DEFINE

Define the problem, improvement activity, opportunity for improvement, the project goals, and customer (internal and external) requirements.

Team 403 involved representatives from the cancer center of TMH. The team was able to develop charts for a better comprehension of the current state of related processes, including scheduling, floor layout, and communication. These factors provided a narrower spectrum on contributing factors that needed to be measured to determine and resolve the gap between the current efficiency and required efficiency. Factors that required further investigation were determined so that these variables could be prioritized in future steps of the problem-solving process.

Figure 1: This fishbone diagram displays the potential causes of 4 major categories that contribute to the low utilization of infusion chairs in the cancer unit.

Known Variables

In the define phase, the shareholder's requirements were identified. The current state of the cancer center's infusion chair process at TMH was analyzed and anticipated efficiency results were determined. Team 403 aims to improve the efficiency so all known factors have been established for analysis. A better understanding of time constraints as well as areas of strength are observed. A detailed list of the unit operations can be found below:

The cancer unit's office hours are from 8AM - 4PM with the last appointment being at 4-5PM.
The lab will see 100-120 patients per day from 7:30AM - 11AM.
Infusion utilization includes:
-Some utilization from 8AM - 10AM.
-High utilization, about 90%, from 10AM - 3PM.
-Lowest utilization from 3PM - 5PM.
Infusion lengths vary:
-Short infusions are about 30 minutes but have a scheduled time of 90 minutes.
-Long infusions can be up to 8 hours.
The pharmacy leaves at 5PM.
-Dispensations of medication and the infusion takes 90 minutes.
-Industry standard of process time is 30 minutes.
-Turnaround time should be 60 minutes.
There are various types of patients which include:
-Blood patients: 4 to 5 hours for red blood cells
-Fluid patients: 1 to 2 liters of fluid
-Magnesium patients: 120 minutes visit.
-Chemotherapy patients: Timing depends on current medication and any pre-medication given to the pharmacy.
IVIG patients are non cancer patients.
-8 hour infusions that are infused by an outside party, not TMH.
-This infusion process reserves a chair for up to 2 days.
-This infusion is scheduled by outside providers.
There are various types of treatments:
-Ocrevus: it's a long drug time that requires a nurse in the cancer center and treatment is every 6 months .
-Reclast: is a short medication with yearly injections of usually 8 to 10 patients. This type of treatment is sually scheduled between 3PM and 5PM if Proclear is not needed.
-Ancillary: services for chemotherapy (blood, fluid, magnesium, pain management) added on at the last minute. Re-arrangement of patients is needed on the schedule to make it happen.
For 8am, outside provider patients, they have to come in for pre-work the day before actual treatment.

Operation Issues

Given team 403's objective is to improve the efficiency and optimization of the infusion chairs and their connecting processes to maximize the number of patients to be seen and treated, it is imperative to identify issues that contribute to the high turnaround time for pharmacy processing. Some of the factors that contribute to the inefficiency of their current process are scheduling issues with patients, communication issues between TMH forecasting process and external referrals, inefficiencies between the doctor and infusion unit, performance bottleneck in scheduling patients, and significant variability in operation procedures. These and more known issues are listed in more detail below:

The unit doesn’t get to see patient until after the patient sees the doctor.
-Process: Patient arrives in the morning, sees the Doctor, may need to do lab work, then gets treatment (potential root cause of why 8am to 10am utilization is low)
Some regimens need a chair for 8 hours.
There is no space to add on new types of treatments.
-Therefore, cancellation of appointments occur.
There can be holds on schedules for potential blood requirements of patients.
There can be back to back scheduling of pateints which will create bottlenecks.
The patient timing is dependent on the doctor and if the patient is on time.
New patient scheduling issues:
-Need "Intent to Treat" athorization which can take 4-5 days.
-The cancer center scheduling office is notified last minute as the scheduling systems do not communicate.
Sompe patients need pre-procedures done before infusions and due to poor communication, the pre-treatments have not beeen done.
-Pateint has to reschedule appointment.
When a patient needs radiation or chemotherapy:
-Before radiation, the patient must recieve chemotherapy. These treatments areas are on different floors.
-Radiation and chemotherapy software systems do not communicate well.
-Nurse navigators schedule and coordinate these two types of treatments.
Patient education is conducted by nurse navigators in advance of chemitherapy treatments.
-Last minute appointments also must go through the hour long patient education.

A patient processing diagram was created to visually represent the flow of the patient through the Cancer Center:

Figure 2: Patient Process Map