4.7 Quality Study. Study Title: Intervention to Improve Safe, Effective And Timely Oral Chemotherapy Administration and Documentation

Transcription

1 4.7 Quality Study Study Title: Intervention to Improve Safe, Effective And Timely Oral Chemotherapy Administration and Documentation

2 Problem Statement There are an increasing number of anticancer therapies available as oral agents. The processes surrounding oral chemotherapy are not as robust as those surrounding IV chemotherapy administration, potentially compromising patient safety and therapeutic outcome. 2

3 Team Members Duke Cancer Network MPMC L. Sutton, MD, Leader A. Boswell, RN, Director E. Abernathy, APRN D. Mack, MD Traci Foster, RN A. Holloway, RN Lee Daly, PA-C J. Falkner, RN R. Muellenbach, MSN I. Altomare, MD A. Boswell, RN H. Breedlove, MSW 3

4 Baseline Clinic Process Map Planning to start med: Provider writes script N Y RN may provide Pt/family education RN given script Y N Pt takes script to local pharmacy RN sends script to spec pharmacy Y Chemo covered by insurance? Is Pt Insured yes/no? Y Script filled Pt start med N Is Pt Insured yes/no? Pt calls clinic N RN/SW seek $ RN/SW seek $ Assistance obtained Script filled Pt starts med? N RN document Y Script filled & shipped Copay assistance Assistance obtained Script filled & shipped Pt starts med? Info in pt chart Pt starts med

5 Baseline Clinic Process Map Cont d Pt starting oral chemotherapy: Pt to call when med received RN talk w/ Pt, assess need for more ed Schd Pt apt lab visit +/- RN check, +/- MD Med added to med rec doc? In record NO NO RN assess Pt knowledge of drug schd & AEs RN document pt call in chart Process inconsistent Med Rec does not reflect oral chemo No documentation in chart 5

6 Cause & Effect Diagram Oncology Clinic Staff Process Issues MD did not write script correctly Inadequate staffing/time Nurse feeling it is not her job/ within her scope Multiple forms needed by pharmacy Med not available Slow Pharmacy Donut hole Insurance Logistics/ Drug Acquisition Nurse could not reach patient and not documented Patient not contacted due to staff not understand importance/ priority MD failed to specify start date Lengthy insurance approval Shipped to wrong address Transfer Pharmacy due to insurance Delay in shipping Paperwork lost/ overlooked No place in computer to easily document Patient failed to fill out financial forms for assistance, so prescription never filled System bypassed, Patient handed script Patient confused about start date Patient Issues Unclear who is responsible for task Ball dropped, communication failure between staff Patient s medical condition changed after script written No documentation within 7 days of start date of oral chemotherapy

7 # Patients Diagnostic Data MPMC Medical Oncology Critical Data Elements in Oral Chemo Patient s Chart July 22 31, N = Date Prescribed 2 Planned Start Date Actual Start Date Consent Patient Education Follow-up Phone Call Scheduled Documentation noted in chart of pt follow up contact w/in 7 days of start 7

8 # Patients Baseline Data MPMC Medical Oncology Critical Data Elements in Oral Chemo Patient's Chart July n= Date Prescribed 2 Planned start date Actual Med start date 0 0 Follow-up Phone call scheduled Documentation noted in chart w/in 7 days of start

9 Aim Statement Create a process whereby.. By October of 2015 > 50% of patients Who are given prescriptions for oral cancer therapy agents Will have documentation in their record within 7 days of start date that they are safely taking the oral anticancer medication(s) as prescribed 9

10 Measures: Measures: Documentation of critical elements in the medical record within 7 days of the planned or actual oral cancer therapy start date. Documentation tool created to include the following elements: prescription, patient education, informed consent, drug acquisition, initiation, toxicities and reeducation. Patient population: Adult cancer patients starting oral cancer therapy at MPMC between August 3 rd, and September 29, Calculation methodology: Numerator: number of pts with documentation completed within 7 days of start date; Denominator: total number of pts prescribed oral agents. Data Source: Oral cancer therapy documentation tool Midstream chart audit: 8/31-9/11/15 Data collection frequency: Weekly for 2 months, at MPMC. Data Quality: Limitations can include: patient identification, communication, buy-in of staff to use tool, time to use the tool. Guideline: Neuss, M. N., Polovich, M., & McNiff, K., et. al. (2013) Updated American Society of Clinical Oncology/Oncology Nursing Society Chemotherapy Administration Safety Standards Including Standards for the Safe Administration and Management of Oral Chemotherapy. Journal of Oncology Practice, 9(2s), 5s 13s. doi: /jop

11 Date Prescribed 2 Planned Start Date Baseline Data MPMC Medical Oncology Critical Data Elements in Oral Chemo Patient s Chart Aug 1 st Aug 14 th, Actual Med Start Informed ConsentPatient Education Followup Phone Call Scheduled Series 1 N = 4 Time frame too limited for data at this point 0 0 Documentation noted in chart w/in 7 d of start 11

12 PDSA Plan (Tests of Change) 1 Date of PDSA cycle Description of intervention Results Action steps 8/14/2015 Meeting to discuss our limited data (n=4); and ideas for improvement. 8/31/2015 Questioning whether all new oral chemo orders are captured by RN despite RN/ clinic manager. 8/31/2015 Edit documentation tool based on comments from providers & clinic staff, and how tool was used. Need start date emphasized. Number of scripts low, though oral chemo and hormonal agents included. Number of required elements low. Only 7 pts to date. Baseline survey data suggested 20/month Measures: % pts who have documentation tool in record within 7 days of start. (0/7) Monitor number of script. Evaluate and work on documentation tool redesign. Consider chart audit. Reeducation to providers. V2 of tool sent out. Communicate changes and reasoning with clinic staff 9/4. Initiate newly edited tool. 12

13 PDSA Plan (Tests of Change) 2 Date of PDSA cycle Description of intervention Results Action steps 9/12-9/18/2015 Meeting(s) to discuss completion of new round of data collection using updated form. Challenges identified: Incomplete documentation Continued small numbers Initiate chart audit. 13

14 Study Only 7 patients identified for project for first month, between 8/4/15-8/31/15. Projected 28 patient prescribed new oral anticancer agents at MPMC by provider survey taken in May charts reviewed for all patient visits to site for 2 week period (8/31/15-9/11/15). 3 pts were identified via data collection tool 3 additional patients identified in audit 14

15 PDSA Plan (Tests of Change) 3 Date of PDSA cycle Description of intervention Results Action steps 9/20/2015 Audit identified the issue of incomplete patient capture at time script given Reeducation of clinic nursing staff and providers Ensure pt will meet with nurse for consent and education prior to leaving clinic Identify clinic space for nurse/patient education 15

16 Documentation Tool Developed Initial Prescription Follow-up Call Drug Acquisition & Delivery Verification of Drug and Dose: Patient Name: MR#: Physician Oral Chemotherapy Prescribed: Date Written: Cycle: Dose: Schedule: Projected Start Date: Directions for patient: Expected Side Effects What to do for missed doses Ability to swallow pills (capsules) Drug storage Safe Handling Drug Interactions Clinic / Emergency Contact Forms Obtained/Given to Patient Consent signed Drug Education Sheet Patient Diary Oral Chemo Home Safety Sheet REMS Forms Provided See additional documentation notes RN/Pharm Date Pharmacy Name: Script faxed (date) Script faxed (date) Pt. given script Script e-prescribed (date) Script faxed (date) Ship Date: Location shipped to: Patient Assistance: Yes No: if yes, reason - No insurance Co-Pay Donut hole Underinsured Other Type of Assistance: Pharma-related Hospital/clinic funds Community funds Public Assistance Other See additional documentation notes Arranged by: PT SW RN RN/MSW/Pharm Date Projected Start Date: Actual Start Date: Scheduled date for initial follow-up call (within 7 days of start date): Date(s) called: Tell me what you are taking and when: Patient taking as prescribed Yes No: Symptoms/toxicities assessed? Yes No: Symptoms/toxicities addressed? Yes No Instructions: See additional documentation notes RN/Pharm Date 16

17 Results MPMC Medical Oncology Critical Elements in Oral Chemo Patient's Chart July n=7 Aug n=7 Sep 1- Oct 1 n=10 100% 75% 50% 25% 0% Date Prescribed Planned Start Date Actual Med Start Date 0% 0% Follow-up phone call scheduled Documentation noted in chart of pt follow up contact within 7 days of start

18 Results MPMC Medical Oncology Critical Elements in Oral Chemo Patient's Chart July n=7 Aug n=7 Sep 1- Oct 1 n=10 GOAL=50% 100% 75% 50% 25% 0% Date Prescribed Planned Start Date Actual Med Start Date 0% 0% Follow-up phone call scheduled Documentation noted in chart of pt follow up contact within 7 days of start

19 Standard 4.8 Quality Improvement Oral documentation tool developed to ensure and facilitate documentation of critical elements in a consistent and timely manner. Documentation tool created to include the following elements: prescription, patient education, informed consent, drug acquisition, initiation, toxicities and reeducation. Process education provided to staff and providers 75% or greater patients prescribed a new oral chemotherapy agent received a follow up phone call to assess compliance and side effects. 19

20 Next Steps/Plan for Sustainability Present study findings and improvements to Cancer Committee Reward the team who helped to make this project successful! Continue ongoing monitoring 20