Cancer Program 2013 Annual Report

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Currently there are approximately 1500 Commission on Cancer (CoC) accredited cancer programs in the US and Puerto Rico.

These program represent 30% of all hospitals that provide more than 70% of all cancer care.

The focus of a CoC accredited cancer program is to ensure that all patients receive a full range

of: diagnostic, treatment and supportive services including outreach to community-based resources.

Our cancer program is accredited by the Commission on Cancer and received Five (5) Commendations.

The following report provides a “snapshot “ for evaluating and monitoring our accomplishments

over the past year. Our mission is to demonstrate compassion in treating and healing the cancer

patient. Additionally, we address and integrate the dynamics of the involved family and the community we serve.

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Cancer Committee:Jayant Ginde, M.D., Chairman

The goal of the Cancer Committee at Advocate South Suburban Hospital is to develop a comprehensive multidisciplinary approach to foster internal relationships, provide educational venues, and assist in clinical, technological, administrative and data management.

Oncology care at Advocate South Suburban Hospital is based on a multidisciplinary approach. The care offered to patients and families is carried out by a dynamic team that addresses physical, spiritual, emotional and social needs.

The Cancer Committee met each quarter of 2013. New members were added in an effort to enhance the cancer care continuum provided by each department and/or discipline.

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Cancer Liaison PhysicianRiaz Elahi, M.D.

The Cancer Care Staff and Program at our facility is positioned to enhance responsiveness in meeting patient needs.

The cancer program as a whole identified areas for opportunity and development.

Our dedicated professionals imposed measurable goals for the purpose of raising the bar in theorientation of cancer standards and quality practices.

We have a collaborative and systematic approach in strengthening our internal processes. The outcome of this effort is benchmarked in terms of improved cancer services as relating to patient care, data collection / reporting and team building.

Our accomplished goals during 2013 included:

Chemotherapy process improvements and educational forums National Quality Forum, Commission on Cancer Breast and Colorectal measures, our levels are consistent with or

exceed designated levels. Benchmarked comparison in prostate cancer; we reviewed stage, national treatment guidelines and survival,

outcome demonstrated that the care we provide to patients is consistent with NCCN guidelines. Ongoing quality data random review, outcome measures are in the high 90 th percentile Tracking of patients referred elsewhere for clinical research trials Quarterly review and dissemination of National Cancer Data Base Reports to the Cancer Committee

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Our Dedicated Oncology Staff:Karen Gordon, Director, Oncology and Pharmacy

Our ancillary services include nurses that are (oncology certified), patient care navigators, pharmacists, rehabilitation and nutrition specialists, certified cancer related technicians and cancer data specialists.

We provide continuity beyond our walls and reach into the home and community setting. In 2012, weestablished genetic counseling via referral to one of our sister hospitals. This year counselors are available one day a week on site at our campus and attend weekly case conference meetings.

We educate our patients and evaluate individual needs for their home environment. Our oncology patient nurse navigator collaborates with clinicians and other cancer care team members to assess individualized needs for patients and families.

We implemented a psycho-social assessment distress tool for our outpatient oncology patients in the hopes of pinpointing and addressing specific needs in wellness management.

We provide ongoing support and have established partnerships with community and national organizations. A show-case of services available at Advocate South Suburban Hospital and those of our community partners complimented the program.

We have a healing spiritual ministry, a dedicated in-house hospice unit and bereavement care.

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Cancer and Case Conferences:Shantha Sreekanth, M.D.Cancer Conference Coordinator

The purpose of this forum is to discuss and recommend best practice management and individualize it to the patient. Assessment is based on the Clinical AJCC stage of disease, national guideline standards and quality of life. The Cancer Registry documents the patient abstract.

The weekly case conference met and exceeded its goal for 40 meetings in the year (42 actual meetings).We presented over #300 prospective cases or approximately 50% of the analytic cases projected forthe year. The number of cases presented exceeded accreditation standards. The majority of cases discussed are prospective in nature and we recommend initial treatment based on apatients individual needs and national care guidelines.

Regarding Site specific conferences, Breast Case Conference is held twice a month and all other weeks focus on Prostate, Colo-rectal, Lung, Gyne, GU and other general sites.

Attendance of all required disciplines has been and continues to be met; Diagnostic Radiology, MedicalOncology, Pathology, Radiation Oncology and Surgery. The collaborating disciplines continue to provide process improvements. The meetings are open to all oncology health-care professionals and is well attended by the core cancer team members.

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Annual Educational Symposiums:Sue Serratore, RN, BSNProfessional Medical Education Coordinator

Two didactic cancer-focused lectures are held on an annual basis for the purpose of clinician and ancillary oncology staff education .

An off site Physician/Oncology Staff Lung Cancer Symposium was hosted during the month of April. The dinner program was well attended and received.

Guest speakers represented topics that included research, intervention with surgery, chemo and radiation therapy as well as the use of genetic testing and counseling for patients and their families.

The second program was held on campus in the lecture halls. The program focused on female reproductive system cancers and our guest lecturer was one of the Advocate Gyne-oncologists; Patrick Lowe, M.D.

The third educational program was targeted to compliment our annual site and quality review which focused on Prostate Cancer. The forum was incorporated into our weekly case conference and was held on the last Wednesday in October. Educational discussion focused on latest treatment opportunity forthis disease and the facilitator was Rajesh Patel, M.D., Surgeon/Urology.

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Diagnostic Radiology:

Steven Klepac, M.D., Radiologist

The Diagnostic Imaging Department at Advocate South Suburban Hospital provides comprehensive

inpatient, outpatient and emergent diagnostic services. The Diagnostic Imaging Department consists of

eight different modalities.

They include Radiology, MRI, CT, Ultrasound, Vascular, Nuclear Medicine, PET/CT

and Mammography. The following departments are accredited by their respective organizations: CT,

MRI, Nuclear Medicine, Ultrasound, Vascular and Mammography.

Pathology:

Shantha Sreekanth, M.D., Director Pathology

Examinations of specimens by our team of pathologists provide expert opinion on type of cancer,

histologic review, p-AJCC staging and prognostic factors. The pathology department is accredited

by the College of American Pathology and all three pathologists are board certified.

Collaborative effort by the Pathology Department and the Cancer Registry includes review on a

retrospective basis. Results range at the 95+ percentile level as the pathology department uses synoptic

reporting for cancer cases.

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Ambulatory Care and Pharmacy:B.J. Haag, Director Ambulatory Care

Adult patients receive chemotherapy at the ambulatory treatment unit. The caring staff, oncology certified nurses and pharmacists, provide one-on-one assistance (before andduring the first treatment and during the treatment.) Nurses provide education and are always available to follow up with each patient.

Objective for study – Patient and staff safety in handling and administration

of chemo therapeutic agents.  Outcome/ Result: A new process was defined that has been implemented and refined during the year. 

Education was conducted with pharmacy and nursing staff  and daily chemo grand rounds established.

Radiation Therapy On-Campus Care:Jayant Ginde, M.D., Medical Director

Trained board-certified radiation oncologists are highly experienced and skilled in a wide range of standard and emerging treatments. The Advocate South Suburban Cancer Center located on our hospital campus provides the patient with expert care and offers community based convenience. Our facility is accredited by the Accreditation Association for Ambulatory Health Care, Inc.

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Oncology Nursing Certification and Ongoing Patient Care Curriculum and Survivorship:Felicia Stubbs, Manager

The nursing staff is committed to providing high quality care to oncology patients and their families. We have three OCN’s (Oncology Certified Nurses) on staff. We have dedicated patient nurse navigator(s)that work with patients, physicians and families in developing a pathway for appropriate cancer treatment.

Ongoing education and training includes: Competency requirement:

3 Day Care of the Oncology Patient Class 2 Day Chemotherapy and Biotherapy Class Chemotherapy medication exam Unit base practicum Annual skills fair Continuing Education:

Subscription to oncology publications and journals Monthly quality audits on chemo documentation with subsequent follow up education Chemo drug of the month educational posting Quarterly medication quizzes

Our nurses work with each patient and family and provide individualized assessment and ongoing services in an effort to provide a continuum in survivorship plan and care.  Currently Advocate has Cancer Survivorship at a system wide level.

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Nutritional Assessment:

Ann O’Malley, Nutritionist

Nutritional assessment is available for both inpatients and outpatients. The following procedure is in place at our facility:

Inpatient Cancer patients:All patients are screened nutritionally within the first 24 hours by nursing.The nutrition screening questions that are asked are as follows: Poor intake greater than one week Unplanned weight loss of 7 pounds or more in a month Any open pressure ulcers (stage 2, 3, 4) Tube Feedings/TPN at home

The nutrition triggers: When a patient is identified at nutritional risk, a daily report is generated to the Food and Nutrition Department. The Registered Dietitians (RD) review this report daily and the patients that are at nutritional risk are seen within

24-48 hours. Any member of the Multi-Disciplinary Team may identify a patient at nutritional risk and request an RD consult via

Care Connection at any time during the patients hospital stay. The Registered Dietitian is responsible for the nutrition assessment, nutrition care plan and reassessment of the

patient. Outpatient Cancer patients: RD is available for consultation upon request. Patients will be provided a meal during their stay when requested.

 

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Palliative Support and Spiritual Care:Jenise Diemer, Patient Nurse Navigator and Rev. Larry Jackson, Vice President Spiritual Mission

The management of ongoing support to our patients and families provides a myriad of cancer services. These services are to help patients and families cope with the day to day details of a cancer diagnosis.

The oncology nurse navigator provides assessment of patient needs and coordinates referrals with physicians for treatment and ongoing support services. We provided a resource fair and invited all of our community partners to showcase reach out services and programs available for our patient, family and care givers.

Services provided by the Patient Nurse Navigator, Case Manager / Social Worker and Spiritual Staff include:

Counseling and SupportReferral to Nutritional GuidanceCare Coordination in concert with the medical plan of careInformation and referrals regarding community servicesLegal and/or financial referralsTransportation arrangementsDischarge arrangements include homecare services, rehab and short or long term care placement Cope and Bereavement Counsel

Hospice Care:Loretta Scurlock. RN, Manager and Jennifer Thelen, RN, Hospice Liaison

End of life care services include home hospice as well as provision of comfort care in our on-site Hospice unit. This service is led with the philosophy of providing compassion, pain management and dying with dignity. Bereavement services are offered to the patient’s family and friends.

Rehabilitation:Melissa Rodenas, Lymphedema and Rehabilitation Specialist

Rehabilitation plays a significant role in assisting patients with cancer. We offer an on site unit and provide gait and transfer training, therapeutic exercise, lymphedema care. Education and counseling on safety techniques for patients and their caregivers are included as part of our treatment plan.

Genetic Counseling:Cristina Ruiz, Terri Blasé, Deborah Oleskowicz, Genetic CounselorsWe have three licensed genetic counselors that are on site every Wednesday. The counselors attended our weekly case conference and provide input on the need for genetic screening, counseling and testing. This year we implemented clinic hours at our Cancer Center which is located on campus.

Research:

Research information is currently available via an oncologist or other cancer specialtyconsult with the individual patient. Currently we work with physician partners that are principal investigator's and offer clinical trial participation on a referral basis only.

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Community Partnership:Lenora Bridges, Community Outreach Coordinator

We provide ongoing outreach programs in a collaborative manner. Our Community Coordinator, and Patient Nurse Navigators and members of our cancer team as whole actively participated and/or hosted the following programs during 2013:

Cancer awareness lectures and programs Smoking Cessation Programs Wellness Programs ACS local unit partnership (CP3 study) Annual cancer screenings for our patients and the community ASSH services Financial support to Cancer Organizations Referral pattern to community partners Spring Tulip Garden Ceremony at the hospital entrance Skin Cancer Screening Summer Prostate Community Education Lecture and Screening Breast Health Awareness October: On site: Mammography Screening / Informational Display Tables

Community lectures targeted Churches, Schools and Local Manufacturers

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Marketing:

Shannon Homolka, Manager of Public Affairs and Marketing

Advocate as a whole engaged in extensive marketing and advertising campaigns to promote its cancer services during 2013.

Mass media and digital campaigns

Activities include the development and placement of newspaper and magazine ads and transit/outdoor billboards

Mammogram campaign – robust direct marketing campaign directed are lapsed and new mammography patients

Advocate South Suburban Hospital Gala Event with proceeds benefiting our Cancer Program

“Stories of the Girls” marketing campaign – guaranteeing a mammography scheduled within 24 hours

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Quality of Cancer Registry Data: Alida Wagner, Catherine Haynes, Abby Bazan

Implemented efficiency measures and improved project management:

Collaborated with quality department for purposes of capturing place of birth in the Electronic Medical Record (EMR) and cancer registry abstract.

Developed and implemented a comprehensive Quality Control (QC) plan that included revised departmental Policy and Procedures and a designated QC- CTR review with CLP/Cancer Committee Chairpersons.

Reviewed re-abstraction of cancer cases for Quality Improvement (e.g.10%) and an annual site study review with rates in data capture and reporting at the 90+ percentile rate.

Submitted 2012 National Cancer Data Base (NCDB) data in timely manner. Conducted preliminary quality data checks, and submissions have been error free.

Cancer incidence reporting for the Illinois State Cancer Registry is current and we received a recognition certificate.

Life long follow up on our cancer patients exceed the 90% standard with our average being 93% or better.

Improvement Study:

National Quality Forum Indicators reviewed for breast and colo-rectal cancer. Outcome of review provided validation that the treatment modalities provided by our oncology team is consistent with indicator measures set by national organizations that monitor quality in patient care.Reviewed CP3R data for quality improvement; rates are consistent with national guidelines set forth in collaboration with the Commission on Cancer.

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Every year our Cancer Committee evaluates a site to review quality in data,, assess treatment methods in comparison to National Standard Guidelines and validate opportunity for process improvement. During 2013 our team reviewed Prostate Cancer in phases and results were presented at each quarterly Cancer Committee meeting. Results are as follows:

The American Cancer Society estimates that prostate cancer is the most common cancer in men in the United States.

Our facility supports endeavors for early stage diagnosis and provides annual screenings in our community; the majority of our patients have early stage disease.

The Gleason score provides an effective measurement that helps clinicians determine the severity of disease and treatment planning. The higher the Gleason grade, the more aggressively the cancer behaves in the body. Our pathologists use synoptic reporting that includes the score and is consistent with regulatory protocols set forth by the College of American Pathologists (CAP Protocols).

The American Joint Committee on Cancer (AJCC) TNM System, in conjunction with results from the PSA level, and Gleason score, provide informatics in prescribing standard of care. The stage (extent) of a cancer is one of the most important factors in the planning of treatment.

The majority of analytic prostate cancer patients seen at our facility were diagnosed with an earlier stage disease. Surgical intervention was the most common type of first course of treatment prescribed by our cancer care team.

Radical Prostatectomy (RP) is surgery that attempts to cure prostate cancer. It is used most often if the cancer is thought to be contained within the gland (stage T1 or T2 cancers). The most common approach is via LRP (Laparoscopic Radical Prostatectomy) a robotic interface. Treatment offered to our patient population is consistent with National Comprehensive Cancer Network (NCCN) guidelines.

Conversely, the five-year overall survival rate at our facility (86%) is consistent when comparing to National Cancer Data Base (NDCB) data (88%).

Jayant Ginde, M.D., Cancer Committee Chairman; Alida Wagner, CTR, Quality Cancer Data Coordinator

Begin Cancer Graphs

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Harvey: 7%

Hazel Crest: 6%

Chicago Heights: 5%

Communities <=4%Calumet City

Chicago HeightsChicago Ridge

Country Club HillsDolton

FlossmoorFrankfort GlenwoodHomewood

LansingMidlothian

MokenaMonee

Orland ParkRichton Park

South HollandTinley Park

Cancer Registry Data, Statistical Data

2013 Annual Year

48

7866

58

126

113119

152

136

188

184

184

151

179

145

170

103

116

102

94

0

2040

60

80

100120

140

160

180200

<=49 50-59 60-69 70-79 80+

Advocate South Suburban Hospital Age DistributionThe Mean age is = 65 years of age

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Cancer Registry Data, Statistical Data n= All Cases Analytic + Non-Analytic

2009 = 5642010 = 6742011 = 6162012= 658

78

30

26

1816

13 11

15 15

8

12

910

0

5

10

15

20

25

30

Stage 0 Stage I Stage II Stage III Stage IV N/A Unknown

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Commission on Cancer, National Cancer Data Base (NCDB) 2011

Stage Comparison/ Percent Distribution Advocate South Suburban Hospital

VersusAll AHC Accredited Hospitals

Definitions & Abbreviations:

Analytic: Patients initially diagnosed and/or received part or all of first course of treatment here. Non-Analytic: Patients that are seen for recurrent disease and/or progressive disease.

Stage: Stage of disease, the extent / spread of disease when initially diagnosed. The stage system used here is AJCC (American Joint Commission on Cancer) or referenced as

TNM. T= Tumor size, N= Lymph node involvement, M=spread to other areas/organs. Classification in TNM Is assigned a group number. Stage 1-4. Stage 1 being early disease and Stage 4 advanced disease. Stage 0 reserved for the non-invasive cancers: in situ

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Cancer Committee Members:

Jayant Ginde, M.D., Radiation Oncology, Cancer Committee Chair Vasia Ahmed, M.D., Medical Oncology, Vice Chair, Cancer Committee Riaz Elahi, M.D., Medical Oncology, Cancer Liaison Physician Shantha Sreekanth, M.D., Director Pathology, Cancer Conference Chair Steven Klepak, M. D., Diagnostic Radiology James O’Donnell, M.D,, General Surgery Rev. Larry Jackson, Vice President, Spiritual Mission Susan Grelak, Quality Improvement Manager and appointed Coordinator Lenora Bridges, Community Out Reach Coordinator and appointed Coordinator Karen Gordon, Director Oncology and Pharmacy Alida Wagner, Cancer Registry Coordinator and appointed Quality Cancer Registry Data Coordinator Cristina Ruiz, Genetics Counselor Felicia Stubbs; Maggie Schultz, OCN-Oncology Nurse BJ Haag, Director Ambulatory Services and Palliative Care

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Cancer Committee Members, Continued

Stephanie Applebaum, M.D. PathologyRami Haddadm M.D., Medical Oncology, Palliative CareVasanta Kumaraiah, M.D., Medical OncologyAnil Lamba, M.D. , General SurgeryJohn McKeown, M.D., Medical OncologyGary Peplinski, M.D., General SurgeryAlia Salhadar, M.D., PathologyLindseu Job, M.D./Shailu Gandhi, M.D.

Karen Clark, Vice PresidentMelissa Rodenas, RehabShannon Homolka, Mgr Public Affairs and MarketingAnne O’Malley, Spvr. Clin. NutritionSusan Serratore, Coord Med. StaffLesliey Adams, Mammography CoordinatorChristine Rosandich, Cancer Support CenterKelly Ford, Adm. Asst. OncologyEdward Warren, Network Development Mgr.Danielle Swets, American Cancer SocietyLisa Vidovic, Director Medical Records & Regulatory ComplianceCatherine Haynes, Cancer RegistrarJenise Diemer, Patient Nurse Navigator/ Palliative Care