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October 2014, Supplement to Volume 18, Number 5
Article
Impact of the Breast Cancer Care Measures Pilot Study on
Quality-Improvement Initiatives
Amy M. McGovern-Phalen, BSN, RN, OCN®, CBCN®
As a participant in the ONS Foundation–supported
Breast Cancer Care Quality Measures Set in 2010, the Edward Cancer Center (ECC)
identified gaps in patient assessment. Sleep-wake disturbance and distress were
two common areas that were lacking consistent assessment when nurses saw
patients during their visits. Another issue is the lack of standard methods of
practice or a standardized tool. The ECC, in collaboration with Edward Diabetes
Center, Linden Oaks Hospital, and other outpatient offices, adopted the use of
the Patient Health Questionnaire-9 depression screening tool. The ECC also
modified the intervention recommendations to meet the needs of the oncology
population. As a result of the findings in the pilot, the ECC was able to
implement an evidence-based practice change to improve the overall quality of
patient care and provide earlier intervention in an effort to further improve
patient outcomes.
The ONS Foundation and the Joint Commission
partnered in the ONS Foundation–supported Breast Cancer Care (BCC) Quality
Measures Set (Fessele, Yendro,
& Mallory, 2014) in 2010 to evaluate the pilot sites’ performance on selected
measures and to identify opportunities for quality improvement in cancer care.
As a participant in the pilot, the Edward Cancer Center (ECC) in Naperville,
Illinois, was able to obtain measurable data on performance and establish goals
for quality improvements and practice change at the ECC.
The BCC pilot study took place from August to
December 2010. At that time, the symptom assessment tool used was the Common
Terminology Criteria for Adverse Events (CTCAE) (U.S. Department of Health and
Human Services [USDHHS], 2006) via a toxicity flow sheet. In terms of anxiety
and depression, the grading can be more subjective (none, mild, moderate,
severe) based on the nurse’s interpretation of a patient response. In addition,
the toxicity assessment is only used for active treatment patients, so all
patients are not assessed consistently in these categories unless specifically
noted in the physician progress note. Completion of the pilot revealed low
scores in the assessment of distress, fatigue, and sleep-wake disturbance.
These measures were found to be a common weakness in many oncology practices.
Subsequent to the BCC pilot study, the ECC implemented the CTCAE, version 4.0
(USDHHS, 2009).
Assessment and
Documentation of Symptoms
The approach for how to improve assessment and
documentation of distress, fatigue, and sleep-wake disturbance is challenging.
Numerous tools are available, and variance is found depending on the tool a
practice selects. In 2011, a team of nurses applied to the ONS Foundation
Institute for Evidence-Based Practice Change, and when the team was accepted,
it used the information from the BCC pilot to select a project for process
improvement. The team selected depression assessment and screening for their
evidence-based project. The team leading the initiative was comprised of a
nurse practitioner, a staff nurse, and the director of the cancer center, who
has a background in nursing.
When researching the literature, several depression
screening tools were identified as appropriate to implement into practice (Fulcher, Badger, Gunter, Marrs,
& Reese, 2008). After looking into the options for screening tools, it was
discovered that several departments within the healthcare organization were
already using the Patient Health Questionnaire (PHQ)-9 tool (Pfizer, Inc.,
2002) (see Figure 1). With the movement to
an electronic medical record approaching, it was evident that a standard tool
needed to be used in the organization to provide continuity and a higher
quality of care for patients. Another important factor was that the PHQ-9 also
asks about fatigue and sleep-wake disturbance to encompass several of the
measures that needed to be addressed. The patient responds to a set of
standardized questions, and a numeric score is generated to indicate the
appropriate intervention. Scores range from 0–27, where a score of 10 or higher
indicates depression (Kroenke & Spitzer, 2002).
Another range of measure is grading depression severity by scores of 5, 10, 15,
and 20 defined as mild, moderate, moderately severe, and severe, respectively (Kroenke & Spitzer, 2002).
Implementing
Assessment Into Practice
Once the PHQ-9 depression screening tool was chosen,
the team collaborated with other departments using the tool to assist with
implementing it into practice. The ECC team joined the Edward Diabetes Center
in a study developed on nurse’s comfort level in assessing depression in
patients. Staff education was provided on depression in cancer, the use of the
tool, how to assess and document, and the established interventions and
workflow process. A two-week pilot was conducted in one of the physician
clinics, an evaluation of the process was done, and feedback obtained from
staff. Working another task into the nurse’s workflow was a concern, and staff
questioned which patients would be screened, who would screen, and who would
initiate the interventions. Staff also questioned what resources would be
available and who would be the key team members. A trial process was
established on how the PHQ-9 would be used in the clinic. All patients with
cancer were given the PHQ-9 at their physician visits. If a patient came every
two weeks or more in a four-week period, they were screened once per month. The
oncology technician, who draws laboratory tests, takes vital signs, and rooms
the patient, gave the questionnaire to the patient, and the nurse reviewed it
with the patient, totaled the score, initiated the appropriate intervention
according to the score, and documented the score in the electronic medical
record (see Tables 1 and 2). The depression screening process was put
into effect March 1, 2012. Monthly audits are conducted to monitor staff
compliance with the process and identify gaps in knowledge of the process.
Continuing the
Assessment Project
Re-education and clarification were provided to
staff as needed. Scorecards were given to the nurses each month to track their
individual improvement in depression screening and assessment. Several barriers
had to be overcome, such as staff reluctance, workflow organization, and
patient education about the new practice. During the time of implementing the
depression screening, the Commission on Cancer (COC) was at the ECC for a
recertification site visit. When the team presented the depression screening
process, the COC was very complimentary and posted the process on their website
as an example of best practice. The ECC recently extended the depression
screening process to the radiation oncology department to provide more
consistent care across the collaborative teams within the cancer center. During
the American College of Radiology accreditation process, the cancer center was
again commended for the processes in place for depression screening.
Conclusions
In April 2013, the ECC met the 90% compliance goal
and currently remains in the upper 80th–90th percentile for the quality
performance measure of administering a depression screening tool and assessing
the psychosocial status of patients. When the electronic medical record was
implemented in the author’s organization, a slight decrease was seen in
compliance as staff adjusted the process and transitioned the screening
documentation to an electronic medical record. The ECC is currently working to
establish a standard set of interventions that can be used universally within
the organization. The cancer center has implemented the PHQ-9 flow sheet in the
electronic medical record, with interventions built in to populate based on the
patient score. The inpatient units are looking at implementing the PHQ-4 (a
shorter version of the PHQ-9) into practice as well.
Many of the measures tested are applicable to breast
cancer in addition to other types of cancer and chronic illnesses. The
depression screening project has become a collaborative effort among the entire
organization and continues to grow and improve. Participation in the 2012 BCC
re-abstraction provided data to show that the author’s practice improved in
assessing for distress. Since the pilot in 2010, quality improvements based on
evidence, benchmark data, and changes in health care have been brought to the
forefront to provide the highest quality of care. Although work still needs to
be done to improve patient assessment and documentation of cancer care measures
and survivorship care, this pilot has helped to set a basic foundation for
practices to start quality-improvement initiatives that will positively affect
the care provided to patients.
Implications for
Practice
Ø
Implement standardized, objective psychosocial
assessment with the use of screening tools to provide valid measures.
Ø
Initiate designated interventions to address
various stages of anxiety and depression.
Ø
Improve overall quality of care and patient
outcomes with a patient-centered approach, including psychosocial aspects of
care.
The author gratefully acknowledges Kim Rohan, RN, MSN, AOCN®, ANP-BC, who had the
vision and started the team on this initiative, Jenna VanGilder,
RN, BSN, OCN®, who supported the project, and the physicians as well
as all of the Edward Cancer Center staff for their efforts and hard work in
implementing this practice change. The author also thanks Kristin Fessele, PhD, RN, AOCN®, for her support and
encouragement in submitting this article.
References
Fessele, K., Yendro, S.,
& Mallory, G. (2014). Setting the bar: Developing quality
measures and education programs to define evidence-based, patient-centered,
high-quality care. Clinical Journal of Oncology Nursing, 18(Suppl.),
7–11. http://dx.doi.org/10.1188/14.CJON.S2.7-11
Fulcher, C.D., Badger, T., Gunter, A.K., Marrs, J.A., & Reese, J.M. (2008). Putting
Evidence Into Practice: Interventions for depression. Clinical
Journal of Oncology Nursing, 12, 131–140.
Kroenke,
K., & Spitzer, R.L. (2002). The PHQ-9: A new depression
diagnostic and severity measure. Psychiatric Annals, 32(9), 1–9.
Kroenke,
K., Spitzer, R.L., & Williams, W. (2001). The
PHQ-9: Validity of a brief depression severity measure. Journal of General
Internal Medicine, 16, 606–613.
Pfizer,
Inc. (2002). Instructions for Patient Health Questionnaire
(PHQ) and GAD-7 measures. Retrieved from http://bit.ly/XV67t6
U.S. Department of Health and Human Services. (2006). Common Terminology Criteria for Adverse Events (CTCAE)
(version 3.0). Retrieved from http://1.usa.gov/1nqTfzb
U.S. Department of Health and Human Services. (2009). Common Terminology Criteria for Adverse Events (version
4.0). Retrieved from http://evs.nci.nih.gov/ftp1/CTCAE/CTCAE_4.03_2010-06-14_QuickReference_5x7.pdf
Amy
M. McGovern-Phalen, BSN, RN, OCN®, CBCN®,
is a clinical nurse educator and a quality coordinator at Edward Cancer Center
in Naperville, IL. The author takes full responsibility for the content of the
article. The author received editorial support from Kristen Fessele,
PhD, RN, AOCN®, in preparation of this article, funded by a grant to
the ONS Foundation from the Breast Cancer Fund of the National Philanthropic
Trust. The content of this article has been reviewed by independent peer
reviewers to ensure that it is balanced, objective, and free from commercial
bias. No financial relationships relevant to the content of this article have
been disclosed by the independent peer reviewers or editorial staff. McGovern-Phalen can be reached at aphalen@edward.org,
with copy to editor at CJONEditor@ons.org.
(Submitted March 2014. Revision submitted May 2014. Accepted for publication May 12, 2014.)
Key words: depression; cancer; Patient Health
Questionnaire; evidence-based practice; quality improvement
http://dx.doi.org/10.1188/14.CJON.S2.17-20
