1. Enhancing the Patient Experience in the Head & Neck Center Pheba Philip Office of Performance Improvement Head & Neck Center

2. MD Anderson Cancer Center  Located in Houston, TX  Found in 1941  20,000 Employees (1,600 faculty)  650 inpatient beds  1.3 M outpatient visits  Provided care to 120,000 patients in 2013 Ranked Number 1 in cancer care by U.S. News and World Report

3. HN Center Approach: Engagement and Integration Strategic Planning Physician/Center Leadership-Led Teams Monthly Accountability Reviews OPI Departments HNS, HNMO, RT

4. Participants Head and Neck Center: Laura Baker, Ursula Broussard, Gloria Brown, Sheila Harris, Hettie Hebert, Eve Huang, Sharon Jamison, Grady Johnson, May Johnson, Rita Langner, Shirley McKenzie, Judy Moore, Maria Morales, Julie Ngo, Mary Penkwitz, Marie Pope, Letitia Reed, Missy Robinson, Marvin Saavedra, Shalamar Spears, Estie Thompson Head and Neck Surgery: Kerith Brandt, Ehab Hanna, M.D., Amy Hessel, M.D., Stephen Lai, M.D., Carol Lewis, M.D., Jeff Myers, M.D., Justine Robinson, Shawn Terry, Abram Trigazis, Randal Weber, M.D. Head and Neck Medical Oncology: Michele Neskey, Karen Oishi Radiation Oncology: Beth Beadle, M.D., Amanda Coldiron, Jennifer Gates, Hamlin Williams Office of Performance Improvement: John Bingham, Laura Burke, Parviz Kheirkhah, Victoria Jordan, Miguel Lozano, Jeremy Meade, Pheba Philip, Larry Vines Marketing: Cecilia Kenneally, Gelb Consulting Clinical Operations: Kathy Denton

5. Background Head and Neck Center formed a partnership with the Office of Performance Improvement to: Define a series of performance improvement initiatives to enhance the patient experience Align projects with Institute of Medicine aims: Safe Effective Patient-Centered Timely Efficient Equitable

6. Initiatives 1.New patient access timeTimely First contact to initial appointment 2.Overall patient cycle timeTimely Time gaps in treatment 3.Clinical variation and overuse of testing Effective, Efficient Duplication and inconsistent use of diagnostic imaging services and lab tests 4.Patient interviewsPatient- Centered Gather the voice of the patient to capture expectations, preferences and concerns 5.Staffing model development Efficient Part of the current RN staffing model development in the ambulatory care centers

7. Team Leader Sheila Harris Patient Access Supervisor, Head and Neck Center New Patient Access Time Faculty Leader Carol Lewis, M.D. Assistant Professor, Head and Neck Surgery Facilitator Pheba Philip Industrial Engineer, Performance Improvement Members Hettie Hebert (PAC), Shalamar Spears (PAS), Judy Moore (CAD), Jeremy Meade (OPI)

8. 300+ New patient referrals per month 200+ New patients registered per month New Patient Access Emphasis on appointment coordination Since FY10, 10% increase in other appointments required to coordinate with NP appointment Project AIMS Reduce referral (first contact) to appointment date, including medical and financial clearance, from 12 days to consistently under 10 days NP Access

9. Cause and Effect NP Access

10. Main Interventions Enforced 24-hour rule for referral acceptances by faculty (no exceptions) Faculty commitment to require minimal acceptance criteria (don’t delay acceptance based on inadequate outside records) Enforced timely filing of delay indicators and educated PAS on the importance (patient preference, insurance pre-approval, financial/social reasons) Trained PAS staff on round robin approach to assigning appointments to physicians Process for immediate redirecting referrals to a more appropriate physician, avoiding patient acceptance delays Standardized patient appointment templates in CARE to facilitate scheduling NP Access

11. Improvement of Metrics Timely filling of delay indicators PAS education & training Enforced 24-hour rule Trained/Re-educated PAS staff on round robin approach Standardized new patient appt durations on templates Reinforced email policy for redirecting referrals to other physicians Corrected CARE default time issue for next available appointment HC Transfers Low sample size sensitive to outliers NP Access

12. Keys to Sustainment Continued support and monitoring from department chair, medical director and CAD PAC monitors and communicates open appointment slots regularly PAC audits charts for accuracy, completeness, and compliance of expectations of 3-5 day appointments Actively monitor % of patients who fall outside of the standard time for testing (3-5 days) NP Access

13. Team Leader Judy Moore Clinical Administrative Director, Head and Neck Center Clinical Variation & Overuse of Testing Faculty Leader Amy Hessel, M.D. Professor & Chair, Head and Neck Surgery Facilitator Laura Burke Performance Improvement Associate Members Jeremy Meade (OPI), Laura Baker (PAS), May Johnson (CBM), Hamlin Williams (PSC), Missy Robinson (PSC), Eve Huang (RN), Julie Ngo (RN), Dr. Beth Beadle (XRT Faculty), Karen Oishi (APN), Justine Robinson (PA), Abram Trigazis (PA), Michele Neskey (PA), Amanda Coldiron (PSC), Jennifer Gates (RN, NM XRT)

14. Standardize the treatment planning and follow up schedules for all HNS cancer patients requiring multidisciplinary care including oropharynx, larynx and hypopharynx Reduction of redundancy of imaging and laboratory tests Increase efficiency and decompress the volume of the clinics Improve patient satisfaction: fewer appointments and decreased wait times Facilitates accommodation of new patients and greater focus on patients with acute care needs Aims Clinical Variation

15. Baseline Data: After 6 months (Post radiation summary date) 43% of appts are within 3 months of last appt 11% of CT scans are within 3 months of last scan Clinical Variation

16. Main Interventions Identified critical timing for follow up & treatment decision- making Defined minimum testing needed for appropriate work-up & follow up Standardized order form to include predefined testing Assigned equal responsibility for patient outcome & complications to all the treating teams Provided training for providers, schedulers, and nurses Created patient education sheet to better inform patients about the benefits of the COC pathway

17. Developed a “leap frog” system for follow up appointments after completion of treatment –3 Month Follow UpRadiation Oncology –6 Month Follow Up Medical Oncology –9 Month Follow Up Surgery –12 Month Follow Up Radiation Oncology –16 Month Follow Up Medical Oncology –20 Month Follow Up Surgery –24 Month Follow Up Radiation Oncology –After 2 yearsSurvivorship Allows patient to have one appointment and one set of tests rather than follow up with each provider team independently Continuity of Care Pathway Clinical Variation

18. Patient Report Card Given out by HNS after the evaluation for surgery Allows for patient responsibility Allows for equal ownership of post treatment follow up Allows for expectation of transition to survivorship Clinical Variation

19. Transition to Follow Up Clinical Variation Standardized CSR to include predefined testing

20. Faculty Involvement Target = 24 Faculty involvement has increased 65% eligible patients are on pathway Clinical Variation Current = 22

21. Preliminary Trends/Results Clinical Variation Appointments 28% reduction in appointments within 3 months of past appointment 37% of eligible patients are expected to have a reduction in total number of appointments Testing Patients are receiving standard labs and imaging As participation increases, expect to see reduced variability in imaging

22. Team Leaders Judy Moore Clinical Administrative Director, Head and Neck Center Patient Wait Time Faculty Leaders Ehab Hanna, M.D. Professor & Medical Director, Head and Neck Surgery Randal Weber, M.D. Professor & Chair, Head and Neck Surgery Facilitators Miguel Lozano Sr. Quality Engineer, Performance Improvement Members Kerith Brandt (PA), Marvin Saavedra (PSC), Jeff Myers, M.D. (HNS), Carol Lewis, M.D. (HNS), Grady Johnson (PSC), Shawn Terry (PA), Mary Penkwitz (RN), Julie Ngo (RN), Amy Hessel, M.D. (HNS)

23. Patient Wait Time Identified lowest wait time performers Documented best practices Analyzed template and scheduling practice and its impact on wait time Wait Time DefineMeasureAnalyze Defined the problem Observed and documented patient process flow Identified patient characteristics and expectations for each appointment type Collected baseline patient wait time data for all physicians Classic PI approach using the DMAIC process

24. Patient Wait Time Preliminary findings to be trialed Reinforce & prioritize best practices around team communication, scheduling decisions, and startup/preparation activities. Avoid appointment clusters in same time slots Spread NP appointments throughout the day Make scheduling arrangements for high need patients ImproveControl Wait Time

25. Earlier start time Reduced appointment clusters New patients spread during day Improved schedule load leveling Scheduling Changes Wait Time

26. Team Leader Judy Moore Clinical Administrative Director, Head and Neck Center The Patient’s Perspective Opportunities for Improvement Through Patient Interviews Faculty Leader Ehab Hanna, M.D. Professor, Head and Neck Surgery Facilitator Cecilia Kenneally Manager, Marketing Members Gelb Consulting, May Johnson (CBM), Shirley McKenzie (CCC), Jeremy Meade (OPI), Ehab Hanna, MD (HNS Faculty)

27. Patient Interviews 41 interviews were completed with patients from June 11 – June 22, 2012. Interviews conducted by Gelb Consulting through Marketing. Interviews were completed on site at the Head & Neck Center. On-site interviews provide visual cues for recall. Some patient interviews included family/caregivers, revealing unique roles and needs. Discussion areas: –Decision criteria –Scheduling –Wait times during and between appointments –Experience with treatment team –Communication processes and gaps –Sources of anxiety –Areas of praise Patient Interviews

28. Head & Neck Center Patient Experience Map Symptoms Diagnosis Awareness of MD Anderson Evaluation of healthcare providers Reputation of MD Anderson’s Specialists Choose healthcare provider Scheduling first visit Resources for patients and their families Scheduling and intake Treatment/exam room Chemotherapy, Radiation Treatment, Surgery Nursing care, Physician care Support groups and wellness services Communication with referring physician Follow-up visits Call-backs for assistance Parking Getting to Head & Neck Center Checking-in Waiting area, including vitals Clinic faculty/staff interactions NeedSchedulingFirst VisitTreatmentFollow Up Primary Experience Stewards MDACC Faculty/Staff Patients and their Families Front Desk Staff Faculty/Medical Staff Support Staff Faculty/Medical Staff Support Staff Faculty/Medical Staff Support Staff Patient’s Primary Physician Key Touchpoints Patient Interviews

29. Action Item Summary Patient Interviews

30. Ambulatory Nursing Staffing Model Nursing Personnel Staffing Model was developed to help leadership: –Make staffing decisions based on data –Make sure resources are properly allocated –Analyze “what-if” scenario for improvement initiatives

31. Keys to Success Combined engagement of OPI, academic department, and center leadership Strategic planning upfront to align projects to goals Monthly accountability meetings with steering team Physician participation/leadership on teams

32. Questions?