Declare the Aim
The GRRCC Systemic Wait Time Reduction Project attempts to reduce the wait times for patients
receiving chemotherapy. Prior to the project, a rolling 3 month median wait time of 5.5 weeks from referral
to treatment was reported for Grand River Regional Cancer Centre (GRRCC) systemic therapy patients.
The project attempts to achieve a wait time target for 2007 / 2008 in which 70% of our new patients start
systemic therapy treatment within 4 weeks of referral.
Wait times are an important indicator of how quickly our patients are getting access to cancer care. Once
a cancer diagnosis has been made, the wait for the treatment phase begins. One part of that treatment is
systemic therapy. Systemic therapy plays a vital role in either prolonging life or by increasing a patient’s
quality of life through the reduction of symptoms. Removing barriers to treatment is essential so patients
have timely access to the appropriate course of treatment. These wait time measures also indicate
GRRCC’s ability to meet the needs of all cancer patients within its catchment area, providing treatment
close to home. Despite the increasing demand and chemotherapies being prescribed, wait times for
chemotherapy remain stagnant across the province.
Timely access to high-quality cancer treatment leads to improved treatment outcomes, prognosis, quality
of life, and satisfaction with care. Waiting for treatment can be emotionally difficult and stressful for
patients and their caregivers. “In the few studies that have explored the setting of cancer care, long wait
times are frequently linked to dissatisfaction.” (Hendershot, 2005).
Potential areas have been identified for improvements related to wait times. Possible solutions /
opportunities included investment in information technology and information management, efficiency
improvement, and better utilization of services. By facilitating the process of each individual step from
booking to the actual treatment, wait times can be reduced. It is the goal of the GRRCC to create a
smoother, timelier scheduling process by increasing efficiencies and this is planned to be achieved by
introducing five sub-aims (for further detail see change section below)
i.
ii.
iii.
iv.
v.
Referral to consult wait time within 2 weeks for 80% of our patients
Reduce waste in the process of orders
Create designated spaces for urgent/emergent patients (to provide sufficient new patient
consult capacity by enabling Medical Oncologist / Hematologist to handle new patient and
emergency consults as their top priority)
Increase flexibility in handling add-on and non-chemo support care treatments (to more fully
utilize the chair capacity of the systemic therapy suite)
Ensure patients are on their first treatment within 3 days of the decision to treat
Simplified Process Flow – Bottlenecks (red boxes) / Implemented Solutions (Yellow Circles)
1) Ref er new
patient to the
Centre f rom
Physicians or DAU
3) Triage the new patient
by Rad Onc or Med Onc
and returns package to
NPR to schedule consult
(if required)
2) Assemble a Triage
package by New Patient
Ref errals and sends to
appropriate Oncologist
4) Schedule a consult and
advise Ref erring
Physician or MedOnc
who advises the patient.
6) Conduct scheduled and
unscheduled consults conduct
nursing assessments and make
a DTT (If possible) or schedule
additional tests or arranges
supportive care by the Med
Onc.
S1
5) Scheduled new patient
arrives at Main Reception
S2
7) Schedule additional testing
& f ollow-up appointments if
required & advises patient by
Clerical Staf f
8.1) Conduct f ollow-up
clinic visits if req’d by
Med Onc
9) Patient makes decision about
treatment and advises Physician
or nurse to schedule chemo
appointments (RTT)
10) Order meds in OPIS & prepares
a Green sheet dated as per prep
date, orders prescription, or prepares
a paper order by Med Onc
8) Conduct testing
S2
11.1) Book Procedures
in the Chemo Suite &
advise patients
12) Install central line
access or conduct other
procedures (if required)
11.2) Schedule Return
Patients & Lab tests and
advise patients
13) Check chemo
orders by Chemo
Nurse
11.3) Establish start date f or treatment
Book Chemo, Blood App’t & Chemo
teach & advise patients
14) Verif y orders and change
start date as determined by
booking clerk by Pharma
11.4) Establish start date f or Chemo & Radiation
when co-modality treatment is required and
advise patients
15)Conduct patient blood draws
at blood lab or in Chemo Suite
and blood work by Blood Lab
16) Conduct chemo
teach with patient
S2
17) Scheduled,
Unscheduled or
Emergency
Patient arrives
Front Desk, Blood
Lab, Clinic or
Chemo.
S3
18) Conduct pre
chemo teach
with patient by
Pharma
19.2) Conduct
assessments,
consult with MD (if
req’d) & deliver
other Supportive
Care treatments
as req’d by Nurse
19.1) Seat patient, assesses patient,
checks blood work, consults with Dr or
Pharma (if req’d), places pre printed
meds orders in Pharma door and
preps f or chemo delivery by Nurse
20) Print orders f or the
day, check blood
results, consult with Dr.
(if req’d) and prepare
meds
21) Monitor Pharma meds
preparation, pick up when
ready, conduct cross ref .
with OPIS, check drug,
dose & calc. by Nurse
22) Administer the
meds and monitor
patient by Nurse
24) Pick-up take home
meds at Pharma by
Patient
23) Discharge patient
af ter conf irming next
app’t, and take home
meds (if req’d)
Measure Improvement
According to Cancer Care Ontario (CCO), “the waiting period from the time a hospital’s regional cancer
centre receives a referral for a patient to receive systemic treatment to the time the patient receives his or
her first treatment” is referred to as “referral to treatment”. “Referral to treatment” wait times are reported
by median, in days (i.e. the point at which half the patients have had their treatment and the other half are
still waiting) and all time intervals longer than 20 weeks are excluded.
The Cancer Care Ontario’s Expert Wait Time Committee announced a wait time target for systemic
treatment and it is consistent with the Canadian Association of Radiation Oncology standard. Our
benchmark is CCO’s target since it is crucial for patients to receive treatment within the recommended
time frame to ensure best outcomes.
ACCESS
CSQI
2007
CSQI
2008
Ontario
Min
Max
Target
*Systemic treatment waits: Median wait (in days), referral to start
of systemic therapy treatment
39.2
32.9**
32.9
73
37.8 28
Source: CCO website.
The chart below shows the indicators that are measured monthly to assess our progress toward our aim.
Indicator
Rationale
Data
Source
Indicates efficient and
Monthly
appropriate patient handling reports
Consistent with CCO
from OPIS
metrics
and OHS
Indicates efficient and
Monthly
appropriate patient handling reports
Consistent with CCO
from OPIS
metrics
and OHS
Indicates availability of NP Monthly
consult slots
report from
OPIS
Baseline Current
(May 07) (Aug 08)
50%
63%
(May 08)
Target
5.2 wks 3.8 weeks
(Oct 07) (June 08)
4
weeks
58%
65%
(June 08)
80%
76.3
Unable to get 95%
current # due to
staff shortages.
Manual
calculation
available Sept
19/08.
47%
70%
(Aug 08)
% of patients who start
their chemo treatment
within 4 weeks of
Referral
Median wait in weeks
from referral to first
treatment
•
% of patients who have
their consult
appointment within 2
weeks of Referral
% of orders processed
within 24 hours of
receipt
•
•
Indicates efficient booking
of treatment
Quarterly
manually
% of new patients
starting treatment within
3 working days of
Ready to Treat
% of emergency
patients seen within a
week
•
Indicates efficient patient
flow into the chemo suite
and supportive care area
Monthly
24%
report from
OPIS
•
Indicates timely handling of Monthly
NA
emergency patient consults report from
PHS
•
•
•
Improved from baseline.
Achieved Target
100% breast
0% GI
100% lung
(May-Aug 08)
70%
90%
Share the Results
The project was initiated in April 2007. Over the course of one year, systemic therapy median wait times
have shown to trend down. Our data shows that the wait time started to decline and stabilize starting
November 2007, and we reached our goal of within 4 weeks in Dec/07, Feb/08, Mar/08, Apr/08, May/08,
and June/08. Approximately, 50 patients start to receive treatments each month.
Systemic Therapy Wait Times
6
In Weeks
5
4
3
2
1
0
Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun07
07
07
07 07
07
07
07
07
08 08
08
08
08
08
Period
Wait Time
Benchmark
Additionally, these changes have resulted in an increased number of patient’s starting systemic therapy
treatment. In the period between April - June 2007 GRRCC accepted 471 new patients. During the same
time period (April - June) in 2008, GRRCC was able to accept 546 new patients, well surpassing the
budgeted volumes. Similarly, the number of new case visits also increased:
Systemic
Therapy
# of new case
visits (C1S)
Budgeted
Volume
2007-2008
1,858
Q4 YTD Actual Volumes
2006-07
1,798
2007-08
1,980
% Variance
6.6%
While improving the wait times for systemic therapy, GRRCC has also managed to increase staff and
patient satisfaction with the new process. The following is a list of quotes:
New Patient Referral Staff:
“The surgeon’s offices are generally surprised by the short wait to see an oncologist and are delighted for
their patients”
Clerical staff in the clinics:
“It is a lot easier to book patients into the chemotherapy suite compared to last year. There seems to be
more time available”
Clerical staff in the chemotherapy suite:
“The patients are pleased with the changes in the supportive treatment area, they say they don’t have to
wait as long in the waiting room when coming to get lab work drawn from their PICC lines”.
Patient response for first chemotherapy visit
“Oh wow – I didn’t expect my first treatment to be booked that early” (the appointment was booked the
same week that the pt saw the oncologist)
Hematologist
“Since the changes have been made it has been easier to treat patients with urgent needs – either
chemotherapy or supportive treatment. These patients are being accommodated much faster.”
“The new way that the bone marrows are organized is working out really well for the physicians and the
patients. Thanks for that.”
Identify the Changes
Solution 1 (S1)
– Proactively monitor and adjust
NP slots to meet DS patient
volumes
– Have some follow-ups and
assesses seen by someone
other then an Oncologist for all
sites so the Oncologists can
see new patients.
Solution 2 (S2)
– One secretary processes all of the orders
for a particular patient group using a
complexity scale
– Book patients to the space
– Create a complexity scale for all protocols
and include acuity (A,B,C,D,E) chosen by
either chemo nurse or physician
Solution 4 (S4)
– Establish a separate
supportive care unit
within the Chemo
Suite
Solution 3 (S3)
– Have designated slots for
each Oncologist to handle
emergency patients based
on site group needs
3 weeks
Referral
24 hrs
Consult
Schedule
Treatment
4 days
1st
Treatment
We implemented seven high impact changes organized into 4 solutions into the systemic therapy
process:
First, we planned to schedule consults within two weeks of referral 80% of the time by having some
follow-ups and assesses seen by someone other then an Oncologist for all sites so the Oncologists can
see new patients. This wait time is associated with the most patient anxiety. Prior to the project
implementation, only 58% of patients were seen within 2 weeks.
Second, we strived to reduce the number of people who process orders for a single patient by having one
secretary process all of the bookings and orders for a particular patient group using a complexity scale.
Large amount of errors is likely to occur in the booking process when many people have to handle a
single booking. Also the handoff of a patient file to multiple secretaries to complete complex bookings
often led to extensive delays. Having 1 person handle all bookings for the patient was intended to
streamline the booking process. To keep the process safe for clerical staff to process all orders, a
complexity scale for all protocols was developed and includes acuity (A,B,C,D,E) chosen by either chemo
nurse or physician. Ultimately, these changes were put in place so we can get patients on their first
treatment within 3 days of the decision to treat (DTT). This complexity scale is an important factor in
scheduling realistic time to administer chemo therapy or other supportive care procedures. In the past,
our lack of ability to match patient needs with the resources led to underutilization of the chemo suite. As
patient volumes increase this situation was expected to result in increased wait times for chemo treatment
delivery.
Third, we have designated slots for each Oncologist to handle emergency patients based on site group
needs so we can handle urgent, emergency and add-on consults in a timely way. In the past urgent or
emergency patients where scheduled into already fully booked clinics. This situation created extensive
delays in a clinic schedule with increased with the resulting increase in patient dissatisfaction.
Lastly, we hoped to increase our flexibility in handling add-on and non chemo supportive care treatments
in the suite by having a separate transfusion unit and possibly a bone marrow unit. If we could manage
these patients differently, it would increase the capacity for chemotherapy.
Sustainability
The success in radiation wait time reduction at GRRCC spread the attempts to improve systemic therapy.
Now that GRRCC has seen success in reducing two aspects of cancer treatment the organization has
developed a culture that knows that improvement is possible.
A critical success factor of this project was our ability to engage all key functions in the decision making
process. It is impossible to implement effective change unless active support is developed leading up to
implementation of the solutions. Many of the solutions were straight forward and had been discussed
before. The engagement process built ownership and commitment to the critical stage of implementation.
It is critical for GRRCC to build on this success and use the tools developed in the initial project – the
Simplified Process Flow Chart, the Report Card and the multifunctional Steering Committee structure
identify new opportunities and respond by implementing ongoing change that counts.
Another key to the success of this project, was the fact that the Solution Sub Teams created and the
Steering Committee a selected solutions which could be implemented within a 30 to 60 day time frame.
This sense of urgency was instrumental in developing and maintaining implementation momentum.
Longer term strategic solutions are important; however it is important that staff see tangible improvement
quickly. This builds confidence and generates additional support for a sustainable change making
process.
Finally, an important learning that we will want to apply in the future is that it is very risky to assume that
we know where the important improvement challenges are without collecting confirming data. The
Steering Committee identified 5 important process improvement opportunities, however they altered 4 of
the 5 after they had a chance to review targeted performance data on the process. The implications are
clear. Had we not invested time at the front end we would have been trying to solve the wrong problem.
To continue moving forward we need to provide the oncologists with sufficient new patient and
emergent/urgent treatment slots by offloading follow-up and assesses to general practitioners, nurse
practitioners, and clinical nurse specialists.
One of the key changes required to support sustainability of this project is a constant monitoring of patient
volumes and projected future demand. It is absolutely essential for GRRCC to be in front of the demand
curve to ensure we have enough staff and treatment spaces to meet the increasing demands.
The process is ever evolving. The business plan was written for over 5 years to ensure it was sustainable.
Now that the project is up and working well, multi-disciplinary team needs to adopt the new process
(changes) into their everyday practice. The project plan will continue to grow and improve to
accommodate future changes.
Reference
Hendershot, E. (2005). Outpatient chemotherapy administration: Decreasing wait times for patients and
families. Journal of Pediatric Oncology Nursing. Vol. 22, No. 1.