April Value Grand Rounds Re-Cap
Dartmouth-Hitchcock’s Norris Cotton Cancer Center (NCCC) Infusion Suite serves more than 13,000 patients a year. It’s a complex operation that requires the collaboration of patients, providers, nurses and pharmacists. However, achieving the synchronicity between the different groups needed to consistently run on time had proved challenging, leading to long wait times for infusion services and frustrated patients. D-H employees were also frustrated because they wanted to provide the best experience possible for patients and improve on-time performance.
At the Value Grand Rounds on April 19, four presenters reported on the results of this project in a presentation titled “Accelerating Patient Experience Improvements: NCCC Infusion Suite RPIW.” The Value Institute’s Performance Improvement team consisted of Senior Value Performance Specialists Dennis McGrath and Sara Simeone, MSN, RN,and the other project leaders and presenters were Nikki Nash, MSN, RN, OCN, BMTCN, nurse manager of NCCC Nursing Operations in the NCCC Infusion Suite and David Crosby, PharmD, BCOP, BCPS, pharmacy manager of NCCC and Investigational Drug Services, Inpatient Pharmacy. As they reported, their project not only achieved its target of treating 80 percent of patients on time, it has exceeded it by three percent.
“This is huge!” Simeone told the Value Grand Rounds audience assembled in the Williamson Translational Research Building’s auditorium H. “After years of being stable at 67 percent they are now stable at over 80 percent. The patient experience has also improved because the majority of them are being treated on time.”
A series of projects over the past five years, led jointly by Value Institute Blackbelts and NCCC operational leaders, streamlined the infusion patient process, stabilized the system and cut delays. But they still weren’t meeting their target of treating 80 percent of patients within 45 minutes of their appointment time. The Value Institute came in again last fall, this time to help reduce waiting times for patients, improve on-time performance and increase system predictability. They used the Define, Measure, Analyze, Improve, Control (DMAIC) methodology delivered via a Rapid Process Improvement Workshop (RPIW), and the interdisciplinary RPIW team included nurses, providers and pharmacists.
As McGrath noted at the start of the Grand Rounds, they were confident that NCCC was primed for success because they were early adopters of the DMAIC methodology, and “had trained Yellowbelts and Greenbelts and had successfully executed some award-winning projects.” But one of the key factors was the successful collaboration of Nursing and Pharmacy, Simeone said, as well as leveraging lessons learned from previous improvement work including Project PRISM (Pharmacy Reliability, Improvement and Safety Mission), which ensured that we “weren’t overloading the pharmacy capacity” when scheduling infusion visits.
Pharmacy does the majority of their clinical review in advance of the patient visit, often preparing patient specific chemotherapy the night before the infusion appointment. “There’s a lot more predictability in our work for NCCC because greater than 80 percent of patients receive the planned regimen exactly as prescribed prior to their arrival,” Crosby said, adding that one of their greatest opportunities for improving delays was infusion-only appointments. By the completion of the RPIW, they went from four out of five cases where the chemotherapy regimen wasn’t ready in a 45-minute window to having weeks where greater than 90 percent of infusion-only appointments had every medication ready within the 45-minute metric. In addition, for cases where the entire drug regimen was available before the infusion appointment, 89 percent of patients started treatment within 45 minutes of their infusion appointment time. If drugs weren’t available prior to infusion, 73 percent were treated within 45 minutes. Crosby said that by identifying more patients whose treatment could be prepared in advance of the appointment, they were able to decrease the amount of time patients would wait for their first medication.
As Nash noted during her presentation on the project’s nursing component, there were still certain delays that had to occur for patient safety, such as the wait between seeing the provider and starting the infusion because “this is when nurses and Pharmacy are doing their safety check.” But nursing was able to reduce patient delays by designating an IV nurse, whose sole responsibility is to place IVs. However, one of the things they learned, she said, is that you can’t simply implement a new role; it took about six weeks of focused, rapid plan-do-study-act (PDSA) cycles to figure out how to make the IV nurse’s role work for patients.
Nursing has been able to reduce delays and now 80 to 90 percent of IVs are placed prior to the start of the scheduled infusion visit, a process that can take from 12 to 85 minutes. Nash said that an infusion nursing huddle board has also been helpful because it allowed them “to look at on-time performance and drill down on missed performances.” She added that “Rate the Day” has showed an improvement in nursing work experiences post-RPIW because complaints about lateness in the clinic have been reduced.
At the conclusion of the Value Grand Rounds, McGrath noted that the project had been “complex, but the solutions were not complicated.” The team used daily huddles, standard work, and level-loading to make the system perform better, and these are the building blocks of continuous improvement. Simeone then pointed to the following keys to the project’s success:
- Baseline performance data and specific goals
- Team familiarity with performance improvement process and tools
- Operational owner commitment
- Staff engagement
- Ongoing data analyst support
- Team’s willingness to engage in rapid change