By Aakash Desai, MBBS, MPH, and Devika Das, MD
On October 20-26, 2019, we celebrated Health Care Quality Week, an initiative by the National Association for Healthcare Quality, to commemorate the contributions of professionals and bring greater awareness to the profession of health care quality. This provides us an opportunity to ask ourselves, what does quality really mean to us, especially in oncology?
The Institute of Medicine (IOM; today known as the National Academy of Medicine) defines health care quality as the “the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” In 2000, the IOM published To Err is Human: Building a Safer Health System, which shined light on the problem that bad systems in health care lead to unsafe care. It was estimated that approximately 98,000 Americans die in hospitals each year because of medical errors, which exposed the massive gaps in health care delivery. Balancing regulatory versus market-based initiatives and public versus private efforts, the IOM presented wide-ranging recommendations for improving patient safety in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care.1 In 2001, “Crossing the Quality Chasm” focused more broadly on how the health system could be reinvented to foster innovation and improve the delivery of care.2
In 2003, McGlynn et al. reported that only 54.9% of patients received recommended standard-of-care treatment across 30 acute and chronic conditions as well as preventive care.3 Furthermore, there has been an estimate that 40% of the U.S. health care costs are attributable to “waste and variation”—which may include administrative, operational, and clinical waste. Administrative waste is the excess administrative overhead that stems primarily from the complexity of the U.S. insurance and provider payment systems, while operational waste refers to other aspects of inefficient production processes. Meanwhile, clinical waste is waste created by the production of low-value outputs, overtreatment/undertreatment, and failure of care coordination.4
Quality improvement (QI) improves outcomes by reducing waste, decreasing variation, and making processes more effective and efficient. When we agree to a fixed standard, work error rates and costs fall while the scientific method can be used systematically for improvement.
A framework put forth by IOM includes the following six aims for the health care system: safe, effective, patient-centered, timely, efficient, and equitable. Such a framework makes it easier for consumers to grasp the meaning and relevance of quality measures. Apart from the lack of awareness and understanding, there is the lack of adequate research in the realm of quality and safety. Data is a powerful tool that separates what we think from what is real and helps us establish a set baseline, understand variations, and avoid solutions that do not solve the real problem.
An important reason for this lack of research is a common misconception that QI is not real science. In fact, traditional research and QI are often complementary, with one being meaningless without the other.
Traditional research discovers new knowledge and often provides an alternative to standard care. It requires a tightly controlled testing environment, blinding of investigators, and a long time commitment that often extends many years. It often studies a single variable in a homogenous population, excluding outliers, and requires statistical comparison of means/medians between large sets of aggregate data.
QI, on the other hand, implements new knowledge and improves care delivery processes. It requires the implementation of knowledge without a controlled setting, smaller test of change (pilot) studies, monitoring of real-time data with active intervention and a shorter (usually 4 to 6 months) time commitment. It tests multiple variables (usually 20 to 30) within a heterogeneous population without exclusion of outliers, and studies variation measured over time using both statistical process control and appropriate statistical analysis. Hence, QI requires a much more adept researcher to work in a real-time, ever-changing landscape beyond one’s control to improve health care delivery practices among various specialties, institutions, states, and nations.
How does the oncology community view and implement QI? Lim et al. recently examined the prevailing attitudes of medical oncologists in Canada toward QI and the causes of low QI publication rate in the medical oncology literature. The authors found that of the responding oncologists, 97% (138) agreed that QI was an important aspect of their practice, although only 49% (70) had participated in QI in the past 5 years. Physicians with administrative responsibilities were more likely be involved in QI than their clinician counterparts (p = 0.008). Among QI participants, 72% did not publish their findings, because of lack of time (34%), no identifiable journals (14%), and unfamiliarity with QI methodology (10%). Barriers for QI nonparticipants included uncertainty about how to get involved (45%), lack of time (18%), and limited institutional support or recognition (18%).5 These findings underscore that QI is a low priority in cancer medicine.
With an increasing number of cancer diagnoses and complex treatment options, there is a growing demand for high-quality cancer care. However, what are the components of quality care in cancer? Hess et al. described the perspectives of various stakeholders about quality metrics in cancer care. The need for psychosocial support and coordination of care were indicated by both patients and providers as important components of high-quality cancer care delivery. Furthermore, providers noted the importance of equity in cancer care and reimbursement concerns while thought leaders focused on barriers and facilitators of quality care.6Another study reported that the aspects of care for which patients wanted the most improvement were associated with the provision of medical information as evaluated by a patient satisfaction survey in an oncology hospital setting.7There has been growing interest in alternative payment models (APMs) such as accountable care organizations, bundled payments, clinical pathways, and patient-centered medical homes as initiatives that show progress towards improving the quality of oncology care delivery in the United States while simultaneously reducing costs.8 The Center for Medicare & Medicaid Innovation is also pursuing the opportunity to further its goals of improved quality of care at the same or lower cost through an oncology payment model called the Oncology Care Model.
As we improve the survival of patients with cancer, we need to provide quality care—not just to our patients, but also to our cancer survivors. Citing shortfalls in the care provided to the country's 10 million cancer survivors, the IOM published From Cancer Patient to Cancer Survivor: Lost in Transition, which recommends that each patient with cancer receive a survivorship care plan. Such plans should summarize information critical to the individual's long-term care, such as the cancer diagnosis, treatment, and potential consequences; the timing and content of follow-up visits; tips on maintaining a healthy lifestyle and preventing recurrent or new cancers; legal rights affecting employment and insurance; and the availability of psychological and support services.9
In order to address these issues in quality of cancer care, ASCO launched the Quality Oncology Practice Initiative (QOPI®) Certification Program. QOPI is a voluntary, physician-led self-assessment and improvement program to help hematology/oncology and medical oncology practices assess the quality of the care they provide to patients. It analyzes individual practice data and compares it to more than 100 quality measures. An evaluation is then provided in reports to participating practices, and they can compare their performance to that of other practices across the country.
Given the increasing interest and need for quality improvement in cancer medicine, we need the next generation of oncologists to be adept at providing quality care to patients with cancer and survivors alike. For an interested oncologist, various resources exist to bolster and improve their understanding of health care quality and improvement, including:
- Institute for Healthcare Improvement (IHI) Open School, which provides a complete catalog of online courses including more than 35 continuing education credits for nurses, physicians, and pharmacists as well as a Basic Certificate in Quality and Safety;
- Advanced degrees in Health Care Quality and Safety; and
- ASCO’s Quality Training Program (QTP), which prepares physician-led oncology teams to design, implement, and lead successful quality improvement activities in their practice settings. It is a program developed by oncologists and oncology care specialists for oncology practice teams.
Furthermore, there are career pathways in quality which one can pursue including, such as director of quality, chief quality officer, chief medical officer, or a career in education with a quality focus.
Recently, the ACGME developed the Clinical Learning Environment Review (CLER) Pathways to Excellence as a tool to promote discussions and actions that will optimize the clinical learning environment. The CLER pathways are designed as expectations rather than requirements. It is anticipated that by setting these expectations, clinical sites that provide education will strive to meet or exceed them in their efforts to provide the best care to patients and produce the highest quality physician workforce.
By holding ourselves to high standards and developing our skills in QI, we hope that the next generation of physicians in the field of oncology, and in all of medicine, are better equipped to provide a cost-effective, efficient, timely, equitable, high-quality standard of care to our patients.
Dr. Desai is currently an internal medicine resident in the Department of Medicine at the University of Connecticut Health Center. Given his interest in the field of hematology oncology, he will be applying for a fellowship position this year. He pursued a Master’s in Public Health from University of Texas Health Science Center in Houston. He holds a certification in Health Professions Education. He also serves as vice chair of the Connecticut State Medical Society Resident and Fellow Section. Follow him on Twitter @ADesaiMD.
Dr. Das is a clinical assistant professor in the Division of Hematology/Oncology and section chief of oncology at the University of Alabama. She holds a certification in Healthcare Quality and Safety. Dr. Das is a member of the ASCO International Quality Task Force. Follow her on Twitter @DevikaDasMD.
- Stelfox HT, Palmisani S, Scurlock C, et al. The “To Err is Human” report and the patient safety literature. Qual Saf Health Care. 2006;15:174-8.
- Corrigan JM. Crossing the quality chasm. In National Academy of Engineering (US) and Institute of Medicine (US) Committee on Engineering and the Health Care System; Reid PP, Compton WD, Grossman JH, et al (eds). Building a Better Delivery System: A New Engineering/Health Care Partnership. Washington, DC: National Academies Press (US); 2005.
- McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348:2635-45.
- Bentley TG, Effros RM, Palar K, et al. Waste in the US health care system: a conceptual framework. Milbank Q. 2008;86:629-59.
- Lim C, Cheung MC, Franco B, et al. Quality improvement: an assessment of participation and attitudes of medical oncologists. J Oncol Pract. 2014;10:e408-14.
- Hess LM, Pohl G. Perspectives of quality care in cancer treatment: a review of the literature. Am Health Drug Benefits. 2013;6:321-9.
- Brédart A, Razavi D, Robertson C, et al. Assessment of quality of care in an oncology institute using information on patients’ satisfaction. Oncology. 2001;61:120-8.
- Wen L, Divers C, Lingohr-Smith M, et al. Improving quality of care in oncology through healthcare payment reform. Am J Manag Care. 2018;24:e93-8.
- Hewitt M, Greenfield S, Stovall E, eds. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: National Academies Press; 2005.