Improving the Chemotherapy Appointment Experience at the BC Cancer Agency Ruben Aristizabal Martin Puterman Pablo Santibáñez Kevin Huang Vincent Chow www.orincancercare.org/cihrteam
Acknowledgements BC Cancer Agency Centre for Operations Excellence Sauder School of Business, UBC CIHR Team in Operations Research for Improved Cancer Care
The CIHR Team Oncologists Administrators Statisticians Faculty Researchers PhD Students Post-Doctorate Fellows BCCA UBC Operations Research Professionals www.orincancercare.org/cihrteam 3
BC Cancer Agency Province-wide, populationbased cancer control program for residents of British Columbia & Yukon Full spectrum of cancer care, from prevention and screening, to diagnosis, treatment, and through to rehabilitation 4
Background Cancer treatments include: - Surgery - Radiotherapy - Chemotherapy Drug treatment: - orally - intravenously Mostly outpatient Multiple appointments Possible adverse reactions CHEMO ROOM Challenges to improve the patient experience - Stressful situation - Pre-appointment arrangements 5
Scope of the Problem Chemotherapy unit at Vancouver Centre: - 14,000+ appointments per year - 200+ treatment protocols Each day: - 65 patients, - Treatments from ½ to 8+ hrs - 9 rooms, 33 chairs - 08:00 to 18:00 6
Current Process: Booking a Chemotherapy Appointment Physician Appt Request 1. Date 2. Treatment Clerk Appt Card 1. Date 2. Time or Appt Card 1. Waitlist status 2. Date 7
Current Process: Pre-specified Capacity and Waitlists Appointment request 1. Daily capacity is pre-assigned based on type of treatment 1 Wed 4 4 2. There is not enough capacity for that treatment type 2 3. Therefore patient is waitlisted 4. However, there is still capacity for other type of treatments (yellow, green) 3 Waitlist Available Taken Open 8
Current Process: Finalizing Treatment List Pre-booked list One or two days before Mon Tue Wed Thu Fri To accommodate the waitlisted patients the clerk has to: Manage capacity: Release pre-specified capacity Add nursing time Cancellations Waitlist Manage demand: Triage patients Re-schedule patients to different days based on clinical tolerance 9
Appointment Waitlist 100 90 80 70 60 Daily Waitlist size Jan 02, 2008 May 01, 2009 50 40 Current system Average 30 20 10 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May 10
Effect of Current Practices Inconvenience for patients: o Last minute confirmation (1 2 days) o Low appointment reliability Rework for clerk Negative effect in other departments planning (pharmacy, RT, Lab) 11
Using Simulation Computer Simulation Operations research tool Model that imitates the system s behavior Allows to make changes to the process and evaluate their effect without disturbing the real system Process Changes INPUT 19300 appt 2008/2009 Computer Simulation Model OUTPUT Waitlist Confirmation time Utilization 12
Process Changes: Increasing Flexibility 1) Add booking flexibility: avoid using pre defined capacity Mon Tue Wed Thu Fri 13
Process Changes: Scheduling Tool 2) Automate allocation of appointments (scheduling tool) Manual Schedule Computer System 14
Process Changes: Scheduling Tool Based on an optimization model developed to allocate appointments to nurses while balancing workload and complexity across the schedule. Computer System p x ˆ 1 i jk p p i iˆ i p p ijk ( pij ) AM Min p i iˆ i x j k x p iˆ jk 1 x p ijk ( pij ) PM k k k k 15
Quantifying Potential Benefits 100 90 80 70 60 Daily Waitlist size Jan 02, 2008 May 01, 2009 50 40 30 Current system Proposed changes Average 20 10 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May AMOUNT OF NOTICE Current System: Proposed Changes: 60% more than 1-week 85% more than 1 week 16
Patient Benefits Earlier confirmation time Fewer waitlisted and re-scheduled appointments Greater appointment reliability 17
Other Benefits General Easier coordination between departments (pharmacy) Approach might portable to other centres Clerks Reduction in booking rework Fewer patient calls Easier way to schedule appointments Nurses Better workload distribution across nurses Breaks are included in scheduling process 18
Implementation Challenges 2009 2010 Apr- Oct Nov Dec Jan Feb Mar Apr UBC PROJECT Preliminary Tasks Tool development Procedure changes HIS changes More than developing mathematical models Requires: Training and pilot run - Strong leadership within the organization - Many resources - Coordination among different departments 19
Improving the Chemotherapy Appointment Experience at the BC Cancer Agency Ruben Aristizabal Martin Puterman Pablo Santibáñez Kevin Huang Vincent Chow www.orincancercare.org/cihrteam