Improving timeliness of care for patients receiving chemoradiation for non-small cell lung cancer

1. Improving timeliness of care for patients receiving chemoradiation for non-small cell lung cancer Todd Carpenter, MD Dept of Radiation Oncology

2. BACKGROUND • Excessive treatment delays can lead to worse outcomes and increase patient distress • Many inter- and intra-departmental factors affect the time to initiation of treatment • Baseline audit showed average time from initial contact to start of treatment was nearly 5 weeks

3. BACKGROUND • The purpose of this project was to • identify factors within the Rad Onc department that may contribute to delays • decrease the total time required for patients to begin treatment

4. Team members • Sylvia Fernandez, RTT • Erin Pino, RTT • Awais Mirza, RTT • Joseph Santoro, PhD • Christine Driscoll, RN • Constantine Souliades • Jenna Moglia • Jason Morgenstern • Ulka Kothari, MD and Lyn Quintos, MD (mentors) • Jonathan Haas, MD and Maureen Oliveri, RN (top dogs)

5. SMART AIM • To shorten the time interval from scheduling of consultation to first day of radiation therapy from 34 to 24 days for all patients receiving definitive chemoradiation for newly diagnosed Stage III nonsmall cell lung cancer by June 2018

6. LEAN • Emphasizes the elimination of waste

7. MACRO PROCESS MAP

8. DETAILED PROCESS MAP • Up to 75 individual steps from initial contact to start of treatment

9. MACRO PROCESS MAP 10.7 d 8.2 d 6.7 d 4.9 d 2 d 1.5 d

10. PARETO (100%) (94.7%) (89.7%) (75.3%) (55.6%) (31.4%)

11. PARETO (100%) (94.7%) (89.7%) (75.3%) (55.6%) (31.4%)

12. KEY DRIVER DIAGRAM

13. INTERVENTIONS • Increase access to physician • Goal to go from 10.7 days to 5 days • Educate front office staff • Create saved appointment slots in MD schedule for lung cancer consultations (3/week) • Increase access to equipment • Goal to go from 8.2 days to 5 days • Create saved slots in CT sim schedule for lung cancer simulations (3/week) • Create process to expedite insurance authorization • First PDSA cycle implemented 1/2018

14. Results Run Chart 3/2017 8/2017 1/2018 5/2018

15. Results • Statistically significant decrease in mean time from initial contact to start of treatment from 34.1 days to 20.375 days (p=0.011) • 87.5% (7/8) patients initiated treatment by the target goal of 24 days • 87.5% (7/8) patients seen by oncologist by the target goal of 5 days • 87.5% (7/8) patients underwent CT simulation by the target goal of 5 days

16. Lessons Learned: • Targeted education and reorganization of departmental resources effectively eliminated excessive delays for our patients • Ongoing education and feedback helped staff appreciate the importance of implementing desired changes • The intervention benefited from the relatively small patient numbers, which minimized any potential conflicts

17. Limitations: • It remains to be seen whether other limitations in resources (eg, departmental treatment capacity and MD availability) will hinder further progress • Identify potential balance measures to ensure that improving patient access to care in this subpopulation is not coming at the expense of other groups of patients treated in our department

18. Next steps • Continue monthly audits • Take steps to continue to ensure that the practices/procedures that improve scheduling efficiency become permanently ingrained in the department • Expand this improved throughput capability to other rapidly growing carcinomas (eg, head and neck cancer and cervical cancer)

19. Acknowledgements • Ulka Kothari, MD • Lyn Quintos, MD • Jonathan Haas, MD • The rest of the team: Maureen Oliveri, RN; Sylvia Fernandez, RTT; Erin Pino, RTT; Joseph Santoro, PhD; Christine Driscoll, RN; Constantine Souliades; AwaisMirza, RTT; Jason Morgenstern; Jenna Moglia

20. Questions?