improving the cycle time to diagnose and begin breast cancer treatment

Improving the Cycle Time to Diagnose Improving the Cycle Time to Diagnose and Begin Breast Cancer Treatmentand Begin Breast Cancer Treatment

The Women’s CenterThe Women’s Centeratat

Boca Raton Community HospitalBoca Raton Community Hospital

March 31,2006

Copyright 2006, BRCH

Boca Raton Community Hospital (BRCH)Boca Raton Community Hospital (BRCH)

• 394 bed community hospital in South Florida

• 45,000 ED visits annually

• 21,000 discharges annually

• 2,000 births

• 250,000 Imaging Procedures


The Women’s Center/Center for Breast CareThe Women’s Center/Center for Breast Care

The Women’s Center @ BRCH• 42,000 procedures in 2005

– 20,800 screening mammo’s– 9,270 diagnostic mammo’s– 4,400 ultrasounds– 2,000 interventional procedures– 4,120 bone densities– 3,000 MRI’s

• 33 FTE’s Budgeted, 24 actual• 363 Cancers detected in 2005


• Promote “Culture of Excellence” across enterprise• State-of-the-art approaches to improvement,

innovation, team-building, and collaboration• BRCH is building a new teaching hospital that is

to be safe, patient- and family-friendly, cost effective and efficient, driving best possible patient outcomes

• We know the height of insanity is to keep doing the same thing over and over again and expect better results!

Enterprise Excellence at BRCH Enterprise Excellence at BRCH


Enterprise Excellence InfrastructureEnterprise Excellence Infrastructure

• EE Department includes:– 4 Executive Directors

• Nursing (CNO)• Imaging Services• Ancillary Services (lab, pharmacy, respiratory, food

services, environmental services / housekeeping)• Finance

– VP experienced Six Sigma Sr. Master Black Belt

• Enterprise Excellence Steering Team– COO, CMO, CNO, CFO, VP HR– Physician representative (board)


EE Infrastructure for Major ProjectsEE Infrastructure for Major Projects

• Project Steering Team– Senior Executive Champion(s)– 2 or more Physicians– EE Black Belts

• Working Teams– Report outs to the Project Steering Team– Facilitated by BB’s or GB’s– Staff and physician members of working teams– Follow EE Improvement Model (e.g., Six Sigma)


EE Process Improvement ModelEE Process Improvement Model

Preparation

EstablishBaseline

IdentifyRoot Causes

IdentifySolutions

Implement &Maintain

Continue?

Continue?

Continue?

Continue?

Yes

Yes

Yes

Yes

End ProjectNo

End ProjectNo

End ProjectNo

End ProjectNo


Background - Why Enterprise Excellence @ the WCBackground - Why Enterprise Excellence @ the WC

Center for BreastCare

Call forAppointment

ScreeningMammogram

DiagnosticMammogram

BreastUltrasound

Biopsy

Results

3 Weeks

4 Weeks

4.5 Weeks

1 Week

3-7 Days

Total Process Time: 13 Weeks


Women’s Center Team InfrastructureWomen’s Center Team Infrastructure

Core Steering Team

Team 1Before the Appointment

Team 2During the Appointment

Team 3After the Appointment

Team 4Coordination of Services

Women’s Center &The Cancer Program


Background – Our Phased ApproachBackground – Our Phased Approach

Multigenerational Project Plan (MGPP)

Months May Jun Jul Aug Sep Oct Nov DecPhase 1

Stabilization

Phase 2Optimization

Phase 3Innovation


Women’s Center Phase 1Women’s Center Phase 1

• Stabilization of processes after conversion to digital imaging and construction. Includes:– Analysis of staffing needs– Alignment of responsibilities– Implementation of film management plan – Decisions regarding equipment configuration

• Goal – 8 weeks Total Cycle Time from initial appointment through biopsy results

• Timeline: May – September 2005



• Optimization of processes– “Today’s” constraints (e.g., budget, facility, staffing)– Alignment (e.g., Imaging services, oncology services,

women’s services)

• Goal– 4 week Total Cycle Time from initial appointment to

biopsy results– Increase in Press Ganey scores for Women’s Center

(Imaging)– 100% Records released with 24 hour notice

• Timeline: July – November 2005



• Innovation / Exploration:– Service expansion– Facility enhancement– Equipment– Staffing

• Goal– 1 Week Total Cycle Time from appointment to biopsy results– Additional services available with similar performance– State of Art Center and Academic Training Site

• Timeline: October - Present


Project TeamsProject Teams

1. Prior to Appointment Process – Mark Viau– Film Storage – Scheduling– Pre-registration– Pre-authorization and Insurance – Film Handling

2. During Appointment Process – Becky Southern– Screening, Diagnostic, Ultrasound, Biopsy– Bone Density

3. After Appointment Process – Dr. Kathy Schilling/Becky Southern– Results / Releases– Follow-up Appointments


PHASE 1 – StabilizationPHASE 1 – Stabilization

Project TeamsProject Teams


Team 1 – “Prior to the Appointment Team 1 – “Prior to the Appointment Process”Process”

Film Releases• Currently

performing at 24 hours

• Goal: 24 hours

Film Storage 5 year savings,

$560,000

Film Releases

Request madeto pick-up films

InformationObtained prior

to Patientarriving

Images areDigital

Inform Patientof delay

STAT Releasesdue to no request

or request notpicked up

Films areprinted by

whoever hastime

Request filmsfrom BRCH or

SterlingWarehouse

Films arebrought tofileroom toready forrelease

Release jacketand paperworkare brought tothe release

desk

Patientarrives andfilms arereleased

Images wereobtainedDigitally

Initiate printingfilms

Films arerequestedSTAT fromBRCH orSterling

Warehouse

Will PatientWait Films arrive

Patient leaveswith

instructions onwhen to return

Yes

No

Yes

No

Yes

No


Team 1 – “Prior to the Appointment Process”Team 1 – “Prior to the Appointment Process”

Goal: Filmless and Paperless

• Implementation of Picture Archiving Communication Systems (PACS) environment

• Additional GE reading station • McKesson PACS station• Tech Workstations• Renovation of workspace planned

Team 1 – “Prior to the Appointment Process”Team 1 – “Prior to the Appointment Process”

Support Service ProcessesSupport Service Processes


Team 1 – “Prior to the Appointment Team 1 – “Prior to the Appointment Process”Process”

Kaizen Event

• Centralized Scheduling

• Registration

• Billing

• HIMS/Coding

• Managed Care

Central Scheduling

Registration Billing

Women’s Center

Patient

HIMSCoding

Supporting Departments

Interrelationship

Diagraph

Manage Care


Pt. or M.D.call/faxes/system

for appt.Screening? Schedule

Appointment

Diagnostic -Requires Script

Pre-RegistrationAuthorization

(1-2 daysprior)

Paperwork goes to IC/WC Green dots to WC, Yellow dots require deductable or co-pay, Red dots has missing info

Patient arrivesat WC, signs-inand completesregistration ifneccassary

(green/yellowred dots).

Requiredtesting

performed

Reportscompleted and

patientcharged

Screening anddiagnosticcharges byfront desk

Paperwork is returned to registration

4-Days fromservice, finalbill drops in

STAR

Medicare?

Paperwork is sent to HIMS

Coders codefrom OPT facesheet (it hasoriginal diag.,pt. demo and

ins. info)

Claimsscrubbing

(Care-Medic)

Account codedinto STAR

Clean bill? Final Bill

Obtain neededinfo from M.D.Worked in B.O.

Yes

No

YesYes

Additionalviews charges

by techs

Accountsflipped PRO to

OPT

Claimsscubbed in

EC2000

No No

Support Services Process


Patient Calls

Obtain PatientsName,

SS#,DOB, Address andInsurance Info

Obtain Examand Selectfrom PHS

EnterDiagnosis

Check nextavailable or

patientprefferanceand location

Select patientfrom database

Previouspatient

Verifyappointment

time andlocation

Updateprevious

patient infowith updatedinformation

Patient still online

Pre-registerpatient with

requiredinformation

Flip to StarRegistration

takes about 2minutes

End Call

Yes

No

Yes

No

Scheduling ProcessScheduling Process




Appointment



(1-2 daysprior)




Requiredtesting

performed


patientcharged




STAR

Medicare?



ins. info)

Claimsscrubbing

(Care-Medic)




Yes

No

YesYes


by techs


OPT

Claimsscubbed in

EC2000

No No

Support Services Support Services ProcessProcess


ScreeningMammo

ScheduledPrior patient

Request FimJacket from

Sterling

New J acket isCreated Note:This J acket is

only forPaperwork at

this Time

SterlingDelivers J acket

to BRCHWarehouse orMain Fileroom

Jacket isDelivered to

WC Front Desk

Jacket Goes toTechnical Work

Area WithPatient

J acket Goes toRads Reading

AfterScreeningMammo isCompleted

Jacket stays inRad Reading

from 1-5 Daysuntil it isDictated

Digital Imagesare Read as

NegativeJ acket goes toWC Fileroom

Jacket goes toFileroom for

PatientCall-back

Catagory 0

When allPaperwork isdone J acket

goes to BRCHWarehouse

Jacket goes toSterling inQuarterly

Purge

Two DaysPrior to Dx.

Mammo J acketgoes to

DiagnosticControl Work

Room

Pick upWork Flow

for Dx.Mammogram

Yes

No

Yes

No

Paperwork/Jacket ProcessPaperwork/Jacket Process




Appointment



(1-2 daysprior)




Requiredtesting

performed


patientcharged




STAR

Medicare?



ins. info)

Claimsscrubbing

(Care-Medic)




Yes

No

YesYes


by techs


OPT

Claimsscubbed in

EC2000

No No

Support Services Support Services ProcessProcess


DiagnosticMammogramCompleted

Previous BRCHPatient

J acket andWorksheetDelivered toRadiologists

Patient hasfilms with them

Patientrequested to

bring inprevious films

Patient deliversfilms to front

deskFilms given to

any tech

Films go totech hold,

matched withcurrent jacket

Radiologistreviews films

Additional filmsrequired

Additional filmscompleted

Patientreleased withpreliminary

report

Radiologistdictates final

report inPowerscribe

and MRS

Radiologistssigns off onreport withelectronicsignature

MRS generatespatient letter

next work day

Letters sent tomailroom

Letters mailedto patient

Letter isreturned due to

wrongaddress

Patient calledto obtain new

address

Patientletter

processfinished

Ordering MD ison Portal orAuto-fax

MDrecievesreport

Reports batchprint every

hour

Reports areplaced inenvolope

Reports sent tomailroom

Reports mailed

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Mammo Reporting ProcessMammo Reporting Process

Team 2Team 2

“During Appointment Process”


Team 2 – “During Appointment Process”Team 2 – “During Appointment Process”

Original Digital Implementation Plan– 2 dedicated digital screening units– 1 additional digital diagnostic unit + analog units– 2006 Budget Year additional diagnostic digital unit (1-2)

Interim Step– Screenings performed on digital and analog to decrease read

time by radiologists

Pre-project Process– 1 dedicated digital screening unit– 2 dedicated digital diagnostic units– 1 analog backup


TechCompetencies

5/3

Dr. Morrell5/4

Clerical Staffing

4/4

IS3/4

Radiologists3/6

Ultrasound2/6

Equipment6/3

Team 2

Interrelationship

Diagraph

TechnologistsStaffing

5/5


Team 2 – “During Appointment Process”Team 2 – “During Appointment Process”

Opportunities • Clarify job responsibilities/accountabilities

• Increase daily procedures to decrease backlog

• Develop and implement protocols

• Identify best practice models for flow and equipment

• Overall Equipment Capacity Study • Capital needs assessment

• Develop Process for Change

Team 3Team 3

“After Appointment Process”


Team 3 – “After Appointment Process”Team 3 – “After Appointment Process”

Opportunities

• Result reporting resolved

• Reviewing all printed patient letters

• Physician communication plan


DiagnosticMammogramCompleted

Previous BRCHPatient

J acket andWorksheetDelivered toRadiologists

Patient hasfilms with them

Patientrequested to

bring inprevious films

Patient deliversfilms to front

deskFilms given to

any tech

Films go totech hold,

matched withcurrent jacket

Radiologistreviews films

Additional filmsrequired

Additional filmscompleted

Patientreleased withpreliminary

report

Radiologistdictates final

report inPowerscribe

and MRS

Radiologistssigns off onreport withelectronicsignature

MRS generatespatient letter

next work day

Letters sent tomailroom

Letters mailedto patient

Letter isreturned due to

wrongaddress

Patient calledto obtain new

address

Patientletter

processfinished

Ordering MD ison Portal orAuto-fax

MDrecievesreport

Reports batchprint every

hour

Reports areplaced inenvolope

Reports sent tomailroom

Reports mailed

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Critical deficiencies were corrected immediately

Results Reporting for Diagnostic MammographyResults Reporting for Diagnostic Mammography


PHASE 2 - OptimizationPHASE 2 - Optimization


Patient Centered Care ModelPatient Centered Care Model


Women’s Center “Patient Centered Care Women’s Center “Patient Centered Care Model”Model”

• Patient Satisfaction• Physician Satisfaction• Employee

Satisfaction• Liability

• Fiscal Responsibility• Grow the Business• Competitive Advantage• 21st Century Medicine

Right Thing to Do!


Procedure Based ModelProcedure Based Model


Call forAppointment

ScreeningMammogram

DiagnosticMammogram

BreastUltrasound

Biopsy

Results

3 Weeks

4 Weeks

4.5 Weeks

1 Week

3-7 Days

Total Process Time: 13 Weeks



Call forAppointment

ScreeningMammogram

DiagnosticMammogram

BreastUltrasound

Biopsy

Results

2 Weeks

Same Day

Same Day

1 Week3-7 Days

Patient Centered Care ModelPatient Centered Care Model 1st Patient 1st Tech 1st Machine 1st Radiologist

8 weeks 2-3 hours



Call forAppointment

ScreeningMammogram

DiagnosticMammogram

BreastUltrasound

Biopsy

Results

2 Weeks

Same Day

Same Day

1 Week3-7 Days

Total Diagnostic Process Time: 1 Week

Patient Centered Care ModelPatient Centered Care Model 1st Patient 1st Tech 1st Machine 1st Radiologist


Patient Centered Care – How we get therePatient Centered Care – How we get there

• No new screening appointments Monday-Friday at the WC (Boca) October 24 through November 8• Saturdays (Boca), Deerfield screenings will continue

• Increase # of diagnostic and ultrasound appointments per day through cut off date

• Pilot new model with previously booked screenings during 2 week period.

• New Model – November 8, 2005


Boca Daily Schedule October 24 - November Boca Daily Schedule October 24 - November

Date Diagnostic Screening Sub-Total Ultrasound TOTAL24-Oct 45 43 88 39 12725-Oct 55 31 86 39 12526-Oct 55 25 80 39 11927-Oct 60 12 72 39 11128-Oct 60 14 74 39 11329-Oct 32/ 48

31-Oct 60 7 67 39 1061-Nov 45 17 62 39 1012-Nov 45 15 60 39 993-Nov 55 8 63 39 1024-Nov 55 6 61 39 1005-Nov 7/ 487-Nov 45 20 65 39 104

Week of 11/ 08 LIVE LIVE 80 39 119Week of 11/ 14 LIVE LIVE 80 39 119Week of 11/ 21 LIVE LIVE 80 39 119Week of 11/ 28 LIVE LIVE 100 39 139


Baseline - Digital Exam Cycle TimeBaseline - Digital Exam Cycle Time

0 5 10 15 20 25 30

100.0%99.5%97.5%90.0%75.0%50.0%25.0%10.0%2.5%0.5%0.0%

maximum

quartilemedianquartile

minimum

30.000 30.000 23.550 15.000 10.000 6.000 4.000 3.000 2.000 2.000 2.000

QuantilesMeanStd DevStd Err Meanupper 95% Meanlower 95% MeanN

7.63513515.22181280.42923048.48339456.7868758

148

Moments

Minutes

Distributions


Patient Care Model Staffing SchedulePatient Care Model Staffing Schedule

• 10 hour vs. 8 hour workdays • 3 Radiologists vs. 2 Radiologists• Additional budgeted technologists• Patient appointments in 15 minute blocks

• Previous schedule allotted screening 5 minute blocks, diagnostic 30 minute blocks, too much variation!

• Allow for “catch up” blocks for 10% of patients requiring extra time

• Increased uniformity in patient care process


Daily DemandDaily Demand

50 100 150 200

100.0%99.5%97.5%90.0%75.0%50.0%25.0%10.0%2.5%0.5%0.0%

maximum

quartilemedianquartile

minimum

205.00205.00195.80178.40155.00134.00111.0093.2077.0075.0075.00

QuantilesMeanStd DevStd Err Meanupper 95% Meanlower 95% MeanN

133.6363629.4639543.9729187141.60159125.67114

55

Moments

Digital Total

Distributions


TestimonialTestimonial

From: Kathy Schilling MD Sent: Friday, November 04, 2005 12:18 PMTo: '[email protected]'; Becky Southern; Mark Viau; Ed PopovichSubject: New model in action

Today at 10:30 am a screening mammo was done on our 80 year old patient. A new finding was noted on the left. She had 3 additional views which were suspicious. An US was performed at 11:30 which was also suspicious for 1cm cancer. I spoke with her and recommended an US core biopsy. We are doing the biopsy as we speak before our scheduled 1pm patient. Now that really has reduced the wait time for our patients and gives all of us much more satisfaction dealing with them. Thank your for all your support in getting us to this point. Our future should be very bright! KS


Monitoring the ProcessMonitoring the Process


Press-Ganey Raw Scores Post Press-Ganey Raw Scores Post Patient Centered Care ModelPatient Centered Care Model

8585.5

86

86.587

87.588

88.589

Nov-Dec 2004 Aug-Sept 2005 Nov-Dec 2005


% of Screenings Converted to Diagnostics per Day% of Screenings Converted to Diagnostics per Day

-0.05

0.00

0.05

0.10

0.15

0.20

0.25

0.30

Run

Cha

rt of

% C

onve

rted

Nov

embe

r 9th

Nov

embe

r 11t

h

Nov

embe

r 15t

h

Nov

embe

r 17t

h

Nov

embe

r 21s

t

Nov

embe

r 23r

d

Janu

ary

18th

Janu

ary

23rd

Janu

ary

31st

Febu

ary

2nd

Febu

ary

8th

Date

Avg=0.1086

Run Chart of % Converted

Run Chart


No Shows per DayNo Shows per Day

-0.05

0.00

0.05

0.10

0.15

0.20

0.25

0.30

Run

Cha

rt of

% N

o Sh

ows

Nov

embe

r 9th

Nov

embe

r 11t

h

Nov

embe

r 15t

h

Nov

embe

r 17t

h

Nov

embe

r 21s

t

Nov

embe

r 23r

d

Janu

ary

18th

Janu

ary

23rd

Janu

ary

31st

Febu

ary

2nd

Febu

ary

8th

Date

Avg=0.1199

Run Chart of % No Shows

Run Chart


Patients Scheduling Follow up AppointmentsPatients Scheduling Follow up Appointments

0.4

0.5

0.6

0.7

0.8

0.9

1.0

Run

Cha

rt of

%Pt

s Sc

hedu

led

Nov

embe

r 9th

Nov

embe

r 11t

h

Nov

embe

r 15t

h

Nov

embe

r 17t

h

Nov

embe

r 21s

t

Nov

embe

r 23r

d

Janu

ary

18th

Janu

ary

23rd

Janu

ary

31st

Febu

ary

2nd

Febu

ary

8th

Date

Avg=0.726

Run Chart of % Pts Scheduled

Run Chart


Benefits to BRCHBenefits to BRCH

• 10-12% of the patients do not have to return for additional testing– Creates 10-12% additional appointment slots– 10-12% fewer registrations/coding/bills

• 18,000 fewer calls to schedule next appointment.

• Reduction in supplies (gowns, armbands, registration supplies)


PHASE 3 - InnovationPHASE 3 - Innovation


Phase 3Phase 3

Innovation • Service expansion

• Facility enhancement– Regional Focus

• New Technology

• Research affiliations

• Medical training


Building The Case For A New FacilityBuilding The Case For A New Facility


Spaghetti Mapping Floor Plan

Patients

Diagnostic Pts with findings

Techs


Additional Equipment JustificationAdditional Equipment Justification


Voice of the Customer (VOC)Voice of the Customer (VOC)

November 8th to February 9th

Avg. demand per day (134)

Maximum daily volume with 3 units

(113)

Current daily volume (100)50

100

150

200

250

Run

Cha

rt of

Dig

ital T

otal

Oct

3

Oct

10

Oct

17

Nov

2

Nov

10

Nov

17

Nov

28

Dec

5

Jan

24

Feb

2

Feb

9

Date

Avg=133.64

Run Chart of Digital Total

Run Chart


Thinking Ahead for New EquipmentThinking Ahead for New Equipment


Distribution of Digital Mammo ImagesDistribution of Digital Mammo Images

Read 2

(Rad)

Read 3

(Tech)

Read 4

(Rad)

Read 1

(Rad) MRS STAR MRS STAR MRS STAR

Mammo 2Raw & Processed Images



CAD PACS

Archive

CAD Images are not stored in PACS


Distribution of Digital Mammo ImagesDistribution of Digital Mammo ImagesGE & HologicGE & Hologic

Read 2 (Rad) GE

Read 3

(Tech)

Read 4

(Rad) GE

Read 1

(Rad) GE & Hologic MRS STAR MRS STAR MRS STAR


GE


GE


GE

CAD PACS

Archive

CAD Images are not stored in PACS


Hologic


Lessons LearnedLessons Learned

• Don’t assume anything• Don’t get caught up in the

emotions• Process map every step and

variable• Over communicate• Pick team members who’ll

communicate• Don’t skip steps• Observe, observe, observe

• Don’t blind side anyone• Clean data is the key to

success• Control charts are effective

communication tools for staff and monitoring the process

• Spaghetti maps have a huge visual impact

• Stay the course during the change process

• Understand the 4 elements that employees go through with change

ConclusionConclusion

Six Sigma teaches the first step is to listen to Six Sigma teaches the first step is to listen to the voice of the customer. the voice of the customer.

In our case when we acknowledged what was In our case when we acknowledged what was best for the patient our direction was clear.best for the patient our direction was clear.

Failure was not an option. Failure was not an option.


Thank YouThank You

Becky Southern (561) 955-5111 [email protected]

Mark Viau (561) 955-4167 [email protected]

Ed Popovich (561) 955-5685 [email protected]

improving the cycle time to diagnose and begin breast cancer treatment

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