Improving Your Cancer Center Operations
How do you move your cancer center operations forward? Who are your real detail-oriented people? Who is good at moving things from point A to point B? Who are your visionaries? Hint—it is not always those with leadership or executive titles.
These questions were posed by Pamela Tobias, MS, RHIA, CHDA, Administrator, Oncology Services, Lehigh Valley Health Network (LVHN), Allentown, PA, at the Association of Community Cancer Centers Annual National Oncology Conference in October 2017. Improving cancer center operations, Ms Tobias said, starts with identifying the common areas for improvement and the actionable sources of benchmark data for performance improvement.
“When we talk about improving operations, collaboration is key. We want to make sure that we are not afraid to talk to each other about other areas of the operations. We want to make it okay for someone in clinical to open up and point out something that isn’t working in operations,” she said. Ms Tobias encouraged attendees to keep an open approach to innovation.
Actionable Areas That Can Improve Cancer Care
LVHN has 3 hospital-based campuses and 8 breast health services sites, and >45 physicians and >100 nurses who administer >45,000 chemotherapy infusions annually. Ms Tobias listed 7 key ideas that her network is pursuing. Each idea may sound simple, but the process of investigating, identifying incidence rates, and enacting improvement in these areas can improve patient services, patient satisfaction, revenue, cost-savings, and operations. These actionable areas are:
- Readmission rates within 7 to 30 days
- Admissions and emergency department visit rates within 15 days of chemotherapy treatment
- Direct admissions versus emergency department visits during office hours: could these admissions have been prevented with better office outreach or availability?
- Referrals to palliative care
- Aderence to treatment pathways
- Chemotherapy treatment within 2 weeks of end of life
- Patient visits throughput reviews for efficiency.
New payment rules for Medicare and some private insurers mean that certain hospital admissions, readmissions, or emergency department visits close to chemotherapy days will result in a direct hit to your center’s bottom line. Ms Tobias discussed a patient in her center who was in the office hallway heading to a scheduled office visit, who then turned around and self-admitted to the emergency department.
This is a perfect example of a potentially avoidable expense if the administrators are looking for improved care opportunities.
Palliative care referrals are critical for quality of care, patient management, and cost-cutting. Ms Tobias’s group was able to get their oncologists to increase referrals by placing a note in their examination rooms, stating: “If you can answer any of these questions, you should talk to your patient about palliative care.” One of the questions was, “Do you expect your patient to be alive in 6 months?” The most successful cancer centers are embedding palliative care in their practice and patient care visits.
Creating Metrics and Benchmarks
If these ideas do not spark something in your group, Ms Tobias provided a list of accreditation organizations, national societies, and payers as good sources for actionable benchmarks (see Sidebar). She noted the example of the Advisory Board company—a best practices organization that joined forces with Optum in November 2017—that compiled files of disease-specific metrics and benchmarks for their members.
If your company is a member of the Advisory Board Roundtable, you could check their website on how to access those benchmarks.
Ms Tobias advises oncology centers to consider the elements of the Choosing Wisely program as the minimum performance bar for discussions with patients and payers.
Listen to Your Patients
Ms Tobias offered another key tip: listen to your patients’ complaints and concerns; satisfying them can affect your bottom line, improve your care quality, and identify issues that you may not otherwise see.
Her favorite experience was 2 years ago, when she followed a patient through her journey in the organization, also known as “a patient throughput visit review.” She followed the patient from registration, through her mammogram, a breast biopsy, test results, and the resultant treatment. “This was out of my comfort zone, but became one of the best experiences, and I learned so much from that,” she said.
Ms Tobias watched the patient ask every person she met to please get her husband before they reviewed the test results, which was very important to her. One clinician did not hear the patient, and Ms Tobias had to intervene to make sure the patient’s wishes were met. This seems simple, but this led their centers to the policy of always asking if patients want to have a family member or a friend join them.
Start with Easy Improvements: Low-Hanging Fruit
The Institute for Strategy & Competitiveness at Harvard Business School reviews healthcare metrics to determine which metrics really matter. Ms Tobias highlighted some low-hanging fruit: the first was a quarterly review of all charges, no matter which department claims responsibility for the pricing. One drug was set at the wrong price and cost LVHN approximately $500,000 in only 6 months.
The next tip is to control drug waste and make sure that all single-dose vials are being billed appropriately for any unused drug with the correct JW modifier. She also recommended to look at the potential of “dose banding,” a European practice that bands the dose automatically to a whole or half vial of a drug to reduce waste (usually a range of +5% to –5%). LVHN has saved approximately $1 million through the appropriate use of dose banding.
The third low-hanging fruit is to hire financial coordinators. If you only have 1 financial coordinator, you probably need more, says Ms Tobias, because they pay for themselves within 3 months. This year, LVHN’s financial counselors are on track to bring in $3 million in drug replacement and $5 million in drug assistance programs for patients.
Ms Tobias noted that LVHN reviews its own operations by focusing on people, services, care quality, cost, and growth, which helps the network to narrow its choices for metrics and projects that generate tangible operations improvement, savings, and increased patient satisfaction and outcomes. These metrics include:
- People. Satisfaction, staffing, productivity, turnover, overdue results and referrals, coordination, and navigation
- Service. Access, capacity, utilization, throughput, wait times, downtime and disruption, cancellations, and waitlists
- Quality. Accreditations, internal goals, error rates, pathways, safety metrics, and underutilization and overutilization
- Cost. Budget, revenues and collections, reconciliations, write-offs, waste, and missing documents and charges
- Growth. Volumes over time and type, referrals from sources, in- and outmigration, market share, philanthropy, and new sites or services.
This framework makes conversations easier across all divisions and job titles in the organization, Ms Tobias suggests, and all participants understand when approaching improvement with this framework.
Which Benchmarks Are Right for You?
But remember to question benchmarks, Ms Tobias advises. Not all benchmarks are based on the same background and information in your facility. You will not achieve anything if you compare against a benchmark that does not reflect your own reality. For example, a staffing benchmark coming from a source that does not include bone marrow transplantations will be wrong for your group if you do provide that labor-intensive service.
Make sure that the benchmark is trustworthy. Ask yourself, “Why am I benchmarking? Are my data good? What am I really comparing?” and, “Am I able to impact a change when I get the findings?”
“Measurement without movement is just wasted effort,” Ms Tobias reminded the audience.
Once you have a dashboard and metrics, you need to display them so that everyone can learn from them. There are options for groups of all sizes. The easiest solution is using Microsoft Excel, but be sure to review the conditional formatting option in the program. She also suggests investigating the use of sparklines for data display. More sophisticated tools will bring you options for dynamic visualization and interactive data visualization. LVHN uses a tool called Tableau.
LVHN also has partnered with a new vendor to track output from infusion centers, which is completely intuitive and interactive. This presents a retrospective view, but on a daily feed. Vendors are able to look for trends in occupancy, no shows, add-ons, and predicting volume. When they see a predicted growth in longer treatments, or more 5- to 6-hour treatments, they can react in ways that can lead to proactive changes in patient scheduling and staffing to make accommodations.
Ms Tobias ended her presentation by emphasizing the need for visionary tools and applications, saying, “Once the data repositories get connected and we have the data and tools, there is no limit to what we can do.” Recognizing that not all groups are of a size to accomplish this on their own, she suggests that administrators look to local universities or colleges and seek partnerships for research projects.
Groups/Programs with Disease-Specific Metrics and Benchmarks
- Advisory Board
- American College of Radiology
- American College of Surgeons Commission on Cancer
- American College of Surgeons Rapid Quality Reporting System
- American Society of Clinical Oncology
- American Society of Clinical Oncology Quality Oncology Practice Initiative
- American Society for Radiation Oncology
- Association of Community Cancer Centers
- Centers for Disease Control and Prevention
- Centers for Medicare & Medicaid Services
- Choosing Wisely campaign
- College of American Pathologists
- National Accreditation Program for Breast Centers
- National Cancer Institute
- National Committee for Quality Assurance Patient-Centered Specialty Practice Recognition program
- National Quality Forum
- National Quality Measures for Breast Centers
- Oncology Nursing Society