Abstract
Quality management with the ability to benchmark quality metrics remains a cornerstone of the authors' overarching strategy to maintain consistent high-quality care throughout our national network.
As health care reform unfolds, attention to clinical quality in its fullest dimensions has become increasingly important. Quality affects most importantly the patient but also the cost of health care services and as such has profound individual, local, and societal implications.
Quality management across integrated health care systems carries many challenges. Among these are the challenges of geography, data interoperability, and differences in organizational cultures, as well as the fundamental challenges in defining quality metrics. Notwithstanding these challenges, we and others believe that it is imperative that health care organizations proceed with rigorous quality assessment. Indeed, for most organizations, including our own, this has become an important part of our long-term strategy. This report provides an overview of our organizational approach to quality assessment across our clinical network.
Institutional Mission
The mission of The University of Texas MD Anderson Cancer Center is to “eliminate cancer in Texas, the nation, and the world through outstanding programs that integrate patient care, research and prevention, and through education for undergraduate and graduate students, trainees, professionals, employees and the public.” Critical elements of this include our commitment to the highest quality patient care across our region, in our nation, and around the world. Consistent with these aspects of our mission, MD Anderson has developed an inter-related series of programs that are being progressively moved onto a nationwide platform (Figure 1). These programs include our metropolitan Houston outpatient clinics, our longstanding certified member program, and our partner member program.
Figure 1.
Map of the United States showing locations of certified members and our partner member, Banner MD Anderson Cancer Center (Phoenix, AZ). Certified members are Advocate Christ Medical Center, Oak Lawn, IL; Community Health Network, Indianapolis, IN; DCH Regional Medical Center, Tuscaloosa, AL; East Jefferson General Hospital, Metairie, LA; Providence Hospital, Mobile, AL; Sacred Heart Health System, Pensacola, FL; Saint Francis Medical Center, Cape Girardeau, MO; Southcoast Health System, Fall River, MA; and Spartanburg Regional Medical Center, Spartanburg, SC. Single discipline partner is Presbyterian Hospital, Albuquerque, NM. Clinical support services are located at the MD Anderson Cancer Center in Orlando, FL.
Metropolitan Houston Area Centers
Our four outpatient clinics are situated throughout the Houston area on the campuses of suburban hospitals. These centers offer subspecialty surgery, medical oncology, and radiation oncology services closer to our suburban patients' homes and workplaces. Our regional expansion has been structured around disease-specific programs such as breast cancer, gynecologic cancer, and head and neck cancer. These centers are staffed by MD Anderson faculty members who have full academic appointments at the cancer center and practice “MD Anderson oncology” in the community. This is coupled with team-based treatment planning enabled by on-site multidisciplinary conferences and clinical trial availability. This brings our brand and format of high-quality cancer care and clinical trials into the community. For our organization, this represents a metamorphosis from a hospital to a regionalized, clinically integrated delivery system.
As with other elements of our national network, quality management is an extremely important aspect of this endeavor, as we must ensure that patients receive the same standard and quality of care that we provide at our main campus in the Texas Medical Center. To this end, our regional centers are certified by the ASCO Quality Oncology Practice Initiative (QOPI), and we have a real time quality assurance process that evaluates provider-specific adherence to MD Anderson staging and clinical practice guidelines for patients with the common cancers, including breast, lung, and colon cancer. This process enables assessment of performance metrics and adherence to practice standards, and has allowed us to begin to pilot test linking regional physician compensation to quality metrics.
Certified Members
The certified member program has been in existence for approximately 8 years, and presently there are nine certified member programs throughout the United States (Figure 1). The certified member program is a comprehensive oncology quality improvement program based on the MD Anderson approach to multidisciplinary care. At its core, the certified member program uses MD Anderson's clinical practice guidelines and best practices in conjunction with nationally accepted and endorsed quality indicators from organizations such as the National Quality Forum, ASCO, National Comprehensive Cancer Network, and American College of Surgeons Commission on Cancer. The primary objective of this program is to help certified members raise the level of cancer care in their local communities. This is vitally important, as approximately 80% of cancer care in the United States is delivered in a community setting.
For a hospital or health system to be considered to become a certified member, they must meet initial clinical requirements, which include Joint Commission and Commission on Cancer accreditation, and be able to organize their oncologic specialty physicians according to MD Anderson's multidisciplinary care model. The key factor that determines success for a certified member program is physician participation. Once these initial requirements are met and there is interest from the hospital or health system to proceed, the applying institution enters into a Development Agreement with MD Anderson. During the Development Agreement phase, the institution undergoes on-site evaluations performed by MD Anderson faculty and MD Anderson Physicians Network (MDAPN) medical directors and staff. Services evaluated include medical oncology (outpatient infusion center, inpatient oncology unit, and private practice offices), radiation oncology, surgery, diagnostic imaging, and inpatient and outpatient pharmacy. The on-site assessments also include an in-depth review of hospital policies and interviews with hospital staff about patient safety. In addition to certification of hospital processes and facilities, physicians nominated by the hospital leadership to participate in the network undergo a clinical practice review. This activity includes a review of selected medical records for each physician.
Once the applicant has corrected any clinical and/or process deficiencies identified during the on-site assessments and a network of participating providers has been selected on the basis of results of the clinical practice assessments, the institution is eligible to become a certified member, after which it can begin to market its affiliation with the MD Anderson Cancer Network. Detailed cobranding standards govern how the certified member can market this affiliation within their geographic region.
A number of clinical quality assessments are performed during the term of the certified member affiliation. The quality assessment and assurance tools used are listed in Figure 2. Most of the quality assessments are performed by MD Anderson faculty and MDAPN medical directors and staff, but some are performed locally by staff at the certified member site, with oversight provided by MDAPN. All of the quality assessments use objective clinical criteria that arebased on MD Anderson clinical practice guidelines and other nationally endorsed best practices and are geared toward identifying opportunities to standardize processes and reduce variation in clinical practice. Opportunities to improve the quality of cancer care delivered at a certified member site are identified by deployment of these quality assessment tools. It is expected that the certified member program will drive all opportunities for quality improvement locally through its Cancer Committee and will measure, report, and improve the quality of cancer care over time.
Figure 2.
Certified member quality assessment and assurance tools.
Education is also a major component of the certified member program. Physicians and other health care providers have access to weekly education programs, which include disease-specific multidisciplinary planning conferences with MD Anderson faculty, clinical practice guideline updates, and presentations from MD Anderson faculty. In addition, credentialed physicians from certified member programs participate in treatment planning by videoconference, which allows interaction with MD Anderson faculty and physicians from other certified member programs across the country. All of these educational programs are approved for continuing medical education credit, and they are videotaped and available to network physicians who are unable to attend the live programs.
The duration of a certified member affiliation with the MD Anderson Cancer Network is 3 years, and there is an opportunity for renewal at the end of each contract term.
Partner Members
The partner member program establishes a cobranded relationship between MD Anderson and another health care organization. The partner member program involves a deeper relationship with MD Anderson that is more clinically integrated than the certified member program. This is exemplified by our cobranded cancer center in partnership with Banner Health in the greater Phoenix, AZ, area. The Banner MD Anderson Cancer Center (BMDACC) is a full-service cancer center that offers complete multidisciplinary oncology services for all solid and hematologic malignancies. Our cobranded cancer center is built on a detailed form of clinical integration with MD Anderson's main Houston campus facilitated by adjunct faculty appointments and reporting relationships for clinical leaders.
Quality measurement with BMDACC has started with comparative assessment of metrics that include Centers for Disease Control and Prevention National Healthcare Safety Network metrics including central line–associated blood stream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI). We track and issue reports to administrative and clinical leaders at both MD Anderson Cancer Center and BMDACC that benchmark CLABSI and CAUTI rates at BMDACC to those at MD Anderson Cancer Center (Figure 3). This process of teamwork between organizations is being extended to breast and colon cancer metrics this year. In the future, we will be able to benchmark quality and outcome measurements for a variety of common cancers.
Figure 3.
Comparative performance of the MD Anderson Cancer Center and the Banner MD Anderson Cancer Center for the Centers for Disease Control and Prevention National Healthcare Safety Network outcome measure central line–associated bloodstream infection (CLABSI). Adapted with permission.
Summary
The approaches outlined in this report, coupled with a spirit of internal and external collaboration, enable complete translation of the MD Anderson multidisciplinary care model as well as extension of our organizational research mission. Quality management with the ability to benchmark quality metrics against our main Houston campus remains a cornerstone of our overarching strategy to maintain consistent high-quality care throughout our national network.
Acknowledgment
Presented as an abstract at The American Society for Clinical Oncology Quality Care Symposium, San Diego, CA, November 30-December 1, 2012.
Authors' Disclosures of Potential Conflicts of Interest
The author(s) indicated no potential conflicts of interest.
Author Contributions
Conception and design: William J. Simeone Jr, John Bingham, Thomas W. Burke
Administrative support: Thomas W. Burke
Data analysis and interpretation: Thomas W. Burke
Manuscript writing: William J. Simeone Jr, Peter W. T Pisters
Final approval of manuscript: William J. Simeone Jr, John Bingham, Thomas W. Burke, Peter W. T Pisters