Implementing large scale fast track diagnostics in a comprehensive cancer center, pre- and post-measurement data

With the increasing incidence of cancer and the introduction of early detection and screening programs, the numbers of patients presenting to be diagnosed is growing. The tendency to concentrate cancer services, in view of quality criteria, use of expensive infrastructure and minimum numbers related to volume-outcome discussions, adds to this trend. The introduction of managed competition-like systems urge hospitals to compete both patient centeredness and efficiency [1, 2]. In response institutions explore innovative approaches to redesign their services, for instance by using techniques that are derived from the business domain or Operations Management [3‐7]. International examples are mostly reported on single tumor services, such as sarcoma [8], brain- [9] and head and neck cancer [10, 11].

Patients with a cancer suspicion often visit the hospital multiple times before the diagnosis is completed. In operations management literature we can find various papers referring to service improvement using redesign or lean management techniques [12], but so far little evidence is found on large scale- or multiple service improvement, especially in the hospital environment. This is especially relevant as, at least theoretically, improvement in isolated services by allocating fast track slots, can lead to suboptimalization elsewhere in the organization. Reports on isolated services, such as breast cancer in oncology are available, but papers on large scale improvement interventions are rather scarce and not found on cancer services.

Using various “operations management” techniques a limited number of fast track diagnostic services were implemented in the Netherlands Cancer Institute (NKI) in 2006. Initially, predominantly fast track diagnostics in breast cancer was provided and later a few more tumor types were added. Increasing process complexity especially due to additional diagnostic modalities, fast growing patient numbers and numbers of clinical trials led to diminished service levels; in about 7 years the number of contacts related to new outpatients almost doubled. From benchmarks [7, 13] as well as feedback from radiology diagnostic companies, we knew that there was already a relatively high degree of efficiency in capacity use and hardly any redundancy. The organization decided to embark on a project to improve the quality and efficiency of all outpatient services for those cancer types that provided diagnostics for at least 50 new patients with the same (suspected) tumor diagnosis per year. Diagnosis is defined as pathological diagnosis including tumor classification and treatment plan proposal. The objective was to introduce fast track diagnostics for the identified 18 cancer types, and decrease the access and throughput time, with no- or as limited capacity extension as possible. For patients this was defined as decreasing the amount of patient visits and the period of uncertainty to a minimum, preferably one day. In popular terms: reduction of “sleepless nights” for patients under suspicion of a cancer diagnosis. We report on the process of analysis, redesign, implementation, organizational dynamics and first results using a pre and post measurement design.

Figure 1 a steering group was formed, consisting of clinical leaders and senior management, to guide the various process steps and show leadership commitment. The project team consisted of internal project staff and two external consultants all experienced in operations improvement. For every tumor pathway, a responsible staff in terms of content (“medical pathway owner”) and organizational issues (“process pathway owner”) was identified; these were not necessarily the same.

Access time is estimated to be 10 to 15 workdays in pre measurement. In the diagnostic phase we measured a pilot series of 175 patients and 10 cancer types to raise awareness among staffs and provide a base measurement for the project. It proved that the throughput time ranged between 2 workdays onwards to 58 (mean throughput time 6.0 workdays) and the numbers of visits ranged from 1 to 12 per patient (Table 1). It has to be taken into account that the all over average score was positively influenced by the breast cancer pathway’s performance, as this relates to relatively large numbers.

In Table 1 cervix (n = 3), endometrium (n = 2), vulva (n = 1), ovary (n = 1) and esophagus/stomach (n = 1) results were not presented due to small samples.

It proved possible to simultaneously design the process of 18 tumors as a fast track of which 7 as “one stop shop” (diagnosis completed in one visit). After 6 months of implementation mean access time was decreased from 10 to 15 to 8.7 workdays and mean throughput time was decreased from 6.0 to 3.3 workdays. In the second quarter after implementation, 27% of the eligible patients expressed the wish to receive fast track diagnostics.

In some tumor types, such as head and neck, speedy diagnostics and with that fast treatment start is likely to result in better treatment response. In other tumor types appointments about responsibilities in the diagnostics improved process control and the care quality.

The involvement of physicians in redesigning and reorganizing their work was important. The necessity for “change management” was addressed already in 1947 by Kurt Lewin [14], identifying relevant socio-dynamic forces and phases of introducing change. This approach was found applicable to change management projects in the hospital sector [15]. As especially personal adjustments in their weekly schedules and team conferences could occur, commitment of physicians and other stakeholders for change was considered essential. In order to build trust and unfreeze the views on the present situation, we let them actively participate in identifying problems and brainstorming on solutions within the group. This step was supported by communicating the results of the baseline measurement in staff meetings, rapid response to their needs and bottlenecks during implementation phase, supportive statements from senior clinical leadership and senior management and formal launch moments. External input from consultants was used to show relative value of existing practices.

Physicians became more open to think about the opportunities to create a better diagnostic process. We had to convince them that the status quo might not always be beneficial to their work by showing the value of alternative approaches such as central planning and the opportunity have a scan report in a few hours. To prevent blockage based on capacity worries, 4 h of additional MRI-capacity per week had to be decided upon as some senior physicians were convinced that some degree of redundancy would prove to be an essential success factor. This extra capacity was however not used in the reported period.

Some tumor groups tried to return to the old process using unforeseen implementation problems to argue that the new work process proved too difficult. Swift reacting to those ad hoc practical problems proved extremely useful.

Especially involvement of senior leadership in the decision process and a formal authorization procedure by team chair and pathway owner(s) is needed to inspire all stakeholders to “move”. A monitoring mechanism was introduced to control the changed processes and improve if necessary. During the follow up period, occasions to present the results were deliberately sought after to reinforce consistent implementation.

Research has shown that approaches such as operations research, lean management, six sigma and benchmarking, can help to improve patient logistics in healthcare [12, 13, 16, 17]. However for practicing clinicians, patient logistics appeared to be a rather new subject. Van Lent et al. 2012, showed that most Dutch hospitals used a combination of approaches and tools and top down steering was mostly absent; only about half of the hospitals reported goal accomplishment and no approach seemed to outperform the others [7]. In this project we noted that clinical staff is not so much interested in the type of operations management approach, but rather in the benefits that a project can generate for patients or staffs; it is thus not very usefull to accentuate the specific OM approach in communication efforts. Not just improving specific services, such as breast cancer, but a broad portfolio of services in a large scale project, requires operations knowledge to prevent suboptimization on organisational levels.

The belief that fast diagnoses relieve distress is the rationale supported by Leinster [18]. Contrary, Morse et al. [19], described women’s emotional responses when facing the possibility of breast cancer and conceptualize strategies for “getting through” the time between finding a breast lump, receiving news of an abnormal mammogram, and hearing biopsy results. They revealed ways that women cope an extremely distressing time in the diagnostic processes for breast cancer [19]. Enduring is a normal, natural, and even healthy response to a potential threat of an unavoidable loss that will continue until the person is able to cognitively accept the fact that they have (or may have) cancer. Further research should point out consequences of less waiting time and whether this is an important issue within fast track diagnostics, as we learned that a varying percentage per tumor type prefers not to enter the fast track procedure.

Another implication for further research is the impact of fast track diagnostics on health care costs. Although improving patient logistics is likely to reduce health care costs and lead to better use of infrastructure, this was not the objective of the project and no budgetary consequences were involved. The absence of a financial target may have assured physicians of the aligned, patient centered motives of senior management.

It proved possible to redesign and implement fast track diagnostics of 18 cancer types within one year. Throughput time and access time were considerably shortened after implementation. The involvement of physicians in redesigning and reorganizing their work was a crucial success factor.