Tag Archives: process improvement

The Ongoing Journey: Improving Molecular Biomarker Testing in NSCLC

By ACCC Provider Education

The treatment of non-small cell lung cancer (NSCLC) has rapidly evolved over the last several years as new molecularly targeted therapies have been approved by the U.S. Food and Drug Administration (FDA).  Among these therapies are novel drugs that target EGFR, ALK, and ROS1 mutations in patients with NSCLC. Anticipating that advances in lung cancer care will be driven by molecularly-targeted therapies, in 2014, eight ACCC member programs participated in Learning Labs for Process Improvement, an ACCC initiative focused on improving molecular biomarker testing in patients with NSCLC.

Participating programs’ improvement plans were based on the 2013 College of American Pathologists (CAP), International Association for the Study of Lung Cancer (IASLC), and Association for Molecular Pathology (AMP) “Molecular Testing Guideline for Selection of Lung Cancer Patients for Epidermal Growth Factor Receptor (EGFR) and Anaplastic Lymphoma Kinase (ALK) Tyrosine Kinase Inhibitors.” These guidelines addressed key questions including:

  • When should molecular testing NSCLC be performed?
  • How should EGFR and ALK testing be performed?
  • Should other genes be routinely tested in lung adenocarcinoma?
  • How should molecular testing of lung adenocarcinomas be implemented and operationalized?

These cancer programs have been on an ongoing journey to improve their molecular biomarker testing processes and to ensure that patients are receiving the most precise care based on actionable test results.

Earlier this year, ACCC had an opportunity to follow up with three of the cancer programs that participated in the 2014 Learning Labs process improvement program. Each program reviewed their current molecular testing processes for patients with advanced NSCLC. They also reviewed their biomarker testing rates from 2016 and found that they had sustained their process improvements by embracing a culture of continuous improvement that is led by clinical champions, administrative support, and refined processes. Their clinical goals have focused on ensuring that a consistent and timely process for biomarker testing and interpretation will guide the use of targeted therapies for appropriate patients. Their programmatic goals have focused on improving the quality and quantity of lung biopsy tissue samples sent for testing, standardizing their biomarker testing process for NSCLC, and tracking biomarker testing as a quality measure. Read the case studies from the following programs:

As cancer programs continue their journey to improve how they provide precision medicine for patients with advanced NSCLC, pathologists are becoming more involved to ensure that the right tests are being ordered for appropriate patients. Radiologists, pulmonologists, and surgeons are collaborating and sharing best practices for obtaining better biopsy samples for molecular testing. Medical oncologists are leading complex discussions around the role of expanded molecular testing as newer targeted therapies emerge on the horizon. Cancer teams are also actively discussing the role of broader next-generation sequencing (NGS) and liquid biopsy (circulating tumor DNA tests) as they manage patients with NSCLC. New targeted therapies are constantly emerging and clinicians must also be aware of when to look for treatment resistance and switch therapies to maximize clinical efficacy.

ACCC encourages member programs to utilize the resources that have been developed that can help them integrate, optimize, and track biomarker testing processes for patients with NSCLC. ACCC, LUNGevity, CHEST, and CAP have partnered on a NSCLC process improvement toolkit for molecular testing. Access the toolkit on the ACCC eLearning Portal.


Stay tuned for more actionable strategies for process and quality improvement from the upcoming ACCC 34 National Oncology Conference, Oct. 18-20, in Nashville, TN. Learn more.

Patient Navigation: Reducing Delays in Care

By Tricia Strusowski, MS, RN

Solutions on corkboard-smallOur last navigation blog discussed how process mapping by disease site can help in managing transitions across the continuum of care.  Process mapping helps the cancer care team identify when to initiate patient navigation and support services as well as to identify goals, barriers, and gaps in care.

Removing barriers and gaps in care is a major goal for any navigation program. Many patients have shared with me that delays in care are the most stressful part of their treatment journey; they call it the “waiting game.” While they are waiting, their imagination can get the best of them. They are not only imaging “the worst” but also questioning “who is coordinating my care?” And if these delays occur time after time across the care continuum—they can have significant implications for the patient’s treatment journey. Is this acceptable?  Absolutely not.

So, How Do We Fix This?  

A great solution to eliminating delays is to create a continuum of care spreadsheet in your electronic medical record (EMR).  Use your process map to help identify the different departments and offices with visits that must be coordinated to avoid delays across the continuum.

The first step in creating your continuum of care spreadsheet is to identify the specific appointments and office visits in the correct order.  Each cancer disease site will look a bit different based on the specific needs of the patient.  For example, let’s consider what this might look like for a head and neck cancer patient. We all know that the patient must have dental clearance prior to any chemotherapy or radiation therapy treatment, but what is an acceptable time frame for this step? One week? Two weeks?  To avoid delays in the patient’s treatment journey, an early appointment for dental clearance is a must and should be completed as soon as possible.

Below is an example of the fields for an overly simplified basic continuum of care spreadsheet.  If an EMR is not available, you can use an Excel spreadsheet to create your continuum of care.  You can also add the initiation of navigation, support services, and survivorship care plan into the care continuum. 

  • Diagnostic work up, imaging, tests, and dates
  • Surgical consult, visit and date
  • Surgical biopsy and date
  • Pathology report results and date
  • Surgery and date
  • Medical Oncology consult, visit and date
  • First chemotherapy treatment and date
  • Radiation Oncology consult visits and date
  • CT simulation and date
  • First Radiation Oncology treatment and date.

Next, your multidisciplinary team needs to review the actual or “real” time period for the delays.  An audit will help you identify the true time lapse between each episode of care.

With these steps completed, you’re ready to initiate a performance improvement (PI) project to decrease delays. The team needs to discuss and create new acceptable time frames between the visits. Identify where the delay is occurring: Registration? Insurance verification? Scheduling?  Look for opportunities to meet with the different departments and offices to brainstorm how these delays can be reduced.  Many times you may also identify duplication of services. Eliminating these redundancies will help with staff productivity.

Sustainability is Key

Once you’ve reduced the delays, you will still need to monitor the new process to ensure that it is continuing to be effective—monitor monthly at first and then move to quarterly or bi-annual monitoring as needed. If the new process is not working, revisit the opportunities for improvement.  Finally, remember that the main goal of all of our programs is to work as efficiently as possible while keeping the patient at the center of all we do.

An efficient and timely patient-centered flow will enhance your patient experience!


Guest blogger ACCC member Tricia Strusowski, MS, RN, is a consultant with Oncology Solutions, LLC.

Patient Navigation—Process Mapping by Disease Site

By Tricia Strusowski, MS, RN

ThinkstockPhotos-467463476For this patient navigation blog post, let’s talk about a recent hot topic on ACCCExchange, the online discussion forum for ACCC members: At what point in the care continuum do you initiate navigation and support services?

Many cancer programs have a difficult time identifying when to initiate these services. Cancer programs know that staff are duplicating services, but they don’t want anything to fall through the cracks for patients and their families. At busy cancer programs, staff may be challenged to find the time to sit down and work out these details. Plus, getting all the healthcare professionals together for one more meeting can be a daunting task. Cancer programs want to provide the best experience for their patients while utilizing staff efficiently. One way to support this goal is by involved the entire team in creating a disease-site-specific process map to review the continuum of care; discuss staff roles and responsibilities; identify gaps, barriers, opportunities for improvement; and goals of care—all with the patient at the center of the discussion. Simply put: Increasing communication among the team and decreasing duplication for the patient.

Who Should Participate?

Ideally, the team participating in the disease-site mapping process should be representative of the offices and departments that will touch the patient during his or her journey. Keep in mind: You need to include the “worker bees,” the staff who really know the details of the patient flow. Let’s consider a head and neck cancer patient for example. In this instance, the following individuals should be invited to participate:

  • Surgery
  • Medical oncology
  • Radiation oncology
  • Inpatient unit case manager and/or discharge planner
  • Speech/swallowing therapist
  • Navigator
  • Social worker
  • Financial counselor
  • Behavioral health
  • Rehabilitation/Prehabilitation
  • Dental office
  • Others (We all know there is always someone we forget to invite!)

Plan your first session for 1.5 to 2 hours. Admittedly, this may be a challenge to schedule but it can be done, and the results will be amazing. Utilizing a large paper flowchart (i.e.,15 feet long x 4 feet wide), the group needs to talk through and record the process starting at the patient’s earliest point of entry. Each detail must be discussed, including length of time from one episode of care to the next, delays, gaps, and opportunities for improvement. Encourage participants share their goals during the discussion and write everything down!

Revisit & Revise

Process mapping exercises are not a one-and-done experience. It takes several meetings to review and revise the process map. There may be key individuals or a process that are missed in a previous session; no big deal, add them to the group. A great facilitator is key to keep the team on task and keep the discussion moving.

After the entire disease-site process is complete, overlay when you would like the navigator and the support staff to intervene. Remember: the goal is to provide the intervention as soon as possible, hopefully in a proactive manner so that you are “staying one step ahead of the patient.” Incorporate when you would like to initiate the distress screening process, identifying periods of highest distress for the patient/family.

The draft process map is also an excellent tool to share with the disease-site-specific healthcare providers who are often are not aware of all the details, delays, and opportunities to enhance the patient experience. Further, your process map will also be excellent tool for on-boarding new staff and for succession planning. Review and update your process map on a bi-yearly or annual basis.

 Go Team!

I always share that the disease-site-specific team is like a football team; the better all the players understand everyone’s role and how to best support the patient and each other, the stronger the team will be. Every team always wants what is best for the patient. The mapping process is a valuable approach to not just identify gaps or delays in the care continuum, but to also then go the extra mile to identify “what is best for the patient.”

Work smarter not harder; teamwork makes the dream work!

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Guest blogger Tricia Strusowski, MS, RN, is a consultant with Oncology Solutions, LLC.