Engagement Resources and Quality Improvement Lesley Breech MD

Engagement, Resources, and Quality Improvement Lesley Breech, MD Comprehensive Fertility Care and Preservation Program

Engagement

Collaboration Oncology/ Endocrinology Gynecology/ Surgery/ Urology/ REI Care Managers Patient Navigator Optimal Outcome Social Work Ethics PCP Patient/Family

Engagement of the Primary Team • Be visible • Various team meetings • Gain information and network • “Yes, we’d love to present to your group” • Local, regional, national • Lectures, social media, blogs, webinars, live-chats • Take the initiative

Engagement of the Primary Team • Be timely • With communication • With consultation • With follow up • Work toward fertility consultation becoming expected, not elective • Establish as the standard approach • Culture change helps to fuel the growth of the program

Make the existing culture work for you • Leukemia/Lymphoma, Solid Tumor, Neuro-onc • On the surface not so different – same guidelines, same players, etc • Actually work very differently • Need a system that is flexible enough to work with all teams but simple enough to understand • Single access point (Fertility Navigator)!!! • Look for the common denominator • Care manager role exists in all teams • Keepers of the new patient checklist

Institutional Engagement • Institutional intranet highlights • Program achievements • Developments in the field • Patient and Family Advocacy • Area magazine highlights • Radio broadcast • Local news story broadcast nationally • 2017 Faculty Clinical Team Award • Recognize the contribution of all team members!!! • Leadership recognition of “return on mission”

Initial Barriers to needed resources • Lack of dedicated institutional support & oncology buy-in • Financial Barriers • Coordination of fertility care (No fertility navigator) • Data management and electronic health record • Tissue processing in pediatric facility • OR logistics for fertility procedures • Lack of Research Infrastructure • Logistics of 3 oncology services + BMT

Overcoming Barriers • Dedicated institutional funding secured • Sound business plan • Partnerships with other programs • Onco. Fertility Consortium • University of Cincinnati adult program • Partnering with patient/family support groups • Stupid Cancer • Leverage divisional resources for additional support • Philanthropic funds to support patient care costs

Facilitating Factors

Quality Improvement Science • Partnered with the Anderson Center at CCHMC • Experienced Quality Improvement Consultant embedded in team • Consistently analyze data • Every miss is a learning opportunity • Use each instance to improve the quality of service • Make yourself accountable • Presented monthly at AYA & CFCPP Meeting • Share with teams requesting consultation

Eligibility for Fertility Consult April 2017 100, 0% 100% 90% Category Percentages 80% 70% 60% 54, 3% 50% 25 21 40% 30% 20% 10% 0% Ineligible Eligible Category Name *Ineligible criteria: observation only, palliative or <20% expected survival, phase I, previous fertility consult/intervention, consult only, surgery only , family declined, severe cognitive delay Individual Quantities & Percentages Cumulative Percentages

100 90 80 70 60 50 40 30 FN began attending testing FN Onc weekly decision team mtgs. aids increased ↓ ↓ time ↑ ↓ Began ↑ counting BMT pt list BMT pts ↑ emailedintomonth fertility consult FN delivered conditioning email inbox Fertility Consult started ↑ email education 4 pts missed during FN transition 2 proton Proton pt therapy pts missed 1 proton therapy & 1 liquids pt missed 4 proton therapy pts missed 20 10 0% 9/01/13 (n=09) 10/01/13 (n=15) 11/01/13 (n=06) 12/01/13 (n=09) 1/01/14 (n=13) 2/01/14 (n=16) 3/01/14 (n=22) 4/01/14 (n=15) 5/01/14 (n=09) 6/01/14 (n=14) 7/01/14 (n=11) 8/01/14 (n=05) 9/01/14 (n=16) 10/01/14 (n=16) 11/01/14 (n=10) 12/01/14 (n=09) 1/01/15 (n=15) 2/01/15 (n=11) 3/01/15 (n=22) 4/01/15 (n=19) 5/01/15 (n=12) 6/01/15 (n=19) 7/01/15 (n=20) 8/01/15 (n=26) 9/01/15 (n=20) 10/01/15 (n=26) 11/01/15 (n=22) 12/01/15 (n=14) 1/01/16 (n=20) 2/01/16 (n=20) 3/01/16 (n=19) 4/01/16 (n=24) 5/01/16 (n=15) 6/01/16 (n=16) 7/01/16 (n=13) 8/01/16 (n=09) 9/01/16 (n=18) 10/01/16 (n=17) 11/01/16 (n=18) 12/01/16 (n=08) 1/01/17 (n=17) 2/01/17 (n=13) 3/01/17 (n=21) 4/01/17 (n=21) % of Eligible Pts Who Received a Fertility Consult Percent of Eligible Patients Receiving a Fertility Consult* P-Chart September 2013 - Present Began Month of Tx Plan Made % of Eligible Pts Receiving a Fertility Consult Average/Mean Control Limits FN=Fertility Navigator *Ineligible criteria: observation only, palliative or <20% expected survival, phase I, previous fertility consult/intervention, consult only, surgery only, family declined, severe cognitive delay

Eligible Patients for Fertility Consult by Team April 2017 (n=21) 100, 0% 100% 90, 5% 90% Category Percentages 80% 66, 7% 70% 60% 50% 40% 38, 1% 8 30% 6 5 20% 10% 2 0% Liquids Solids BMT Neuro-Onc Category Name Individual Quantities & Percentages Cumulative Percentages

60 50 20 10 Sep-13 (n=01) Oct-13 (n=04) Nov-13 (n=02) Dec-13 (n=03) Jan-14 (n=06) Feb-14 (n=01) Mar-14 (n=07) Apr-14 (n=08) May-14 (n=01) Jun-14 (n=07) Jul-14 (n=03) Aug-14 (n=03) Sep-14 (n=06) Oct-14 (n=01) Nov-14 (n=02) Dec-14 (n=00) Jan-15 (n=02) Feb-15 (n=04) Mar-15 (n=04) Apr-15 (n=06) May-15 (n=05) Jun-15 (n=05) Jul-15 (n=10) Aug-15 (n=01) Sep-15 (n=04) Oct-15 (n=07) Nov-15 (n=04) Dec-15 (n=03) Jan-16 (n=06) Feb-16 (n=03) Mar-16 (n=03) Apr-16 (n=07) May-16 (n=03) Jun-16 (n=05) Jul-16 (n=03) Aug-16 (n=01) Sep-16 (n=06) Oct-16 (n=02) Nov-16 (n=09) Dec-16 (n=00) Jan-17 (n=03) Feb-17 (n=05) Mar-17 (n=09) Apr-17 (n=06) % of Patients Who Received a Fertility Consult Percent of Eligible SOLIDS Patients Receiving a Fertility Consult* September 2013 - Present 100 90 80 70 ↑ FN Increased Time 2 proton therapy pts missed 40 30 Median baseline period Sep - Dec 2013 = 58% 2 proton therapy pts missed 0% Month of Tx Plan Made FN=Fertility Navigator *Ineligible criteria: observation only, palliative or <20% expected survival, phase I, previous fertility consult/intervention, consult only, surgery only, family declined, severe cognitive delay

Se O p-1 c N t-13 (n ov 3 = D -1 (n 03 e 3 = ) Ja c-1 (n 07 3 = ) Fen-1 (n 03 4 = ) b M -1 (n 05 ar 4 = ) A -1 (n 06 p M r-14 (n=12) ay 4 = ) Ju -1 (n 13 n 4 = ) Ju -14 (n=04) A l-1 (n 06 u 4 Seg-1 (n=04) 4 = ) O p-1 (n 06 ct 4 =0 ) N -1 (n 2 o 4 D v-1 (n=06) e 4 = ) Ja c-1 (n 12 4 = ) Fen-1 (n 04 5 = ) M b-1 (n 04 ar 5 = ) A -1 (n 05 p M r-15 (n=06) ay 5 = ) Ju -1 (n 09 n 5 = ) Ju -15 (n=05) A l-1 (n 04 u 5 Seg-1 (n=05) 5 = ) O p-1 (n 04 ct 5 =1 ) N -1 (n 4 o 5 D v-1 (n=09) e 5 = ) Ja c-1 (n 08 5 = ) Fen-1 (n 10 6 = ) b M -1 (n 06 ar 6 = ) A -1 (n 12 p M r-16 (n=08) ay 6 = ) Ju -1 (n 07 n 6 = ) Ju -16 (n=07) A l-1 (n 03 u 6 Seg-1 (n=04) 6 = ) O p-1 (n 07 ct 6 =0 ) N -1 (n 3 o 6 D v-1 (n=07) e 6 = ) Ja c-1 (n 05 6 = ) Fen-1 (n 05 7 = ) M b-1 (n 02 ar 7 = ) A -1 (n 06 pr 7 = ) -1 (n 04 7 =0 ) (n 2 =0 ) 8) % of Patients Who Received a Fertility Consult Percent of Eligible LIQUIDS Patients Receiving a Fertility Consult* September 2013 - Present 100 90 80 70 60 50 40 30 20 Median baseline period Sep - Dec 2013 = 51% 10 0% Month of Tx Plan Made FN=Fertility Navigator *Ineligible criteria: observation only, palliative or <20% expected survival, phase I, previous fertility consult/intervention, consult only, surgery only, family declined, severe cognitive delay

Se O p-1 c N t-13 (n ov 3 = D -1 (n 01 e 3 = ) Ja c-1 (n 01 3 = ) Fen-1 (n 00 4 = ) b M -1 (n 01 ar 4 = ) A -1 (n 00 p M r-14 (n=03) ay 4 = ) Ju -1 (n 01 n 4 = ) Ju -14 (n=01) A l-1 (n 02 u 4 Seg-1 (n=02) 4 = ) O p-1 (n 01 ct 4 =0 ) N -1 (n 1 o 4 D v-1 (n=04) e 4 = ) Ja c-1 (n 02 4 = ) Fen-1 (n 04 5 = ) M b-1 (n 04 ar 5 = ) A -1 (n 07 p M r-15 (n=01) ay 5 = ) Ju -1 (n 03 n 5 = ) Ju -15 (n=07) A l-1 (n 03 u 5 Seg-1 (n=08) 5 = ) O p-1 (n 05 ct 5 =1 ) N -1 (n 1 o 5 D v-1 (n=07) e 5 = ) Ja c-1 (n 08 5 = ) Fen-1 (n 08 6 = ) b M -1 (n 04 ar 6 = ) A -1 (n 02 p M r-16 (n=09) ay 6 = ) Ju -1 (n 08 n 6 = ) Ju -16 (n=08) A l-1 (n 08 u 6 Seg-1 (n=06) 6 = ) O p-1 (n 03 ct 6 =0 ) N -1 (n 4 o 6 D v-1 (n=04) e 6 = ) Ja c-1 (n 10 6 = ) Fen-1 (n 03 7 = ) M b-1 (n 03 ar 7 = ) A -1 (n 08 pr 7 = ) -1 (n 02 7 =0 ) (n 6 =0 ) 5) % of Patients Who Received a Fertility Consult Percent of Eligible BMT Patients Receiving a Fertility Consult* September 2013 - Present 100 90 80 70 ↑ Began counting BMT pts in month conditioning started 60 50 40 30 20 10 0% Month of Tx Plan Made *Ineligible criteria: observation only, palliative or <20% expected survival, phase I, previous fertility consult/intervention, consult only, surgery only, family declined, severe cognitive delay

# Days Fertility Consult done prior to Conditioning Start Date (Negative value means consult was done after start date) -4000% 138 255 80 60 40 -2000% # days consult done prior to start date 197 100 200 164 Median 453 154 Would have done TTC if available at CCHMC Pre Tx - Ideal 236 175 Would have done TTC if offered at CCHMC Would have done TTC if available at CCHMC Post Tx 20 5/15/2015 5/23/2015 5/24/2015 6/3/2015 6/4/2015 6/8/2015 6/9/2015 6/21/2015 6/28/2015 6/29/2015 7/2/2015 7/9/2015 7/23/2015 7/28/2015 7/30/2015 8/8/2015 8/11/2015 8/14/2015 8/16/2015 8/20/2015 8/25/2015 8/26/2015 8/27/2015 8/31/2015 9/9/2015 9/10/2015 9/11/2015 9/14/2015 9/20/2015 9/21/2015 9/28/2015 10/10/2015 10/15/2015 10/19/2015 10/20/2015 10/22/2015 10/24/2015 10/29/2015 11/10/2015 11/11/2015 11/14/2015 11/17/2015 11/20/2015 11/27/2015 12/3/2015 12/6/2015 12/13/2015 12/29/2015 1/4/2016 1/12/2016 02/02/16 02/03/16 02/09/16 02/10/16 02/16/16 02/29/16 03/08/16 03/10/16 03/15/16 03/16/16 03/19/16 03/25/16 04/02/16 04/05/16 04/06/16 04/09/16 04/22/16 04/25/16 04/29/16 04/30/16 05/02/16 05/03/16 05/12/16 05/19/16 05/23/16 05/24/16 05/26/16 05/31/16 06/02/16 06/07/16 06/08/16 06/13/16 06/20/16 06/28/16 07/11/16 07/12/16 07/15/16 08/16/16 08/17/16 08/23/16 09/25/16 09/26/16 09/27/16 09/28/16 10/04/16 10/10/16 10/11/16 10/17/16 10/18/16 10/24/16 10/26/16 10/29/16 11/17/16 11/29/16 12/02/16 12/13/16 12/20/16 01/11/17 01/22/17 01/23/17 01/24/17 01/26/17 02/14/17 02/27/17 3/5/2017 3/10/2017 3/14/2017 3/15/2017 3/28/2017 3/31/2017 04/13/17 04/18/17 04/19/17 04/21/17 04/26/17 BMT: # Days Fertility Consult done prior to Conditioning Start Date Run Chart May 2015 - present 120 224 Patient Conditioning Start Date Goal 143 180 OTC Pre Tx - 0% Acceptable

Se p O -1 ct 3 N -1 (n o 3 = D v-1 (n 09) e 3 = Ja c-1 (n=15) 3 Fen-1 (n 06) 4 = M b-1 (n 09) ar 4 =1 A -1 (n 3) p 4 = M r-1 (n 16 ay 4 =2 ) Ju -1 (n 2) n 4 =1 Ju -14 (n= 5) A l-1 (n 09 u 4 = ) Seg-1 (n 14) p 4 = O -1 (n=11) ct 4 0 N -1 (n 5 o 4 = ) D v-1 (n 16) e 4 = Ja c-1 (n=16) 4 Fen-1 (n 10) 5 = M b-1 (n 09) ar 5 =1 A -1 (n 5) p 5 = M r-1 (n 11 ay 5 =2 ) Ju -1 (n 2) n 5 =1 Ju -15 (n= 9) A l-1 (n 12 u 5 = ) Seg-1 (n 19) p 5 = O -1 (n=19) ct 5 2 N -1 (n 6 o 5 = ) D v-1 (n 20) e 5 = Ja c-1 (n=26) 5 Fen-1 (n 21) 6 = b M -1 (n 14) ar 6 =2 A -1 (n 0) p 6 = M r-1 (n 20 ay 6 =1 ) Ju -1 (n 9) n 6 =2 Ju -16 (n= 4) A l-1 (n 15 u 6 = ) Seg-1 (n 16) p 6 = O -1 (n=13) ct 6 0 N -1 (n 9 o 6 = ) D v-1 (n 18) e 6 = Ja c-1 (n=17) 6 Fen-1 (n 18) 7 = b M -1 (n 08) ar 7 =1 A -1 (n 7) pr 7 =1 -1 (n 3) 7 =2 (n 1 =2 ) 1) % of Patients Who Received a Fertility Consult Percent of Consult-Eligible Patients Electing a Fertility Preservation Option September 2013 - Present 100 90 80 70 60 Median: 15. 4% Average: 16. 9% 50 40 30 20 10 0% Month of Tx Plan Made *Ineligible criteria: observation only, palliative or <20% expected survival, phase I, previous fertility consult/intervention, consult only, surgery only, family declined, severe cognitive delay

MMM-yy MMM-yy MMM-yy MMM-yy MMM-yy MMM-yy MMM-yy MMM-yy MMM-yy MMM-yy MMM-yy Count (# of Patients) # of Patients Electing Fertility Preservation by Option Sep. 2013 - Present 10 9 8 7 6 5 4 3 2 1 0 Sperm Cryopreservation Ovarian Tissue Cryopreservation Month Testicular Tissue Cryopreservation Oocyte

Fertility Consult Outcome April 2017 (n=21 consult-eligible patients) 95, 2% 100% 90, 5% 85, 7% 90% Category Percentages 81, 0% 80% 66, 7% 70% 60% 50% 40% 38, 1% 8 30% 6 20% 3 10% 0% Preservation No option preservation declined option SCP 1 1 0 OTC TTC Missed consult Oocyte Unsuccessful SCP attempt Individual Quantities & Percentages Cumulative Percentages

Comprehensive Fertility Care and Preservation Program at CCHMC • Began with dedicated passionate team members • Survived and grew due to diligence, passion of team and increased awareness inside and outside CCHMC • Has become a national leader in the pediatric fertility preservation care delivery space