Lean healthcare - optimizing the chemotherapy process
FEATURE – A Brazilian hospital has used lean healthcare principles to optimize the chemotherapy process and prevent patients from unnecessarily wasting hours before their treatment.
Words: Paloma Rubinato Perez, Head of Lean Healthcare, Lean Institute Brasil
This article was originally published by Lean Institute Brasil here.
Each chemotherapy session takes on average eight hours – a procedure that cancer patients sometimes need to complete three times per week. A private healthcare organization here in Brazil that handles highly complex cases and is recognized as one of the best in Latin America managed to reduce the total cycle time of this process by approximately 50%, bringing a better experience to the patient and eliminating the waste of time for the healthcare professionals involved.
By following and recording the patient's journey throughout the hospital to understand how the value chain works and to improve it, they were able to increase the organization’s capacity with no additional resources.
The analysis of the entire value chain from the patient’s perspective highlights improvement opportunities, in some cases (and this one is clearly an example of this) bringing benefits to society as a whole. In this article, we will show how closely observing and following the journey of a chemotherapy patient called Pedro (a fictitious name) enabled the organization’s lean team to achieve better results.
HOW IS HEALTHCARE DOING IN BRAZIL?
Healthcare is an industry riddled with problems anywhere in the world. Many private healthcare providers in Brazil have recently begun to change their remuneration policies. Previously, the established model was “fee for service” – that is, the more procedures the organization performs, the greater the revenue it receives from the operator. This system, however, can represent a disincentive to provide high-quality care and, in the worst cases, even encourage organizations to perform unnecessary procedures. The main objective of the new “fee for value” remuneration model is based on the value provided and on the resolution of the patient’s problem. In this system, patient needs lie at the heart of the care the team provides and the organizations are paid for the value they offer and for generating the best outcomes for patients. This new model started a trend of payment per package of procedures linked to clinical outcomes.
In one such scenario, a cross-functional team working in one of the largest hospitals in Latin America decided to focus their efforts on implementing process improvement, focusing on changing the service model to make their work more efficient and improve the experience of patients, family members and employees. They chose the Oncology Department, with the main objective of understanding the journey of a patient in need of chemotherapy treatment. The organization is recognized as a leader in cancer treatment and delivers chemotherapy to a large number of patients.
The team consisted of nurses, administrators, physicians and physiotherapists, as well as lean specialists. The first step, which seemed easy enough, was to choose a patient whose journey they’d follow: in doing so, the team pulled data from the system and went through the list of patients registered for chemotherapy treatment. The list contained each patient’s full name, date of birth, reference physician and other information about the treatment, but it was complicated to simply pick a name, without any “human warmth” – to put it as one of the team members did. The concern was valid, as the team wanted to know about the patient’s life, not just describe a sterile process. They wanted the patient to be part of the solution, to invite them into the team.
So, they put the list aside and asked the head nurse in the area, who was also part of the team, what patient she’s recommend they reach out to. After thinking for a bit, she said enthusiastically: “We can ask Pedro!”
“Why Pedro?” the team asked her. She explained that Pedro needs to undergo chemotherapy treatment three times per week, that he is extremely approachable and friendly person, who likes to talk and loves to help others. Pedro is a retired businessman, who lives with his daughter. Despite his precarious health situation, he makes his way to the hospital on his own, with a big smile on his face. “He’s the ideal patient for this project,” the head nurse said.
The team spoke with Pedro and explained the project’s objective to him. He immediately said he was happy to help. The following week, the team was already accompanying Pedro to his chemotherapy sessions. They did so for a few months. When they got tired and grumpy, Pedro remained tireless, leaving his house three times a week and going to his sessions. Every day, he was grateful for being alive.
A DAY IN PEDRO’S LIFE
As they followed Pedro on his journey, the team took lots of notes. Yet, the most valuable part of the exercise was the fact that they got to experience a typical day in the Pedro’s life. They took the opportunity to connect with him and developed great empathy for his situation. Along the way, the real purpose of their lean project became clearer and clearer: it was about Pedro’s time.
At that point, Pedro was spending 14% of his precious time in the hospital to carry out the treatment that was keeping him alive. What enthused the team was now the idea of delivering the best possible treatment in the shortest possible time. They began to realize that the only way to achieve that would be eliminating waste from Pedro’s journey.
Here’s what Pedro’s routine looked like at the time:
During the exercise, the team had the opportunity to map out and understand the procedure from Pedro’s point of view and distinguish the good practices from the bad ones – in other words, what was value and what was waste in his eyes. What they found out was that, despite the fact that this is an excellent institution with very capable and professional staff, there were huge gaps in the system, problems and rework, and waste all along the value chain. By actively observing the journey, they were able to share Pedro’s anguish, waits and fears and developed the ability to feel empathy for others.
When they got together to discuss the team’s impressions, they were surprised to find each member paid attention to different details of the journey – a result of their professional and life experiences. For example, the nurses mentioned that measuring vital signs was unnecessary because physicians already did that during the exam in their office. Administrative staff, in turn, challenged the fact that the patient – who in this case was paying for his treatment privately – had to pay for each trip to the hospital rather than being offered a “package”. Doctors questioned the long waits between procedures.
The lean expert suggested that the team could use a few tools to inform their work, organize their ideas and identify waste. After everyone agreed, they started to design the process using value stream mapping, as shown in Figure 1. Starting from the patient’s arrival at the hospital, each activity was written down in a box with its processing times, waiting times, quantity of employees involved and the percentage of correct and complete. This latest piece of data translates into the number of patients who arrive “correctly” at that stage in the process without the need for any rework (for example of “incomplete” is a patient who arrives at the doctor’s office without the result of her blood test, forcing the doctor to ask her to perform the exam again and comes back). Whenever a process needs to be repeated, this generates unnecessary rework and additional costs – that is, waste.
Figure 1: Map of a simplified chemotherapy process
After analyzing and discussing each step in the process in depth, the team moved on to the next stage: identifying the potential improvements for each step. The objective was to reduce waste and make the process leaner and faster. After studying the seven lean wastes, they identified 13 opportunities for improvement, as shown in Figure 2. At this point, many questions appeared about what should be done first, what should not be done at all, and what action would have the greatest impact on the process.
Figure 2: Improvement opportunities
Several doubts were also exposed during the team meetings. Despite this, the team never lost hope that change would be possible and that ultimately everyone would benefit from the improvements – especially Pedro. The hospital board promptly authorized the team to go for their next move: identifying countermeasures and designing an action plan to improve the current process.
CHANGES BASED ON PATIENT VALUE
After analyzing the findings, the team began to propose countermeasures with the objective of improving Pedro’s journey and experience, reducing waste and making it possible to price the procedure based on the value provided (as per the organization’s new strategic approach). Several ideas were put forward, but the most important thing was that the process analysis and improvement ideas were always discussed with Pedro. He actively participated in the project, providing invaluable information and input that the team had not seen.
Before any implementation would start, however, they created a risk matrix to understand the potential of occurrence and frequency of different problems. This aimed to always maintain patient safety. The team even began to ask for Pedro’s approval before implementing an action. They held a meeting to present high-priority ideas and those that got approved would be implemented.
At this point in the process, it is critical to review the problems identified, to ensure the ideas and countermeasures that will be implemented truly address them (and prove to be feasible). From an administrative point of view, the team proposed the introduction of a unit access card for returning patients to prevent them from having to go to reception to pick one up each time they came to the hospital. They also introduced a two-month package for private patients that can be used to pay for the expenses of a procedure, taking the opportunity to price the package that would then be offered to healthcare providers.
The care team decided to eliminate the step of measuring vital signs, as it was a duplicate procedure that also occurred during the doctor’s consultation. They were also responsible for working with engineering to design a better layout for the hospital and better flows, in order to reduce patient movement from one stage to the next. This action proved rather complex and, because it would probably require extra funding, it was left for a future phase.
The action that had the greatest impact on reducing processing time and increasing Perdro’s satisfaction was the elimination of blood collection on the day of the procedure. Thus, the lab partner contract was modified to include the possibility for the patient to get their blood collected the day before the session, at home. Blood collection and analysis of the results represents a critical step in the process and often caused a lot of waiting as the analysis of the blood samples takes around one hour. It couldn’t be eliminated altogether, because the physician needs the test to assess the patient’s clinical condition and ensure he or she can undergo chemotherapy treatment. The change to home collection was only possible because, in discussing the issues with the doctors, the team learned that the test result would not change from one day to the next.
Patients who opted for home collection now receive a call from the hospital if the result shows any issues that prevent them from undergoing treatment. That way, they don’t need to travel to the hospital for nothing. Those whose test shows no problem show up for their appointment with a time-consuming step in the process already taken care of.
The project team was concerned that the operations team might struggle to accept and incorporate these changes into their routine. Therefore, they held group and individual meetings to explain their proposal, they conducted training, mapped critical cases, and laid all the foundations for a successful start. After tests and adjustments, the team was ready to start the service in the new format, as shown in Figure 3.
Figure 3: Map of the new chemotherapy process
A DAY IN PEDRO’S NEW LIFE
Following the changes, Pedro and the other patients began to enjoy a smoother journey through the chemotherapy process, with less waiting. They also felt that the healthcare providers were no longer in a rush and had more time available to welcome them and talk to them.
Pedro was still happy and kept thanking everyone like he did before, but now he had more time to spend with his daughter, go to the park and read his books. He continued to undergo chemotherapy treatment three times a week but opted for home collection. He now spends four hours at the hospital, rather than the previous eight.
Here’s what the new journey looks like:
The improvements implemented by the team, together with Pedro, eliminated four hours of waste from the chemotherapy process – that is 50% of the time. Pedro got approximately 48 hours a month of quality time, which he can spend doing what he likes rather than at the hospital.
Paloma Rubinato Perez is Head of Lean Healthcare at Lean Institute Brasil.