patients about what matters most to them both before and after starting treatment.

PURPOSE: In the United States, lung cancer accounts for 14% of cancer diagnoses and 28% of cancer deaths annually. Because no cure exists for advanced lung cancer, the primary treatment goal is to prolong survival. OBJECTIVES: The study aim was to determine whether individual preferences, characteristics, and treatment experiences affect the meaning of treatment success. MATERIALS AND METHODS: A quantitative study using an observational, longitudinal cohort of patients with advanced stage non-small-cell lung cancer was conducted. Data sources included medical records and patient interviews. Data were analyzed using chi(2), Fisher's exact, and McNemar's tests, as well as logistic regressions. RESULTS: At the first interview of 235 individuals, 12% considered survival alone as their definition of treatment success; others defined treatment success as survival plus other aspects, such as quality of life and reaching an important personal goal. As they moved through chemotherapy, 47% of the patients changed their definition of treatment success. Bivariate analysis showed that patients with lower incomes tended to be more likely to change their definition of treatment success compared with their counterparts with higher income (P = .0245). CONCLUSION: By taking chemotherapy, patients expect to increase their odds of survival and want to maintain the quality of life and functionality. A patient's definition of treatment success is often changing as treatment continues, making it appropriate to ensure patient-provider communication throughout their clinical care. The study results are limited to patients with advanced non-small-cell lung cancer and drawn from a predominantly white patient population, mainly from the US Midwest.

93 Background: Patients’ preferences regarding treatment adverse events are not systematically considered when choosing a treatment for stage lung cancer. Further, there is no clinical guide for patients or physicians on how to integrate patient preferences of adverse events in treatment and care decisions. Although it is assumed that most cancer patients prefer either an active or a shared role in decision making, particularly in late stage cancers. Our specific aim of this abstract is: Aim: Determine whether individual patients’ preferences, characteristics, and treatment experiences affect the meaning of chemotherapy treatment success. Methods: We have completed two years of our three-year research using a mixed method study design, which includes focus groups, cross-sectional, prospective, and randomized experimental designs. We initially selected three cancer centers in Nebraska and one in South Dakota for patient and provider recruitment. Currently, we have six cancer centers participating in this multi-center Patient Centered Outcomes Research. Results: Four focus groups were conducted with 36 participants that included patients, family members and caregivers and oncology providers. Patients and caregivers confirmed that survival alone is not their measure of lung cancer treatment success Definition of treatment success should emphasize effective clinical guidance throughout treatment, symptom management, functionality, and quality of life Definition of treatment success evolves over time, appearing to be linked to patients’ experiences with chemotherapy. Participants advocated for better patient-provider communication practices as well as the expanded use of patient navigation and new patient orientation programs. Conclusions: Late stage lung cancer patients have definite opinions about the impact of adverse treatment effects on their quality of life.

Susan Knapp, (2015),"Lean Six Sigma implementation and organizational culture", International Journal of Health Care Quality Assurance, Vol. 28 Iss 8 pp. 855-863 http://dx.doi.org/10.1108/ IJHCQA-06-2015-0079 Praveen T Rajasekhar, Colin J Rees, Catherine Nixon, James E East, Sally Brown, (2016),"Factors influencing change in clinical practice: A qualitative evaluation of the implementation of the quality improvement in colonoscopy study", International Journal of Health Care Quality Assurance, Vol. 29 Iss 1 pp. 5-15 http://dx.doi.org/10.1108/IJHCQA-09-2014-0093 Tapani Jorma, Hanna Tiirinki, Risto Bloigu, Leena Turkki, (2016),"LEAN thinking in Finnish healthcare", Leadership in Health Services, Vol. 29 Iss 1 pp. 9-36 http://dx.doi.org/10.1108/ LHS-08-2015-0021

Purpose - A significant proportion of veterans use dual care or health care services within and outside the Veterans Health Administration (VHA). In this study conducted at a VHA medical center in the USA, the authors used Lean Six Sigma principles to develop recommendations to eliminate wasteful processes and implement a more efficient and effective process to manage medications for dual care veteran patients. The purpose of this study is to: assess compliance with the VHA's dual care policy; collect data and describe the current process for co-management of dual care veterans' medications; and draft recommendations to improve the current process for dual care medications co-management.Design/methodology/approach - Input was obtained from the VHA patient care team members to draw a process map to describe the current process for filling a non-VHA prescription at a VHA facility. Data were collected through surveys and direct observation to measure the current process and to develop recommendations to redesign and improve the process.Findings - A key bottleneck in the process that was identified was the receipt of the non-VHA medical record which resulted in delays in filling prescriptions. The recommendations of this project focus on the four domains of: documentation of dual care; veteran education; process redesign; and outreach to community providers.Research limitations/implications - This case study describes the application of Lean Six Sigma principles in one urban Veterans Affairs Medical Center (VAMC) in the Mid-Western USA to solve a specific organizational quality problem. Therefore, the findings may not be generalizable to other organizations.Practical implications - The Lean Six Sigma general principles applied in this project to develop recommendations to improve medication management for dual care veterans are applicable to any process improvement or redesign project and has valuable lessons for other VAMCs seeking to improve care for their dual care veteran patients.Originality/value - The findings of this project will be of value to VA providers and policy makers and health care managers who plan to apply Lean Six Sigma techniques in their organizations to improve the quality of care for their patients.

Although lung cancer is the leading cause of cancer death in the USA, there have been few studies on patient-centered advanced lung cancer treatment practices. As part of a larger research study on how to use a patient-inclusive approach in late-stage lung cancer treatment, this present study describes patient, caregiver, and provider perspectives on the role of the health care system in helping patients cope with an advanced stage lung cancer diagnosis. Four focus group sessions were conducted with six to eleven participants per group for a total of 36 participants. Two focus groups were held with patients and family members/caregivers and two with physicians and nurses. A major theme that emerged concerned coping with an advanced lung cancer diagnosis, which is the subject of this paper. The patients, caregivers, and providers spoke passionately about interactions with the health care system and volunteered examples of supportive and non-supportive relationships between patients and clinicians. They advocated for better patient-provider communication practices as well as the expanded use of patient navigation and new patient orientation programs. This study contributes additional knowledge by including the perspectives of caregivers and providers who live and work closely with patients with advanced lung cancer. The findings can inform the development of comprehensive patient-centered care plans for patients living with an advanced lung cancer diagnosis.

Participatory and patient-centered approaches to cancer research have been highlighted as the most appropriate means of engaging patients in the conduct of clinical research. However, there is a paucity of patient-centered outcomes research (PCOR) on lung cancer. Previous studies seeking to define lung cancer treatment success have generally not included patients' and caregivers' perceptions and views in treatment decision-making. Additionally, little is known about effective strategies for the engagement of lung cancer patients in PCOR. We sought to gain insights into the perceptions of patients, caregivers, and providers on lung cancer treatment success, as well as on strategies for patient engagement in lung cancer PCOR. Four focus groups were conducted with provider, patient, and caregiver participants from four cancer centers in Nebraska and South Dakota. A total of 36 providers, patients, and caregivers participated in this study. Patients and caregivers confirmed that survival alone should not be the measure of lung cancer treatment success and that definitions of treatment success should emphasize factors such as effective clinical guidance throughout treatment, symptom management, functionality, and quality of life. Clinician participants noted that the definition of treatment success evolved over time and appeared to be linked to patients' experiences with chemotherapy. Participants identified barriers to and facilitators of research participation and suggested strategies for the recruitment and retention of research participants. Our study indicates that patients can successfully play active and engaged roles in clinical research, ranging from participant to partner. Judging from the enthusiasm of our focus group attendees, patients and caregivers want to participate and be engaged in clinical research.

PCOR provides information about the best available evidence to help patients and their health care providers make more informed decisions.This research is intended to give patients a better understanding of the prevention, treatment, and care options available and the science that supports those options, and to encourage physicians and other clinicians to adopt a more patient-centered approach to treatment [1].PCOR projects require patient voices to be heard in discussions

Many rural Veteran patients receive healthcare services from both Veterans Affairs (VA) and non-VA providers. Effective management of dual care Veteran patients to ensure the best clinical outcomes is a VA mission. The previous VA studies indicate that coordination between VA and non-VA providers has been lacking for dual care management of Veteran patients. In this study, we propose that VA proactively shares information with non-VA providers to enhance the communication process and identify the best practices to be carried out by both VA and non-VA providers for better coordination. Structured questionnaires are designed and distributed to VA and non-VA providers to obtain their evaluations on the proposed VA proactive information sharing approaches and the best practice items for dual care management. The non-VA provider respondents largely support the proposed proactive sharing items by VA, with the lowest average score being 3.96 out of a 5.0 scale on one item. In terms of the best practice items on co-managing dual care patients, three out of five items are overall rated higher than 4.0 from both sides. A pair-wise comparison between VA and non-VA perspectives further shows that the difference in average ratings of a proposed item could be significant. For such best practice items, the implementations from both sides may not be most effective.

The purpose of this study was to develop an in-depth understanding of the barriers and enablers of effective dual care (care obtained from the Veterans Health Administration [VHA] and the private health system) for rural veterans. Telephone interviews of a random sample of 1,006 veterans residing in rural Nebraska were completed in 2010. A high proportion of the rural veterans interviewed reported receiving dual care. The common reasons cited for seeking care outside the VHA (or VA [Veterans Administration]) included having an established relationship with a non-VA provider and distance to the nearest VA medical center. Almost half of the veterans who reported having a personal doctor or nurse reported that this was a non-VA provider. Veterans reported high levels of satisfaction with the quality of care they receive. Ordinal logistic regression models found that veterans who were Medicare beneficiaries, and who rated their health status higher had higher satisfaction with dual care. The reasons cited by the veterans for seeking care at the VHA (quality of VHA care, lower costs of VHA care, entitlement) and veterans perceptions about dual care (confused about where to seek care for different ailments, perceived lack of coordination between VA and non VA providers) were significant predictors of veterans' satisfaction with dual care. This study will guide policymakers in the VA to design a shared care system that can provide seamless, timely, high quality and veteran centered care.