Quality Improvement Cycle in Patient-Centered Care for Oncology Patients in an Outpatient Service

Technical Summary: Quality Improvement Cycle in Patient-Centered Care for Oncology Patients

Problem Statement
The study addresses the challenge of integrating palliative care into outpatient oncology services, specifically for patients with advanced disease who are no longer benefiting from disease-modifying treatments. In many settings, including the Brazilian Northeast, care remains heavily oriented toward curative outcomes, leading to a dichotomy where palliative care is often delayed until the very end of life. This delay can result in prolonged suffering, inappropriate use of healthcare resources, and a lack of patient-centered decision-making. A specific operational gap identified was the low adherence of healthcare teams to decision-making processes regarding palliative care for patients with a Palliative Performance Scale (PPS) score of 50% or lower. The study sought to determine if a structured quality improvement cycle could effectively identify and address modifiable causes of nonconformity in this process.

Methodology
The research employed a quasi-experimental, before-and-after study design without a control group, conducted at an outpatient oncology service in Fortaleza, Brazil. The institution is certified by the Organização Nacional de Acreditação (ONA) at Level 1. The study population consisted of patients aged 18 or older undergoing chemotherapy from the second cycle onward between January 2023 and March 2024.

The core methodology followed the Quality Improvement Cycle framework proposed by Saturno Hernández, executed in sequential stages:

1. Problem Identification: A multidisciplinary team (including physicians, nurses, pharmacists, and a social worker) identified "low adherence of the healthcare team in decision-making related to palliative care" as the priority issue.
2. Cause Analysis: An Ishikawa (fishbone) diagram was used to analyze causes. The team prioritized modifiable "process-related" causes over structural ones.
3. Criteria Definition: Four specific quality criteria were established:
   • C1: Application of the PPS at every chemotherapy cycle for eligible patients.
   • C2: Requesting the attending physician to reassess the therapeutic plan for patients with PPS ≤50%.
   • C3: Documenting meetings with patients/families to discuss palliative care for those with PPS ≤50%.
   • C4: Evaluating the interval between the last chemotherapy session and death (targeting ≥30 days).
4. Baseline Assessment: Data from the first quarter of 2023 (301 patients) were analyzed to establish a baseline.
5. Intervention Planning and Implementation: Based on the baseline, the team implemented multifaceted actions, including:
   • Training nursing teams on PPS application.
   • Shifting PPS application responsibility to the triage team.
   • Replacing WhatsApp notifications with direct, in-person communication between the navigation team and attending physicians.
   • Establishing a multidisciplinary palliative care team (nursing, nutrition, psychology, palliative physician) to conduct weekly case discussions.
   • Implementing a pilot program for patient/family engagement and telemonitoring.
6. Reassessment: Compliance was measured in August 2023 and the first quarter of 2024. Data were standardized using the rule of three to allow for comparative Pareto analysis. Statistical significance was assessed using a one-sided hypothesis test (p < 0.05).

Key Results
The study observed a reduction in nonconformities from 15 in the baseline evaluation to 8 in the third evaluation (a 46.7% reduction).

• Criterion 1 (PPS Application): Showed a 50% reduction in nonconformities, moving from the highest frequency of defects to the lowest by the third evaluation. This indicates the interventions regarding training and process reorganization were highly effective.
• Criterion 2 (Physician Reassessment): Showed initial improvement but did not maintain statistical significance between the first and third evaluations. The authors note that while communication methods improved (shifting to structured team meetings), documentation inconsistencies and varying physician receptiveness affected the metrics.
• Criterion 3 (Patient/Family Discussion): Did not show improvement; compliance remained at 0% in the third evaluation. The authors attribute this to the complexity of cultural barriers, the lack of specific training for physicians on end-of-life communication, and the fact that this was the least implemented intervention.
• Criterion 4 (Interval to Death): Demonstrated a statistical improvement (0.28% relative improvement) between the first and third evaluations. However, the authors caution that this result is influenced by multiple factors, including underreporting of deaths in an outpatient setting and the exclusion of patients who died shortly after treatment discontinuation for reasons unrelated to the disease.

Significance and Claims
The paper claims that the Quality Improvement Cycle is an effective tool for identifying and addressing modifiable causes of poor performance in healthcare services, regardless of geographic location. The study highlights that while successful practices from other contexts may not be directly transferable to the Brazilian Northeast due to cultural and contextual differences, the methodology of the improvement cycle is universally applicable.

Key contributions include:

• Demonstrating that process-related interventions (training, workflow changes, multidisciplinary engagement) can significantly improve the identification and documentation of palliative care needs (Criterion 1).
• Illustrating that improving patient-centered communication (Criterion 3) is a more complex, long-term challenge requiring cultural change and specific physician training, which was not fully achieved within the study's timeframe.
• Validating the use of the PPS ≤50% threshold as a trigger for palliative care intervention, while noting the need for earlier identification (e.g., upon metastasis or treatment failure) to maximize patient benefit.

The authors conclude that leadership engagement and the collaborative selection of improvement opportunities are essential for success. They acknowledge that the study's limitations—specifically the lack of a control group, potential underreporting of deaths, and incomplete implementation of certain interventions (particularly regarding Criterion 3)—mean that the findings should be interpreted with caution. The study suggests that further cycles of improvement are necessary to sustain gains and address the remaining gaps in patient-centered care.