Transcript Hazel Crest: 6% - Advocatehealth.com

Cancer Program
2013 Annual Report
1
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.
2
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.
3
Cancer Liaison Physician
Riaz 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 the
orientation 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 90th percentile
Tracking of patients referred elsewhere for clinical research trials
Quarterly review and dissemination of National Cancer Data Base Reports to the Cancer Committee
4
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, we
established 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.
5
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 for
the 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 a
patients 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, Medical
Oncology, 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.
6
Annual Educational Symposiums:
Sue Serratore, RN, BSN
Professional 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 for
this disease and the facilitator was Rajesh Patel, M.D., Surgeon/Urology.
7
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.
8
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 and
during 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.
9
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.
10
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.
11
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 Support
Referral to Nutritional Guidance
Care Coordination in concert with the medical plan of care
Information and referrals regarding community services
Legal and/or financial referrals
Transportation arrangements
Discharge 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.
12
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 Counselors
We 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 specialty
consult 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.
13
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
14
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
15
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.
16
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
17
Begin Cancer Graphs
18
Harvey: 7%
Hazel Crest: 6%
Communities <=4%
Calumet City
Chicago Heights
Chicago Ridge
Country Club Hills
Dolton
Flossmoor
Frankfort
Glenwood
Homewood
Lansing
Midlothian
Mokena
Monee
Orland Park
Richton Park
South Holland
Tinley Park
Chicago Heights:
5%
Cancer Registry Data,
Statistical Data
2013 Annual Year
19
200
180
160
140
120
100
80
60
40
20
0
Advocate South Suburban Hospital Age Distribution
The Mean age is = 65 years of age
184
170
152
184
179
188
151
145
126
113
94
119
116
136
103
102
58
78
66
48
<=49
50-59
60-69
70-79
80+
Cancer Registry Data, Statistical Data
n= All Cases Analytic + Non-Analytic
2009 = 564
2010 = 674
2011 = 616
2012= 658
20
Stage Comparison/ Percent Distribution
Advocate South Suburban Hospital
Versus
All AHC Accredited Hospitals
30
30
25
26
20
15
18
15
16
10
15
13 11
12
10
5
0
8
8
9
7
Stage 0
Stage I
Stage II
Stage III
Stage IV
N/A
Unknown
Commission on Cancer, National Cancer Data Base (NCDB) 2011
21

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
22
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
23
Cancer Committee Members, Continued





















Stephanie Applebaum, M.D. Pathology
Rami Haddadm M.D., Medical Oncology, Palliative Care
Vasanta Kumaraiah, M.D., Medical Oncology
Anil Lamba, M.D. , General Surgery
John McKeown, M.D., Medical Oncology
Gary Peplinski, M.D., General Surgery
Alia Salhadar, M.D., Pathology
Lindseu Job, M.D./Shailu Gandhi, M.D.
Karen Clark, Vice President
Melissa Rodenas, Rehab
Shannon Homolka, Mgr Public Affairs and Marketing
Anne O’Malley, Spvr. Clin. Nutrition
Susan Serratore, Coord Med. Staff
Lesliey Adams, Mammography Coordinator
Christine Rosandich, Cancer Support Center
Kelly Ford, Adm. Asst. Oncology
Edward Warren, Network Development Mgr.
Danielle Swets, American Cancer Society
Lisa Vidovic, Director Medical Records & Regulatory Compliance
Catherine Haynes, Cancer Registrar
Jenise Diemer, Patient Nurse Navigator/ Palliative Care
24