By Michael K. Keng, MD
Assistant Professor of Medicine and Quality Director in the Division of Hematology and Oncology
University of Virginia Cancer Center

Editor’s note: In 2015, Dr. Keng and his team participated in ASCO’s Quality Training Program, which is designed to train oncology health care providers to investigate and implement data-driven quality improvement and manage clinical and administrative processes and outcomes. His practice had such a positive experience, that they signed up again in 2016.

In his article, Dr. Keng discussed the importance of quality in the field of oncology and the way in which the University of Virginia, and National Cancer Institute designated cancer center, strives for the highest quality of care for patients with cancer.

“Quality improvement is a method for ensuring that all the activities necessary to design, develop, and implement a product or service are effective and efficient with respect to the system and its performance.”  —W. Edwards Deming, PhD

Dr. W. Edwards Deming, the father of quality improvement, is best known for his work in Japan after World War II, particularly his work with the leaders of the Japanese automotive industry. He discovered the deficiencies in the process of car-making and improved the efficiency and quality of the cars that we now know as the brand Toyota. Many in Japan credit Deming as the inspiration for how Japan rose from the ashes of war to becoming one of the largest economies in the world. Deming’s principles were not unique to the car industry, and multiple professions have adopted his ideas to improve their disciplines. But especially in the setting where human lives are at stake, the field of medicine is even more in need of measures that can eliminate deficiencies and fine tune efficiencies.

As physicians, we have the responsibility not only to care for our patients, but to improve patient care. Quality improvement is often known as a mechanism to reduce cost, but quality improvement is much more than that. It is an opportunity to improve the full patient experience. Whether we want to admit it or not, quality control is becoming a significant part of our oncology world. Our licensing boards, governing bodies, and insurance companies are basing our competency and reimbursements on our ability to standardize care. Programs such as American Board of Internal Medicine Maintenance of Certification; Centers for Medicare & Medicaid Services’ Hospital Value-Based Purchasing, Physician Quality Reporting System, and Merit-Based Incentive Payment System; and ASCO’s Quality Oncology Practice Initiative (QOPI^®) are changing the ways we practice. Although measures of quality have not invaded all cancer subspecialties, it is only a matter of time until we will all have to prove that we are delivering quality.

Most of our colleagues would agree on the importance of quality improvement focus. But they may be quick to give the responsibility to the administration or the nursing staff because when it boils down to the process of assessing quality as a whole, we are not adequately trained. When do we ever receive education on how to measure the quality of our patient care? Our medical students, residents, and fellows are focused on learning standard of care and clinical guidelines. Besides subjective evaluations from their attendings, they do not learn how to assess their patient care as individuals and as a whole. Evaluations provide feedback on individual performance but do not address the system and context in which the trainee is performing. Learning how to evaluate and change the medium in which patient care is delivered is not a standard part of the medical training curriculum. But if we were to train our students on the basic principles of quality improvement as delineated by Deming—identifying a problem, planning a solution, executing the solution, and evaluating its progress—we would be training our students for the real world, indeed. The real world cares greatly about quality because poor quality care leads to medical errors. We tend to learn about system errors only after errors occur instead of being proactive about finding ways to improve deficiencies. But if we taught our trainees how to approach these deficiencies before errors occur, they would be much more prepared for the less glamorous aspects of medicine.

Despite the practical life applications of quality improvements on the macroscopic level, the field of quality improvement is not seen as a hard science. Involvement in quality improvement is not as sexy on the curriculum vitae as multiple research projects and published articles. The hardest challenge to overcome is helping everyone understand the value of this kind of training. We say we understand the importance of quality care but do not think it is worth our time to obtain formal training in a “softer” side of oncology to find out how to deliver this care.

I only started to appreciate the value of quality improvement during my fellowship at the Cleveland Clinic, when I participated in a quality improvement project and realized that my previous training did not provide me the skillset to tackle the problem at hand—timely antibiotic administration for those patients with febrile neutropenia. Through my mentor and quality improvement coaches, I learned how to deliver a better system that not only met national guidelines, but decreased the length of stay for patients with febrile neutropenia and improved patient outcomes. We implemented a system that allowed patients to receive the correct antibiotics promptly and consistently. The project was both presented and published, but, most importantly, the project solved a problem that greatly impacted patient care. When I saw the impact of my research changing the outcomes of patient care, decreasing medical errors, and solving system inefficiencies, I knew that I had found the underdog of academic medicine. My journey in quality improvement had begun.

This journey led me to be an Assistant Professor of Medicine and Quality Director in the Division of Hematology and Oncology at the University of Virginia (UVA). We are committed to continuously improving the quality of patient care, research, and training through a comprehensive review and evaluation process. At UVA, delivering the highest-quality and most advanced health care to our patients is our top priority. Our goal is to be the safest place in America to receive care and to work, as we believe that team member safety is essential to providing the best health care to our patients.

In 2014, under the leadership of UVA’s Executive Vice President Richard Shannon, MD, the Be Safe initiative was developed. The Be Safe program emphasizes three main areas: First, a root cause analysis will be performed promptly after an identified deficiency. The expectation is that any team member can—and is encouraged to—identify any safety concerns. Then the quality officers investigate the root cause of the problem as a health care system. Second, we implement “standard work” to all units and specialties. Once we have found the best way to complete a task, we automatically apply this method to all units in the same way to improve consistency. Third, we have a rapid escalation of safety issues within a tiered leadership chain. There is an open communication between the “bottom” and “top” of the chain of command that allows for quick responses and results. The initiative focuses on six priorities of improvement in patient care: mortality, central line associated bloodstream infections, catheter-associated urinary tract infections, hospital-acquired pressure ulcers, patient falls with injury, and team member injuries. Every UVA inpatient and outpatient setting runs its own daily Be Safe Rounds with its Unit-Based Leadership. All of the top six priorities are always discussed, but each unit has its own secondary objectives and priorities. UVA provides and highly recommends all unit leaders to obtain formal training in quality improvement.

As a result of the Be Safe campaign, we decided to enroll our team in ASCO’s Quality Training Program (QTP) in 2015. We were hoping to gain knowledge that would help us create and implement a workflow process to be used across the UVA Health System for assessing and treating patients with febrile neutropenia. Implementing a new workflow process across multiple areas of the Health System, including the emergency department, outpatient oncology clinics, and inpatient acute care hospital, would require a significant amount of coordination between patient care teams in each area of the Health System. We hoped to learn techniques to analyze areas of needed improvement and develop strategies to implement new workflow processes and methods of tracking our progress.

An important part of our project was tracking performance over time to ensure that our workflow process was leading to increased efficiency in patient care, namely improving the time to initiation of antibiotics in the setting of neutropenic fever. We hoped to learn strategies in evaluating data to identify areas for both clinical and operational improvement. Our main focus was on the inpatient hospital at the UVA.

As a result of our QTP projects, we have implemented a new clinical practice guideline that standardized the definition of fever and neutropenia, outlined a clinical workflow for the treatment of febrile neutropenia, and created an automatic alert with our electronic medical record. We are currently collecting data regarding episodes of febrile neutropenia and timing of subsequent interventions, including cultures, radiology studies, and antibiotic administration. We are looking at outcomes, as well, including survival, need for Intensive Care Unit transfers, and hospital length of stay. We were able to present preliminary data at ASCO’s 2016 Quality Care Symposium in Phoenix, Arizona, and hope to publish our findings in the next six months. The next phase of the project is to expand this to the pediatric department of UVA and outpatient cancer center.

Our primary goal will be to decrease the time between a new episode of febrile neutropenia and the administration of appropriate antibiotics to less than one hour. Success will be measured based on the percentage of patients who are treated with antibiotics within one hour, which we hope will be close to 100% by the end of 2016.

The QTP is such an educational program and innovative for the field of oncology. It is great to see ASCO’s commitment to quality improvement and its desire to educate its members in this arena. The QTP has given me the tools to approach, review, problem-solve, and implement potential solutions to resolve any problem, no matter how small or large, in a systematic manner. I have the confidence to now lead groups and quality improvement projects at UVA myself with the techniques learned. It has furthered my career in quality improvement, as I am the quality lead for the division. As a team, we have learned a substantial amount of quality improvement strategies that have helped us organize our project, from using data tools to track our progress to prioritizing our interventions to reach our project goals. We have enjoyed working with our coach, Amy Guthrie, as well as meeting ASCO staff members and the QTP lecturers.

One of the most educational aspects of the program has been meeting teams from other institutions across the country and learning about their projects and proposed solutions. Hearing from past QTP participants also was very informative. It is very encouraging to see successful projects from the previous year!

Another significant focus of quality improvement at UVA is in fellowship education. Fellows receive lectures on quality improvement and patient safety, participate in morbidity and mortality conferences, and regularly perform chart reviews. With faculty support, every fellow is required to execute a quality improvement project during the course of fellowship and apply knowledge to real-world clinical practice. Many times it is not until the trainees go through the process themselves that they are able to understand the value of quality improvement training. Designing and implementing their own projects helps them grasp the reasons behind quality improvement, the importance of these efforts, and how to use these tools in their clinical practice going forward. Faculty are engaged and actively participate in the formation of a multidisciplinary team, as well as the design, implementation, data collection, and analysis of the fellow quality improvement project. Presentations and publications of the quality improvement projects are highly encouraged. We learn from all projects, building upon positive and negative aspects to continuously provide self-evaluation and improvement.

The current UVA fellow projects include: early palliative care referral for patients with metastatic non-small cell lung cancer, implementation of prophylactic beta blocker use and standardization of cardiac imaging for breast cancer patients, use of anti-factor Xa versus partial thromboplastin time in heparin dosing nomogram, improving the rates of fungal infections in patients with acute leukemia, direct admission process for patients scheduled for chemotherapy, and a health-system-wide approach to febrile neutropenia. The latter three projects have been selected for participation in ASCO’s QTP. Other quality improvement projects initiated on our inpatient oncology unit are: improving oral mucositis care in our hematologic malignancy patients, pharmacy-led discharge of medication rounds, and utilization of early warning system for acutely ill patients. The scope of these projects has the potential to broaden and improve the care at other cancer centers.

In addition to the training and implementation of quality care, the goal of UVA is to ensure that we focus on our patients and families first. UVA measures the quality of care not only through our clinical outcomes, but also through our patients’ measures of their experiences. We value our patients’ feedback and invite them to be an active part of their care. UVA aims to provide “quality” care in each patient’s experience by respecting the patient’s culture, personal preferences, and quality of life goals as part of his or her treatment plan. UVA values patient-centered care models through multidisciplinary care and interdisciplinary collaborations. We strive to treat the whole patient through the journey of diagnosis to treatment to recovery.

As we focus on improving our system deficiencies daily and train our future physicians to see the benefit of fixing inefficiencies that directly impact their patients, we believe we are giving a unique experience to every UVA patient who has a choice for his or her health care. When the patients see the extent to which their hospital system delivers quality care on every level, even those with a discouraging diagnosis are given hope that they are in a place that will help them. Their confidence in their high-quality care is the reason we continue to strive for better and hope to inspire other institutions to do the same.

Surely Deming did not know how his principles applied to car manufacturing would someday save lives when applied to medicine. Because he was not satisfied with complacency and aimed for perfection, a whole economy was reborn. We still have much to learn in medicine and how to improve quality care has become an expectation. It is only when we are trained in how to handle the deficiencies in health care and strive to make our health systems better, that we are able to look our patient in the eye and tell him or her, “We have done our best.”