building on strength - baylor scott & white …...1 baylor garland leadership: building on...

2013 ANNUAL REPORTBUILDING On STRENGTH

MULTIDISCIPLINARY CLINICAL TEAMS + PATIENT NAVIGATION

+ GENETIC COUNSELING + CLINICAL RESEARCH + CLINICAL

EDUCATION + INTEGRATIVE MEDICINE + PATIENT SUPPORT

AND EDUCATION + INNOVATIVE CLINICAL TRIALS CENTER

+ SURVIVOR CELEBRATIONS + COMMUNITY OUTREACH

1 Baylor Garland Leadership: Building on Strength

3 Cancer Committe Report

4 Cancer Committee Members

5 Baylor Charles A. Sammons Cancer Center at Garland

7 Programs of Focus

NICHE

Pathway to Excellence® Designation and Magnet

Recognition Program® Journey

Oncology Nursing Forum

9 Patient Support

Community Events/Outreach

Spotlight on Patients

American Cancer Society

15 Continuum of Care

Patient Advocate – Lynda Dyer

Breast Imaging Statistics

Breast Nurse Navigator Statistics

19 Cancer Registry

Summary of 2012 Cancer Registry Data

Patient Outcome Study

27 Education

Cancer Conferences

29 Campus, Hospital and Area Maps

Cancer research studies on the campus of Baylor Medical Center at Garland are conducted through Baylor Research Institute, Texas Oncology, and US Oncology. Each reviews, approves, and conducts clinical trials independently. Their clinical trials are listed together, in this publication, for the convenience of patients and physicians.

Physicians provide clinical services as members of the medical staff at one of Baylor Scott & White Health’s subsidiary, community or affiliated medical centers and do not provide clinical services as employees or agents of those medical centers, Baylor Medical Center at Garland, Baylor Health Care System, Scott & White Healthcare or Baylor Scott & White Health. © 2014 Baylor Scott & White Healthcare. All rights reserved.Photographs may include models or actors and may not represent actual patients. SAMMONS_444_2014 SC

2300 Marie Curie Blvd.Garland, TX 75042972.487.5000BaylorHealth.com/GarlandCancer

CONTENTS

BUILDING On STRENGTH

1 Baylor Charles A. Sammons Cancer Center at Garland | BUILDING On STRENGTH

BAYLOR GARLAND LEADERSHIP LETTER

Over the past year, Baylor Medical Center at Garland has taken great strides toward improving the cancer care

services we provide to the community by building on the strength of our commitment and dedication.

In 2013, we maintained our relationship with the American College of Surgeons’ Commission on Cancer (CoC)

as an Accredited Community Hospital Cancer Program. We are proud of this distinction because it indicates to

the community that our oncology program provides quality care and continuously strives to address each

patient’s needs while improving outcomes. Our breast cancer program continued to be accredited by the

National Accreditation Program for Breast Centers, signifying our firm commitment to offer our patients every

significant advantage in their battle against breast disease. We also maintained accreditation from the American

College of Radiology (ACR) for breast MRI, ultrasound, mammography and stereotactic breast biopsy. Baylor

Garland also was honored by being named a Breast Center of Excellence from the American College of

Radiology (ACR) for exceeding standards in breast imaging and diagnostics. As a result of these accreditations

and honors and through Baylor Garland’s participation in research, education and quality improvement

initiatives, we continued to be a proud member of the Baylor Charles A. Sammons Cancer Center network.

Other 2013 highlights included:

• Baylor Garland Cancer Resource Center served a growing number of cancer patients and families with the

latest cancer information and resources.

• The breast cancer nurse navigator helped guide 329 cancer patients and their families through their

sometimes complex cancer journey.

• The Breast Imaging Center expanded its operating hours to evenings to accommodate increased diagnostic

and screening exam volumes.

BUILDING On STRENGTH | Baylor Charles A. Sammons Cancer Center at Garland 2

Sashidhar Reddy, MD

Tom Trenary, President

Sincerely,

Tom Trenary Sashidhar Reddy, MD

President Chairman

Baylor Medical Center at Garland Baylor Garland Cancer Committee

• The Therapeutic Touch Time program, begun in 2012, found continued success in 2013. The unique

team-based approach enabled newly diagnosed cancer patients and their families to meet their

entire care team – oncologist, nurse, social worker and chaplain – at one time in a group setting.

During the meeting, the care team explained diagnosis, treatment options, what to expect and team

members provided clear information by answering questions andaddressing concerns.

Baylor Garland’s oncology program continued to strengthen and flourish in 2013, setting the stage for

a bright 2014. On behalf of the Oncology Steering Committee and the entire team at Baylor Garland, I

offer heartfelt thanks for the community’s continue support and commitment to our cancer patients and

their families.

• Working closely with the American Cancer Society for education, information and supplies such as

wigs for patients in need

• Enhancing the efforts of our nurse navigator in guiding patients and families through what can be a

challenging experience.

Sincerely,

Sashidhar Reddy, MD

Cancer Committee Chair

CANCER COMMITTEE MEMBERS

Bannister, Paul

Cabug-Os, Naomi

Caruso, Michela

Cole, Donas

Cook, Jane

Cunnyngham, Melissa

Ellis, Tracey

Fitch, Donna

Hammon, Carey

Hemlock, Melissa

Hockett, Sheri

Holmes, Lavelle

Hummel, Eva

Johnson, Susan

Johnston, Walter S.

Li, Zhiyong

Lowe, Ines

Mehta, Ameet

Melmed, Gavin

Miller, Alan

Petty, Elizabeth

Presson, Eric

Randall, Ethel

Redding-Tempelmeyer, Amy

Reddy, Sashidhar

Siciliano, Laura

Simon, Walter

Trenary, Tom

Womack, Mary

CANCER COMMITTEE REPORT

Sashidhar Reddy, MD

I am pleased to provide this update from the Baylor Medical Center at Garland Cancer Committee for 2013.

This annual report of the Cancer Committee’s activities provides an opportunity to highlight the achievements

we have made as an organization in expanding and improving the care we provide to the many patients and

their families who turn to us during their cancer journey.

Due to the high standards we previously achieved and maintain, we remain accredited by both the Commission

on Cancer® of the American College of Surgeons and the National Accreditation Program for Breast Centers.

We also remain part of the Baylor Charles A. Sammons Cancer Center, which allows us to draw upon the

strength of the entire network, including national experts and clinical trials.

In 2013, the Baylor Garland Cancer Committee continued to focus on increasing nursing oncology certification,

enhancing the medical center’s palliative care program, and decreasing pathology turnaround time. All of these

initiatives were designed to create a better cancer patient experience and improved quality of care.

Over the past year, the Cancer Committee at Baylor Garland has been active in numerous cancer-related

activities and programs, including:

• Putting on multiple education seminars

• Conducting cancer-related grand rounds for our physician staff and community lectures on both lung and

breast cancer

• Conducting men’s and women’s heath events where our community could interact with our oncologists and

receive information on a variety of cancers

3 Baylor Charles A. Sammons Cancer Center at Garland | BUILDING On STRENGTH BUILDING On STRENGTH | Baylor Charles A. Sammons Cancer Center at Garland 4


BAYLOR CHARLES A. SAMMONS CANCER CENTER AT GARLAND

When someone receives a diagnosis of cancer, a world of difficult

choices lies ahead. One of the first, and most important, decisions

for the new patient is where to get quality care. For people living

in North Texas, that decision became easier with the launch of the

Baylor Charles A. Sammons Cancer Center network. Last year,

Baylor Garland became a proud member of the network. Baylor

Garland worked diligently to achieve the distinction of using the

Baylor Sammons Cancer Center name for its oncology programs

by meeting or exceeding the stringent criteria established by

Baylor Health Care System (BHCS). Baylor Garland is honored to

be part of this collaborative effort to bring quality cancer care to

the citizens of Garland, North Texas and beyond.

In 2013, Baylor Garland maintained accreditation from a number

of organizations for many components of its oncology program:

• American College of Surgeons’ Commission on Cancer

Accredited Community Hospital Cancer Program

• National Accreditation Program for Breast Centers

• American College of Radiology accreditation for breast MRI,

ultrasound, mammography and stereotactic breast biopsy

• Breast Center of Excellence award from The American College

of Radiology (ACR)

All of these accreditations and honors in addition to participation

in research, education and quality improvement initiatives signify

Baylor Garland’s commitment to oncol-

ogy programming and care and meeting

the high standards of participation in

the Charles A. Sammons Cancer Center

network.

Integration with the network has allowed

Baylor Garland to further explore

opportunities to work closely with

physicians interested in sponsoring their

own clinical studies. Patients are the

major beneficiaries of the network

because they have the assurance that

any cancer program carrying the Baylor

Charles A. Sammons Cancer Center

brand will offer consistently quality

cancer care. By receiving care at a

network participating cancer center,

patients can be treated close to home

for most of their cancer care needs. As

oncology services become more

sophisticated, Baylor Garland is

committed to being a step ahead, offer-

ing more advanced, innovative proce-

dures with one main focus, improving

patient outcomes.

7 Baylor Medical Center at Garland | BUILDING On STRENGTH

PROGRAMS OF FOCUS

NICHE

Baylor Garland became a Nurses Improving Care for Health-

system Elders (NICHE) designated hospital in 2013. NICHE is a

national program designed to improve care for older hospitalized

adults. By joining NICHE, Baylor Garland expects to significantly

advance its understanding of the needs of older patients, train

nurses to meet those needs and launch several new protocols to

prevent health care problems that are common in this population.

The hospital implemented the confusion assessment method to

help with early identification of delirium in the geriatric population.

Using NICHE education modules, Baylor Garland nurses have

been educated about normal and abnormal age related changes,

preventing ageism, elderly abuse and more. The hospital’s goal

for 2014 is to bring more evidence based practices to the patient’s

bedside through the Geriatric Resource Nurse (GRN) programs.

NICHE | JOURNEY TO MAGNET® STATUS | NURSING ONCOLOGY FORUM

American Nurses Credentialing Center’s

Pathway to Excellence® Designation

and Magnet Journey

In 2013, Baylor Garland began to lay the

ground work to apply for re-designation

from the American Nurses Credential-

ing Center’s Pathway to Excellence

Program. The prestigious designation

recognizes health care organizations

that have the essential elements of an

ideal nursing practice environment. To

obtain re-designation, Baylor Garland

must demonstrate that it has integrated

12 practice standards into its operating

policies, procedures and management

structure. Data was gathered to

complete a written application that will

be submitted in 2014. The Pathway

to Excellence designation will be the

first step in Baylor Garland’s journey to

Magnet® status, also conferred by the

American Nurses Credentialing Center.

Oncology Nursing Forum

In 2013, Baylor Garland participated in

the Baylor Health Care System oncology

nursing forum. The forum was created

to provide oncology clinicians from

throughout the system with a way to

discuss shared concerns/issues that

affect the safety and outcomes of their

oncology patient population. Prabh

Batra and Tracey Ellis represented Baylor

Garland at forum meetings.


COMMUNITY EVENTS/OUTREACH

PATIENT SUPPORT +

Looking after the health of Garland and surrounding communi-

ties involves far more than treating sick patients who come

through the hospital’s door. It also means providing education,

screening and the opportunity for people to take control of

their own health in a preventive and meaningful way. One of

the ways Baylor Garland fulfills this role is through community

health events and outreach activities.

In 2013, Baylor Garland’s oncology program hosted several

awareness events and screenings and traveled into the com-

munity with cancer information and screenings.

For Women for LifeTM was held on in January 2013 and attract-

ed nearly 400 women from across the Garland area. The event

offered health screenings and presentations by specialists

during the day that celebrated women’s health.

The 2013 men’s health event, It’s A Guy Thing, was held in June

2013 with more than 260 participants from the Garland area.

The one-half day event featured health screenings and pre-

sentations by physicians and health care

professionals.

Community outreach activities through-

out 2013 included breast screening and

general cancer information for Wylie ISD,

Garland ISD, Mesquite ISD and the City

of Garland. Members of the Baylor Gar-

land oncology team appeared on Good

Morning Texas in May to discuss skin

cancer and in October to discuss breast

cancer. An enthusiastic team of Baylor

Garland employees, friends and family

members raised money for the American

Cancer Society by participating in the

Relay for Life in May and the hospital

hosted the monthly meeting of a breast

cancer support group and I Can Cope,

an American Cancer Society sponsored

program for adults facing cancer. The

Baylor Garland Breast Center sponsored

an information booth at the Healthy Living

Expo, the Garland ISD Pink Out event, the

Ulta Cut-A-Thon and the City of Garland

Health Fair.



Every Friday night in the fall, Texas high schools celebrate their

heroes on the football field. So, it was fitting that on Oct. 4, 2013,

three additional heroes received accolades at the game between

Garland High School and Rowlett High School. Sponsored by

Baylor Garland, “Pink Out” night at the game focused on breast

cancer awareness by honoring three women who were breast

cancer survivors. Marsha Johnson and Lynda Dyer, both diag-

nosed in 2005 joined Melanie Parsons, diagnosed in 2009, on the

field as they were recognized for being fearless warriors and survi-

vors. They were selected because of their impact on the com-

munity by providing breast cancer awareness, education, support

groups and special events. As a model, Johnson was devastated

by her diagnosis. Because of her love for modeling, she founded

Fashions for the Cure, a cancer awareness celebration where

many of the models are cancer survivors. In 2012, Johnson lost

a grandson to leukemia so in 2013 she added a memory walk

to the fashion show, enabling families

to honor a loved one they had lost to

cancer. You can read more about Dyer

in the volunteer patient advisor story

in this report. A teacher in the Garland

ISD, Parsons underwent six surgeries,

radiation and chemo therapy treatments.

She is an inspiration to her students and

fellow teachers. She, along with fellow

educators, family and friends established

A Cure for a Teacher, a team that has suc-

cessfully raised more than $53,000 for the

Susan G. Komen Foundation.


SPOTLIGHT ON PATIENTS

PATIENT SUPPORT +

Melanie Parsons, Marsha Johnson and Lynda Dyer


TOGETHER,

WE ARE A

RELENTLESS

FORCE

FIGHTING

CANCER.

AMERICAN CANCER SOCIETY

PATIENT SUPPORT +

The American Cancer Society has been an incredible supporter of

Baylor Sammons Cancer Centers, including Baylor Garland, deliv-

ering lifesavings results. American Cancer Society representatives

collaborated with oncology staff to deliver support, and served on

the cancer committee to help provide resources to fulfill the

Commission on Cancer standards for cancer care.

In 2013, the American Cancer Society engaged with 71 patients

providing 234 services at Baylor Garland. All newly diagnosed

patients received a Personal Health Manager kit from the Society

which provided personalized information on the patient’s specific

cancer type, resource information and tools that helped patients

and caregivers keep appointments, monitor test results and keep

prescriptions organized throughout treatment. American Cancer

Society patient navigators provided free and confidential sup-

port and guidance to all patients and their caregivers during their

cancer journey.

As the official sponsor of birthdays, the American Cancer Society

knows how important each and every birthday can be. In May of

2013, the Society celebrated its 100th birthday – one-hundred

years of saving lives and twenty years supporting Baylor

hospitals. The Society saves lives by

helping individuals stay well through

prevention and early detection, helping

them get well by being there during and

after a diagnosis, finding cures through

groundbreaking discovery, and fighting

back through public policy. In the last two

decades, the Society has contributed

to a 20% decline in cancer death rates

in the U.S. Last year, the Society and

Baylor hospitals reached more than 2,100

patients with more than 6,000 programs

and services, that’s one in four cancer

patients treated at Baylor hospitals.

The American Cancer Society is the only

organization offering cancer patients and

their families around-the-clock guidance

and support through its toll-free line,

1-800-227-2345 and at www.cancer.org.

For two-time cancer survivor Lynda Dyer, volunteering at Baylor

Garland as a cancer patient advisor is a passion. The former

bank vice president and wife and mother of two daughters has

survived breast cancer and non Hodgkin’s lymphoma. Her

empathy and compassion for cancer patients and their care-

givers stems from her personal experience with the emotional

highs and lows of diagnosis and treatment.

“Helping people who are going through cancer by listening to

their stories and sharing my experience helps them release

some of their anguish and brings them comfort,” says Dyer.

“After eight and one-half years as a breast cancer survivor, then

surviving non Hodgkin’s lymphoma for two and one-half years,

I knew that the hospital needed someone on the cancer floor to

just listen. I would have loved to have had someone visit with

me and listen to me when I was a patient, especially someone

who had experienced her own cancer journey including

diagnosis, treatment and surgeries.”

Her vision for volunteering began in 2006 after she attended a

six-week breast cancer survivor support group at Baylor

Garland. When it was over, she looked for another support

group to join, but could find nothing. “After I recovered, God

thumped me on the head and told me to go do it. After many

discussions with the hospital, I secured its support for New

PATIENT ADVOCATE - LYNDA DYER

CONTINUUM OF CARE +


Life New Hope Breast Cancer Survivors

Group. Seven years later, the group is

still going strong, meeting once a month

with an average attendance of 15-25.”

Knowledge of Dyer’s commitment and

passion spread and in 2010 she was

contacted by Baylor Dallas about be-

coming a volunteer and patient advisor

for cancer patients at Baylor Garland.

She jumped at the chance. She began

her new role in January 2012.

“I’m not a nurse and I don’t have a clini-

cal background,” says Dyer. “I am a can-

cer survivor, and that’s proven to be the

most important knowledge for my role

as patient advisor. In the Breast Imaging

Center, I help women dress and prepare

for their procedure. That’s when I begin

a conversation with them. I show them

how to do a proper self breast exam and

many are surprised to discover how high

up the breast starts. I often accompany

them into the biopsy room and stay with


them during their procedure. I try to keep

them calm by letting them know that I

understand what they are going through.

My reward comes after the procedure

is over and I get a big smile and a hug

from the patient. I know that I have truly

helped someone by lending an ear and

giving her time to share her story.”

When her schedule permits, Dyer visits

patients on the cancer floor. “I introduce

myself as a volunteer patient advisor,”

she explains. “I ask how they are feeling,

if they are satisfied with their care and

what kind of cancer they are battling and

when they were diagnosed. I also ask

their caregiver(s) how they are doing and

if they have a support system to turn to

and talk to. I then let them know I am a

two-time cancer survivor and they are

usually amazed that I am active and look

healthy. They gain hope from seeing

me and hearing my story. Sometimes,

the caregivers will ask me to step into

the hallway and they will pour out their

hearts to me, cry on my shoulder and I

cry with them.”

She remembers vividly her encounter

with a man who was gravely ill with non

Hodgkin’s lymphoma. “He was visiting

with his best friend,” recalls Dyer. “I told

them I too was a non Hodgkin’s lympho-

ma survivor. Suddenly, the patient had a

sparkle in his eye. He began to ask me

questions about my cancer experience

and how long I had been in remission.

His best friend and I could literally see

him come alive. He had hope when be-

fore, he had none. As I left his room his

friend walked me out and thanked me

for giving him a dose of medicine that no

one else had been able to give. A tear

came to my eye and I left knowing I had

helped someone, but feeling I had done

so little.”

BUILDING On STRENGTH | Baylor Charles A. Sammons Cancer Center at Grapevine 14

Baylor Garland Breast Imaging Center

Total procedures in 2013: 30,862

Screening mammograms: 11,082

Diagnostic mammograms: 3,043

New cancers detected: 88

Baylor Garland Breast Imaging Center

Total patients navigated In 2013: 142

Coordinated referrals: 142

Total patient encounters: 329

Breast biopsies attended: 131

ACS Personal Health

Manager organizers

distributed 100

Tumor board meetings

attended: 23


BREAST IMAGING AND BREAST NURSE NAVIGATOR STATISTICS

CONTINUUM OF CARE +


CANCER REGISTRY +SUMMARY OF 2012 CANCER REGISTRY DATA

Estimated Number* of New Cancer Cases by Sex, US, 2013/State of Texas, 2013 versus Actual Number** of Analytic Cancer Cases by Sex, Baylor Health Care System, 2012

TOP TEN CANCER SITES

SITE MEN

Estimated NewCancer Cases

Nationally,2013

238,590

118,080

73,680

54,610

45,060

40,430

37,600

29,620

27,880

22,740

854,790

28%

14%

9%

6%

5%

5%

4%

3%

3%

3%

100%

Prostate

Lung & Bronchus

Colon & Rectum

Urinary Bladder

Melanoma of the Skin

Kidney & Renal Pelvis

Non-Hodgkin Lymphoma

Oral Cavity & Pharynx

Leukemia

Pancreas

All Sites

Estimated NewCancer Cases in the State of Texas, 2013

17,579

9,034

6,058

3,081

2,989

2,794

2,540

1,943

1,870

1,449

62,740

28%

14%

10%

5%

5%

4%

4%

3%

3%

2%

100%

ActualCancer Cases, Baylor Garland

2012

6

34

20

7

1

6

13

2

2

5

132

5%

26%

15%

5%

1%

5%

10%

2%

2%

4%

100%

TOP TEN CANCER SITES

SITE WOMEN

Estimated NewCancer Cases

Nationally,2013

232,340

110,110

69,140

49,560

45,310

32,140

31,630

24,720

22,480

22,240

805,500

29%

14%

9%

6%

6%

4%

4%

3%

3%

3%

100%

Breast

Lung & Bronchus

Colon & Rectum

Uterine Corpus

Thyroid

Non-Hodgkin Lymphoma

Melanoma of the Skin

Kidney & Renal Pelvis

Pancreas

Ovary

All Sites

Estimated NewCancer Cases in the State of Texas, 2013

17,002

6,570

4,975

2,663

2,076

2,111

1,978

1,775

1,325

1,628

54,632

31%

12%

9%

5%

4%

4%

4%

3%

2%

3%

100%

ActualCancer Cases, Baylor Garland

2012

120

36

18

1

10

6

0

3

2

5

251

48%

14%

7%

0%

4%

2%

0%

1%

1%

2%

100%

Source: *2013, American Cancer Society, Inc., Surveillance Research Source: *Cancer Epidemiology and Surveillance Branch, Texas Department of Stat Health Services, April 2013 ** Baylor Health Care System Cancer Registry, Electronic Registry System

Source: *2013, American Cancer Society, Inc., Surveillance Research Source: *Cancer Epidemiology and Surveillance Branch, Texas Department of Stat Health Services, April 2013 ** Baylor Health Care System Cancer Registry, Electronic Registry System

Estimated Number* of New Cancer Cases by Sex, US, 2013/State of Texas, 2013 versus Actual Number** of Analytic Cancer Cases by Sex, Baylor Health Care System, 2012


2010 & Prior 2012 Forward Diagnosis Year 2011 (CoC) *2009 *2010 *2011 *2012 Breast Cancer

Post Breast Conserving Surgery Irradiation: Radiation therapy is administered within 1 year (365 days) of diagnosis for women under age 70 and receiving breast conserving surgery for breast cancer (Accountability Measure)

Adjuvant Chemotherapy: Combinationchemotherapy is considered or administered within 4 months (120 days) of diagnosis for women under 70 with AJCC T1cNoMo, or Stage II or III hormone receptor negative breast cancer (Accountability Measure)

Adjuvant Hormonal Therapy: Tamoxifen or third generation aromatase inhibitor is consid-ered or administered within 1 year (365 days) of diagnosis for women with AJCC T1cNoMo, or Stage II or III hormone receptor positive breast cancer (Accountability Measure) Colorectal Cancer

Adjuvant Chemotherapy: Adjuvant chemo-therapy is considered or administered within 4 months (120 days) of diagnosis to patientsunder age 80 with AJCC III (lymph node posi-tive) colon cancer (Accountability Measure)

Surgical Resection Includes at Least 12 Lymph Nodes: At least 12 regional lymph nodes are removed and pathologically exam-ined for resected colon cancer (Surveillance Measure)

Rectal Cancer

Radiation Therapy for Rectal Cancer: Radiation therapy is considered or adminis-tered within 6 months (180 days) of diagnosis for patients under the age of 80 with clinical or pathological AJCC T4NoMo or Stage III receiv-ing surgical resection of rectal cancer (Surveil-lance Measure)

ONCOLOGY QUALITY METRICS 2012NCDB Target

NCDB, CoC, NQF, NAPBC



NCDB, CoC, NQF

NCDB, CoC, NQF

NCDB, CoC, NQF

90%

90%

90%

90%

80%

90%

CoC Stateof Texas

PerformanceRate

90%

90%

90%

90%

80%

90%

86.8%

90%

86.1%

88.5%

90.5%

91.6%

88.8%

90.5%

87.1%

89.4%

89%

90.6%

91.8%

92.5%

90.3%

90.6%

87.8%

91.8%

CoC Census Region (West)Performance

Rate

All CoCPrograms

PerformanceRate

Baylor GarlandPerformance Rate

100%

100%

100%

100%

82.4%

100%

88.2%

100%

96.4%

100%

94.4%

100%

100%

100%

100%

100%

94.4%

NA

100%

87.5%

92.6%

85.7%

85.7%

NA

*Source: Baylor Health Care System Cancer Registry/Baylor Garland

Breast Female GenitalCervix UteriCorpus UteriOvaryVulvaOther Male GenitalProstateTestisOther Urinary SystemBladderKidney/RenalOther Brain & CNSBrain (Benign)Brain (Malignant)Other EndocrineThyroidOther Lymphatic SystemHodgkin’s DiseaseNon-Hodgkin’s Unknown Primary Other/Ill-Defined

154

1952

1200

3332

10

271314

0

3119

21

2013

7

375

32

10

1

Primary Site Total Analytic Nonanalytic Male Female In Situ Local Regional Distant NA/Unknown

34

1131700

2626

00

8350

7052

000

152

13

1

0

2

000000

3332

10

16970

9036

633

203

17

3

0

152

1952

1200

0000

11470

2216

15

1410

4

172

15

7

1

21

000000

0000

5500

0000

000

000

0

0

64

110000

6510

6420

4040

990

808

0

0

41

100100

3300

2020

0000

220

110

0

0

9

840400

6600

6240

0000

110

918

0

0

19

902700

1818

00

8260

2715

21

817

193

16

10

1

120

821500

7610

1910

90

2414

19

2013

7

223

19

9

1

Data Source: Electronic Registry System, Baylor Health Care System Cancer RegistryThis report INCLUDES CA in-situ cervix cases, squamous and basal cell skin cases, and intraepithelial neoplasia cases phoma/myeloma category.

All Sites Oral CavityLip TongueOropharynxHypopharynxOther Digestive SystemEsophagusStomachColonRectumAnus/Anal CanalLiverPancreasOther Respiratory SystemNasal/SinusLarynxLung/BronchusOther Blood & Bone MarrowLeukemiaMultiple MyelomaOther

Bone

Connect/Soft Tissue

SkinMelanomaOther

592

500005

10046

38181

11148

11603

1103

301686

2

2

541

Primary Site Total Ananalytic Nonanalytic Male Female In Situ Local Regional Distant NA/Unknown

209

300003

36118

100772

4402

402

20974

0

1

330

228

400004

5743

20120585

5901

562

14563

1

1

321

364

100001

4303

1861663

5702

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BAYLOR MEDICAL CENTER AT GARLAND: ANALYTIC/NON-ANALYTIC CASES DIAGNOSED 2012



PATIENT OUTCOME STUDY +PROVIDING ADVANCED DIRECTIVE REFERRALS

Advanced Directives (AD) documentation plays an integral part in

helping patients receive the care they desire. The Pastoral Care

(PC) department at Baylor Medical Center of Garland plays a large

part in completing this process. The Pastoral Care department

also serves as a liaison to assisting the patient in formulating this

document or helping to begin the discussion with patient and

family. It was brought to the Cancer Committee’s attention that

PC seemed to be seeing less ADs on the chart and fewer referrals

were coming to their department. The Cancer Committee decided

to explore improvement options.

A retrospective closed chart review was done for patients with

an oncology diagnosis that were admitted to 4E. Fifty-four charts

were reviewed. The study asked these questions:

• On admission, did the patient state that he or she had

Advanced Directives?

• If yes, was there a copy of those directives on the chart?

• If the patient requested further information was there a follow up

consultation from Pastoral Care?

Results of the initial study showed a gap

in the number of patients who stated that

they had AD and actually having the AD

on the chart. The larger gap was for those

who requested additional information,

documentation of the PC referral was only

found on 20% of the charts. This was to

be the focus of the Quality Improvement

(QI) Team that was then formed.

A multidisciplinary QI team studied the

issue. Working through the Plan, Do,

Study, Act format, the team followed

the Advanced Directive Referral process

flow, studied the barriers to the referral

and prioritized interventions. The primary

intervention was to be staff education.

Recent changes to the electronic health

record (EHR) had changed the referral

process and staff needed additional

education about these changes.

The QI team included informatics

resource nurses (IRN’s) to provide EHR

training. Flyers were made for the staff

and placed by the computer terminals to

help the staff become familiar with the

changes. Inservice Education was given

at staff meetings.

After the interventions the team moni-

tored this population for appropriate

referrals. Feb-July 2013 had 100%

compliance with the referral process.

Providing our patients with the tool to

make their wishes known is vital for

ensuring that we are honoring the wishes

of our patients and providing dignified

and appropriate care.

27 Baylor Charles A. Sammons Cancer Center at Garland | BUILDING On STRENGTH BUILDING On STRENGTH | Baylor Charles A. Sammons Cancer Center at Grapevine 28

CANCER CONFERENCES

EDUCATION +

Cancer conferences are an essential forum to provide multidisci-

plinary, consultative services for oncology patients, as well as to

offer education to physicians and allied health professionals. To

provide a consultative service patients and physicians, 80 percent

of the cases presented must be discussed prospectively, that is,

address patient management issues. Prospective cases are pre-

sented by physicians to the multidisciplinary team.

Prospective cases include, but are not limited to the following:

• Cases requiring an adjustment or change in the original treat-

ment plan

• Cases requiring consideration of adjuvant treatment or

palliative care

• Cases with treatment complications or disruptions

• Cases with recurrent cancer requiring/needing further

treatment consideration

At Baylor Irving, the general cancer conference met monthly with

the following multidisciplinary composition – medical oncology,

radiation oncology, surgery, pathology and diagnostic radiology.

Site conference case presentations include, but are not limited to:

• Case summary with prospective and interdisciplinary discussion

• Image projections with radiologic findings

• Pathology slides, pathologic findings

including special stains

• Molecular studies/prognostic indicators

• Clinical and pathologic staging (AJCC or

other specific staging)

• Treatment planning

• Citation of national treatment guidelines

(e.g., NCCN)

• Citing of clinical trials availability

• Discussion of need to refer for genetic

testing

• Discussion for referral to palliative care

services

In 2013, Baylor Medical Center at Garland

sponsored three cancer conferences. The

general cancer conference met monthly and

the breast cancer conference met twice a

month. A combined total of 158 cases were

presented to the conferences, all prospec-

tively. The top five cancer sites reported to

the conferences included: breast, lung, colon,

lymphoma, urinary-bladder, thyroid.

INSIGHT

CASE-SOLVING

EDUCATION

CAMARADERIE


CAMPUS MAP


HOSPITAL MAP

Senior Center

Third FloorMain ElevatorsRooms 300–320 (3 West/Observation Unit)Rooms 371–395 (3 Main)East ElevatorsRooms 340–363 (Physical Medicine and Rehabilitation)

Fourth FloorMain ElevatorsRooms 400–427 (4 West)Rooms 471–495 (4 Main)East ElevatorsRooms 440–470 (4 East)

i

Key Telephone Numbers

Administration 972.487.5232Admitting and Registration 972.487.5355

Day Surgery 972.487.5013

Breast Center 972.487.5441Billing Inquiry 800.299.2925Cafeteria 972.487.5032

Hours: 6:30 a.m.– 3:00 p.m.Breakfast: 6:30 a.m.–10:30 a.m.Lunch: 11:00 a.m.–3:00 p.m.

Chaplain 972.487.5454

Digestive Disease Center 972.487.5004Diabetes Education 972.487.5483

Gift Shop 972.487.5245Heart and Vascular Center 972.487.5041Hospital Operator Dial 0Information Desk 972.485.2347Insurance Assistance 877.810.0372Outpatient Scheduling 972.487.5293Physician Referral Service 1.800.4BAYLORRadiology 972.487.5170

972.487.5444Sleep Center 972.487.5143Social Work 972.487.5042Supervisor (Nursing Administration) 972.487.5213Support Services and Education

Classes (Information) 1.800.4BAYLORSurgery 972.487.5176Volunteer Services 972.487.5520Women’s Center 972.487.5010Wound Center 972.696.1234

BasementMain ElevatorsCafeteriaAB Conference RoomsService ElevatorsCafeteriaMedical Records

Fifth FloorEast ElevatorsDigestive

Disease CenterBaylor Sleep

Center

Second FloorMain ElevatorsChapelHeart and Vascular CenterRooms 202–221 (ICU)Pastoral CareEast ElevatorsRooms 240–270 (2 East)

Women’s Center (Secured Area)

East Entrance

Baylor MedicalPlaza I

Patient Towers

EmergencyEntrance

Women’s Center/Behavioral Health

Entrance

Main EntranceMedical Plaza I

Entrance

BreastCenter

Main Elevator

East Elevator

Elevator toPhysicianOffices

Day Surgery

Administration

Admitting,Registration& Billing Human

Resources

SurgeryWaiting

Laboratory

Labor & Delivery Entrance

Cath Lab

ServiceElevator

OutpatientMedicalImaging/Radiology

MedicalStaffServices

Cardiopulmonary

EmergencyDepartment

PublicSafety

AuxiliaryConferenceCenter

Women’sCenterConferenceRoom

West Entrance

Administrative Supervisor/Room Control

LegendGift Shop

Information

Restrooms

Vending

ATM

Elevators

Emergency

First Floor

Parking Services

DiabetesEducation

Breast Center Registration

ECI

Cancer Resource Center

Pre-AdmitTesting

L&D Waiting

Cath LabWaiting

Stairs to Café

Free Valet Parking

Elevators toCardiovascularServices and Physician Offices

Social Workand CareCoordination

Behavioral Health

InfectionControl

EmployeeHealth

ServiceElevator

Dialysis

Emergency Department 972.487.5582

Westwood Drive

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Baylor Medical Center at Garland2300 Marie CurieGarland, Texas 75042972.487.5000BaylorHealth.com/Garland

900 North Shiloh Road(Baylor Senior Health Center)

Medical Plaza II777 Walter Reed Boulevard(Comprehensive Wound Center)

A

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Pickett Hartman Annex705 Walter Reed Boulevard(Suite 100–Outpatient Rehabilitation)(Suite 110–Education)

Baylor Medical Center at Garland2300 Marie Curie Boulevard

Medical Plaza I700 Walter Reed Boulevard

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H

IMedical Plaza III601 Clara Barton Boulevard

618 Clara Barton Boulevard

2241 Peggy Lane

2231 Peggy Lane

2225 Peggy Lane

Parking Areas

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Medical Plaza IV530 Clara Barton Boulevard

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BEATING CANCER


Westwood Drive

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2300 Marie CurieGarland, Texas 75042(972) 487-5000BaylorHealth.com

900 North Shiloh Road(Diabetes Education Center)

800 North Shiloh Road(Baylor Senior Health Center)

Medical Plaza II777 Walter Reed Boulevard(Wound Care Center)

760 North Shiloh Road

A

B

C

F

D

E

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Pickett Hartman Annex705 Walter Reed Boulevard(Outpatient Rehabilitation)

Baylor Medical Center at Garland2300 Marie Curie Boulevard

Medical Plaza I700 Walter Reed Boulevard

H

J

K

Medical Plaza III601 Clara Barton Boulevard

618 Clara Barton Boulevard

2241 Peggy Lane

2231 Peggy Lane

2225 Peggy Lane

Parking Areas

Streets

L

M

Buckingham

Belt Line

Arapaho

Walnut

Forest

Miller Miller

Hwy. 66

Lavo

n

BroadwayNorthwest Hwy.I-635

Shilo

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Lakeview

Dalro

ck

Row

lett

Rd.

I-30

Satu

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N. G

arla

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S. G

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Center

ville

Garland Rowlett

Mesquite

Sachse

Sunnyvale

Wylie

Sachse Rd.

Campbell

Jupi

ter

N. Garl

and

Hwy. 190

Mile

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Pleasan

t Valley

Firs

t St.

Medical Plaza IV530 Clara Barton Boulevard

I

Duck Creek

AREA MAP

BaylorHealth.com/GarlandCancer2300 Marie Curie Blvd.Garland, TX 750421.800.4BAYLOR972.487.5000

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