The staff at the Dana-Farber/Brigham and Women’s Cancer Center in clinical affiliation with South Shore Hospital, a community hospital in suburban Boston, recognized inefficiencies in their process for requesting a port-a-cath placement for a patient requiring an implant venous access device for chemotherapy. The existing process, previously delineated in 2009, relied on a form that collected incomplete demographic and medical information, and the form was not reviewed and cleared by a clinical staff member. The incomplete information caused frustration for office staff, surgeons, and patients. Many cases required multiple telephone calls/faxes to obtain the correct information. The surgeons encountered issues and became frustrated when meeting the patient in the pre-op area and discovering that there were no updated labs or the patient was not screened for anticoagulation medication use or a complete history, which would have prompted medical/cardiac clearance prior to the procedure. This caused delay in treatment for the patients, adding to their already high anxiety level, as well as internal workflow and cost inefficiencies.
The case of patient AF demonstrates the problems that the cancer program faced. AF was diagnosed with T3 N0 rectal adenocarcinoma. Following National Comprehensive Cancer Network guidelines, his treatment plan included neoadjuvant chemoradiation, and the protocol for 5-fluorouracil continuous infusion that requires a port-a-cath.
When AF presented to the pre-op area for the insertion of the port-a-cath, it was discovered that he was on Coumadin and had never been instructed to stop taking the medication 7 days prior. Due to his history of recent cardiac stent placement, he was not able to stop the Coumadin without a bridge. Port-a-cath placement was cancelled that day, and the patient was sent to his cardiologist for clearance and a Lovenox bridge. The delay in placing the port-a-cath resulted in a delay in the treatment start date.
As a result of delays in treatment for AF and other previous patients, the nurse navigator led an effort to review the existing process and implement a quality improvement project for port consult/insertion to better serve patients and to improve internal operations. The nurse navigator and her team followed these steps in this project:
The nurse navigator oversaw a gap analysis to identify the aspects of the process that needed changes and the countermeasures needed to make the necessary changes from the current status to the desired future status (Table). In their analysis of the existing process, they learned that there were issues from both the clinical and the clerical perspectives.
What was not working:
The team established a solution approach based on defining the process(es) that would change the current operations workflow, adding necessary fields to the form to support that process, and monitoring effectiveness defined by metrics related to decrease in cancellations, increase in patient satisfaction, and level loading of administrative tasks.
The team determined that they would use the following target state metrics to evaluate the new experimental form:
The nurse navigator created an updated form for requesting a port-a-cath that included all the needed information. Definitions were established on the request form that included:
The surgeons came to a consensus on acceptable patient lab values for port insertion.
The nurse navigator also created a document describing the new workflow that addressed how to rotate clerical tasks among all the administrative staff (Figure 1).
The nurse navigator and her team tested out the new process for 6 months.
After a 6-month trial period, the nurse navigator met with the medical oncology nurse manager, the office managers, and the surgeons to review the results of the pilot (Figure 2). They reviewed the Port Request Log and the Data Tracking Sheet that the nurse navigator created and determined that the new form was effective in collecting meaningful medical information and resulted in improvements on the defined metrics:
At this meeting, the team agreed to continue improving the process for positive patient outcomes.
The nurse navigator applied the lessons learned and the new process to roll out a similar improvement project with the PEG-J tube request form and workflow.
Patient navigators play a key role in observing clinic workflow and operations management. Based on their tracking of patients and an understanding of their barriers to care, navigators can work with the care team to identify ways of improving efficiency in the clinic, which has a positive impact on the utilization of resources, patient satisfaction, and timelines of treatment.
Marian E. Gilmore, RN, OCN, ONN-CG Dana-Farber/Brigham & Women’s Cancer Center This email address is being protected from spambots. You need JavaScript enabled to view it. Pamela Goetz, BA, OPN-CG Sibley Memorial Hospital, Johns Hopkins Medicine This email address is being protected from spambots. You need JavaScript enabled to view it. Barbara McHale, RN, BS, OCN, ONN-CG, CBCN Retired, Hildegard Medicus Cancer Treatment Center This email address is being protected from spambots. You need JavaScript enabled to view it.
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