94 Background: The Commission on Cancer (CoC) standard 3.3 requires that all patients who complete cancer treatment receive a survivorship care plan (SCP). To aid in care coordination, the standard also requires that the SCP be provided to the patient’s primary care provider (PCP). St. Luke’s Mountain States Institute (MSTI) has been providing patients and PCPs with SCPs for more than 5 years. Other local accredited cancer centers also provide SCPs for their patients. Methods: In partnership with the local chapter of the American Cancer Society, MSTI created an online survey aimed at assessing the utilization of the SCP in primary care clinics and the PCP’s comfort level carrying out the recommended surveillance. The survey link was distributed through email to approximately 300 PCPs across a large geographical area in varying sized practices. Results: Sixty three responses were received in 3 weeks with 46 responses from physicians and 17 responses from advanced practice providers. All of the respondents said they care for cancer survivors in their practice but 54% have never received a SCP. Twenty nine reported having received a SCP and answered 8 questions related to how they use the SCP in practice. The majority refer to the SCP to monitor for recurrence and 52% use it as a tool for coordination of care. Forty eight percent use the SCP to manage co-morbid conditions. Ninety-five percent of all respondents indicated they feel comfortable carrying out a surveillance plan provided by the oncologist for patients 2 years out from treatment. Sixty-four percent indicated they would like additional education about caring for cancer survivors. A common theme in comments included the desire for improved communication between the oncologists and PCPs. Conclusions: This standard was created in part to improve care coordination between oncologists and PCPs. More than have of the PCPs in the MSTI service area have not seen a SCP for their patients. Most indicated they are comfortable providing surveillance if they have a clear follow-up care plan from the oncologist. More than half want additional information about caring for cancer survivors. Future exploration could include assessment of barriers to communication and utilizing the SCP in practice.

203 Background: Defining and quantifying quality care is a challenge for cancer care providers. Since 2007 St. Luke’s Mountain States Tumor Institute (MSTI) has been participating in QOPI and was one of 23 practices that received the inaugural QOPI Certification in June 2010. The goal of participation is to benchmark MSTI’s performance with oncology practices across the nation and identify areas for improvement that are recognized as national quality standards. Methods: After each round of QOPI data abstraction, physician and administrative leadership selected measures with the greatest opportunity for improvement. Monthly chart audits for each measure were completed and the results were shared with individual staff to increase education and accountability. In Spring 2010, the education assessment in MSTI’s Electronic Medical Record (EMR) was redesigned to facilitate efficient documentation and data collection of smoking cessation counseling. In July 2011, the performance improvement (PI) team created “Quality Checklists (QCL)” in MSTI’s EMR for three different QOPI measures: i) signed chemotherapy consent, ii) smoking cessation counseling, and iii) assessment of emotional well-being. To ensure signed chemotherapy consent, one QCL included a reminder sent by the primary nurse or secretary to the chemotherapy infusion nurses. To ensure smoking cessation counseling and assessment of emotional well-being by social work, the other QCL included an alert sent by the new patient representative to the primary nurse and social worker. Results: Signed chemotherapy consent improved from 10% (n=229) in 2007 to 100% (n=117) in 2012. Smoking cessation counseling improved from 13% (n=40) in 2007 to 93% (n=272) in 2012. Assessment of emotional well-being improved from 78% (n=302) in 2007 to 95% (n=120) in 2012. Of the patients that had problems with emotional well-being, 73% (n=55) in 2007 had their problems addressed and 95% (n=41) in 2012. Conclusions: QOPI has provided MSTI with the initiatives and benchmarks to quantify quality cancer care. By combining participation in QOPI and ongoing PI data collection, analysis, and action plan implementation MSTI has enjoyed marked improvements in quality.

183 Background: In 2006 the American Society of Clinical Oncology (ASCO) recommended that oncologists discuss infertility as a result of cancer treatment with patients of reproductive age and provide referrals to specialists as needed. Despite these guidelines the majority of cancer centers are not in compliance. Mountain States Tumor Institute (MSTI) piloted a process to improve quality of oncofertility preservation (OP) through identification, documentation, and referral to reproductive specialists. Methods: A physician survey in 2010 indicated that perceived barriers to OP discussion were a lack of accessible materials as well as oversight on the part of the provider. Random chart audits of the Quality Oncology Practice Initiative (QOPI) measures (infertility risks discussed prior to treatment and fertility preservation options discussed/referral to a specialist) occurred biannually at that time. To increase awareness of the data chart audits and reporting shifted to quarterly and included all patients that met OP criteria. Additionally, a committee was formed in 2011 to develop patient/provider packets, collaborate with the local reproductive specialists, and create an OP process. The committee established an OP algorithm involving support staff to flag patients of reproductive age at initial medical oncology consultation and utilizing genetic counselors (GC) and social workers (SW) to expedite and facilitate referrals to reproductive specialists. GC/SW were chosen due to sensitivity with psychosocial issues and to share the additional workload. The OP program was launched in October of 2012. Results: Baseline assessment in 2009 revealed MSTI was compliant 6% and 6%. Six months after program initiation the OP measures improved to 47% and 45% respectively. Notably March and April 2013 showed dramatic improvements with 100% and 75% compliance for both OP measures. Conclusions: It is well known that OP has been a challenge for many cancer centers. This multipronged approach is an example of a novel process implementation that demonstrated significant improvement with the QOPI oncofertility measures. Continued work is needed on improving physician documentation and consistency of OP patient identification.