Southern Maryland Hospital Center Cancer Program Annual Report

Transcription

1 2012 Southern Maryland Hospital Center Cancer Program Annual Report

2 Letter from our Chairmen/Liaison On behalf of the Southern Maryland Hospital Center, the Cancer Committee is very proud to present the 2012 Cancer Program Annual Report. The report offers an overview of the many services available to our oncology patients. Since 1990, Southern Maryland Hospital has been providing continuous and ever improving cancer care to the residents of the region. Approved as a Community Hospital Cancer Center by the American College of Surgeons Commission on Cancer (CoC) with receipt of a three-year approval, we continue to strive for ensuring excellent patient-centered care. The Cancer Committee is delighted to pursue improvements annually to our cancer program. We both feel privileged to work with the dedicated group of people from various departments that contribute to our efforts this year. In 2012, we added new committee members from Nursing Administration, Quality Improvement, and Radiology, and it is particularly gratifying to see what our group can accomplish with such a hard-working and talented bunch. Each year, the Cancer Committee sets specific goals. One goal for 2012 was to change the process by which chemotherapy patients present to the hospital and receive their treatment on the inpatient unit. These changes were implemented in October. Not only is the new process more efficient for patients and physicians, but it could serve as a model for how our center manages patients once we are administering chemotherapy in the outpatient setting. The Committee has been paying close attention to future plans for our medical center, as outlined by Michael Chiaramonte and our current leadership team. It is exciting for us to learn that cancer care will play such a prominent role as Southern Maryland Hospital Center expands our campus and provides additional services. We are willing to work hard to meet the needs of our community as this expansion in cancer care takes place. Sincerely, Nicholas DeMonaco, M.D. Andrew Satinsky, M.D., Liaison Physician Co-chairs; Cancer Committee Southern Maryland Hospital Center ii

3 TABLE OF CONTENTS Quality and Accreditations Community Outreach.. 1 Radiology. 2 Mammography. 2 Chemotherapy Navigation 3 Oncology Nursing 3 Out-Patient Nutrition. 3 Rehabilitation 4 Breast Cancer Combined Stage Study. 4 Breast Cancer Patient 1 st Course Treatment Study.. 5 Summary of Body Systems Report.. 6 Breast Cancer Age-Grouped The Cancer Committee Members. 7-8 iii

4 Quality and Accreditation The Quality and Accreditation Department at Southern Maryland Hospital Center considers high quality health services in a safe environment to be our top priority. To achieve this goal, we regularly collect and review quality and safety measures related to all aspects of our services, to ensure that we meet regulatory and accreditation requirements, measure up to other health inpatient facilities, and meet the needs of our patients and families. The Quality staff interacts regularly with the nursing and medical staff to provide quality patient care. Southern Maryland Hospital Center is committed to providing our patients and families with effective medical care in a safe and caring environment Community Outreach/Cancer Support & Educational Groups/Volunteer Services The community outreach team has been heavily involved in hosting events that promote cancer awareness and education. Two free Ask the Doctor seminars were hosted by Southern Maryland Hospital; one was on the topic of prostate cancer treatment options, presented by Dr. Robert Chiaramonte, and the other was on the topic of Cancer Prevention and Maintenance, presented by Dr. Nicholas DeMonaco. At these events, a question-andanswer session is followed by a 45 minute presentation. Two free cancer screenings also took place this year: a skin cancer screening was held in June and a prostate cancer screening was held in October. In addition to free screenings and educational seminars, Southern Maryland Hospital also offers a variety of classes and support groups, including: 1) Look Good, Feel Better (meets 6 times per year), 2) Prostate Cancer Support Group (meets 12 times per year), 3) cancer nutrition classes (4 times per year) and 4) smoking cessation classes. In April 2012, Southern Maryland Hospital hosted the Third Annual Heart & Health Expo. Various vendors offered cancer screening and/or cancer education (such as skin cancer screenings and breast cancer education) at this event. In June 2012, the community outreach team attended a Men s Health Day at Prince George s Community College. They promoted prostate cancer awareness by providing literature and education to members of the surrounding community. Southern Maryland Hospital has also sponsored two presentations for the Leukemia & Lymphoma Society in 2012, one took place on November 8 and the other is scheduled to take place on December 4. The hospital volunteer program has provided the Tumor Registry Department with several qualified volunteers to assist with the workload. 1

5 Southern Maryland Professional Radiology Cancer Committee Program Highlights A fully accredited outpatient imaging facility, Southern Maryland Professional Radiology offers cancer diagnostic imaging services utilizing state-of-the-art imaging equipment which includes digital mammography, ultrasound, breast MRI, spiral computed tomography and stereotactic breast biopsy. Exams are performed by experienced, credentialed technologists and interpreted by board certified radiologists who work collaboratively to ensure the highest quality in diagnostic imaging. Southern Maryland Professional Radiology has partnered with Greater Baden Medical Services to offer community outreach by providing screening mammography as a negotiated cost for uninsured and underinsured women in our community. The Executive Director of Southern Maryland Professional Radiology Is a member of the National Capital Area Breast Health Quality Consortium (BHQC) which has been initiated to engage providers of breast services to improve the quality of care and reduce breast health treatment disparities for lowincome and uninsured women. Breast self-exam (BSE) education is available to every patient at the time of her mammogram. BSE shower cards are displayed in the suite for patient s to take home with her at the completion of her mammography exam. As an organization within the Southern Maryland Healthcare System, Southern Maryland Professional Radiology is privileged to work closely with some of the most respected board certified physicians, surgeons, pathologists, medical and radiation oncologists and other highly qualified health care specialist credentialed on the medical staff of Southern Maryland Hospital. Tracking Mechanism for mammography Patients All mammography patients receive a letter mailed to their home address within 30 days of their appointment. A copy of the radiology report is sent to the patient s referring physician within hours of the exam. Any highly suspicious mammographic findings in which a biopsy is recommended are placed in our tracking system. The Radiologist notifies the patient s referring physician by telephone and dictates in the mammography interpretation who he spoke with including the date and time. A certified letter is sent to the referring physician requesting documentation of follow-up. Also, we send the patient s letter via certified mail which states your recent mammography examination showed an abnormality that requires further follow-up by your physician. All copies of the certified receipt cards are filed and maintained indefinitely. We are at a 94.7% patient follow-up rate for recommended biopsy for this past year. 2

6 Chemo Navigation In an effort to streamline the process for our patients receiving chemotherapy we started a program in October entitled Great (Get Results Early and Timely). A physician s office need only make one phone call to our Outpatient Services department to schedule a patient for chemotherapy, followed by a fax with the required documents. Outpatient services then contacts the patient to schedule an appointment for any labs and tests they might need prior to chemotherapy. At that appointment the preregistration is done and the nursing interview is completed. After receiving confirmation from the physician that the chemotherapy may precede the patient is contacted with an admission date and time. On arrival the patient is already registered, escorted to the nursing unit saving the patient a long wait time while labs are processed and called to the physician. It also eliminates the possibility of being sent home for abnormal labs. As part of this process, patients requiring Neulasta injections the day after chemotherapy may now be discharged after the infusion is finished and come back the following day to outpatient services to receive the injections. This allows them to return to their home environment in a timelier manner. Oncology Nursing Unit The oncology unit at Southern Maryland Hospital has staff educated and trained to provide emotional care of oncology patient, in addition to their physical care. We provide both medical and surgical care on the unit. In addition, nurses meeting the criteria are required to maintain a provider card from the Oncology Nurses Society, for the purpose of infusing Chemotherapy and Biotherapy drugs to inpatients and outpatients. The unit provides holistic care for the patient and their families. A library with information about various topics related to cancer is located on the unit easily accessed by both patients and family. Hospice care is facilitated through our case management team when appropriate. Staff is encouraged to seek outside continuing education in the care of the oncology patient in order to stay current in their practice. Cancer patient Nutrition Registered Dietitians (3) provide customized nutrition assessments as well as nutrition intervention, counseling, and education for all Cancer patients at Southern Maryland Hospital. Education is provided during the hospital stay, as well as through one outpatient nutrition and cancer class per quarter. Medical nutrition therapy is individualized to provide optimal support for each and every Cancer patient assuring that each patient s nutritional needs are met during their hospital stay. 3

7 PERCENT OF TOTAL CASES Rehabilitation Southern Maryland Hospital Center provides specialized programs of physical and occupational therapy that maximizes functional abilities for cancer patients who encounter problems associated with lymph edema and other pre- and post-surgical conditions that result in pain and swelling, scar tissue formation or loss of mobility. Southern Maryland Hospital Center Standard 2.11 The percentages of total Breast Cancer patients diagnosed and treated at Southern Maryland Hospital were compared with other area facilities in the state of Maryland. There were very small percentile differences when comparing stages. 40% 35% FIGURE 1 STAGES - COMBINED 5 YEARS TOTAL % 25% 20% 15% 10% 5% 0% O I II III IV NA UNK SMHC 17.2% 35.3% 29.8% 8.5% 4.8% 0.2% 4.3% OTHER 16.5% 33.7% 28.5% 9.9% 4.9% 0.0% 6.4% 4

8 PERCENT OF TOTAL CASES 30% 25% 20% 15% 10% 5% 0% surg only surg & rad surg & chemo surg, rad & chem FIGURE 2 FIRST COURSE TREATMENT - COMBINED 5 YEARS TOTAL surg, rad & horm ther surg & horm ther surg, rad, chem & horm ther surg, chem & horm ther other ther no 1st course Rx SMHC 25.9% 11.6% 6.3% 11.6% 15.0% 7.6% 7.6% 4.3% 8.7% 1.5% OTHER 24.4% 8.4% 10.6% 10.2% 10.4% 8.6% 6.2% 3.5% 15.3% 2.4% 5

9 6

10 Cancer Committee Mission Statement The mission of the Cancer Committee at Southern Maryland Hospital Center is to meet and exceed customer expectations and assure that high Standards of Care are maintained for our Cancer Patients. In relationship to the oncology population, the Cancer Committee is charged with the responsibility of planning, implementation and evaluation of The Tumor Board Conferences, Performance Improvement, and Patient Care Evaluations. Furthermore, it serves as the supervising body of the Tumor Registry Cancer Committee Members Chairman Nicholas DeMonaco, MD Hematology/ Oncology Andrew Satinsky, MD Co-Chairman/Radiation Oncology Alan Oroxom, MD Pathology N. Guaouguaou, MD Radiology Andrew Sumner, MD VP of Medical Affairs and CMO Thomas K. Huisman, MD Surgery/Oncology Grant McClure, MBA, PhD VP Professional Services Michele Chiriaco, RHIA, CCS Director HIM 7

11 2012 Cancer Committee Members cont. Anne Johnson, RN Teresa Barnes, RN Emily Butzer, Rd Anne Koutsavlis, Rd Millie Kashmere, RN Karen Powers, RN Cheryl Huseman Fr. Jeffrey F. Samaha Johnny Beason, BS, CTR Cynthia Parkinson Darlene D. Rose, RN Frank Shen Gwen C. Johnson Stephanie Hubbard Deborah Harding Karen Schettler, RN Tracey Boseman Jessica Talley 4 East Nursing Oncology RadOnc RN Dietary Dietary Administration/ MD Liaison Case Management Marketing Chaplain/Pastoral Care Tumor Registry HIM Transcription Manager Quality & Accreditation Pharmacy Southern MD Professional Radiology ACS Rep. Tumor Registry PI Hospice Hospice 8