Create QI projects to reach a high volume of patients

Look at high-risk or problem-prone areas

Every year, all departments at City of Hope National Medical Center in Duarte, CA, must develop a quality improvement plan and determine what outcomes measures to review.

Therefore, at the beginning of the year, the patient education department determines what measures are significant for patient education and focuses on these during the next 12 months, says Annette Mercurio, MPH, CHES, director of patient, family and community education at City of Hope.

To make the determination, Mercurio looks for quality improvement projects that impact a high volume of patients, are of high risk to patients, or problem-prone areas. The year she selected chemotherapy education as a performance improvement project, there were indications based on feedback from patients that lack of information was a problem.

"Patients said that they were not receiving written information about chemotherapy until the day they were getting their chemo, and they wanted the information sooner," said Mercurio.

Before tackling the problem, Mercurio first selected outcome measures so that she could determine whether the interventions made by the patient education department were effective. She wanted to measure whether patients were receiving information prior to starting chemotherapy and also what percentage of patients felt well informed about the therapy before starting treatment.

To get baseline measures to determine if interventions worked, the patient education department distributed a survey to chemotherapy patients that asked several questions. This included whether patients had received written information prior to chemotherapy, how well informed they felt, and when they would have preferred to get information. There were a few other questions, such as whether they had been informed about side effects.

"When patients come in for their first chemotherapy appointment they get more intensive teaching, but they weren’t getting basic information about chemotherapy and its side effects prior to their visit," says Mercurio.

Therefore, a packet of generic chemotherapy information was created that included such items as a pamphlet published by the National Cancer Institute titled, "Chemotherapy and You." To make sure that patients received the packets before their first treatment, the information was distributed to the clinical areas where patients would be making the decision about chemotherapy with their physician.

Patients were alerted to the fact that they should receive the packets by orange signs placed in exam rooms that instructed them to ask the physician or clinic assistant for a packet of information on chemotherapy if they hadn’t yet received the information.

In addition to the information packet, 60 chemotherapy information sheets were created that are specific to City of Hope. This project was completed after nurses revealed that the sheets being generated by a database at the center were too generic. "Every area that administers chemotherapy has copies of those sheets," says Mercurio.

A checklist also was developed for nursing staff to use when teaching patients about chemotherapy, and an instruction sheet on teaching patients about chemotherapy.

A work in progress

About six months after the baseline survey, a follow-up survey was conducted. This was done after steps were set in place to deliver basic chemotherapy information to patients in a more timely fashion and teaching tools had been developed for staff. That survey showed marked improvement in all the measures, says Mercurio.

However, when the next survey was taken, the numbers had dropped slightly so staff are trying to determine why this has occurred. One problem is the distribution of materials. "Some of our physicians are giving patients the packets and some aren’t, so we need to do more follow-up," she says.

Improvement projects generally are completed in four phases. The first is to create a plan. In the case of chemotherapy education, Mercurio looked at feedback from patients then figured out how to tackle the problem.

The second step in the process is to take action, or do something about the problem. In this project, she conducted an initial baseline assessment and developed interventions such as the packet of generic chemotherapy information.

The third step is to conduct a study to determine if the interventions solved the problem or made improvements in any way. The follow-up surveys that were conducted to assess the chemotherapy education quality-improvement project were part of this phase.

Finally, continued action is taken to improve numbers on the outcome measurements. "You just keep trying to achieve the level of improvement that you want," says Mercurio.

There is a systematic performance improvement-reporting structure at City of Hope, says Mercurio. Each department must submit a report every three months on the outcome measures it selected for the year. The executive leadership committee reviews the report. As a result, patient education is well integrated into the performance-improvement sector. "Leadership sees patient education performance-improvement efforts regularly," she says.

For more information about selecting outcomes measures for quality improvement projects, contact:

  • Annette Mercurio, MPH, CHES, Director of Patient, Family, and Community Education, City of Hope National Medical Center, 1500 E. Duarte Road, Duarte, CA 91010-0269. Telephone: (626) 301-8926. E-mail: