In 2013, the Quality Oncology Practice Initiative (QOPI^®), ASCO’s quality assessment and improvement program, was opened to international participation. Institutions in Greece were among the first to register for QOPI outside of the United States. QOPI physician-champion Evangelia Razis, MD, PhD, discusses cancer care in Greece and her practice’s experience with QOPI.

By Evangelia Razis, MD, PhD

Cancer care in Greece is full of contradictions, as are many aspects of our society. The scientific level of most physicians is quite high, many have studied abroad, conducted clinical research, and participated in international conferences. On the other hand, the level of supportive facilities and nursing care is not as high. Much of the care is delivered at state institutions, while a significant number of oncologists provide care in the private sector; but, even in the private setting, chemotherapy is largely delivered in the hospital and is not office-based.

I returned to Greece after studying in the United States, and joined the practice of my father, Dr. Dennis V. Razis, a very inspiring physician and a pioneer in oncology in Greece. Oncology was not only ingrained in me by my family, but during my studies, I also found it to be an exciting mix of scientific progress and compassionate care. My father was always concerned with quality assurance and patient safety. Later we were joined by Dr. S. Labropoulos and recently by Dr. G. Rigakos.

Health care in Greece operates under highly challenging economic and social conditions. Furthermore, national medical education does not emphasize accurate independent observation and documentation. Nursing staff and junior physicians, while having the necessary medical knowledge and skills, are completely unaware of how a complex medical environment operates. These two factors severely impact the
safety and quality of medical care. In 2011, Hygeia Hospital became the first hospital in the country to go through the process of accreditation by The Joint Commission International, which gave us a front-seat view of standardized quality assurance measures. In 2013, QOPI participation was opened for practices outside the United States. This fortuitous synchronization led our practice to participate in QOPI.

We registered for one module in the fall 2013 round and approached the task wondering whether we would measure up to the challenge. Soon enough, though, we found that we would fare well in some areas, while also directly benefiting from the materials offered and the overall experience. We were doing well with the documentation of histology, staging, and the appropriate use of hormone therapy, but realized we were not always documenting the discussion about the patients’ emotional well-being, fertility, or even the discussion of their therapy plan. Since our first participation in QOPI, we improved patient follow-up forms, which now include fields that remind us to document pain intensity, patient mood, our recommendations for smoking cessation, etc.

We fully participated in the spring 2014 round and scored very well, but again identified areas for improvement and continued to work on them. Consequently, our scores improved by 6.66% in our most recent round of participation.

In summer 2014, we set out to meet the standards to receive QOPI certification. During the summer, we offered internship positions for Johns Hopkins University undergraduate students. One of the students, Angela Roller, had an interest in health administration and worked with us on achieving those standards. As a result, we were able to improve our chemotherapy order forms to include more patient identifiers, created special labels for prescribed drugs, and put together a special booklet for oral chemotherapy compliance recording by the patient. Additionally, we worked to improve our standard operating procedures.

A big part of the process was improving upon the continuing education resources available for our staff. We encouraged our nurses to participate in established programs through the Oncology Nursing Society and its European chapter, with our head nurse, O. Spyri, actually coming to the United States for an onsite course.

Another area of improvement has been that of consent and confidentiality. New, more complete consent forms were created for the practice. Naturally, this has also improved our procedures during research study participation.

Each cycle identified new areas for improvement. Currently, we are working on our fertility discussions with patients and the palliative-care setting. The latter is quite challenging as there are neither hospice facilities nor home hospice care in Greece. We do our best to provide such care at home or in the hospital, but that is still a challenge.

Interestingly, our patients have really embraced this effort and were more than willing to give consent for participation. The patients whom we have followed during this effort have noticed the difference and welcomed the change. It’s fascinating to see, as it is a more comprehensive change in our society’s culture. Furthermore, it has been a maturing process for our program, opening new doors, such as a more streamlined path towards electronic health record implementation.

I would encourage all of my Greek colleagues to participate in QOPI, in order to discover potential areas for improvement. Additionally, this may also permit the development of office-based chemotherapy, which could also offer some relief to our crowded state facilities.

Ultimately, our dream is to achieve QOPI certification (and maybe even participate in CancerLinQ) and the ASCO staff is by our side helping us overcome any potential logistic issues. We also hope QOPI will expand its modules to other tumors and stages. For example, we are a referral center for brain tumors, a tumor type with several unique aspects in need of quality assurance.

QOPI is, overall, a great effort and I would love to see it implemented throughout Europe, both in the private and public sectors. Not only is it likely to improve patient safety, but it will also lead to cost reductions and more data collection from real-life oncology practices.