The objective for the “Wait Time Reduction Project” at the Grand River Regional Cancer Centre (GRRCC) was to reduce the wait times for patients receiving chemotherapy. Prior to the project, the average wait time, based on a rolling 3 month median, was 5.5 weeks from referral to treatment. The project goal was to achieve the Ontario wait time target set for 2007 / 2008, where 70% of new patients started systemic therapy treatment within 4 weeks of referral.
Basadur Health in consultation with senior staff established a project team made up of professionals involved in all functional aspects of the treatment process, including referral, scheduling, planning, treatment and post-treatment. After a thorough, yet quick review of the existing systemic therapy process, four opportunities were identified and four teams implemented high impact solutions.
Fig 4. Four solutions were implemented.
In terms of patient impact, it was confirmed that the period of time from referral to the initial Oncologist meeting was a key driver of patient anxiety. Prior to the project implementation, only 58% of patients were seen within 2 weeks.
The Client targeted to schedule consults within two weeks of referral, 80% of the time. This was accomplished by assigning some follow-ups and assesses for all sites to staff other than Oncologists. This eliminated a significant bottleneck, enabling Oncologists to see more new patients in a timely manner.
It had been determined that errors were more likely to occur in the booking process when multiple secretaries handled multiple patient files and complex bookings. This often led to extensive delays. Furthermore, the chemotherapy suite was often underutilized due to an inability to match patient needs with resources. Generally, as patient volumes for chemotherapy treatment delivery increased, wait times increased.
In order to streamline the booking process and get patients to their first treatment within 3 days of the decision to treat (DTT), one secretary was assigned to process all bookings and orders for each patient group using a complexity scale.
In order to maintain a safe process for clerical staff, a complexity scale for all protocols was developed and included an acuity rating (A,B,C,D,E) chosen by either a chemo nurse or physician. This complexity scale was an important aid in scheduling realistic time to administer chemotherapy or other supportive care procedures.
Urgent or emergency patients where often scheduled into fully booked clinics. This bumped already booked patients and set the entire schedule askew. It created extensive delays and dissatisfaction for the delayed patients and their families.
Designated “emergency patient” time slots were established for each Oncologist. This enabled emergency and urgent patients to be effectively attended to in a timely manner while respecting site group needs.
There was inflexibility in the chemotherapy suite scheduling for add-on patients and non chemotherapy support treatments.
A separate transfusion unit and bone marrow unit were established. This enabled flexible handling of these special patients without negatively impacting suite capacity for regular chemotherapy treatments.
The project was initiated in April 2007. Over the course of one year, chemotherapy median wait times have trended down. Our data show 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.
Fig 5. Wait Time Change
Additionally, these changes have resulted in an increased number of patient’s starting chemotherapy 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.
Sustainability and Learnings
Now that GRRCC has seen success in reducing wait times , 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.
For sustainability of achieved gains GRRCC recognizes the need to build on their success and continue using the tools developed in the initial project – the Simplified Process Flow Chart, the Report Card and the multifunctional Steering Committee structure.
Another key to project success, was the fact that the Solution sub teams created, and the Steering Committee selected, solutions which could be implemented within 30 to 60 days. 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.
An important learning for 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.
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 enough staff and treatment spaces are available to meet the increasing demand.
The process is ever evolving. Now that the project is up and working well, the multi-disciplinary team needs to adopt the new changes into their everyday practice.