ASCOs Quality Training Program Project Title: Incorporating Distress Screening Tool in an Oncology Office Presenters Name: Caroline Usry, RN, BSN, OCN Laura Holder, Pharm.D. Jennifer Lamneck Heaberlin DO, MPH Institution: University Oncology, Augusta, Georgia Date: 10/08/2015 1 Setting Institutional Overview University Oncology is a hospital based hematology oncology practice We have two locations: Augusta, Georgia and Aiken, South Carolina The practice has 6 physicians providers and one physician assistant. The practice caters to an average of 1200 new patients a year 2 Problem Statement Identifying and addressing all of the stressors within the relationship-centered care process of our practice will enhance our ability to better relieve or lessen distress,
hopefully improving outcomes. The integration of the ambulatory and hospital based services also offers the ability to impact admissions and hospital length of stay, both impacted by psychosocial issues that can severely compound symptoms related to the primary disease and its treatment. An effective process may, therefore, reduce the overall cost of care while maximizing outcomes and patient outcomes and patient satisfaction. 3 Team Members Role Team Sponsor Name Kim Taylor Job Function Chief Operating Officer Team Leader Jennifer Lamneck Physician Core Team Members
Meg Harmon Laura Holder Caroline Usry Cancer Liaison Pharmacist Charge Nurse Other Team Members Anu Batra Alan Faulkner Physician Chaplain Michael Shlaer Physician Advisor 4 Process Map Patient arrives at the front desk
Form scanned in patients chart New Patient No MD visit PA visit RN eval Lab draw only Yes Patient is given the new patient packet to be filed out with NCCN distress thermometer Form given to Chaplain Yes Distress score 0-4
Form scanned in patients chart 5 No Form Filled out >= 5 Referred to Cancer Liaison Financial Assistant Chaplain Patient Advocate MD Cause & Effect Diagram Patient Material Staff Educationally appropriate for alll
Unwilling to ask Time/efficiency Dont know how to response Staffing ratios Is it working..the form Another office process Who should address Not enough time to fill out form Already under stress of referral Overwhelmed with forms Privacy Stress level is multifacttorial and varies constantly Environment 6 Do not want to share Not a priority at the time of
appointment Language barrier Illiteracy Dont want to be held up Cultural Perceived lack of resources Low screening Lack of training to detect stress Lack of training to implement program Lack of standardization in asking questions When is the right time / How often Instructions not given initially on why this is I mportant Workflow Lack of resources Who should follow up No outpatient psychiatrist
No outpatient dietician Lack of referral resources Resources Diagnostic Data We have not had consistent process of documenting distress We have previously documented spiritual and emotional distress using part of the NCCN tool, but comprehensive distress assessment has not been carried out. We found only 45% of responders marked the distress thermometer. 7 Common Barriers to Screening Time versus efficiency among staff Instructions not clearly given Lack of referral resources once distress identified 8 Aim Statement By September 30, 2015, incorporate a comprehensive
assessment tool and increase the documentation of physical, practical, emotional and spiritual problems for new oncology patients being seen in University Oncologys office to 75% at the time of their initial visit. 9 Measures Measure: Percentage of new patients screened for distress Patient population: New patients Exclusions (if any): Calculation methodology: Numerator : Number of patients with screening tool documented Denominator (if applicable): Number of new patients Data source: New Patient Packet Data collection frequency: weekly Data quality (any limitations) Incomplete filling out of forms 10 Baseline Data Breakdown of Distress Scores 90 1
20 0.2 10 0.1 0 0 Not Marked 0-4 5-7 Range 8 - 10 Cumulative 0.75 60 11
1 Prioritized List of Changes (Priority/Pay-Off Matrix) Self screening tool provided to patients as a part of the new patient packet which is later scanned into our system High Change format of the form to 2 pages to help ensure patients fill out both parts of the tool Impact 12 Education of front desk staff about importance of form and making sure it is completed Tool filled out by MD/RN with questions directly asked to the patient Low
No standardized tool Review of distress by providers and Nurses Easy Filling out the tool at each visit and reviewing with MD/ RN Difficult Ease of Implementation 12 PDSA Plan (Tests of Change) Date of PDSA cycle 13 Description of intervention Results
Action steps 4/18/2015 5/5/2015 Identification of tool Workflow NCCN Distress thermometer Educated MDs, Nurses, Staff in the practice regarding implementation 5/5/2015 7/1/2015 Pilot Implementation of tool Development of data collection plan Low screening not meeting goals Plan to educate the front desk to
reinforce the importance of form to the patient 8/1/20159/30/2015 Changed the format of the distress tool Educated the front desk on administration of the tool and asking patients to fill it out. Overall percentage of pts filling out the form completely is improved. Plan to continue distress screening tool and start to find ways to better address stressors in patients lives. Materials Developed 14
Materials Developed 15 Change Data P Chart Percent Distress Screening Not Filled Out Completely 1.00 0.80 0.60 0.40 0.20 0.00 Intervention 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Weeks Distress Screening Not Filled Out Completely Actual Value Upper Control Limit Percent
Mean Lower Control Limit 100% 80% 60% 40% 20% 0% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Weeks Baseline Mean Lower Control Limit 16 Actual Value Upper Control Limit Conclusions Our p chart does not show specific cause as we dont have enough data points since the intervention
We did see a trend toward a change and achieving our aim of having at least 75% of new patients filling out the form completely. 17 Next Steps/Plan for Sustainability Continue to collect data on if patients are filling out the form completely to evaluate our intervention Explore resources so we can address the concerns appropriately on the distress screening which was the original plan for project before we realized that patients were not using the form correctly. Meet with social worker, chaplain and team to develop a plan on how to find better ways to address the stressors that we are identifying in the patients. Continue with staff education. Continue to meet on weekly basis 18
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