Fox Chase Cancer Center (FCCC) participated in the NCCN Opportunities for Improvement (OFI) project with the purpose of optimizing the quality of care delivered at FCCC to patients with breast cancer based on ASCO and NCCN Guidelines. Historically, FCCC’s performance has demonstrated a high level of concordance, based on findings from the NCCN Oncology Outcomes Database project benchmarking data in breast cancer. Access to the NCCN Breast Cancer Timing in Continuation and Transition of Care (TiCToC) Measures data analysis (performed by NCCN) provided an opportunity to further identify specific opportunities related to care along the continuum. The initial goal of the project was to continue participation in the NCCN Oncology Outcomes Database for Breast Cancer, with the overall objective of sustaining high concordance. FCCC’s recent data were compared with historical data and benchmarked against those from other participating NCCN Member Institutions.
Annual NCCN outcomes data for breast cancer that included patients with newly diagnosed breast cancer presenting at FCCC were adjudicated by the FCCC staff who completed a detailed chart review. These findings were reviewed by members of the multidisciplinary Breast Service Line Team. Reasons for nonconcordance were determined and strategies for improvement were identified and implemented. FCCC’s concordance was measured against the 9 ASCO and NCCN quality measures, and ranged from 70% to 94% (Table 1). Initially, 16 cases were identified as nonconcordant for the ASCO3 measure, yielding a 70% rate. After closer analysis, the team discovered that 4 of these cases did not meet the criteria for inclusion. Medical staff stakeholders participated in a critical analysis of the 12 remaining cases. Of these, 25% (3 of 12) did not meet criteria because of patient choice, and in another 25% (3 of 12) nonconcordance occurred because of delay in patient arrival at FCCC or because the procedure was performed at an outside facility. In 6 of the 12 cases (50%), additional workup or consultation for reconstruction was needed before the patient could undergo definitive surgery.
ASCO/NCCN Quality Measuresa
Results were presented to the Breast Service Line Team. Opportunities for improvement were identified to reduce the median time from diagnosis to first definitive treatment at various treatment points along the continuum (ie, first and last definitive surgery, adjuvant chemotherapy, and neoadjuvant therapy).
Process Improvement Initiatives
In the spring of 2012, as part of a major institutional initiative to address patient access, process improvement cross-functional working groups (including patient and family advisors) were established to redesign several processes and roles involved in providing clinical services to patients with breast cancer. The goals of this redesign were to 1) improve the experience for new and returning patients in front-end access and scheduling; 2) enhance the revenue cycle to better support preregistration and insurance precertification; 3) improve patients first call experience by moving the role of the nurse navigator to the first-connection-to FCCC position; and 4) move follow-up scheduling to the service line level.
The Breast Service Line Redesign Team and the Infusion Room Task Force used process mapping, SIPOC (suppliers, inputs, process, outputs, customers) analysis, Kaizen performance improvement techniques, and other improvement tools that addressed the opportunity to reduce “next available” physician appointment time and other operational and patient experience-specific measures. Areas that were addressed included the nurse navigator program as it relates to scheduling and care coordination; assessment of the multiple hand-offs that occur during the intake and registration processes; obtaining patient materials (pathology tissue, radiology films) with complete interpretation in advance of the patient’s first visit; and wherever possible, performance of studies in-house. In addition, efforts were made to reduce the “next available” physician appointment time and other operational and patient experience-specific measures.
Patient Access Redesign
In the preimprovement phase, the call center had no formal structure and minimal capability to monitor calls or capture call data to measure performance. Multiple phone numbers were listed as points of contact for clinical and related services. The improvement plan included: 1) creation of one point of contact for all clinical and ancillary services (billing, financial counselors, nurse navigators, phone triage, providers, and schedulers); 2) creation of a system to monitor calls and associated data; and 3) development of a dashboard to measure performance over time.
Before this initiative, new patient intake was performed by nonclinical schedulers, who transferred patients to the preregistration line to leave a message. In addition, because of understaffing, preregistration was inconsistently completed before the patient’s first visit. In the revised model, the new patient intake is performed by a nurse navigator with a “soft” handoff to the preregistration staff for real-time patient registration and insurance verification. In addition, with an increase in staff, preregistration is now performed before the first visit on a consistent basis, reregistration is performed every 90 days (best practice), and benefits are verified electronically.
Nurse Navigation Program
When faced with a cancer diagnosis, patients must deal with numerous issues, including emotional, logistic, financial, making it difficult for them to focus on their treatment and return to health. The FCCC nurse navigators are experienced oncology-certified nurses with a high degree of clinical expertise who are responsible for the identification and removal of barriers to timely and appropriate cancer treatment. After a patient calls FCCC to schedule an appointment, they are connected with a nurse navigator within 24 hours. Based on the clinical information surrounding the patient’s diagnosis, the nurse navigator will ensure the patient is scheduled for the appropriate type of appointment. The nurse navigator will make sure patients are aware of what they need to bring with or send before the visit, and will answer any questions about coming to FCCC. If the patient needs slides, scans, or records delivered from another institution, the nurse navigator will provide direction on how to have the information sent before the scheduled appointment and explain why this is so important to the patient’s clinical visit and decision-making.
Nurse navigators work within clinicians’ schedules to secure appropriate and timely appointments, and can often help coordinate the patient’s schedule so multiple appointments and tests can be completed in the same day. The nurse navigator greets patients in person as they arrive on campus and introduces them to the team of medical specialists, tailor an individualized, comprehensive treatment plan based on the patient’s diagnosis.
Outcomes of Improvement Efforts
The FCCC nurse navigator program for the Breast Service Line originally launched in April 2010, and was further enhanced in 2012. It has seen more than 5100 patients as of June 2013. Approximately 99% of patients have accepted this service when offered, and it has resulted in more than a 74% retention rate after the first appointment. The total average monthly volume is 125 patients.
FCCC’s conversion rate (call to the center to speak with a navigator, scheduling, and arrival to first appointment) to 98% and has improved significantly since the program enhancements. Before launching the nurse navigation program, FCCC’s call-to-first-appointment time ranged from 14 to 21 days; for more than a year, the average time has been 7 days (Figure 1). Additional enhancements include embedding plastic surgery and risk assessment into the program.
Future plans include integration of nurse navigators into the clinical trials goals of the breast cancer team. Novel clinical research and the multidisciplinary Breast Evaluation Center (BEC) set FCCC apart from the community. A BEC educational DVD has been produced to share with patients before their first visit to provide information about the BEC team members and their roles, breast cancer natural history, and availability of resources. With the launching of the Epic electronic medical record, further operational changes will also be made.