#36
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 staffsinto 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 theaverage 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.
Tools and Measurement
The team plotted the flow of the entire colorectal cancer care system from screening to surveillance.
Thistool 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.
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.
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:
- 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
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 anddemonstrated in the control chart:
The chart shows the cycle time for consult completed to OR in days with a pre-intervention average of 58.67 days. The physician team members voiced concern over this cycle time. Brain storming and multi-voting produced numerous prioritized interventions:
- 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 priorto the Veteran being scheduled for surgical consult. Implemented: October, 2009.
- 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.
- Intervention #3, Integrated both GI and Surgical specialties to stimulatecollaboration between specialties. Implemented: August 2012.
- 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.
- Intervention #5, request high priority to hire the needed Tumor Registry personnel. Subsequent accreditation is dependent upon filling this position.ImplementedApril 2012.
- 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.
- 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.
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.
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 sampleassuming unequal variances to verify that there is a statistically significant difference in the cycle time between Pre and Post-Test populations.
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.
- 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.
- 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.
•Leadersplan 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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