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“Reduction of T& O Treatment Cancellation Rates”

Clinical Safety & Effectiveness. “Reduction of T& O Treatment Cancellation Rates”. AIM STATEMENT. To reduce the rates of T&O* treatment cancellation at the CTRC Radiation Oncology Clinic by at least 10% (or absolute 10% improvement) in the next 6 months (December to May 2010).

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“Reduction of T& O Treatment Cancellation Rates”

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  1. Clinical Safety & Effectiveness “Reduction of T& O Treatment Cancellation Rates”

  2. AIM STATEMENT To reduce the rates of T&O* treatment cancellation at the CTRC Radiation Oncology Clinic by at least 10% (or absolute 10% improvement) in the next 6 months (December to May 2010). *Tandem & Ovoids Intracavitary Brachytherapy for cervical cancer treatment.

  3. Secondary Aim To reduce treatment delays by 10% (treatment duration less than 9 weeks or <63 days)

  4. Project Name: UTHSCSA CTRC ProjectReduction of T&O Treatment Cancellation Rates Participants: Tony Eng, MD Vanessa Magel, RN Team members: Jonathan Tinker, MBA Kathleen Schwegmann, RN Lupe Martinez, Edward Bustos, Diane Stewart, Kathy Scales, Luis Rocha, Liz Meyers CS&E Course Facilitators: Wayne Fischer, PhD Amruta Parekh, MD

  5. Tony Eng, MD Project Leader Oversee team progress Analyze data Vanessa Magel, RN In charge of patient coordinators Patient education Nurses and MA’s Jonathan Tinker, MBA Administrative support Problem solver “Team Facilitator” Kathleen Schwegmann, RN In charge of OR scheduling OR resources OR data OR nurses Major Responsibilities

  6. Team Organization Tony Eng, MD Team leader Vanessa Magel, RN Team leader Lee Carlisle, MD ASC Director Jonathan Tinker, MBA Facilitator David Fuller, MD, Resident Kathleen Schwegmann, RN Surgery Ctr Edward Bustos, Diane Stewart, Kathy Scales OR scheduling Lupe Martinez Med assist Luis Rocha CT Vicky & Liz Patient coordinators

  7. BACKGROUND • Cervical Cancer can be cured with radiation therapy. • One of the important prognostic factors is overall treatment time. • The duration of treatment from the first external beam treatment to the last brachytherapy has shown to decrease control rates up to 10-15% (See Ref). • Therefore, any cancellation leading to delay in radiation therapy will ultimately affect patient survival or cure. • The goal of this project is to find the causes of treatment cancellation, implement corrective actions, and ensure sustainable improvement.

  8. RT duration > 9 wks correlates with worse local control of cancer Reference Loss of pelvic control Girinsky et al. 1.0% /day Petereit et al. 0.7% /day Perez et al. 0.9% /day Fyles et al. 1.0% /day Lanciano et. ~1%/day

  9. 9-week Treatment Plan Brachytherapy 5-6 treatments, 2/wk 3 weeks Pelvic Radiation 5 weeks Break 5-7 days Consult Discharge Chemo Pelvic Sidewall Boost

  10. Discharge & Follow up Back to Referring MD New Patient Chemo Brachytherapy Pelvic sidewall boost Schedule for OR Treatment Planning Pelvic Radiation Patient Process Flowchart Yes Yes Yes Brachy-therapy ? More Treatments ? Radiation ? No No No

  11. Observation and Analysis • Treatment Cancellations • Pelvic external beam therapy-minimal • Chemotherapy-minimal • Brachytherapy-YES • So, we have to look into the brachytherapy cancellation rates and why

  12. Base Data Control Chart

  13. Secondary Endpoint Treatment Delays: May-Nov 2009Base Data Summary • 28 patients received T&O treatment • 43% completed the treatment on time (within 9 weeks or <63 days) • 57% were delayed (over 9 weeks or >63 days)

  14. Brainstorming Team Meet

  15. Created a “fishbone”

  16. Cause & Effect Diagram Patient System Environment LACK OF PATIENT REMINDER LOW PERSONNEL MOTIVATION TRANSPORATION NEEDS POOR UNDERSTANDING LOW MORALE POOR EFFFICIENCY LOW PATIENT MOTIVATION LACK OF FAMILY SUPPORT LACK OF PAITIENT EDUCATION Treatment cancellations Mother Nature LIMITED PHYSICS SUPPORT FEW PERSONNEL SUPPORT CONFLICTS CT SIM CONFLICTS NO AVAILABILITY LIMITED ROOM AVAILABILITY INADEQUATE NURSING SUPPORT TOO MANY SCHEDULERS LACK OF EQUIPMENT Scheduling Resources OR Support

  17. Common Root Causes Discussed • Patient factors (understanding, motivation, education) • Scheduling • Logistics (Transportation, finance) • Social Work • Medical problems • Resources/personnel cut

  18. Affinity sort

  19. Patient=11 System=8 Scheduling=7 Resources=2 OR support=2 Environment=2 Mother nature=1 Causes of Cancellations

  20. Pareto Diagram “80-20 rule”- roughly 80% of the effects come from 20% of the causes

  21. Brainstorm Team Suggestions • Patient Education=19 • Patient Pre-op Instructions=13 • T&O Coordinator=12 • Patient Reminder=4 • Scheduling Conflicts=4 • Schedule checklist=4 • RX in Computer=3 • Social Work Consultation=0

  22. Recommended Interventions • Reminder calls-two • Patient education • Written info for pt • Scheduling check –Pre-op meet with surg center (ASC) • Promoting Motivation • Better Communication

  23. Intervention Timeline Nurses & MAs Attending & Residents Nursing & Surg Ctr Head Nurse Increase Patient Education Written Info to patients Re-EmphasisTo patients Reminder calls Communication pre-op pts meet ASC personnel May March December January February

  24. Results

  25. Cancellation rates: 27% vs. 15%

  26. Treatment CancellationsLeading to Delays: Dec 2009-May 2010Post-intervention Summary • 10 patients received T&O treatment • 50% (vs. 43%) completed the treatment on time (within 9 weeks or <63 days) • 50% (vs. 57%) were delayed (over 9 weeks or >63 days)

  27. Statistical Significance • Cancellation rates: 27% (36/134) vs. 15% (11/73) • Z-test for 2 proportions, 95% Conf, 1-tail, • Yes, Z=1.763, • Treatment Delay rates: 57% (16/28) vs. 50% (5/10) • No, Z=0.019

  28. Return on Investment(ROI) • Primary Endpoint – Decrease cancellations • Reduction of manpower • Less waste of resources • $23,637 annualized cost savings • Secondary Endpoint – Decrease tx delays • Improved disease control • Increase pt capacity

  29. How we estimated ROI (Primary Endpoint) Step 1. Calculate Labor Cost to Schedule the Procedure • 10.6 hours of staff time • $489.24

  30. ROI (Primary Endpoint) Step 2a. Multiple Cost of Labor times 40 cases (pre-intervention) Cancelled (May through Dec) • $19,570 Step 2b. Multiple Cost of Labor times 7 cases (post-intervention) Cancelled (Jan through May) • $3,811 Step 3. Determine the difference - $15,758

  31. ROI (Primary Endpoint) $15,758 direct cost savings over 8 month period due to decreasing cancellations $23,637 cost savings annualized

  32. ROI (Secondary Endpoint) • ROI based on Reducing time to complete treatment within a 63 day period • Priceless (local control of cancer)

  33. Results Update June-Aug 2010

  34. Update: Treatment CancellationsLeading to Delays: Jun 2009-Sep 2010Post-intervention Summary • 18 patients completed HDR T&O treatment • 56% (vs. 43%) completed the treatment on time (within 9 weeks or <63 days) • 43% (vs. 57%) were delayed (over 9 weeks or >63 days) • Significant reduction of treatment delays

  35. Summary • Cancellation rates were substantially improved • Primary aim achieved • Good ROI • Significant reduction of treatment delays • Secondary aim achieved • However, other uncontrolled factors: hospitalizations (DM, amp,..), unexpected side effects (bladder spasm,..) • Limitations • small study, short follow up

  36. Future Direction • Sustain current interventions • Consider additional interventions • Continue data collection and analyses • Apply the method to other scheduled brachytherapy procedures, not just T&Os • Introduce this project to other facilities • Apply this method to other scheduled procedures

  37. Thank God it snows. I get to leave early!

  38. References • Wash U, 1995. Carcinoma of the uterine cervix. I. Impact of prolongation of overall treatment time and timing of brachytherapy on outcome of radiation therapy. Perez CA et al. Int J Radiat Oncol Biol Phys. 1995 Jul 30;32(5):1275-88. • Patterns of Care, 1993. The influence of treatment time on outcome for squamous cell cancer of the uterine cervix treated with radiation: a patterns-of-care study. Lanciano RM, Int J Radiat Oncol Biol Phys. 1993 Feb 15;25(3):391-7. • Gustave-Roussy, 1993. Overall treatment time in advanced cervical carcinomas: a critical parameter in treatment outcome. Girinksy T et al. Int J Radiat Oncol Biol Phys. 1993 Dec 1;27(5):1051-6. • Princess Margaret, 1992. The effect of treatment duration in the local control of cervix cancer. Fyles A, Radiother Oncol. 1992 Dec;25(4):273-9.

  39. Acknowledgement MY PROJECT PARTNER: VANESSA MAGEL, RNTEAM MEMBERS:JONATHAN TINKER, MBA KATHLEEN SCHWEGMANN, RNLUPE MARTINEZ, EDWARD BUSTOS, DIANE STEWART, KATHY SCALES, LUIS ROCHA, LIZ MEYERSCS&E COURSE FACILITATORS:AMRUTA PAREKH, MDWAYNE FISCHER, PHD

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