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Improving the Cycle Time to Diagnose and Begin Breast Cancer Treatment


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Improving the Cycle Time to Diagnose and Begin Breast Cancer Treatment

  1. 1. Improving the Cycle Time to Diagnose and Begin Breast Cancer Treatment The Women’s Center at Boca Raton Community Hospital March 31,2006
  2. 2. Boca Raton Community Hospital (BRCH) <ul><li>394 bed community hospital in South Florida </li></ul><ul><li>45,000 ED visits annually </li></ul><ul><li>21,000 discharges annually </li></ul><ul><li>2,000 births </li></ul><ul><li>250,000 Imaging Procedures </li></ul>
  3. 3. The Women’s Center/Center for Breast Care <ul><li>The Women’s Center @ BRCH </li></ul><ul><li>42,000 procedures in 2005 </li></ul><ul><ul><li>20,800 screening mammo’s </li></ul></ul><ul><ul><li>9,270 diagnostic mammo’s </li></ul></ul><ul><ul><li>4,400 ultrasounds </li></ul></ul><ul><ul><li>2,000 interventional procedures </li></ul></ul><ul><ul><li>4,120 bone densities </li></ul></ul><ul><ul><li>3,000 MRI’s </li></ul></ul><ul><li>33 FTE’s Budgeted, 24 actual </li></ul><ul><li>363 Cancers detected in 2005 </li></ul>
  4. 4. <ul><li>Promote “Culture of Excellence” across enterprise </li></ul><ul><li>State-of-the-art approaches to improvement, innovation, team-building, and collaboration </li></ul><ul><li>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 </li></ul><ul><li>We know the height of insanity is to keep doing the same thing over and over again and expect better results! </li></ul>Enterprise Excellence at BRCH
  5. 5. Enterprise Excellence Infrastructure <ul><li>EE Department includes: </li></ul><ul><ul><li>4 Executive Directors </li></ul></ul><ul><ul><ul><li>Nursing (CNO) </li></ul></ul></ul><ul><ul><ul><li>Imaging Services </li></ul></ul></ul><ul><ul><ul><li>Ancillary Services (lab, pharmacy, respiratory, food services, environmental services / housekeeping) </li></ul></ul></ul><ul><ul><ul><li>Finance </li></ul></ul></ul><ul><ul><li>VP experienced Six Sigma Sr. Master Black Belt </li></ul></ul><ul><li>Enterprise Excellence Steering Team </li></ul><ul><ul><li>COO, CMO, CNO, CFO, VP HR </li></ul></ul><ul><ul><li>Physician representative (board) </li></ul></ul>
  6. 6. EE Infrastructure for Major Projects <ul><li>Project Steering Team </li></ul><ul><ul><li>Senior Executive Champion(s) </li></ul></ul><ul><ul><li>2 or more Physicians </li></ul></ul><ul><ul><li>EE Black Belts </li></ul></ul><ul><li>Working Teams </li></ul><ul><ul><li>Report outs to the Project Steering Team </li></ul></ul><ul><ul><li>Facilitated by BB’s or GB’s </li></ul></ul><ul><ul><li>Staff and physician members of working teams </li></ul></ul><ul><ul><li>Follow EE Improvement Model (e.g., Six Sigma) </li></ul></ul>
  7. 7. EE Process Improvement Model Preparation Establish Baseline Identify Root Causes Identify Solutions Implement & Maintain Continue? Continue? Continue? Continue? Yes Yes Yes Yes End Project No End Project No End Project No End Project No
  8. 8. Background - Why Enterprise Excellence @ the WC 3 Weeks 4 Weeks 4.5 Weeks 1 Week 3-7 Days Total Process Time: 13 Weeks
  9. 9. Women’s Center Team Infrastructure Core Steering Team Team 1 Before the Appointment Team 2 During the Appointment Team 3 After the Appointment Team 4 Coordination of Services Women’s Center & The Cancer Program
  10. 10. Background – Our Phased Approach <ul><li>Multigenerational Project Plan (MGPP) </li></ul><ul><li>Months May Jun Jul Aug Sep Oct Nov Dec </li></ul><ul><li>Phase 1 </li></ul><ul><li>Stabilization </li></ul><ul><li>Phase 2 </li></ul><ul><li>Optimization </li></ul><ul><li>Phase 3 </li></ul><ul><li>Innovation </li></ul>
  11. 11. Women’s Center Phase 1 <ul><li>Stabilization of processes after conversion to digital imaging and construction. Includes: </li></ul><ul><ul><li>Analysis of staffing needs </li></ul></ul><ul><ul><li>Alignment of responsibilities </li></ul></ul><ul><ul><li>Implementation of film management plan </li></ul></ul><ul><ul><li>Decisions regarding equipment configuration </li></ul></ul><ul><li>Goal – 8 weeks Total Cycle Time from initial appointment through biopsy results </li></ul><ul><li>Timeline: May – September 2005 </li></ul>
  12. 12. Women’s Center Phase 2 <ul><li>Optimization of processes </li></ul><ul><ul><li>“ Today’s” constraints (e.g., budget, facility, staffing) </li></ul></ul><ul><ul><li>Alignment (e.g., Imaging services, oncology services, women’s services) </li></ul></ul><ul><li>Goal </li></ul><ul><ul><li>4 week Total Cycle Time from initial appointment to biopsy results </li></ul></ul><ul><ul><li>Increase in Press Ganey scores for Women’s Center (Imaging) </li></ul></ul><ul><ul><li>100% Records released with 24 hour notice </li></ul></ul><ul><li>Timeline: July – November 2005 </li></ul>
  13. 13. Women’s Center Phase 3 <ul><li>Innovation / Exploration: </li></ul><ul><ul><li>Service expansion </li></ul></ul><ul><ul><li>Facility enhancement </li></ul></ul><ul><ul><li>Equipment </li></ul></ul><ul><ul><li>Staffing </li></ul></ul><ul><li>Goal </li></ul><ul><ul><li>1 Week Total Cycle Time from appointment to biopsy results </li></ul></ul><ul><ul><li>Additional services available with similar performance </li></ul></ul><ul><ul><li>State of Art Center and Academic Training Site </li></ul></ul><ul><li>Timeline: October - Present </li></ul>
  14. 14. Project Teams <ul><li>Prior to Appointment Process – Mark Viau </li></ul><ul><ul><li>Film Storage </li></ul></ul><ul><ul><li>Scheduling </li></ul></ul><ul><ul><li>Pre-registration </li></ul></ul><ul><ul><li>Pre-authorization and Insurance </li></ul></ul><ul><ul><li>Film Handling </li></ul></ul><ul><li>During Appointment Process – Becky Southern </li></ul><ul><ul><li>Screening, Diagnostic, Ultrasound, Biopsy </li></ul></ul><ul><ul><li>Bone Density </li></ul></ul><ul><li>After Appointment Process – Dr. Kathy Schilling/Becky Southern </li></ul><ul><ul><li>Results / Releases </li></ul></ul><ul><ul><li>Follow-up Appointments </li></ul></ul>
  15. 15. PHASE 1 – Stabilization Project Teams
  16. 16. Team 1 – “Prior to the Appointment Process” <ul><li>Film Releases </li></ul><ul><li>Currently performing at 24 hours </li></ul><ul><li>Goal: 24 hours </li></ul><ul><li>Film Storage </li></ul><ul><li>5 year savings, $560,000 </li></ul>
  17. 17. Team 1 – “Prior to the Appointment Process” <ul><li>Goal: Filmless and Paperless </li></ul><ul><li>Implementation of Picture Archiving Communication Systems (PACS) environment </li></ul><ul><ul><li>Additional GE reading station </li></ul></ul><ul><ul><li>McKesson PACS station </li></ul></ul><ul><ul><li>Tech Workstations </li></ul></ul><ul><ul><li>Renovation of workspace planned </li></ul></ul>
  18. 18. Team 1 – “Prior to the Appointment Process” Support Service Processes
  19. 19. Team 1 – “Prior to the Appointment Process” <ul><li>Kaizen Event </li></ul><ul><li>Centralized Scheduling </li></ul><ul><li>Registration </li></ul><ul><li>Billing </li></ul><ul><li>HIMS/Coding </li></ul><ul><li>Managed Care </li></ul>
  20. 20. Support Services Process
  21. 21. Scheduling Process
  22. 22. Support Services Process
  23. 23. Paperwork/Jacket Process
  24. 24. Support Services Process
  25. 25. Mammo Reporting Process
  26. 26. Team 2 “ During Appointment Process”
  27. 27. Team 2 – “During Appointment Process” <ul><li>Original Digital Implementation Plan </li></ul><ul><ul><li>2 dedicated digital screening units </li></ul></ul><ul><ul><li>1 additional digital diagnostic unit + analog units </li></ul></ul><ul><ul><li>2006 Budget Year additional diagnostic digital unit (1-2) </li></ul></ul><ul><li>Interim Step </li></ul><ul><ul><li>Screenings performed on digital and analog to decrease read time by radiologists </li></ul></ul><ul><li>Pre-project Process </li></ul><ul><ul><li>1 dedicated digital screening unit </li></ul></ul><ul><ul><li>2 dedicated digital diagnostic units </li></ul></ul><ul><ul><li>1 analog backup </li></ul></ul>
  28. 28. Tech Competencies 5/3 Dr. Morrell 5/4 Clerical Staffing 4/4 IS 3/4 Radiologists 3/6 Ultrasound 2/6 Equipment 6/3 Team 2 Interrelationship Diagraph Technologists Staffing 5/5
  29. 29. Team 2 – “During Appointment Process” <ul><li>Opportunities </li></ul><ul><li>Clarify job responsibilities/accountabilities </li></ul><ul><li>Increase daily procedures to decrease backlog </li></ul><ul><li>Develop and implement protocols </li></ul><ul><li>Identify best practice models for flow and equipment </li></ul><ul><li>Overall Equipment Capacity Study </li></ul><ul><ul><li>Capital needs assessment </li></ul></ul><ul><li>Develop Process for Change </li></ul>
  30. 30. Team 3 “ After Appointment Process”
  31. 31. Team 3 – “After Appointment Process” <ul><li>Opportunities </li></ul><ul><li>Result reporting resolved </li></ul><ul><li>Reviewing all printed patient letters </li></ul><ul><li>Physician communication plan </li></ul>
  32. 32. Critical deficiencies were corrected immediately Results Reporting for Diagnostic Mammography
  33. 33. PHASE 2 - Optimization
  34. 34. <ul><li>Patient Centered Care Model </li></ul>
  35. 35. Women’s Center “Patient Centered Care Model” <ul><li>Patient Satisfaction </li></ul><ul><li>Physician Satisfaction </li></ul><ul><li>Employee Satisfaction </li></ul><ul><li>Liability </li></ul><ul><li>Fiscal Responsibility </li></ul><ul><li>Grow the Business </li></ul><ul><li>Competitive Advantage </li></ul><ul><li>21 st Century Medicine </li></ul>Right Thing to Do!
  36. 36. Procedure Based Model 3 Weeks 4 Weeks 4.5 Weeks 1 Week 3-7 Days Total Process Time: 13 Weeks
  37. 37. Patient Centered Care Model 2 Weeks Same Day Same Day 1 Week 3-7 Days 1st Patient 1st Tech 1st Machine 1st Radiologist 8 weeks  2-3 hours
  38. 38. Patient Centered Care Model 2 Weeks Same Day Same Day 1 Week 3-7 Days Total Diagnostic Process Time: 1 Week 1st Patient 1st Tech 1st Machine 1st Radiologist
  39. 39. Patient Centered Care – How we get there <ul><li>No new screening appointments Monday-Friday at the WC (Boca) October 24 through November 8 </li></ul><ul><ul><li>Saturdays (Boca), Deerfield screenings will continue </li></ul></ul><ul><li>Increase # of diagnostic and ultrasound appointments per day through cut off date </li></ul><ul><li>Pilot new model with previously booked screenings during 2 week period. </li></ul><ul><li>New Model – November 8, 2005 </li></ul>
  40. 40. Boca Daily Schedule October 24 - November Hurricane Wilma
  41. 41. Baseline - Digital Exam Cycle Time
  42. 42. Patient Care Model Staffing Schedule <ul><li>10 hour vs. 8 hour workdays </li></ul><ul><li>3 Radiologists vs. 2 Radiologists </li></ul><ul><li>Additional budgeted technologists </li></ul><ul><li>Patient appointments in 15 minute blocks </li></ul><ul><ul><li>Previous schedule allotted screening 5 minute blocks, diagnostic 30 minute blocks, too much variation! </li></ul></ul><ul><ul><li>Allow for “catch up” blocks for 10% of patients requiring extra time </li></ul></ul><ul><li>Increased uniformity in patient care process </li></ul>
  43. 43. Daily Demand
  44. 44. Testimonial <ul><li>From: Kathy Schilling MD Sent: Friday, November 04, 2005 12:18 PM To: ''; Becky Southern; Mark Viau; Ed Popovich Subject: New model in action </li></ul><ul><li>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 </li></ul>
  45. 45. Monitoring the Process
  46. 46. Press-Ganey Raw Scores Post Patient Centered Care Model
  47. 47. % of Screenings Converted to Diagnostics per Day
  48. 48. No Shows per Day
  49. 49. Patients Scheduling Follow up Appointments
  50. 50. Benefits to BRCH <ul><li>10-12% of the patients do not have to return for additional testing </li></ul><ul><ul><li>Creates 10-12% additional appointment slots </li></ul></ul><ul><ul><li>10-12% fewer registrations/coding/bills </li></ul></ul><ul><li>18,000 fewer calls to schedule next appointment. </li></ul><ul><li>Reduction in supplies (gowns, armbands, registration supplies) </li></ul>
  51. 51. PHASE 3 - Innovation
  52. 52. Phase 3 <ul><li>Innovation </li></ul><ul><li>Service expansion </li></ul><ul><li>Facility enhancement </li></ul><ul><ul><li>Regional Focus </li></ul></ul><ul><li>New Technology </li></ul><ul><li>Research affiliations </li></ul><ul><li>Medical training </li></ul>
  53. 53. Building The Case For A New Facility
  54. 54. <ul><li>Spaghetti Mapping Floor Plan </li></ul><ul><li>Patients </li></ul><ul><li>Diagnostic Pts with findings </li></ul><ul><li>Techs </li></ul>
  55. 55. <ul><li>Spaghetti Mapping Floor Plan </li></ul><ul><li>Patients </li></ul><ul><li>Diagnostic Pts with findings </li></ul><ul><li>Techs </li></ul>
  56. 56. <ul><li>Spaghetti Mapping Floor Plan </li></ul><ul><li>Patients </li></ul><ul><li>Diagnostic Pts with findings </li></ul><ul><li>Techs </li></ul>
  57. 57. <ul><li>Spaghetti Mapping Floor Plan </li></ul><ul><li>Patients </li></ul><ul><li>Diagnostic Pts with findings </li></ul><ul><li>Techs </li></ul>
  58. 58. Additional Equipment Justification
  59. 59. 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)
  60. 60. Thinking Ahead for New Equipment
  61. 61. Distribution of Digital Mammo Images Read 2 (Rad) Read 3 (Tech) Read 4 (Rad) Read 1 (Rad) MRS STAR MRS STAR MRS STAR Mammo 2 Raw & Processed Images Mammo 1 Raw & Processed Images Mammo 3 Raw & Processed Images CAD PACS Archive CAD Images are not stored in PACS
  62. 62. Distribution of Digital Mammo Images GE & Hologic Read 2 (Rad) GE Read 3 (Tech) Read 4 (Rad) GE Read 1 (Rad) GE & Hologic MRS STAR MRS STAR MRS STAR Mammo 2 Raw & Processed Images GE Mammo 1 Raw & Processed Images GE Mammo 3 Raw & Processed Images GE CAD PACS Archive CAD Images are not stored in PACS Mammo 4 Raw & Processed Images Hologic
  63. 63. Lessons Learned <ul><li>Don’t assume anything </li></ul><ul><li>Don’t get caught up in the emotions </li></ul><ul><li>Process map every step and variable </li></ul><ul><li>Over communicate </li></ul><ul><li>Pick team members who’ll communicate </li></ul><ul><li>Don’t skip steps </li></ul><ul><li>Observe, observe, observe </li></ul><ul><li>Don’t blind side anyone </li></ul><ul><li>Clean data is the key to success </li></ul><ul><li>Control charts are effective communication tools for staff and monitoring the process </li></ul><ul><li>Spaghetti maps have a huge visual impact </li></ul><ul><li>Stay the course during the change process </li></ul><ul><li>Understand the 4 elements that employees go through with change </li></ul>
  64. 64. Conclusion Six Sigma teaches the first step is to listen to the voice of the customer. In our case when we acknowledged what was best for the patient our direction was clear. Failure was not an option.
  65. 65. Thank You [email_address] (561) 955-4167 Mark Viau [email_address] (561) 955-5685 Ed Popovich [email_address] (561) 955-5111 Becky Southern