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Quality Improvement/Clinical Outcomes

E398: Operative Standards in Lung Cancer: Exploring Stakeholder Perspectives

Introduction: The ACS recently published over 134 operative standards across 15 cancer types aiming to reduce variation in surgical technical quality. The Commission on Cancer (CoC) has implemented six of these standards and expects CoC hospitals to reach 80% adherence by 2024. Operative Standard 5.8, which targets lung cancer surgery, requires the resection of lymph nodes from at least three mediastinal nodal stations and one hilar station for any curative-intent resection. The CoC estimates that up to 30% of hospitals are non-compliant with this standard. We conducted a qualitative study to evaluate barriers and facilitators to implementation of Standard 5.8.

Methods: Ten semi-structured interviews were conducted with key stakeholders including thoracic surgeons, pathologists, a clinical data analyst and a CoC site liaison across two large academic institutions. Themes were identified through narrative thematic analysis performed by two independent coders and mapped to a comprehensive and integrated checklist of determinants of practice, the Tailored Implementation for Chronic Disease framework (TICD).

Results: Themes were mapped to five of the seven TICD domains (Table). The majority of participants felt that the guideline was not burdensome and did not alter their clinical practices (Guideline Factors). Although there was overall agreement with the principles of the standard, many stakeholders were either uncertain of the supporting evidence or felt the standard was controversial and identified several potential technical and logistical barriers to implementation (Individual Health Professional Factors). Collaboration among thoracic surgeons, pathologists, and operating room staff was identified as a key facilitator to compliance (Professional Interactions) as well as alignment with other professional society guidelines (Incentives and Resources). Higher compliance rates were thought to reflect increased documentation of preexisting clinical practices and improved interdisciplinary communication (Capacity for Organizational Change).

Conclusions:

Many surgeons believe current reporting mechanisms fail to capture the extent of their lymph node dissections which may contribute to low recorded compliance rates at some institutions. However, overall positive attitudes toward Standard 5.8 suggest that interdisciplinary communication, regular feedback mechanisms, and departmental leadership may help offset potential logistical or technical barriers and lead to improved implementation.

Learning Objectives:

  • Upon completion, participant will be able to define the unique challenges of implementing Operative Standard 5.8.
  • Upon completion, participant will be able to describe the key facilitators and strategies that can lead to successful guideline implementation.
  • Upon completion, participant will be able to identify several important opportunities for improvement in guideline implementation and reporting.