio affect cells i three ways 1. Oe outcome occurs whe damaged cells repair themselves, causig o further biological effects to the perso. Secod, the cell dies ad is replaced through ormal biological processes. Lastly, the cells do ot repair the damage or repair themselves icorrectly which leads to potetial egative outcomes. Radiatio risk is the based o the amout of radiatio ecoutered, the area of the body exposed ad the amout of time over which the exposure happeed. The relatioship betwee radiatio exposure ad the cause of cacer are mostly based o populatios that have received high levels of ioizig radiatio such as the Japaese atomic bomb survivors. A high-dose exposure of greater tha 50,000 mrem show cacer developmet for leukemia, breast, bladder, colo, liver, lug, esophagus, ovaria, multiple myeloma, ad stomach cacers 1. Accordig to the Natioal Cacer Istitute, lifestyle factors such as smokig, alcohol cosumptio, ad diet, cotribute largely too may of these same diseases 1. Natioal Academy of Scieces is asked every years to evaluate the risks of radiatio at low levels because there is o scietific evidece to show the occurrece of cacer resultig from exposure to low dose of 10,000 mrem 1, which is double the occupatioal dose limit for workers. What is the beefit of usig radiatio i medical imagig ad therapy? Medical imagig ad radiatio therapy is eeded for screeig, diagosig, ad treatig cacer. It s a set of importat tools i diagosig ad treatig cacer ad other huma health problems. Radioactive materials ad x-ray radiatio are commoly used i medical imagig ad cacer therapy procedures, with more tha 20 millio uclear medicie studies ad 300 millio x-rays give each year i the US 4. While it s very easy to measure or estimate the amout of radiatio workers are exposed to, it s ot always as easy for workers to see the beefits that are derived from the radiatio exposure, ad compare that to the risk. Federal law requires all workers to be traied i radiatio safety if their aual occupatioal exposure is more tha 100 mrem ad moitored if their exposure will be more tha 500 mrem per year 4. To miimize radiatio exposure to all employees, the As Low As Reasoably Achievable (ALARA) priciple is applied accordig to state regulatios. This priciple meas that a reasoable effort is made to maitai exposures to ioizig radiatio as far below the dose limit as possible. I additio, our goal is to keep the aual radiatio dose to urses below oe-teth the Federal occupatioal limit of 5,000 mrem per year. Oe-teth of the Federal occupatioal limit is 500 mrem 2 & 3. This allows lifetime occupatioal exposure to be kept low. To date, we have ever had oe urse have more tha 500 mrem i a year (or do we ever expect ayoe to)! Well doe! The ALARA may be achieved by urses practicig several simple work practices, amely cotrollig oe s time ad distace Time: A urse ca keep his or her exposure as low as possible by limitig the time they sped i a area where radiatio is preset whe performig their duties. These areas usually iclude rooms marked with radiatio warig sigs, ad lights that idicate whe x-ray equipmet is i use. Materials that emit ioizig radiatio are kept i areas that are marked with warig sigs, ad the time i those areas should be limited. Patiets receivig kow doses of radioactive materials that emit radiatio are cosidered safe by regulatory agecies however you ca still miimize time spet close to radioactive patiets. Distace: Exposure to ioizig radiatio ca be miimized by keepig some distace betwee oeself ad the source of the radiatio, except as eeded to provide the appropriate level of care. I fact, doublig the distace betwee yourself ad a source of radiatio reduces your exposure to oe quarter of its origial rate. Casual social cotact with our patiets will ot expose employees to usafe levels of Cotiued o ext page

15 radiatio. Other methods of miimizig radiatio exposure iclude wearig protective gloves whe workig with radioactive patiets ad washig hads immediately after leavig the room if hadlig bodily fluids such as blood ad urie. Each licesed facility has a assiged Radiatio Safety Officer that evaluates the Radiatio Safety Program ad to esure that all occupatioal staff members adhere to the State ad Federal guidelies with keepig radiatio exposure levels below the set allowed aual limit. Devices used to measure radiatio exposure for urses are dosimeter badges. The Radiatio Safety Officer provides dosimeter badges whe workig with x-ray equipmet, radioactive patiets, ad radioactive materials to Icome Treasurer s Report Budget Service Project $235 $250 Advertisig $400 $400 Fudametals $30,332 $38,000 Membership $4,858 $6,600 Mothly Educatioal Programs $6,991 $7,000 OCN Review $1,954 $2,500 Symposium $58,514 $60,000 Total Icome $103,284 $114,750 Expeses Board Meetigs $1,590 $1,590 Chapter Fees $558 $558 Doatio ONS Foudatio $1,000 $1,000 Fudametals $33,826 $38,000 Scholarships $3,886 $7,800 Mothly Educatioal Programs $12,747 $13,000 OCN Review $1,078 $1,500 Newsletter $10,068 $10,000 Office Supplies $250 $250 Postage & Mailig $255 $250 Symposium $46,141 $46,000 Vedor Relatios Mailig --- $110 Service Project $1,568 $1,000 Nomiatig Committee Mailig $14 $14 Travel to Leadership Weeked $790 $800 Operatios - Other $ Bak Fees $ Website $383 $1,500 Presidet Travel to ONS --- $2,200 Total Expeses $114,675 $125,572 measure occupatioal radiatio exposure. Dosimeter badges are ot to be wor if oe eeds a x-ray for medical or detal reasos. Medical doses resultig from ecessary medical ad detal procedures do ot eed to be icluded i the documetatio of the radiatio exposure of the wearer. It is importat to review the dosimetry report whe available to help moitor ad miimize radiatio exposure. The Radiatio Safety Office will cotact ay perso whose dose exceeds acceptable levels. Ad every facility is ispected, either by a State Office of radiatio protectio as i Washigto, or by the Federal Nuclear Regulatory Commissio. The ispectios are to evaluate the program, ad judge whether the facility is operatig i compliace with all regulatios ad safety practices. Trag Marquez has worked i the Medical Imagig Departmet at Seattle Cacer Care Alliace for 7 years. She is the lead techologist for Nuclear Medicie, Positio Emissio Tomography (PET), ad Computed Tomography (CT) ad is curretly completig her master s i Health Physics. Refereces 1. U.S. Nuclear Regulatory committee. (.d.). Fact Sheet o Biological Effects of Radiatio. Retrieved from rc.gove.readig-rm/doc-collectios/fact-sheets/bio-effectsradiatio.html. 2. Reima, Robert E. MD (2012) Duke Uiversity ad Duke Medicie Radiatio Safety Divisio. Nurse Radiatio Safety for Nurses. Retrieved from U.S. Nuclear Regulatory committee. (.d.) Protectig People ad the Eviromet. Retrieved from rc.gov/readig-rm/basic-ref/ glossary/alara.html. 4. NCRP Report No Ioizig Radiatio Exposure of the Populatio of the Uited States (2009). Puget Soud Chapter of the Ocology Nursig Society Cotact Iformatio for PSONS Board, Committees, ad Project Teams Please utilize the followig addresses for cotact. We wat your iput ad would love to hear from our members! All board meetigs are ope to the membership. Board of Directors Presidet: Reiko Torgeso [email protected] Presidet-Elect: Leise Taylor [email protected] Secretary: Jeifer Wulff [email protected] Treasurer: Heather Freebore [email protected] Immediate Past Presidet: Lois Williams Stadig Committees Chairs are board members Nomiatig Committee: Kay Walz, Chair [email protected] Membership Committee: Sadra Olso, Chair [email protected] Educatio Committee: Judy Peterse & A Bree, Co-Chairs [email protected] Commuicatios Committee: Bob Chapma, Chair [email protected] Webmaster: Agela Kox [email protected] Research Committee: Kathlee Shao-Dorcy, Chair [email protected] Govermet Relatios Committee: Vacat [email protected] Symposium Committee: Deb Leslie & Juaita Madiso, Co-Chairs [email protected] Ocology Nursig Educatio Cooperative Committee: Leise Taylor [email protected] Project Teams Vedor Relatios: Mary Jo Sarver & Lisa Westmorelad [email protected] Commuity Service: Nacy Thompso [email protected] Scholarship: Moa Stage [email protected] Letters, articles ad aoucemets are requested from all PSONS members ad other readers o topics of iterest to the membership. Submissios ad questios should be set i electroic format to [email protected]. Neither the Puget Soud Chapter of the Ocology Nursig Society, the Ocology Nursig Society, the Board of Directors, or the America Cacer Society assumes resposibility for the opiios expressed by authors. Acceptace of advertisig does ot idicate or imply edorsemet by ay of the above-stated parties. The PSONS Quarterly is published four times a year by the Puget Soud Chapter of the Ocology Nursig Society with the support of the America Cacer Society. To cotact the PSONS please commuicate with above idividuals or go to our website at for additioal iformatio. Puget Soud Quarterly Vol. 37, No. 1 15

16 America Cacer Society P.O. Box Seattle, WA PSONS Uveils Its New Logo Logo Cotest Wier: Bob Chapma, RN, MN, CCRN Puget Soud Ocology Nursig Society