#36
PROJECT NAME: Improving the Art of Colorectal
Cancer Care Delivery
Project Time-frame 2008 -- 2012
Institution: South Texas Veterans Health Care System
Primary Author: Edna Cruz, M.Sc., RN, CPHQ
Project Category: General Efficiency
Purpose
Veterans Health Administration is focused on research and development in clinical and
system improvements designed to enhance the overall well-being of the Veteran. This is
stated in our Mission statement “To Honor America’s Veterans by providing exceptional
health care that improves their health and well-being”. This is further supported by our
Vision statement “To be a patient centered, integrated health care organization for
Veterans providing excellent health care, research, and education”. South Texas
Veterans Health Care System (STVHCS) is undergoing a cultural change that integrates
the improvement sciences staffs into management’s planning initiatives. These initiatives
will provide system redesign training throughout STVHCS. The goal is to fully implement
a culture of innovative improvements maintained and disseminated by the staff at the
sharp end of care.
Aim
This project concerns itself with the STVHCS colorectal cancer care system. A full
assessment of the system included patients with stage 1, 2, and 3 colorectal cancer
having surgery in 2008 through December 2012, the projects timeframe. The team
determined that improving the cycle time to OR was critical to avoiding costly inpatient
days, decreasing the disease burden and improving Veteran well-being. Our aim and one
metric for this project are:
“To reduce the average cycle time from surgical consult completion to
OR from 58.7 days to < 30 days by December 2012”.
The stakeholders for this project are the friends, family of Veterans experiencing stage
1,2, 3 colorectal cancer, the oncologist and staffs caring for this patient population,
STVHCS and VHA administrations.
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Tools and Measurement
The team plotted the flow of the entire colorectal cancer care system from screening to
surveillance.
Colon Cancer Collaborative
Pre-Intervention Process Flow Map
Clinical
Presentation
Diagnosis /
Pathology
Screening
Work-Up &
Clinical
Staging
Colectomy w en
bloc removal of
regional lymph
nodes
NO
Signs &
Symptoms
YES
Diagnostic
Colonscopy
- Screening Colonoscopy
@ age 50 if Low Risk
@ age 40 if High Risk
- CT Colonography
- Flexible Sigmoidoscopy
. w/BE if patient refused
. Colonscopy or there
. are no facilities to do
. colonoscopy
Invasive
Colon
Cancer,
Resectable,
Non - Mets &
Non-Obst.
Pathology
Review
Colonoscopy
CBC, Platelets,
Chem Profile
CEA
Chest/ABD/
Pelvic CT
YES
Stent or Diversion
Locally
Resectable
or Medically
Operable
Polyp w/
Invasive
Cancer
Adenoma
-Tubular
-Tubulovillous
-Villous
Pathology
Review
Colonoscopy
Marking of
cancerous polyp
site (at time of
colonoscopy or
within 2 wks)
Adjuvant Therapy
and Surveillance
NO
YES
Single
Specimen
Obtained
NO
Stage II* & III
H&P - Q 3-6 Months 1st through
2nd year
Resection w/Diversion
YES
Obstructing
Stage II* & III
Stage II* & III
Colectomy w en bloc
removal of regional
lymph nodes
Palliative
Therapy
Stage I - IV
Observe
Return to Colon
Cancer,
Resectable, Non Mets & Non-Obst.
Colectomy w en
bloc removal of
regional lymph
nodes
Surveillance
Stage II* & III
1-Stage colectomy
with en bloc
removal of
regional lymph
nodes.
NO
Adjuvant
Therapy
Pathologic
Staging
Treatment
Stage II* & III
. Chemotherapy for
. advanced or
. metastatic disease
Adjuvant Therapy
and Surveillance
H&P – Q 6 Months 3rd through
5th year
CEA – Q 3-6 Months 1st through
2nd year
CEA – Q6 Months 3rd through
5th Year for T2 or greater lesion
CT / MRI – Chest/Abd/Pelvic
Annually for 3 Years for patients
at high risk for recurrence.
Colonoscopy in 1 year of
surgery if no pre-operative
colonoscopy done due to
obstructing lesion, or
colonoscopy in 3-6 months.
- If advanced adenoma, then
repeat in 1 year
- If no advanced adenoma,
repeat in 3 year then every 5
years
Colonoscopy every 5 years, if
3 or less adenomas.
Colonoscopy every 3 years, if
more than 3 adenomas or
advanced pathology of
Tubulovillous or Villous.
* Adjuvant Treatment may be considered for Stage II high risk patients.
This tool showed us a comprehensive system and so the team next measured the
timeframes between processes and produced a Value Stream Map. The analysis
exposed a prolonged cycle time in “Q5 Surgical Consult to Surgery Date”. The team chose
this metric for process improvement.
Yet to be disclosed was the patient’s opinions about our colorectal cancer care. The team
implemented the following patient satisfaction survey.
Page 2
An opportunity for improvement exists in the Appointment Access category labeled
“Convenience of the Office Location” where 7 of 18 or 40% of patients report either Good
or Fair appointment access and “Getting Through to the office by phone” where there were
8 of 18 or 44% of patients report Good or Fair appointment access. Another improvement
opportunity exists in the Individual Provider Qualities category, “Your feeling about the
overall quality of the visit” where 6 of 18 or 33% of the patients report Good or Fair
individual provider qualities.
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The second portion of the Patient Survey shows that 4 out of 17 or 24% of patients report
“Sometimes” to the question “Are you able to get appointments when you choose”?. 41%
of patients report “Yes, some things” or “Yes, many things” to the question “Is there
anything our practice can do to improve care / service?. After verification with individual
patients, the team interpreted these results as the patients having difficulty coordinating
consult appointments.
The team proceeded to study the root causes for the dissatisfaction with a prolonged cycle
time and completed the cause and effects diagram below:
The team gave serious thought to the different causes for delays in getting our colorectal
cancer patient to the OR and discovered that there was a cluster around process issues
as follows:
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Loss of Cancer Program Certification, Credibility and stature within STVHCS
Complex multi-disciplinary approach required
Complex patient population with multi-system involvement
Negative attitudes toward cancer specialties
Pre-conceived ideas about cancer treatment
Ignorance, fear and bias
Care coordination not automatic
Lack social work support
Poor patient care coordination
Poor coordination of external information
Page 4
There were some people issues:
 Lost Tumor Registry Personnel
 Insufficient CNSs
 No VA Radiation Coordinator
 High provider frustration levels
There were communication issues:
 No external information case manager
 No contract information sharing, nor communication plan
 Lack of provider role definition
All of these causes contributed in some fashion to delay in getting our patient to the OR
and demonstrated in the control chart:
The chart shows the cycle time for consult completed to OR in days with a preintervention average of 58.67 days. The physician team members voiced concern over
this cycle time. Brain storming and multi-voting produced numerous prioritized
interventions:
1. e-Consult Re-design – The team considered this intervention to be the strongest and
prioritized it as #1. From a human factors engineering perspective this intervention
was easily hardwired, leads the provider through a series of screens which must be
completed prior to e-Consult submission, and simplifies and standardizes the process
so that all of the labs and imaging studies are performed prior to the Veteran being
scheduled for surgical consult. Implemented: October, 2009.
2. Intervention #2, submit proposal for the purchase of ultrasound equipment to perform
in-house trans-rectal ultra-sound studies. Monies for this type of equipment is tight
and the team knew that this proposal may have to be submitted through several
budget cycles. This intervention allows for first-hand knowledge of test results and
easy access to dictated ultrasound results (in CPRS/e-HR). Implemented:
Equipment Cleared by Vendor: February 2013, EUS July 2013, and TRUS
August 2013.
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3. Intervention #3, Integrated both GI and Surgical specialties to stimulate collaboration
between specialties. Implemented: August 2012.
4. Intervention #4, request a CNS position for Colorectal Cancer Patient Navigator.
Positions are tight, but our administration appreciated the risk and cost involved with
cancer care coordination. Implemented: February 2013.
5. Intervention #5, request high priority to hire the needed Tumor Registry personnel.
Subsequent accreditation is dependent upon filling this position. Implemented April
2012.
6. Intervention #6, request full time social work position solely to address our Veteran’s
care needs. This cancer population requires complex multi-disciplinary approach, and
Social Work support is critical to successful treatment. Implemented: May 2010.
7. Intervention #7, re-negotiate the radiation contract and include in the terms and
conditions quality measures such as cycle time, timely report access. It was time to
end the practice of awarding business on the basis of price tag alone. Implemented:
April 2012.
The team chose intervention #1, the re-design of the e-Consult as the first step in
improving the cycle time because it was perceived as quick, easy and comprehensive in
solving the cycle time issue. The team scheduled re-measurement through May of 2010 to
assess aim attainment of 30 days or less.
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Intervention and Improvement
After implementation of Intervention #1 the e-Consult, data dramatically improved:
This intervention was piloted, as the primary care physician had to be made aware of the
new e-Consult, educated on the rationale for implementation and trained on the
mechanics of e-Consult submission. A series of power point slides were distributed to all
of the physician staff and their response was positive as evidenced by the heavy usage of
the e-Consult. The measurement after implementation of Intervention #1, the front loaded
e-Consult, demonstrates an improvement from 58.7 to 36.5 in cycle tme. Our aim was to
bring the cycle time down to 30 days or less. While a 22 day reduction appears
significant, we had NOT reached our goal. The team implemented interventions #2
through #7.
Final re-measurement occurred through February 2013 as follows:
Re-Measurement demonstrates reduction in cycle time from 36.5 to 17.7 days. Our aim
was to bring this cycle time down to 30 days or less and the team exceeded that AIM.
Page 7
Intervention Results
To determine significance or p-Value, we first had to appreciate the variability of our data.
To make this assessment a Normality Test indicated that our data was NOT normally
distributed and had a great degree of variation.
We chose t-Test two sample assuming unequal variances to verify that there is a
statistically significant difference in the cycle time between Pre and Post-Test populations.
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We conducted a Pre and Post Capability Analysis to determine whether there was an
expansion in processing capability.
The analysis revealed a 3 fold increase in capability from Pre-Test Cp of 0.10 to Post-Test
Cp of 0.32. Further improvement is desired until the Cp is ~ 1.33.
Revenue Enhancement /Cost Avoidance / Generalizability
Obtaining accurate cost data is difficult, and quantifying complex multi-disciplinary and
multi-organ/systems of care is ambiguous at best. Our team quoted from National
Comprehensive Cancer Network literature as follows:

Assessment of early vs. late detection of colorectal cancer shows early detection cost
is estimated at $30,000 / patient compared to late stage detection estimated at
$120,000.
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Decrease disease burden and cost per case through timely access to managed care.

Create process capability so that more patients may be seen at a lower cost per case.
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Increase cost avoidance of bed days through appropriate use of hospitalization.
Lessons Learned
•
Leaders are given the responsibility to create a culture of safety, prioritized and
implemented through the Mission, Vision and Values.
•
Leaders plan to provide services required to meet the needs of patients and have
available human, financial, and physical resources to provide care.
•
Leaders manage ongoing evaluation, improvement of staff performance.

Leadership set priorities for the work of the bedside provider.
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