Using Quality Improvement Methods to Pilot Test and Scale a Program of Serious Illness Conversations in an Oncology Learning Health System

• Published in: Journal of pain and symptom management Vol. 63; no. 5; p. 875
• Main Authors: Cullinan, Amelia, Wasp, Garrett, Vergo, Maxwell, Wilson, Matthew, Buus-Frank, Madge
• Format: Journal Article
• Language: English
• Published: Madison Elsevier Inc 01.05.2022; Elsevier Limited
• Subjects: Anesthesia; Behavior change; Coaching; Collaborative learning; Head & neck cancer; Health status; Illnesses; Interdisciplinary aspects; Mapping; Medical prognosis; Medical screening; Multidisciplinary teams; Oncologists; Oncology; Optimization; Pain Medicine; Patients; Quality improvement; Quality management; Quality of life; Sarcoma; Skin melanoma; Teams; Treatment preferences; Uptake; Verbal communication
• ISSN: 0885-3924; 1873-6513
• DOI: 10.1016/j.jpainsymman.2022.02.070

1. Recognize at least 3 quality improvement strategies used to improve the number of serious illness conversations (SICs) with patients with advanced cancer 2. Identify the range of interdisciplinary and multidisciplinary team members needed for a SIC implementation team Structured discussions of prognosis, patient preferences, and values, called serious illness conversations (SICs), are associated with improved quality of life and are ASCO-guideline recommended. However, only a minority of patients report having SICs with their primary oncologists. Aim 1: Increase and sustain SICs in patients with head/neck cancer and sarcoma. Aim 2: Test a method to scale our initial results to 3 additional oncology teams. We formed a local Oncology Learning Health System collaborative that included interdisciplinary team training and coaching in SICs; use of the Model for Improvement during team meetings; embedding a SIC subject matter expert, patient partner, and quality improvement (QI) consultant in the clinical microsystem; universal definition of and process for SIC screening; key driver diagram; process mapping and work flow optimization; standardized electronic medical record documentation; iterative Plan-Do-Study-Act (PDSA) cycles; and data audit and feedback using run charts. Pilot: From March to December 2020, two oncology teams (head/neck and sarcoma) screened 161 patient encounters and identified 41 eligible patients, and SIC increased from a baseline near zero to 29/40 (73%) patients, demonstrating two shifts in the median (95% CI). As of July 2021, both teams have sustained these improvements with a rate of 73%. Scale-Up: From January to July 2021, we expanded to additional teams (melanoma, neuro-oncology, thoracic), with 28 interdisciplinary team members conducting 22 PDSA cycles. Combined, the teams screened 291 patients and identified 166 eligible patients, and SIC increased from a baseline near zero to 46/166 (28%), demonstrating one shift in the median. Early results suggest our approach of embedding communication and QI coaches and family partners into oncology teams leads to uptake of universal screening and statistically important shifts in SIC performance within and between clinics, as well as sustained behavior change after coaching is complete. Ongoing work is being performed to sustain and continue to grow this effort.