Background: Palliative care outpatient clinics should assess patients' symptoms and quality of life prior to visits to guide care and response to treatments. We describe the implementation of a quality improvement initiative to increase symptom and quality of life screening in the outpatient oncology palliative care (OOPC) clinics of one National Cancer Institute-designated Comprehensive Cancer Center. Method: Our quality improvement project structure was based on the RE-AIM framework. Guided

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... the Plan-Do-Study-Act (PDSA) approach, we focused on assessing effective implementation of the Edmonton Symptom Assessment Scale (ESAS-r ) and one Quality of Life (QoL) question at each OOPC visit. At the end of each 3-week PDSA cycle, barriers and facilitators were recognized and addressed. The implementation's effectiveness was determined by percentage of adherence using the following formula: [(number of ESAS-r +1 QoL forms completed per clinic/Number of OOPC completed patient appointments per clinic) x 100].Results: A total of 372 patient appointments were completed during the four PDSA cycles, with overall 59% adherence. The first PDSA cycle compliance was 69%, 58% in the second, 52% in the third, and 65% at the last PDSA cycle. The primary barrier was staff turnover.Conclusion: We were able to implement the ESAS-r + 1 QoL form in a complex clinical outpatient setting. We identified barriers for sustainability, including staff turnover. We addressed these barriers by providing robust instructions that outlined an overview of the clinic workflow and education for all staff members involved in the implementation process. Based on our experience, we suggest integrating this form into the electronic medical record to monitor patient outcomes in the outpatient oncology clinics.