User login
Implementation of Harm Reduction Syringe Services Programs at 2 Veterans Affairs Medical Centers
Implementation of Harm Reduction Syringe Services Programs at 2 Veterans Affairs Medical Centers
A syringe services program (SSP) is a harm reduction strategy designed to improve the quality of care provided to people who use drugs (PWUD). SSPs not only provide sterile syringes but establish a connection to medical services and resources for the safe disposal of syringes. By engaging with an SSP, patients may receive naloxone, condoms, fentanyl test strips, opioid use disorder medications, vaccinations, or testing for infectious diseases such as HIV and hepatitis C virus (HCV). Patients may also be connected to housing or social work services.
SSPs do not lead to increased drug use,1 increased improperly disposed supplies needed for drug use in the community, or increased crime.2,3 New users of SSPs are 5 times more likely to enter treatment for drug use than those who do not use SSPs.4-8 Further, SSPs have been found to reduce HIV and HCV transmission and are cost-effective in HIV prevention.9-11
Syringe Services Program
SSPs were implemented at the US Department of Veterans Affairs (VA) Alaska VA Healthcare System (AVAHCS) and VA Southern Oregon Healthcare System (VASOHCS). AVAHCS provides outpatient care across Alaska, with sites in Anchorage, Fairbanks, Homer, Juneau, Wasilla, and Soldotna. VASOHCS provides outpatient care to Southern Oregon and Northern California, with sites in White City, Grants Pass, and Klamath Falls, Oregon. Both are part of Veterans Integrated Service Network 20
Workgroups at AVAHCS and VASOHCS developed SSPs to reduce risks associated with drug use, promote positive outcomes for PWUD, and increase availability of harm reduction resources. During the July 2023 to June 2024 pharmacy residency cycle, an ambulatory care pharmacy resident from the Veterans Integrated Services Network 20 Clinical Resource Hub—a regional resource for clinical services—joined the workgroups. The workgroups established a goal that SSP resources would be made available to enrolled patients without any exclusions, prioritizing health equity.
SSP implementation needed buy-in from AVAHCS and VASOHCS leadership and key stakeholders who could participate in the workgroups. Following AVAHCS and VASOHCS leadership approval, each facility workgroup drafted standard operating procedures (SOPs). Both facilities planned to implement the program using prepackaged kits (sterile syringes, alcohol pads, cotton swabs, a sharps container, and an educational brochure on safe injection practices) supplied by the VA National Harm Reduction Program.
Each SSP offered patients direct links to additional care options at the time of kit distribution, including information regarding medications/supplies (ie, hepatitis A/B vaccines, HIV preexposure prophylaxis, substance use disorder pharmacotherapy, naloxone, and condoms), laboratory tests for infectious and sexually transmitted diseases, and referrals to substance use disorder treatment, social work, suicide prevention, mental health, and primary care.
The goal was to implement both SSPs during the July 2023 to June 2024 residency year. Other goals included tracking the quantity of supplies distributed, the number of patients reached, the impact of clinician education on the distribution of supplies, and comparing the implementation of the SSPs in the electronic health record (EHR) systems.
Alaska VA Healthcare System
An SOP was approved on December 20, 2023, and national supply kits were stocked in collaboration with the logistics department at the Anchorage AVAHCS campus. Social and behavioral health teams, primary care social workers, primary care clinicians, and nursing staff received training on the resources available through the SSP. A local adaptation of a template was created in the Computerized Patient Records System (CPRS) EHR. The template facilitates SSP kit distribution and patient screening for additional resources. Patients can engage with the SSP through any trained staff member. The staff member then completes the template and helps to distribute the SSP kit, in collaboration with the logistics department. The SSP does not operate in a dedicated physical space. The behavioral health team is most actively engaged in the SSP. The goal of SSP is to have resources available anywhere a patient requests services, including primary care and specialty clinics and to empower staff to meet patients’ needs. One patient has utilized the SSP as of June 2025.
Southern Oregon Healthcare System
Kits were ordered and stocked as pharmacy items in preparation for dispensing while awaiting medical center policy approval. Education began with the primary care mental health integration team. After initial education, an interdisciplinary presentation was given to VASOHCS clinicians to increase knowledge of the SSP. To enable documentation of SSP engagement, a local template was developed in the Cerner EHR to be shared among care team members at the facility. Similar to AVAHCS, the SSP does not have a physical space. All trained facility staff may engage in the SSP and distribute SSP kits. The workgroup that implemented this program remains available to support staff. Five patients have accessed the SSP since November 2024 and 7 SSP kits have been distributed as of June 2025.
Discussion
The SSP workgroups sought to expand the program through additional education. A number of factors should be considered when implementing an SSP. Across facilities, program implementation can be time-consuming and the timeline for administrative processes may be long. The workgroups met weekly or monthly depending on the status of the program and the administrative processes. Materials developed included SOP and MCP documents, a 1-page educational handout on SSP offerings, and a PowerPoint presentation for initial clinician education. Involving a pharmacy resident supported professional development and accelerated implementation timelines.
The facilities differed in implementation. AVAHCS collaborated with the logistics department to distribute kits, while VASOHCS worked with the Pharmacy service. A benefit of collaborating with logistics is that patients can receive a kit at the point of contact with the health care system, receiving it directly from the clinic the patient is visiting while eliminating the need to make an additional stop at the pharmacy. Conversely, partnering with the Pharmacy service allowed supply kits to be distributed by mail, enabling patients direct access to kits without having to present in-person. This is particularly valuable considering the large geographical area and remote care services available at VASOHCS.
Implementation varied significantly because AVAHCS operated on CPRS while VASOHCS used Cerner, a newer EHR. AVAHCS adapted a national template produced for CPRS sites, while VASOHCS had to prepare a local template (auto-text) for SSP documentation. Future plans at AVAHCS may include adding fentanyl test strips as an orderable item in the EHR given that AVAHCS has a local instance of CPRS; however, VASOHCS cannot order fentanyl test strips through the Pharmacy service due to legal restrictions. While Oregon permits fentanyl test strip use, the Cerner instance used by VA is a national program, and therefore the addition of fentanyl test strips as an orderable item in the EHR would carry national implications, including for VA health care systems in states where fentanyl test strip legality is variable. Despite the challenges, efforts to include fentanyl test strips in both SSPs are ongoing.
No significant EHR changes were needed to make the national supply kits available in the Cerner EHR through the VASOHCS Pharmacy service. To have national supply kits available through the AVAHCS Pharmacy service, the EHR would need to be manipulated by adding a local drug file in CPRS. Differences between the EHRs often facilitated the need for adaptation from existing models of SSPs within VA, which were all based in CPRS.
Conclusions
The implementation of SSPs at AVAHCS and VASOHCS enable clinicians to provide quality harm reduction services to PWUD. Despite variations in EHR systems, AVAHCS and VASOHCS implemented SSP within 1 year. Tracking of program engagement via the number of patients interacting with the program and the number of SSP kits distributed will continue. SSP implementation in states where it is permitted may help provide optimal patient care for PWUD.
- Hagan H, McGough JP, Thiede H, Hopkins S, Duchin J, Alexander ER. Reduced injection frequency and increased entry and retention in drug treatment associated with needle-exchange participation in Seattle drug injectors. J Subst Abuse Treat. 2000;19(3):247-252. doi:10.1016/s0740-5472(00)00104-5
- Marx MA, Crape B, Brookmeyer RS, et al. Trends in crime and the introduction of a needle exchange program. Am J Public Health. 2000;90(12):1933-1936. doi:10.2105/ajph.90.12.1933
- Galea S, Ahern J, Fuller C, Freudenberg N, Vlahov D. Needle exchange programs and experience of violence in an inner city neighborhood. J Acquir Immune Defic Syndr. 2001;28(3):282-288. doi:10.1097/00042560-200111010-00014
- Des Jarlais DC, Nugent A, Solberg A, Feelemyer J, Mermin J, Holtzman D. Syringe service programs for persons who inject drugs in urban, suburban, and rural areas — United States, 2013. MMWR Morb Mortal Wkly Rep. 2015;64(48):1337-1341. doi:10.15585/ mmwr.mm6448a3
- Tookes HE, Kral AH, Wenger LD, et al. A comparison of syringe disposal practices among injection drug users in a city with versus a city without needle and syringe programs. Drug Alcohol Depend. 2012;123(1-3):255-259. doi:10.1016/j.drugalcdep.2011.12.001
- Klein SJ, Candelas AR, Cooper JG, et al. Increasing safe syringe collection sites in New York State. Public Health Rep. 2008;123(4):433-440. doi:10.1177/003335490812300404
- de Montigny L, Vernez Moudon A, Leigh B, Kim SY. Assessing a drop box programme: a spatial analysis of discarded needles. Int J Drug Policy. 2010;21(3):208-214. doi:10.1016/j.drugpo.2009.07.003
- Bluthenthal RN, Anderson R, Flynn NM, Kral AH. Higher syringe coverage is associated with lower odds of HIV risk and does not increase unsafe syringe disposal among syringe exchange program clients. Drug Alcohol Depend. 2007;89(2-3):214-222. doi:10.1016/j.drugalcdep.2006.12.035
- Platt L, Minozzi S, Reed J, et al. Needle syringe programmes and opioid substitution therapy for preventing hepatitis C transmission in people who inject drugs. Cochrane Database Syst Rev. 2017;9(9):CD012021. doi:10.1002/14651858.CD012021.pub2
- Fernandes RM, Cary M, Duarte G, et al. Effectiveness of needle and syringe programmes in people who inject drugs — an overview of systematic reviews. BMC Public Health. 2017;17(1):309. doi:10.1186/s12889-017-4210-2
- Bernard CL, Owens DK, Goldhaber-Fiebert JD, Brandeau ML. Estimation of the cost-effectiveness of HIV prevention portfolios for people who inject drugs in the United States: a model-based analysis. PLoS Med. 2017;14(5):e1002312. doi:10.1371/journal.pmed.1002312
A syringe services program (SSP) is a harm reduction strategy designed to improve the quality of care provided to people who use drugs (PWUD). SSPs not only provide sterile syringes but establish a connection to medical services and resources for the safe disposal of syringes. By engaging with an SSP, patients may receive naloxone, condoms, fentanyl test strips, opioid use disorder medications, vaccinations, or testing for infectious diseases such as HIV and hepatitis C virus (HCV). Patients may also be connected to housing or social work services.
SSPs do not lead to increased drug use,1 increased improperly disposed supplies needed for drug use in the community, or increased crime.2,3 New users of SSPs are 5 times more likely to enter treatment for drug use than those who do not use SSPs.4-8 Further, SSPs have been found to reduce HIV and HCV transmission and are cost-effective in HIV prevention.9-11
Syringe Services Program
SSPs were implemented at the US Department of Veterans Affairs (VA) Alaska VA Healthcare System (AVAHCS) and VA Southern Oregon Healthcare System (VASOHCS). AVAHCS provides outpatient care across Alaska, with sites in Anchorage, Fairbanks, Homer, Juneau, Wasilla, and Soldotna. VASOHCS provides outpatient care to Southern Oregon and Northern California, with sites in White City, Grants Pass, and Klamath Falls, Oregon. Both are part of Veterans Integrated Service Network 20
Workgroups at AVAHCS and VASOHCS developed SSPs to reduce risks associated with drug use, promote positive outcomes for PWUD, and increase availability of harm reduction resources. During the July 2023 to June 2024 pharmacy residency cycle, an ambulatory care pharmacy resident from the Veterans Integrated Services Network 20 Clinical Resource Hub—a regional resource for clinical services—joined the workgroups. The workgroups established a goal that SSP resources would be made available to enrolled patients without any exclusions, prioritizing health equity.
SSP implementation needed buy-in from AVAHCS and VASOHCS leadership and key stakeholders who could participate in the workgroups. Following AVAHCS and VASOHCS leadership approval, each facility workgroup drafted standard operating procedures (SOPs). Both facilities planned to implement the program using prepackaged kits (sterile syringes, alcohol pads, cotton swabs, a sharps container, and an educational brochure on safe injection practices) supplied by the VA National Harm Reduction Program.
Each SSP offered patients direct links to additional care options at the time of kit distribution, including information regarding medications/supplies (ie, hepatitis A/B vaccines, HIV preexposure prophylaxis, substance use disorder pharmacotherapy, naloxone, and condoms), laboratory tests for infectious and sexually transmitted diseases, and referrals to substance use disorder treatment, social work, suicide prevention, mental health, and primary care.
The goal was to implement both SSPs during the July 2023 to June 2024 residency year. Other goals included tracking the quantity of supplies distributed, the number of patients reached, the impact of clinician education on the distribution of supplies, and comparing the implementation of the SSPs in the electronic health record (EHR) systems.
Alaska VA Healthcare System
An SOP was approved on December 20, 2023, and national supply kits were stocked in collaboration with the logistics department at the Anchorage AVAHCS campus. Social and behavioral health teams, primary care social workers, primary care clinicians, and nursing staff received training on the resources available through the SSP. A local adaptation of a template was created in the Computerized Patient Records System (CPRS) EHR. The template facilitates SSP kit distribution and patient screening for additional resources. Patients can engage with the SSP through any trained staff member. The staff member then completes the template and helps to distribute the SSP kit, in collaboration with the logistics department. The SSP does not operate in a dedicated physical space. The behavioral health team is most actively engaged in the SSP. The goal of SSP is to have resources available anywhere a patient requests services, including primary care and specialty clinics and to empower staff to meet patients’ needs. One patient has utilized the SSP as of June 2025.
Southern Oregon Healthcare System
Kits were ordered and stocked as pharmacy items in preparation for dispensing while awaiting medical center policy approval. Education began with the primary care mental health integration team. After initial education, an interdisciplinary presentation was given to VASOHCS clinicians to increase knowledge of the SSP. To enable documentation of SSP engagement, a local template was developed in the Cerner EHR to be shared among care team members at the facility. Similar to AVAHCS, the SSP does not have a physical space. All trained facility staff may engage in the SSP and distribute SSP kits. The workgroup that implemented this program remains available to support staff. Five patients have accessed the SSP since November 2024 and 7 SSP kits have been distributed as of June 2025.
Discussion
The SSP workgroups sought to expand the program through additional education. A number of factors should be considered when implementing an SSP. Across facilities, program implementation can be time-consuming and the timeline for administrative processes may be long. The workgroups met weekly or monthly depending on the status of the program and the administrative processes. Materials developed included SOP and MCP documents, a 1-page educational handout on SSP offerings, and a PowerPoint presentation for initial clinician education. Involving a pharmacy resident supported professional development and accelerated implementation timelines.
The facilities differed in implementation. AVAHCS collaborated with the logistics department to distribute kits, while VASOHCS worked with the Pharmacy service. A benefit of collaborating with logistics is that patients can receive a kit at the point of contact with the health care system, receiving it directly from the clinic the patient is visiting while eliminating the need to make an additional stop at the pharmacy. Conversely, partnering with the Pharmacy service allowed supply kits to be distributed by mail, enabling patients direct access to kits without having to present in-person. This is particularly valuable considering the large geographical area and remote care services available at VASOHCS.
Implementation varied significantly because AVAHCS operated on CPRS while VASOHCS used Cerner, a newer EHR. AVAHCS adapted a national template produced for CPRS sites, while VASOHCS had to prepare a local template (auto-text) for SSP documentation. Future plans at AVAHCS may include adding fentanyl test strips as an orderable item in the EHR given that AVAHCS has a local instance of CPRS; however, VASOHCS cannot order fentanyl test strips through the Pharmacy service due to legal restrictions. While Oregon permits fentanyl test strip use, the Cerner instance used by VA is a national program, and therefore the addition of fentanyl test strips as an orderable item in the EHR would carry national implications, including for VA health care systems in states where fentanyl test strip legality is variable. Despite the challenges, efforts to include fentanyl test strips in both SSPs are ongoing.
No significant EHR changes were needed to make the national supply kits available in the Cerner EHR through the VASOHCS Pharmacy service. To have national supply kits available through the AVAHCS Pharmacy service, the EHR would need to be manipulated by adding a local drug file in CPRS. Differences between the EHRs often facilitated the need for adaptation from existing models of SSPs within VA, which were all based in CPRS.
Conclusions
The implementation of SSPs at AVAHCS and VASOHCS enable clinicians to provide quality harm reduction services to PWUD. Despite variations in EHR systems, AVAHCS and VASOHCS implemented SSP within 1 year. Tracking of program engagement via the number of patients interacting with the program and the number of SSP kits distributed will continue. SSP implementation in states where it is permitted may help provide optimal patient care for PWUD.
A syringe services program (SSP) is a harm reduction strategy designed to improve the quality of care provided to people who use drugs (PWUD). SSPs not only provide sterile syringes but establish a connection to medical services and resources for the safe disposal of syringes. By engaging with an SSP, patients may receive naloxone, condoms, fentanyl test strips, opioid use disorder medications, vaccinations, or testing for infectious diseases such as HIV and hepatitis C virus (HCV). Patients may also be connected to housing or social work services.
SSPs do not lead to increased drug use,1 increased improperly disposed supplies needed for drug use in the community, or increased crime.2,3 New users of SSPs are 5 times more likely to enter treatment for drug use than those who do not use SSPs.4-8 Further, SSPs have been found to reduce HIV and HCV transmission and are cost-effective in HIV prevention.9-11
Syringe Services Program
SSPs were implemented at the US Department of Veterans Affairs (VA) Alaska VA Healthcare System (AVAHCS) and VA Southern Oregon Healthcare System (VASOHCS). AVAHCS provides outpatient care across Alaska, with sites in Anchorage, Fairbanks, Homer, Juneau, Wasilla, and Soldotna. VASOHCS provides outpatient care to Southern Oregon and Northern California, with sites in White City, Grants Pass, and Klamath Falls, Oregon. Both are part of Veterans Integrated Service Network 20
Workgroups at AVAHCS and VASOHCS developed SSPs to reduce risks associated with drug use, promote positive outcomes for PWUD, and increase availability of harm reduction resources. During the July 2023 to June 2024 pharmacy residency cycle, an ambulatory care pharmacy resident from the Veterans Integrated Services Network 20 Clinical Resource Hub—a regional resource for clinical services—joined the workgroups. The workgroups established a goal that SSP resources would be made available to enrolled patients without any exclusions, prioritizing health equity.
SSP implementation needed buy-in from AVAHCS and VASOHCS leadership and key stakeholders who could participate in the workgroups. Following AVAHCS and VASOHCS leadership approval, each facility workgroup drafted standard operating procedures (SOPs). Both facilities planned to implement the program using prepackaged kits (sterile syringes, alcohol pads, cotton swabs, a sharps container, and an educational brochure on safe injection practices) supplied by the VA National Harm Reduction Program.
Each SSP offered patients direct links to additional care options at the time of kit distribution, including information regarding medications/supplies (ie, hepatitis A/B vaccines, HIV preexposure prophylaxis, substance use disorder pharmacotherapy, naloxone, and condoms), laboratory tests for infectious and sexually transmitted diseases, and referrals to substance use disorder treatment, social work, suicide prevention, mental health, and primary care.
The goal was to implement both SSPs during the July 2023 to June 2024 residency year. Other goals included tracking the quantity of supplies distributed, the number of patients reached, the impact of clinician education on the distribution of supplies, and comparing the implementation of the SSPs in the electronic health record (EHR) systems.
Alaska VA Healthcare System
An SOP was approved on December 20, 2023, and national supply kits were stocked in collaboration with the logistics department at the Anchorage AVAHCS campus. Social and behavioral health teams, primary care social workers, primary care clinicians, and nursing staff received training on the resources available through the SSP. A local adaptation of a template was created in the Computerized Patient Records System (CPRS) EHR. The template facilitates SSP kit distribution and patient screening for additional resources. Patients can engage with the SSP through any trained staff member. The staff member then completes the template and helps to distribute the SSP kit, in collaboration with the logistics department. The SSP does not operate in a dedicated physical space. The behavioral health team is most actively engaged in the SSP. The goal of SSP is to have resources available anywhere a patient requests services, including primary care and specialty clinics and to empower staff to meet patients’ needs. One patient has utilized the SSP as of June 2025.
Southern Oregon Healthcare System
Kits were ordered and stocked as pharmacy items in preparation for dispensing while awaiting medical center policy approval. Education began with the primary care mental health integration team. After initial education, an interdisciplinary presentation was given to VASOHCS clinicians to increase knowledge of the SSP. To enable documentation of SSP engagement, a local template was developed in the Cerner EHR to be shared among care team members at the facility. Similar to AVAHCS, the SSP does not have a physical space. All trained facility staff may engage in the SSP and distribute SSP kits. The workgroup that implemented this program remains available to support staff. Five patients have accessed the SSP since November 2024 and 7 SSP kits have been distributed as of June 2025.
Discussion
The SSP workgroups sought to expand the program through additional education. A number of factors should be considered when implementing an SSP. Across facilities, program implementation can be time-consuming and the timeline for administrative processes may be long. The workgroups met weekly or monthly depending on the status of the program and the administrative processes. Materials developed included SOP and MCP documents, a 1-page educational handout on SSP offerings, and a PowerPoint presentation for initial clinician education. Involving a pharmacy resident supported professional development and accelerated implementation timelines.
The facilities differed in implementation. AVAHCS collaborated with the logistics department to distribute kits, while VASOHCS worked with the Pharmacy service. A benefit of collaborating with logistics is that patients can receive a kit at the point of contact with the health care system, receiving it directly from the clinic the patient is visiting while eliminating the need to make an additional stop at the pharmacy. Conversely, partnering with the Pharmacy service allowed supply kits to be distributed by mail, enabling patients direct access to kits without having to present in-person. This is particularly valuable considering the large geographical area and remote care services available at VASOHCS.
Implementation varied significantly because AVAHCS operated on CPRS while VASOHCS used Cerner, a newer EHR. AVAHCS adapted a national template produced for CPRS sites, while VASOHCS had to prepare a local template (auto-text) for SSP documentation. Future plans at AVAHCS may include adding fentanyl test strips as an orderable item in the EHR given that AVAHCS has a local instance of CPRS; however, VASOHCS cannot order fentanyl test strips through the Pharmacy service due to legal restrictions. While Oregon permits fentanyl test strip use, the Cerner instance used by VA is a national program, and therefore the addition of fentanyl test strips as an orderable item in the EHR would carry national implications, including for VA health care systems in states where fentanyl test strip legality is variable. Despite the challenges, efforts to include fentanyl test strips in both SSPs are ongoing.
No significant EHR changes were needed to make the national supply kits available in the Cerner EHR through the VASOHCS Pharmacy service. To have national supply kits available through the AVAHCS Pharmacy service, the EHR would need to be manipulated by adding a local drug file in CPRS. Differences between the EHRs often facilitated the need for adaptation from existing models of SSPs within VA, which were all based in CPRS.
Conclusions
The implementation of SSPs at AVAHCS and VASOHCS enable clinicians to provide quality harm reduction services to PWUD. Despite variations in EHR systems, AVAHCS and VASOHCS implemented SSP within 1 year. Tracking of program engagement via the number of patients interacting with the program and the number of SSP kits distributed will continue. SSP implementation in states where it is permitted may help provide optimal patient care for PWUD.
- Hagan H, McGough JP, Thiede H, Hopkins S, Duchin J, Alexander ER. Reduced injection frequency and increased entry and retention in drug treatment associated with needle-exchange participation in Seattle drug injectors. J Subst Abuse Treat. 2000;19(3):247-252. doi:10.1016/s0740-5472(00)00104-5
- Marx MA, Crape B, Brookmeyer RS, et al. Trends in crime and the introduction of a needle exchange program. Am J Public Health. 2000;90(12):1933-1936. doi:10.2105/ajph.90.12.1933
- Galea S, Ahern J, Fuller C, Freudenberg N, Vlahov D. Needle exchange programs and experience of violence in an inner city neighborhood. J Acquir Immune Defic Syndr. 2001;28(3):282-288. doi:10.1097/00042560-200111010-00014
- Des Jarlais DC, Nugent A, Solberg A, Feelemyer J, Mermin J, Holtzman D. Syringe service programs for persons who inject drugs in urban, suburban, and rural areas — United States, 2013. MMWR Morb Mortal Wkly Rep. 2015;64(48):1337-1341. doi:10.15585/ mmwr.mm6448a3
- Tookes HE, Kral AH, Wenger LD, et al. A comparison of syringe disposal practices among injection drug users in a city with versus a city without needle and syringe programs. Drug Alcohol Depend. 2012;123(1-3):255-259. doi:10.1016/j.drugalcdep.2011.12.001
- Klein SJ, Candelas AR, Cooper JG, et al. Increasing safe syringe collection sites in New York State. Public Health Rep. 2008;123(4):433-440. doi:10.1177/003335490812300404
- de Montigny L, Vernez Moudon A, Leigh B, Kim SY. Assessing a drop box programme: a spatial analysis of discarded needles. Int J Drug Policy. 2010;21(3):208-214. doi:10.1016/j.drugpo.2009.07.003
- Bluthenthal RN, Anderson R, Flynn NM, Kral AH. Higher syringe coverage is associated with lower odds of HIV risk and does not increase unsafe syringe disposal among syringe exchange program clients. Drug Alcohol Depend. 2007;89(2-3):214-222. doi:10.1016/j.drugalcdep.2006.12.035
- Platt L, Minozzi S, Reed J, et al. Needle syringe programmes and opioid substitution therapy for preventing hepatitis C transmission in people who inject drugs. Cochrane Database Syst Rev. 2017;9(9):CD012021. doi:10.1002/14651858.CD012021.pub2
- Fernandes RM, Cary M, Duarte G, et al. Effectiveness of needle and syringe programmes in people who inject drugs — an overview of systematic reviews. BMC Public Health. 2017;17(1):309. doi:10.1186/s12889-017-4210-2
- Bernard CL, Owens DK, Goldhaber-Fiebert JD, Brandeau ML. Estimation of the cost-effectiveness of HIV prevention portfolios for people who inject drugs in the United States: a model-based analysis. PLoS Med. 2017;14(5):e1002312. doi:10.1371/journal.pmed.1002312
- Hagan H, McGough JP, Thiede H, Hopkins S, Duchin J, Alexander ER. Reduced injection frequency and increased entry and retention in drug treatment associated with needle-exchange participation in Seattle drug injectors. J Subst Abuse Treat. 2000;19(3):247-252. doi:10.1016/s0740-5472(00)00104-5
- Marx MA, Crape B, Brookmeyer RS, et al. Trends in crime and the introduction of a needle exchange program. Am J Public Health. 2000;90(12):1933-1936. doi:10.2105/ajph.90.12.1933
- Galea S, Ahern J, Fuller C, Freudenberg N, Vlahov D. Needle exchange programs and experience of violence in an inner city neighborhood. J Acquir Immune Defic Syndr. 2001;28(3):282-288. doi:10.1097/00042560-200111010-00014
- Des Jarlais DC, Nugent A, Solberg A, Feelemyer J, Mermin J, Holtzman D. Syringe service programs for persons who inject drugs in urban, suburban, and rural areas — United States, 2013. MMWR Morb Mortal Wkly Rep. 2015;64(48):1337-1341. doi:10.15585/ mmwr.mm6448a3
- Tookes HE, Kral AH, Wenger LD, et al. A comparison of syringe disposal practices among injection drug users in a city with versus a city without needle and syringe programs. Drug Alcohol Depend. 2012;123(1-3):255-259. doi:10.1016/j.drugalcdep.2011.12.001
- Klein SJ, Candelas AR, Cooper JG, et al. Increasing safe syringe collection sites in New York State. Public Health Rep. 2008;123(4):433-440. doi:10.1177/003335490812300404
- de Montigny L, Vernez Moudon A, Leigh B, Kim SY. Assessing a drop box programme: a spatial analysis of discarded needles. Int J Drug Policy. 2010;21(3):208-214. doi:10.1016/j.drugpo.2009.07.003
- Bluthenthal RN, Anderson R, Flynn NM, Kral AH. Higher syringe coverage is associated with lower odds of HIV risk and does not increase unsafe syringe disposal among syringe exchange program clients. Drug Alcohol Depend. 2007;89(2-3):214-222. doi:10.1016/j.drugalcdep.2006.12.035
- Platt L, Minozzi S, Reed J, et al. Needle syringe programmes and opioid substitution therapy for preventing hepatitis C transmission in people who inject drugs. Cochrane Database Syst Rev. 2017;9(9):CD012021. doi:10.1002/14651858.CD012021.pub2
- Fernandes RM, Cary M, Duarte G, et al. Effectiveness of needle and syringe programmes in people who inject drugs — an overview of systematic reviews. BMC Public Health. 2017;17(1):309. doi:10.1186/s12889-017-4210-2
- Bernard CL, Owens DK, Goldhaber-Fiebert JD, Brandeau ML. Estimation of the cost-effectiveness of HIV prevention portfolios for people who inject drugs in the United States: a model-based analysis. PLoS Med. 2017;14(5):e1002312. doi:10.1371/journal.pmed.1002312
Implementation of Harm Reduction Syringe Services Programs at 2 Veterans Affairs Medical Centers
Implementation of Harm Reduction Syringe Services Programs at 2 Veterans Affairs Medical Centers
VA Cancer Clinical Trials as a Strategy for Increasing Accrual of Racial and Ethnic Underrepresented Groups
Background
Cancer clinical trials (CCTs) are central to improving cancer care. However, generalizability of findings from CCTs is difficult due to the lack of diversity in most United States CCTs. Clinical trial accrual of underrepresented groups, is low throughout the United States and is approximately 4-5% in most CCTs. Reasons for low accrual in this population are multifactorial. Despite numerous factors related to accruing racial and ethnic underrepresented groups, many institutions have sought to address these barriers. We conducted a scoping review to identify evidence-based approaches to increase participation in cancer treatment clinical trials.
Methods
We reviewed the Salisbury VA Medical Center Oncology clinical trial database from October 2019 to June 2024. The participants in these clinical trials required consent. These clinical trials included treatment interventional as well as non-treatment interventional. Fifteen studies were included and over 260 Veterans participated.
Results
Key themes emerged that included a focus on patient education, cultural competency, and building capacity in the clinics to care for the Veteran population at three separate sites in the Salisbury VA system. The Black Veteran accrual rate of 29% was achieved. This accrual rate is representative of our VA catchment population of 33% for Black Veterans, and is five times the national average.
Conclusions
The research team’s success in enrolling Black Veterans in clinical trials is attributed to several factors. The demographic composition of Veterans served by the Salisbury, Charlotte, and Kernersville VA provided a diverse population that included a 33% Black group. The type of clinical trials focused on patients who were most impacted by the disease. The VA did afford less barriers to access to health care.
Background
Cancer clinical trials (CCTs) are central to improving cancer care. However, generalizability of findings from CCTs is difficult due to the lack of diversity in most United States CCTs. Clinical trial accrual of underrepresented groups, is low throughout the United States and is approximately 4-5% in most CCTs. Reasons for low accrual in this population are multifactorial. Despite numerous factors related to accruing racial and ethnic underrepresented groups, many institutions have sought to address these barriers. We conducted a scoping review to identify evidence-based approaches to increase participation in cancer treatment clinical trials.
Methods
We reviewed the Salisbury VA Medical Center Oncology clinical trial database from October 2019 to June 2024. The participants in these clinical trials required consent. These clinical trials included treatment interventional as well as non-treatment interventional. Fifteen studies were included and over 260 Veterans participated.
Results
Key themes emerged that included a focus on patient education, cultural competency, and building capacity in the clinics to care for the Veteran population at three separate sites in the Salisbury VA system. The Black Veteran accrual rate of 29% was achieved. This accrual rate is representative of our VA catchment population of 33% for Black Veterans, and is five times the national average.
Conclusions
The research team’s success in enrolling Black Veterans in clinical trials is attributed to several factors. The demographic composition of Veterans served by the Salisbury, Charlotte, and Kernersville VA provided a diverse population that included a 33% Black group. The type of clinical trials focused on patients who were most impacted by the disease. The VA did afford less barriers to access to health care.
Background
Cancer clinical trials (CCTs) are central to improving cancer care. However, generalizability of findings from CCTs is difficult due to the lack of diversity in most United States CCTs. Clinical trial accrual of underrepresented groups, is low throughout the United States and is approximately 4-5% in most CCTs. Reasons for low accrual in this population are multifactorial. Despite numerous factors related to accruing racial and ethnic underrepresented groups, many institutions have sought to address these barriers. We conducted a scoping review to identify evidence-based approaches to increase participation in cancer treatment clinical trials.
Methods
We reviewed the Salisbury VA Medical Center Oncology clinical trial database from October 2019 to June 2024. The participants in these clinical trials required consent. These clinical trials included treatment interventional as well as non-treatment interventional. Fifteen studies were included and over 260 Veterans participated.
Results
Key themes emerged that included a focus on patient education, cultural competency, and building capacity in the clinics to care for the Veteran population at three separate sites in the Salisbury VA system. The Black Veteran accrual rate of 29% was achieved. This accrual rate is representative of our VA catchment population of 33% for Black Veterans, and is five times the national average.
Conclusions
The research team’s success in enrolling Black Veterans in clinical trials is attributed to several factors. The demographic composition of Veterans served by the Salisbury, Charlotte, and Kernersville VA provided a diverse population that included a 33% Black group. The type of clinical trials focused on patients who were most impacted by the disease. The VA did afford less barriers to access to health care.
Improving Colorectal Cancer Screening via Mailed Fecal Immunochemical Testing in a Veterans Affairs Health System
Colorectal cancer (CRC) is among the most common cancers and causes of cancer-related deaths in the United States.1 Reflective of a nationwide trend, CRC screening rates at the Veterans Affairs Connecticut Healthcare System (VACHS) decreased during the COVID-19 pandemic.2-5 Contributing factors to this decrease included cancellations of elective colonoscopies during the initial phase of the pandemic and concurrent turnover of endoscopists. In 2021, the US Preventive Services Task Force lowered the recommended initial CRC screening age from 50 years to 45 years, further increasing the backlog of unscreened patients.6
Fecal immunochemical testing (FIT) is a noninvasive screening method in which antibodies are used to detect hemoglobin in the stool. The sensitivity and specificity of 1-time FIT are 79% to 80% and 94%, respectively, for the detection of CRC, with sensitivity improving with successive testing.7,8 Annual FIT is recognized as a tier 1 preferred screening method by the US Multi-Society Task Force on Colorectal Cancer.7,9 Programs that mail FIT kits to eligible patients outside of physician visits have been successfully implemented in health care systems.10,11
The VACHS designed and implemented a mailed FIT program using existing infrastructure and staffing.
Program Description
A team of local stakeholders comprised of VACHS leadership, primary care, nursing, and gastroenterology staff, as well as representatives from laboratory, informatics, mail services, and group practice management, was established to execute the project. The team met monthly to plan the project.
The team developed a dataset consisting of patients aged 45 to 75 years who were at average risk for CRC and due for CRC screening. Patients were defined as due for CRC screening if they had not had a colonoscopy in the previous 9 years or a FIT or fecal occult blood test in the previous 11 months. Average risk for CRC was defined by excluding patients with associated diagnosis codes for CRC, colectomy, inflammatory bowel disease, and anemia. The program also excluded patients with diagnosis codes associated with dementia, deferring discussions about cancer screening to their primary care practitioners (PCPs). Patients with invalid mailing addresses were also excluded, as well as those whose PCPs had indicated in the electronic health record that the patient received CRC screening outside the US Department of Veterans Affairs (VA) system.
Letter Templates
Two patient letter electronic health record templates were developed. The first was a primer letter, which was mailed to patients 2 to 3 weeks before the mailed FIT kit as an introduction to the program.12 The purpose of the primer letter was to give advance notice to patients that they could expect a FIT kit to arrive in the mail. The goal was to prepare patients to complete FIT when the kit arrived and prompt them to call the VA to opt out of the mailed FIT program if they were up to date with CRC screening or if they had a condition which made them at high risk for CRC.
The second FIT letter arrived with the FIT kit, introduced FIT and described the importance of CRC screening. The letter detailed instructions for completing FIT and automatically created a FIT order. It also included a list of common conditions that may exclude patients, with a recommendation for patients to contact their medical team if they felt they were not candidates for FIT.
Staff Education
A previous VACHS pilot project demonstrated the success of a mailed FIT program to increase FIT use. Implemented as part of the pilot program, staff education consisted of a session for clinicians about the role of FIT in CRC screening and an all-staff education session. An additional education session about CRC and FIT for all staff was repeated with the program launch.
Program Launch
The mailed FIT program was introduced during a VACHS primary care all-staff meeting. After the meeting, each patient aligned care team (PACT) received an encrypted email that included a list of the patients on their team who were candidates for the program, a patient-facing FIT instruction sheet, detailed instructions on how to send the FIT primer letter, and a FIT package consisting of the labeled FIT kit, FIT letter, and patient instruction sheet. A reminder letter was sent to each patient 3 weeks after the FIT package was mailed. The patient lists were populated into a shared, encrypted Microsoft Teams folder that was edited in real time by PACT teams and viewed by VACHS leadership to track progress.
Program Metrics
At program launch, the VACHS had 4642 patients due for CRC screening who were eligible for the mailed FIT program. On March 7, 2023, the data consisting of FIT tests ordered between December 2022 and May 2023—3 months before and after the launch of the program—were reviewed and categorized. In the 3 months before program launch, 1528 FIT were ordered and 714 were returned (46.7%). In the 3 months after the launch of the program, 4383 FIT were ordered and 1712 were returned (39.1%) (Figure). Test orders increased 287% from the preintervention to the postintervention period. The mean (SD) number of monthly FIT tests prelaunch was 509 (32.7), which increased to 1461 (331.6) postlaunch.
At the VACHS, 61.4% of patients aged 45 to 75 years were up to date with CRC screening before the program launch. In the 3 months after program launch, the rate increased to 63.8% among patients aged 45 to 75 years, the highest rate in our Veterans Integrated Services Network and exceeding the VA national average CRC screening rate, according to unpublished VA Monthly Management Report data.
In the 3 months following the program launch, 139 FIT kits tested positive for potential CRC. Of these, 79 (56.8%) patients had completed a diagnostic colonoscopy. PACT PCPs and nurses received reports on patients with positive FIT tests and those with no colonoscopy scheduled or completed and were asked to follow up.
Discussion
Through a proactive, population-based CRC screening program centered on mailed FIT kits outside of the traditional patient visit, the VACHS increased the use of FIT and rates of CRC screening. The numbers of FIT kits ordered and completed substantially increased in the 3 months after program launch.
Compared to mailed FIT programs described in the literature that rely on centralized processes in that a separate team operates the mailed FIT program for the entire organization, this program used existing PACT infrastructure and staff.10,11 This strategy allowed VACHS to design and implement the program in several months. Not needing to hire new staff or create a central team for the sole purpose of implementing the program allowed us to save on any organizational funding and efforts that would have accompanied the additional staff. The program described in this article may be more attainable for primary care practices or smaller health systems that do not have the capacity for the creation of a centralized process.
Limitations
Although the total number of FIT completions substantially increased during the program, the rate of FIT completion during the mailed FIT program was lower than the rate of completion prior to program launch. This decreased rate of FIT kit completion may be related to separation from a patient visit and potential loss of real-time education with a clinician. The program’s decentralized design increased the existing workload for primary care staff, and as a result, consideration must be given to local staffing levels. Additionally, the report of eligible patients depended on diagnosis codes and may have captured patients with higher-than-average risk of CRC, such as patients with prior history of adenomatous polyps, family history of CRC, or other medical or genetic conditions. We attempted to mitigate this by including a list of conditions that would exclude patients from FIT eligibility in the FIT letter and giving them the option to opt out.
Conclusions
CRC screening rates improved following implementation of a primary care team-centered quality improvement process to proactively identify patients appropriate for FIT and mail them FIT kits. This project highlights that population-health interventions around CRC screening via use of FIT can be successful within a primary care patient-centered medical home model, considering the increases in both CRC screening rates and increase in FIT tests ordered.
1. American Cancer Society. Key statistics for colorectal cancer. Revised January 29, 2024. Accessed June 11, 2024. https://www.cancer.org/cancer/types/colon-rectal-cancer/about/key-statistics.html
2. Chen RC, Haynes K, Du S, Barron J, Katz AJ. Association of cancer screening deficit in the United States with the COVID-19 pandemic. JAMA Oncol. 2021;7(6):878-884. doi:10.1001/jamaoncol.2021.0884
3. Mazidimoradi A, Tiznobaik A, Salehiniya H. Impact of the COVID-19 pandemic on colorectal cancer screening: a systematic review. J Gastrointest Cancer. 2022;53(3):730-744. doi:10.1007/s12029-021-00679-x
4. Adams MA, Kurlander JE, Gao Y, Yankey N, Saini SD. Impact of coronavirus disease 2019 on screening colonoscopy utilization in a large integrated health system. Gastroenterology. 2022;162(7):2098-2100.e2. doi:10.1053/j.gastro.2022.02.034
5. Sundaram S, Olson S, Sharma P, Rajendra S. A review of the impact of the COVID-19 pandemic on colorectal cancer screening: implications and solutions. Pathogens. 2021;10(11):558. doi:10.3390/pathogens10111508
6. US Preventive Services Task Force. Screening for colorectal cancer: US Preventive Services Task Force recommendation statement. JAMA. 2021;325(19):1965-1977. doi:10.1001/jama.2021.6238
7. Robertson DJ, Lee JK, Boland CR, et al. Recommendations on fecal immunochemical testing to screen for colorectal neoplasia: a consensus statement by the US Multi-Society Task Force on Colorectal Cancer. Gastrointest Endosc. 2017;85(1):2-21.e3. doi:10.1016/j.gie.2016.09.025
8. Lee JK, Liles EG, Bent S, Levin TR, Corley DA. Accuracy of fecal immunochemical tests for colorectal cancer: systematic review and meta-analysis. Ann Intern Med. 2014;160(3):171. doi:10.7326/M13-1484
9. Rex DK, Boland CR, Dominitz JA, et al. Colorectal cancer screening: recommendations for physicians and patients from the U.S. Multi-Society Task Force on Colorectal Cancer. Gastroenterology. 2017;153(1):307-323. doi:10.1053/j.gastro.2017.05.013
10. Deeds SA, Moore CB, Gunnink EJ, et al. Implementation of a mailed faecal immunochemical test programme for colorectal cancer screening among veterans. BMJ Open Qual. 2022;11(4):e001927. doi:10.1136/bmjoq-2022-001927
11. Selby K, Jensen CD, Levin TR, et al. Program components and results from an organized colorectal cancer screening program using annual fecal immunochemical testing. Clin Gastroenterol Hepatol. 2022;20(1):145-152. doi:10.1016/j.cgh.2020.09.042
12. Deeds S, Liu T, Schuttner L, et al. A postcard primer prior to mailed fecal immunochemical test among veterans: a randomized controlled trial. J Gen Intern Med. 2023:38(14):3235-3241. doi:10.1007/s11606-023-08248-7
Colorectal cancer (CRC) is among the most common cancers and causes of cancer-related deaths in the United States.1 Reflective of a nationwide trend, CRC screening rates at the Veterans Affairs Connecticut Healthcare System (VACHS) decreased during the COVID-19 pandemic.2-5 Contributing factors to this decrease included cancellations of elective colonoscopies during the initial phase of the pandemic and concurrent turnover of endoscopists. In 2021, the US Preventive Services Task Force lowered the recommended initial CRC screening age from 50 years to 45 years, further increasing the backlog of unscreened patients.6
Fecal immunochemical testing (FIT) is a noninvasive screening method in which antibodies are used to detect hemoglobin in the stool. The sensitivity and specificity of 1-time FIT are 79% to 80% and 94%, respectively, for the detection of CRC, with sensitivity improving with successive testing.7,8 Annual FIT is recognized as a tier 1 preferred screening method by the US Multi-Society Task Force on Colorectal Cancer.7,9 Programs that mail FIT kits to eligible patients outside of physician visits have been successfully implemented in health care systems.10,11
The VACHS designed and implemented a mailed FIT program using existing infrastructure and staffing.
Program Description
A team of local stakeholders comprised of VACHS leadership, primary care, nursing, and gastroenterology staff, as well as representatives from laboratory, informatics, mail services, and group practice management, was established to execute the project. The team met monthly to plan the project.
The team developed a dataset consisting of patients aged 45 to 75 years who were at average risk for CRC and due for CRC screening. Patients were defined as due for CRC screening if they had not had a colonoscopy in the previous 9 years or a FIT or fecal occult blood test in the previous 11 months. Average risk for CRC was defined by excluding patients with associated diagnosis codes for CRC, colectomy, inflammatory bowel disease, and anemia. The program also excluded patients with diagnosis codes associated with dementia, deferring discussions about cancer screening to their primary care practitioners (PCPs). Patients with invalid mailing addresses were also excluded, as well as those whose PCPs had indicated in the electronic health record that the patient received CRC screening outside the US Department of Veterans Affairs (VA) system.
Letter Templates
Two patient letter electronic health record templates were developed. The first was a primer letter, which was mailed to patients 2 to 3 weeks before the mailed FIT kit as an introduction to the program.12 The purpose of the primer letter was to give advance notice to patients that they could expect a FIT kit to arrive in the mail. The goal was to prepare patients to complete FIT when the kit arrived and prompt them to call the VA to opt out of the mailed FIT program if they were up to date with CRC screening or if they had a condition which made them at high risk for CRC.
The second FIT letter arrived with the FIT kit, introduced FIT and described the importance of CRC screening. The letter detailed instructions for completing FIT and automatically created a FIT order. It also included a list of common conditions that may exclude patients, with a recommendation for patients to contact their medical team if they felt they were not candidates for FIT.
Staff Education
A previous VACHS pilot project demonstrated the success of a mailed FIT program to increase FIT use. Implemented as part of the pilot program, staff education consisted of a session for clinicians about the role of FIT in CRC screening and an all-staff education session. An additional education session about CRC and FIT for all staff was repeated with the program launch.
Program Launch
The mailed FIT program was introduced during a VACHS primary care all-staff meeting. After the meeting, each patient aligned care team (PACT) received an encrypted email that included a list of the patients on their team who were candidates for the program, a patient-facing FIT instruction sheet, detailed instructions on how to send the FIT primer letter, and a FIT package consisting of the labeled FIT kit, FIT letter, and patient instruction sheet. A reminder letter was sent to each patient 3 weeks after the FIT package was mailed. The patient lists were populated into a shared, encrypted Microsoft Teams folder that was edited in real time by PACT teams and viewed by VACHS leadership to track progress.
Program Metrics
At program launch, the VACHS had 4642 patients due for CRC screening who were eligible for the mailed FIT program. On March 7, 2023, the data consisting of FIT tests ordered between December 2022 and May 2023—3 months before and after the launch of the program—were reviewed and categorized. In the 3 months before program launch, 1528 FIT were ordered and 714 were returned (46.7%). In the 3 months after the launch of the program, 4383 FIT were ordered and 1712 were returned (39.1%) (Figure). Test orders increased 287% from the preintervention to the postintervention period. The mean (SD) number of monthly FIT tests prelaunch was 509 (32.7), which increased to 1461 (331.6) postlaunch.
At the VACHS, 61.4% of patients aged 45 to 75 years were up to date with CRC screening before the program launch. In the 3 months after program launch, the rate increased to 63.8% among patients aged 45 to 75 years, the highest rate in our Veterans Integrated Services Network and exceeding the VA national average CRC screening rate, according to unpublished VA Monthly Management Report data.
In the 3 months following the program launch, 139 FIT kits tested positive for potential CRC. Of these, 79 (56.8%) patients had completed a diagnostic colonoscopy. PACT PCPs and nurses received reports on patients with positive FIT tests and those with no colonoscopy scheduled or completed and were asked to follow up.
Discussion
Through a proactive, population-based CRC screening program centered on mailed FIT kits outside of the traditional patient visit, the VACHS increased the use of FIT and rates of CRC screening. The numbers of FIT kits ordered and completed substantially increased in the 3 months after program launch.
Compared to mailed FIT programs described in the literature that rely on centralized processes in that a separate team operates the mailed FIT program for the entire organization, this program used existing PACT infrastructure and staff.10,11 This strategy allowed VACHS to design and implement the program in several months. Not needing to hire new staff or create a central team for the sole purpose of implementing the program allowed us to save on any organizational funding and efforts that would have accompanied the additional staff. The program described in this article may be more attainable for primary care practices or smaller health systems that do not have the capacity for the creation of a centralized process.
Limitations
Although the total number of FIT completions substantially increased during the program, the rate of FIT completion during the mailed FIT program was lower than the rate of completion prior to program launch. This decreased rate of FIT kit completion may be related to separation from a patient visit and potential loss of real-time education with a clinician. The program’s decentralized design increased the existing workload for primary care staff, and as a result, consideration must be given to local staffing levels. Additionally, the report of eligible patients depended on diagnosis codes and may have captured patients with higher-than-average risk of CRC, such as patients with prior history of adenomatous polyps, family history of CRC, or other medical or genetic conditions. We attempted to mitigate this by including a list of conditions that would exclude patients from FIT eligibility in the FIT letter and giving them the option to opt out.
Conclusions
CRC screening rates improved following implementation of a primary care team-centered quality improvement process to proactively identify patients appropriate for FIT and mail them FIT kits. This project highlights that population-health interventions around CRC screening via use of FIT can be successful within a primary care patient-centered medical home model, considering the increases in both CRC screening rates and increase in FIT tests ordered.
Colorectal cancer (CRC) is among the most common cancers and causes of cancer-related deaths in the United States.1 Reflective of a nationwide trend, CRC screening rates at the Veterans Affairs Connecticut Healthcare System (VACHS) decreased during the COVID-19 pandemic.2-5 Contributing factors to this decrease included cancellations of elective colonoscopies during the initial phase of the pandemic and concurrent turnover of endoscopists. In 2021, the US Preventive Services Task Force lowered the recommended initial CRC screening age from 50 years to 45 years, further increasing the backlog of unscreened patients.6
Fecal immunochemical testing (FIT) is a noninvasive screening method in which antibodies are used to detect hemoglobin in the stool. The sensitivity and specificity of 1-time FIT are 79% to 80% and 94%, respectively, for the detection of CRC, with sensitivity improving with successive testing.7,8 Annual FIT is recognized as a tier 1 preferred screening method by the US Multi-Society Task Force on Colorectal Cancer.7,9 Programs that mail FIT kits to eligible patients outside of physician visits have been successfully implemented in health care systems.10,11
The VACHS designed and implemented a mailed FIT program using existing infrastructure and staffing.
Program Description
A team of local stakeholders comprised of VACHS leadership, primary care, nursing, and gastroenterology staff, as well as representatives from laboratory, informatics, mail services, and group practice management, was established to execute the project. The team met monthly to plan the project.
The team developed a dataset consisting of patients aged 45 to 75 years who were at average risk for CRC and due for CRC screening. Patients were defined as due for CRC screening if they had not had a colonoscopy in the previous 9 years or a FIT or fecal occult blood test in the previous 11 months. Average risk for CRC was defined by excluding patients with associated diagnosis codes for CRC, colectomy, inflammatory bowel disease, and anemia. The program also excluded patients with diagnosis codes associated with dementia, deferring discussions about cancer screening to their primary care practitioners (PCPs). Patients with invalid mailing addresses were also excluded, as well as those whose PCPs had indicated in the electronic health record that the patient received CRC screening outside the US Department of Veterans Affairs (VA) system.
Letter Templates
Two patient letter electronic health record templates were developed. The first was a primer letter, which was mailed to patients 2 to 3 weeks before the mailed FIT kit as an introduction to the program.12 The purpose of the primer letter was to give advance notice to patients that they could expect a FIT kit to arrive in the mail. The goal was to prepare patients to complete FIT when the kit arrived and prompt them to call the VA to opt out of the mailed FIT program if they were up to date with CRC screening or if they had a condition which made them at high risk for CRC.
The second FIT letter arrived with the FIT kit, introduced FIT and described the importance of CRC screening. The letter detailed instructions for completing FIT and automatically created a FIT order. It also included a list of common conditions that may exclude patients, with a recommendation for patients to contact their medical team if they felt they were not candidates for FIT.
Staff Education
A previous VACHS pilot project demonstrated the success of a mailed FIT program to increase FIT use. Implemented as part of the pilot program, staff education consisted of a session for clinicians about the role of FIT in CRC screening and an all-staff education session. An additional education session about CRC and FIT for all staff was repeated with the program launch.
Program Launch
The mailed FIT program was introduced during a VACHS primary care all-staff meeting. After the meeting, each patient aligned care team (PACT) received an encrypted email that included a list of the patients on their team who were candidates for the program, a patient-facing FIT instruction sheet, detailed instructions on how to send the FIT primer letter, and a FIT package consisting of the labeled FIT kit, FIT letter, and patient instruction sheet. A reminder letter was sent to each patient 3 weeks after the FIT package was mailed. The patient lists were populated into a shared, encrypted Microsoft Teams folder that was edited in real time by PACT teams and viewed by VACHS leadership to track progress.
Program Metrics
At program launch, the VACHS had 4642 patients due for CRC screening who were eligible for the mailed FIT program. On March 7, 2023, the data consisting of FIT tests ordered between December 2022 and May 2023—3 months before and after the launch of the program—were reviewed and categorized. In the 3 months before program launch, 1528 FIT were ordered and 714 were returned (46.7%). In the 3 months after the launch of the program, 4383 FIT were ordered and 1712 were returned (39.1%) (Figure). Test orders increased 287% from the preintervention to the postintervention period. The mean (SD) number of monthly FIT tests prelaunch was 509 (32.7), which increased to 1461 (331.6) postlaunch.
At the VACHS, 61.4% of patients aged 45 to 75 years were up to date with CRC screening before the program launch. In the 3 months after program launch, the rate increased to 63.8% among patients aged 45 to 75 years, the highest rate in our Veterans Integrated Services Network and exceeding the VA national average CRC screening rate, according to unpublished VA Monthly Management Report data.
In the 3 months following the program launch, 139 FIT kits tested positive for potential CRC. Of these, 79 (56.8%) patients had completed a diagnostic colonoscopy. PACT PCPs and nurses received reports on patients with positive FIT tests and those with no colonoscopy scheduled or completed and were asked to follow up.
Discussion
Through a proactive, population-based CRC screening program centered on mailed FIT kits outside of the traditional patient visit, the VACHS increased the use of FIT and rates of CRC screening. The numbers of FIT kits ordered and completed substantially increased in the 3 months after program launch.
Compared to mailed FIT programs described in the literature that rely on centralized processes in that a separate team operates the mailed FIT program for the entire organization, this program used existing PACT infrastructure and staff.10,11 This strategy allowed VACHS to design and implement the program in several months. Not needing to hire new staff or create a central team for the sole purpose of implementing the program allowed us to save on any organizational funding and efforts that would have accompanied the additional staff. The program described in this article may be more attainable for primary care practices or smaller health systems that do not have the capacity for the creation of a centralized process.
Limitations
Although the total number of FIT completions substantially increased during the program, the rate of FIT completion during the mailed FIT program was lower than the rate of completion prior to program launch. This decreased rate of FIT kit completion may be related to separation from a patient visit and potential loss of real-time education with a clinician. The program’s decentralized design increased the existing workload for primary care staff, and as a result, consideration must be given to local staffing levels. Additionally, the report of eligible patients depended on diagnosis codes and may have captured patients with higher-than-average risk of CRC, such as patients with prior history of adenomatous polyps, family history of CRC, or other medical or genetic conditions. We attempted to mitigate this by including a list of conditions that would exclude patients from FIT eligibility in the FIT letter and giving them the option to opt out.
Conclusions
CRC screening rates improved following implementation of a primary care team-centered quality improvement process to proactively identify patients appropriate for FIT and mail them FIT kits. This project highlights that population-health interventions around CRC screening via use of FIT can be successful within a primary care patient-centered medical home model, considering the increases in both CRC screening rates and increase in FIT tests ordered.
1. American Cancer Society. Key statistics for colorectal cancer. Revised January 29, 2024. Accessed June 11, 2024. https://www.cancer.org/cancer/types/colon-rectal-cancer/about/key-statistics.html
2. Chen RC, Haynes K, Du S, Barron J, Katz AJ. Association of cancer screening deficit in the United States with the COVID-19 pandemic. JAMA Oncol. 2021;7(6):878-884. doi:10.1001/jamaoncol.2021.0884
3. Mazidimoradi A, Tiznobaik A, Salehiniya H. Impact of the COVID-19 pandemic on colorectal cancer screening: a systematic review. J Gastrointest Cancer. 2022;53(3):730-744. doi:10.1007/s12029-021-00679-x
4. Adams MA, Kurlander JE, Gao Y, Yankey N, Saini SD. Impact of coronavirus disease 2019 on screening colonoscopy utilization in a large integrated health system. Gastroenterology. 2022;162(7):2098-2100.e2. doi:10.1053/j.gastro.2022.02.034
5. Sundaram S, Olson S, Sharma P, Rajendra S. A review of the impact of the COVID-19 pandemic on colorectal cancer screening: implications and solutions. Pathogens. 2021;10(11):558. doi:10.3390/pathogens10111508
6. US Preventive Services Task Force. Screening for colorectal cancer: US Preventive Services Task Force recommendation statement. JAMA. 2021;325(19):1965-1977. doi:10.1001/jama.2021.6238
7. Robertson DJ, Lee JK, Boland CR, et al. Recommendations on fecal immunochemical testing to screen for colorectal neoplasia: a consensus statement by the US Multi-Society Task Force on Colorectal Cancer. Gastrointest Endosc. 2017;85(1):2-21.e3. doi:10.1016/j.gie.2016.09.025
8. Lee JK, Liles EG, Bent S, Levin TR, Corley DA. Accuracy of fecal immunochemical tests for colorectal cancer: systematic review and meta-analysis. Ann Intern Med. 2014;160(3):171. doi:10.7326/M13-1484
9. Rex DK, Boland CR, Dominitz JA, et al. Colorectal cancer screening: recommendations for physicians and patients from the U.S. Multi-Society Task Force on Colorectal Cancer. Gastroenterology. 2017;153(1):307-323. doi:10.1053/j.gastro.2017.05.013
10. Deeds SA, Moore CB, Gunnink EJ, et al. Implementation of a mailed faecal immunochemical test programme for colorectal cancer screening among veterans. BMJ Open Qual. 2022;11(4):e001927. doi:10.1136/bmjoq-2022-001927
11. Selby K, Jensen CD, Levin TR, et al. Program components and results from an organized colorectal cancer screening program using annual fecal immunochemical testing. Clin Gastroenterol Hepatol. 2022;20(1):145-152. doi:10.1016/j.cgh.2020.09.042
12. Deeds S, Liu T, Schuttner L, et al. A postcard primer prior to mailed fecal immunochemical test among veterans: a randomized controlled trial. J Gen Intern Med. 2023:38(14):3235-3241. doi:10.1007/s11606-023-08248-7
1. American Cancer Society. Key statistics for colorectal cancer. Revised January 29, 2024. Accessed June 11, 2024. https://www.cancer.org/cancer/types/colon-rectal-cancer/about/key-statistics.html
2. Chen RC, Haynes K, Du S, Barron J, Katz AJ. Association of cancer screening deficit in the United States with the COVID-19 pandemic. JAMA Oncol. 2021;7(6):878-884. doi:10.1001/jamaoncol.2021.0884
3. Mazidimoradi A, Tiznobaik A, Salehiniya H. Impact of the COVID-19 pandemic on colorectal cancer screening: a systematic review. J Gastrointest Cancer. 2022;53(3):730-744. doi:10.1007/s12029-021-00679-x
4. Adams MA, Kurlander JE, Gao Y, Yankey N, Saini SD. Impact of coronavirus disease 2019 on screening colonoscopy utilization in a large integrated health system. Gastroenterology. 2022;162(7):2098-2100.e2. doi:10.1053/j.gastro.2022.02.034
5. Sundaram S, Olson S, Sharma P, Rajendra S. A review of the impact of the COVID-19 pandemic on colorectal cancer screening: implications and solutions. Pathogens. 2021;10(11):558. doi:10.3390/pathogens10111508
6. US Preventive Services Task Force. Screening for colorectal cancer: US Preventive Services Task Force recommendation statement. JAMA. 2021;325(19):1965-1977. doi:10.1001/jama.2021.6238
7. Robertson DJ, Lee JK, Boland CR, et al. Recommendations on fecal immunochemical testing to screen for colorectal neoplasia: a consensus statement by the US Multi-Society Task Force on Colorectal Cancer. Gastrointest Endosc. 2017;85(1):2-21.e3. doi:10.1016/j.gie.2016.09.025
8. Lee JK, Liles EG, Bent S, Levin TR, Corley DA. Accuracy of fecal immunochemical tests for colorectal cancer: systematic review and meta-analysis. Ann Intern Med. 2014;160(3):171. doi:10.7326/M13-1484
9. Rex DK, Boland CR, Dominitz JA, et al. Colorectal cancer screening: recommendations for physicians and patients from the U.S. Multi-Society Task Force on Colorectal Cancer. Gastroenterology. 2017;153(1):307-323. doi:10.1053/j.gastro.2017.05.013
10. Deeds SA, Moore CB, Gunnink EJ, et al. Implementation of a mailed faecal immunochemical test programme for colorectal cancer screening among veterans. BMJ Open Qual. 2022;11(4):e001927. doi:10.1136/bmjoq-2022-001927
11. Selby K, Jensen CD, Levin TR, et al. Program components and results from an organized colorectal cancer screening program using annual fecal immunochemical testing. Clin Gastroenterol Hepatol. 2022;20(1):145-152. doi:10.1016/j.cgh.2020.09.042
12. Deeds S, Liu T, Schuttner L, et al. A postcard primer prior to mailed fecal immunochemical test among veterans: a randomized controlled trial. J Gen Intern Med. 2023:38(14):3235-3241. doi:10.1007/s11606-023-08248-7
Enhancing Veteran Health Research: A Quality Improvement Initiative to Optimize Biorepository Efficiency
Purpose
Biorepositories are critical to scientific research within the VA. They offer high-quality, well-characterized biospecimens linked to clinical, demographic, and molecular data. Biorepositories support studies on disease mechanisms, personalized therapies, and emerging infectious diseases by systematically collecting, processing, storing, and distributing biological materials, including tissue, blood, and DNA samples. Within the Department of Veterans Affairs (VA), biorepositories provide essential support to clinical and translational research on service- related conditions such as PTSD, traumatic brain injury, cancers, and toxic exposures. While the need for harmonized quality processes and resource allocation has long been acknowledged within the biorepository community (Siwek, 2015), each biorepository operates independently, limiting scalability and standardization. This quality improvement project describes a collaboration between two VA biorepository sites supporting a national genomic study investigating disease risk and treatment outcomes. The project aimed to expand capacity, improve processing times, and enhance quality control. Each site mirrors the other’s functions, including receiving, accessioning, processing, storing, and shipping biospecimens, and serves as a contingency site to strengthen operational resilience.
Methods
To address space limitations and improve processing efficiency, one site implemented a custom rack design, expanding storage capacity per freezer. Robotic workflows were optimized, reducing biospecimen processing time. An in-process quality control step was introduced to identify data discrepancies earlier in the workflow, reducing investigation time and supporting overall data integrity. Efficiency was measured by the increase in storage capacity and decreased processing time. Descriptive statistics were used to evaluate changes in performance. Metrics were monitored over twelve months and compared against baseline data.
Results
Following implementation, storage capacity per freezer increased by 20%, and specimen processing time decreased by 30%. The new quality control checkpoint reduced investigation times by 98%, resulting in a more streamlined workflow. These improvements enhanced coordination between sites and improved support for ongoing studies.
Conclusions
This effort demonstrates that collaboration between biorepositories can significantly enhance efficiency, reduce turnaround times, and support high-quality research. Strengthening infrastructure through joint initiatives enables more effective support of large-scale clinical studies and contributes to improved outcomes for Veterans. These findings may also inform process improvements at other VA research facilities.
Purpose
Biorepositories are critical to scientific research within the VA. They offer high-quality, well-characterized biospecimens linked to clinical, demographic, and molecular data. Biorepositories support studies on disease mechanisms, personalized therapies, and emerging infectious diseases by systematically collecting, processing, storing, and distributing biological materials, including tissue, blood, and DNA samples. Within the Department of Veterans Affairs (VA), biorepositories provide essential support to clinical and translational research on service- related conditions such as PTSD, traumatic brain injury, cancers, and toxic exposures. While the need for harmonized quality processes and resource allocation has long been acknowledged within the biorepository community (Siwek, 2015), each biorepository operates independently, limiting scalability and standardization. This quality improvement project describes a collaboration between two VA biorepository sites supporting a national genomic study investigating disease risk and treatment outcomes. The project aimed to expand capacity, improve processing times, and enhance quality control. Each site mirrors the other’s functions, including receiving, accessioning, processing, storing, and shipping biospecimens, and serves as a contingency site to strengthen operational resilience.
Methods
To address space limitations and improve processing efficiency, one site implemented a custom rack design, expanding storage capacity per freezer. Robotic workflows were optimized, reducing biospecimen processing time. An in-process quality control step was introduced to identify data discrepancies earlier in the workflow, reducing investigation time and supporting overall data integrity. Efficiency was measured by the increase in storage capacity and decreased processing time. Descriptive statistics were used to evaluate changes in performance. Metrics were monitored over twelve months and compared against baseline data.
Results
Following implementation, storage capacity per freezer increased by 20%, and specimen processing time decreased by 30%. The new quality control checkpoint reduced investigation times by 98%, resulting in a more streamlined workflow. These improvements enhanced coordination between sites and improved support for ongoing studies.
Conclusions
This effort demonstrates that collaboration between biorepositories can significantly enhance efficiency, reduce turnaround times, and support high-quality research. Strengthening infrastructure through joint initiatives enables more effective support of large-scale clinical studies and contributes to improved outcomes for Veterans. These findings may also inform process improvements at other VA research facilities.
Purpose
Biorepositories are critical to scientific research within the VA. They offer high-quality, well-characterized biospecimens linked to clinical, demographic, and molecular data. Biorepositories support studies on disease mechanisms, personalized therapies, and emerging infectious diseases by systematically collecting, processing, storing, and distributing biological materials, including tissue, blood, and DNA samples. Within the Department of Veterans Affairs (VA), biorepositories provide essential support to clinical and translational research on service- related conditions such as PTSD, traumatic brain injury, cancers, and toxic exposures. While the need for harmonized quality processes and resource allocation has long been acknowledged within the biorepository community (Siwek, 2015), each biorepository operates independently, limiting scalability and standardization. This quality improvement project describes a collaboration between two VA biorepository sites supporting a national genomic study investigating disease risk and treatment outcomes. The project aimed to expand capacity, improve processing times, and enhance quality control. Each site mirrors the other’s functions, including receiving, accessioning, processing, storing, and shipping biospecimens, and serves as a contingency site to strengthen operational resilience.
Methods
To address space limitations and improve processing efficiency, one site implemented a custom rack design, expanding storage capacity per freezer. Robotic workflows were optimized, reducing biospecimen processing time. An in-process quality control step was introduced to identify data discrepancies earlier in the workflow, reducing investigation time and supporting overall data integrity. Efficiency was measured by the increase in storage capacity and decreased processing time. Descriptive statistics were used to evaluate changes in performance. Metrics were monitored over twelve months and compared against baseline data.
Results
Following implementation, storage capacity per freezer increased by 20%, and specimen processing time decreased by 30%. The new quality control checkpoint reduced investigation times by 98%, resulting in a more streamlined workflow. These improvements enhanced coordination between sites and improved support for ongoing studies.
Conclusions
This effort demonstrates that collaboration between biorepositories can significantly enhance efficiency, reduce turnaround times, and support high-quality research. Strengthening infrastructure through joint initiatives enables more effective support of large-scale clinical studies and contributes to improved outcomes for Veterans. These findings may also inform process improvements at other VA research facilities.
Enhancing Coding Accuracy at the Hematology/Oncology Clinic: Is It Time to Hire a Dedicated Coder?
Background
Accurate clinical coding that reflects all diagnoses and problems addressed during a patient encounter is essential for the cancer program’s data quality, research initiatives, and securing VERA (Veterans Equitable Resource Allocation) funding. However, providers often face barriers such as limited time during patient visits and difficulty navigating Electronic health record (EHR) systems. These challenges lead to inaccurate coding, which undermines downstream data integrity. This quality improvement (QI) study aimed to identify these barriers and implement an intervention to improve coding accuracy, while also assessing the financial implications of improved documentation.
Methods
This QI study was conducted at the Albany Stratton VA Medical Center, focusing on hematology/ oncology outpatient encounters. A baseline chart audit of diagnosis codes from June 2023 revealed an accuracy rate of 69.8%. To address this, an intervention was implemented in which dedicated coders were assigned to support attending physicians in coding for over a two-week period. These coders reviewed and corrected diagnosis codes in real-time. A follow-up audit conducted after the intervention showed an improved coding accuracy of 82%.
Discussion/Implications
Coding remains a timeconsuming task for providers, made more difficult by EHR systems that are not user-friendly. This study demonstrated that involving dedicated coders significantly improves documentation accuracy—from 69% to 82%. In addition to data quality, the financial benefits are notable. A projected annual return on investment of $216,094 was calculated, based on an internal analysis showing that in a sample of 124 patients, 10% could have qualified for higher VERA funding based on accurate coding, generating an estimated $17,427 in additional reimbursement per patient. This cost-benefit ratio supports the recommendation to staff dedicated coders. Other interventions were also utilised, such as updating the national encounter form and auto-populating documentation in Dragon software, but had limited impact and did not directly address diagnosis accuracy respectively.
Conclusions
Targeted interventions improved coding accuracy, but sustainability remains a challenge due to time and system limitations. Future efforts should focus on hiring full-time coders. These steps can further enhance coding quality and potentially increase hospital revenue.
Background
Accurate clinical coding that reflects all diagnoses and problems addressed during a patient encounter is essential for the cancer program’s data quality, research initiatives, and securing VERA (Veterans Equitable Resource Allocation) funding. However, providers often face barriers such as limited time during patient visits and difficulty navigating Electronic health record (EHR) systems. These challenges lead to inaccurate coding, which undermines downstream data integrity. This quality improvement (QI) study aimed to identify these barriers and implement an intervention to improve coding accuracy, while also assessing the financial implications of improved documentation.
Methods
This QI study was conducted at the Albany Stratton VA Medical Center, focusing on hematology/ oncology outpatient encounters. A baseline chart audit of diagnosis codes from June 2023 revealed an accuracy rate of 69.8%. To address this, an intervention was implemented in which dedicated coders were assigned to support attending physicians in coding for over a two-week period. These coders reviewed and corrected diagnosis codes in real-time. A follow-up audit conducted after the intervention showed an improved coding accuracy of 82%.
Discussion/Implications
Coding remains a timeconsuming task for providers, made more difficult by EHR systems that are not user-friendly. This study demonstrated that involving dedicated coders significantly improves documentation accuracy—from 69% to 82%. In addition to data quality, the financial benefits are notable. A projected annual return on investment of $216,094 was calculated, based on an internal analysis showing that in a sample of 124 patients, 10% could have qualified for higher VERA funding based on accurate coding, generating an estimated $17,427 in additional reimbursement per patient. This cost-benefit ratio supports the recommendation to staff dedicated coders. Other interventions were also utilised, such as updating the national encounter form and auto-populating documentation in Dragon software, but had limited impact and did not directly address diagnosis accuracy respectively.
Conclusions
Targeted interventions improved coding accuracy, but sustainability remains a challenge due to time and system limitations. Future efforts should focus on hiring full-time coders. These steps can further enhance coding quality and potentially increase hospital revenue.
Background
Accurate clinical coding that reflects all diagnoses and problems addressed during a patient encounter is essential for the cancer program’s data quality, research initiatives, and securing VERA (Veterans Equitable Resource Allocation) funding. However, providers often face barriers such as limited time during patient visits and difficulty navigating Electronic health record (EHR) systems. These challenges lead to inaccurate coding, which undermines downstream data integrity. This quality improvement (QI) study aimed to identify these barriers and implement an intervention to improve coding accuracy, while also assessing the financial implications of improved documentation.
Methods
This QI study was conducted at the Albany Stratton VA Medical Center, focusing on hematology/ oncology outpatient encounters. A baseline chart audit of diagnosis codes from June 2023 revealed an accuracy rate of 69.8%. To address this, an intervention was implemented in which dedicated coders were assigned to support attending physicians in coding for over a two-week period. These coders reviewed and corrected diagnosis codes in real-time. A follow-up audit conducted after the intervention showed an improved coding accuracy of 82%.
Discussion/Implications
Coding remains a timeconsuming task for providers, made more difficult by EHR systems that are not user-friendly. This study demonstrated that involving dedicated coders significantly improves documentation accuracy—from 69% to 82%. In addition to data quality, the financial benefits are notable. A projected annual return on investment of $216,094 was calculated, based on an internal analysis showing that in a sample of 124 patients, 10% could have qualified for higher VERA funding based on accurate coding, generating an estimated $17,427 in additional reimbursement per patient. This cost-benefit ratio supports the recommendation to staff dedicated coders. Other interventions were also utilised, such as updating the national encounter form and auto-populating documentation in Dragon software, but had limited impact and did not directly address diagnosis accuracy respectively.
Conclusions
Targeted interventions improved coding accuracy, but sustainability remains a challenge due to time and system limitations. Future efforts should focus on hiring full-time coders. These steps can further enhance coding quality and potentially increase hospital revenue.
Evaluating the Implementation of 60-minute Iron Dextran Infusions at a Rural Health Center
Background
Due to risk for infusion-related reactions (IRR), administration of iron dextran requires an initial test dose with an extended monitoring period and subsequent doses given as a slow infusion over 2-3 hours. Safe use of a 60-minute iron dextran infusion protocol has been demonstrated previously at fully staffed academic teaching institutions. This study sought to determine the impact on patient safety and infusion clinic efficiency after implementing a 60-minute iron dextran administration protocol at a small, rural facility utilizing a decentralized clinical model.
Methods
This single-site, prospective, interventional study was conducted at a rural level 1C Veterans Affairs secondary care facility. The Hematology/Oncology clinic staffing includes one onsite clinical pharmacy practitioner (CPP) and advanced practice nurse. Remote providers complete patient encounters through video and telehealth modalities. A 60-minute iron dextran infusion service line agreement was designed by the Hematology/Oncology CPP and approved by the facility prior to data collection. The protocol included administration of a test dose and 15-minute monitoring period for treatment naïve patients. Pre-medications were allowed at the discretion of the ordering providers. All patients who received iron dextran between May 31, 2024 and April 14, 2025 per protocol were included in data analysis and results were stratified by treatment naïve and pre-treated patients. Outcomes included the proportion of patients experiencing any grade of IRR based on the Common Criteria for Adverse Events Version 5.0, and the average duration of administration. Descriptive statistics were used for safety and efficiency outcomes.
Results
Eighty patients received 103 iron dextran infusions and were included for analysis. Pre-medications were administered for 16 of the 103 (15.5%) included infusions. Two patients experienced grade 1 IRR (nausea) on 4 occasions (3.8%) which quickly resolved with intravenous ondansetron, and full iron dextran doses were received. The mean infusion time was 94 minutes in the treatment naïve cohort vs 71 minutes in the pre-treated cohort.
Conclusions
This study suggests a Hematology/ Oncology CPP developed iron dextran 60-minute infusion protocol may be safely and efficiently administered for qualifying patients in a decentralized, rural healthcare setting.
Background
Due to risk for infusion-related reactions (IRR), administration of iron dextran requires an initial test dose with an extended monitoring period and subsequent doses given as a slow infusion over 2-3 hours. Safe use of a 60-minute iron dextran infusion protocol has been demonstrated previously at fully staffed academic teaching institutions. This study sought to determine the impact on patient safety and infusion clinic efficiency after implementing a 60-minute iron dextran administration protocol at a small, rural facility utilizing a decentralized clinical model.
Methods
This single-site, prospective, interventional study was conducted at a rural level 1C Veterans Affairs secondary care facility. The Hematology/Oncology clinic staffing includes one onsite clinical pharmacy practitioner (CPP) and advanced practice nurse. Remote providers complete patient encounters through video and telehealth modalities. A 60-minute iron dextran infusion service line agreement was designed by the Hematology/Oncology CPP and approved by the facility prior to data collection. The protocol included administration of a test dose and 15-minute monitoring period for treatment naïve patients. Pre-medications were allowed at the discretion of the ordering providers. All patients who received iron dextran between May 31, 2024 and April 14, 2025 per protocol were included in data analysis and results were stratified by treatment naïve and pre-treated patients. Outcomes included the proportion of patients experiencing any grade of IRR based on the Common Criteria for Adverse Events Version 5.0, and the average duration of administration. Descriptive statistics were used for safety and efficiency outcomes.
Results
Eighty patients received 103 iron dextran infusions and were included for analysis. Pre-medications were administered for 16 of the 103 (15.5%) included infusions. Two patients experienced grade 1 IRR (nausea) on 4 occasions (3.8%) which quickly resolved with intravenous ondansetron, and full iron dextran doses were received. The mean infusion time was 94 minutes in the treatment naïve cohort vs 71 minutes in the pre-treated cohort.
Conclusions
This study suggests a Hematology/ Oncology CPP developed iron dextran 60-minute infusion protocol may be safely and efficiently administered for qualifying patients in a decentralized, rural healthcare setting.
Background
Due to risk for infusion-related reactions (IRR), administration of iron dextran requires an initial test dose with an extended monitoring period and subsequent doses given as a slow infusion over 2-3 hours. Safe use of a 60-minute iron dextran infusion protocol has been demonstrated previously at fully staffed academic teaching institutions. This study sought to determine the impact on patient safety and infusion clinic efficiency after implementing a 60-minute iron dextran administration protocol at a small, rural facility utilizing a decentralized clinical model.
Methods
This single-site, prospective, interventional study was conducted at a rural level 1C Veterans Affairs secondary care facility. The Hematology/Oncology clinic staffing includes one onsite clinical pharmacy practitioner (CPP) and advanced practice nurse. Remote providers complete patient encounters through video and telehealth modalities. A 60-minute iron dextran infusion service line agreement was designed by the Hematology/Oncology CPP and approved by the facility prior to data collection. The protocol included administration of a test dose and 15-minute monitoring period for treatment naïve patients. Pre-medications were allowed at the discretion of the ordering providers. All patients who received iron dextran between May 31, 2024 and April 14, 2025 per protocol were included in data analysis and results were stratified by treatment naïve and pre-treated patients. Outcomes included the proportion of patients experiencing any grade of IRR based on the Common Criteria for Adverse Events Version 5.0, and the average duration of administration. Descriptive statistics were used for safety and efficiency outcomes.
Results
Eighty patients received 103 iron dextran infusions and were included for analysis. Pre-medications were administered for 16 of the 103 (15.5%) included infusions. Two patients experienced grade 1 IRR (nausea) on 4 occasions (3.8%) which quickly resolved with intravenous ondansetron, and full iron dextran doses were received. The mean infusion time was 94 minutes in the treatment naïve cohort vs 71 minutes in the pre-treated cohort.
Conclusions
This study suggests a Hematology/ Oncology CPP developed iron dextran 60-minute infusion protocol may be safely and efficiently administered for qualifying patients in a decentralized, rural healthcare setting.
Improving Palliative Care Referrals through Education of Hematology/Oncology Fellows: A QI initiative
Purpose/Background
Palliative care referrals are recommended for patients with advanced or metastatic cancer to enhance patient and caregiver outcomes. However, challenges like delays or lack of referrals hinder implementation. This study identified rate of palliative care referrals at James A. Haley Veterans’ Hospital in Tampa, Florida; explored potential barriers to referral, and implemented targeted interventions to improve referral rates and patient outcomes.
Methods
A Plan-Do-Study-Act (PDSA) cycle was used for this quality improvement project. Data was collected from electronic medical record, focusing on consult dates, patient demographics, and reasons for seeking palliative care. Pre-intervention surveys were administered to Hematology-Oncology fellows at the institution to identify barriers to referral. Following a root cause analysis, a targeted intervention was developed, focusing on educational programs for fellows for streamlined referral processes.
Results
Before the intervention, monthly average for palliative care consults was low (3-8, typically 5). Pre-intervention surveys revealed that fellows lacked knowledge about palliative care resources, which contributed to low referral rates. To address this issue, a didactic session led by a palliative care specialist was conducted for the fellows in the fellowship program. This session provided education on the role of palliative care, how to initiate referrals, and the benefits of early involvement of palliative care teams in oncology patient management. Post-intervention surveys showed a marked improvement in fellows’ confidence regarding identification of patients suitable for palliative care. Following the session, 90% (9/10) of fellows reported being “very likely” to consult palliative care more often and 80% (8/10) indicated they were “very likely” to initiate palliative care discussions earlier in patient’s disease trajectory, with the remaining 20% (2/10) reporting a neutral stance. All fellows (100%) agreed that earlier palliative care involvement improves patient outcomes.
Implications/Significance
This PDSA cycle demonstrated that targeted education for fellows can increase awareness of palliative care resources and improve referral rates. Future work will focus on reassessing usage of palliative care consults post-intervention to evaluate effects of fellows’ education of appropriate palliative care consultation, make necessary interventions based on data and further evaluate the long-term impact on patient outcomes at James A. Haley Veterans’ Hospital.
Purpose/Background
Palliative care referrals are recommended for patients with advanced or metastatic cancer to enhance patient and caregiver outcomes. However, challenges like delays or lack of referrals hinder implementation. This study identified rate of palliative care referrals at James A. Haley Veterans’ Hospital in Tampa, Florida; explored potential barriers to referral, and implemented targeted interventions to improve referral rates and patient outcomes.
Methods
A Plan-Do-Study-Act (PDSA) cycle was used for this quality improvement project. Data was collected from electronic medical record, focusing on consult dates, patient demographics, and reasons for seeking palliative care. Pre-intervention surveys were administered to Hematology-Oncology fellows at the institution to identify barriers to referral. Following a root cause analysis, a targeted intervention was developed, focusing on educational programs for fellows for streamlined referral processes.
Results
Before the intervention, monthly average for palliative care consults was low (3-8, typically 5). Pre-intervention surveys revealed that fellows lacked knowledge about palliative care resources, which contributed to low referral rates. To address this issue, a didactic session led by a palliative care specialist was conducted for the fellows in the fellowship program. This session provided education on the role of palliative care, how to initiate referrals, and the benefits of early involvement of palliative care teams in oncology patient management. Post-intervention surveys showed a marked improvement in fellows’ confidence regarding identification of patients suitable for palliative care. Following the session, 90% (9/10) of fellows reported being “very likely” to consult palliative care more often and 80% (8/10) indicated they were “very likely” to initiate palliative care discussions earlier in patient’s disease trajectory, with the remaining 20% (2/10) reporting a neutral stance. All fellows (100%) agreed that earlier palliative care involvement improves patient outcomes.
Implications/Significance
This PDSA cycle demonstrated that targeted education for fellows can increase awareness of palliative care resources and improve referral rates. Future work will focus on reassessing usage of palliative care consults post-intervention to evaluate effects of fellows’ education of appropriate palliative care consultation, make necessary interventions based on data and further evaluate the long-term impact on patient outcomes at James A. Haley Veterans’ Hospital.
Purpose/Background
Palliative care referrals are recommended for patients with advanced or metastatic cancer to enhance patient and caregiver outcomes. However, challenges like delays or lack of referrals hinder implementation. This study identified rate of palliative care referrals at James A. Haley Veterans’ Hospital in Tampa, Florida; explored potential barriers to referral, and implemented targeted interventions to improve referral rates and patient outcomes.
Methods
A Plan-Do-Study-Act (PDSA) cycle was used for this quality improvement project. Data was collected from electronic medical record, focusing on consult dates, patient demographics, and reasons for seeking palliative care. Pre-intervention surveys were administered to Hematology-Oncology fellows at the institution to identify barriers to referral. Following a root cause analysis, a targeted intervention was developed, focusing on educational programs for fellows for streamlined referral processes.
Results
Before the intervention, monthly average for palliative care consults was low (3-8, typically 5). Pre-intervention surveys revealed that fellows lacked knowledge about palliative care resources, which contributed to low referral rates. To address this issue, a didactic session led by a palliative care specialist was conducted for the fellows in the fellowship program. This session provided education on the role of palliative care, how to initiate referrals, and the benefits of early involvement of palliative care teams in oncology patient management. Post-intervention surveys showed a marked improvement in fellows’ confidence regarding identification of patients suitable for palliative care. Following the session, 90% (9/10) of fellows reported being “very likely” to consult palliative care more often and 80% (8/10) indicated they were “very likely” to initiate palliative care discussions earlier in patient’s disease trajectory, with the remaining 20% (2/10) reporting a neutral stance. All fellows (100%) agreed that earlier palliative care involvement improves patient outcomes.
Implications/Significance
This PDSA cycle demonstrated that targeted education for fellows can increase awareness of palliative care resources and improve referral rates. Future work will focus on reassessing usage of palliative care consults post-intervention to evaluate effects of fellows’ education of appropriate palliative care consultation, make necessary interventions based on data and further evaluate the long-term impact on patient outcomes at James A. Haley Veterans’ Hospital.
Optimizing Symptom Management in VA Oncology: A Workflow-Based Quality Improvement Initiative
Background
Enhancing symptom assessment and management of patients undergoing cancer treatment presents several challenges, ranging from workflow integration to application of evidenced-based interventions (Minteer, et al., 2023). Previously, our team conducted a VA mixed-methods study and identified a lack of standardized approaches for symptom assessment, lack of technology support to optimize workflows, and the need for adaptable workflows that reflect both facility and patient preferences. In response, the National Oncology Program Office at Palo Alto VA (PAVA) launched the Proactive Patient-Centered Care Program (PPP) to address these care gaps and develop a feasible, replicable, sustainable workflow to guide broader VA-wide implementation based on prior work conducted by the PAVA team (Banks, et al., 2024).
Methods
Prior to launch, the PPP team engaged oncology leadership in VISN21 and VISN22. Long Beach VA (LBVA) was selected as the initial pilot implementation site. A multidisciplinary group from PAVA and LBVA comprised of oncology and palliative care clinicians, nurses, pharmacists, a lay health worker, and project manager guided the workflow adaptations. To support scalability and sustainability, the Empowering Learning, Innovation, and experiences through Implementation of health Informatics (ELIXIR) team designed an electronic health record agnostic technology-enabled tool to support workflow. The group met weekly to bi-monthly over 5 months, virtually and two in-person sessions, to map current practices, co-develop workflows, and identify key decisions regarding patient eligibility criteria, frequency of symptom assessments, triage responsibilities, escalation protocols, and closed-loop communication processes.
Results
A technology-enabled workflow was developed to deploy proactive symptom assessment and management across VA oncology sites with streamlined coordination between peer support staff and clinicians along with technology to support timely interventions.
Conclusions
Process improvement for symptom management requires on the ground adaptation even within an integrated health system like the VA. This initiative underscores the need for multidisciplinary collaboration, sustainability, and technology integration to support long-term intervention fidelity and scalability. The workflow developed will guide the PPP program’s expansion to LBVA, with patient enrollment beginning May 2025. The approach used to develop this workflow will serve as a model for standardizing supportive care processes across the VA to account for local needs.
Background
Enhancing symptom assessment and management of patients undergoing cancer treatment presents several challenges, ranging from workflow integration to application of evidenced-based interventions (Minteer, et al., 2023). Previously, our team conducted a VA mixed-methods study and identified a lack of standardized approaches for symptom assessment, lack of technology support to optimize workflows, and the need for adaptable workflows that reflect both facility and patient preferences. In response, the National Oncology Program Office at Palo Alto VA (PAVA) launched the Proactive Patient-Centered Care Program (PPP) to address these care gaps and develop a feasible, replicable, sustainable workflow to guide broader VA-wide implementation based on prior work conducted by the PAVA team (Banks, et al., 2024).
Methods
Prior to launch, the PPP team engaged oncology leadership in VISN21 and VISN22. Long Beach VA (LBVA) was selected as the initial pilot implementation site. A multidisciplinary group from PAVA and LBVA comprised of oncology and palliative care clinicians, nurses, pharmacists, a lay health worker, and project manager guided the workflow adaptations. To support scalability and sustainability, the Empowering Learning, Innovation, and experiences through Implementation of health Informatics (ELIXIR) team designed an electronic health record agnostic technology-enabled tool to support workflow. The group met weekly to bi-monthly over 5 months, virtually and two in-person sessions, to map current practices, co-develop workflows, and identify key decisions regarding patient eligibility criteria, frequency of symptom assessments, triage responsibilities, escalation protocols, and closed-loop communication processes.
Results
A technology-enabled workflow was developed to deploy proactive symptom assessment and management across VA oncology sites with streamlined coordination between peer support staff and clinicians along with technology to support timely interventions.
Conclusions
Process improvement for symptom management requires on the ground adaptation even within an integrated health system like the VA. This initiative underscores the need for multidisciplinary collaboration, sustainability, and technology integration to support long-term intervention fidelity and scalability. The workflow developed will guide the PPP program’s expansion to LBVA, with patient enrollment beginning May 2025. The approach used to develop this workflow will serve as a model for standardizing supportive care processes across the VA to account for local needs.
Background
Enhancing symptom assessment and management of patients undergoing cancer treatment presents several challenges, ranging from workflow integration to application of evidenced-based interventions (Minteer, et al., 2023). Previously, our team conducted a VA mixed-methods study and identified a lack of standardized approaches for symptom assessment, lack of technology support to optimize workflows, and the need for adaptable workflows that reflect both facility and patient preferences. In response, the National Oncology Program Office at Palo Alto VA (PAVA) launched the Proactive Patient-Centered Care Program (PPP) to address these care gaps and develop a feasible, replicable, sustainable workflow to guide broader VA-wide implementation based on prior work conducted by the PAVA team (Banks, et al., 2024).
Methods
Prior to launch, the PPP team engaged oncology leadership in VISN21 and VISN22. Long Beach VA (LBVA) was selected as the initial pilot implementation site. A multidisciplinary group from PAVA and LBVA comprised of oncology and palliative care clinicians, nurses, pharmacists, a lay health worker, and project manager guided the workflow adaptations. To support scalability and sustainability, the Empowering Learning, Innovation, and experiences through Implementation of health Informatics (ELIXIR) team designed an electronic health record agnostic technology-enabled tool to support workflow. The group met weekly to bi-monthly over 5 months, virtually and two in-person sessions, to map current practices, co-develop workflows, and identify key decisions regarding patient eligibility criteria, frequency of symptom assessments, triage responsibilities, escalation protocols, and closed-loop communication processes.
Results
A technology-enabled workflow was developed to deploy proactive symptom assessment and management across VA oncology sites with streamlined coordination between peer support staff and clinicians along with technology to support timely interventions.
Conclusions
Process improvement for symptom management requires on the ground adaptation even within an integrated health system like the VA. This initiative underscores the need for multidisciplinary collaboration, sustainability, and technology integration to support long-term intervention fidelity and scalability. The workflow developed will guide the PPP program’s expansion to LBVA, with patient enrollment beginning May 2025. The approach used to develop this workflow will serve as a model for standardizing supportive care processes across the VA to account for local needs.
Implementation of Consult Template Optimizes Hematology E-Consult Evaluation
Purpose/Background
The purpose of this project was to understand how implementing a consult template could optimize hematology E-consult evaluation. At the Tampa VA, providers can submit hematology E-consults for interpretation of lab abnormalities and management recommendations that do not require an in-person hematology evaluation. Previously, submission of an E-consult did not require prerequisite labs or imaging or for lab parameters to be met, leading to an increased number of hematology E-consults and subsequently, lower efficiency for hematologists.
Methods
A hematology E-consult template was created through collaboration between the hematology/ oncology and ambulatory care sections, which lists specific diagnoses and required parameters/workup needed for each diagnosis prior to submission of the E-consult. If those criteria were not met, the consult was cancelled. A representative sample of one month pre- and post-implementation data was analyzed.
Results
The E-consult template was implemented in September 2024. From April to August 2024, the average number of E-consults per month was 243, averaging at 11.0 per day, while from October 2024 to February 2025, the average number of E-consults per month was 146.4, averaging at 6.6 per day. In August 2024, the leading reasons for consult were anemia (77), leukocytosis (26), and thrombocytopenia (24). That month, there were 15 consult cancellations, with the primary reason being the patient was established in clinic (9). In October 2024, the leading reasons for consult were anemia (39), leukocytosis (14), and thrombocytopenia (13). That month, there were 34 consult cancellations, with the primary reason being that hematology advised a clinic consultation rather than an E-consult (10).
Implications/Significance
These data reveal that the hematology E-consult template was associated with a decreased number of E-consults per day and per month. Implementation of the hematology E-consult template allows the hematology consultants to focus on interpretation of lab results and providing management recommendations, as opposed to providing standard of care diagnostic recommendations. It also serves as an educational tool to referring providers, to understand appropriate indications for hematology E-consultation. Lastly, the template has created increased efficiency in providing hematology recommendations and ultimately, improved timely care for our veterans.
Purpose/Background
The purpose of this project was to understand how implementing a consult template could optimize hematology E-consult evaluation. At the Tampa VA, providers can submit hematology E-consults for interpretation of lab abnormalities and management recommendations that do not require an in-person hematology evaluation. Previously, submission of an E-consult did not require prerequisite labs or imaging or for lab parameters to be met, leading to an increased number of hematology E-consults and subsequently, lower efficiency for hematologists.
Methods
A hematology E-consult template was created through collaboration between the hematology/ oncology and ambulatory care sections, which lists specific diagnoses and required parameters/workup needed for each diagnosis prior to submission of the E-consult. If those criteria were not met, the consult was cancelled. A representative sample of one month pre- and post-implementation data was analyzed.
Results
The E-consult template was implemented in September 2024. From April to August 2024, the average number of E-consults per month was 243, averaging at 11.0 per day, while from October 2024 to February 2025, the average number of E-consults per month was 146.4, averaging at 6.6 per day. In August 2024, the leading reasons for consult were anemia (77), leukocytosis (26), and thrombocytopenia (24). That month, there were 15 consult cancellations, with the primary reason being the patient was established in clinic (9). In October 2024, the leading reasons for consult were anemia (39), leukocytosis (14), and thrombocytopenia (13). That month, there were 34 consult cancellations, with the primary reason being that hematology advised a clinic consultation rather than an E-consult (10).
Implications/Significance
These data reveal that the hematology E-consult template was associated with a decreased number of E-consults per day and per month. Implementation of the hematology E-consult template allows the hematology consultants to focus on interpretation of lab results and providing management recommendations, as opposed to providing standard of care diagnostic recommendations. It also serves as an educational tool to referring providers, to understand appropriate indications for hematology E-consultation. Lastly, the template has created increased efficiency in providing hematology recommendations and ultimately, improved timely care for our veterans.
Purpose/Background
The purpose of this project was to understand how implementing a consult template could optimize hematology E-consult evaluation. At the Tampa VA, providers can submit hematology E-consults for interpretation of lab abnormalities and management recommendations that do not require an in-person hematology evaluation. Previously, submission of an E-consult did not require prerequisite labs or imaging or for lab parameters to be met, leading to an increased number of hematology E-consults and subsequently, lower efficiency for hematologists.
Methods
A hematology E-consult template was created through collaboration between the hematology/ oncology and ambulatory care sections, which lists specific diagnoses and required parameters/workup needed for each diagnosis prior to submission of the E-consult. If those criteria were not met, the consult was cancelled. A representative sample of one month pre- and post-implementation data was analyzed.
Results
The E-consult template was implemented in September 2024. From April to August 2024, the average number of E-consults per month was 243, averaging at 11.0 per day, while from October 2024 to February 2025, the average number of E-consults per month was 146.4, averaging at 6.6 per day. In August 2024, the leading reasons for consult were anemia (77), leukocytosis (26), and thrombocytopenia (24). That month, there were 15 consult cancellations, with the primary reason being the patient was established in clinic (9). In October 2024, the leading reasons for consult were anemia (39), leukocytosis (14), and thrombocytopenia (13). That month, there were 34 consult cancellations, with the primary reason being that hematology advised a clinic consultation rather than an E-consult (10).
Implications/Significance
These data reveal that the hematology E-consult template was associated with a decreased number of E-consults per day and per month. Implementation of the hematology E-consult template allows the hematology consultants to focus on interpretation of lab results and providing management recommendations, as opposed to providing standard of care diagnostic recommendations. It also serves as an educational tool to referring providers, to understand appropriate indications for hematology E-consultation. Lastly, the template has created increased efficiency in providing hematology recommendations and ultimately, improved timely care for our veterans.
Enhancing Workforce Practices to Achieve Commission on Cancer Accreditation
Background
The American College of Surgeons’ Commission on Cancer (CoC) Accreditation requires establishment of a comprehensive cancer program, multi-disciplinary tumor boards, active cancer registry, quality improvement activities and cancer research.
Methods
In 2022, the Tibor Rubin VA Medical Center (TRVAMC) set out to obtain accreditation through enhancing workforce practices. Changes in workforce practices included (1) leadership engagement; (2) acquisition of staff; (3) enhancing staff efficiency and (4) inter-departmental collaboration, leading to CoC accreditation in August 2024. executive leadership team (ELT) buy-in was essential. ELT engagement included communicating the benefits of accreditation, alignment with organizational mission and values, protected time for Cancer Committee members, Chief of Staff presence in Cancer Committee, commitment to recruiting new staff, and membership in the Medical Executive Council to voice cancer program needs. New staff included a cancer program manager, cancer case conference RN care coordinator, certified oncology data specialist and survivorship nurse practitioner. Staff development included structured and focused training. Enhancing staff efficiency included developing standards of work with clear delineation of duties (delegation of specific CoC standards), decentralizing decision making, a shared governance council, and weekly Cancer Program meetings. These changes allowed staff members to be active, autonomous decision-making participants, and increased efficiency. Inter-departmental collaboration involved Hematology/Oncology, Surgery, Radiation Oncology, Pharmacy, Nutrition, Pathology, Palliative Care, Rehabilitation, Chaplaincy and Cancer Research, with key individuals serving as Cancer Committee members. Each department set performance goals and metrics. Each employee’s contribution was rated in annual performance reviews.
Results
TRVAMC thus elevated cancer care delivery standards through structured workforce practices within the framework of CoC standards required for accreditation. Additionally, the accreditation process achieved desirable and measurable outcomes, e.g. 100% growth in oncology dietitian referrals, 75% increase in early palliative care referrals (TRVAMC ranked in the top 5 in the US), and more than 200 patients enrolled in cancer clinical trials (TRVAMC was the highest enrolling VA in the US to NCI trials in 2024).
Conclusions
Our model demonstrates how strategic improvements in healthcare workforce practices at a VA can directly contribute to sustained improvements in quality and delivery of cancer care services.
Background
The American College of Surgeons’ Commission on Cancer (CoC) Accreditation requires establishment of a comprehensive cancer program, multi-disciplinary tumor boards, active cancer registry, quality improvement activities and cancer research.
Methods
In 2022, the Tibor Rubin VA Medical Center (TRVAMC) set out to obtain accreditation through enhancing workforce practices. Changes in workforce practices included (1) leadership engagement; (2) acquisition of staff; (3) enhancing staff efficiency and (4) inter-departmental collaboration, leading to CoC accreditation in August 2024. executive leadership team (ELT) buy-in was essential. ELT engagement included communicating the benefits of accreditation, alignment with organizational mission and values, protected time for Cancer Committee members, Chief of Staff presence in Cancer Committee, commitment to recruiting new staff, and membership in the Medical Executive Council to voice cancer program needs. New staff included a cancer program manager, cancer case conference RN care coordinator, certified oncology data specialist and survivorship nurse practitioner. Staff development included structured and focused training. Enhancing staff efficiency included developing standards of work with clear delineation of duties (delegation of specific CoC standards), decentralizing decision making, a shared governance council, and weekly Cancer Program meetings. These changes allowed staff members to be active, autonomous decision-making participants, and increased efficiency. Inter-departmental collaboration involved Hematology/Oncology, Surgery, Radiation Oncology, Pharmacy, Nutrition, Pathology, Palliative Care, Rehabilitation, Chaplaincy and Cancer Research, with key individuals serving as Cancer Committee members. Each department set performance goals and metrics. Each employee’s contribution was rated in annual performance reviews.
Results
TRVAMC thus elevated cancer care delivery standards through structured workforce practices within the framework of CoC standards required for accreditation. Additionally, the accreditation process achieved desirable and measurable outcomes, e.g. 100% growth in oncology dietitian referrals, 75% increase in early palliative care referrals (TRVAMC ranked in the top 5 in the US), and more than 200 patients enrolled in cancer clinical trials (TRVAMC was the highest enrolling VA in the US to NCI trials in 2024).
Conclusions
Our model demonstrates how strategic improvements in healthcare workforce practices at a VA can directly contribute to sustained improvements in quality and delivery of cancer care services.
Background
The American College of Surgeons’ Commission on Cancer (CoC) Accreditation requires establishment of a comprehensive cancer program, multi-disciplinary tumor boards, active cancer registry, quality improvement activities and cancer research.
Methods
In 2022, the Tibor Rubin VA Medical Center (TRVAMC) set out to obtain accreditation through enhancing workforce practices. Changes in workforce practices included (1) leadership engagement; (2) acquisition of staff; (3) enhancing staff efficiency and (4) inter-departmental collaboration, leading to CoC accreditation in August 2024. executive leadership team (ELT) buy-in was essential. ELT engagement included communicating the benefits of accreditation, alignment with organizational mission and values, protected time for Cancer Committee members, Chief of Staff presence in Cancer Committee, commitment to recruiting new staff, and membership in the Medical Executive Council to voice cancer program needs. New staff included a cancer program manager, cancer case conference RN care coordinator, certified oncology data specialist and survivorship nurse practitioner. Staff development included structured and focused training. Enhancing staff efficiency included developing standards of work with clear delineation of duties (delegation of specific CoC standards), decentralizing decision making, a shared governance council, and weekly Cancer Program meetings. These changes allowed staff members to be active, autonomous decision-making participants, and increased efficiency. Inter-departmental collaboration involved Hematology/Oncology, Surgery, Radiation Oncology, Pharmacy, Nutrition, Pathology, Palliative Care, Rehabilitation, Chaplaincy and Cancer Research, with key individuals serving as Cancer Committee members. Each department set performance goals and metrics. Each employee’s contribution was rated in annual performance reviews.
Results
TRVAMC thus elevated cancer care delivery standards through structured workforce practices within the framework of CoC standards required for accreditation. Additionally, the accreditation process achieved desirable and measurable outcomes, e.g. 100% growth in oncology dietitian referrals, 75% increase in early palliative care referrals (TRVAMC ranked in the top 5 in the US), and more than 200 patients enrolled in cancer clinical trials (TRVAMC was the highest enrolling VA in the US to NCI trials in 2024).
Conclusions
Our model demonstrates how strategic improvements in healthcare workforce practices at a VA can directly contribute to sustained improvements in quality and delivery of cancer care services.