PROMs Give Patients a Voice in Improving Quality

Mass General Brigham is measuring our success by more than just the number of lives we save. 

In our delivery of lifesaving care, our clinical teams are focused on relieving suffering and improving the experience of our patients, guided by their feedback about what matters most to them.

“We care deeply about the quality of the lives we save,” said Andrea Pusic, MD, MHS, medical director of the Mass General Brigham PROMs program.

Through PROMs, patient-reported outcome measures, our system is directly engaging patients in their care journeys — asking them about their symptoms, pain, quality of life, ability to function — and then using this feedback to identify and address individual patients’ unmet needs and improve the overall quality of care that we provide for all patients.

Mass General Brigham has been the national leader in the use of PROMs since launching our program in 2012. Our program is the largest in the world, collecting more than 5 million validated clinical questionnaires from patients each year. This data captures our patients’ perspective and is central to our For Every Patient unified quality strategy for delivering safe, highly effective and personalized care, rooted in equity.

By providing the patient’s point of view, patient-reported outcomes are key to treating the whole person and not just their disease. In certain specialties, like cancer care, where depression is common and proven to have an impact on the disease’s outcomes, Mass General Brigham has begun depression screening and connecting patients who need support to appropriate mental health services within our system.

“A cancer patient who struggles with depression is less likely to adhere to their treatment. They may miss appointments and increase their risk of unplanned care (in the emergency department),” Dr. Pusic said. “Ultimately, they won’t do as well through the course of their treatment. By checking in with them early and regularly throughout their care, we hope to proactively identify patients who would benefit from additional support.”

Treating the whole person 

At Mass General Brigham’s Radiation Oncology Center in Mansfield, MA, care teams recently added a research-validated depression screening that patients complete after their diagnosis and before each weekly visit with a clinician.

Patients fill out the questionnaire either through Mass General Brigham’s Patient Gateway online portal or with a clinic-provided tablet just before seeing a clinician. Their responses are integrated into the patient’s medical record where they are visible to their care team. Clinicians then refer patients who screen for moderate or severe depression to a social worker. 

The eight-question tool gauges patients’ responses across a range of potential problems. For example, questions ask how often patients are feeling down, depressed or hopeless; whether they are having trouble falling asleep, staying asleep or sleeping too much; or if they are feeling tired or have little energy.

“Patients tend to be more forthcoming when they document their feelings privately and independently as opposed to being directly asked by a provider,” said Colleen Whitehouse DNP, RN, OCN, regional nurse director of Radiation Oncology, Brigham and Women’s Hospital, explaining the value of the screening tool.

Before depression screening at the center, social work referrals were generated through observation and communication between the care team. A clinician might notice, for example, that a patient was teary-eyed during an appointment or struggled when setting up their radiation schedule.

Some patients might have self-referred after seeing a sign promoting the availability of social work support in the waiting room, inspiring them to reach out for help. These more informal processes, however, contributed to delays in identifying patients with depression and providing timely access to mental health support. The new PROMs screening tool enables immediate intervention, said Donna Tuleja, LICSW, the social worker who meets one-on-one with each Radiation Oncology patient dealing with depression at the Mansfield center.

Ensuring patients have a voice

Patients facing a cancer diagnosis shoulder a heavy emotional burden, but they shouldn’t have to do it alone. “Understanding what our patients are going through, the stressors they are dealing with in their daily lives, in addition to their diagnosis, helps us better work with and care for them,” Tuleja said.

It also prevents patients from “flying under the radar.” Tuleja pointed out how one patient, who exhibited no outward signs of distress, benefited from proactive depression screening. She learned that the patient, who had been sober for 20 years, started drinking again in response to their diagnosis and other exacerbating factors related to their physical and mental health.

“PROMs help remind staff of the importance of the patient’s perspective,” Whitehouse said. “If we don’t have the patient as part of the care team, we’re not going to be as successful as we can be in our treatment.”

Building on the Mansfield model, plans call for an expansion of the use of depression screening throughout our Mass General Brigham Cancer Institute as well as other clinical areas in our health system where depression is linked to outcomes, including neurologic and cardiovascular care.

Embracing, expanding PROMs

Mass General Brigham’s PROMs program has evolved to address four main areas:

• Individual patient care (assessing how a patient is feeling and functioning)
• Quality of our clinical care (are we meeting patients’ goals in the aggregate?)
• Research (how effective is a new medication or surgical technique?)
• Value (was a treatment cost-effective in producing the desired outcome?)

Teams across Mass General Brigham have embraced the use of PROMs and are working together to improve quality for our patients. Physical and occupational therapists recently developed PROMs that are now in use in 58 clinics systemwide.

“Across the whole system, patients are getting the same experience, the same assessment that uses ‘the outcomes that matter most’ to patients to improve quality,” said Peter Meyers, director of PROMs for Mass General Brigham.

Mass General Brigham has also standardized the collection of PROMs within certain specialties, including orthopedics, that require the data to demonstrate value and qualify for Medicare funding. “The only quality measure for a knee replacement shouldn’t be whether or not a patient suffered an infection,” Dr. Pusic said. “We want to know if a patient’s pain decreased, and if their physical function improved.”

Within our Heart and Vascular Institute, teams are developing a set of PROMs to acquire more extensive feedback from patients on the increasing number of available therapies and procedures to learn more about patient experiences and satisfaction with treatment.

“We want to dive deeper into outcomes. Are patients satisfied with the decision they made? If not, why not? What were the trade-offs?” said Thor Sundt, MD, chief of Cardiac Surgery for Mass General Brigham. “Our objective is to restore health, and our patients can provide vital insights into whether or not we’re doing the best job we can to achieve this goal.”