Improving timely initiation of oral chemotherapy in an outpatient malignant hematology practice.
Authors: Mejaki Brittany , Williams Michael , Graff Justin , Hamm Mark , Thompson Amanda , Chesmore Kristyn , Popp Maren , Gerber Melissa , Robe Samantha , Bray Lisa , Jones Sherry , Meulemans Shaun , Kuss Jennifer , Phelan Susan , Weers Anne , Muetze Mary , Kaufman Laura 
Published: October 2023

374

Background: Timely initiation of subsequent oral chemotherapy cycles for hematologic malignancies is essential as delays can lead to suboptimal treatment and provider and patient confusion. Between July 1, 2022, and January 31, 2023, we identified a mean 59% of patients with hematologic malignancies who were prescribed oral chemotherapy at our practice began cycle 2 or cycle 3 on time. Methods: A multidisciplinary team applied quality improvement methodologies and tools, taught by ASCO Quality Training Program, to improve the processes associated with providing timely cycles of oral chemotherapy. By using the Model for Improvement, process map development, brainstorming, affinity sorting, fishbone diagram, pareto charts, and prioritization matrices, an aim was established, and improvement focus was narrowed. We aimed to increase timely initiation of cycle 2 or cycle 3 oral chemotherapy prescribed in our practice to an average > 90%. The following outcome measure was developed based on an internal benchmark to define improvement: on-time cycle 2 or cycle 3 oral chemotherapy documented initiation defined as being within 3 days before or after the anticipated cycle start date for patients within our practice site. We designed multiple small-scale tests of change to minimize issues including creation of a pharmacist-generated communication process for admitted patients on oral chemotherapy followed by our practice and enhancement of process education resources. Using the Plan Do Study Act (PDSA) Cycle, process measures were developed to identify whether interventions were performed as planned and measure how the system reacted to change over time. Change management is equally important to testing or implementing change. To protect psychological safety and minimize distractions, we encouraged in-person meetings with established ground rules. Agenda goal, problem, and aim statements were displayed as visual reminders. Results: Between February 1, 2023, and May 31, 2023, resulting from PDSA Cycle #1, implementation of a pharmacist-generated communication process, mean on-time cycle 2 or cycle 3 oral chemotherapy starts increased to 87%. After optimizing staff education resources, PDSA Cycle #2 exceeded the AIM for the month of May at 92%. The average documentation of patients crossing transitions of care in response to a new pharmacist communication workflow increased to 98% from pre-intervention 19%. Documentation following process education resource optimization increased to 90% from pre-intervention 80%. Conclusions: By implementing a new pharmacist communication workflow and optimizing process education resources, we improved our mean on-time cycle 2 or cycle 3 oral chemotherapy starts to 89%. Sustainability plans include monthly outcome and process measure evaluation, presentation to system senior leadership, and transitioning review to our system quality improvement coordinator.