Tracking the clinical experience of women with metastatic breast cancer at an academic cancer center.

Abstract

93 Background: Time-driven activity-based costing (TDABC) can be used by health systems to identify inefficiencies and improve the patient experience in clinical encounters. This quality improvement project utilized a Plan, Do, Study, Act (PDSA) cycle to evaluate routine clinic-based care for women with metastatic breast cancer (MBC). Methods: A project plan was developed to directly observe the time spent by MBC patients in clinic (Plan). Patient clinical encounters could include a physician visit along with scans, infusion, and/or labs. We then created process maps of typical patient clinical experiences (Do). Next, we tabulated times (mean, standard deviation [SD]) that patients spent in waiting areas and with each clinical team member (physician, fellow, nurse practitioner, registered nurse, medical assistant, chaplain, social worker, pharmacist, navigator) to identify care inefficiencies (Study). Lastly, we discussed results with providers and identified and implemented strategies for improving efficiency (Act). Results: We directly observed clinic visits (n = 33) for MBC patients from November 2016 to June 2017. On average, patients spent 219 minutes (SD 108) at clinic visits including 71 minutes (SD 45) spent with clinical team members and 85 minutes (SD 43) spent in waiting areas. We identified several opportunities for efficiency improvement, including the delay prior to rooming by medical assistants (n = 31; mean 22, SD 20 minutes), delays with port lab draws in infusion (n = 5; mean 22, SD 13 minutes), and delays awaiting drug from pharmacy (n = 22; mean 15, SD 29 minutes). To improve efficiency, we implemented strategies including having a dedicated infusion nurse assigned to draw labs from patient ports and modifications to medical assistants’ workflow. Conclusions: In this PDSA cycle, we found that patients spend a substantial amount of time at clinic visits, and the majority of this time is spent in waiting areas. Our use of process mapping and evaluation of time spent receiving care identified important opportunities for improving care delivery and efficiency for patients with MBC.

Personalising monitoring for chemotherapy patients through predicting deterioration in renal and hepatic function

“…Routine clinical practice is to assess kidney and liver function prior to each treatment cycle 4 ; however, the value of this process with respect to detecting significant changes that necessitate chemotherapy dose modifications is uncertain. Where patients are very unlikely to experience significant changes in renal and hepatic function during chemotherapy, monitoring at every cycle may be unnecessary, and for many patients involves increased waiting times and unnecessary blood tests 5 . With the use of chemotherapy increasing, 6 there is a need to rationalise the amount of tests that are conducted for patients.…”

“…Where patients are very unlikely to experience significant changes in renal and hepatic function during chemotherapy, monitoring at every cycle may be unnecessary, and for many patients involves increased waiting times and unnecessary blood tests. 5 With the use of chemotherapy increasing, 6 there is a need to rationalise the amount of tests that are conducted for patients. Accurate stratification of patients, in order to conduct blood tests only for those that are likely to experience deterioration in renal and hepatic function during chemotherapy, would have benefits both in terms of patient experience and reducing the cost of delivering care.…”