Patients undergoing surgery for pancreatic cancer at University of Colorado Hospital are reporting a better overall experience and improved outcomes, thanks to enhanced communication and clearer patient pathways.
“Quality and safety are very high priorities for the Department of Surgery,” said Randall Meacham, MD, professor of surgery-urology and vice chair for clinical affairs and quality. And with improving outcomes the goal, a team entered the Institute for Healthcare Quality, Safety and Efficiency (IHQSE) with the vague idea of the need to reduce length of stay.
The team was made up of Nurse Manager Angela Hill, MSN, RN, CMSRN, Clinical Nurse Educator Shannon Haas, BSN, RN, CMSRN, and Christan Bartsch, MSHS, PA-C, MPH. (Pictured on right, from left to right: Hill, Bartsch and Haas)
“Angie, Shannon and I had been working together on monthly teams, and we all spend the majority of our days with patients. So we all knew the service well and had a lot of experience with these patients,” said Bartsch.
The unit had existing safety and quality programs in place, yet there was room for improvement.
“There was an existing pancreas SUSP (surgical unit-based safety program), but there wasn’t much ownership. Because of our involvement in IHQSE, we had the opportunity to revamp and revise,” said Haas.
First, they needed data. And five months into their IHQSE project, they had their first data point.
“I remember all of us feeling disappointed that it took five months to get our data,” said Haas.
“But during those five months, we were building relationships, identifying stakeholders, creating a business case--important work that we didn’t know how to do before IHQSE,” said Hill.
The first data set included cost and length of stay (LOS), which they were surprised to learn were higher than national averages. Soon after they learned readmission and complication rates could also be improved.
“It raised a lot of questions, because we know we’re all providing great care,” said Hill. “And we were pretty emotional about it. Many of us tried to poke holes in it.”
They knew they needed to drill down deeper. That’s where the “voice of the patient” interviews came into play.
“We gathered qualitative data of our patients and their experiences,” said Bartsch. “These spoke louder to me that the quantitative data. The interviews help us tell a story about our data.”
“We’d been focused on the numbers,” said Haas. “But in the end, we relied heavily on the direct quotes from our patients to help get our post-op team on board with making changes. The stories really resonated with our frontline nursing staff. Patient stories had the most impact in helping us tie it all together.”
As the team examined the processes identified in the patient stories, they learned that compliance with the existing pathways was lacking. They evaluated the paths in place, questioning all points along the pathway to ensure the right things happened at the right time.
“By talking to the patients, we learned that many weren’t feeling ready for discharge because of pain and lack of mobility or the inability to tolerate food. So we altered the pathway to ensure patients would start working with physical therapy and occupational therapy on the first day,” said Bartsch.
Pre-operatively, the team improved communication to help manage expectations, including having social workers meet with patients before surgery to identify any needs they may have at discharge.
“We spent a lot of time educating our nurses and residents as well,” said Haas. “It was about getting systems in place that work and that everyone can follow.”
About a month after the updated pathways were in place, they started to examine complications. They looked at whether the pathway was followed, and drilled down to hone in on interventions that could help reduce complications.
“We didn’t realize it at the time, but our interventions were helping with all of our data points—reducing readmissions, LOS, and complications,” said Bartsch.
Improving communication has also had a major impact on the post-operative teams delivering care. Each person on the team learned the workflows of the other disciplines, which has served to strengthen relationships and help people know where their work fits in with the bigger picture.
“Overall, the team reacted very positively,” said Bartsch. “Having the support of attendings helped to encourage and engage everyone on these projects, and create excitement for projects in the future.”
“Christan brought in a cake to celebrate everyone’s accomplishments to underscore the group efforts that led to our successes. Everyone played a part,” said Hill.
According to Jeffrey Glasheen, MD, professor of medicine-internal medicine and chief quality officer for UCHealth, the pancreas team’s accomplishments demonstrate the power of standardized work. “They started by creating a shared baseline—an order set of agreed upon steps to care for their patients. They then embedded a data system to measure the compliance with each step and, most importantly, committed to following the order set and intervening to change it when the data dictated,” he said.
Dr. Glasheen also underscored the importance of the shared baseline coming from the pancreas team itself. “This speaks to the necessity of this kind of work being led from the front—from the people who care for these patients every day.”
Richard Schulick, MD, MBA, FACS, professor of surgery-surgical oncology and chair of the school's surgerydepartment is pleased with the team's approach to improving outcomes.
"This is a great example of how high performing teams always strive to do better. Rather than resting on our laurels as one of the top pancreas teams in the country, we dared to be exceptional," Dr. Schulick said. "There were many things that were being done well, but there were also things that could be improved. Data were collected, the issues understood, and then they were systematically addressed. Most importantly, this was done using a multidisciplinary approach with team members from all departments and sections of the hospital and School of Medicine."
The team is now examining new initiatives to keep improving the care of pancreatic cancer patients, including preparing for the rigorous process of becoming certified by the Joint Commission.
“Quality improvement is a continuous process. It never stops,” said Hill. “There are always things we can work on to make improvements.”
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