Successful use of problem-solving methodology to reduce pharmacy chemotherapy processing time.

OBJECTIVES: The primary objectives of this study were to (1) reduce pharmacy turnaround time (TAT) without compromising safety and quality and (2) reduce compounding order overload during peak hours (8:00 AM-5:00 PM). The secondary objective was to decrease patient wait time pertinent to pharmacy services. SETTING: The setting was a hospital-based pharmacy. PRACTICE DESCRIPTION: Pharmacy dispensing more than 1800 doses daily, 30% of which goes to outpatient cancer treatment. Patients usually receive multiple compounded medications; thus, compounding numbers are several folds higher than patient number. High compounded chemotherapy order volume overloaded pharmacy staff during peak hours and was a major contributor to patient wait time. PRACTICE INNOVATION: Using Define Measure Analyze Improve Control Six Sigma and intelligent risk-taking strategies, a dedicated team identified root causes of problems and designed long-lasting solutions that would not compromise quality. EVALUATION: The most effective initiative was the advanced preparation of chemotherapy for select patients (Concierge), which addressed pharmacy TAT, patient wait time, and chemotherapy order overload, all without affecting safety or quality of dispensed medications. RESULTS: Pharmacy TAT decreased by 77% for Concierge patients and 31% for standard patients. Comparable decreases were observed for patient wait time: 67% for Concierge and 27% for standard patients. Safety and quality were maintained for all dispensations during and after implementation of Concierge. A concurrent 8% increase in patient number was observed despite no changes in physical capacity. CONCLUSION: The implementation of Concierge initiatives: markedly reduced pharmacy TAT without compromising safety checks performed by pharmacists; decreased chemotherapy order overload during peak hours; improved distribution of assignments for pharmacy staffand statistically significant decreased wait time for all patients, especially those selected for Concierge. Effective selection of Concierge patients minimized additional costs associated with wasted premixed chemotherapy. Improving workflow for a subset of patients affected a greater patient population, allowing additional patients to be treated daily.

Using Rapid Cycle Improvement (Plan, Do, Study, Act) to Design a Scalable Appointment Scheduling System for Complex Oncology Clinical Trials at an Academic Cancer Center.

PURPOSE: This study's purpose was to optimize the efficiency of and to design a scalable research scheduling team to meet the growing demands of an academic cancer center with increasing clinical trial accruals. METHODS: The Plan, Do, Study, Act improvement methodology was deployed to increase the efficiency of research scheduling, to reduce non-value-added (NVA) activities, and to reduce cycle time to meet takt time. In the Plan phase, voice-of-the-customer interviews were conducted. In the Do phase, the baseline workflow was mapped and billing data were analyzed. In the Study phase, cycle time, takt time, and capacity analysis metrics were calculated at baseline. In the Act phase, interventions were implemented to increase efficiency by reducing NVA activities and increasing value-added activities, and metrics were reassessed after intervention. RESULTS: An 8% increase in appointment requests was noted from baseline to after intervention, and the cycle time for appointment scheduling decreased by 11%, demonstrating increased efficiency. Process steps decreased from 15 to 10, eliminating NVA activities and rework and waiting, two types of waste. CONCLUSION: Although efficiency increased, the number of total appointments scheduled weekly increased by 4%, resulting in a reduced takt time, or a shorter time to schedule each appointment to meet demand. A capacity analysis demonstrated that even after interventions, an additional 0.5 full-time employee is required to reduce cycle time to equal takt time. Capacity analysis creates a scalable framework for the scheduling team and facilitates movement from reactive to proactive staffing, which can be applied throughout the research enterprise.

Using Process Improvement Tools to Improve the Care of Patients With Neutropenic Fever in the Emergency Room.

PURPOSE: The purpose of this study was to improve the care of patients with neutropenic fever in an academic acute care hospital's emergency room (ER). METHODS: Using the define, measure, analyze, improve, control method, a two-phase project with three critical to quality metrics (reduction in time to antibiotic administration, increase in percentage of patients with neutropenic fever identified as an oncology emergency, and increase in patients cohorted on oncology units) was completed. Phase I consisted of implementation of best practices (ie, use of neutropenic fever protocol and order set, altering ER workflow, and educating patients and staff). In phase II, the team drew from cardiac and stroke alerts and response teams and implemented an innovative hospital-wide overhead neutropenic fever alert and an ER neutropenic fever response team. RESULTS: After implementing phase I interventions, the time to antibiotic administration decreased from a mean of 100 minutes at baseline to a mean of 67 minutes. After implementing phase II interventions, the mean decreased by 73%, from 100 minutes at baseline to 27 minutes. Furthermore, after phase II interventions, 89% of neutropenic patients were assigned an Emergency Severity Index of 2 and 88% were placed appropriately in a bed on the oncology floor on admission, compared with 11% and 74%, respectively, at baseline. CONCLUSION: Interventions were effective at improving three critical to quality metrics. Multiple iterations of the define, measure, analyze, improve, control cycle, together with new innovative interventions, were crucial to meeting project goals.

Delivering Patient Value by Using Process Improvement Tools to Decrease Patient Wait Time in an Outpatient Oncology Infusion Unit.

PURPOSE: This study aimed to streamline workflow from arrival to premedication by decreasing patient wait time to increase value in a high-volume academic outpatient oncology infusion unit. The streamlining process involved identifying and prioritizing patients for treatment by driving out waste in patient flow. METHODS: The plan-do-check-act (PDCA) method and Lean Methodology were used in completing a project to streamline a defined subset of patient experiences within an outpatient oncology infusion unit in an academic comprehensive cancer center. Wait time for patients whose labs were completed before treatment day and within normal limits and whose orders were signed the day before treatment was collected manually for a period of 5 months and tracked via value stream and control charts. RESULTS: Postimplementation, patients experienced a decrease of 17 minutes in mean patient arrival to premedication start time (preimplementation 77 minutes, postimplementation 60 minutes). Additionally, a value stream analysis demonstrated that in the new process, patient touch points were decreased by two, and value-added time was increased by 17%. CONCLUSION: By using the systematic PDCA tool, the team was able to identify opportunities to reduce waste in the system and streamline patient care. The results demonstrated a significant improvement in reducing patient wait time from arrival to premedication start time and increasing percentage of total value added during a patient's treatment cycle.

Decreasing laboratory turnaround time and patient wait time by implementing process improvement methodologies in an outpatient oncology infusion unit.

PURPOSE: Prolonged patient wait times in the outpatient oncology infusion unit indicated a need to streamline phlebotomy processes by using existing resources to decrease laboratory turnaround time and improve patient wait time. METHODS: Using the DMAIC (define, measure, analyze, improve, control) method, a project to streamline phlebotomy processes within the outpatient oncology infusion unit in an academic Comprehensive Cancer Center known as the Comprehensive Treatment Unit (CTU) was completed. Laboratory turnaround time for patients who needed same-day lab and CTU services and wait time for all CTU patients was tracked for 9 weeks. RESULTS: During the pilot, the wait time from arrival to CTU to sitting in treatment area decreased by 17% for all patients treated in the CTU during the pilot. A total of 528 patients were seen at the CTU phlebotomy location, representing 16% of the total patients who received treatment in the CTU, with a mean turnaround time of 24 minutes compared with a baseline turnaround time of 51 minutes. CONCLUSIONS: Streamlining workflows and placing a phlebotomy station inside of the CTU decreased laboratory turnaround times by 53% for patients requiring same day lab and CTU services. The success of the pilot project prompted the team to make the station a permanent fixture.