QUALITY MANAGEMENT/ PERFORMANCE IMPROVEMENTS 2001

The American College of Surgeons (ACoS), the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and Del Sol Medical Center (DSMC) set high standards for our Cancer Program and the care of all patients admitted to our hospital. To insure these standards various program and patient care areas are monitored daily, monthly, quarterly and annually.

Following are a sample of the quality management and performance improvement standards monitored during the past year:

Improving Patient Care:

Assessment and reassessment of pain management will be completed and documented for patients at the Del Sol Regional Oncology Center and on the inpatient oncology unit at Del Sol Medical Center. During 2001, Del Sol Medical Center developed and implemented a hospital-wide administrative policy on pain management and documentation. The expected compliance outcome for this patient care area is 100%. For outpatient radiation oncology patients, compliance has ranged from 55%-100% with little consistency in the first three (3) quarters of 2001. The final quarter of 2001, however, showed a steady improvement of 88%-92%. Review of this standard for the inpatient oncology unit indicates compliance varied from 66%-87%. Continued implementation, improvement, review and documentation of this essential patient care related issue will continue into 2002.

Improving Patient Care:

Chemotherapy agents will be delivered to the oncology unit by the pharmacy within three (3) hours of the oncology unit receiving the physician's order. In order to assure the prompt treatment of patients receiving chemotherapy the oncology unit, pharmacy and physicians collaborated to devise a more efficient process to accomplish this goal. Initial compliance at implementation of the process was at 67%. In April, October and November 2001 compliance reached 100%. For the remaining months, compliance averaged above 80% on a consistent basis. To insure the highest quality of patient care, this area of patient care will continue to be monitored in 2002.

Improving Organizational Performance:

The radiation therapists will perform a weekly check on Radiation Oncology patient charts, and document that check. In January compliance with this standard was at 50%. Compliance percentages were between 70% and 100% during the first three quarters of the year. And 100% compliance was maintained during the last quarter of 2001.

Management of Information:

Less than 10% of patients will be lost to follow up, per ACoS guidelines (or patients will be followed until death at least 90% of the time.) One specific requirement for an ACoS approved cancer program states that all patients in an institution's database will be followed until death to assess recurrence and survival rates. To achieve this standard, the cancer registry staff updates patient information on a monthly basis. In 2001, our follow up rate was consistently at 91% or higher. Follow up rate at the end of 2001 was at 96%. This quality standard will continue to be monitored in 2002.

Other Areas Monitored and Improved:

• All outpatient areas implemented a screening tool to determine patient's functional and nutritional needs and to insure that appropriate referrals are completed. Compliance is being monitored and will be reported in 2002.
• AJCC staging forms were present in 100% of all inpatient records of newly diagnosed cancer patients.
• One hundred percent (100%) of the Del Sol Regional Oncology outpatient records were monitored and contained complete informed consent forms.
• Cancer Registry abstracted data matched the patient's medical record data with 100% compliance.