2018 Public Report of Outcomes

 
HSHS St. Vincent Hospital Cancer Centers (SVHCC) is accredited by the American College of Surgeons Commission on Cancer (CoC) as an Integrated Network Cancer Program – the highest level of accreditation possible for a non-teaching hospital. This voluntary accreditation process takes place every three years.

Our cancer program provides a broad scope of services ranging from cancer prevention, outreach and education for cancer detection, treatment, palliative care and survivorship. Our program receives guidance and leadership from the HSHS St. Vincent Hospital Cancer Centers’ Cancer Committee, which convenes regularly to ensure that we are meeting the standards outlined by the American College of Surgeons CoC. These standards address education, treatment, clinical research, data collection, performance and quality improvements.
 
We are deeply committed to the design and implementation of quality patient care and treatment services. In this report, we highlight select accountability measures that the CoC uses to measure our program outcomes. We also highlight one of our quality improvement projects designed to improve cancer prevention in the communities we serve.
 

Accountability Measures

National Measures CoC  % SVHCC
2015
Radiation is administered within 1 year (365 days) of diagnosis for women under the age of 70 receiving breast conservation surgery for breast care 90% 98.20%
Tamoxifen or third generation aromatase inhibitor is recommended or administered within 1 year (365 days) of diagnosis for women with AJCC T1c or stage IB-III hormone receptor positive breast cancer 90% 98.40%
Image or palpation-guided needle biopsy to the primary site is performed to establish diagnosis of breast cancer 80% 84.60%
Breast conservation surgery rate for women with AJCC clinical stage 0, I or II breast cancer None 76.40%
Combination chemotherapy is recommended or administered within 4 months (120 days) of diagnosis for women under 70 with AJCC T1cNO, or stage 1B-II hormone receptor negative breast cancer None 100.00%
At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer 85% 89.30%

The above measures are nationally accepted standards of practice as defined by the CoC.The CoC provides a benchmark comparison for programs to assess performance. As noted in the above table, HSHS St. Vincent Hospital Cancer Centers performed higher than the CoC benchmark across all measures.
 

Quality Improvement Project

Through feedback from patients, our observations, national and local trends, and other sources, HSHS St. Vincent Hospital Cancer Centers continuously evaluates and improves the quality of care we provide to our patients. This report publically shares outcomes from one of our studies completed in 2018.    
  
2018 Quality Improvement Effort: 
In partnership with Prevea providers, standardize the Human Papillomavirus (HPV) vaccination education materials that are utilized for patients, families, staff and the general public. 

Objective: 
To increase the HPV immunization rate of patients seen by Eastern Wisconsin Prevea providers and ultimately decrease overall incidence of future HPV related cancers.
 
Background and Rationale from 2017 study topic:                                                                
Out of 1,039 Prevea patients who met the criteria for vaccination, 353 15 year old patients had completed the two-part series. The HPV vaccination rate for adolescents (15 year olds) seen by Prevea Health was 33.97 percent. A Wisconsin data base, including 20 physician practices throughout Wisconsin, was used as a benchmark for comparison. The vaccination rate for these practices ranged from 25 to 75 percent, with an overall rate of 48.5 percent for the state. The vaccination rate of Prevea providers was below the overall state rate. Our aim with this project was to standardize our education materials and in turn provide a consistent message to our patients and the community about the importance of HPV vaccination in the overall prevention of cancer.

Actions:
  • Evaluate educational pieces for distribution to parents, providers and to the public.
  • Determine which educational pieces will be used for distribution to parents, providers and the public.
  • Develop marketing plan for disseminating information to each of these groups to include social media education. 
  • Implement marketing and education plan.
  • Establish Partnership Agreement with the American Cancer Society through their Collaborative Action Plan to improve HPV vaccination rates. 
 

Outcomes of Quality Improvement Effort:

Development of Marketing Plan and Materials
A small group met to review HPV vaccination educational materials written by the following organizations:  American Cancer Society, the CDC, US Department of Health and Human Services and the American Academy of Pediatrics. These documents were presented to the Prevea Pediatric physicians to review and to recommend which tools to utilize. A packet of educational materials was identified for use in educating the community, parents, medical providers and HSHS-EWD colleagues and Prevea staff. 

The marketing department developed the following: 
  1. A strategy for educating the public and distribution of various educational pieces. 
  2. An “HPV Toolkit” complete with a cover letter and sample selection of available educational fliers that was sent to all providers from primary care, internal medicine, OB / GYN, and pediatrics. This packet includes instructions on how these fliers can be ordered from our internal print shop for patient distribution. This gives providers the opportunity to select the information that they would like available for their patients from a defined set of materials. 
  3. A Social Media campaign has been planned which includes 14 different posts to be shared over a four week period of time. 
 
American Cancer Society Partnership – “Mission:  HPV Cancer Free Campaign”
HSHS St. Vincent Hospital has been selected by the American Cancer Society as one of the systems in Wisconsin to partner with them on the ‘Mission: HPV Cancer Free Campaign’. As part of this campaign, we have agreed to: 
  • Prioritize HPV vaccination as a QI project (completed)
  • Develop a collaborative action plan with our ACS staff partner (completed)
  • Calculate and share baseline and follow-up adolescent vaccination rates (completed)
  • Set HPV vaccination goal(s) (completed)
  • Host an internal event to kick-off the campaign (optional) 
  • Organize and conduct provider and staff training (Needs further planning)
  • Implement evidenced-based interventions and/or policy changes (In process)
  • Celebrate and share project activities and success!
Baseline information and a Collaborative Action Plan have been completed. The activities listed in the Action Plan are in the process of being implemented. The impact that this has on the HPV Vaccination rate will be monitored over the upcoming year.    

Further Improvement Opportunities:
  1. Per the ‘Mission: HPV Cancer Free’ / ACS Collaborative Project:
    • Set HPV vaccination goal(s) (completed)
    • Host an internal event to kick-off the campaign (optional) 
    • Organize and conduct provider and staff training (Needs further planning)
    • Implement evidenced-based interventions and/or policy changes (In process)
  2. Ongoing Education of Community about the importance of the HPV vaccine at Health fairs.
  3. Ongoing education of staff, patients and medical providers.
  4. Monitor HPV Vaccination Rates 
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