Purpose: Development of a quality improvement (QI) tracking tool that allows staff to monitor care on an ongoing basis and make changes and modify system processes to improve outcomes for breast cancer care. The National Quality Forum (NQF) of the Commission on Cancer and National Consortium of Breast Centers Program (NQMBC) have collaborated and defined breast cancer quality measures. Timeliness and quality of breast cancer care will have a direct impact on quality of life and survivorship. The West Palm Beach VAMC did not have a process in place for data collection and ongoing performance improvement for breast cancer care.
Methods: The major aims of the project are to (1)Identify collaborative team members; (2) identify standardized benchmarks that track timeliness and quality of care; and (3) create a tracking tool to enter data that automatically measures timeliness and quality of care. A collaborative group of staff from the cancer registry, women’s health department, radiology, oncology, pathology, and applied systems engineers met biweekly/monthly over 9 months to add, define, and continuously retest data entry sets within the tool. Several timeliness measures have been identified by the NQMBC. The final measures for our facility were chosen by a multidisciplinary breast cancer committee and approved by the cancer committee. Timeliness measures included (1) time between diagnostic mammogram and open surgical biopsy/excision; (2) time between diagnostic mammogram and needle/core biopsy; (3) time between needle biopsy and initial breast cancer surgery; (4) time between initial breast biopsy (core/needle or incisional/excisional) and pathology results; (5) time between open (incisional/excisional) and pathology results; and (6) time between initial breast cancer surgery and pathology results. Quality measures from the NQF include (1) radiation therapy administration within 1 year of diagnosis; (2) combination chemotherapy considered or administered within 4 months (120 days) of diagnosis; and (3) tamoxifen or third-generation aromatase inhibitor (AI) considered or administered within 4 months (120 days) of diagnosis.
Results: Outcomes for baseline data for n = 30 patients demonstrated (1) time between diagnostic mammogram and open surgical biopsy/excision—52 days; (2) time between diagnostic mammogram and needle/core biopsy—50 days; (3) time between needle biopsy and initial breast cancer surgery—32 days; (4) time between initial breast biopsy (core/needle or incisional/excisional); and (5) pathology results—8 days. Quality measures from the NQF include (1) radiation therapy administration within 1 year of diagnosis—92%; (2) combination chemotherapy considered or administered within 4 months (120 days) of diagnosis—72%; and (3) tamoxifen or third-generation AI is considered or administered within 4 months (120 days) of diagnosis—72%.
Conclusions: Verification of tool data indicated the need for additional columns and definitions to accurately report timeliness measures. Patient refusal of care was included in data, although it skewed the data. Refusal of care will be individually analyzed to make sure patients were educated regarding disease process and scope of treatment options, which indicate informed consent. Facility goals for timeliness range from 2 to 30 days. Quality measure goal is 100%. As a continual evaluation process occurs, monitoring and adjustment of processes will advance our facility closer to meeting its goal of providing comprehensive quality breast care to our women veterans.
