Purpose: Fellows are required to develop, implement, and evaluate quality improvement projects. In order to determine areas in which quality improvement projects were needed, we evaluated standardized quality oncology practice improvement (QOPI) scores developed by ASCO. Using these scores, we identified communication in intent-of-chemotherapy as an area needing improvement in our program at the University of Arkansas for Medical Sciences (UAMS) and the Central Arkansas Veterans Healthcare System (CAHVS). Communication about intent-of-chemotherapy is important so that patients understand if the intent is to cure or palliate disease, and thereby have realistic expectations about outcome. After noting low scores in these areas of patient care, we organized additional training in communications on intent-of-treatment and we added optional checkboxes to our electronic templates for progress notes in order to remind ourselves to address intent-of-chemotherapy and to document such conversations at every clinic visit.
Methods: Using Plan-Do-Study-Act (PDSA) cycles to expeditiously analyze early results in order to change courses as needed, we did chart reviews after 1 month of implementation. Chart reviews focused on the number of times that intent-of-treatment conversations were noted either in the text or in the checkboxes. To assess the impact of our training and modified templates, we also did patient satisfaction assessments to determine the impact of conversations on satisfaction and understanding. The surveys included questions relating to satisfaction after discussion of chemotherapy intent and whether the physician listened carefully, took time to answer questions, explained concerns, answered questions, and spent sufficient time. Baseline QOPI scores showed discussion of chemotherapy intent were 85% nationally for all oncologists, 83% nationally for oncology fellows, and 63% at UAMS/CAVHS for oncology fellows, respectively. QOPI scores for documentation of such discussions was 88% nationally for all oncologists, 89% for fellows nationally, and 74% of oncology fellows at UAMS/CAVHS. After implementation of the practice improvement project (training and optional checkboxes in the progress note templates), we selected 10 random patient charts for review. Review of charts showed that intent-of-treatment was documented in 80% of cases, compared with 74% prior to implementation of the program, which reflects some improvement in compliance to discussion and documentation of discussions compared with baseline evaluations. Patient satisfaction scores were 100% for receiving clear information, understanding the reason for which they were receiving chemotherapy, willingness to listen carefully, taking time to answer questions, explaining things clearly, and spending adequate time. To further improve the number of times that intent-of-chemotherapy conversations occur, we are planning to change checkboxes from optional to mandatory boxes so that the provider cannot proceed with the note until answering whether or not such conversations occurred. In summary, we show that participation in QOPI quality improvement programs can identify areas of concern in which quality improvement projects can be implemented to improve performance and that rapid assessments using PDSA cycles can be useful for rapidly incrementally further improving results.
Conclusions: In this study, we identified communication in intent-of-chemotherapy and documentation of such as areas of concern for which quality improvement projects could be implemented. We devised training in communication and use of checkboxes to overcome the deficiency and used rapid PDSA methodology to assess results. Better understanding of the intent of treatment may result in better compliance, higher trust in physicians, and improved patient satisfaction.