This document summarizes a project to improve wait times for chemotherapy patients at a VA hospital. The team analyzed the current chemotherapy process, identified problems through interviews and time studies, and developed recommendations in three key areas. They recommend standardizing scheduling, preparing some drugs in advance, improving communication between departments, and installing signal lights. Their recommendations aim to reduce the maximum wait time from 89 to 30 minutes for 80% of patients through process improvements. The team also suggests implementing an electronic tracking system for continued monitoring and improvement.

1. Chemotherapeutic Agent Process Improvement ProjectVeteran’s Affairs Ann Arbor Hospital College of Engineering, University of Michigan Problem Solving Engineering Molly Beggs, Austin Kloske, Brittany Morales, Kyle Valentine, C. Paoro Yin-Blair 1

2. Presentation Agenda 2 I. II. III. IV. V. VI.

3. I. Project Definition 3

4. Project Background Team: Problem Solving Engineering (PSE) Client: Veteran’s Affairs (VA) Ann Arbor Healthcare System, Chemotherapy Outpatient Clinic Project Name: Chemotherapeutic Agent Process Improvement Project Three primary areas involved: the Chemotherapy Outpatient Clinic, the Pharmacy, and the Technician Lab 4

5. Project Definition Problem: chemotherapy patients experience long wait times, sometimes up to 8 hours Project goal: minimize patient wait time in chemotherapy outpatient clinic Patient wait time: duration of time from when patient arrives to outpatient clinic to time drug is administered PSE goal: reduce wait time to 30 minutes or less for 80% of patients 5

6. 6 Process Overview

7. II. Summary of Activity and Methods 7

8. Summary of Activity Data Collection: Conducted expert interviews with 5 nurses, 4 pharmacists, and 3 technicians Collected historical data (arrival times and cancellation rates) Gathered relevant chemotherapeutic agent details (i.e. cost, shelf life) Conducted 65 hours of time studies of the process Benchmarked with the University of Michigan Hospital Data Analysis Determined current state Microsoft Excel and Minitab 15 Statistical Software to analyze data Utilized Lean Principles: Process Mapping to identify the current state of the process Cause and Effect Diagrams to identify problem areas for improvement Pareto Analysis to detect areas with the greatest opportunity for improvement Determined feasibility of recommendations and implementation methods 8

9. III. Summary ofData and Analysis 9

10. Current State AnalysisSummary of Total Patient Wait Time 10

11. Current State AnalysisHistorical Data of Patient Arrivals 11

12. Current State AnalysisProcessing Time for Individual Steps 12

13. Benchmarking withUniversity of Michigan Cancer Center Met with Cancer Center Pharmacist at University of Michigan Hospital 30 Minute incremental scheduling blocks Chair Scheduling Light signaling system Standardized treatment forms Electronic Tracking System 13

14. IV. Recommendations 14

15. Criteria for Recommendations Reduction of primary quality metric (Total Patient Wait Time) Benchmarking of similar processes Consider employee interest and input Transferability of recommendations to a new location Potential solutions will not add or subtract major resources (facilities, equipment, labor) and have little to no cost Recommendations were ultimately divided into three areas: Chemotherapy Outpatient Clinic, Pharmacy, and Technician Lab 15

16. A. Chemotherapy Outpatient Clinic Standardized Scheduling Procedure Chair Scheduling Importance of Scheduling Document Removal of Clinic’s side of Pass-Way Door 16

17. Recommendation A1: Standardized Scheduling Procedure Description: A standard procedure for RN’s to schedule patients Benefit: Allow RN’s to have an appropriate number of patients per block of time and thus giving patients adequate attention, reduces overall wait time for patients, and helps pharmacy prepare agents Support: Patients often arrive in batches which cause bottlenecks and increase wait time Implementation: Distribute the Standardized Scheduling Procedure work document to all RN’s, education of new procedure Cost: Time spent on education (~ 1 hour) 17

18. Recommendation A2:Chair Scheduling Description: Scheduling patients per chair in the clinic Support: Scatter plot of patient arrival time Benefit: Reduce wait time for chairs, proper allocation of patients per RN, allow for appropriate attention to patients Implementation: Education of procedure to RNs Cost: time spent on education and scheduling 18

19. Recommendation A3: Importance of Scheduling Document Description: A paper document for patients that explains why they need to arrive on time to appointments Support: Patients do not follow scheduling policies without strict enforcement Benefit: Aids the scheduling procedure, because for scheduling to be effective, patients must arrive on time Implementation: Point nurse will include this document in patients initial briefing session and go over it with each patient Cost: Time spent explaining to patients (~ 5 minutes) 19

20. Recommendation A4: Removal of 1 Side of Pass-Way Door Description: Complete removal of door on clinic’s side of pass-through Support: Large variance in delivery time from dumbwaiter to pass-way door and large variance in time from pass-way door to administration of agent Benefit: Reduce wait time for patients Implementation: Facility maintenance will remove the door Cost: Facility maintenance 20

21. B. Pharmacy Standardized Chemotherapy Order Forms Standardized Work Policy Prepare Chemotherapy in Advance Access to CPRS Templates Signal Lights 21

22. Recommendation B1: Standardized Chemotherapy Order Forms Description: Create and implement a set of standardized order forms Forms will be unique to each treatment Easier to fill out patient and dosage information Support: Per pharmacists’ request and UM Benchmarking Benefit: PSE can reasonably estimate an improvement of 5 minutes per order form Implementation: Pharmacists have begun work on new templates, once complete (2-3 weeks) begin use Cost: No cost 22

23. Recommendation B2: Standardized Work Policy Description: Patient files should be completed the evening before the patient is to be seen Currently happens a majority of the time; should be enforced Especially important for Monday’s files Support: The step for pharmacists to complete paperwork has a larger variation when the forms are not completed beforehand Benefits: Uncompleted files take average of 12 minutes to complete the paperwork At least 10 minutes can be removed from patient wait time Saves more time if doctor consent is missing Implementation: Create a policy that pharmacists must complete files the day before patients are expected (immediate implementation) Cost: No Cost 23

24. Recommendation B3: Prepare Chemotherapy in Advance Description: Prepare certain chemotherapeutic agents in advance Support: The total time in the Technician Lab can be removed from the patient’s wait time Benefits: Can decrease patient wait time by 20-30 minutes Implementation: Determine if any chemotherapeutic agents should be made ahead and treat them as preorders (can be implemented as soon as agents are chosen) Cost: Expected costs of common chemotherapeutic agents Assumed 15% cancellation rate Estimated average cost per dose of each chemotherapeutic agent 24

25. Recommendation B4: Access to CPRS Templates Description: Pharmacists/Computer Technicians need access to the CPRS templates Some prescription templates are unclear Only doctors have access to change templates Support: Many instances of confusion between doctors and pharmacists cost up to 30 minutes Benefits: Can save about a half hour of clarification time Implementation: Grant access to CPRS templates (immediate implementation) Cost: None 25

26. Recommendation B5: Signal Lights Description: Place a signal light in the Outpatient Pharmacy with two light switches Support: If phones are busy the Outpatient Pharmacy is not called Benefits: Can reduce an average of 5 minutes for the chemotherapeutic agent to reach the Outpatient Clinic Implementation: Install a light in the outpatient pharmacy and indicator light switches next to the dumbwaiter on both floors Cost: $19.70 for two switches 26

27. C. Technician Lab Tubing and Draining IV Bags in Advance Signal Lights Posted Policies Standard Work Instructions Folder Racks White Board 27

28. Recommendation C1: Tubing & Draining IV Bags in Advance Description: Attach tubing and remove extra solution so IV bag is ready for CA at time of patient arrival Support: Median processing time of 6 minutes Benefit: Shorter lead time, free IV technician Implementation: Write standard work instruction, pharmacists share folders with technicians prior to patient arrival (Next 2-4 weeks) Cost: (0.15)*($4.90)*($0.62) = $0.50 / CA = (Cancelation Rate)*(Tubing Cost)*(Bag Cost) 28 Drain appropriate amount of fluid. Mark bag and hang in queue. Attach tubing to IV bag Select correct tubing and close drip chamber

29. Recommendation C2:Signal Lights Description: Replace pharmacy intercom system with ‘Drug Ready’ signal lights Support: CA’s commonly wait up to 15 minutes to be checked Benefit: Reduce chances for Pharmacists to forget announcement or not hear announcement Implementation: Install two new light fixtures above pharmacy desk, install two new light switches in Technician Lab Cost: $28.11 + electrician time 29

30. Recommendation C3: Posted Policies Description: Summarize and post all work policies relating to technician lab Support: Certain policies are currently passed between techs as hearsay (i.e. CA’s that must be produced in chemo hood) Benefit: Less time loss over discussion, Eliminate time loss due to CA’s taking space in chemo queue Implementation: Organize, Outline, Write, Post (Next 2-6 weeks) Cost: Lead Technician Time 30

31. Recommendation C4:Standard Work Instructions Description: Clear descriptions of common tasks (not to replace 797 logs) Support: Current lack of standardized training Benefit: Increase confidence between technicians Implementation: Photograph, write, print, post, review, update, repeat (Next 1-6 weeks) Cost: Lead Technician Time 31

32. Recommendation C5:Wall-Mounted Folder Rack Description: Rack to hold chemo folders in queue Support: Congestion related to larger queues Benefit: More counter space, reduce mixing queue order Implementation: Order, Hang (Next 2 weeks) Cost: $28.68 32 Pre-makes Preps

33. Recommendation C6:White Board Description: Wall mounted whiteboard in main IV room (36”x24”) Support: Techs often do not transition between shifts Benefit: Less information would be lost across shifts Implementation: Order and hang white board (Next 2 weeks) Cost: $43.59 33

34. V. New Process and Future State 34

35. Future State of Process 35 Prior to Patient Arrival Post Patient Arrival

36. Future StateExpected Patient Wait Time Reduction 36 Expected distribution Recommendations will reduce expected maximum wait time from 89 minutes to 30 minutes for 80% of patients. Current distribution

37. 37 Project Improvements

39. Implement an electronic tracking system similar to the system used by UMHS in the near future

40. All departments would be kept up to date on patient and medication information relative to their appointment times