By Jeffrey Carter, PhD; Caroline Pardo, PhD; Cherilyn Heggen, PhD; Tamar Sapir, PhD; and Kathleen Moreo, RN, B-C, BSN, BHSA, CCM, Cm, CDMS, PRIME Education, LLC
In response to national initiatives for quality improvement (QI), healthcare professionals face formidable challenges in transforming cultural dynamics and clinical practices toward achieving benchmarks for high-quality, patient-centered care. These challenges have created exciting new opportunities for continuing education professionals. In this awarding-winning project, PRIME Education designed, executed and evaluated a QI education program that supported U.S. hematology-oncology teams in improving systems-based care processes for patients with chronic lymphocytic leukemia (CLL).
One of the most common types of leukemia in adults, CLL is characterized by the accumulation of cancerous B-cells in the lymph nodes, spleen and liver. Challenges in providing high-quality care for CLL patients stem from its complex genetic basis; the indolent nature of the disease; its high prevalence in older adults, many of whom have comorbid conditions; and its rapidly expanding treatment landscape. Through needs assessment studies applying CLL patient-provider surveys and chart audits, our research team at PRIME identified major gaps in CLL care quality that are associated with these defining challenges of the disease and its treatment. We found that, in addition to suboptimal performance of clinical quality measures and evidence-based guidelines for CLL assessment for guiding treatment decisions, many of these gaps were rooted in systems-based processes, including ineffective care coordination and communication among interprofessional team members and patients.
Design of the QI Education Program
To support interprofessional hematology-oncology teams in closing pivotal gaps in CLL care quality, we designed a QI education program for implementation in four large and diverse healthcare systems across the country. Participants in the IRB-approved program included hematologists-oncologists and their clinical teams of nurses, nurse practitioners, physician assistants and case managers. At baseline, the QI cohort completed surveys designed to assess quality-related aspects of CLL knowledge, attitudes and competence. To assess performance on evidence-based CLL clinical quality measures and practice guidelines, along with patient-centered and systems-based measures of care quality, we audited the electronic medical records (EMRs) of 200 patients with CLL.
We applied our analyses of the survey and EMR data to designing gap-targeted QI education interventions, which comprised strategically timed live audit-and-feedback activities organized in plan-do-study-act (PDSA) cycles. The feedback was presented by CLL experts from outside the participating healthcare systems. In addition, to promote sustainability and scalability, the educational interventions included multi-accredited online activities, which we disseminated through various channels to a nationwide audience of interprofessional healthcare providers.
Six months after the educational interventions, we audited another 200 CLL patient EMRs in the participating systems. We also analyzed post-education surveys completed by members of the QI cohort. Statistical analyses were conducted to assess the impact of the educational interventions on quality-related knowledge, attitudes, and competence — as well as on EMR-documented compliance with CLL clinical practice and patient-centered quality measures.
Positive Performance Outcomes of the QI Education Program
EMR analyses indicated that the QI education program was associated with statistically significant and clinically meaningful improvements in the hematology-oncology teams’ rates of compliance with evidence-based guidelines and quality measures for CLL assessment.
- 23 percent for CLL staging
- 22 percent for use of flow cytometry for diagnosis
- 26 percent for use of fluorescence in situ hybridization (FISH) testing for mutation status
- 10 percent for functional status assessment
Moreover, our analyses demonstrated positive educational outcomes for the team-based and patient-centered care processes. EMR-documented performance rates increased by:
- 17 percent for essential care coordination and communication practices
- 7 percent for communicating with CLL patients about their treatment goals
- 18-20 percent for counseling patients about CLL treatment options and risks/benefits
National Recognition of the Program’s Impact and Value
This award-winning program demonstrates positive outcomes of a QI education initiative on key indicators of quality care for patients with CLL, including clinical assessment practices, patient counseling, and care coordination across large and diverse U.S. healthcare systems. Moreover, the outcomes reflect process improvements that are essential for sustainable and scalable change in these systems.
In addition to receiving the ACEhp Award for Outstanding CE Outcomes Assessment, the impact and value of this QI education program are reflected by acceptance of an abstract for our presentation of the program methods and findings at the 2017 annual meeting of The American Society of Hematology.1
Independent medical education support for this initiative was provided by Genentech.
- Davids M, Mato AR, Pagel J, Lad T, Mateka JJL, Heggen C, Carter JD, Sapir T. A quality improvement initiative advancing CLL care practices across four US health systems. Poster presentation at the 59th Annual Meeting and Exposition of the American Society of Hematology; Atlanta, GA; December 9, 2017.