Trust introduces an assessment proforma to improve the safety of chemotherapy prescribing in oncology, improving the quality of assessments and documentation of patient’s performance status

* Please provide a brief outline of your work.

 Improving the quality and safety of chemotherapy prescribing was prioritised by the oncology service in the Northern Ireland Cancer Centre (NICC), following review of adverse incidents and M&M cases. The Manual for Cancer Services: Chemotherapy Measures (MCS) provides clear guidance on essential criteria that should be assessed and documented for patients during chemotherapy.

This project aimed to ensure clinicians’ assessments documented at least 95% of the key parameters from MCS and local medical record keeping standards, based on GMC guidance. It was felt documentation of these key components should encourage considered decision making and appropriate management plans being initiated.

 * Please describe the actions you took to achieve your result.

 A multi-professional quality improvement team (QIT) was established, with representation from groups involved in chemotherapy prescribing, dispensing and delivery. A proforma was developed, incorporating a checklist of key components defined by MCS, local medical record keeping standards and information deemed important from incident reviews e.g. recent hospital admissions/GP contact. Completeness of chemotherapy assessments were scored out of 20, with the aim of documentation being on average ≥ 95% complete (19/20).

The project’s first phase focused on the successful introduction in NICC of a paper proforma into medical notes, replacing ‘freehand’ annotations (12/2015–08/2016). Baseline data was collected over ten weeks, with twenty case notes sampled weekly for the entire eight month phase.

A staggered roll out to different oncology clinics was undertaken, with frequent PDSA cycles continually refining the proforma, making it more compact, systematic and usable. Continuous informal user feedback to QIT members was encouraged, leading to important prompts being included e.g. checking consent forms were signed and premedication taken.

Results of tested changes and feedback was discussed weekly by the QIT and regularly presented at departmental quality improvements meetings. Written anonymous staff feedback (May 2016) ensured everyone could express their views and highlight areas for improvement.

A suggestion proformas be pre-filed in medical notes significantly impacted proforma completion. (see supporting information bmj_qip_chemoproforma paper) The project’s second eight month phase (05/2017-12/2017) focused on the successful introduction of electronic proformas, to replace the paper proforma and importantly be viewable by all staff immediately.

It was similarly initially refined through a small number of NICC clinics, before being introduced across all oncology clinics, following staff training. A further staff questionnaire (August 2017), resulted in separate proformas for cycle one, ongoing cycles and end of treatment, which were subsequently implemented in the other regional cancer centre and units.

From 10/2017 proforma use and completeness of documentation was assessed by weekly sampling of ten patients from NICC and ten from Craigavon hospital (a representative cancer unit).

Results and ongoing user feedback informed further modifications, to continue to improve the profromas’ acceptability and usefulness.

No financial costs have been incurred. 91% staff reported electronic assessments reduced pharmacy queries, reporting more efficient dispensing and positive effects on time to and capacity for chemotherapy delivery. Approximately twenty NICC chemotherapy patients have been surveyed monthly throughout, ensuring no detrimental impact on patients’ service experience. Ultimately this project strives to ensure Northern Irish patients consistently have high quality, appropriate and safe chemotherapy treatment. (PDF of sample completed end of treatment proforma attached as supporting information)

 * Please list the most significant results

 100% of assessments 10 -12/2017 in NICC and Craigavon Hospital were documented using the electronic proforma. Quality of assessments improved in NICC from 62% complete (12/2015) to >95% with the paper proforma (07/2016) and then consistently 100% with the electronic proforma (from 10/2017). In Craigavon, assessments improved from 70% complete (05/2017) to consistently 100% (from 10/2017).

Crucially performance status documentation has improved from 88% (NICC) and 70% (Craigavon) to 100% at both sites using the electronic proforma. Staff view the proforma positively, with 94% agreeing it promotes safety and high patient satisfaction with the chemotherapy service continues to be reported. (please see attached -Data 2)

 * Describe how your project has spread to other teams, departments or organisations

 The electronic assessment proformas are currently in use in all oncology chemotherapy clinics in Northern Ireland (two cancer centres and three cancer units). It is also used in NICC’s haematology chemotherapy clinics, with a planned introduction to all regional haematology clinics. Our experience incorporating checklist components into chemotherapy assessments has been published to share learning.

A complementary, electronic nursing administration checklist has also been successfully developed using similar methodology. Following development in BCH oncology clinics, it has been implemented in oncology regionally with positive feedback; strengthening prescribers’ assessment proformas and ensuring nursing documentation for chemotherapy administration also meets MCS standards.