Chairman’s Message.............................................................................................................. 1
Continuum of Care Role Statement .................................................................................2
The Cancer Committee.........................................................................................................3
Cancer Conferences (Tumor Boards) ............................................................................. 4
Cancer Registry Report ....................................................................................................... 4
2014 Cancer Registry Data Statistics .............................................................................. 4
2014 Analytical Cancer Cases by County (Figure A) .......................................5
Patient Age at Diagnosis by Gender (Figure B) .................................................5
PSJMC Top 10 Cancer Sites (Figure C) ..................................................................5
Clinical Research ................................................................................................................... 6
Quality Improvement
Improvement starts with “I” ................................................................................... 8
Get Up and Go ............................................................................................................ 10
2015 Community Outreach Report ................................................................................12
Patient/Family Resources and Support ........................................................................14
Cancer Screening Program — CT Lung Scan ...............................................................15
Glossary of Terms ................................................................................................................ 22
References ............................................................................................................................. 23

Dear Colleagues,
For your review, the Cancer Committee of Presence Saint Joseph Medical
Center respectfully submits our Cancer Program Annual Report for 2015.
The Presence St. Joseph Medical Center Cancer Program focuses on improving the quality of care that we provide to our patients and on enhancing the support services for their caregivers and families.
Our Cancer Program is accredited by the American College of Surgeons
Commission on Cancer. As a result of our last survey, we received a full three-year Accreditation with five commendations. The Accreditation acknowledges cancer programs that achieve excellence in providing quality care to cancer patients.
In addition to this Accreditation, we also continued the fight against cancer in many ways. We introduced many more clinical trials and other procedures including chemoembolization. We participated in our first breast program survey from the National Accreditation Program for
Breast Centers and received a full three-year approval. Presence Saint
Joseph Medical Center is proud to be the first Accredited Breast Center in
Will, Grundy and Kankakee County.
I am pleased to share these highlights from our 2015 cancer program with you:
+ Offering clinical trials of promising new treatments
+ Using high-dose radiation therapy to attack tumors more aggressively with pinpoint precision
+ Providing free lung screenings to the community to detect lung cancer in its earliest stage
It is my hope that you find the data in this report to be useful and insightful as we come together to battle this disease each and every day.
Thank you for your interest.
Respectfully,
Jason Suh, MD
2015 Cancer Committee Chair
SM
Jason Suh, MD
2015 Cancer Committee Chair

2
The cancer program at Presence Saint Joseph Medical
Center is accredited by the American College of Surgeons
Commission on Cancer (CoC). CoC accreditation is a voluntary commitment by a cancer program that ensures its patients will have access to the full scope of services required to diagnose, treat, rehabilitate, and support patients with cancer and their families. A cancer program is able to continually evaluate performance and take proactive, corrective actions when necessary. This continuous evaluation reaffirms our commitment to provide highquality cancer care. Our most current Commission on
Cancer program survey was held on September 24, 2014 after which our program was awarded a three-year with commendation accreditation.
Accreditation by the National
Accreditation Program for
Breast Centers (NAPBC) is granted only to those centers that are voluntarily committed to providing the best possible care to patients with diseases of the breast. Each breast center must undergo a rigorous evaluation and review of its performance and compliance with NAPBC standards. To maintain accreditation, centers must monitor compliance to ensure quality care and undergo an on-site review every three years. Presence
Saint Joseph Medical Center participated in its first NAPBC review on February 11, 2015 and was awarded a three-year full accreditation. PSJMC is the first and currently the only
NAPBC-accredited breast cancer program in Will, Grundy, and Kankakee Counties.

Five elements are vital to the success of an accredited cancer program:
+ Clinical services to provide state-of-the-art pretreatment evaluation, staging, treatment, and clinical follow-up for cancer patients
+ Cancer Committee to lead the cancer program
+ Cancer Conferences to provide a forum for patient consultation and contribute to physician/allied staff education
+ Quality Improvement program to evaluate and improve patient outcomes
+ Cancer Registry and database to monitor the quality of care
The success of the cancer program depends on the Cancer
Committee to lead the program through setting goals, monitoring program activity, evaluating patient outcomes, and improving patient care. The committee membership includes multidisciplinary physician members from the diagnostic and therapeutic specialties, as well as allied health professionals involved in the care of cancer patients.
Jason Suh, MD, Hematology/Oncology, Chair
James Urban, MD, Pathology; Cancer Conference Coordinator
Brian Blonigen, MD, Radiation Oncology
Diane Drugas, MD, General Surgery
Ellen Gustafson, MD, Hematology/Oncology, Cancer Program
Liaison Physician
Lynn McDonald, MD, Palliative Medicine
Bhavin Shah, MD, Surgical Oncology
Joshua Tepper, MD, Radiology
Janice Nemri, Chief Administrative Officer
Linda Castello, Director Imaging, Cardiac Cath Lab,
Cardiopulmonary Services
Deborah Condon, Senior Physical Therapist
Shirley Koren, Director Alverno Presence Lab
Susan Krueger, Director Clinical Diagnostic Services
Carrie Kruse, Director Care Management
Susan Kuhel, Oncology Nurse Navigator PCC/JOHA
Diane Labriola, License Cosmetologist, Reflections
Pete LaMotte, Regional Director Palliative Care
Loretta Mangers, Mammo QA Tech/Breast Navigator
Laura McHugh, Quality Improvement Analyst
Kim Midlock, Clinical Nurse Manager PCC/JOHA
Kathie Morris, RN, Palliative Care Nurse Navigator
Therese Murphy, Patient Care Manager 5 West
Diana Page, Clinical Pharmacist
Beth Rader, CTR, Lead Cancer Registrar
Karen Schlueter, CTR, Cancer Registrar
Elizabeth Schwenke, Community Outreach Manager
Michelle Shaban, GI Oncology Nurse Navigator
Eva Stobbe, Clinical Dietitian
Pam Tabler, CNP, Palliative Medicine
June Vargocko, General Manager Alverno Presence Lab
Danielle Villari-Swets, ACS Account Rep, Hospital Systems
Brittney Wirth, Social Worker
Jennifer Waters, Clinical Nutrition Manager
Jennifer Yanak, Oncology/Nurse Navigator PCC/JOHA

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Cancer conferences improve the care of patients with cancer by providing multidisciplinary treatment planning and contributing to physician and allied medical staff education. PSJMC Cancer and breast conferences are held on the second and fourth Wednesday at 12:00 p.m.
One conference per month is held jointly with the staff at Presence Mercy Medical Center in Aurora. The team reviews each patient’s history and physical examination, diagnostic procedures performed, radiology images, pathology slides, and treatment given. Physicians from
Pathology, Radiology, Medical Oncology, Radiation
Oncology and Surgery attend as well as other physician and allied health specialties. All physicians attending cancer conferences at PSJMC receive one hour of
Category I Continuing Medical Education (CME) credit for each hour of tumor board/specialty cancer conference that they attend. Information about upcoming Cancer
Conferences is posted in the Medical Staff lounge and the
CME bulletin board.
In July 2014, we instituted Breast Cancer Conferences twice a month as a supplement to our bi-monthly Tumor
Boards. In August 2015, we added a monthly GI Specialty
Conference. For 2015, we held 27 Tumor Boards, 24 Breast
Cancer Conferences and four GI Specialty Conferences and presented a grand total of 176 cases.
The Cancer Registry monitors all types of reportable neoplasms diagnosed and/or treated at Presence Saint
Joseph Medical Center (PSJMC). This is a critical element in the evaluation of oncology care. Registry data collected include patient demographics, diagnosis, staging, treatment, and disease outcome. Data management contributes to each patient’s treatment planning, staging, and continuity of care. Complete and accurate cancer registry data enables the facility cancer program and administration to plan and allocate hospital resources and is a valuable resource for research activities. The Cancer
Registry reports to the Director of Clinical Diagnostic
Services.
For accession year 2014, the cancer registry abstracted and reported 898 reportable oncology cases - 773 analytic cases and 125 non-analytic cases. The following data for
2014 includes only analytic cases. Analytic cases are cases that are accessioned because the patient was diagnosed at PSJMC and/or the patient received all or part of the first course of treatment at PSJMC. Since 1/1/2001, the cancer registry has abstracted 9681 analytic cases into our database (class of case 10-14, 20-22). Of those, we are currently following 4864 cases. Our current follow-up rate since our cancer registry reference date is 94.35%; our follow-up rate for analytic patients diagnosed within the last five years is 95.38%.
Approximately 80% of our patients live in Will County (see
Figure A). The 2014 analytic cases consist of 344 males and 429 females. Seventy-two percent of male and 66% of female patients were diagnosed between the ages of 50 and 79 (see Figure B).
Breast, bronchus/lung and colon/rectum were the most common sites of cancer for all patients combined (Figure
C). Bronchus/lung, colon/rectum, and prostate were the most frequent cancer sites for men, accounting for 42% of the total number of male cases. For females, breast, bronchus/lung, and colon/ rectum were the most frequent cancer sites, accounting for 59% of the total number of female cases.

5

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The oncology program has been in effect since 1992.
The program is affiliated with the Eastern Cooperative
Oncology Group (ECOG) as an affiliate of Northwestern
University of Chicago. Through our ECOG affiliation we can also offer our patients additional clinical trials sponsored by the National Cancer Institute’s Cancer Trial Support
Unit. In 2004 we expanded our program to include
Pharmaceutical Trials. The research team enrolls an average of 100 patients annually to treatment, prevention and observational clinical trials. Recently the team led by
Dr. Kulumani Sivarajan is the first medical center in the world to begin a study with a new chemotherapy drug for a type of non-Hodgkin’s lymphoma. The study is a Phase I trial which is truly experimental and the first time patients’ have ever received the drug. Other centers within the
United States and Europe eventually will be participating in the trial, as well.
CoC Standard 1.9: As appropriate to the cancer program category, the required percentage of patients is accrued to cancer-related clinical trials each year. The clinical trial coordinator or representative reports clinical trial participation to the cancer committee each year.
+ Seen at PSJMC for diagnosis and/or treatment and placed on a trial through another facility
+ Seen at PSJMC for any reason and placed on a prevention or cancer control trial
Patients eligible to meet this standard are those:
+ Seen at PSJMC for diagnosis and/or treatment and placed on a trial through PSJMC
+ Seen at PSJMC for diagnosis and/or treatment and placed on a trial through office of staff physician
At the community hospital comprehensive cancer program
(COMP) category, the minimum required percentage accrual to clinical trials is four percent of the number of annual analytic cases. For commendation, the percentage accrual to clinical trials is six percent of the number of annual analytic cases.
Type of Trial
Prevention and control research studies
Quality of life and economics of care studies
Bio-repository/ bio-bank studies
Patient registry studies
Other — please specify
Treatment Trials
Total
2014 Breast
0
0
0
0
2014 All Sites
0
0
0
0
14
14
52
52

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Source of Evidence
EP10: Provide two examples with supporting evidence from different practice settings where trended data was used during the budget process, with clinical nurse input, to assess actual-to-budget performance to redistribute existing nursing resources or to acquire additional nursing resources. Trended data must be presented.
Objectives
Trended data is used during the budget process to acquire additional nursing resources: Patient acuity and chemotherapy administration data was used to advocate for the approval of additional nursing resources.
Methods and Approach
In November 2014, UBLC members Ally Broderick and Kira
Smoots consulted with physicians from Joliet Oncology-
Hematology Associates (JOHA) for input into their staffing proposal. Suggestions included gathering data and focusing on the financial impact. With the physicians’ feedback, the UBLC developed a data collection tool to quantify the unit’s patient acuity to support their request for additional nursing resources. The charge nurse collected data during every shift in January and February
2015 and compiled the data for analysis.
Clinical nurses have input in the budget process:
Clinical nurses collaborated with nursing leaders and interprofessional partners to develop a staffing proposal, which was presented to the CNO and approved.
Pharmacy Director Kim Janicek assisted the 5 West
UBLC with gathering data related to the number of chemotherapy treatments and blood products administered by the 5 West nurses:
+ The nurses administered nearly as many units of chemotherapy in the first 4 months of 2015 as in the last
8 months of 2014 combined:
Purpose and Background
PSJMC’s 5 West Unit cares for patients with oncology or hematology disorders and also serves general medical and cardiac patients. In October 2014, the 5 West Unit Based
Leadership Council (UBLC) voiced concerns to the unit manager regarding the nurse to patient ratio. The nurses felt that the current staffing acuity tool did not accurately reflect the actual acuity and demands of the unit.
– 56 units of chemotherapy administered May-Aug 2014
– 78 units of chemotherapy administered Sept-Dec 2014
– 120 units of chemotherapy administered Jan-April
2015
+ A total of 1000 units of blood products were administered in 2014, more than the 2 West Telemetry
Unit and 4 East Progressive Care Unit combined.
5 West analyzed contributing factors that drive higher acuity such as the administration and monitoring of chemotherapy and frequent administration of blood products. The unit administers the most blood products in the Medical Center, outside of the operating room and the intensive care units. In addition, patients often require repeated pain medication interventions and emotional support during their transition to hospice care. The 5 West
UBLC believed that the unit’s current nurse to patient ratio was inadequate when compared to national and local competitors.
In collaboration with Director of Nursing Annmarie
McDonough, Director of Nursing Karen Gallagher, and Patient Care Manager Therese Murphy, the UBLC developed a staffing proposal that included a literature review, the analysis of acuity data, nurse to patient ratios of competing hospitals, and forecasted chemotherapy administration rates. On July 9, 2015, clinical nurses Ally
Broderick, Kim Perona, Lisa Bailey, Kira Schmitt, Teresa
Orszulak and Matt Sanders met with Chief Nursing Officer
Jackie Medland to present their proposal.

Outcomes and Impact
From the data presented by the 5 West UBLC, Medland agreed that staffing resources should be modified to be better aligned with patient care needs. Medland gave administrative approval for the staffing proposal, which then was reviewed at the August 27, 2015, meeting of the Staffing Acuity Committee. While the proposal went through the full approval process, Medland approved an increase in nursing resources by increasing the Hours Per
Patient Day from 9.2 to 9.82. Medland also committed to a further evaluation of the unit’s resource needs for the 2016 budget year.
The 5 West staffing proposal was entirely nurse-driven, embodying the Every Nurse a Leader philosophy. Clinical nurses collaborated with interprofessional partners and nursing leaders to advocate for increased resources to meet patient care needs.
Participants
+ Clinical Nurses
– Lisa Bailey, RN, CCRT
– Ally Broderick, RN, BSN, 5 West
– Teresa Orszulak, RN, 5 West
– Kim Perona, RN, BSN, 5 West
– Matt Sanders, RN, BSN, 5 West
– Kira Schmitt, RN, BSN, 5 West
+ JOHA Physicians
– Nafisa Burhani, MD
– Ellen Gustafson, MD
– Sanjiv Modi, MD
– Sarode Pundaleeka, MD
– Kulumani Sivarajan, MD
– Jason Suh, MD
+ Karen Gallagher, RN, MSN, Director of Nursing
+ Kim Janicek, Regional Director, Pharmacy
+ Annmarie McDonagh, FNP, MBA, Director of Nursing
+ Jackie Medland, RN, PhD, Chief Nursing Officer
+ Therese Murphy, RN, BSN, FGNLA, Patient Care Manager,
5 West Medical/Oncology/Telemetry
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Source of Evidence
EP7EO: Provide one example, with supporting evidence, of an improvement resulting from a change in clinical practice due to the application of a professional organization’s standards of nursing practice. The example provided may be at the unit, division, or organizational level. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data.
Goal Statement
To reduce ventilator associated complications by implementing AACN’s standards of nursing practice for delirium monitoring and early ambulation as measured by the decrease in rate or absence of possible ventilatorassociated pneumonia (PVAP). Exemplary Professional
Practice EP7EO.
Objective
An improvement resulting in a change in clinical practice: The implementation of delirium monitoring and early mobility interventions on 3 West MISICU resulted in a decrease in the rate of possible ventilator-associated pneumonia.
Application of a professional organization’s standards of nursing practice: Interventions were implemented based on standards set by the American Association of Critical-
Care Nurses.
Methods and Approach
3 West MISICU nurses, respiratory therapists and physical therapists collaborated to decrease incidence of PVAPs through implementation of professional nursing practice standards as outlined by the AACN. The ABC portion of the Wake Up and Breath protocol reduces patient sedation to “wake” patients up and assess readiness to wean from ventilator use. Early Mobility interventions were added to the ABC protocol to improve outcomes for acutely ventilated patients.
Purpose and Background
In 2008, PSJMC implemented the American Association of
Critical-Care Nurses (AACN)’s ABC protocol (Awakening and
Breathing Trial Coordination) – also known as the “Wake Up and Breathe” protocol – for the care of patients requiring acute or short-term mechanical ventilation. The goal of the protocol is to evaluate patients for early removal from ventilation. Prolonged use and the associated immobility can result in possible ventilator-associated pneumonia
(PVAP) and delirium.
In November 2011, AACN issued a practice alert regarding its ABCDE protocol, recommending that hospitals implement Delirium monitoring and management and
Early mobility for acute ventilator patients. Early mobility helps combat the loss of functional mobility, which can also delay ventilator weaning.
The Presence Health System Critical Care Council began discussions to implement the AACN’s ABCDE core bundle into practice. Progress had stalled at the system level and PSJMC’s 3 West Medical/Surgical Intensive Care Unit
(MISICU) Unit-Based Leadership Council (UBLC), embodying the Every Nurse a Leader professional practice model, stepped forward to implement the AACN standard at PSJMC.
Early Mobility
If the patient is not ready to be weaned from the ventilator, incorporating early mobility into their plan of care may help the patient regain the functional ability to breathe independently. When a patient fails the breathing trial, a prompt is automatically sent to physical therapy to perform an Early Mobility Safety Screen. The physical therapist coordinates with the charge nurse to obtain a physician order for early mobility if the patient does not meet any of the exclusion criteria in the safety screening. The physical therapist then works with the patient to perform active range of motion activities – progressing to sitting, standing and optimally walking.
Pilot Implementation
Critical Care Training and Development Specialist Christina
Martin and Respiratory Education Coordinator Wayne
Meirhofer helped implement the two new interventions into the Meditech system. With assistance from the 3 West
UBLC, Martin and Meirhofer educated the MISICU nurses to perform the assessments and implement appropriate interventions. The pilot project was implemented on
September 16, 2014.

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Outcomes and Impact
In Q3 2014, prior to the implementation of Early Mobility interventions, the rate for possible ventilator-associated pneumonias (PVAP) on 3 West was 2.79 per 1000 ventilator days. After the pilot implementation, the PVAP rate decreased to zero for the following three quarters.
In addition, caregivers have succeeded in assisting five acutely ventilated patients to walk. PSJMC plans to expand the use of the Delirium and Early Mobility interventions to the 4 West Cardiovascular ICU and 6 West Neuro ICU.
In October 2014, Meirhofer presented the results of PSJMC’s early mobility program to the Presence Health System
Critical Care Council. It is the team’s hope that this best practice will be implemented system-wide to help improve quality of life for acutely ventilated patients and reduce the side effects associated with acute mechanical ventilation.
Exemplary Professional Practice EP7EO
Participants
+ Jennifer Fewell, BSN, RN, Training and Development
Specialist, Former 3 West UBLC Chair
+ Jayne Haake, MP (ASCP), CIC, Manager, Infection Control
+ Christina Martin, MS, APN, RN ACCNS-AG, CCRN-CSC,
Former Training and Development Specialist
+ Julie Mills, BSN, RN, CCRN, Patient Care Manager,
3 West Medical/Surgical ICU
+ Physical Therapy
– Janet Clark, PT, Manager, Physical Therapy
– Paul Lagomarcino, PT, MBA, Director, Therapy Services
– Emily Mackanin, DPT, Physical Therapist
+ Respiratory Therapy
– Wayne Meirhofer, RRT, ACCS, NPS,
Respiratory Education Coordinator
– Kevin Schaumberg, RRT, NPS,
Manager Respiratory Care Services

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January 20 Dr. Ayub – 15 attendees
February 13 Will Grundy Free Clinic Health Fair – 200 attendees
March 7 TEAM Asset Fair – 100 attendees
March 7
March 14
March 12
Shorewood Glen Health Fair – 300 attendees
New Lenox Chamber Expo – 200 attendees
Homer Glen Family Health Fair – 125 attendees
March Plainfield Chamber Expo – 300 attendees
March 25
March 26
April 15
Lewis University Student Health Fair – 150 attendees
New Lenox Triad Health Fair – 50 attendees
City of Shorewood Employee Health Fair – 75 attendees
April 21 New Lenox Health & Safety Fair – 175 attendees
April 25 Joliet West High School Support Day – 130 attendees
May 1 Carillon Lakes Health Expo – 200 attendees
May 11 New Lenox VFW Senior Meeting – Dr. Ansari – 25 attendees
May 15 Joliet Hospice Employee Health Fair – 50 attendees
May 16 Brown Church Health Fair – 120 attendees
May 26 Plainfield Cruise Night – 100 attendees
May 27 Timbers of Shorewood Expo – 250 attendees
May 30 Blue Stem Earth Festival – 200 attendees
June 3 Carillon Health Fair – 300 attendees
June 11 Chasing the Sun – 500 attendees
June 17
June 20
July 18
Teacher Expo – 300 attendees
Chicagoland Speedway Expo – 1200 attendees
Plainfield Fest – 500 attendees
August 1 New Lenox Fire Department Family Health Fair – 75 attendees
August 28 Ladies Night Out at the Commons – 350 attendees
September 11 Carillon Health Fair – 300 attendees
September 14 Lisle High School – Jennifer Yanak
September 23 Guy Sell Older Adult Health Fair – 25 attendees
October 2 Emily McAsey Health Fair – 300 attendees
October 2 Breast Screening Fair – Presence Cancer Center – 12 attendees
October 6 Bosom Buddies Support Group, Deb Condon – 12 attendees
October 10 New Lenox Fire Department Health & Safety Fair – 100 attendees
October 10 Shorewood Glen Health Expo – 250 attendees
October 16 Friends Over 50 Radio Show – Dr. Drugas
October 21 New Strides in Mammography, Dr. Jester – 15 attendees
October 22 Prostate Cancer Screening – Presence Cancer Care
October 24 Mt. Zion Church Prostate Screenings – 35 attendees
November 14 New Lenox Fire Department Senior Pancake Breakfast
– 45 attendees
November 20 Latest Advances in Medical Oncology, Dr. Gustafson – 6 attendees

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As much as 80% of lung cancer could be cured if detected at an early stage. With the help of computerized tomography (CT) scans, the Presence Lung Scan can do just that. This simple test is a non-invasive, low radiation procedure that dramatically improves the detection of tumors, and takes approximately 15 minutes. To register, call (877) 737-INFO. This test is FREE.
Findings: PSJMC provides free colorectal cancer screening annually. Kits have been distributed at many Health
Fairs and through the mail. Results are mailed to each patient by the Laboratory Department. Those patients with positive hemoccult blood tests are encouraged to seek follow-up with a physician. A process is in place to determine if patients with positive test results actually do receive recommended follow-up. The majority of patients with positive test results should undergo a complete diagnostic evaluation. According to the American
Cancer Society, among the tests performed as part of a complete diagnostic workup is a colonoscopy or a flexible sigmoidoscopy together with a barium enema x-ray. The test is especially recommended for men and women age
50 and older as well as individuals with a family history of colorectal cancer. Call the INFO Line at Presence Health at 877-737-INFO (4636) to request a colorectal cancer screening kit. (Free)
In 2015, PSJMC offered offering several exercise programs.
All classes are held in Suite 275 at the Presence Healing
Arts Pavilion, 410 East Lincoln Highway in New Lenox.
+ T’ai Chi Fundamentals is an introductory Yang style class that combines relaxed, fluid non-impact movements with a calm mind. Designed to improve posture awareness, balance, strength and energy while reducing stress. Cost: $30.00 for 5-week session.
+ Hatha Yoga focuses on breathing, poses and gentle stretches. Positions will feel natural and comfortable with fluid movement into another relaxed pose. The practice begins with deep breathing through the nose, followed by a series of stretches and positions, ending with guided meditation. Taught by a certified personal trainer and yoga instructor. Cost: $43 for 4-week session or $15 per class drop-in.
+ PiYo is a music-driven, athletic workout that is inspired by a combination of Pilates and yoga. It includes flexibility and strength training, conditioning and dynamic movement. Cost: $43 for 4-week session or $15 per class drop-in.
+ Candlelight Yoga: Hatha yoga practice that begins with deep breathing through the nose, followed by a series of stretches and poses, ending with guided meditation performed in a serene and peaceful candlelight glow.
Cost: $43 for 4-week session or $15 per class dropin
+ Yoga Aroma strives to support the well-being of body, mind and spirit. Aromatherapy achieves its effects through the application and diffusion of pure plant essential oils that influence physical wellness, a positive emotional state and mental clarity. Combining aromatherapy with yoga can powerfully enhance the yoga journey. Cost: $48 for 4-week session or $15 per class drop-in.
These classes run continuously throughout the year with approximately 8-12 participants in each session. Classes are open to all ages but attendees are mostly women ages
40–60.
PSJMC provides the Shape Shop exercise room and equipment for all employees, physicians, volunteers and their spouses. Retired employees may continue to use the
Shape Shop if they volunteer. The Shape Shop opened in
1995 and is open 24 hours a day, seven days a week.
PSJMC Clinical Nutrition staff members see patients in the inpatient setting based on physician consults, information from nursing admission assessment, their own screening parameters tool or for follow-up. They also have an outpatient nutrition and diabetes clinical at the PSJMC campus and now also at the Healing Grounds in New
Lenox. Patients are generated from physician referrals.

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They are seen for many different reasons, including weight loss/management. PSJMC also has a bariatric program in which the dietitians are involved in counseling.
The American Cancer Society provides free informational materials on obesity/overweight, nutrition, and physical activity at http://www.cancer.org/ or by calling
1-800-227-2345.
Summary
PSJMC physicians and employees participated in over
284 community outreach events in 2014 which included health fairs, radio spots, and talks to outside groups and at several adult living facilities and skilled nursing facilities, including the Timbers, Shorewood Glen, Carillon, Carillon
Lakes, Guy Sell Senior Housing, Grand Haven, New Lenox
VFW, and Inwood Athletic Club.
Employees & physicians participated in the 9th Annual
Shorewood Scoot to benefit the Make Your Mark Pediatric
Cancer Foundation.
Roughly 1,450 monthly mammogram trigger reminders are sent out each month to women who have not had their annual mammogram.
American Cancer Society
The American Cancer Society provides educational information and resources in PSJMC’s Patient
Resource Center located in the
West Tower. The Resource Center also provides computers for patient, families, and visitors to access the intranet in order to research their health care questions. In addition, the American Cancer Society actively works with the Cancer Care staff to provide information and resources for patients undergoing treatments.
PSJMC Website
The PSJMC website at PresenceHealth.org/stjoseph-joliet provides information about the Sister Theresa Cancer Care
Center and radiation oncology services; infusional therapy; inpatient oncology unit; clinical trials; support services and counseling; rehabilitation services; surgical services; support groups; facility accreditations and affiliations; and specific information about breast, prostate, and colorectal cancers.
Positive People
For cancer patients and their families. Contact the Sister
Theresa Cancer Care Center at (815) 741-7560.Meets the first and third Wednesday of each month, 3:30 – 5 p.m.
Patient Resource Center
To enhance patient access to ACS services and information, the Medical Center worked with the ACS to provide an ACS
Patient Resource Center within our facility. The ACS Patient
Resource Center opened at PSJMC on January 8, 2007, and is now part of the Resource Center located in PSJMC
West Tower.
Bosom Buddies
Bosom Buddies support group for breast cancer meets the 1st and 3rd Tuesday of each month at Presence Cancer
Care/JOHA, 2614 West Jefferson Street, Joliet.
“Look Good Feel Better”
The American Cancer Society “Look Good Feel Better” is offered six times per year at Presence Cancer Care/JOHA at
2614 West Jefferson Street, Joliet.

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CoC Standard 4.2: Each year, the cancer committee provides at least one cancer screening program that is targeted to decreasing the number of patients with late-stage disease. The screening program is based on community needs and is consistent with evidence-based national guidelines and evidence-based interventions. A process is developed to follow up on all positive findings.
Purpose: To decrease the numbers of patients with late-stage lung cancers.
National Guideline: Clinicians with access to high-volume, high quality lung cancer screening and treatment centers should initiate a discussion about lung cancer screening with apparently healthy patients ages 55-74 who have at least a 30 pack-year smoking history, and who currently smoke or have quit within the past
15 years. A process of informed and shared decision making with a clinician related to the potential benefits, limitations, and harms associated with screening for lung cancer with LDCT should occur before any decision is made to initiate lung cancer screening. Smoking cessation counseling remains a high priority for clinical attention in discussions with current smokers, who should be informed of their continuing risk of lung cancer. Screening should not be viewed as an alternative to smoking cessation.
(American Cancer Society Cancer Facts and Figures 2015)
Identified Need: Approximately 221,200 new cancers of the bronchus and lung are expected in the U.S. in 2015, accounting for approximately 13% of new cancer cases. Lung cancer will account for 27% of all cancer deaths for both sexes combined. Cigarette smoking is by far the most important risk factor for lung cancer; risk increases with both quantity and duration of smoking. (American Cancer Society Cancer
Facts and Figures 2015)
The American Cancer Society issued guidelines for lung cancer screening in January 2013. The Soci ety recommends that clinicians with access to high-volume, high-quality lung cancer screening and treatment programs should discuss lung cancer screening with patients 55 to 74 years of age who have at least a 30 pack-year smoking history, who currently smoke or have quit within the past 15 years, and who are in good health.
Informed shared decision making with a clinician related to the potential benefits, limitations, and harms associated with screening for lung cancer with low dose CT (LDCT) should occur before any decision is made to initiate lung cancer screening. Smoking cessation counseling should be a high priority in discussions with current smokers, who should be informed of their continuing risk of lung cancer. Screening should not be viewed as an alter native to smoking cessation.
Risks associated with LDCT screening include cumulative radiation exposure from multiple CT scans and unnecessary biopsy and/or surgery in patients who do not have lung cancer (false positives). Some smokers might use LDCT screening as an excuse to continue smoking although some studies show higher rates of smoking cessation among those choosing to be screened than are seen at the community level in unscreened groups.
Therefore, smoking cessation efforts must accompany CT screening for current smokers. (American Cancer Society
Cancer Prevention & Early Detection Facts and Figures
2015-2016)

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The Community Health Status Assessment (CHSA) is one of four assessments performed as part of the Mobilizing for Action through Planning and Partnerships (MAPP) strategic framework. During the assessment, information about health status, quality of life, behavioral risk factors and risk factors in the community is gathered and analyzed. Data is collected from a variety of resources and analyzed comparing local, state and national benchmarks when available. This assessment is performed to meet the hospital partners’ IRS requirement every three years and the Will County Health Department’s Illinois Department of
Public Health IPLAN (Illinois Plan for Local Assessment of
Needs) requirement every five years.
organizations; Will County Health Department; www.chna.org website; Behavioral Risk Factor Surveillance
System (BRFSS); and Illinois County Behavioral Risk Factor
Surveys (ICBRFS). The most recent county-level data available is for the 2007 – 2009 round of the survey. Some data sources may not be as current or complete as others.
Benchmarks were included wherever possible and came from either Healthy People 2020 (HP2020) or County
Health Rankings (CHR) National benchmark. HP2020 goals are set every ten years by the US Department of Health and Human Services. The CHR standards are set at 90% of current data. The goal is for all counties to be as healthy as the top 10% of counties are now.
Behavioral risk factors: Risk factors in this category include behaviors that are believed to cause, or are contributing factors to injuries, disease and death during youth and adolescence as well as significant morbidity and mortality later in life.
The CHSA provides a picture of our community by answering three questions:
1. Who are we and what do we bring to the table?
2. What are the strengths and risks in our community that contribute to health?
3. What is our health status?
MAPP identifies health indicators in the following categories for conducting the CHSA:
1. Demographics
2. Socioeconomics
3. Health resource availability
4. Quality of life
5. Behavioral risk factors
6. Environmental health
7. Social and mental health
8. Maternal and child health
9. Death, illness and injury
10. Communicable diseases
11. Sentinel events
Data was gathered from several sources including: US
Census and American Community Survey; Illinois state agencies including IDPH IQUERY and IPLAN data sets;
US Department of Health and Human Services; community
Key findings
Adults
+ While only 29% of adults have been diagnosed with high blood pressure, 29% of those with high blood pressure are not taking their required medicine.
+ 30.3% of adults are considered obese and 38.3% are considered overweight.
+ The number of current smokers in Will County has decreased but is still higher than the HP2020 target.
Youth
+ Alcohol is the primary substance used among students in all grades (6th – 12th grade).
+ The use of cigarettes and marijuana increased as the grades increased, while the use of inhalants decreased.
+ The intake of fruits and vegetables slightly decreased as the grades increased.
+ The prevalence of obesity remained the same across all grades.

In 2007-2009, 17.6% of Will County adults were current smokers. The number of adult smokers in Will County improved between 2001 and 2009, but continues to be worse than the HP2020 target, indicating an area of opportunity.
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HP2020 Target: 12% of adults aged 18 years and older are current cigarette smokers.
In 2010, there were 3,761 deaths in Will County.
2010 leading causes of death in Will County
Cancer
Heart disease
Chronic lower respiratory diseases
Accidents
Cerebrovascular disease
Nephritis and nephrosis
Alzheimer’s disease
Diabetes
Pneumonia
Septicemia
All causes
Source: IDPH, Health Statistics
Number of deaths
973
923
183
175
173
104
100
86
69
55
3761
Percent of Deaths
25.8%
24.5%
4.8%
4.6%
4.5%
2.7%
2.6%
2.2%
1.7%
1.4%
100%

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For the past three years, cancer has been the leading cause of death in Will County. There were no notable findings with cancer deaths by race. In 2009, the Will County cancer mortality rate was 146.5 deaths per 100,000 population
— below the HP2020 target (160.6 deaths per 100,000 population). In 2009, there were 1004 deaths in Will County due to cancer; 54% of those were due to the following:
Lung cancer ............................................................................272 deaths
Colorectal cancer ...................................................................84 deaths
Breast cancer ............................................................................73 deaths
Prostate cancer ....................................................................... 54 deaths
Leukemia .................................................................................... 43 deaths
Review of the Will County Health Status Assessment Report clearly demonstrates a continued need for smoking cessation programs and CT lung cancer screenings in our community.

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PSJMC Cancer Registry Statistics:
At PSJMC in 2011-2014, cancers of the bronchus/lung were the most common site among men and second most common site in women.
Incidence of lung cancer at PSJMC by gender (based on date of first contact):
Accession year
2011
2012
2013
2014
Male
87
74
87
69
Female
61
80
60
60
Total
148
154
147
129
Annual analytic caseload
869
819
784
773
Percentage of annual caseload
17%
19%
19%
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Although the analytic caseload dropped slightly from 2011 to 2014, the percentage of lung cancer cases has remained relatively constant.
Stage of disease at diagnosis at PSJMC (% of lung cancer cases by accession year):
AJCC Stage
Stage IA
Stage IB
Stage IIA
Stage IIB
Stage III
Stage IIIA
Stage IIIB
Stage IV
Unknown stage
2011
20%
3%
6%
3%
1%
16%
4%
47%
0%
2012
15%
6%
4%
4% n/a
12%
7%
52% n/a
7%
1%
12%
4%
2013
16%
6%
3%
50%
1%
2014
9%
11%
2%
6%
2%
10%
6%
54% n/a
The percentage of cases diagnosed at Stage IA has dropped significantly from 2010 to 2014. Approximately 50% of our lung cancer patients have Stage IV disease at diagnosis. There has been no improvement.
Tobacco History for patients accessioned at PSJMC in 2014:
Tobacco History
Never smoked (00)
Current smoker
Previous hx of smoking
Unknown smoking hx
Number of cases
2012
11
68
75
0
2014
21
46
61
1
Percentage of cases
2012 2014
7%
44%
16%
36%
49%
0%
47%
1%
In 2014, 83% of PSJMC lung cancer patients were smokers or had a history of smoking; 36% of those patients were active smokers at the time of diagnosis of lung cancer. Tobacco use remains a significant health threat to our patient population but there has been improvement since 2012.

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+ Public not aware service offered at PSJMC
+ Current smoker resistant to smoking cessation counseling
+ Most participants are self-referred; patients are more apt to participate if physician provides counseling and recommendation for screening
+ Self-pay service not covered by Medicare/insurance; individual unable to pay
NOTE: Beginning in April 2015, PSJMC offers the low dose
CT lung screening exam at no charge; patients no longer pay $99.

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Cancer Site:
Population:
Lung
Current or former smokers ages 55-74 in good health with at least a 30 pack-year history
Test or procedure: Low dose helical CT (LDCT)
Frequency: Clinicians with access to high-volume, high quality lung cancer screening and treatment centers should initiate a discussion about lung cancer screening with apparently healthy patients ages 55-74 who have at least a 30 pack-year smoking history, and who currently smoke or have quit within the past 15 years.
A process of informed and shared decision making with a clinician related to the potential benefits, limitations, and harms associated with screening for lung cancer with LDCT should occur before any decision is made to initiate lung cancer screening. Smoking cessation counseling remains a high priority for clinical attention in discussions with current smokers, who should be informed of their continuing risk of lung cancer. Screening should not be viewed as an alternative to smoking cessation.
Findings: PSJMC offers lung cancer screening with the Presence Lung Scan. Beginning in April 2015, there is no cost for the exam. Patients can call the central INFO line at 877-737-INFO (4636) to schedule a screening.
Each patient participating in this screening receives a
Lung Scan Screening Health Guide and Report along with the actual CT report stored in Meditech. In addition, each patient receives a flyer of the various pulmonologists available. Those patients who are currently still smoking also receive a copy of the PSJMC “No Smoking” brochure.
John Walsh, MD, Pulmonology oversees all of these lung cancer screening scans and a copy is sent to both him and to the patient’s own PCP. Dr. Walsh sends a certified letter to patients who require some form of follow up. He will also at that time contact the PCP directly. Margaret Downey also contacts each patient by telephone. Patient identifiers,
CT findings, referrals and contact attempts are documented and this form is forwarded to Health Information Services to be maintained as part of the patient’s permanent medical record. Margaret Downey tracks pertinent data items for each screening on a spreadsheet.
PSJMC began offering lung cancer screening in 2011.
Number of screenings performed by year:
2011 ....................................................................................................................26
2012 ...................................................................................................................77
2013 ...................................................................................................................24
2014 ....................................................................................................................19
2015 ................................................................................... 172 (as of 11/4/15)
Results of CT lung cancer screenings as of 11/12/15:
Results
Number of screenings performed
Number with lung abnormalities
Number with abnormalities other than lung
Number with normal results
Number with biopsies as result of screening
Biopsy results
Stage of disease
2012: T3 N2 M0 Stage IIIA
T2a N2 M0 Stage IB
2013: T3 N0 M0 Stage IIB
2015: T2a N0 M0 Stage IB
2011
7
2
26
17
0 n/a
2012
77
47
18
12
2
2/2+
Improvement:
As of April 2015, PSJMC is offering LDCT lung screening for free to eligible patients.
2013
24
15
6
3
1
1/1+
2014
6
3
19
12
0 n/a
2015
172
121
104
21
2
1/2+
TOTAL
319
212
141
42
5
4/5+

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Abstract: A summary of pertinent information about the patient, cancer, treatment, and outcome.
Components include patient identification, cancer identification, stage of disease at initial diagnosis, first course of treatment, recurrence, treatment for recurrence or progression, and follow-up.
AJCC: American Joint Committee on Cancer (TNM staging).
Analytic case: Any patient diagnosed and/or receiving all or part of the first course of cancer treatment at Presence Saint Joseph Medical Center.
Non-analytic case: Any patient diagnosed elsewhere and received their entire first course of cancer treatment at another facility, or a patient diagnosed at autopsy.
Class of case: Determination of patient’s diagnosis and/or treatment status at first admission or encounter for cancer at our facility.
First course of therapy: Cancer-directed treatment or series of treatments, which is planned and usually initiated within four months of diagnosis.
TNM staging: Classification given to the extent of disease by the American Joint Committee on
Cancer. The TNM letters correspond to the extent of disease for the tumor, nodal involvement, and distant metastases.

AJCC Cancer Staging Manual Seventh Edition
American Cancer Society Cancer Facts and Figures 2015
American Cancer Society Cancer Prevention
& Early Detection Facts & Figures 2015–2016
American College of Surgeons Commission on Cancer
National Cancer Data Base Benchmark Reports
Commission on Cancer Facility Oncology Registry Data
Standards (FORDS)
Commission on Cancer, Cancer Program Standards 2012
Elekta IMPAC Information Services
National Comprehensive Cancer Network web site
NCCN Clinical Practice Guidelines in Oncology
Presence Saint Joseph Medical Center web site
“Will County Community Health Status Assessment Report
August 2013
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