Transcript Mercedes Project

Enhancing the Patient Experience
in the Head & Neck Center
Pheba Philip
Office of Performance Improvement
Head & Neck Center
MD Anderson Cancer Center
 Located in Houston, TX
 Found in 1941
 20,000 Employees (1,600
faculty)
 650 inpatient beds
 1.3 M outpatient visits
 Provided care to 120,000
patients in 2013
• Ranked Number 1 in
cancer care by U.S. News
and World Report
Approach: Engagement and
Integration
HN Center
Strategic
Planning
Physician/Center
Leadership-Led Teams
Monthly Accountability Reviews
OPI
Departments
HNS, HNMO, RT
Participants
Head and Neck Center:
•
Laura Baker, Ursula Broussard, Gloria Brown, Sheila Harris, Hettie Hebert, Eve Huang, Sharon Jamison,
Grady Johnson, May Johnson, Rita Langner, Shirley McKenzie, Judy Moore, Maria Morales, Julie Ngo,
Mary Penkwitz, Marie Pope, Letitia Reed, Missy Robinson, Marvin Saavedra, Shalamar Spears, Estie
Thompson
Head and Neck Surgery:
•
Kerith Brandt, Ehab Hanna, M.D., Amy Hessel, M.D., Stephen Lai, M.D., Carol Lewis, M.D., Jeff Myers, M.D.,
Justine Robinson, Shawn Terry, Abram Trigazis, Randal Weber, M.D.
Head and Neck Medical Oncology:
•
Michele Neskey, Karen Oishi
Radiation Oncology:
•
Beth Beadle, M.D., Amanda Coldiron, Jennifer Gates, Hamlin Williams
Office of Performance Improvement:
•
John Bingham, Laura Burke, Parviz Kheirkhah, Victoria Jordan, Miguel Lozano, Jeremy Meade, Pheba
Philip, Larry Vines
Marketing:
•
Cecilia Kenneally, Gelb Consulting
Clinical Operations:
•
Kathy Denton
Background
Head and Neck Center formed a partnership with the Office
of Performance Improvement to:
• Define a series of performance improvement initiatives to
enhance the patient experience
• Align projects with Institute of Medicine aims:
• Safe
• Effective
• Patient-Centered
• Timely
• Efficient
• Equitable
Initiatives
1. New patient access time
Timely
First contact to initial
appointment
2. Overall patient cycle time
Timely
Time gaps in treatment
3. Clinical variation and
overuse of testing
Effective,
Efficient
Duplication and inconsistent
use of diagnostic imaging
services and lab tests
4. Patient interviews
PatientCentered
Gather the voice of the patient
to capture expectations,
preferences and concerns
5. Staffing model
development
Efficient
Part of the current RN staffing
model development in the
ambulatory care centers
New Patient Access Time
Faculty Leader
Carol Lewis, M.D.
Team Leader
Sheila Harris
Assistant Professor,
Head and Neck Surgery
Patient Access Supervisor,
Head and Neck Center
Facilitator
Pheba Philip
Industrial Engineer, Performance Improvement
Members
Hettie Hebert (PAC), Shalamar Spears (PAS), Judy Moore
(CAD), Jeremy Meade (OPI)
NP Access
New Patient Access
300+
New patient referrals per month
200+
New patients registered per month
Emphasis on Since FY10, 10% increase in other appointments
appointment required to coordinate with NP appointment
coordination
Project Reduce referral (first contact) to appointment date,
AIMS including medical and financial clearance, from 12
days to consistently under 10 days
NP Access
Cause and Effect
NP Access
Main Interventions
Enforced 24-hour rule
for referral
acceptances
by faculty
(no exceptions)
Trained PAS staff on
round robin approach
to assigning
appointments to
physicians
Faculty commitment
to require minimal
acceptance criteria
(don’t delay acceptance
based on inadequate
outside records)
Process for immediate
redirecting referrals to
a more appropriate
physician, avoiding
patient acceptance
delays
Enforced timely filing
of delay indicators and
educated PAS on the
importance
(patient preference,
insurance pre-approval,
financial/social reasons)
Standardized patient
appointment templates
in CARE to facilitate
scheduling
NP Access
Improvement of Metrics
H&N Center - Referral to Appointment
20.0
Baseline
Post intervention
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17.5
•
•
Days
15.0
12.5
10.0
7.5
Timely filling of delay
indicators
PAS education & training
Enforced 24-hour rule
•
_
X=11.53
•
Trained/Re-educated
PAS staff on round robin
approach
_
X=8.21
Reinforced email policy
for redirecting referrals
to other physicians
Corrected CARE default
time issue for next
available appointment
•
Standardized new
patient appt
durations on
templates
•
•
1
HC
Transfers
Low
sample
size
sensitive to
outliers
1
_
X=7.36
5.0
0
p-1
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1
2
2
2
3
3
3
3
-11 ay- 11
p-1 Jan-1
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p- 1 Jan -1
y-1
p-1 ec-1
a
a
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Jan
D
M
S
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M
S
Month
NP Access
Keys to Sustainment
Continued support and
monitoring from
department chair, medical
director and CAD
PAC monitors and
communicates open
appointment slots
regularly
PAC audits charts for
accuracy, completeness,
and compliance of
expectations of 3-5 day
appointments
Actively monitor % of
patients who fall outside
of the standard time for
testing (3-5 days)
Clinical Variation & Overuse of Testing
Faculty Leader
Amy Hessel, M.D.
Team Leader
Judy Moore
Professor & Chair, Head and Neck
Surgery
Clinical Administrative Director,
Head and Neck Center
Facilitator
Laura Burke
Performance Improvement Associate
Members
Jeremy Meade (OPI), Laura Baker (PAS), May Johnson (CBM), Hamlin
Williams (PSC), Missy Robinson (PSC), Eve Huang (RN), Julie Ngo (RN),
Dr. Beth Beadle (XRT Faculty), Karen Oishi (APN), Justine Robinson (PA),
Abram Trigazis (PA), Michele Neskey (PA), Amanda Coldiron (PSC),
Jennifer Gates (RN, NM XRT)
Clinical Variation
Aims
• Standardize the treatment planning and follow up
schedules for all HNS cancer patients requiring
multidisciplinary care including oropharynx, larynx and
hypopharynx
• Reduction of redundancy of imaging and laboratory tests
• Increase efficiency and decompress the volume of the
clinics
• Improve patient satisfaction: fewer appointments and
decreased wait times
• Facilitates accommodation of new patients and greater
focus on patients with acute care needs
Clinical Variation
Baseline Data:
After 6 months (Post radiation summary date)
Time Between Appointments and CT Scans (Soft Neck Tissue)
Appointments
CT Scans
Percent of Appointments
60%
56%
•
43% of appts are within 3 months of
last appt
•
11% of CT scans are within 3
months of last scan
50%
40%
45%
30%
22%
20%
18%
13%
10%
0%
0.5%
7%
0.8%
8%
6%
9%
1%
1%
Less than 1 Week - 1 - 2
2-3
3-6
6-9
9 - 12
1 Week 1 Month Months Months Months Months Months
Time Frame
6%
6%
1%
More
than 1
Year
Main Interventions
Identified critical timing
for follow up &
treatment decisionmaking
Assigned equal
responsibility for
patient outcome &
complications to all the
treating teams
Defined minimum
testing needed for
appropriate work-up &
follow up
Standardized order
form to include
predefined testing
Provided training for
providers, schedulers,
and nurses
Created patient
education sheet to
better inform patients
about the benefits of
the COC pathway
Clinical Variation
Continuity of Care Pathway
• Developed a “leap frog” system for follow up appointments after
completion of treatment
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–
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3 Month Follow Up
6 Month Follow Up
9 Month Follow Up
12 Month Follow Up
16 Month Follow Up
20 Month Follow Up
24 Month Follow Up
After 2 years
Radiation Oncology
Medical Oncology
Surgery
Radiation Oncology
Medical Oncology
Surgery
Radiation Oncology
Survivorship
• Allows patient to have one appointment and one set of tests
rather than follow up with each provider team independently
Clinical Variation
Patient Report Card
Patient Report Card
• Given out by HNS after
the evaluation for surgery
• Allows for patient
responsibility
• Allows for equal
ownership of post
treatment follow up
• Allows for expectation of
transition to survivorship
Clinical Variation
Transition to Follow Up
Standardized CSR
to include
predefined testing
Clinical Variation
Faculty Involvement
Faculty with COC Appointments
30
25
Target = 24
Current = 22
15
Providers
10
•
Faculty involvement
has increased
•
65% eligible patients
are on pathway
5
Target
Month
Sep-13
Aug-13
Jul-13
Jun-13
May-13
Apr-13
Mar-13
Feb-13
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
Apr-12
Mar-12
Feb-12
Jan-12
Dec-11
Nov-11
Oct-11
Sep-11
Aug-11
Jul-11
Jun-11
0
May-11
# Faculty
20
Clinical Variation
Preliminary Trends/Results
Appointments 28% reduction in appointments
within 3 months of past
appointment
37% of eligible patients are
expected to have a reduction in
total number of appointments
Testing Patients are receiving standard
labs and imaging
As participation increases, expect
to see reduced variability in
imaging
Patient Wait Time
Faculty Leaders
Ehab Hanna, M.D.
Team Leaders
Judy Moore
Professor & Medical Director, Head
and Neck Surgery
Clinical Administrative Director,
Head and Neck Center
Randal Weber, M.D.
Professor & Chair, Head and Neck
Surgery
Facilitators
Miguel Lozano
Sr. Quality Engineer, Performance Improvement
Members
Kerith Brandt (PA), Marvin Saavedra (PSC), Jeff Myers, M.D. (HNS), Carol
Lewis, M.D. (HNS), Grady Johnson (PSC), Shawn Terry (PA), Mary
Penkwitz (RN), Julie Ngo (RN), Amy Hessel, M.D. (HNS)
Wait Time
Patient Wait Time
Classic PI approach using the DMAIC process
Define
Measure
Analyze
• Defined the problem
• Observed and documented patient process flow
• Identified patient characteristics and expectations for
each appointment type
• Collected baseline patient wait time data for all
physicians
• Identified lowest wait time performers
• Documented best practices
• Analyzed template and scheduling practice and its
impact on wait time
Wait Time
Patient Wait Time
Preliminary findings to be trialed
Improve
•
Reinforce & prioritize best practices around team communication,
scheduling decisions, and startup/preparation activities.
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Avoid appointment clusters in same time slots
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Spread NP appointments throughout the day
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Make scheduling arrangements for high need patients
Wait time to see Physician
250
NP
NP
NP
NP
150
CO
Minutes
Control
200
NP
NP
100
Linear (Wait time to see Physician)
NP
CO
50
Wait time to see Physician
NP
0
Appointment Time
Wait Time
Scheduling Changes
• Earlier start time
• Reduced
appointment
clusters
• New patients
spread during day
• Improved
schedule load
leveling
Average Patient Wat Time
140
122
120
100
83
80
70
58
60
40
20
0
Baseline
Improvement
Provider A
Baseline
Improvement
Provider B
The Patient’s Perspective
Opportunities for Improvement Through Patient Interviews
Faculty Leader
Ehab Hanna, M.D.
Team Leader
Judy Moore
Professor, Head and Neck
Surgery
Clinical Administrative Director,
Head and Neck Center
Facilitator
Cecilia Kenneally
Manager, Marketing
Members
Gelb Consulting, May Johnson (CBM), Shirley McKenzie
(CCC), Jeremy Meade (OPI), Ehab Hanna, MD (HNS
Faculty)
Patient Interviews
Patient Interviews
•
41 interviews were completed with patients from June 11 – June
22, 2012. Interviews conducted by Gelb Consulting through
Marketing.
•
Interviews were completed on site at the Head & Neck Center.
On-site interviews provide visual cues for recall.
•
Some patient interviews included family/caregivers, revealing
unique roles and needs.
•
Discussion areas:
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Decision criteria
Scheduling
Wait times during and between appointments
Experience with treatment team
Communication processes and gaps
Sources of anxiety
Areas of praise
Patient Interviews
Head & Neck Center Patient Experience Map
Need
Symptoms
Diagnosis
Awareness of
MD Anderson
Evaluation of
healthcare providers
Scheduling
First Visit
Choose healthcare
provider
Parking
Scheduling and intake
Getting to Head &
Neck Center
Treatment/exam room
Scheduling first visit
Resources for patients
and their families
Checking-in
Waiting area,
including vitals
Reputation of
MD Anderson’s
Specialists
•
•
MDACC Faculty/Staff
Patients and their
Families
Treatment
Clinic faculty/staff
interactions
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Front Desk Staff
Faculty/Medical Staff
•
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Faculty/Medical Staff
Support Staff
Chemotherapy,
Radiation Treatment,
Surgery
Follow Up
Communication with
referring physician
Follow-up visits
Call-backs for
assistance
Nursing care,
Physician care
Support groups and
wellness services
•
•
Faculty/Medical Staff
Support Staff
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•
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Primary Experience Stewards
Key Touchpoints
Faculty/Medical Staff
Support Staff
Patient’s Primary
Physician
Patient Interviews
Action Item Summary
Need
Action
Strengthen relationship with referring/primary Send personalized thank you note to
care physicians
patients' referring physicians
Lead
Dr. Hanna
Actively get referring physicians connected to
myMDAnderson
Include w/communication (thank you note)
Judy Moore
to referring physicians
Improve coordination of out of town patients
and set expectations to patients needs
Improve BC practice of coordinating out of
town appointments to a standard of 3-5
days for HNS and up to 7 days for HNMO
Judy Moore
Comment
Status
Letter complete. Next step is to gather faculty
Inpreferences on who to send to (all on cc list or
progress
patient preference)
Will be included with letter
Adopted process - PAC checks/validates
Inreferring physician in system. July Physician progress
Communication Initiative Report increased to
100%
Adopted process:
PAC audits charts for accuracy, completeness,
and compliance of expectations of 3-5 day
appointments
Complete
Actively monitors % patients that fall outside
of the standard time for testing (3-5 days)
Ensure we are providing clear, consistent
information prior and duration patient visits
Work with Patient Education to better
leverage patient and staff resources
Judy Moore
Met with Patient Education. Options to
consider:
1) Provide patient with patient education flyer
or post in center/exam room
2) Provide patient with flyer about patient
orientation course or post in center/exam
Inroom
progress
3) Re-train staff about benefits/offerings of
Patient Education Center (take tour, CEU
credit?)
4) Allow patients to take on-line orientation
course on exam room computer
Improve patient communication about
treatment options
Continue to compress appointments and
improve coordination between services
Decrease appointment wait times and improve
communication when wait times exist
Work with Patient Education to better
leverage patient and staff resources
Judy Moore
See above
Leverage Continuity of Care project
Dr. Hessel
Current, on-going project team
On-going
Leverage Wait Time project
OPI - Miguel Lozano Current, on-going project team
On-going
Ambulatory Nursing Staffing Model
• Nursing Personnel Staffing Model was developed
to help leadership:
– Make staffing decisions based on data
– Make sure resources are properly allocated
– Analyze “what-if” scenario for improvement initiatives
Keys to Success
Combined engagement
of OPI, academic
department, and center
leadership
Monthly accountability
meetings with steering
team
Strategic planning
upfront to align projects
to goals
Physician
participation/leadership
on teams
Questions?