A Lean Survivorship Program
Building the Bridge
October 28, 2011
San Antonio, Texas
DATE
1
A Lean Survivorship Program - The Team
• Team Members
–
–
–
–
–
–
•
Facilitator
–
•
Kathy Denton
Jenny Tektiridis
Chris Smith
Sally Scroggs
Texas A&M University Interns: Courtney Overholt, Kayleigh Campbell, Larissa
Marek
Cancer Prevention Center Lean Kaizan Team
Margaret Bell, MPH, Clinical Administrative Director, Cancer Prevention Center
Sponsor
–
Alma Rodriguez, MD, Vice President, Medical Affairs
2
What We Are Trying to Accomplish?
OUR AIM STATEMENT
Reduce the time, process steps, and documentation errors each
by 30%
for all process owners
in the Cancer Prevention Center while completing the
Survivorship Passport by July 2011.
OUR OVERALL DIRECTIVE
Determine best practices for completing the Survivorship Passport
using the Cancer Prevention Center’s Lean Kaizen processes and roll
out this best practice to all MDACC centers completing a
3
Survivorship Passport.
Not this one!
4
Survivorship Passport Plan at MDACC
• ASCO and IOM 2005 Symposium recommendation:
– Create a Cancer Survivorship Care Plan to support continuity of care from
oncologists to Primary Care Physicians or other Follow up Providers.
• MD Anderson Cancer Center developed and implemented the Survivorship Passport
in 2008 to coordinate clinical care for cancer survivors.
• The Cancer Prevention Center (CPC) provides survivorship patient services:
– Breast Cancer Survivorship Clinic (>3,500 pts/yr)
– Colorectal Survivorship Clinic
– Endocrine/Thyroid Survivorship Clinic (starting 2012)
• This influx of patients, along with the newly developed Survivorship Passport has
presented several challenges:
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–
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Educate survivorship patients.
Integrate survivorship providers from other clinics.
Pre-populate Passports accurately
Improve operational flow of survivor visits in the clinic
6
Measuring Improvement
Our CS&E team is using the following metrics to
measure the improvement in the completion of the
survivorship passport:
• Reduction in duplicate information the patient is
asked to provide.
• Reduction in the percentage of pre-populated
passports with errors.
• Reduction in the amount of time taken by
providers in completing the passport. Results in
increased number of appointments available due
to provider time saved.
• Reduction in time and distance required by all
staff to provide final, completed passport to the
patient.
7
Created Pre-Lean Process Flow - Swim Lane
Pre
CPC
Drafter
Passport Breast Cancer Survivorship
Open Clinic
Station
Surgery
Open Operative
Report for Surgery
if not in last
transcribed note
Double Click Open
Survivorship
Folder
Chemotherapy
Search historical
transcribed notes
for chemotharapy
drug/cycle/years
Click Create
Recommended
Surveillance/
Prevention
Open Patient
Schedule
Click Breast
Passport Plan for
Health
(Pt Demographics,
MRN,Allergies
prepopulated)
In Patient Schedule
find future appts for
Colonoscopy,
Mamogram, Gyn
Screening, Bone
Density testing
Healthcare
Provider – click in
from drop down
box
Open Endocrine
Folder for Bone
Density Test
information
Open last Breast/CPC
Breast Transcribed
Document
Complete Passport Fields
Open GI Medicine
& Nutrition for
Colonoscopy
Information
Radiation
Open XRTor External
Beam Summary
notes for Radiation if
not in last transcribed
note
Open and Review
past transcribed
notes for missing
information
Click Draft when
finished drafting
CPC
8
Created Post-Lean Process Flow - Swim Lane:
44% reduction in Process Steps
Pre
CPC
Drafter
Passport Breast Cancer Survivorship
Click Breast
Passport Plan for
Health
(Pt Demographics,
MRN,Allergies
prepopulated)
Radiation
Open XRTor External
Beam Summary
notes for Radiation if
not in last transcribed
note
X X X X X X X
X X X X X X X X
Open Clinic
Station
Surgery
Open Operative
Report for Surgery
if not in last
transcribed note
Double Click Open
Survivorship
Folder
Chemotherapy
Search historical
transcribed notes
for chemotharapy
drug/cycle/years
Click Create
Recommended
Surveillance/
Prevention
Open Patient
Schedule
In Patient Schedule
find future appts for
Colonoscopy,
Mamogram, Gyn
Screening, Bone
Density testing
Healthcare
Provider – click in
from drop down
box
Open Endocrine
Folder for Bone
Density Test
information
Open last Breast/CPC
Breast Transcribed
Document
Complete Passport Fields
Open GI Medicine
& Nutrition for
Colonoscopy
Information
Open and Review
past transcribed
notes for missing
information
Click Draft when
finished drafting
CPC
X
X XX X
X
XX
9
Utilized Fishbone Diagram
10
Prioritized Issues Using Team Voting as a Decision Tool
11
Improvement in Passport Drafting Process
Resulted in over 50% Reduction in Errors
7
6
5
4
Before Change
After Change
3
2
1
0
Past Medical History
PR/ER/Her2
Surgery
Chemotherapy
Radiation Therapy
Total Passports After Change 56
Total Passports Before Change 57
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Completed Spaghetti Map
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Identified Duplicate Patient Information
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Timed Baseline (Pre-Burst) Process
Data Collection Form – Front Desk Data Collection Form – Providers
Tracking of Patient Forms
Completion
CPC Data Collection Form: Front Desk
Clinic Process Time Sheet - One Per Patient
Date
Patient Name
MRN
Provider
Observer
Check the appropriate box:
Visit Type
Follow-up Patient
Consult Patient
Process Step
Time
Notes
Arrival Time
Appointment Time
Patient given paperwork
Patient returns paperwork
Instructions:
In General:
-Use the Avaya Phone Time To Record The Time
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Lean Bursts to Challenge Passport Process
• Timed current process used to complete the passport
• Burst 1
– Changed ROS to include more information to be filled out by the patient
– Removed duplicate fields in the ROS and Progress Note
– RN completed 2nd page of Passport “Recommended Surveillance/Prevention”
section in the room with the patient using ClinicStation in the patient room
• Burst 2
– Continued Burst 1 process steps and added:
– Provider reviewed, discussed and completed passport in the room with the
patient relying on ClinicStation for the Passport (no hard copy)
– Asked patient their preference - receive a hard copy on the way out or retrieve
their copy via MyMDAnderson
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Collaborated to Create New Patient Education Materials to
Support Patient Access to MyMDAnderson for Passport Retrieval
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Time Savings after Burst #2 is 7:03 or 40%
Reduction in RN and Provider Time
Passport BURST CPC Br SurvivorshipR
Baseline data
Burst Day 1 RN Challenge Burst Day 2 RN/Provider
5/17/11
Challenge 5/19/11
Average amount of time for pt to complete front desk paperwork
5:42
9:09
7:20
Average amount of time for RN to complete f/u progress note pre-exam
3:59
0
0
Average amount of time for RN to complete f/u progress note in exam room
6:08
3:32 review + 2:24 PP +
1:15 Fall/Pain= 7:11
3:27 review + 2:13 PP +
1:15 Fall/Pain= 6:55
10:07
7:11
6:55
Average amount of time for provider to complete PP pre-exam
4:20
3:56
0
Average amount of time for provider to discuss PP in exam room
3:04
2:51
3:33
Total RN Time
Total Provider Time
7:24
6:47
3:33
Total Time to Complete Passport
17:31
13:58
10:28
Reduced Total RN Time
by 30%
Burst 1 saved some time, but
Burst 2 process changes resulted
in a significant reduction in time
Burst 2 overall time savings
is 7:03 or 40%.
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Growth in Survivorship Patient Population
SEER Cancer Statistics Review, 1975-2007http://seer.cancer.gov/csr/1975_2007
5th Most Common Type of Cancer*
•
•
•
•
•
Colorectal
Lung
Breast
Prostate
Second primary cancer
– Approximately10% of all cancers
*Excluding non-melanoma skin cancers
Rheingold SR, et al. Secondary cancers: incidence, risk factors and management; in Bast RC et al (eds): Cancer Medicine. Hamilton, B.C.
Decker, 2000, 2399-2406.
Lessons Learned from Our Patients and Employees
“In my final acute care appointment with my doctor,
something should be said to me about graduation.
If my doctor gave me the Passport, it would let me
know the survivorship staff will know what to do
with me. I want to make sure when they send me
to survivorship – survivorship knows everything
that they need to know about me.”
Patient quote
“We can use the Passport as a tool to run the
visit...helps build rapport with the patient. It could
be more beneficial than I thought.”
Breast Survivorship Provider
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RECOMMENDATIONS:
• Implement Burst 2 in CPC
– RN’s completes 2nd page of Passport in room
– Providers reviews and completes Passport with patient
• Disseminate passport related process improvement results to other
clinics seeing Survivorship patients
• Present process improvements to senior clinical leadership
• Initial Passport completed by Oncologist or Oncologist staff and given
at the last treatment visit prior to Survivorship transistion
• Automatically populate the Passport using ClinicStation (EMR) data
Overall Results and Potential Savings
•
•
•
•
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Significant reduction in duplication of 4 forms.
Reduction in errors of pre-populated passports by greater than 50%.
Reduction in process steps related to the passport by 44%.
Reduction in RN and Provider time related to the passport by 40%.
Relatively small time savings in a high volume operation equates to
significant time savings providing additional capacity without increased
costs.
• Value of Lean Kaizen has been recognized and achieved in the Cancer
Prevention Center. Implementation across campus can result in a large
institutional impact.
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Overall Results and Potential Savings
• Saved 3 minutes of RN time and 4 minutes of Provider time per
survivorship appointment.
• Equates to 175 hours of RN time and 233 hours of Provider time
saved per year based on 3,500 survivorship appointments in the
Cancer Prevention Center alone!
• Potential Savings: With 23,540 survivorship eligible patients at
MDACC, this equates to 2,744 hours of time saved: time we could use
see more cancer patients.
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Next Steps
• Identify other Survivorship process
improvement initiatives- E.g. Checklist for
Survivorship transition
• Use Cancer Prevention Center as launch
pad for other Survivorship process
improvements throughout the institution
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26
Created Training / Job Aids for Process Participants
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Return on Investment
• Not cost intensive due to leaning out of processes
• Mostly Soft Savings/ Some Reduction in FTE
Soft Savings/Increased Productivity
Time Relieved but no actual reduction in FTE's
Increased Capacity, Revenue or Cost Savings Potential
$44,378.00
$209,700.00
$254,078.00
ROI Calcuation Summary
Cost of Capital
Investments/Costs
Benefit/ Revenue
Annual Net Benefit/ Revenue (Costs)
ROI
Net Present Value
Internal Rate of Return (Expected Return)
Modified Internal Rate of Return
9%
Initial Costs (Yr 0)
$30,831.08
$30,831.08
Yr 1
Yr 2
$1,500.00 $1,500.00
$29,952.00 $29,952.00
$28,452.00 $28,452.00
Yr 3
$1,500.00
$29,952.00
$28,452.00
154%
$41,189.32
75%
42%
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Post-Bursts, Evaluated Changes in a Team “Fireside Chat”
Pros
• “Nice to be in front of the patient when making
changes to the Passport – avoids potential
duplication” (Provider)
• “We can use the Passport as a tool to run the
visit...helps build rapport with the patient. It could
be more beneficial than I thought.” (Provider)
• “The patient is more involved in their own care by
filling out the forms in the lobby.” (Front Desk)
• May get more MyMDAnderson uptake because we
offer a copy of the Passport via MyMDAnderson.
• Helps to make sure the providers do not miss
anything
• Overall, an orderly visit process
Cons
•
•
•
•
•
•
•
Change of practice for the provider; benefit to
the provider may not be viewed as “worth it.”
Difficult to convince providers from multiple
practice areas of the benefits to standardizing
practice processes
Need sponsor support to promote care center
process changes, both in the ??????
Could be a problem if the computer signon is
slow
Couldn’t print from the exam room – printer not
set up
“It seems awkward to go into the room not
knowing anything about the patient.” (Nurse)
Patients are not familiar with MyMDAnderson,
but are interested in obtaining the Passport in
this way – we do not have instructions to provide
them.
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Business Plan Objectives
• A comprehensive Survivorship program
• Transition of eligible survivors to provide:
→ better continuum of care for survivors
→additional capacity for new patients
• Program that is financially self-sustaining
Common Assumptions
• Survivor patient population will grow 7-9% each year
• No additional clinical resources added in FY09
• Include a 5% increase in the utilization of
recommended survivorship services
• For every 4 survivors transitioned, 1 new patient or
consult will be seen by faculty in the Care Centers
• The Survivorship Program financial projections will
be updated annually
FY 2009 Update
Projected
Actual
Total Survivors * at MDACC
22,800
23,520
Survivors seen under Program
3,156
4,268
Survivors with a screening visit in CPC
2,831
3,430
Breast Survivor Total Population
6,070
5,824
Breast Survivors seen in CPC
(Low Risk)
1,800
1,668
Breast Survivors seen in CPC
(High Risk)
-
838
FY 2008
FY 2009
2,686
3,220
New Patients Served - Breast
(534 or 20% incr.)
* Defined as alive and no active treatment at 3 yrs out from diagnosis
Survivorship Program Pilot Timeline
Ratio of Cost to Charges
FY 2008
FY 2009
% Change
Breast High Risk
73%
63%
10%
Breast Low Risk
83%
77%
6%
Thyroid
70%
79%
9%
GU
59%
55%
4%
Gyn
96%
1.03%
7%
Total Survivors
54%
43%
11%
Resources to Move Forward
• IT/Data Support:
– Data infrastructure (i.e. system/application)
– Data acquisition and analysis resources
– Data coordinators
• Staffing Support:
– Part-time Faculty Support
– Mid-level Providers
• Leadership Support:
– Faculty transition of patients
• Infrastructure Support:
– Centralized Survivorship Program Space (Proactive
Planning)