1
|
Park KU, Padamsee TJ, Birken SA, Lee S, Niles K, Blair SL, Grignol V, Dickson-Witmer D, Nowell K, Neuman H, King T, Mittendorf E, Paskett ED, Brindle M. Factors Influencing Implementation of the Commission on Cancer's Breast Synoptic Operative Report (Alliance A20_Pilot9). Ann Surg Oncol 2024:10.1245/s10434-024-15515-2. [PMID: 38862840 DOI: 10.1245/s10434-024-15515-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 05/09/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND The technical aspects of cancer surgery have a significant impact on patient outcomes. To monitor surgical quality, in 2020, the Commission on Cancer (CoC) revised its accreditation standards for cancer surgery and introduced the synoptic operative reports (SORs). The standardization of SORs holds promise, but successful implementation requires strategies to address key implementation barriers. This study aimed to identify the barriers and facilitators to implementing breast SOR within diverse CoC-accredited programs. METHODS In-depth semi-structured interviews were conducted with 31 health care professionals across diverse CoC-accredited sites. The study used two comprehensive implementation frameworks to guide data collection and analysis. RESULTS Successful SOR implementation was impeded by disrupted workflows, surgeon resistance to change, low prioritization of resources, and poor flow of information despite CoC's positive reputation. Participants often lacked understanding of the requirements and timeline for breast SOR and were heavily influenced by prior experiences with templates and SOR champion relationships. The perceived lack of monetary benefits (to obtaining CoC accreditation) together with the significant information technology (IT) resource requirements tempered some of the enthusiasm. Additionally, resource constraints and the redirection of personnel during the COVID-19 pandemic were noted as hurdles. CONCLUSIONS Surgeon behavior and workflow change, IT and personnel resources, and communication and networking strategies influenced SOR implementation. During early implementation and the implementation planning phase, the primary focus was on achieving buy-in and initiating successful roll-out rather than effective use or sustainment. These findings have implications for enhancing standardization of surgical cancer care and guidance of future strategies to optimize implementation of CoC accreditation standards.
Collapse
Affiliation(s)
- Ko Un Park
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.
- Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
- Breast Oncology Program, Dana-Farber/ Brigham Cancer Center, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
- James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA.
| | - Tasleem J Padamsee
- James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Sarah A Birken
- Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Sandy Lee
- James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Kaleigh Niles
- James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Sarah L Blair
- University of California San Diego, La Jolla, CA, USA
| | - Valerie Grignol
- James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | | | - Kerri Nowell
- Physicians' Clinic of Iowa, Cedar Rapids, IA, USA
| | - Heather Neuman
- School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Tari King
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber/ Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Elizabeth Mittendorf
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber/ Brigham Cancer Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Electra D Paskett
- James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Mary Brindle
- Ariadne Labs, Brigham and Women's Hospital, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Surgery, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Canada
| |
Collapse
|
2
|
White RL, Wallander ML, Leighliter ME, Sha W, Palmer PP, Sejdic A, Benbow JH, Sarma D, Robinson MM, Trufan SJ, Sarantou T. Assessing trends in breast care surveillance metrics after implementing surgeon-specific tracking and performance reporting in a large, integrated cancer network. Cancer 2023; 129:3230-3238. [PMID: 37382238 DOI: 10.1002/cncr.34924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 04/06/2023] [Accepted: 05/02/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND There are few quality metrics and benchmarks specific to surgical oncology. Development of a surgeon-level performance metrics system based on peer comparisons is hypothesized to positively influence surgical decision-making. This study established a tracking and reporting system comprised of evidence and consensus-based metrics to assess breast care delivered by individual surgeons. METHODS Surgeons' performance is assessed by a surveillance tracking system of metrics pertaining to referrals and surgical elements. This retrospective analysis of prospectively collected breast care data reports on recurring 6-month and cumulative data from nine care locations from 2015 to 2021. RESULTS Breast care was provided to 6659 patients by 41 surgeons. A total of 27 breast care metrics were evaluated over 7 years. Metrics with consistent, proficient results were retired after 18 months, including the rate of core biopsy, specimen orientation, and referrals to medical oncology, genetics, and fertility, among others. In clinically node-negative, hormone receptor-positive patients 70 years of age or older, the cumulative rate of sentinel lymph node (SLN) biopsy significantly decreased by 40% over 5.5 years (p < .001). The overall breast conservation rate for T0-T2 cancer increased 10% over 7 years. At the surgeon level, improvements were made in the median number of SLNs removed and in operative note documentation. CONCLUSIONS Implementation of a surgeon-specific, peer comparison-based metric and tracking system has yielded substantive changes in breast care management. This process and governance structure can serve as a model for quantification of breast care at other institutions and for other disease sites.
Collapse
Affiliation(s)
- Richard L White
- Division of Surgical Oncology, Department of Surgery, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Michelle L Wallander
- Clinical Trials Office, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Marjorie E Leighliter
- Breast Clinic, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Wei Sha
- Department of Cancer Biostatistics, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Pooja P Palmer
- Division of Community and Social Impact, Atrium Health, Charlotte, North Carolina, USA
| | - Almira Sejdic
- Department of Cancer Biostatistics, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Jennifer H Benbow
- Clinical Trials Office, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Deba Sarma
- Division of Surgical Oncology, Department of Surgery, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Myra M Robinson
- Department of Cancer Biostatistics, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Sally J Trufan
- Department of Cancer Biostatistics, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Terry Sarantou
- Division of Surgical Oncology, Department of Surgery, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| |
Collapse
|
3
|
Mehta SN, Shenvi EC, Blair SL, Caudle A, Lowenstein LM, Kelly KJ. Leveraging the Multidisciplinary Tumor Board for Dissemination of Evidence-Based Recommendations on the Staging and Treatment of Gastric Cancer: A Pilot Study. Ann Surg Oncol 2023; 30:1120-1129. [PMID: 36222932 PMCID: PMC9555252 DOI: 10.1245/s10434-022-12628-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 09/13/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Compliance with evidence-based treatment guidelines for gastric cancer across the United States is poor. This pilot study aimed to create and evaluate a change package for disseminating information on the staging and treatment of gastric cancer during multidisciplinary tumor boards and for identifying barriers to implementation. METHODS The change package included a 10-min video, a brief knowledge assessment, and a discussion guide. Commission on Cancer-accredited sites that perform gastrectomy were invited to participate. Participants completed the Organizational Readiness for Implementing Change (ORIC) scale (range, 12-60) and scales to measure the feasibility, acceptability, and appropriateness (score range, 4-20). Semi-structured interviews were conducted to further define inner and outer setting barriers. RESULTS Seven centers participated in the study. A total of 74 participants completed the pre-video knowledge assessment, and 55 participants completed the post-video assessment. The recommendations found to be most controversial were separate staging laparoscopy and modified D2 lymphadenectomy. Sum scores were calculated for acceptability (mean, 17.43 ± 2.51) appropriateness (mean, 16.86 ± 3.24), and feasibility (mean, 16.14 ± 3.07) of the change package. The ORIC scores (mean, 46.57 ± 8.22) correlated with responses to the open-ended questions. The key barriers identified were patient volume, skills in the procedures, and attitudes and beliefs. CONCLUSIONS The change package was moderately to highly feasible, appropriate, and acceptable. The activity identified specific recommendations for gastric cancer care that are considered controversial and local barriers to implementation. Future efforts could focus on building skills and knowledge as well as the more difficult issue of attitudes and beliefs.
Collapse
Affiliation(s)
- Shivani N. Mehta
- Department of Surgery, University of California, San Diego, CA USA
| | - Edna C. Shenvi
- Department of Surgery, University of California, San Diego, CA USA
| | - Sarah L. Blair
- Department of Surgery, University of California, San Diego, CA USA
| | - Abigail Caudle
- Department of Surgery, University of Texas MD Anderson Cancer Center, Houston, TX USA
| | - Lisa M. Lowenstein
- Department of Surgery, University of Texas MD Anderson Cancer Center, Houston, TX USA
| | - Kaitlyn J. Kelly
- Department of Surgery, University of California, San Diego, CA USA
| |
Collapse
|
4
|
Carpenter EL, Adams AM, McCarthy PM, Chick RC, Spitzer HV, Nelson DW, Clifton GT, Bowen DK, Krell RW, Vreeland TJ. Meeting the New Commission on Cancer Operative Standards: Where Do We Stand Now? Mil Med 2022; 188:usac274. [PMID: 36111895 DOI: 10.1093/milmed/usac274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/21/2022] [Accepted: 09/01/2022] [Indexed: 02/18/2024] Open
Abstract
INTRODUCTION The 2020 Commission on Cancer accreditation standards 5.7 and 5.8 address total mesorectal excision for rectal cancer and lymph node sampling for lung cancer. The purpose of this review was to assess our institution's compliance with these operative standards, which will be required in 2022 and 2023, and provide recommendations to other military training facilities seeking to comply with these standards. MATERIALS AND METHODS A 2018-2020 single institution chart review was performed of operative and pathology reports. Identified deficits were addressed in meetings with colorectal and thoracic surgery leadership, and cases were followed to reassess compliance. RESULTS A total of 12 rectal and 48 lung cancer cases met the inclusion criteria and were examined. Pre-intervention compliance for standards 5.7 and 5.8 was 58% and 35%, respectively, because of inadequate synoptic reporting and lymph node sampling. After intervention, compliance was 100%. CONCLUSIONS Our institution requires changes to comply with new standards, including in areas of documentation and systematic pulmonary lymph node sampling. We provide lessons learned from our own institutional experience, including practical tips and recommendations to achieve compliance. All military training facilities performing lung and rectal oncologic resections should conduct an internal review of applicable cases in preparation for upcoming American College of Surgeons Commission on Cancer site visits.
Collapse
Affiliation(s)
| | - Alexandra M Adams
- Department of Surgery, Brooke Army Medical Center, San Antonio TC, TX 78234, USA
| | - Patrick M McCarthy
- Department of Surgery, Brooke Army Medical Center, San Antonio TC, TX 78234, USA
| | - Robert C Chick
- Department of Surgery, Brooke Army Medical Center, San Antonio TC, TX 78234, USA
| | - Holly V Spitzer
- Department of Surgery, William Beaumont Army Medical Center, 5005 N Piedras St, El Paso, TX 79920, USA
| | - Daniel W Nelson
- Department of Surgery, William Beaumont Army Medical Center, 5005 N Piedras St, El Paso, TX 79920, USA
| | - Guy T Clifton
- Department of Surgery, Brooke Army Medical Center, San Antonio TC, TX 78234, USA
| | - Donnell K Bowen
- Department of Surgery, Brooke Army Medical Center, San Antonio TC, TX 78234, USA
| | - Robert W Krell
- Department of Surgery, Brooke Army Medical Center, San Antonio TC, TX 78234, USA
| | - Timothy J Vreeland
- Department of Surgery, Brooke Army Medical Center, San Antonio TC, TX 78234, USA
| |
Collapse
|
5
|
Francescatti AB, Hunt KK, Katz MHG. ASO Author Reflections: Technical Standards for Cancer Surgery: From "How I Do It" to "How We Do It". Ann Surg Oncol 2022; 29:6559-6560. [PMID: 35288816 DOI: 10.1245/s10434-022-11518-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 02/11/2022] [Indexed: 11/18/2022]
Affiliation(s)
| | - Kelly K Hunt
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | |
Collapse
|
6
|
Soegaard Ballester JM, Goodsell KE, Ermer JP, Karakousis GC, Miura JT, Saur NM, Mahmoud NN, Brooks A, Tchou JC, Gabriel PE, Shulman LN, Wachtel H. New Operative Reporting Standards: Where We Stand Now and Opportunities for Innovation. Ann Surg Oncol 2022; 29:1797-1804. [PMID: 34523005 DOI: 10.1245/s10434-021-10766-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 08/15/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND The American College of Surgeons Commission on Cancer's (CoC) new operative standards for breast cancer, melanoma, and colon cancer surgeries will require that surgeons provide synoptic documentation of essential oncologic elements within operative reports. Prior to designing and implementing an electronic tool to support synoptic reporting, we evaluated current documentation practices at our institution to understand baseline concordance with these standards. METHODS Applicable procedures performed between 1 January 2018 and 31 December 2018 were included. Two independent reviewers evaluated sequential operative notes, up to a total of 100 notes, for documentation of required elements. Complete concordance (CC) was defined as explicit documentation of all required CoC elements. Mean percentage CC and surgeon-specific CC were calculated for each procedure. Interrater reliability was assessed via Cohen's kappa statistic. RESULTS For sentinel lymph node biopsy, mean CC was 66% (n = 100), with surgeon-specific CC ranging from 6 to 100%, and for axillary dissection, mean CC was 12% (n = 89) and surgeon-specific CC ranged from 0 to 47%. The single surgeon performing melanoma wide local excision had a mean CC of 98% (n = 100). For colon resections, mean CC was 69% (n = 96) and surgeon-specific CC ranged from 39 to 94%. Kappa scores were 0.77, 0.78, -0.15, and 0.78, respectively. CONCLUSIONS We identified heterogeneity in current documentation practices. In our cohort, rates of baseline concordance varied across surgeons and procedures. Currently, documentation elements are interspersed within the operative report, posing challenges to chart abstraction with resulting imperfect interrater reliability. This presents an exciting opportunity to innovate and improve compliance by introducing an electronic synoptic documentation tool.
Collapse
Affiliation(s)
| | - Kristin E Goodsell
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jae P Ermer
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Giorgos C Karakousis
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - John T Miura
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Nicole M Saur
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Najjia N Mahmoud
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ari Brooks
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Julia C Tchou
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Peter E Gabriel
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Lawrence N Shulman
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Heather Wachtel
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA.
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| |
Collapse
|
7
|
Hieken TJ, Burns WR, Francescatti AB, Morris AM, Wong SL. Technical Standards for Cancer Surgery: Improving Patient Care through Synoptic Operative Reporting. Ann Surg Oncol 2022; 29:6526-6533. [PMID: 35174447 DOI: 10.1245/s10434-022-11330-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 11/30/2021] [Indexed: 11/18/2022]
Abstract
The Operative Standards for Cancer Surgery manuals define critical elements of optimal cancer surgery based on data and expert opinion. These key aspects of commonly performed cancer operations define technical standards that can be used as a quality assurance tool for practicing surgical oncologists and as an educational tool for trainees. This article provides background on these operative standards and their subsequent integration into synoptic operative report templates. With the goal of codifying the most important aspects of surgical oncology care to elevate and harmonize cancer care, the American College of Surgeons Cancer Programs has developed comprehensive synoptic operative reports. Synoptic operative reports are structured so that key data elements are recorded in a standardized format with prespecified terminology. In contrast to the narrative or structured operative reports frequently used by surgeons, these synoptic operative reports improve semantic clarity, provide uniform fields for abstraction, and facilitate passive data collection and real-time analytics while delivering key information for downstream multidisciplinary patient care. In this way, the synoptic operative report is a key component of a comprehensive effort to elevate the quality of cancer care nationally.
Collapse
Affiliation(s)
- Tina J Hieken
- Department of Surgery, Mayo Clinic, Mayo Clinic Alix School of Medicine, Rochester, MN, USA.
| | - William R Burns
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Arden M Morris
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Sandra L Wong
- Department of Surgery, The Geisel School of Medicine at Dartmouth, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | | |
Collapse
|