Q yp uality Improvement 

Toolkit : Lung Cancer 

Care

January 6, 2011
Logistics

• Questions during the LiveMeeting?

– Questions will be answered at the end of 

Questions will be answered at the end of 

session

– Send questions via LiveMeeting or to Send questions via LiveMeeting or to

cyberseminar@va.gov
Agenda

• Welcome• Recap: OQP Special Study on the Qual

Lung Cancer Care

• Overview to the Quality Improvement T

project

• Lung Cancer Care Toolkit Website Tou• Q lit I Quality Improvement/T l t di t/Tool case studies

– Lung nodule reminder dialog template– Multi-disciplinary tumor board

• Q&A
Presenters

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

Director, Special Studies

of Quality and Performance

• Jennifer Malin, MD, PhD - Division of Hematolog

VA G t L A l H lth S t VA Greater Los Angeles Healthcare System 

• Steven Asch, MD, MPH, Associate Chief of Staff

VA Greater Los Ang y eles Healthcare System

• Dexter T. Estrada, MD, Chief, Hematology and M

Oncology, VA Central California Health Care Syst

• Mark Fuster, MD, Pulmonary & Critical Care Serv

Diego Healthcare System

• Philippe Montgrain, MD Philippe Montgrain, MD, Pulmonary & Critical Ca

Pulmonary & Critical Ca

VA San Diego Healthcare System
Welcome

Dede Ordin MD MPH Ordin, MD, MPH

Director, Special Studies

VA Office of Quality and PerformanVA Office of Quality and Performan
Recap: OQP Special Study

Jennifer Malin MD PhD Jennifer Malin, MD, PhD

Division of Hematology Oncolog

VA Greater Los Angeles Healthcare SVA Greater Los Angeles Healthcare S
OQP Special Study of Lung Can

• Pur

p q yp ose: 

qualit

y im

provement

• 25 evidence and/or guideline-based quali

indicators and timeliness measures valid

expert panels

– address continuum of lung cancer care: diag

address continuum of lung cancer care: diag

treatment, supportive care, end of life care

• Lun

g y cancer cases newl

y dia

gnosed in 2

identified from VA Central Cancer Regist

• Data abstraction by WVMI using EPRP pr

Data abstraction by WVMI using EPRP pr

• Analysis by WVMI (algorithms validated b

team)
Treatment

Number

# Cases 

Per Quality Indicators Cases VAMC 

(Range)

DTM5: Resection for stage I or II Resection for stage I or II NSCLC 1575 0 – 48 DTM6: No adjuvant chemotherapy for 

stage IA NSCLC

435 0 – 16 

DTM7: No radiation therapy for No radiation therapy for resected resected 973 0 35 

stage I or II NSCLC 

973 0 – 35 

DTM8: Adjuvant chemotherapy for 

resected stage II or IIIA NSCLC

279 0 – 14 

stage II or IIIA NSCLC

DTM9: Combined chemotherapy-radiation 

therapy for stage III NSCLC

922 0 – 34 

DTM10: Platinum-based doublet 

chemotherapy for stage IV NSCLC

891 0 – 23 

DTM11: Platinum-based doublet 444 0 – 19 

chemotherapy for SCLC
DTM5 – Resection for Stages I an

NSCLC

100%

80%90%60%70%

Rate

30%40%50%

QI R

10%20%30%

0%

VAMCs with 5 or more eligible cases N=8

National Mean National Median
DTM9 – Combined chemotherapy

therapy for sta

ge III NSCLC

100%

py g

80%90%60%70%

Rate

30%40%50%

QI R

10%20%30%

0%

VAMCs with 5 or more eligible cases N=76

National Mean National Median
Supportive Care

Q lit I di t Number

# Cases 

Per

Quality Indica

tors 

Number Cases Per

VAMC 

(Range)

DTM13: Prevention of chemotherapy

- 2029 0 

– 58 

related nausea/vomiting

DTM14: Outpatient screening for pain in 

advanced cancer

1707

9485 visits

0 – 586 

visits 

DTM15: Reassessment after change in 

opioid treatment in advanced cancer

113 0 – 9 

DTM16: Short-acting opioids for 113 0 – 9 

breakthrough pain in advanced cance

r

DTM17: Radiation therapy for brain mets 372 0– 14 DTM18: Steroids for sus

p p ected s

pinal cord 34 0 

–

3 

compression 

DTM19: Spine MRI or myelography for 

suspected spinal cord compression 50

0 – 4 

DTM20: Treatment for confirmed spinal cord compression 20 0 

– 2 
DTM13 – Prevention of chemothe

related nausea/vomitin

g

100%

80%90%60%70%

Rate

30%40%50%

QI R

10%20%30%

0%

VAMCs with 5 or more eligible cases N=100

National Mean National Median
DTM14 – Outpatient screening fo

patients with advanced cancer

100%

80%90%60%70%

Rate

30%40%50%

QI R

10%20%30%

0%

VAMCs with 5 or more eligible cases N=110

National Mean National Median
Timeliness Measures

Number Median 

Cases 

Time from suspicion to diagnosis

• Solitary nodule or mass <10 mm

4048

523

32 day47 day

• Solitary nodule or mass <10 mm • Solitary nodule or mass 10 to 30 mm

S lit d l 30

523

13561682

47 day48 day25 day

•

S

olitary no

d

ule or mass >30 mm 1682 25 day

Time from diagnosis to initial treatment 3649 35 day• Initial treatment: surgical resection• Time from diagnosis to PET scan*

877243

50 day17 day

• Time from diagnosis to consult with 

thoracic surgeon*

852 27 day
Time from diagnosis to first treat

sur

gical resection

100

80906070

me (Days)

304050

QI Median Tim

102030

0

VAMCs with 5 or more eligible cases N=68

Median Time National Median
Summary

• Overall performance encouraging• Substantial variation across faciliti

virtually all measures Æ considerab

opportunity for improvement

• More information available on OQ 

P 

Special Studies section

http://vaww.oqp.med.va.gov/programs/qi/qu

aspx
Overview of the Toolkit project

Steven Asch MD MPH Steven Asch, MD, MPH

Associate Chief of Staff, HSR&D

VA Greater Los Angeles Healthcare SVA Greater Los Angeles Healthcare S
Imagine a school where perfo

was graded, but little else waprovided to guide performa

performa

improvement...

Without the proper toperformance improvem

cannot be evaluated,

measured, or improve

improve
Lung Cancer Care Toolkit .... to th

• Lung Cancer Care Toolkit website w

launched November 2010.

• Toolkit has been designed to help c

feasible feasible QI plan by recommending recommending s

s

tools as linked to specific indicators
Lung Cancer Care 

Toolkit

W b it T Website Tour

Joya Golden
Lung Cancer Toolkit Tou

•User s’ Guide to Quality Improvement Guide to Quality Improvement

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

•User s’ Guide to Quality Improvement Guide to Quality Improvement•How to find tools for possible adoption

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

•User s’ Guide to Quality Improvement Guide to Quality Improvement•How to find tools for possible adoption•How to share your experiences and 

i ti ith th T lkit innovations with other 

Toolkit

users

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Lung Cancer Indicator/To

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Lung Cancer Indicator/To

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Lung Cancer Indicator/To

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Tool 4: CPRS PET scan te

T2 - Time from diagnosis to first tre

90

100

607080

ays)

405060

edian Time (Da

20

QI M 30e

0

10

VAMCs with 5 or more eligible cases

N 105

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

N

=105

Median Time National Median
Lung Cancer Indicator/To

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Lung Cancer Indicator/To

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Tool 4: CPRS PET scan te

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Tool 4: CPRS PET scan te

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Tool 4: CPRS PET scan te

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Tool 4: CPRS PET scan te

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Tool 4: CPRS PET scan te

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Tool 4: CPRS PET scan te

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Tool 4: CPRS PET scan te

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Tool 4: CPRS PET scan te

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Tool 4: Request Tool opt

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Tool 4: Request Tool form

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Tool 4: CPRS PET scan te

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Tool 4: CPRS PET scan te

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Tool 4: “Join the Discuss

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Tool 4: “Join the Discuss

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Tool 4: “Join the Discuss

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Tool 4: “Join the Discuss

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Tool 4: “Join the Discuss

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Tool 4: “Join the Discuss

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
Tool 4: CPRS PET scan te

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

https://vaww.visn11.portal.va.gov/sites/Indianapolis/verc/occ/Pages/toolkit_h
“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
Tool Development: Case Stu

Dexter T Estrada MD Dexter

T. Estrada, MD

Chief, Hematology and Medical Onc

VA Central California HCS VA Central California HCS

discussing

Tool 35: Lung Nodule Reminder Dialog Tem
Tool 35

Lung g nodule reminder dialog tem

Issues/Challenges

•Wait time from an abnormal image to a diagn

lung cancer was unacceptably high at 23 dalung cancer was unacceptably high at 23 da

1/2009.

•No integp p rated process in place at that time fo

facilitating the workup of suspicious lung nodfound on routine imaging.

•Many cases were being lost to follow-up or 

unnecessarily delayed due to fragmented ca
Tool 35

Lung g nodule reminder dialog tem

Solution

•VA CCHCS was selected as a participant in the 

Cancer Care Collaborative Cancer Care Collaborative.

•A reminder dialog template was developed patt

after the recommendations of the American Co

Chest Physicians and the Fleischner Society foevaluation of suspicious lung nodules.

•The template augmented the implementation o

multidisciplinary lung nodule clinic on 7/2009.
Tool 35

Lung g nodule reminder dialog tem
Tool 35

Lung g nodule reminder dialog tem
Tool 35

Lung g nodule reminder dialog tem
Tool 35

Lung g nodule reminder dialog tem
Tool 35

Lung g nodule reminder dialog tem
Tool 35

Lung g nodule reminder dialog tem
Tool 35

Lung g nodule reminder dialog tem

Impact

•The OQP special study on lung cancer reported 

11/2010 h d ti f b l i 11/2010 showed a mean time from abnormal im

lung cancer diagnosis of 32 days for the entire 

system.

•VA CCHCS had a mean time of 16 days for this 
Tool 35

Lung g nodule reminder dialog tem

Points to Consider Points to Consider

• The lung nodule reminder dialog template for 

Vi tA/CPRS b bt i d th h CAC VistA/CPRS can be obtained through our CAC

McFarland and Julie Evans.

• It is best used by a clinical provider who acts a

It is best used by a clinical provider who acts a

patient “navigator” for the facility.

• It is also best used in conj 

unction with a multid

lung nodule clinic that meets regularly.

• A separate tracking tool is essential and is also 

avail bl d l d ith th h l f VERC 

ilable, developed with the help of VERC en
Tool Development: Case Stu

Mark Fuster, MD & Philippe Montgrai

Pulmonary/ Critical Care Section

VA S Di H lth S t VA

San Diego 

Healthcare 

Sys

tem

discussing

Tool 5: Tumor Board 

process
Tool 5

Tumor Board process

Issues/Challenges

Typical Thoracic Oncology Referrals:

1. Solitary nodule

2. “Heralding” signs/ symptoms and/or Mass +/- met

- Demands on Quality Evidence-Based care and Timeliness - Volume is HIGH

Two major problems in a Two major problems in a Referral Referral-Only (No Board) process Only (No Board) process:

- Quality of care: Under- and Mis-staging Æ Mis-trea

Fix: Group/ concensus Æ Accurate workup; C

Fix: Optimal Fix: Optimal treating specialist communicatio

treating specialist communicatio

- Timeliness of care: Inefficient use of evidence/ guid

Fi C di t d ll l ti

x: Coordinated parallel actions
Tool 5

Tumor Board process

Solution

-In VASDHS - Original T-Board framework: Cancer Committe-“Site-specific” Tumor Boards-Weekly multidisciplinary attendance – Mandated

( , In other Centers, freq y uenc, gy 

 site of meeting in facility/ netw

Anatomic Site – Multidisciplinary:

“Body” – Gen Surg, GI Med ,Onc, Path, Radiol, Rad Onc, Nurs, Pa

Pa

“Thorax”: Pulm, CT surg, Med Onc, Path, Radiol, Rad Onc, Nurs, P

-Prospective Prospective presentation presentation – OK to allow later OK to allow later “point of entry point of entry”

-Service reminders for common mtg. site, weekly

Post board coordinated efforts Dx/Treating teams

-Post-board coordinated efforts – Dx/Treating teams
Tool 5

Tumor Board process

Impact

-Not solely one surgeon, oncologist, etc... making decisions-Assurance of teams centered on Assurance of teams centered on AJCC staging AJCC staging-Open input from multiple specialties

Including dialogue:

State-of-Art diagnosis, treatment, compassion, and pr

-W ll e prepared P th l i t/ R di l i t d Pathologist/ Radiologist – A / Effi i Accuracy/ Efficien

-Follow-up – Consolidate with Additional signatures (added 

-Documentation of T-Board options in CPRS: TB Note, and A-Education – Housestaff and Patient (MSW referral + Brochu
Treatment-Focused Patient Educational Booklet

VA SAN DIEGO HEALTHCARE SYSTEMVA SAN DIEGO HEALTHCARE SYSTEM 
Tool 5

Tumor Board process

Points to Consider: 

Challenges & Strategies in Establishing a TuChallenges & Strategies in Establishing a Tu

-Ensuring representatives from key services 

Rotating system or other Rotating system or other “designated designated” individual(s) per serv

individual(s) per serv

May include partnering with other network affiliates, univers

-D id ec e setting, att d (i l di ti t ) ttendance (including meeting rate)-Pre-review cancer registry data/ volume of yearly cases by 

(May be done via a cancer care team in facility: Define top 

-Designate a coordinator/ leader/ oversight (e.g ,. from Cance

-Be sure to include education base and recipients (Residents- Use of a Virtual tumor board if needed (Tool 6 in Toolkit)- link 
Visit our website!

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

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

_hom

aspx
Project team and sponso

Indianapolis VERC collaborators

Heather Woodward Hagg 

Steven Asch, MD, MPH

f l h Heather Woodward

‐Hagg, 

Gail Edwards, RNTonya ReznorDeborah Griffith Ed D

Jenni

fer Malin, MD,

P

h

D

Jeff Luck, PhD, MBA

Laura York, MA Deborah Griffith, Ed.D. Candice Bowman, PhD, RN

Joya Golden, MSW

Ann Zisser, RNJenny GirardNina Smith, MPHCynthia Gammage