Improvement from July 2016 Front Office to Front Line ... · Diagnosing and Treating “Alarm Fatigue”: ... set a 10-year goal of reducing CRC mortality by ... Identifying Evidence-Based

www.jcrinc.com

Improvement fromFront Office to Front Line

July 2016Volume 42 Number 7

“Although designed specifically for introduction of

a new monitoring system in the general care setting where none previously existed, the

described methods are largely generalizable to a wide variety

of systems where patient monitoring is in place

to prevent harm.” —Surveillance Monitoring Management

for General Care Units: Strategy, Design, and Implementation

(p. 300)

Designing a Patient Surveillance Monitoring System for General Care UnitsFeaturesClinical Monitoring

■■ Diagnosing and Treating “Alarm Fatigue”: Pragmatic and Evidence-Based Approaches Needed

■■ Surveillance Monitoring Management for General Care Units: Strategy, Design, and Implementation

Methods, Tools, and Strategies■■ Using Literature Review and Structured Hybrid Electronic/Manual Mortality Review to Identify System-Level Improvement Opportunities to Reduce Colorectal Cancer Mortality

Performance Improvement■■ Perceived Factors Associated with Sustained Improvement Following Participation in a Multicenter Quality Improvement Collaborative

Departments Case Study in Brief

■■ PSYCH: A Mnemonic to Help Psychiatric Residents Decrease Patient Handoff Communication Errors

■■ Managing Disruptions to Patient Flow Capacity: Rapid-Cycle Improvement in a Pediatric Cardiac Procedure Complex

Tool Tutorial■■ A National Organizational Assessment (NOA) to Build Sustainable Quality Management Programs in Low- and Middle-Income Countries

Forum■■ Behavioral Health Integration in Acute Medical Settings: An Opportunity to Improve Outcomes and Reduce Costs

The Joint Commission Journal on Quality and Patient Safety

Volume 42 Number 7July 2016 303

Of all cancers that affect both men and women, colorectal cancer (CRC) is second only to lung cancer in both inci-

dence and mortality.1 In 2009–2013, incidence and mortali-ty rates in the United States were 41.0 and 15.1, respectively, per 100,000 men and women.2 Much research related to CRC focuses on improving treatment efficacy, but opportunities for improving systems of care also exist. For example, one in three adults in the United States has not been screened for CRC as recommended3; a national action campaign promotes CRC screening among men and women aged 50 years and older.4

In 2006 Kaiser Permanente Southern California (KPSC; Pasadena) began leveraging the electronic health record (EHR) to improve screening rates for many conditions, including CRC.5 The CRC screening rate for the eligible population using Healthcare Effectiveness Data and Information Set (HEDIS) criteria improved from 45.3% in January 2006 to 81.9% in August 2014. However, in 2012, we also noted infrequent de-lays in diagnosis arising from failure to recognize iron deficiency anemia and/or rectal bleeding as possible CRC symptoms. We created an electronic “safety net” to increase the reliability of diagnostic processes and prevent advanced-stage CRC at diag-nosis.6 Decreasing CRC mortality rates reflect improved detec-tion. In 2014 the KPSC five-year mortality rate (25%) was 29% lower than comparable national rates (35%).2

However, we believed a substantial proportion of CRC mor-tality could be prevented through more prompt evaluation of suspicious symptoms and improved surveillance and treatment. Consequently, quality and clinical leaders [J.E.S., M.H.K.] at the Southern California Permanente Medical Group (SCPMG; Pasadena) set a 10-year goal of reducing CRC mortality by 50%, from a three-year (2009–2011), age- and gender-adjusted average of 13.8 to 6.9 per 100,000 patients per year. To the best of our knowledge, no organization has achieved comparable re-ductions in CRC mortality, and little guidance exists in the lit-erature as to how to achieve this goal. Consequently, our first step was to identify and examine system-level factors that both

Methods, Tools, and Strategies

Using Literature Review and Structured Hybrid Electronic/Manual Mortality Review to Identify System-Level Improvement Opportunities to Reduce Colorectal Cancer MortalityJoanne E. Schottinger, MD; Michael H. Kanter, MD; Kerry C. Litman, MD; Helen Lau, RN, MHROD;

Gary E. Schwartz, MD; Farah M. Brasfield, MD; Najeeb S. Alshak, MD; Louis A. DiFronzo, MD

Article-at-a-Glance Background: Despite colorectal cancer (CRC) screening and survival rates exceeding national averages in the Unit-ed States, Kaiser Permanente Southern California (KPSC) aimed to identify system-level improvement opportunities to further reduce mortality from CRC.Methods: To examine modifiable factors contributing to CRC mortality, a structured hybrid electronic/manual mor-tality review was used to examine 50 randomly selected cases among 524 individuals aged 25–75 years diagnosed with stage II, III, or IV CRC after July 2008 who subsequently died. Physicians conducted chart reviews using a standardized data extraction tool based on evidence-based best practices.Results: Eighty-six percent (43) of the 50 decedents were initially diagnosed with stage III or IV CRC; two cases of ap-pendiceal cancer were excluded. Thirty-one percent (15) of the remaining 48 cases presented with no history of screen-ing; 15% (7) had documented iron deficiency anemia and abdominal pain or rectal bleeding; and 6% (3) had no fol-low-up colonoscopy after positive screening. Eleven (52%) of the 21 patients with initial stage II-III CRC received ap-propriate surveillance after curative surgery; 57% (12) devel-oped metastases. Adjuvant chemotherapy was offered to 88% (14/16) of patients with stage III (node-positive) CRC; che-motherapy initiation was delayed in 6 patients. Missed op-portunities for surgical oncology evaluation occurred among 61% (11/18) of patients with liver metastases at diagnosis. Failure to report clinically significant features on pathology occurred in 2 patients; they received appropriate treatment for other reasons. Conclusions: Improvement opportunities existed at mul-tiple stages of care, including screening, evaluation of symp-toms, timeliness of care, use of adjuvant chemotherapy, and surgical oncology practices.

Copyright 2016 The Joint Commission


Volume 42 Number 7July 2016304

potentially affected mortality and could be modified.Structured mortality reviews can effectively pinpoint evi-

dence-based system-level quality improvement (QI) opportuni-ties.7–9 Mortality reviews use structured data extraction tools to assess the health care records of deceased patients and identify modifiable system issues contributing to avoidable deaths.10–12 Structured mortality reviews can be used to examine deaths or adverse outcomes related to condition-specific care (“eAutop-sy”).13 Previous KPSC experience with mortality review process-es yielded system-level improvement opportunities.11,13

We report here on an evidence-based structured mortality review conducted to identify system-level opportunities to im-prove CRC surveillance and treatment.

MethodsSetting KPSC is one of seven regions of Kaiser Permanente, the na-tion’s largest not-for-profit integrated health care delivery sys-tem. Nearly 62,000 employees and staff and more than 6,000 physicians representing nearly every clinical specialty provide care for 4.1 million members. An integrated EHR is available at all points of care—14 medical centers and 209 medical of-fices—and approximately 1.6 million KPSC members are regis-tered on kp.org, the EHR patient portal.

Mortality review ProceSS The mortality review process is summarized in Sidebar 1

(right). We reviewed the literature to identify modifiable sys-tem-level factors affecting CRC mortality and then examined whether these issues arose in our delivery system by filtering electronic patient records to identify cases for review, develop-ing a data extraction tool, manually reviewing patient charts, and analyzing the data.

Identifying Evidence-Based Best Practices. We used clin-ical guidelines from the National Comprehensive Cancer Network (NCCN) and the literature to identify potentially modifiable factors occurring after screening and diagnosis that were potentially associated with CRC mortality. NCCN guide-lines pertained to surveillance schedules after curative surgery, pathologic review, adjuvant chemotherapy use and timeliness, and surgical treatment.14 We also assessed the prevalence and clinical impact of side effects from chemotherapy and radiation therapy, the contribution of comorbid conditions to mortality, and the use of perioperative blood transfusions.15,16

NCCN clinical guidelines and the literature review also pro-vided evidence about factors associated with reduced mortality that were being addressed by existing or planned QI initiatives

at KPSC. These included universal screening for Lynch syn-drome and tracking physician adenoma detection rates during colonoscopy.14,17 Finally, the literature review provided evidence about the potential benefits of aspirin and vitamin D use and exercise.18–31

Electronic Filtering of Patient Records. We electronically filtered all KPSC patient records by variables contained in the hospital coding database to obtain a pool of charts from which to select cases for review. We identified individuals aged 25 to 75 years with stage II, III, or IV CRC diagnosed after July 2008 who subsequently died. Of 524 patients meeting these criteria, we se-lected every fifth case until 50 cases for review were identified.

Data Extraction Tool Development. The data extraction tool was developed by two authors [K.C.L., H.L.] who were experienced at conducting focused mortality reviews for QI, in consultation with the KPSC clinical leader for oncology [J.E.S.]. The iterative development process took place in a two-month period. In our previous structured mortality reviews, limiting the number of questions to approximately 20 kept the process from becoming burdensome for reviewers, so we aimed for the same number of questions and used response options of yes/no/other when possible. They were designed to identi-fy areas of practice variation or failure to provide evidence- or consensus-based care that potentially impacted outcomes. We focused on care pathways occurring after diagnosis, eliminating evidence-based factors for which QI efforts were already under way and for which EHR documentation was inconsistent (for example, use of over-the-counter products and exercise).

We divided the data extraction tool into sections for review by physicians with specific clinical and QI expertise. Three re-viewers validated the tool by applying it in a small sample of

Sidebar 1. Mortality Review Process

• Obtain leadership support and sponsorship for the review.• Identify a clinical topic to be reviewed and the outcome of interest.• Review the literature in the clinical topic to identify system-level

factors potentially affecting the outcome of interest that can be modified (for example, care pathways and processes).

• Collaboratively with experts in the clinical topic, develop a data extraction tool comprising approximately 20 questions and reflecting evidence-based modifiable factors.

• Identify the population of affected patients and sample charts by random or purposeful sampling (for example, consecutively over time).

• Conduct manual chart reviews using the data extraction tool and expert clinicians in domains of the clinical topic (for example, surgery, oncology, radiology, pathology).

• Tabulate results.• Identify quality improvement opportunities and report to leadership

to address identified system improvements.




cases to ensure that questions were unambiguous and compre-hensible. Some questions were added or edited in response to their input. The complete tool included 17 items with yes/no/other response options and six text fields for specific data or clarifying “other” responses (Appendix 1, available in online ar-ticle). An additional item solicited a narrative case summary, in which reviewers identified opportunities to improve, delays, unique aspects, errors, and other salient factors. In our previous experience, sharing brief case narratives effectively communi-cated system-level issues and opportunities to senior leaders in a patient-centered and accessible manner, helping to inspire and energize QI.11

Manual Review Process and Analysis. Between August 2013 and February 2014, six physicians with expertise in pa-thology [N.S.A.], surgical oncology [L.A.D.], medical oncol-ogy and hematology [J.E.S., G.E.S, F.M.B.], and QI [K.C.L.] conducted chart reviews. Each reviewer looked at items on the data extraction tool relevant to his or her area of expertise. Man-ual reviews required 15–30 minutes per case for each reviewer, depending on complexity.

When manual reviews were complete, we [J.E.S., K.C.L., H.L.] aggregated and analyzed the data to identify patterns re-flecting variations in care or gaps between evidence-based care and the care patients received. The study received approval from the KPSC Institutional Review Board.

ResultsOf the 50 cases reviewed, 10% (5) of decedents were initially diagnosed with stage II CRC, 31% (16) were initially diagnosed with stage III disease, and 54% (27) were initially diagnosed with stage IV disease. Two (4%) of the 50 cases of primary ap-pendiceal cancer were excluded from further analysis.

Surveillance. For the remaining 48 cases, we assessed the adequacy of surveillance after curative surgery and the devel-opment of metastases in 21 patients with stage II-III CRC at diagnosis. The proportion of cases in which patients received surveillance was 52% (11) for follow-up colonoscopy at one, three, and five years, 52% (11) for carcinoembryonic antigen (CEA) testing every six months for five years, and 57% (12) for computerized tomography (CT) scan of chest/abdomen/pel-vis. Reasons why decedents did not receive surveillance includ-ed death from surgical complications or comorbid conditions, patient refusal, and discontinuation of KPSC membership. Among patients with stage II-III CRC at diagnosis, 57% (12) developed metastases.

Medical Treatment. We examined the use of adjuvant che-motherapy among patients for whom it was indicated and the

prevalence of serious side effects. Among 16 patients with stage III (node-positive) CRC, adjuvant chemotherapy was offered to 88% (14). Ten (63%) patients completed adjuvant chemother-apy; 1 patient and 1 health care proxy declined, and 2 patients had severe side effects necessitating discontinuation. Adjuvant chemotherapy was not offered to 2 patients because of their baseline medical or functional status.

For 6 patients, adjuvant chemotherapy was initiated > 35 days after surgery; wait times beyond 35 days ranged from 1 to 11 weeks. Initiation was delayed in 3 patients because of pro-longed recovery from tumor resection or poor performance sta-tus; reasons for the delay were not specified for the remaining patients. One patient with high-risk stage II CRC (< 12 lymph nodes resected) was not offered adjuvant chemotherapy for unclear reasons. Among 10 patients receiving chemotherapy, serious side effects occurred in 33% (3), resulting in dose mod-ifications and early discontinuation.

Timeliness of Surgical Interventions After Development of Metastatic Disease. We assessed the timeliness of surgical intervention following the development of metastases among patients with stage II-III CRC at diagnosis. No patients who de-veloped metastatic disease while under surveillance experienced delays in referrals to a surgical oncologist or between surgical oncology evaluation and a subsequent operative procedure.

Pathology Findings. The goal of the pathology review was to look for unreported histologic/pathologic clues that might have contributed to understaging. Focal areas of the review included the number of lymph nodes recovered, evidence of micrometas-tases in lymph nodes, lymphovascular invasion (LVI), histologic subtype of the carcinoma (signet ring and mucinous), and the status of margins, particularly radial.

Slides were available for 33 cases. No evidence was found for understaging of disease. In 9 patients, fewer than 12 lymph nodes were recovered; 6 of these patients received neoadjuvant or adjuvant chemotherapy or both. Two patients with only dis-ease-free lymph nodes received no chemotherapy. An addition-al patient was too ill to undergo adjuvant chemotherapy after neoadjuvant therapy and surgical resection. LVI and focal muci-nous carcinoma were not reported for 2 patients; however, both received adjuvant chemotherapy for other reasons.

Radiation Treatment. We evaluated the potential impact on mortality of serious side effects from radiation therapy. Of 7 patients receiving radiation therapy for CRC at any stage, seri-ous side effects occurred in 2. However, the side effects did not contribute to mortality.

Surgical Treatment. We assessed referral patterns to surgical oncology for metastatic disease, evidence of disease at surgical




closure, and diagnostic adequacy of surgery. Of 18 decedents with metastatic liver disease on presentation, referral to surgical oncology to evaluate resectability was appropriate for 7 patients. Of these, 3 were referred to surgical oncology and 1 subsequent-ly underwent resection of liver metastases with clear surgical margins. In terms of diagnostic adequacy, among 38 decedents who had surgery after diagnosis, 82% (31) had 12 lymph nodes resected. Two patients had 11 or fewer nodes removed after pre-operative chemoradiation, 1 had a palliative resection, and 1 had surgery before becoming a KPSC member.

Other Treatment and Interventions. We assessed the im-pact of potentially preventable comorbid conditions unrelated to CRC on mortality and the use of blood transfusions. Pul-monary embolism and sepsis were assessed as causing death in 2 patients. The question on blood transfusions failed to specify the CRC perioperative period, yielding uninterpretable results.

Additional Findings. Although the mortality review did not examine screening, reviewers’ narrative summaries identified 15 cases in which patients presented with CRC and no history of screening. Seven patients had documented iron deficiency anemia and abdominal pain or rectal bleeding but had not been screened for CRC; 3 of these patients did not complete the fecal occult blood test (FOBT) or colonoscopy as recom-mended by providers.

DiscussionThe structured mortality review identified improvement oppor-tunities at every stage along the CRC care path in an organiza-tion with baseline screening and mortality rates better than those reported for the population of the United States.1,32 KPSC qual-ity leaders identified five major variations in care that became the focus of continuing efforts to improve CRC detection and treatment: screening, evaluation of symptoms, timeliness of care, use of adjuvant chemotherapy, and surgical oncology practices.

Although CRC screening was not a focus of the structured mortality review and despite a high baseline screening rate, findings from the review identified it as a QI opportunity. Only 3 patients were reported as being up to date on CRC screening at diagnosis. Nearly one third of patients had no documenta-tion of past screening. Consequently, improving screening rates continued as an organizational QI initiative. Strategies to im-prove screening rates included coordinated outreach to all el-igible members using their preferred screening option (FOBT, sigmoidoscopy, or colonoscopy), “live” telephone calls to aug-ment other outreach strategies, in-reach at all ambulatory and inpatient settings, a pilot of colonoscopy outreach for patients at average CRC risk, and maintaining high quality and volume

models of endoscopic care. However, despite high baseline rates and increased effort, we anticipate reaching a screening rate ceil-ing related to nonadherence to recommendations. Among all cases reviewed, 4 were documented as not following through on screening recommendations, reflecting a nonadherence rate of 8.3%. If validated, this indicates a possible ceiling rate of approximately 91%, which KPSC continues to approach. In October 2014, four hospital service areas had screening rates greater than the regional goal of 83%, and the highest ser-vice-area screening rate was 84.4%.

Strategies to improve symptom evaluation include the de-velopment of clinical guidelines for evaluating the co-occur-rence of iron deficiency anemia and rectal bleeding. KPSC has an electronic clinical surveillance program to identify and re-solve potential care gaps in the outpatient setting.5,33 The pro-gram now includes a goal of increasing the use of colonoscopy among members with documented or presumed iron deficiency anemia or a history of rectal bleeding and no colonoscopy in the past 10 years. Outreach typically occurs via automatically generated letters; however, if FOBT outreach kits have not been returned within 30 days, a live call from a trained nurse is made to encourage the patient to return the kit or book a colonosco-py. These calls have increased the kit return rate by about 10%. Since KPCS has implemented outreach, patients with polyps, adenomas, and cancer have received colonoscopy and subse-quent treatment as needed.

The mortality review revealed that 42% of patients who re-ceived chemotherapy did so within 35 days. Biagi et al. found that survival decreased 14% for every four-week delay between surgery and starting chemotherapy.34 To improve timeliness of care, the chiefs of surgery and oncology throughout KPSC adopt-ed a goal of decreasing the time from surgery to chemotherapy, with the goal of 80% of patients starting chemotherapy within 35 days.35–37 The proportion of patients receiving chemotherapy within 35 days gradually improved from 39% in 2013 to 58% in the first half of 2015. The chiefs of surgery and oncology, as well as the KPSC CRC mortality group, track to ensure that evi-dence-based surveillance follows treatment.

Offering adjuvant chemotherapy at KPSC to 88% of pa-tients with node-positive CRC compared favorably with nation-al use rates of 65% among patients with node-positive (N1-2) disease.38 To continue to improve delivery of adjuvant chemo-therapy, KPSC instituted a care pathway in which all stage II patients receive an oncology consultation, which will capture those with fewer than 12 lymph nodes resected. In 2015, 93% of stage II patients received referrals to medical oncology. To improve surgical oncology practices, a metric was implemented




to track the number of patients with metastatic disease on diag-nosis who are evaluated by surgical oncology. As of the fourth quarter of 2015 (October–December), 95% of these patients were seen by surgical oncology. In addition, KPSC developed a multidisciplinary regionwide tumor board, which helps facili-tate referrals and discussion of treatment recommendations.

As noted above, the review of literature revealed other factors related to CRC prevention and detection that were not includ-ed in the structured mortality review. However, additional ma-jor opportunities for improvement in CRC mortality exist, and strategies to address them are under way.

To begin addressing genetic components of CRC, in 2014 the clinical laboratory started universal testing of polyp specimens for Lynch syndrome, for which the lifetime risk of developing CRC has been reported as 8%–53%.39,40 Adenoma detection rates (ADRs) of physicians performing colonoscopy are inverse-ly associated with the risks of developing CRC 6 months to 10 years after the procedure and have been suggested as a quality indicator.17,41 Reducing variations in ADRs across KPSC physi-cians performing colonoscopies is a key QI goal, and KPSC has developed the capacity to generate physician-level ADR reports.

The literature review also identified evidence related to life-style and over-the-counter medications and dietary supple-ments. Increased physical activity after diagnosis with CRC is associated with risk reductions of 45%–61% for CRC mortal-ity and 23%–63% for all-cause mortality.18–20 KPSC providers routinely assess physical activity while rooming patients for am-bulatory care encounters. A first step toward helping patients lower the risk of CRC mortality is to evaluate the frequency with which all patients reporting < 150 minutes per week of physical activity are counseled to increase their activity or re-ferred to health coaching.

Evidence from a limited number of observational studies assessing the role of aspirin in reducing CRC mortality is less robust but highly suggestive.21–26 Finally, emerging evidence suggests that vitamin D intake and serum 25-hydroxyvita-min D levels are inversely associated with risk of CRC.28–30,42 KPSC providers currently recommend aspirin and vitamin D for many members to reduce cardiovascular risk and promote bone health; planned interventions include point-of-care deci-sion support in the EHR to ensure that all appropriate patients take aspirin and vitamin D.

After the first year of implementing multiple strategies, the age- and gender-adjusted average mortality rate for CRC at KPSC decreased from 13.8 to 12.5 per 100,000 patients per year—an encouraging start to the mortality reduction program. The 2015 mortality rate was 11.85 per 100,000 patients. Ongoing assess-

ment is required to track overall progress toward the 10-year goal of 6.9 deaths from CRC per 100,000 patients per year.

Limitations to our review process include the fact that the review question related to blood transfusions did not specify a perioperative time frame; results included transfusions patients received at many points in care, rendering this information less valuable. Despite multiple iterative reviews of the data collec-tion tool, this shortcoming was not detected, highlighting the importance of careful tool review. In addition, we were only able to review patients whose care was provided exclusively at KPSC facilities. Finally, we excluded patients older than 75 years of age because age-related comorbidities may contraindi-cate chemotherapy or surgical interventions. However, patients in this age group comprise a substantial proportion of all pa-tients with CRC. Future reviews should include this group of patients as a subset with specialized questions addressing age- related care issues.

ConclusionsA literature review and structured hybrid electronic/manual mortality review revealed substantial opportunities for improv-ing CRC prevention, screening, treatment, and surveillance. KPSC initiatives address each opportunity. Further research is required to assess the extent to which they contribute to meet-ing our goal of reducing mortality from colorectal cancer by 50% over the next 10 years. J

Joanne E. Schottinger, MD, is Assistant Medical Director, Quality and Clinical Analysis, and Michael H. Kanter, MD, is Medical Direc-tor, Quality and Clinical Analysis, Southern California Permanente Medical Group, Pasadena, California. Kerry C. Litman, MD, is Assis-tant Medical Director, Quality, Performance Improvement and Com-plete Care, Southern California Permanente Medical Group, Fontana, California. Helen Lau, RN, MHROD, is Regional Director for Clinical Performance Excellence, Kaiser Permanente Southern California, Pasadena. Gary E. Schwartz, MD, is a Hematologist and Oncolo-gist, Southern California Permanente Medical Group, Woodland Hills, California. Farah M. Brasfield, MD, is Regional Chief for Hematology and Oncology, Southern California Permanente Medical Group, Ana-heim, California. Najeeb S. Alshak, MD, is a Surgical Pathologist, and Louis A. DiFronzo, MD, is a Surgical Oncologist, Southern Cali-fornia Permanente Medical Group, Los Angeles. Please address cor-respondence to Joanne Schottinger, [email protected].

Online Only Contenthttp://www.ingentaconnect.com/content/jcaho/jcjqs

See the online version of this article for Appendix 1. Data Extraction Tool




References1. National Program of Cancer Registries. United States Cancer Statistics (USCS): 2012 Top Ten Cancers. Atlanta: Centers for Disease Control and Pre-vention, 2015.2. National Cancer Institute. SEER Stat Fact Sheets: Colon and Rectum Can-cer. Accessed May 30, 2016. http://seer.cancer.gov/statfacts/html/colorect.html.3. Centers for Disease Control and Prevention. Sortable Risk Factors and Health Indicators: Preventive Services. Accessed May 30, 2016. http://sortable stats.cdc.gov/#/summary.4. Centers for Disease Control and Prevention. Screen for Life: National Col-orectal Cancer Action Campaign. (Updated: Jul 14, 2015.) Accessed May 30, 2016. http://www.cdc.gov/cancer/colorectal/sfl/.5. Kanter MH, et al. Complete care at Kaiser Permanente: Transforming chronic and preventive care. Jt Comm J Qual Patient Saf. 2013;39:484–494.6. Graber ML, et al. The next organizational challenge: Finding and addressing diagnostic error. Jt Comm J Qual Patient Saf. 2014;40:102–110.7. Move Your Dot™: Measuring, Evaluating, and Reducing Hospital Mortality Rates (Part 1). IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement, 2003.8. Teixeira PG, et al. Preventable or potentially preventable mortality at a mature trauma center. J Trauma. 2007;63:1338–1346.9. NHS Institute for Innovation and Improvement. Leading Improvement in Patient Safety (LIPS) for Acute Care. 2012. Accessed May 30, 2016. http://www.institute.nhs.uk/safer_care/leading_improvement_in_patient_safety _programme/leading_improvement_in_patient_safety_programme_(lips).html.10. Montgomery AL, et al. Capturing the context of maternal deaths from ver-bal autopsies: A reliability study of the maternal data extraction tool (M-DET). PLoS One. 2011 Feb 7;6(2):e14637.11. Lau H, Litman KC. Saving lives by studying deaths: Using standardized mortality reviews to improve inpatient safety. Jt Comm J Qual Patient Saf. 2011;37:400–408.12. Patient Safety Federation. Patient Safety Toolkit: Mortality Review Template. Accessed May 30, 2016. http://www.patientsafetyfederation.nhs.uk/Other -Workstreams/reducing-needless-harm-and-death/resources.aspx.13. Litman KC, et al. E-autopsy: Using structured hybrid manual/electronic mortality reviews identify quality improvement opportunities. Jt Comm J Qual Patient Saf. 2014;40:444–451.14. National Comprehensive Cancer Network. NCCN Guidelines®. Accessed May 30, 2016. http://www.nccn.org/professionals/physician_gls/f_guidelines .asp#site.15. Halabi WJ, et al. Blood transfusions in colorectal cancer surgery: Incidence, outcomes, and predictive factors: An American College of Surgeons National Surgical Quality Improvement Program analysis. Am J Surg. 2013;206:1024–1032.16. Acheson AG, Brookes MJ, Spahn DR. Effects of allogeneic red blood cell transfusions on clinical outcomes in patients undergoing colorectal cancer sur-gery: A systematic review and meta-analysis. Ann Surg. 2012;256:235–244.17. Corley DA, et al. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med. 2014 Apr 3;370(14):1298–1306.18. Ballard-Barbash R, et al. Physical activity, biomarkers, and disease out-comes in cancer survivors: A systematic review. J Natl Cancer Inst. 2012 Jun 6; 104:815–840.19. Campbell PT, et al. Associations of recreational physical activity and leisure time spent sitting with colorectal cancer survival. J Clin Oncol. 2013 Mar 1; 31:876–88520. Davies NJ, Batehup L, Thomas R. The role of diet and physical activity in breast, colorectal, and prostate cancer survivorship: A review of the literature. Br J Cancer. 2011 Nov 8;105 Suppl 1:S52–73.21. Chan AT, Ogino S, Fuchs CS. Aspirin use and survival after diagnosis of colorectal cancer. JAMA. 2009 Aug 12;302:649–658.

22. Bastiaannet E, et al. Use of aspirin postdiagnosis improves survival for colon cancer patients. Br J Cancer. 2012 Apr 24;106:1564–1570.23. Liao X, et al. Aspirin use, tumor PIK3CA mutation, and colorectal-cancer survival. N Engl J Med. 2012 Oct 25;367:1596–1606.24. McCowan C, et al. Use of aspirin post-diagnosis in a cohort of patients with colorectal cancer and its association with all-cause and colorectal cancer specific mortality. Eur J Cancer. 2013;49:1049–1057.25. Walker AJ, Grainge MJ, Card TR. Aspirin and other non-steroidal anti- inflammatory drug use and colorectal cancer survival: a cohort study. Br J Can-cer. 2012 Oct 23;107:1602–1607.26. Reimers MS, et al. Aspirin use after diagnosis improves survival in older adults with colon cancer: A retrospective cohort study. J Am Geriatr Soc. 2012; 60:2232–2236.27. Langley RE, et al. Aspirin and cancer: Has aspirin been overlooked as an adjuvant therapy? Br J Cancer. 2011 Oct 11;105:1107–1113.28. Gandini S, et al. Meta-analysis of observational studies of serum 25-hy-droxyvitamin D levels and colorectal, breast and prostate cancer and colorectal adenoma. Int J Cancer. 2011 Mar 15;128:1414–1424.29. Ma Y, et al. Association between vitamin D and risk of colorectal cancer: A systematic review of prospective studies. J Clin Oncol. 2011 Oct 1;29:3775–378230. Woolcott CG, et al. Plasma 25-hydroxyvitamin D levels and the risk of colorectal cancer: The multiethnic cohort study. Cancer Epidemiol Biomarkers Prev. 2010;19:130–134.31. Lazzeroni M, et al. Vitamin D supplementation and cancer: Review of randomized controlled trials. Anticancer Agents Med Chem. 2013;13:118–125.32. Centers for Disease Control and Prevention. Press Release: Colorectal Can-cer Screening Rates Remain Low. Nov 5, 2013. Accessed May 30, 2016. http://www.cdc.gov/media/releases/2013/p1105-colorectal-cancer-screening.html.33. Danforth KM, et al. Electronic clinical surveillance to improve outpa-tient care: Diverse applications within an integrated delivery system. eGEMS. 2014;2(1). Accessed May 30, 2016. http://repository.academyhealth.org/egems /vol2/iss1/9.34. Biagi JJ, et al. Association between time to initiation of adjuvant chemo-therapy and survival in colorectal cancer: A systematic review and meta-analy-sis. JAMA. 2011 Jun 8;305:2335–2342.35. Wolmark N, et al. Adjuvant 5-fluorouracil and leucovorin with or without interferon alfa-2a in colon carcinoma: National Surgical Adjuvant Breast and Bowel Project protocol C-05. J Natl Cancer Inst. 1998 Dec 2;90:1810–1816.36. Wolmark N, et al. The benefit of leucovorin-modulated fluorouracil as postoperative adjuvant therapy for primary colon cancer: Results from Na-tional Surgical Adjuvant Breast and Bowel Project protocol C-03. J Clin Oncol. 1993;11:1879–1887.37. Wolmark N, et al. Adjuvant therapy of Dukes’ A, B, and C adenocarci-noma of the colon with portal-vein fluorouracil hepatic infusion: Preliminary results of National Surgical Adjuvant Breast and Bowel Project Protocol C-02. J Clin Oncol. 1990;8:1466–1475.38. Englum BR, et al. Optimizing the utilization of adjuvant chemotherapy following surgical resection of colon cancer: A comparison of laparoscopic ver-sus open approach. Gastroenterology. 2014;146(5 Suppl 1):S549.39. Win AK, et al. Colorectal and other cancer risks for carriers and noncarri-ers from families with a DNA mismatch repair gene mutation: A prospective cohort study. J Clin Oncol. 2012 Mar 20;30:958–964.40. Hampel H, et al. Cancer risk in hereditary nonpolyposis colorectal cancer syndrome: Later age of onset. Gastroenterology. 2005;129:415–42141. Rex DK, et al. Quality indicators for colonoscopy. Am J Gastroenterol. 2006;101:873–885.42. Jenab M, et al. Association between pre-diagnostic circulating vitamin D concentration and risk of colorectal cancer in European populations: A nested case-control study. BMJ. 2010 Jan 21;340:b5500.



Volume 42 Number 7July 2016 AP1

Appendix 1. Data Extraction Tool

Questions Response optionsReviewer

Assignment 1a Surveillance: Performed according to standard? Colonoscopy

frequency—within one year, then 3 years after that, 5 years after that (sooner intervals if advanced adenomas found).

YesNoOther, use item 8 for comments

Oncologist

1b Surveillance: Performed according to standard? CEA (carcinoembryonic antigen) frequency—every 6 months for 5 years.

YesNoOther, use 8 for comments

Oncologist

1c Surveillance: Performed according to standard? CT scan chest/abdomen/pelvis frequency—annually for 5 years.

YesNoOther, use 8 for comments

Oncologist

1d Surveillance: Did patient have stage II/early stage cancer that metastasized?

Yes (review pathology slides to identify possible diagnostic errors, then answer 1e)

NoOther

Pathologist

1e Review of pathology slides: If yes to question 1d, were there discrepancies between original pathology report and reviewer’s diagnosis?

Yes (explain below)NoOther

Pathologist

2a Timeliness of intervention: Was there a delay in following appropriate surveillance for patients who developed metastatic disease?

Yes, please indicate estimate of delay in days on 2d

NoOther, use 2d for comments

Oncologist

2b Timeliness of intervention: If patient developed metastases while on surveillance, was the physician late in referring to an oncologic surgeon?

Yes, please indicate delay in days on question 2d

No metastases while on surveillanceDid develop metastases while on surveillance

but no delay notedOther, use 2d for comments

Surgeon

2c Timeliness of intervention: If patient developed metastases while on surveillance, were there delays by the oncologic surgeon in getting the patient to the OR?

Yes, delays were evident, please indicate delay in days on 2d

No metastases while on surveillanceDid develop metastases while on surveillance

but no delay noted Other, use 2d for comments

Surgeon

2d Timeliness of intervention: Please indicate delays in days from all of the above questions.

Text input Surgeon

3a Medical treatment: Was adjuvant chemotherapy offered/given for node-positive (AKA stage III) colon cancer?

Yes, offered and givenOffered, not given use 3d for comments Not offered use 3d for comments Other, use 3d for comments

Oncologist

3b Medical treatment: Was adjuvant chemotherapy offered/given for high risk stage II colon cancer (an option for poorly differentiated, lymphatic or vascular invasion, positive margins, less than 12 lymph nodes removed, perforation, T3 tumor through the muscularis)?

Yes, offered and givenOffered, not given use 3d for comments Not offered use 3d for comments Other, use 3d for comments

Oncologist

(continued on page AP2)

Online Only Content



Volume 42 Number 7July 2016AP2

Appendix 1. Data Extraction Tool (continued)

3c Medical treatment: Did side effects/toxicity from chemotherapy result in serious morbidity or mortality?

Yes, serious side effects noted (describe in 3d)No serious side effectsN/A, no chemotherapy Other, use 3d for comments

Oncologist

3d Comments regarding medical treatment Text input Oncologist4 Radiation treatment: Did side effects/toxicity from radiation result in

serious morbidity or mortality?Yes, serious side effects noted, describe in 3dNo serious side effectsN/A, no radiation treatmentOther, use 8 for comments

Oncologist

5a Surgical treatment: Referral to oncologic surgeon for evaluation of resectability of liver metastases?

Yes, referred to oncologic surgeonNot referred but should have beenNot referred and not indicatedOther, use 5d for comments

Surgeon

5b If liver metastasis excision performed, were margins clear? Yes, margins clearNo, margins were not clearN/A, no excision of liver mets done.Other, use 5d for comments

Surgeon

5c Adequacy of diagnostic evaluation: Were at least 12 lymph nodes removed?

YesNo, describe below in 5d if indicatedOther, use 5d for comments

Surgeon

5d Comments for 5a,b,c Text input Surgeon6 Did the patient die of potentially preventable comorbid disease (e.g.,

MI, sepsis)Yes, died of potentially preventable non-

oncologic conditionNo, did not die of potentially preventable non-

oncologic conditionOther, use 8 for comments

Quality physician

7a Time interval between surgery and administration of adjuvant chemotherapy?

Did not undergo surgeryUnderwent surgery but did not receive

adjuvant chemotherapyEnter number of weeks between surgery and

administration of adjuvant chemotherapy in the text box below

Other, use 8 for comments

Oncologist

7b Enter number of weeks between surgery and administration of adjuvant chemotherapy.

Text input in weeks Oncologist

7c Blood transfusion: Please enter number of units patient received. Please use N/A for no blood transfusion ordered and 0 for blood transfusion ordered but patient did not receive any units.

Text input Quality physician

8 Comments for “other” response above Text input ALL9 Please briefly summarize the patient’s story to document

important aspects of his or her course, including opportunities to improve, delays in care, unique aspects of care, errors, etc.

Text input Oncologist

CT, computerized tomography; OR, operating room; AKA, also known as; N/A, not applicable; MI, myocardial infarction.

The complete data extraction tool, divided into sections for review by physicians with specific clinical and quality improvement expertise, as shown, included 17 items with yes/no/other response options (1a–1e; 2a–2c; 3a–3c; 4; 5a–5c; 6; 7a) and seven text fields for specific data or clarifying “other” responses (2d, 3d, 5d, 7b, 7c, 8, 9).

Online Only Content


Documents

Improvement from July 2016 Front Office to Front Line ... · Diagnosing and Treating “Alarm Fatigue”: ... set a 10-year goal of reducing CRC mortality by ... Identifying Evidence-Based