bluuebunny/crossref_metadata_2025_split huggingface dataset:
Large-scale fast-track diagnostics in a comprehensive cancer center.
Authors: Heintzbergen Sanne , van Harten Wim , Goedbloed Nicolette , van Wijngaarden Marja , Dernison Arthur , Boekhout Annelies H. 
Published: February 2017

185 Background: In general, patients with a cancer suspicion visit the hospital multiple times before the diagnosis is completed. Using various “operations management” techniques a limited number of fast track diagnostic services were implemented in the Netherlands Cancer Institute (NKI) in 2006. Fast growing patient numbers and increasing process complexity, led to diminished service levels. To decrease the amount of patient visits and period of uncertainty, fast track diagnostics is implemented for 17 cancer types. The in benchmarks proven high efficiency, hardly any redundancy, and no capacity extension made this a large efficiency challenge. We report on the process of redesign, implementation, and first results. Methods: The throughput time (first visit to diagnosis conversation) was measured before redesigning the diagnosis process, and repeated after implementation of fast track diagnostics. In pre-measurement throughput time was retrospectively measured for 105 patients and 7 cancer types. The diagnosis process for 17 cancer types was redesigned by multidisciplinary teams. Input and process variation, slot use and constraints were analysed for all processes. In an eclectic approach, elements from lean management, theory of constraints, and mathematical analysis were used to organize slots for MRI, CT, PET, and echo with reservations turning into capacity available for short-term planning. Results: In premeasurement diagnosis was completed from 2 workdays onward to 58 (mean throughput time 13.3 workdays). It proved possible to design 15 of 18 tumors as a one-stop shop (Table). Through involvement of clinical and board leadership, massive communication efforts, commitment of physicians to reschedule their weekly activities was rather positive. In the post measurement the mean throughput time was 0.8 days (median 0 days). Conclusions: The involvement of physicians in redesigning and reorganizing their work was important: implementation of fast track diagnosis proved successful for 14 out of 17 cancer types. For 3 tumor types fast track diagnosis implementation is designed but not yet completed. Throughput time was considerably shortened after implementation of fast track diagnostics. [Table: see text]
Collaborating with Ontario cancer centers to ensure coordinated access to safe, evidence-based, high-quality IMRT treatment.
Authors: Murray Elizabeth , Bak Kate , Gutierrez Eric , Warde Padraig Richard 
Published: February 2017

187 Background: In 2007, CCO identified variability in access to Intensity Modulated Radiation Therapy (IMRT) across the province. To ensure access to this technology, a three-year IMRT implementation Project was started in 2008, focusing on the development of: disease site guidelines and targets, cost-effectiveness analyses, a provincial quality assurance program, disease and discipline specific communities of practice and knowledge-sharing platforms. Methods: Needs assessments were conducted to identify educational and training needs in all disciplines. Systematic reviews were undertaken to establish disease site specific IMRT indications, set targets and conduct cost effective analyses. Educational courses and hands on expert-based coaching, were made available and a provincial IMRT quality assurance program was established. Results: The needs assessments identified a strong interest in educational and coaching opportunities. IMRT indication guidelines were developed for 10 disease sites and utilization targets were set for 6 disease sites. Results from two cost effectiveness analyses confirmed IMRT as a standard of care over 3D Conformal Radiation Therapy. 11 cancer centres received IMRT expert-based coaching, which included hands on-training, site visits, and educational support. Knowledge sharing and educational opportunities were provided to over 949 radiation therapists, oncologists and physicists. 13 cancer centres participated in external IMRT quality assurance testing for head and neck and prostate cancer. IMRT utilization has increased without affecting wait times or patient safety with no increase in incidents during this time period. All six disease sites have me their targets for 2012/13. Conclusions: IMRT knowledge and expertise across the province has grown along with a dramatic increase in the percentage of patients being treated for curative intent receiving IMRT. This jurisdictional implementation project was successful in making this treatment available to all Ontarians who would benefit. The lessons learned from this experience may be useful in the future rollout of other new technologies in Ontario and in other health care settings.
Disseminating team training across an academic cancer center and community-based satellites.
Authors: Gross Anne , Mann Susan , Weingart Saul , Kalfin Michael , Norden Andrew David , Buswell Lori A. , Constantine Michael , Fuller Frances , Briccetti Frederick , Thiele Jodi , Freter Rolf , Kostka Judith , Sherwood Geoffrey K. , O'Connor Janet , Bunnell Craig A. 
Published: February 2017

188 Background: Dana-Farber Cancer Institute is the first cancer center to implement Team Training (TT). This program illustrates critical lessons about disseminating a quality improvement initiative across an academic center and its regional community-based satellites. Methods: We adapted TT principles to the needs of our satellite centers. This required recognizing different work flows and communication patterns, identifying hazards in routine communications, integrating satellite-main campus communication, and facilitating situational awareness when practicing at multiple sites. Key components included: support from executive leadership and Board of Trustees; previous success at the main campus; use of data and actual near-miss scenarios; development of workflows for critical communications; and workflows for shared care of patients at different sites. Results: Staff surveys demonstrated safer, more efficient, and more respectful practice environments. Higher scores were seen across most categories in comparison to main campus. We observed an increase in the number of chemotherapy orders without issues (81.7% to 91.9%) and a decrease in the number of missing (7.0% to 3.4%) or noncommunicated order changes (3.1% to 1.0%) when the patient arrived for treatment pre TT vs. post TT. Patient perception of teamwork, measured by Press-Ganey, showed a statistically significant increase at both the main and satellite campuses. Conclusions: TT improved communication, task coordination, perceptions of efficiency, quality, safety, and patient perception of care coordination, at both the academic main campus and our community-based satellite practices. [Table: see text]
Diabetes care management during cancer treatment.
Authors: Harper Gregory R. , Sharma Janelle , Habeck Cara , Coyne Cathy , Kincaid Hope , Hamadani Roya , Rivera Ada , Perilli Gretchen , Sully Nicole 
Published: February 2017

189 Background: Cancer treatment negatively affects glucose control and puts patients at risk for hospital admissions. A one year medical record review at Lehigh Valley Hospital revealed that 75.4% of diabetic patients receiving treatment in the cancer center had at least one emergency department (ED) and/or inpatient (IP) admission—13.2% had a diabetes code present among the top 3 discharge diagnoses. We implemented a program in which a certified diabetes educator (CDE) and nurse practitioner worked with oncologists and primary care providers (PCP) to coordinate care for these patients. Methods: Cancer patients with diabetes or treatment related hyperglycemia were referred to the Diabetes Oncology Program for care management (CM). CM included patient assessment, education, care plan development, collaboration with PCP, and follow-up during treatment. A clinical practice guideline was developed for infusion nurses to treat hyperglycemia. Diabetes medications were modified during cancer treatment in collaboration with the PCP. CM ended at the conclusion of the course of treatment or with end of life care. Program evaluation consisted of patient and provider surveys, and analysis of ED/IP admissions. Results: In a preliminary analysis of 98 patients that received CM, 74 ED/IP admissions occurred between the first appointment with the CDE and the end of CM; 11 admissions (14.8%) were for diabetes or hyperglycemia related diagnosis. At baseline, participant mean FACT-G scores were slightly lower than published normative data for cancer patients. Significant improvements from baseline to 2 months post program enrollment were found among participants in diabetes empowerment and satisfaction with diabetes treatment scores. Provider survey responses at baseline found that PCPs are more satisfied with oncologist communication than oncologists are with PCP communication. Final results of the patient and provider surveys and program impact on ED/IP admissions will be presented. Conclusions: Patient empowerment and satisfaction with treatment may be improved by focused diabetes care management. Final data analyses will indicate if this improvement is achieved along with reductions in ED/IP admissions for diabetes related diagnoses among cancer patients.
Building clinical volumes, research capacity, and quality care in testicular cancer.
Authors: Nichols Craig R. 
Published: February 2017

198 Background: Developing consistent, evidence-based, personalized and cost appropriate management of germ cell tumors is challenging for two reasons: these are uncommon diseases and successful management requires nuanced input from many disciplines with specialized interest in germ cell tumors. We speculated model combining a working tumor board and a true multidisciplinary clinic would improve volumes, research contributions, consistency and personalized care for patients with germ cell tumors. Methods: Beginning in March 2011, we developed a multidisciplinary clinic model, flow and communications with the following principles in mind. 1.) embed electronic capacity to capture clinical and biological datasets to serve as a template for research collaborations with national and international colleagues, 2.) coordinate clinical operations around a mandate for expert pathological and radiographic review, 3.) develop and apply evidence-based clinical guidelines, 4.) build an “open-source” operation and accept cases for electronic review and deliberation from patients and providers who desired expert oversight from an experienced team. Results: Our current clinical volumes have grown to an average of two new cases/week along with 1-2 outside reviews. Ongoing follow-up patients average 10/week. RPLND volumes have increased markedly to more than 20/year. All cases undergo pathology and radiology review. Adherence to published guidelines is superb with few deviations. Imaging schedules have been scaled down to approximately one third of previous radiation exposure. Research contributions have increased with the development of international collaborations, publications and new investigator-initiated studies. Conclusions: Our results demonstrate that purposeful coordination and consolidation of expertise and interests can result in the development of regional and national resources for management of rare malignancies such as testicular cancer. These high functioning clinics result in cost-effective, evidence-based management and high patient satisfaction.
An academic medical center's journey to a survivorship care plan.
Authors: Korber Susan 
Published: February 2017

210 Background: Cancer clinicians are challenged by the need to give patients an initial treatment plan and a summary of their care at the end of the treatment period. Both are essential elements in the care continuum and the summary is now a required standard for accreditation by the Commission on Cancer. By 2015, each patient’s Survivorship Care Plan should be a collaborative document shared with the patient, their primary care and/or referring provider. A well-written plan includes a road map for the patient and their PCP to use as the patient transitions from active care into surveillance. Our academic medical center, part of the Lifespan system, began exploration of the transition process in 2007. The goal of our multidisciplinary group was to develop a patient and PCP friendly record of the treatment experience and recommendations for follow up. Methods: Two oncology staff nurses at The Miriam Hospital developed an early home-grown tool in 2008, a simple one page document in layman’s terms. From 2009 to 2010 we participated in a national Breast Cancer Registry Pilot Program using ASCO templates and assessing patient and staff perspectives on the use of treatment plans and summaries. Lessons learned from both experiences was to "keep it simple." At the urging of the CoC we moved on to the Journey Forward website and tried to utilize plans for breast and colorectal patients. We have now formed a partnership with our state Department of Health and have developed a template for use by all cancer programs in our state. Results: Our state will be the first to offer to all cancer programs the ability to download a user friendly one page template for a Survivorship Care Plan. Clinicians enter demographics, the patients’ providers, simplified disease information, treatment given and surveillance suggestions. A list of community references is included on the second page. The Department of Health will have this available on their website for download into each cancer center’s electronic system. Conclusions: Development of a user friendly summary of patient treatment and future surveillance needs is possible with a collaborative effort between clinicians and engaged public health officials. Understanding the value of a simple, single page form available online has been essential.
Science of quality: Communication, decision making, and behavior.
Authors: Harrison Deb , Hoverman J. Russell , Mikan Sabrina Q. , Olson Kevin Donald , Taniguchi Cynthia , Arlen Aimee Ginsburg , Ash-Lee Susan 
Published: February 2017

22 Background: Addressing advance care planning (ACP) early in metastatic disease is a challenge for providers across oncology. Providing a systematic method to engage providers and patients in these discussions offers opportunities to improve end of life outcomes, improve patient quality of life and engage in shared decision making that supports effective transition to appropriate palliative care and hospice. Methods: A multidisciplinary group of oncology providers developed a framework for ACP which included defining a target population for early introduction, utilizing a standard patient-centered measurement tool (Values Assessment), reviewing practice workflow to schedule ACP conversations, and incorporating documentation elements embedded in the electronic health record. The model included physician referral of patients to a nurse practitioner or social worker who scheduled meetings with patients to assess values, assist patients with advance directives (AD), and explore patient end-of-life wishes based on disease. Seven cancer center sites of service engaged in the pilot study for a 90-day period to test tools, workflow and effectiveness of implementation methods. Documented values assessments, code status, and advance directives were pilot outcomes measures. Results: All sites in the pilot study implemented the framework and participated for 90 days. Workflows were validated to support scheduling of ACP conversations. Use of the values assessment tool was slow to be incorporated in ACP process as was physician referral for introduction. Conclusions: Engaging in a systematic approach to gather and assimilate information provides an opportunity to comparatively assess adoption of an ACP program. Providers are not inherently experienced in basic ACP introduction or deeper ACP discussions. Communications training, including conversations for values assessment and ACP, is in development for use with pilot and new practices engaging in the program, which supports program scalability. [Table: see text]
Improving patient safety: Factors leading to radiation therapy events in a large academic institution.
Authors: Walker Gary V. , Johnson Jennifer , Edwards Timothy , Hayden Sandra E. , Riley Beverly A. , Sittig Dean F. , Gillin Michael , Ibbott Geoffrey , Buchholz Thomas A. , Das Prajnan 
Published: February 2017

224 Background: The purpose of this study was to elucidate the factors associated with radiation therapy (RT) treatment events and near misses at a large academic institution. Methods: All RT patient events and near misses/good catches were prospectively collected using an electronic incident reporting system from April 1, 2011-April 30, 2013. The event origin was categorized according to the step in the treatment process (simulation, physician prescription, dosimetry/physics, treatment delivery and other). The incident database was linked to the RT delivery (record and verify) database which contains date of treatment, radiation beam duration, number of fractions, and type of treatment. A treatment record was defined as a unique site description and date/time. Results: There were 224 reported RT events or near misses/good catches analyzed, of which there were 59 RT treatment delivery events associated with 105 treatment records, including 0 level I (most severe), 18 level II, 35 level III (least severe), and 6 level IV (near misses/good catches) among the 13,899 patients and 468,489 treatments. The remaining 165 RT events occurred at the other steps of the treatment process. The overall rate of RT events and near misses was 161.2 per 10,000 patients. The rate of RT treatment delivery events and near misses was 42.4 per 10,000 patients and 2.2 per 10,000 treatment records. Logistical multivariate analysis showed that treatment on Tuesday (Odds Ratio = 2.50, 95% CI 1.67-3.73, p<0.001), first day of treatment (5.16, 95% CI 3.32-8.02, p<0.001), number of fractions (continuous) (0.98, 95% CI 0.96-0.997, p<0.03), intensity modulated radiation therapy (IMRT) (2.87, 95% CI 1.44-5.74, p=0.003), electron only fields (2.00, 95% CI 1.27-3.14, p=0.003), and radiation beam duration (continuous minutes) (1.03, 95% CI 1.02-1.04, p<0.001), were associated with RT treatment events and near misses, while age, proton treatment, number of fields and after hours treatment were not. Conclusions: Treatments delivered on Tuesdays, on the first day of treatment, with fewer fractions, with IMRT, with electron only fields, and with longer radiation beam duration were associated with an increased risk of RT treatment events.
Chemotherapy safety initiative.
Authors: Tomaro Maria , Silverman Paula , Miano Wendy Rowehl , Wakeling Amy , Gonzalez Kathleen 
Published: February 2017

226 Background: The 2006 Institute of Medicine report "Preventing Medication Errors," stated that “medication errors harm at least 1.5 million patients every year…” Chemotherapy (CT) has a narrow therapeutic index and safety margin which can and does lead to fatal errors. University Hospitals Seidman Cancer Center (UHSCC), an National Cancer Institute (NCI) designated Comprehensive Cancer Center, dispensed 10,500 CT doses in 2012 and has taken an active approach to enhance CT safety. Methods: In the last quarter of 2012, a nurse coordinator (NC) for chemotherapy orders and a Chemotherapy Safety Governance Committee (CSGC) was conceptualized. The NC’s role would be to incorporate CT safety best practices into order set development. The charter for the CSGC includes 1) to establish cancer CT standards and operating procedures across the adult and pediatric oncology population; 2) to develop and oversee cancer CT order set infrastructure applicable to our hybrid electronic/paper current state; and 3) to lead performance improvement initiatives related to CT safety. Leading organizations involved in oncology practice and medication safety standard-setting (ASCO, Oncology Nursing Society, Institute For Safe Medication Practices, National Comprehensive Cancer Network, Journal of Cancer Research) were reviewed for recommendations for standards for CT order sets. Results: Thirty standards for a CT order template were identified by the NC. A comprehensive gap analysis was completed to compare the current inpatient and ambulatory CT order sets to these standards. Results of the gap analysis were brought to the CSGC, a multi-disciplinary group of cancer and quality clinicians and leaders over 6 meetings. Consensus was achieved on the application of these standards to CT order sets. Our new orders will adopt 100% of all identified standards for CT orders. Conclusions: The gap analysis led to the development of a CT order set template that maximizes safety by applying best-practice standards. This template is designed to be applicable to electronic and paper-based order sets and with minor variation, appropriate to all disease-based order sets. This template is currently being utilized to revise 330 electronic and 398 paper CT order sets at UHSCC. [Table: see text]
Developing a culture of safety in systemic cancer treatment at the system level.
Authors: Hertz Sherrie , Kaizer Leonard , Krzyzanowska Monika K. , Simanovski Vicky , Vu Kathy 
Published: February 2017

230 Background: Chemotherapy ordering, preparation and delivery involve multiple providers and complex systems where high impact errors may occur. Cancer Care Ontario, a provincial agency responsible for continually improving cancer services in Ontario, Canada employs a comprehensive systematic approach to build a culture of safety for systemic treatment. Methods: A comprehensive strategy is applied at 77 systemic treatment hospitals in the Province. A multi-pronged approach is used that includes: 1) system planning, organization and funding, 2) engagement of health care providers working at the regional and local levels, 3) guidelines implementation and, 4) quality measurement. Results: Institutions are organized into regional networks, according to four levels of service complexity based on quality standards, planning, funding, coordination and health human resources. A customized, system-wide incident reporting system is available. Quality improvement is undertaken in several ways. Regional clinical and administrative leaders foster engagement with local providers and work is facilitated by a provincial multidisciplinary community of practice, an annual Safety Symposium, and local improvement projects with funding support. In this way, collaborative sharing and learning occurs across the Province. Comprehensive evidence-based guidelines have been produced addressing safe labeling, administration, handling and the use of computerized prescriber order entry systems. Routine performance management together with guideline concordance measurement, public reporting, planning for improvement and re-evaluation strategies, has produced system improvements. Conclusions: A comprehensive, evidence-based and systematically applied approach to providing systemic cancer treatment can produce a culture of safety that is coordinated and standardized across multiple providers and provider sites.