Gibbs Cancer Center & Research Institute Comprehensive Community Cancer Program (CCCP)

Transcription

1 American American College College of of Surgeons 2013 Content 2014 Content cannot be be reproduced or or repurposed without written permission of of the the American College College of Surgeons. of Surgeons. How to Get Your Cancer Program Ready to Start RQRS R. Diane Skinner, BS, CTR, Gibbs Cancer Center & Research Institute Spartanburg, South Carolina Gibbs Cancer Center & Research Institute Comprehensive Community Cancer Program (CCCP) A CoC Accredited site since 1938 Approximately 1900 cancer cases annually Recipient of the CoC Outstanding Achievement Award since it s inception in 2006 Comprehensive Cancer Services provided at 5 cancer treatment centers Other Accreditations: NAPBC, ACR Breast Center of Excellence, ACR Radiation Oncology, QOPI Certification, and MD Anderson Physicians Network Certified Member 2 Cancer Data Management Gibbs Cancer Center & Research Institute Registry in place since early 1930s Responsible for data collection, abstraction, and submission of cancer cases for the Spartanburg Regional Healthcare System (includes 3 hospitals within the healthcare system) Utilize Elekta Medical Systems Inc. METRIQ software program Staffing 3 Full time CTR 0.5 CTR 1 Full time CTR Eligible 0.5 Clerical Staff 3

2 4 Objectives Project Development Project Implementation Outcomes Project Development Decision to Participate Define Key Stakeholders Evaluate current processes Evaluating workflow Suspensing cases Registry Staffing 5 Decision to Participate in RQRS Invited to participate as a beta test site due to our NCI Community Cancer Center Program (NCCCP) award Site visit by CoC to share information about RQRS and beta test site participation Our Leadership saw this as an opportunity to improve the quality of patient care by providing real time feedback on specific indicators to physicians Opportunity to improve data quality 6

3 7 Key Stakeholders Cancer Program Leadership Physicians CoC Cancer Liaison Physician Cancer Care Committee Cancer Registry Staff Current Registry Process Does current staff allow for abstracting by primary cancer site designation? Who What Does the current process accommodate RQRS workflow? Does this impact how we will case find, abstract, and submit cancer data? Do you have a mechanism to continually update treatment information in order to complete the abstract concurrently? When 8 Project Implementation Networked with alpha and beta test sites Designated 1 full time senior CTR for breast and colorectal RQRS modules Developed a trigger process: MIDAS Smartrac Work list which proved ineffective to adequately trigger METRIQ follow up scheduler module Access to EMR Began RQRS submissions in June, 2009 Upload of 2008 data Designated one full time CTR for NSCL cancer cases & began submitting to RQRS from January 1,

4 10 Elekta Medical Systems, Inc. METRIQ Plan Follow up Screenshot Program Implementation Monthly reporting RQRS Alerts Created a process to review the non compliant cases and intervene where appropriate Reviewed charts to assure completeness of the record and appropriate documentation in METRIQ Worked with the Quality staff to close the loop on cases. Quality Staff notified the physician of record to provide additional documentation or follow up with patient to assure compliance 11 RAPID QUALITY REPORTING SYSTEM (RQRS) SPARTANBURG MEDICAL CENTER DASHBOARD 12

5 13 Outcomes Real time feedback loop to physicians for non compliance on the RQRS quality indicators Created a safety net for patients to assure guideline compliance with the RQRS quality indicators Improved data quality for reporting purposes Lessons Learned/Key Takeaways Commitment by leadership and physicians Evaluate current process and network Adequate staffing is key Develop a reminder system for treatment information Don t be afraid to go back to the drawing board 14