MULTIDISCIPLINARY CLINICAL TEAMS + PATIENT NAVIGATION

+ GENETIC COUNSELING + CLINICAL RESEARCH + CLINICAL

EDUCATION + INTEGRATIVE MEDICINE + PATIENT SUPPORT

AND EDUCATION + INNOVATIVE CLINICAL TRIALS CENTER

+ SURVIVOR CELEBRATIONS + COMMUNITY OUTREACH

2014 ONCOLOGY ANNUAL REPORTBUILDING On STRENGTH

CLINICAL PROGRAM PRACTICE PROFILE REPORT (CP3R)ONCOLOGY QUALITY METRICS

Physicians provide clinical services as members of the medical staff at one of Baylor Scott & White Health’s subsidiary, community or affiliated medical centers and do not provide clinical services as employees or agents of those medical centers, Baylor Health Care System, Scott & White Healthcare or Baylor Scott & White Health. Photography may include models or actors and may not represent actual patients. ©2015 Baylor Scott & White Health. BID BHCSONC_83 8.15

NCDB Target

CoC Stateof Texas

PerformanceRate

CoC Census Region (West)

PerformanceRate

All CoCPrograms

PerformanceRate

Baylor Scott & White – Irving

Performance Rate

Breast Cancer 2012 Forward Diagnosis Year 2011 (CoC) 2012* 2013*

BCRST: Post Breast Conserving Surgery Irradiation: Radiation therapy is administered within 1 year (365 days) of diagnosis for women under age 70 and receiving breast conserving surgery for breast cancer (Accountability Measure)

90% 86.8% 88.6% 91.8% 100.0% 100.0%

MACl: Adjuvant Chemotherapy: Combination chemotherapy is considered or administered within 4 months (120 days) of diagnosis for women under 70 with AJCC T1cNoMo, or Stage II or III hormone receptor negative breast cancer (Accountability Measure)

90% 90.0% 90.5% 92.5% 100.0% 100.0%

HT: Adjuvant Hormonal Therapy: Tamoxifen or third generation aromatase inhibitor is considered or administered within 1 year (365 days) of diagnosis for women with AJCC T1cNoMo, or Stage II or III hormone receptor positive breast cancer (Accountability Measure)

90% 86.1% 87.1% 90.3% 100.0% 100.0%

NbX: Image or palpation-guided needle biopsy (core or FNA) is performed for the treatment of breast cancer (Quality Improvement Measure)

80.0% 73.2% 74.0% 76.4% 98.5% 98.0%

BCS: Breast Conservation surgery rate for women with AJCC clinical stage 0, I, or II breast cancer (Surveillance Measure)

NA 54.3% 57.0% 63.9% 70.5% 62.8%

Colorectal Cancer

ACT: Adjuvant Chemotherapy: Adjuvant chemotherapy is considered or administered within 4 months (120 days) of diagnosis to patients under age 80 with AJCC III (lymph node positive) colon cancer (Accountability Measure)

90% 88.5% 89.4% 90.6% 100.0% 100.0%

12 RLN: Surgical Resection Includes at Least 12 Lymph Nodes: At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer (Surveillance Measure)

85% 90.5% 89.0% 87.8% 95.8% 93.3%

Rectal Cancer

RECRCT: Pre-operative chemo and radiation are administered for clinical AJCC T3N0, T4N0, or Stage III; or Postoperative chemo and radiation are administered within 180 days of diagnosis for clinical AJCC T1-2N0 with pathologic AJCC T3N0, T4N0, or Stage III; or treatment is considered, for patients under the age of 80 receiving resection for rectal cancer (Quality Improvement)

NA 91.6% 90.6% 91.8% 100.0% 100.0%

CLINICAL PROGRAM PRACTICE PROFILE REPORT (CP3R)ONCOLOGY QUALITY METRICS

m Target m Target & Acceptable Deviation m Target & No Further Action

*Source: Data is pending results by the Rapid Quality Reporting Process via the National Cancer Data Base

The Clinical Program Practice Profile Report (CP3R) was created by the American College of Surgeons’ Commission on Cancer (CoC). It provides a report-card style summary of program-specific performance rates for five process measures obtained from the National Cancer Data Base (NCDB): three for breast, one for colorectal and one for rectal cancer. The performance measures

review how well a particular hospital delivers cancer care as determined by national treatment guidelines. These reports allow comparisons to other CoC-accredited programs by state, regional and national characteristics. The performance rates are based on retrospective data, typically 18-24 months after a patient’s diagnosis and treatment.

“M” IN THE BOXSM ANCHORS ONCOLOGY UNIT INITIATIVE TO IMPROVE COMMUNICATION ABOUT MEDICATIONS

When the Oncology/Medical-Surgical Unit at Baylor Scott & White Medical Center – Irving* reviewed its HCAHPS scores, it determined that its rank in the 1st percentile for “Communication About Medications” was unacceptable. The Unit assembled a project team to determine why the score was so low and to identify interventions that could quickly improve the score to the 75th percentile. Led by a nurse manager and with representation from nursing and the pharmacy, the team set about its work.

Using the Accelerating Best Care at Baylor (ABC Baylor) approach, the team constructed a fishbone diagram to clearly identify factors contributing to the poor communication score. These factors were segmented by patient, nurse, environment and equipment. The key findings included:

Patient: low level of engagement, confused or unaware that medication education was being done, language barrier and lack of knowledge about health care in general.

Nurse: education not completed or not reinforced with patient, patient understanding not validated, other tasks interfering with education, next shift unaware of education or lack thereof.

Environment: busy, rushed, too much to do, short-staffed, competing priorities.

Equipment: whiteboard unused and not updated, handouts not used, computer downtime or technology barrier between nurse and patient, language line phone not used.

The team’s aim statement for this quality improvement initiative read, “The staff on MS6-Oncology/Medical-Surgical Unit at Baylor Scott & White Medical Center – Irving will improve education of new medications to patients as evidenced by improvement of HCAHPS rank from 1st percentile to the 75th percentile rank by September 30, 2013 with use of a visual and teach-back tactic called ‘M’ in the Box℠ (Studer Group, 2012).”

In the first phase of the improvement initiative, the entire staff on the unit was educated on the tactic and the team decided on a March 1 start date. One unexpected issue that arose during implementation was the staff’s comfort level in explaining the tactic to patients. The Communication About

Medications HCAHPS score was monitored during the first month of the project and the mean score jumped from 32.2 to 83.4. The relatively quick, stellar improvement convinced the staff to permanently adopt the tactic. Over time, the staff became more comfortable using the tactic.

The “M” in the Box℠ tactic served as a visual reminder to staff, provided a teach-back method for staff to verify patients’ understanding of the medication education they were receiving, proved to be fun and engaging, served as an excellent communication tool and incorporated the “must haves” for improvement.

Scripting was developed for introducing new medications to the patient…“Mrs. Jones, I’m writing the ‘M’ in the box to indicate that you have a new medication and that I have informed you of the reason for the medicine and common side effects. This picture will remind both of us.”

Using the teach back method to confirm the patient’s understanding of the information about the new medication, nurses would use this scripting during hourly rounding and repeat the process until the patient could repeat back to the nurse the name of the new medication, its purpose and its common side effects…“Sally, Dr. Davis ordered Mrs. Jones a new medication today. Mrs. Jones, are you able to tell us the name of the new medication? Can you tell us the purpose of the medication? And can you tell us common side effects of this medication?” “Mrs. Jones, since you are able to teach back to us the name, purpose and common side effects of your new medication, I am now erasing the ‘M’ in the box. This indicates that you have a good understanding of your new medicine.”

During phase 2 of the improvement initiative, the team noted a decline in the Communication About Medication score in May and June. They noted that the lowest scoring question related to the initiative was explaining the side effects. The team created and began distributing a fact sheet handout listing common medications and their related side effects. The handout was implemented in July 2013. The nurse would fill in the handout with the name of the patient’s new medication and review the common side effects with the patient/family during “M” in the Box teaching. The team noted that the HCAHPS score improved to 83.3 in July, so,

distributing the handout was adopted permanently. The team also discovered that the handout needed to be translated into Spanish to accommodate Spanish-speaking patients and their families.

The third phase of the improvement initiative saw another dip in the HCAHPS score. The team reconvened and, after speaking to staff, determined that a visual reminder was needed. A placemat for the mobile workstations was designed and in September 2013 the visual reminder began being placed on the carts. In September, the HCAHPS mean score soared to 100. In October the score dipped slightly to 93.8. Both of these scores were in the 99th percentile. Before the end of September, a staff member from the Pharmacy was added to the improvement initiative team. The Pharmacy representative started rounding twice a week on patients to provide medication education prior to the patients’ discharge.

In summary, the improvement initiative team surpassed its original goal of reaching the 75th percentile for “Communication About Medications” by September 2013, by reaching the 99th percentile in September and October 2013. For fiscal year 2013, the HCAHPS measure had a top box score of 49.4 (2nd percentile) and for fiscal year 2014, year-to-date, the top box score was 80.6 (99th percentile).

At the end of the formal improvement initiative’s timeframe, the project team listed two key lessons learned:

• You must explain the “why” we need to improve medication education to create more of an awareness of the importance to properly educate patients on medications

• To sustain improvement results, constant reminding and auditing of tactics are needed.

CANCER SCREENINGSBAYLOR SCOTT & WHITE MEDICAL CENTER – IRVING 2014

COMMUNITY NEEDS ASSESSMENT

CANCER SCREENINGS AND OUTCOMESBaylor Scott & White Medical Center – Irving performs a “Community Needs Assessment” every three years to identify health care disparities and barriers to care for patients within our service area. Once these barriers are identified, Baylor Scott & White – Irving is able to develop strategies to address these needs. The chart below shows the community cancer

screenings offered and the outcomes of the screenings at Baylor Scott & White – Irving during 2014. Patients who are screened and found to be at risk for cancer need follow-up treatment and evaluation by cancer specialists. These patients are referred to a nurse navigator who helps the patient connect with an appropriate specialist.

SCREENING SITE # OF SCREENINGS # AT RISK CANCER DIAGNOSISBreast 10,623 1,472 127Colon 292 247 Referred for biopsy Low Dose CT Lung 22 10 1

*All 2014 data and recognition applies to Baylor Medical Center at Irving which changed it’s name to Baylor Scott & White Medical Center - Irving in Spring, 2015.