Treating Brain Tumors

Quality Improvement Tools Guide a Complicated Process

By implementing and studying small tests of changes, Norris Cotton Cancer Center's Neuro-Oncology Program's quality improvement team increased fulfillment of its indicators from 66% to 91% between 2010 to 2011.

Focus article photo

A CT scan of a brain.

The concept of patient care protocols first attracted the attention of the Neuro-Oncology Program in 2005. A Journal of the American Medicine Association (JAMA) article documented 52 institutions with different approaches to the treatment of brain tumors.

Enhancing Care through Process Improvement

Neuro-Oncology Program Leader Camilo Fadul, MD, reached out to the Dean of the Dartmouth Medical School for help. Fadul was interested in learning more about the Microsystems Academy, a Dartmouth program aimed at helping small groups of people who work together build microsystems that improve the patient care.

Dr. Fadul's goal was to increase the likelihood that patients had access to best care practices from the time they were diagnosed with a brain tumor until the time they received treatment with radiation and/or chemotherapy. Toward that end, a quality improvement team, sponsored by Mark Israel, MD; Evelyn Schlosser, MPH, RN; and David Roberts, MD, used a popular model from the process improvement field: DMAIC.

Photo: Camilo Fadul, MD, medical director of the Neuro-Oncology Program at Norris Cotton Cancer Center

Camilo Fadul, MD, medical director of the Neuro-Oncology program at Norris Cotton Cancer Center.

The DMAIC process improvement framework has five steps:

  • Define aim
  • Measure current performance
  • Analyze current process
  • Improve the process
  • Control the new process
Establishing the Best-Practice Indicators 

With a goal of reducing process variation and maximizing safety and efficiency, they developed a process flow chart of how patients enter and move through the system of care. From this schematic they decided to focus on the initial workup and development of the plan of care, using a set of 10 best-practice indicators:

  • Neuro-Oncology should be notified of all patients with a brain mass
  • Patients should be seen by Neuro-Oncology as an inpatient
  • Standard post-op orders should be used
  • All post-op patients should receive steroids
  • All post-op patients should receive a prophylactic antiepileptic
  • Patients should be seen by a social worker within two weeks of diagnosis
  • All patients should have appointments for followup appointments scheduled at the time of discharge
  • All cases should be presented at the Neuro-Oncology tumor board
  • Presentation of cases to the Neuro-Oncology tumor board should occur with two weeks of diagnosis
  • Patient should be seen by Radiation Oncology within two weeks of diagnosis
Changing the Processes and Measuring the Results

A series of changes have contributed to the overall gains seen by the team. To ensure that Neuro-Oncology is notified of all patients, brain tumor codes were added to scheduling sheets to trigger e-mails to the Neuro-Oncology team notifying them of a diagnosis of a brain mass. To improve compliance with social worker visits and followup appointments, nursing developed checklists for discharge and patient education. By involving patients and families in the process, the team learned that the primary concern of discharged patients—constipation—had to be added to the discharge packet.

The group continues to work towards improving performance by developing airtight processes to ensure that every patient, every time receives care proven most effective by stringent clinical research. Their effort also includes sustaining process change and measurement. As they move forward with defining patient- and family-centered care, the quality improvement team plans next to work with patients and families to identify measurable indicators for patient-centered care.

November 10, 2011