Objectives: Early palliative-care integration is recognised by the World Health Organization, American Society of Clinical Oncology and European Society for Medical Oncology as an essential component of comprehensive oncology care, yet referral practices in many low- and middle-income countries (LMICs) remain inconsistent. At our cancer care department in a private tertiary superspeciality hospital with integrated medical, surgical, radiation oncology and palliative care services, only 7.5% of newly registered patients with Stage IV cancer were being referred to the specialist palliative-care team. The objective of this palliative care quality-improvement project was to raise the referral rate to 25% within the next 6 months through structured, system-level interventions. Materials and Methods: Guided by the National Cancer Grid Enable Quality Improvement in the Patient Care-India programme and the Stanford promoting assessment and improvement of the cancer experience framework, we applied an A3-based Plan-Do-Study-Act cycle. A multidisciplinary team following this methodology refined the problem statement, created a SMART goal, mapped the process using GEMBA walk, performed root-cause analysis using fishbone diagram, formulated key drivers and an impact-effort matrix to prioritise interventions while maintaining a run chart. Key actions included (1) finalising and implementing consensus referral criteria, (2) placing placards in outpatient areas/sending referral criteria on e-mail, (3) ensuring mandatory documentation of treatment intent and referral status in electronic prescriptions and tumour-board reports respectively and (4) bi-monthly compliance audits. The primary outcome was the monthly percentage of patients with Stage IV cancer referred to palliative care, plotted on a run chart from November 2020 to July 2021. Results: During the study period, 537 patients with Stage IV cancer (range 35–72/month) were registered; 66 patients were referred to specialist palliative care (range 4–13/month). In the months of November and December 2020, the baseline referral proportion averaged 7.5%. After sequential implementation of the intervention bundle, referrals rose steadily, and an absolute increase of 10.8% was noted, reaching 18.3% in July 2021 despite pandemic-related limitations. Although the project fell short of its target which was 25%, informal oncologist–palliative-care dialogue and tumour-board documentation of treatment intent and referral status compliance improved. Due to COVID-19-related restrictions, certain activities, e.g. standees, Hindi patient leaflets, could not be implemented. Conclusion: This initiative demonstrates that targeted mentorship, locally tailored referral criteria and seamless workflow prompts, can substantially strengthen palliative care integration in oncology, laying the groundwork for durable culture change and better patient outcomes. Scaling similar QI models across services and institutions will be essential to normalise early palliative care as a core component of high-quality cancer care in LMICs.
Chanana et al. (Sat,) studied this question.