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Paving a new road for cancer patients

September 18, 2008

Before she leaves The Credit Valley Hospital, the woman I’m speaking with has one last mission: to ring a bell that will signal the end of her cancer treatment. The bell is popular among patients, as it symbolizes the triumph of their survival.*

Her story – like countless other cancer survivors – is inspiring. To overcome a devastating illness takes strength, courage and hope. Yet hearing how she coped with the competing demands of her job and her family begged the question: how was she able to juggle it all and still make her health a priority?  The answer lies in a journey taken by the Peel Regional Cancer Center (PRCC) when its staff decided it was time for a change.

THE PEEL REGIONAL CANCER CENTER’S JOURNEY OF CHANGE:
How they got from then… to now….

These two images illustrate the BEFORE and AFTER process for receiving breast cancer treatment at The Credit Valley Hospital.

A GROWING NEED FOR CANCER CARE

According to Cancer Care Ontario (CCO), over the next 10 years it is estimated that the number of Ontarians diagnosed with cancer will grow from about 64,000 to 85,000, largely because of a population that is both increasing and ageing.

These kinds of numbers are exactly what prompted The Credit Valley Hospital to expand. In mid-2005 the hospital opened the PRCC, a 90,000 square foot facility within the hospital with a staff of 150, seeing 3500 new patients per year, and up to 50,000 visits per year. And while this rapid expansion was necessary, it is also why the PRCC found itself looking for ways to improve the patient experience.

Michael Durkacz, regional planning associate for the PRCC

Michael Durkacz, regional planning associate for the PRCC

The problem, according to Michael Durkacz, regional planning associate for the Peel Regional Cancer Program, was that patients were experiencing lengthy wait times – in some cases waiting up to two hours to confirm their next appointment. This was causing anxiety and stress for both patients and medical staff.

HOW A SHARED EXPERIENCE CREATED A NEW VISION FOR THE PRCC

This prompted a number of senior level administrators to spend two days at The Tatham Group offices attending an Executive Boot Camp in May of 2006. What happened at this Boot Camp was profound: these senior administrators came to realize that although the staff at the PRCC is highly skilled and professional, they were all focused on their own divisions. So, while patients are receiving the best possible care, the overall patient experience wasn’t being taken into account. Boot Camp showed them that by applying the Tatham Method, the PRCC could build a more collaborative model.

The senior administrators launched a multi-disciplinary team comprised of nurses, doctors, pharmacists, lab technicians, information system personnel, unit clerks and administrators to redesign a high-stake process. After a second Boot Camp in September of 2006, eight Boot Camp participants formed Stream Team I – a group whose mandate was to use their new found knowledge to build a new process for the breast cancer patients receiving systemic treatment. Once the new process was designed, a second set of individuals would form Stream Team II to implement the recommendations.

TAKING THE ROAD LESS TRAVELED

Kathy McKay, Audrey O’Hare and Yolanda Corrigan – registered nurses and members of Stream Team II, explain how the team framed their mandate. McKay says, “See, it’s a bad experience to have cancer. For some people we’re like family. But for others, they just want to come and go. Some of our patients have to pick up their kids from school or they have jobs and just don’t want to be here. The Stream Team’s initiative was to help the patient get in and out of the door as quickly as possible.”

But, as Corrigan adds, the problem with getting patients through the system efficiently was the cancer center’s rapid growth. “We got so big and we were still trying do things the way we did them prior to moving into the larger space. It just doesn’t work that way anymore.”

So the team got to work in applying the Tatham Systematic Method. Durkacz, leader of both Stream Team I and II, says they began by looking at the current process for a breast cancer patient – from the moment they enter the clinic to the moment they leave after receiving treatment. They discovered that although each area of the clinic was functioning well, the most pressing patient issue was the delay between each step of the process. The team thus set out to reduce the amount of wait time between each of the 10 steps of the process, with a maximum wait-time of 15 minutes.

After several months of collecting data and conducting experiments, they came up with a new way of operating: they streamlined 10 processes down to 7; they decreased the patient wait time from 2 hours and 17 minutes down to 34 minutes; they created nurse/doctor assessment teams, which enhanced their collaborative practice; they gave the volunteers more responsibility, giving them the ownership of patient flow within the clinic; and they increased the number of patients being seen — from 42 to a potential of 65 per day.

STAYING THE COURSE

“Now things are much better,” says O’Hare. “Patients know they’ve got one doctor and one nurse, they know who they depend on. People are seen within 15 minutes, and they’re getting to the chemo chairs.” Still, McKay says, “It’s been a bit difficult for patients who have been coming here for years because we’ve changed their routine. But for a new patient it’s seamless.” She adds, “I think the volunteers are our biggest success.”

In fact, using the volunteers to manage the patient flow – from registration to the exam room, frees up time for nurses to focus on primary care and for clerical staff to keep the paperwork moving. This has been so successful that the radiation, lung and palliative care units in the hospital plan to leverage this learning.

Despite all these positive changes, there is more work ahead. One of the most difficult aspects of implementation is the coordination of change management and reminding those affected by the change that it’s about the end-to-end process. Durkacz says even though staff wanted a new way of doing things, at times there was resistance. “But in the end, what made the difference is that it was always about the patients. Doctors, nurses, management — we all saw patients falling between the cracks. It was always about making the patient-experience better.”

BLENDING TWO PILLARS OF CARE

Dr. Sheldon Fine, regional vice president of Cancer Services and chief of the department of oncology at the PRCC

Dr. Sheldon Fine, regional vice president of Cancer Services and chief of the department of oncology at the PRCC

Still, Dr. Sheldon Fine, regional vice president of Cancer Services and chief of the department of oncology at PRCC believes that for people to begin thinking differently about how they provide health care, they must ask themselves why they are there in the first place. “And presumably,” he says, “we’re here to look at patient symptoms, to improve their outlook and to reduce the burden of illness. And you do that with two pillars. The first is to apply treatment that you think can work and that makes sense to the patient. The second is to look at the way you deliver the treatment. We need to blend the two to give the best possible care, because anything short of that is really inadequate.”

He stresses that when people reframe the way they think about measurement, critically evaluate what they do, and discard the processes that don’t make sense, the patient will benefit. “First, you need to consider that you’re there to provide care for patients. That is fundamental. Second, the ideas for the way you provide that care need to be looked at critically and openly.  If it doesn’t make sense, discard it. And third – we have to apply the same kind of rigour that we use to invest and develop treatments using the scientific method, to the processes we use to provide the care.”

Nevertheless, it is clear that the hard work and commitment has paid off. Durkacz says there has been significant improvement in the culture, and staff sees the need to create a collaborative work environment. “Previously, people were not taking the patient’s overall experience into consideration. But by empowering staff to own the processes, by giving them a voice and a mode for change, there has been a better buy-in with change management.”

As I wander back towards the main lobby, I can’t help but think about the patient I had been speaking with earlier. Although she couldn’t put her finger on any significant changes, she did say that in the last six months she was in and out of the hospital within an hour. This left me with the distinct impression that the care she received allowed her to spend as much time as possible with her loved ones, doing exactly what she wanted to be doing so that she could overcome her illness. And isn’t that precisely what the Stream Team set out to do? As I walk out of the elevators pondering that question, I hear a bell ring.

*(Name has been excluded to maintain patient privacy.)