Spring 2014 

Donald L. Trump, MD, FACP, is President & CEO of Roswell Park Cancer Institute, in Buffalo, NY

Commentary Overview

* A cornerstone of bridging the healthcare "quality chasm" is holding those who provide the care accountable for demonstrating quality.

* The best organizations identify effective measures of cancer care and build databases and evidence that add to "best practice" knowledge.

* Roswell Park Cancer Institute participates in a variety of voluntary quality assessments and is working with other top cancer centers to develop meaningful measures of quality for adoption by government and private payers.

About AACI Commentary

As part of AACI's efforts to feature the work and views of its member centers, AACI has launched AACI Commentary, a quarterly editorial series. Written by cancer center leaders, each edition will focus on a major issue of common interest to the nation's cancer centers.

All Good Work Requires Self-Revelation


Sidney Lumet, the director of such fine films as 12 Angry Men and Dog Day Afternoon, was highly regarded for both his technical skills and his ability to get the best performances from the actors he hired. He once said, "All good work requires self-revelation." While making good on our commitments to the patients we serve may not seem similar to making a movie, there are commonalities, and Mr. Lumet's quote definitely applies.

Our self-revelation comes when we examine our performance and the outcomes we achieve and compare them with those of other high-performing organizations. Saying we're good, or even great, is one thing; proving it is another.

Some healthcare providers make available only the kind of proof required by accrediting bodies, state and federal governments, and payers. Better organizations seek out opportunities to test themselves against others by participating in collaborative databases that allow comparison on many levels. The best organizations are leaders in identifying effective measures of cancer care and in building the databases and evidence that adds to the accumulated "best practice" knowledge.

In 2001, the Institute of Medicine published Crossing the Quality Chasm: A New Health System for the 21st Century. This seminal work called for a more accountable national healthcare system to meet the changing needs of an aging population that will live longer, have access to the most innovative (and expensive) technology and drugs, and demand a more active role in health decision-making. One of the cornerstones of bridging that "quality chasm" is holding those who provide the care accountable for demonstrating quality within six key domains. Organizations today have to demonstrate that they are:

Safe: avoiding injuries to patients as they deliver the care intended to help them.
Effective: providing services based on scientific knowledge to all who may benefit, and not providing services to those who are unlikely to benefit.
Patient-centered: ensuring that care is provided in a respectful way that values the individual patient's needs and preferences.
Timely: reducing the time a patient waits both for an appointment and to see the doctor.
Efficient: avoiding waste of resources such as time, equipment, supplies, and ideas.
Equitable: providing care that does not vary because of personal attributes such as race, gender, geography, or socioeconomic status.

This all sounds so obvious, and yet these characteristics of good quality care are difficult to measure. In fact, it's difficult to get agreement on what the measures should be and how the data should be collected.

Voluntary Assessment, Improved Quality

Roswell Park is working with other top cancer centers to develop meaningful measures and to shepherd them through so that government and private payers will see the merit of adopting them. With these efforts underway, we're also voluntarily and transparently participating in several databases that allow us to compare ourselves against the best healthcare organizations in the country. Through these comparisons, we learn where we excel, where we have opportunity for improvement and how to better collaborate with patients in order to get the outcomes we all want.

One of the assessments we take part in beyond required quality reporting is the Leapfrog Patient Safety Initiative, a program developed by a coalition of public and private employers. Roswell Park was awarded the Leapfrog Group's top decile distinction for three consecutive years, but fell off the top achiever list last year when the organization implemented new training recommendations that we had not yet incorporated into our practices. This is another benefit of self-evaluation; we learned from that experience and, even amid challenging financial times, we're finding ways to include the training for staff, faculty, and our governance board.

In 2012, we committed to improving our surgical outcomes by joining the National Surgical Quality Improvement Program (NSQIP); this year, although we had to make tough choices between good resources, we advocated to be allowed to join the University Hospital Consortium and, when permission came, we signed up. Will we look perfect compared to the best hospitals in the country? No. Will we look better in two years and will we be better able to prove our value to patients and the community we serve? If our experience with NSQIP is any indication, the answer will be a resounding "yes."

Our organizational values lead us to go beyond the quality reporting that is required far beyond, and always in a way that is guided by both organizational values and our "value proposition"--our commitment to provide value to our constituents. However, the data we are now accumulating are more helpful to us internally than they are to the external user our patients.

At a recent meeting, those leading the "measure development" movement lamented that today's patients aren't using the data as much as we might like. True, but we are wholly to blame for that. We're putting out more data, but it's too often inscrutable. Technology is not a magic bullet; it doesn't help us to present the data in an easy-to-find, easy-to-interpret manner. An interactive dialogue between a patient/family unit and the caregiving team is still the most valuable way to achieve an understanding of what the patient values and what they're willing to endure to reach an anticipated outcome. That dialogue can also make a physician template irrelevant. It takes time to listen, put aside our own predilections, and understand; but taking that time is vitally important.

If our mission is to be among the best of the best, we have to know where we stand today, continuously compare ourselves against others in the top tier and, for the benefit of those who come to us for care, make it happen. Then we have to be willing to listen to patients when they tell us which road they wish to travel. We may not win an Academy Award, as Sidney Lumet did, but we'll be more satisfied with our ongoing self-evaluation and the improvements that it makes possible.

An earlier version of this AACI Commentary appeared in the August 2013 issue of Connections, a publication of Roswell Park Cancer Institute.

Representing 92 of the nation's premier academic and free-standing cancer centers, the Association of American Cancer Institutes is dedicated to reducing the burden of cancer by enhancing the impact of the nation's leading cancer centers.