Oct 25, 2017
ASCO’s Quality Training Program (QTP) is designed for teams made up of and representing all members of the professional oncology team, including physicians, nurses, and pharmacists. Since the entire team is dedicated to and invested in providing the highest-quality care, it is appropriate that all members are represented.
In honor of National Pharmacy Week (Oct. 15-21), which was celebrated last week to pay tribute to the contributions of pharmacy professionals to patient care and safety, George Carro, RPh, MS, BCOP, shares his experience participating in the QTP in 2016. Mr. Carro is the director of oncology pharmacy services at NorthShore University HealthSystem (NorthShore).
Why did you and your team decide to enroll in the QTP?
GC: Our interest was cultivated from our previous interactions with ASCO through QOPI® [the Quality Oncology Practice Initiative] and poster presentations at the Quality Care Symposium, which were inspiring.* The symposium is a unique experience compared to other meetings and presentations. I think the amount of engagement—for example, questions at the posters—is robust, and we found it really rewarding, in terms of presenting, getting feedback, and talking to other presenters and attendees; it was very interactive.
What also makes it work is our remarkable team and the people I’ve worked with at ASCO—Elaine Holton, Barbara Corning-Davis, and Holley Stallings with the Quality Training Program and Terry Gilmore with the QOPI Certification Program™. They were very encouraging about the projects we were working on and about having oncology pharmacy viewpoints and perspectives. Our progress was supported by the ASCO team and the NorthShore Kellogg Cancer Center.
What was your team’s quality project, and how did you select it?
GC: Our project centered on decreasing the risk of financial toxicity in an ambulatory oncology practice. We considered this project at a point when indications and utilization of immune checkpoint inhibitors expanded rapidly. At the same time, increasing costs of these new therapies was concerning to us, so it was definitely high on our list, but we were not sure if it would be an appropriate project. We worked with ASCO to prioritize and evaluate the potential impact and timeliness of the issue, and with the help of the QTP team, we decided a financial toxicity project centered around immune checkpoint inhibitors would be best and something we could address.
The project certainly was a challenge for us: the costs of these therapies, differences in coverage for patients, and perceived discomfort on the part of both staff and patients about having cost discussions at the time of informed consent. We also wanted to include key quality measures that would give us insight into patient financial toxicity, including patient-reported outcomes, as well as the effects of these high-cost therapies on our institution and overall practice. It was important to make sure we looked at balance measures to ensure we would not inadvertently exacerbate treatment disparities in underinsured patients.
How did the program help improve operations at your practice?
GC: Our goal was to provide education and discussion prior to treatment decisions, and we achieved it. The proportion of patients receiving information about financial risk and available support services at the time of informed consent improved dramatically. That was just in the initial implementation. There were many things that we realized during our initial pilot study; we were able to simplify and improve our workflow dramatically, and it increased the proportion of patients with successful prior authorization before initiating treatment from approximately 50% to 95%. At the same time, we were able to significantly decrease the time to successful prior authorization, which also occurred through optimized workflows and staff education about the risks of financial toxicity and of the importance of early consultation with the patient financial advocates to minimize the financial exposure of our patients.
It also enabled us to identify patients at a potential risk at a much earlier point, and the program provided us with a systemic approach and formal process that we are able to use for all of our quality initiative endeavors now.
Going through the program also provided the opportunity to create tools in our electronic medical records to assist the financial advocates with communicating the costs and the clinicians with understanding the costs of the therapies when they’re creating a care plan. Basically, these are tools they can bring into their consents to show cost information, as well as tools that help communication between staff and financial advocates by providing information regarding the treatment regimen.
What was the most surprising thing you learned in the process of going through the program?
GC: When we examined our workflow, we realized that we had no idea how complicated it was and how all the different stakeholders had very different perspectives and ideas about responsibilities and timelines. We realized when we looked at all of the processes that the workflow was not clear at all, and it was very complicated. When we did our workflow diagram, it took up a couple of walls, from the time a patient hit the center to completed treatment. When we included all the stakeholders and all the disciplines, it was truly eye-opening. Seeing that allowed us to change it, which we did, simplifying the process and prioritizing where things happen. Another lesson we learned was the importance of getting patient feedback about the education tool. Including our patient advisory board was paramount to developing and optimizing our patient information tools.
Something else that was surprising was the total buy-in in a short time by all the staff. It was a big change across all of our practices and the staff, but the engagement was complete. Everyone appreciated that it was going to improve our care for our patients. Once all the disciplines understood the goal and the team approach, it was the most amazing collaboration—even to the point where there was relief and gratitude from staff because we were minimizing the financial risk and the distress for our patients.
Have you been able to sustain your gains in what you’ve learned and the changes you’ve made?
GC: Yes, in fact, we’re expanding the project to include all therapies, including oral chemotherapy. Originally we focused on just a select group of high-cost treatments to see if we could manage that. I think what helped us sustain our project was acknowledging the accomplishments of all the stakeholders. We were able to increase the number of financial advocates through this, which helped us dramatically, because we had the data to show the need and justification for hiring additional financial advocates.
What also helped was that we had interest from across the oncology landscape—including our peers—and increasing interest in the literature at the same time we were addressing this. Many places are trying to address similar financial toxicity issues, so I think that helped keep us on the right track. In addition, I think the team continues to support this process, which is important in helping us sustain this.
What were your favorite aspects of the QTP, and would you recommend the program to others?
GC: The team was empowered and completely engaged by this process. We looked forward to our weekly meetings and particularly to our meetings at ASCO, which allowed us to divest ourselves of our typical day-to-day crisis management and evaluate the bigger picture. The ASCO staff was incredibly supportive, talented, and encouraging, guiding us to the bigger picture while at the same time teaching us. They helped us to remove all the silos and made everyone an equal player and all perspectives equal, so we weren’t looking at things from just one viewpoint.
I think the process was very effective, and the experience was amazing. As oncology pharmacists, it gave us a unique experience and another way in which to contribute to an oncology practice while we were collaborating in this sharing environment with other disciplines. It was a great experience, and I was pretty excited by the inclusion and involvement of oncology pharmacists involved in the program: Margie Curry, PharmD, BCOP, of Grady Health System in Georgia; Amy Morris, PharmD, of the University of Virginia Health Services; Anna Palafox, PharmD, BCOP, of NorthShore University HealthSystem; and Jeremy Sen, PharmD, BCOP, of University of Virginia Health Services.
I am hoping this is another opportunity to work with oncology pharmacists in coordination with the Hematology/Oncology Pharmacy Association (HOPA) and to possibly include an oncology pharmacist on the QTP training team.
*ASCO Quality Care Symposium poster presentations:
- Hensing T, Brockstein B, Gavin S, Carro G, Hui W, Harper A. Tobacco cessation program in an outpatient oncology center. Poster session presented at: ASCO Quality Care Symposium; 2012.
- Carro G, Fleming P, Gavin S, Spath W, Harper A, Hui W, Uhlig B, Hughes B. Evaluation of oral chemotherapy prescribing at an outpatient oncology clinic. Poster session presented at: ASCO Quality Care Symposium; 2013.
- Carro G, Hensing T, Brockstein B, Hullett A, Harper A, Palafox A, Gavin S, Jee C, Hui W. EMR optimized oral chemotherapy monitoring program: adherence and ADR outcomes. Poster session presented: American Society of Clinical Oncology (ASCO) Quality Care Symposium; 2014.
- Hensing T, Brockstein B, Hullett A, Jee C, Palafox A, Hughes B, Harper A, Gavin S, Hui W. Developing and implementing EMR functionality to improve oral chemotherapy outcomes. Poster session presented at: ASCO Quality Care Symposium; 2016.
- Hensing T, Bauer, T, Palafox A, Whalen M, Carro G. Addressing risk of financial toxicity in an ambulatory oncology practice: Our institutional experience with the ASCO Quality Training Program. Poster session presented at: ASCO Quality Care Symposium; 2017.