Lean Health: How US Cancer Center Saved Time, Money
This case study by Ashly Mason, Process Excellence Manager at US-based H. Lee Moffitt Cancer Center & Research Institute discusses what Moffitt did to dramatically improve customer satisfaction and reduce waiting times in its infusion center.
Moffitt Cancer Center’s outpatient Infusion Center has over 40,000 chemotherapy patient visits per year. For several years, the Infusion Center was experiencing many problems, the primary one being a steady decline in patient satisfaction especially with regards to wait times. With the steady increase in volumes across Moffitt, the outpatient clinic physicians and nurses were becoming increasingly frustrated with the difficulty of getting their patients into the Infusion Center in a timely manner. The Infusion Center and Pharmacy staff were also experiencing unbalanced workloads and starting to have safety concerns, especially during their daily 4-hour period of peak volumes.
Since the majority of Moffitt’s patients go through the Infusion Center, senior leadership prioritized this area as one for Process Excellence (PEx) to partner with and help facilitate improvements.
Before starting project teams, Moffitt’s internal PEx Consultants performed a rapid assessment which involved observing processes, high-level data analysis, and stakeholder interviews. The assessment showed substantial troubleshooting occurring when patients were waiting for treatment, duplication of work across many roles, as well as a large volume of rework which was having a negative impact on capacity. In addition, there were incomplete revenue cycle processes such as medical necessity and authorization that were impacting the bottom line. Therefore, there were opportunities to improve wait times, satisfaction, safety, quality, and the bottom line.
Since problems were occurring across the full value-stream (clinics, authorization, infusion pharmacy, and infusion center), the scope was set from "infusion order written within clinic" to "patient check-out after treatment." Due to the large scope, leadership support and governance was critical to be successful. Therefore, an Infusion Leadership Council made up of VP and Director stakeholders was formed as the governing body and met throughout the duration of the project. The creation of an Infusion Operations Management Group with key management stakeholders was also formed to improve communication and coordination. This group met weekly throughout the project and is now continuing to meet monthly for monitoring, sustainment, and continuous improvement.
How we began – Value Stream Mapping
Before any project teams were formed, 14 process users participated in a 3-day Value Stream Mapping session where they mapped current state, identified issues, and prioritized solutions. The map and findings were then posted for several months in a staff hallway behind the Infusion Center for all to view. Seeing the holistic process and all its complexity was an "ah-ha" moment for many people. The solutions were categorized into three main groups: patient readiness, patient processing, and scheduling. Multi-disciplinary project teams were then created to design and implement the solutions. Grass roots engagement and empowerment was critical to successful buy-in, implementation, and sustainment.
Incomplete orders were a major cause for delays. The two initial improvements were training the clinics on chemo order requirements using Standard Work and Visual Management and integrating Clinical Pharmacists within the highest volume clinics.
It was a challenge to get clinics to see their role in infusion patient wait times. This challenge was overcome with data. For instance, being able to show a certain clinic that only 8% of their chemo orders were complete upon arrival to the Pharmacy was an eye opener to how they needed to be part of the solution as well. That particular clinic jumped to 86% of their orders being complete. Workload Balancing, Error-Proofing feedback loops, and providing real-time data to manage workflow were other key techniques used to eliminate duplicate work, prevent rework, and streamline the process. This resulted in 60 hours of prep work per day across many roles decreasing to 18 hours per day, a 70% improvement. The Pharmacy staff also went from being able to prep 40% of patients prior to the patients’ arrival up to 82%, thereby reducing the troubleshooting that had been occurring when patients were already there waiting for treatment. From the patient perspective, the non-value-add (waste) prep time of the staff decreased from 68% to 8% which also resulted in improvements in staff morale. For instance, an Infusion Coordination Assistant involved with patient prep stated, "Now I feel that I’m doing more value-add proactive work versus only fixing errors."
The importance of communication in Patient Processing
One of the simple yet highly impactful solutions was to implement Instant Messenger software. Rather than infusion staff and pharmacists spending time searching through patient record notes to identify issues, delays, etc, everyone in the infusion area is now linked to one another so real-time communication can occur which directly impacts patient wait times.
New reports and dashboards were also implemented to monitor patient delays. One of the major challenges was how busy the Manager of the Infusion Center was and therefore unable to provide the necessary oversight to assist with flow and realign staff as needed throughout the day. This is why the addition of a Workflow Coordinator responsible for managing patient flow was critical for implementation and sustainment.
From a financial perspective, one of the improvements involved establishing accountability for medical necessity checks (an insurance company mandated check to ensure that the treatment is relevant and necessary) by assigning one patient service representative per clinic to be responsible for medical necessity. This change resulted in missing medical necessity occurrences dropping from 7 per month (~$52,000 in charges) to zero and therefore also eliminating missed charges.
Additional improvements came from pharmacists, nurses, technicians, and medical assistants working together to analyze their current responsibilities and transition tasks to the most appropriate roles to improve their capacity and job satisfaction.
The creation of guidelines and Standard Work were the primary techniques implemented in order to reduce overbooking, deviations from policies, and errors. The biggest issue in terms of unbalanced workloads and safety concerns occurred during the peak hours of 10:00am to 2:00pm where 47% of the daily volume was scheduled, yet the infusion center was open for 13 hours. Guidelines have already begun to Load Level the schedule so now 33% of volume is scheduled during the peak.
Capacity has also increased due to improving the utilization of nurses and treatment chairs based on the new scheduling guidelines. Accommodating add-on (unscheduled) patients needing blood was a major frustration for physicians and the infusion center. So the team designed a new add-on process defining critically ill patients and appropriate turnaround times. Also, two chemo patient rooms were converted into four dedicated chairs just for critical patients needing blood. These solutions resulted in the number of delayed add-ons decreasing by 50% and their average wait time decreasing from 3.4 to 1.5 hours.
Scheduling is still the process that causes the most frustrations due to the variability in patient arrivals, delays in clinic, treatment reactions, etc. Ongoing communication is required to clinics that scheduling is a work in progress and will be in a state of continuous improvement, especially in an environment whose volumes increase every year.
So what did the patients think about all this?
There were many metrics monitored throughout the project but the one of most importance is patient satisfaction. A special survey with 14 questions was conducted monthly throughout the project to have a more immediate knowledge of the patients’ perceptions of the improvements. The score of every question has improved.
On a 5-point scale, overall infusion patient satisfaction has reached 4.65, the highest score ever for this particular area. More specifically, the patients’ satisfaction with wait times increased by 29% (4.22). Their perception of the overall efficiency of the area (4.78) as well as quality and safety of care (4.80) also increased by 7% and 4% respectfully.
Improvements in efficiency and quality went hand-in-hand by focusing on removing waste from the processes.
Moffitt practices patient- and family-centered care and therefore the initiative included a Patient Advisor who attended the weekly Infusion Operations Management Group meetings and provided guidance, along with other patients, throughout the duration of the project. This patient summed up the initiative well when he said, "I’ve been a patient of the Infusion Center for over 4 years. There is a noticeable change in how the staff operates. It used to be more hectic and now it’s more like a ballet where people know their role and everything flows. It makes my experience better and I feel more confident about my quality of care."
For further listening…
Hear more about what worked and what didn’t during Moffitt’s improvement journey when PexNetwork speaks to Ashly Mason in this Profit Through Process podcast.