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:
- Identify the problem
- Conduct a gap analysis of the situation
- Identify a solutions approach with defined metrics to improve the process
- Pilot the new process
- Evaluate outcomes
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:
- Insufficient information was requested on the previous form
- Required lab values were not identified
- Timeline for port insertion was not defined
- Workflow in the clerical area resulted in unequal distribution among the staff
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:
- Target state is a decrease in cancellations over time, and the number of faxes, e-mails, and phone calls needed for each port-a-cath surgical request
- Target state includes the new port-a-cath surgical request form is filled out in its entirety. They would review which fields were being left out and why
- Measure days between contact with office for insertion and actual port-a-cath insertion date; this should not be more than 7 to 10 days
- Target state is a new level loading of clerical work, shared among office staff.
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:
- Relevant and required clinical information
- Medical history
- Fast Track versus ASAP
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:
- Cancellations, number of faxes/e-mails/phone calls
- Form fully completed
- Days from office contact re: port insertion to actual insertion
- Level loading of clerical work
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.
The authors can be contacted as follows:
Marian E. Gilmore, RN, OCN, ONN-CG
Dana-Farber/Brigham & Women’s Cancer Center
Pamela Goetz, BA, OPN-CG
Sibley Memorial Hospital, Johns Hopkins Medicine
Barbara McHale, RN, BS, OCN, ONN-CG, CBCN
Retired, Hildegard Medicus Cancer Treatment Center