Quality Improvement 

Toolkit

Colorectal Cancer Care 

April 27, 2011
Logistics

Questions during the LiveMeeting?

– Questions will be answered at the end of – Send questions via LiveMeeting or to 

cyberseminar@va gov cyberseminar@va.gov
Agenda

• Welcome!• Toolkit Series Overview • CRC Care Toolkit: Website Tour• QI in Action: Two CRC tool case st

QI in Action: Two CRC tool case st

• Q&A
Presenters

• Dede Ordin, MD, MPH - Director, Special Studies, VA 

Informatics and Analytics Informatics and Analytics

• Jennifer Malin, MD, PhD - Division of Hematology On

Greater Los Angeles Healthcare System 

• Steve Asch, MD, MPH - Associate Chief of Staff, HSR

Los Angeles Healthcare System

• Joy , a Golden, MSW - Evaluation Coordinator, , HSR&D 

Los Angeles Healthcare System

• Adam Powell, PhD, MBA - Investigator, VA Center fo

Disease Outcomes Research

• Andrea Leaf, MD - Assistant Chief, Clinical Oncology, N

Harbor Healthcare System, Brooklyn Campus
Welcome & 

Recap: Quality of CRC Care in 

Dede Ordin MD MPH Dede Ordin, MD, MPH

Director, Special Studies

VA Office of Informatics and AnalytVA Office of Informatics and Analyt
% of members 50 - 75 years of age who 

appropriate CRC screening CRC screening

YTD FY 2011 (by VISN)

appropriate CRC screening

YTD FY 2011 (by VISN)

9095

100

75808590556065704045505520253035

05

1015

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h

0
% of patients who underwent colonoscopy 

≤ 90 days after the 

positive CRC screening FOBT (by facility)

FY 2010 FY 2010

90

100

70806040502030

0

10

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
13 or more lymph nodes resected for stage II and III CRC patie

curative-intent surgical resection (VISN level dat

(OQP Special Study on Quality of CRC Care in the VA 2003

8060704050301020

0

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Toolkit Series Overview Toolkit Series Overview

Jennifer Malin, MD, PhD

Division of Hematology Oncolog

VA Greater Los An

g 

eles Healthcare S

Steve Asch, MD, MPH

Associate Chief of Staff, HSR&D

VA Greater Los Angeles Healthcare S
Imagine a school whe

performance was graded, 

else was provided to gelse was provided to g

performance improvem

else was provided to g

performance improvem

Without the proper toperformance improvem

cannot be evaluated,

measured, or improve

improve

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Colorectal Cancer Care Too

.... t th ! oe rescue e rescue

!

• Launched March 2011 • D i d t h l VA f iliti t Designe

d

to 

h

elp VA

facilities crea

te a f ibl 

feasible 

9 each tool linked to 1+ VA quality metrics

9 search f t l b i di t b h

for 

too

ls 

by 

indica

tor or 

by name

• Special thanks to QUERI Colorectal Cancer C

Collaborati es (C4 Treatment and Diagnosis Collaborati

ves (C4 Treatment and Diagnosis

Collaboratives)

• This is your website! (many interactive feature

This is your website! (many interactive feature

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
CRC Toolkit

Website Tour

Joya Golden, MSW
CRC Care Toolkit Tour CRC Care Toolkit Toolkit Tour

•User s’ Guide to Quality Improvem

Guide to Quality Improvem

•How to find tools for possible adop

How to find tools for possible adop

•H th i 

How 

to s

hare your experiences an

innovations with other Toolkit 

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Toolkit Series Homepage

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Toolkit Series Homepage

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Homepage (cont ) Homepage (cont

.

)

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Homepage (cont ) Homepage (cont

.

)

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Homepage (cont ) Homepage (cont

.

)

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Homepage (cont ) Homepage (cont

.

)

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
User s ’ Guide to Quality Impr

Guide to Quality Quality Impr

Impr

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
User s ’ Guide to Quality Impr

Guide to Quality Quality Impr

Impr

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
User s ’ Guide to Quality Impr

Guide to Quality Quality Impr

Impr

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
User s ’ Guide to Quality Impr

Guide to Quality Quality Impr

Impr

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
User s ’ Guide to Quality Impr

Guide to Quality Quality Impr

Impr

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
User s ’ Guide to Quality Impr

Guide to Quality Quality Impr

Impr

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
User s ’ Guide to Quality Impr

Guide to Quality Quality Impr

Impr

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Toolkit Series Homepage

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Toolkit Series Homepage Toolkit Series Homepage

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
CRC Toolkit CRC Toolkit

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
CRC Toolkit CRC Toolkit

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
CRC Toolkit CRC Toolkit

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
CRC Toolkit CRC Toolkit

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
CRC Toolkit CRC Toolkit

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
CRC Toolkit CRC Toolkit

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
CRC Metric by Tool Table CRC Metric by Tool Table

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
CRC Toolkit CRC Toolkit

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
CRC Tool by Metric Table CRC Tool by Metric Table

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
CRC Metric by Tool Table CRC Metric by Tool Table

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
CRC Metric by Tool Table CRC Metric by Tool Table

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
CRC metric/Tool Table

Example: Using a Tool to AdSpCRCecific Metric metric/Tool Table

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
CRC metric/Tool Table

Example: Using a Tool to AdSpCRCecific Metric metric/Tool Table

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Tool 29: CPRS Surgical C

Tool 29: CPRS Surgical Surgical C

C

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Tool 29: CPRS Surgical C

Tool 29: CPRS Surgical Surgical C

C

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Too 9 C S Su g ca C

l 29: CPRS Surgical C

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Tool 29: CPRS Sur

gical C

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Too 9 C S Su g ca C

l 29: CPRS Surgical C

1 2

34

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Too 9 C S Su g ca C

l 29: CPRS Surgical C

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Tool 29: CPRS Surgical C

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Tool 29: CPRS Surgical C

Tool 29: CPRS Surgical Surgical C

C

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Tool 29: CPRS Surgical C

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Tool 29: CPRS Surgical C

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Tool 29: CPRS Surgical C

Tool 29: CPRS Surgical Surgical C

C

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Tool 29: CPRS Surgical C

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Tool 29: CPRS Surgical C

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Tool 29: CPRS Surgical C

Tool 29: CPRS Surgical Surgical C

C

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
“Suggest a Tool Suggest a Tool”

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
“Suggest a Tool Suggest a Tool”

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Toolkit Series Homepage

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Visit our website! Visit our website!

https://vaww.visn11.portal.va.gov/site

napolis/verc/occ/Pages/toolkit homnapolis/verc/occ/Pages/toolkit

_hom

aspx
QI in Action: CRC Tool Case 

QI in Action: Action: CRC Tool Case 

Adam Powell, PhD, MBA

Investigator, VA Cente

r

for Chronic Disease Outcomes Resea

Assistant Professor, Department of Me

University of Minnesota

discussing

Tool 6: Positive FOBT Tracking 
Tool 6: Positive FOBT Track

Tool 6: Positive Positive FOBT Track

Track

Issues/Challenges

Prior to C4 timely follow-up of +FOBTs was a bproblem

• In FY04 ~70% of VA +FOBTs had no doc

follow-up in one year 

You can’t improve what you don’t measure
Tool 6: Positive FOBT Track

Tool 6: Positive Positive FOBT Track

Track

Solution

Developed measurement tool during C4 PhaEvolved to meet needs of C4 teams and lateneeds of the +FOBT monitor
+FOBT Tracking Tool +FOBT Tracking Tracking Tool

– Data 

Data 

A B C D E F G H 

Was CRC 

Screening 

FOBT 

Indicated?

Y,Na - Ng, Ns

(Scroll over cell

Comments on CRC 

Screening FOBT Not 

Indicated Designation

OPTIONAL

Co

Is VA 

Colonoscopy 

Indicated? 

(performed or 

paid for by VA)

Y N1 N2 N3

Comments on 

Colonoscopy Not Indicated 

Designation

Date of Initial 

Provider 

Response to 

Colonscopy Completion 

Date 

(MM/DD/YY)

REQUIRED for

Date of 

Patient's First 

Lab Report 

of Positive 

CRC (Scroll over cell

to see codes)

OPTIONAL

(M

O

Y, N1, N2, N3, 

N4, N5

(Scroll over this 

cell to see 

codes)

REQUIRED if N5 is 

entered into the 

previous column, 

otherwise OPTIONAL

Positive FOBT

(MM/DD/YY)

OPTIONAL

REQUIRED for

VA 

colonoscopy 

Strongly 

encouraged for 

non-VA followFOBT- Positive Patient Identifier 

CRC

Screening 

FOBT in 

Fiscal Year

(MM/DD/YY) If non-screening FOBTs are entered in Column A, Column C should be coded 

"Ns" and patient will be excluded from all 

Patient 1 1/24/10 Y Y fee based 1/28/10 2/14/10 

Patient 2 1/30/10 Y N2 2/25/10 Patient 3 1/22/10 Ne 78yr, -cscope 3yrs ago N4 1/22/10 

Patient 4 1/30/09

Y y 4/25/09 

REQUIRED up REQUIRED REQUIRED p results. Use of other codes is OPTIONAL.

Patient 4 1/30/09

Y y 4/25/09 

Patient 5 2/14/10 Nd 76yr, family hx N2 private sector 

Patient 6 2/15/10 y y 3/3/10 4/3/10 Patient 7 2/25/10 Y y fee base 2/27/10 5/22/10 Patient 8 2/4/10 Nc 58yr, anemia N2 private sector 2/15/10 

Patient 9 Patient 9 2/15/10 2/15/10 Nd FAMILY HX, FAMILY HX, y fee base fee base 4/12/10 4/12/10 

Patient 10 2/16/10 Nc 84yr, anemia y pacemaker 3/13/10 4/4/10 

Patient 11 2/2/10 y y pat refused colonoscopy 

Patient 12 2/11/10 Nc 87yr, anemia N3 

Patient 13 2/11/10 y y fee base 2/12/10 5/3/10 Patient 14 2/11/10 Ne 60yr, prior colonoscopy y 2/13/10 2/24/10 

Patient 15 2/23/10 y y 
+FOBT Tracking Tool +FOBT Tracking Tracking Tool

– Tabl

% Positive

% Positive 

Screening FO

with "Initia

% Positive 

Screening 

FOBTs with

% Positive Screening FOBTs with VA Colonoscopy 

within 30/60/90 Days, EXCLUDING patients who refuse 

colonoscopy, choose non-VA follow-up, are clinically "inappropriate" for colonoscopy have had a previous

FOBT 

Month

% Positive

Screening 

FOBTs minus 

cases classified 

as VA 

Colonoscopy not 

"Indicated"

Total 

Positive 

Screening 

FOBTs 

entered

< 90 Days

Calculated from

with Initia

Provider 

Response

question 

answered fowhom Initia

Provider 

Response

FOBTs with

"Screening 

Indicated" 

question 

answered for 

whom 

Screening 

FOBT was

< 30 Days

Calculated from

< 60 Days

Calculated from

inappropriate for colonoscopy, have had

a previous

positive FOBT in measurement year, or have nonscreening FOBT

Month

Total: 760 513/760 68

% 66/513 13

% 298/513 58

% 391/513 76

% 694/755 92

% 677/737 92

Calculated from 

Required data

entered Calculated from

Optional data

Response

within 14 Da

Calculated fr

Optional da

FOBT was

Indicated

Calculated from 

Optional data

TBD = To Be Determined

TBD numbers will be calculated 30/60/90 days after end of 

measurement month (based on date of positive FOBT). 

Calculated from

Required data

Calculated from

Required data

Sep-07 9 4/9 44% 0/4 0% 1/4 25% 3/4 75% 7/9 78% 4/7 57

Oct-07 32 19/32 59% 0/19 0% 7/19 37% 10/19 53% 27/32 84% 26/30 87

Nov-07 33 22/33 67% 0/22 0% 7/22 32% 12/22 55% 27/33 82% 29/31 94

Dec-07 40 27/40 68% 0/27 0% 9/27 33% 19/27 70% 37/40 93% 36/39 92

Jan-08 39 22/39 56% 0/22 0% 19/22 86% 21/22 95% 32/39 82% 36/39 92

Feb 08 - 44 33/44 75% 2/33 6% 19/33 58% 27/33 82% 43/44 98% 42/44 95Mar-08 50 30/50 60% 2/30 7% 20/30 67% 26/30 87% 43/49 88% 49/50 98

Apr-08 46 32/46 70% 3/32 9% 22/32 69% 28/32 88% 43/46 93% 46/46 100

May-08 37 24/37 65% 1/24 4% 15/24 63% 18/24 75% 33/37 89% 34/34 100

Jun-08 61 40/61 66% 3/40 8% 28/40 70% 29/40 73% 51/61 84% 58/59 98

Jul-08 55 38/55 69% 5/38 13% 17/38 45% 23/38 61% 54/55 98% 53/55 96

A g 08 u - 47 37/47 79% 2/37 5% 19/37 51% 28/37 76% 42/43 98% 32/46 70Sep-08 33 25/33 76% 2/25 8% 11/25 44% 15/25 60% 32/33 97% 26/31 84

Oct-08 41 28/41 68% 0/28 0% 14/28 50% 18/28 64% 40/41 98% 34/38 89

Nov-08 41 29/41 71% 3/29 10% 12/29 41% 20/29 69% 40/41 98% 34/41 83

Dec-08 26 17/26 65% 1/17 6% 10/17 59% 15/17 88% 25/26 96% 21/26 81

Jan-09 32 20/32 63% 2/20 10% 11/20 55% 17/20 85% 29/32 91% 29/32 91

09 16 10/16 63% 7/10 70% 10/10 100% 10/10 100% 14/16 88% 16/16 100

Feb-09 16 10/16 63% 7/10 70% 10/10 100% 10/10 100% 14/16 88% 16/16 100Mar-09 19 11/19 58% 5/11 45% 9/11 82% 11/11 100% 19/19 100% 16/17 94
+FOBT Tracking Tool +FOBT Tracking Tracking Tool

– Run 

Run 

Note: As patients spreads

% Positive Screening FOBTs with VA Colonoscopy within 30/60/90 Days, EXCLUDING patients who 

refuse colonoscopy, choose non-VA follow-up, are clinically "inappropriate" for colonoscopy, have had a previous 

86%

58%

67% 69%

63%

70%

45%

51%

44%

50%

59%

55%

100%

82% 79%

91%

75%

60%70%80%90%

100%

30 Days 60 Days 90 Days

25%

37%

32% 33%

45% 44% 41%

0%

10%20%30%40%50%

07

07

07

07

08

08

08

08

08

08

08

08

08

08

08

08

09

09

09

09

09

09

09

09

09

09

09

09

10

10

10

Sep-0

Oct-0

Nov-0

Dec-0

Jan-0

Feb-0

Mar-0

Apr-0

May-0

Jun-0

Jul-0

Aug-0

Sep-0

Oct-0

Nov-0

Dec-0

Jan-0

Feb-0

Mar-0

Apr-0

May-0

Jun-0

Jul-0

Aug-0

Sep-0

Oct-0

Nov-0

Dec-0

Jan-1

Feb-1

Mar-1

88%

100%

90%

100%

% Positive Screening FOBTs with "VA Colonoscopy Indicated" question answered for 

whom VA Colonoscopy Indicated

Note: Aadded fentered data po

44%

59%

67% 68%

56%

75%

60%

70%

65% 66%

69%

79%

76%

68% 71%

65%

63% 63%

58%

63%

40%50%60%70%80%90%

0%

10%20%30%

40%

07

07

07

07

08

08

08

08

08

08

08

08

08

08

08

08

09

09

09

09

09

09

09

09

09

09

09

09

10

0

0

Sep-0

Oct-0

Nov-0

Dec-0

Jan-0

Feb-0

Mar-0

Apr-0

May-0

Jun-0

Jul-0

Aug-0

Sep-0

Oct-0

Nov-0

Dec-0

Jan-0

Feb-0

Mar-0

Apr-0

May-0

Jun-0

Jul-0

Aug-0

Sep-0

Oct-0

Nov-0

Dec-0

Jan-1

Feb-1

Mar-1
Tool 6: Positive FOBT Track

Tool 6: Positive Positive FOBT Track

Track

Points to Consider Points to Consider

3⁄4 Who will complete the tool? Who will complete the tool?3⁄4 How will you obtain the input data? How will you obtain the input data?

All +FOBTs from lab vs. GI consults

3⁄4 How will you review/use the data?
QI in Action: CRC Tool Case 

QI in Action: Action: CRC Tool Case 

Andrea Leaf MD Andrea Leaf, MD

Assistant Chief – Clinical Oncolog

New York Harbor HCS Brooklyn CamNew York Harbor HCS, Brooklyn Cam

discussing

Tool 5: CPRS Order Set for C
Treatment of Patient with Re

Cancer,

VA-NYHHS 

(2006-2008

)

Treatment of Patient with ReCancer,

VA-NYHHS 

(2006-2008

)

Colonoscopy

Rectal mass seen Median 49 

(35 89)

C ,

(

)

LAB

PATH +

PRE-OP CEA

(35

-89) 

RAD

CT CHEST 

PRE OP CEA

CT ABDOMEN

4 

(0-72) 4 

(0 21)

MED 

ONC Reques

t

Complete

(0-21)

4 

(0-20) 

9 

(0-24) 

SUR

t

TRUS

PORT 

20.5 

(0-37) 

36 

GI

RAD

SUR INSERTION

20 

9 10 11.5 

(3-83)

RAD

ONC

Request Simulation 

begins

Complete

(0-62) (0-24) (0-29) (5-35) 
Tool 5: CPRS Order Set for C

Tool 5: CPRS Order Set for C

Colonoscopyrectal mass

Pathology +Cancer 

B

GI notified 

C

GI performs

TRUS

GI places Med Onc

consult

Radiation Onc consult 

C

Tumor Board

C

RT simulation

RT begins
Tool 5: CPRS Order Set for C

Tool 5: CPRS Order Set for C

Pathology +Cancer Colonoscopy 

rectal mass

GI notified 

GI performs TRUS

Tumor Board

GI places GI places

Order Set

Radiation Onc consult Surgery 

Consult for port

Venous port

inserted

Ch th

RT simulation

Chemotherapy

begins RT begins
CPRS Order Sets 

for Colon and Rectal Cance

r

Rectal has these ordersORDER SET COMPONENTS:

10 Q.LRZ COMPREHENSIVE OPT20 Q.LRZ CBC OPT30 LRZBK CEA

40 Q.RAZ CT ABD W CONTRAST BK50 LRZ CREATININE W/EGFR60 GO-NURS INSERT HEPLOCK70 Q.CT CHEST W CONTRAST80 QO-CONS BK-GENERAL SURGERY OUTPT90 ORZ RADIATION ONCOLOGY100 QO-CONS BK-ONCOLOGY OUTPT

Colon has

ORDER SET COMPONENTS:

10 Q.LRZ COMPREHENSIVE OPT20 Q.LRZ CBC OPT30 LRZBK CEA

40 Q.RAZ CT ABD W CONTRAST BK50 LRZ CREATININE W/EGFR60 GO-NURS INSERT HEPLOCK70 Q.CT CHEST W CONTRAST80 QO-CONS BK-GENERAL SURGERY OUTPT
Tool 5: CPRS Order Set for C

Tool 5: CPRS Order Set for C
Tool 5: CPRS Order Set for C

Tool 5: CPRS Order Set for C
Tool 5: CPRS Order Set for C

Tool 5: CPRS Order Set for C
Tool 5: CPRS Order Set for C

Tool 5: CPRS Order Set for C
Metrics-based Process Map: 

T fP i ihR lTreatment o reatment o

f

Patient wit

h

Rectal 

Colonoscopy

Rectal mass seen

GI

RAD CT CHEST 

TRUS(median 20.7 days) NYH

TRUS 4 4 

LAB PATH +

PRE-OPCEA

CT ABD

CT 1 

SURG Central venous INSERTION

M di 3 5 M di 9

Median 36 

(3-83) 

PRE-OP CEA

Central venous insertion 15

RAD M di 9 M di 10

MED 

ONC

Request

R t

Complete

M

edian 

3.5

(0-20) 

M di 20 

M

edian 

9

(0-24) 

Median 29 

(11-59) 

Request Complete

3

M

edian 

9

(0-24) 

M

edian 10

(0-29) 

RAD

ONC

Request Complete

M

edian 20

(0-62) 

Request Complete 17 8 SIMULATION

NEO

SIMULATION

-

ADJUVANT 

RT +/-CHEMO
Toolkit Series project team and 

VA Greater Los Angeles VA-CASE, IndJennifer Malin, MD, PhDSteven Asch, MD, MPHJeff Luck PhD MBA

Heather WoodwaGail Edwards, RN

Jeff Luck, PhD, MBA Tonya ReznorLaura York, MACandice Bowman, PhD, RN

Tonya ReznorDeborah Griffith, E

Joya Golden, MSWAnn Zisser, RNJenny Girard BA Jenny Girard, BANina Smith, MPH