Download OTTUMWA REGIONAL HEALTH CENTER ANNUAL REPORT

OTTUMWA REGIONAL HEALTH
CENTER ANNUAL REPORT
May 2015
COVERING 2014 ACTIVITES
Cancer Program Provides Quality Care
In order to assure that patients
at Ottumwa Regional Health
Center (ORHC) are receiving the
best possible quality care, we
monitor approved accountability
measures on a regular basis.
Three of those accountability
measures cover patients diagnosed with breast cancer. Each
measure is described below;
mended to receive a combination of chemotherapy within four
months (120 days) of diagnosis.
BCS/RT: Patients who are diagnosed with breast cancer and
elect to undergo breast conserving surgery (lumpectomy or excisional biopsy) should receive
post-operative radiation therapy
within one year of diagnosis.
HT: Patients who are diagnosed with AJCC T1cN0M0 or
Stage II or Stage III breast cancer and are estrogen or progesterone receptor
positive are rec100%
ommended to
receive Tamoxi98%
fen or any aro96%
matase inhibitor
2
94%
within one year
0
(365 days) of
1
92%
diagnosis.
2
MAC: Patients (under the age
of 70) who are diagnosed with
AJCC T1cN0M0 or Stage II or
Stage III breast cancer and are
estrogen and/or progesterone
receptor negative are recom-
The American
College of Surgeons Commission on Cancer
(ACoS/CoC) set
the minimum
90%
compliance rates for each facility to
meet. As shown in the graph below, ORHC consistently meets and
exceeds the minimum Goal of 90%
compliance with each of the
measures.
2
0
1
3
2
0
1
4
2
0
1
2
2
0
1
3
2
0
1
4
88%
2
0
1
2
2
0
1
3
86%
84%
BCS/RT
MAC
Goal 90%
2
0
1
4
HT
Radiology Achieves Accreditation
Accreditation is a process showing that our facility meets or exceeds set quality
goals and care provided to our patients. In 2014, the Radiology Department applied for and achieved Accreditation in Computerized Topography (CT) due to the
purchase of a new Phillips128 slice CT Scan. In addition to the new CT Accreditation, the Radiology Department has previously achieved and is currently Accredited
for Mammography, Magnetic Resonance Imaging, and Nuclear Medicine.
Inside this issue:
Special points of interest:
Evaluation of Telemedicine
2
Cancer Conference Review
2
New Lung Cancer Screening Program
3
Cancer Screenings and Preventions
3
Assessment and Treatment Evaluation Study
3
Number of Cases Accessioned by ORHC
4

Look Good...Feel Better Classes, contact Joan Heslinga-Boer
at 641-684-2742.

Monthly Cancer Support Group held at the McCreery Cancer
Center 2nd Wednesday of each month starting at 6 p.m.

NEW: Frankly Speaking men’s cancer seminar meets monthly
at noon in the McCreery Cancer Center Conference Room,
contact Joan Heslinga-Boer at 641-684-2742 for dates.

McCreery Cancer Center Walking Club for Survivors and
Caregivers meet the 4th Monday of each month at 5 p.m. at
Quincy Place Mall.
Page 2
OTTUMWA REGIONAL HEALTH CENTER
Evaluation of Telemedicine Medical Oncology Consults
April 2014 brought
change to Ottumwa Regional Health Center; in
order to expand services
and continue to provide
quality care in Southeast
Iowa, the Jefferson County and Ottumwa Regional
Health Centers partnered
to create the McCreery
Cancer Center at Jefferson County Health Center
Medical Oncology.
One of the gaps this
move created was a lack
of availability for the Medical Oncologist to provide
consultations for inpatients with cancer at
ORHC. The gap was
addressed by establishing
a process and providing
equipment for telemedicine consultations.
over six months. It was
also reported an increase
in the number of patients
being diagnosed here and
sent elsewhere for treatment (possibly reflecting
a trend of transferring
patients out to other facilities).
We discovered that requests for telemedicine
consultations were not
being done; dropping
from average of 18 per
month down to just one in
In order to support the
new service line , education of the hospitalists and
nursing staff was undertaken. Recent review in
early 2015 has shown an
The two pie charts demonstrate the increase in the
number of patients who were diagnosed at ORHC
and received all their care elsewhere prior to the
move of Medical Oncology (pie chart to the left showing 14% ) to after the move of Medical Oncology (pie
chart below showing 26%).
Page 3
Cancer Conference Review
Each month, a Cancer Conference is held with multidisciplinary attendance that
includes pathologists, medical
oncologist, radiation oncology,
diagnostic radiologist, and
surgeons. The goal of the
Cancer Conference is to aid
the physicians in formulating
an effective treatment plan
and improved care for patients with cancer.
Cancer Conferences are most
effective when cases are presented prospectively and preferably prior to the patient
starting treatment. One of the
quality studies focused on
improving the number of
cases being presented prior
to starting treatment and/
or reducing the number of
days after the patient
started treatment that the
case is presented at Cancer Conference.
measure and working closely with physicians, improvements have been documented as illustrated in the graph below.
One of the recommended
improvements was to run
pathology reports on a
weekly basis (instead of
monthly) to help identify
patients sooner and closer to the Cancer Conference. Between this
Cancer Screenings and Preventions
Providing cancer screenings and cancer prevention education on healthy
behaviors to reduce the
risk of developing cancer
are important aspects of
any cancer program. In
2014, ORHC provided
over 400 screening colonoscopies with several
positive findings requiring
follow-up/treatment.
Prevention efforts included a Community Lecture,
providing free or low cost
mammograms through
partnerships with Susan
G. Komen and the
BCCEDP (Breast and
Cervical Cancer Early
Detection Program), and
participation in the annual
Think Pink Day, an event
that provides information
for breast cancer awareness and screening recommendations provided
by both the Susan G.
Komen foundation and
the American Cancer
Society.
In addition, the Wellness
Department at ORHC
provides Wellness
Screenings for several
employers in the community throughout the year.
The review for 2014 covered patients diagnosed
with Stage 1-3A and if a
sentinel lymph node biop-
sy was performed if axillary lymph nodes were
clinically negative at the
time of diagnosis per National Comprehensive
Cancer Network (NCCN)
guidelines.
The review was conducted for cases diagnosed in
2012 to 2013 resulting in
the review of 41 breast
cancer cases meeting all
the criteria.
Low Dose CT
Scan for Lung
Cancer
Screening are
now available
with a
physicians
order!
Assessment and Treatment Evaluation Study
On a yearly basis, a physician chooses a topic
regarding one of ORHC’s
most common cancer
sites and assesses
whether appropriate evaluation and treatment was
provided in compliance to
nationally set guidelines.
NEW!
In summary, all breast
cancers in which the patient had their surgery at
ORHC followed the recommended guidelines.
Only one case did not
meet the NCCN recommendations but the surgery was not performed
here at ORHC (patient
received part of their
treatment at ORHC but
not all treatment).
OTTUMWA REGIONAL HEALTH
CENTER
Mission Statement
McCreery Cancer Center
1001 Pennsylvania
Ottumwa, IA 52501
Phone: 641-684-2480
Fax: 641-684-2746
Ottumwa Regional Health
Center is a regional hospital
committed to providing
exceptional care in a
compassionate manner to you
and your family.
We’re on the web!
ORHC.com
Number of Cancer Cases Accessioned Per Year at ORHC
Cases that are abstracted and added
(accessioned) to the cancer registry each year
are broken down into two major categories:
analytical and non-analytical cases.
Number of Cases Accessioned at ORHC
Per Year
The categories describe the purpose for which
the patient presents to the hospital for their cancer care.
Analytical: describes patients in which are first
diagnosed and/or receives all or part of their
cancer treatment at our facility.
500
Non-Analytical: describes patients who may
only present for ancillary testing or staging workup but have been diagnosed and received all
their care elsewhere. This category also includes cases in which patients are diagnosed
and treated in a staff physicians office only and
are not seen at the hospital for any services.
This category can also includes patients in which
their disease has progressed and presents for
additional cancer care services.
300
400
178
171
138
98
104
219
225
218
207
200
100
Non-Analytical
Cases
Analytical Cases
252
0
2010 2011 2012 2013 2014