1. Results According to the process mapping diagram (Chart 1), the procedure for per os prescribing included seven steps from the beginning to the end of the path of a patient. The total time spent for obtaining the per os treatment was 1 hour and 41 minutes. In order to receive chemotherapy, patients had to proceed through six steps with a mean time of 4 hours and 57 minutes. The percentage of the waste time (time that didn't spent in activities contributing directly towards the patient’s outcome, e.g. physician consultation, prescribing) was 88.2% (1 hour and 29 minutes) of the total time needed to complete the procedure and obtain the treatment. However, in the case of chemotherapy the absolute mean time of waiting exceeded the two hours (Table 1). Methods Background and objectives Conclusions - Discussion This study was funded by NOVARTIS HELLAS Table 1: Total time spent for obtaining the treatment (per os or chemotherapy) The sample of the study were 86 patients diagnosed with breast cancer at two large public oncological hospitals. A process mapping study, by applying PERT (Program Evaluation Review Technique) analysis, was conducted. In particular, a mapping of the route of patients with breast cancer was developed. The observation and recording of times, step by step, started from the time that patients entered hospital until their departure from it, and continued to the local pharmacies of EOPYY (Social Security Fund) where they obtained the medicines... Waiting time represented the higher percentage of the total time needed to complete the process for obtaining the treatment. According to PERT analysis, the total time spent for obtaining treatment (per os or chemotherapy) is higher up to seven times compared with the time spent in activities contributing directly towards the patient’s outcome. The study revealed that increased waiting times were associated with poor coordination between the involved departments and insufficient scheduling of appointments and organization of medical records. Several studies have documented the negative correlation between the increased waiting time and patient satisfaction of the provided health services. While for cancer patients this association is more intense (Lee et al., 2004; Cartwright and Windsor, 1992). In order to achieve improvements in breast cancer patient journey some lean-inspired changes could be implemented to the Greek NHS system including improvements to communication and coordination between departments, hospital personnel allocation and taking advantage of technology advancements. Waiting time represented the higher percentage of the total time needed to complete the process for obtaining the treatment. According to PERT analysis, the total time spent for obtaining treatment (per os or chemotherapy) is higher up to seven times compared with the time spent in activities contributing directly towards the patient’s outcome. The study revealed that increased waiting times were associated with poor coordination between the involved departments and insufficient scheduling of appointments and organization of medical records. Several studies have documented the negative correlation between the increased waiting time and patient satisfaction of the provided health services. While for cancer patients this association is more intense (Lee et al., 2004; Cartwright and Windsor, 1992). In order to achieve improvements in breast cancer patient journey some lean-inspired changes could be implemented to the Greek NHS system including improvements to communication and coordination between departments, hospital personnel allocation and taking advantage of technology advancements. Based to the findings, patient journey could have been completed in 14 minutes in the case of per os prescription and 116 minutes in case of chemotherapy (best case scenario) (Table 2). The main reasons for increased waiting times for prescription was the dysfunctional Central Information System for e-prescribing, insufficient hospital personnel or their inefficient allocation, lack of electronic health records and coordination between involved hospital departments (Chart 2). References Ben-Tovim D., Bassham J., Bolch D., Martin M., Dougherty M. and Szwarcbord M. (2007). “Lean thinking across a hospital: redesigning care at the Flinders Medical Centre”, Australian Health Review, 31(1), pp 10-15. Ben-Tovim DI, Dougherty ML, O’Connell TJ, McGrath KM. (2008) Patient journeys: the process of clinical redesign. Med J Aust, 188(suppl 6):S14-7. Trebble, T., Hansi, N., Hydes, T., Smith, M.A., Baker, M. (2010). Process mapping the patient journey through health care: an introduction, BMJ, 341:c4078 Bar-Dayan Y, Leiba A, Weiss Y, Carroll JS, Benedek P. (2002). "Waiting time is a major predictor of patient satisfaction in a primary military clinic". Mil Med, 167(10):842-5. Cartwright A, Windsor J. Outpatients and their doctors 1992; London: HMSO. Dansky KH, Miles J. (1997). "Patient satisfaction with ambulatory healthcare services: waiting time and filling time". Hosp Health Serv Adm 42(2):165-177. Huang XM. (1994). "Patient attitude towards waiting in outpatient clinic and its applications". Health Serv Manage Res, 7(1):2-8. Probst JC, Greenhouse DL, Selassie AW. (1997). "Patient and Physician Satisfaction with an Outpatient Care Visit". J Fam Pract, 45(5):418-25. Zoller JS, Lackland DT, Silverstein MD (2001). "Predicting patient intent to return from patient satisfaction scores". J Ambul Care Manage, 24(1):44-50. Anderson RT, Camacho FT, Balkrishnan R. (2007). "Willing to wait?: the influence of patient wait time on satisfaction with primary care". BMC Health Serv Res, 28;7:31. Lee, Y-M, Francis, K., Walker, J., Lee, SM. (2004). "What are the information needs of Chinese breast cancer patients receiving chemotherapy?". European Journal of Oncology Nursing, 8(3): 224-233. Cartwright A, Windsor J. Outpatients and their doctors 1992; London: HMSO. Ben-Tovim D., Bassham J., Bolch D., Martin M., Dougherty M. and Szwarcbord M. (2007). “Lean thinking across a hospital: redesigning care at the Flinders Medical Centre”, Australian Health Review, 31(1), pp 10-15. Ben-Tovim DI, Dougherty ML, O’Connell TJ, McGrath KM. (2008) Patient journeys: the process of clinical redesign. Med J Aust, 188(suppl 6):S14-7. Trebble, T., Hansi, N., Hydes, T., Smith, M.A., Baker, M. (2010). Process mapping the patient journey through health care: an introduction, BMJ, 341:c4078 Bar-Dayan Y, Leiba A, Weiss Y, Carroll JS, Benedek P. (2002). "Waiting time is a major predictor of patient satisfaction in a primary military clinic". Mil Med, 167(10):842-5. Cartwright A, Windsor J. Outpatients and their doctors 1992; London: HMSO. Dansky KH, Miles J. (1997). "Patient satisfaction with ambulatory healthcare services: waiting time and filling time". Hosp Health Serv Adm 42(2):165-177. Huang XM. (1994). "Patient attitude towards waiting in outpatient clinic and its applications". Health Serv Manage Res, 7(1):2-8. Probst JC, Greenhouse DL, Selassie AW. (1997). "Patient and Physician Satisfaction with an Outpatient Care Visit". J Fam Pract, 45(5):418-25. Zoller JS, Lackland DT, Silverstein MD (2001). "Predicting patient intent to return from patient satisfaction scores". J Ambul Care Manage, 24(1):44-50. Anderson RT, Camacho FT, Balkrishnan R. (2007). "Willing to wait?: the influence of patient wait time on satisfaction with primary care". BMC Health Serv Res, 28;7:31. Lee, Y-M, Francis, K., Walker, J., Lee, SM. (2004). "What are the information needs of Chinese breast cancer patients receiving chemotherapy?". European Journal of Oncology Nursing, 8(3): 224-233. Cartwright A, Windsor J. Outpatients and their doctors 1992; London: HMSO. Process mapping is a tool which is used to capture the patients journey of care at every stage (Ben-Tovim et al., 2007; 2008). Process maps are an effective way to identify constraints and bottlenecks, rework (activity required to correct situations that could have been avoided) and unnecessary process steps, using the patient’s perspective to identify problems and suggest improvements (Trebble et al., 2010). The present study aimed to examine how breast cancer patients proceed through the public Greek health care system by using process mapping to identify constraints and bottlenecks and unnecessary process steps. Table 2: PERT analysis Chart 1: Process mapping diagram for per os prescription Group of patientsPathWaste time (activities that didn't contribute directly towards the patient’s outcome) Patients with breast cancer for prescription 1 hour and 41 minutes 1 88.2% of the total (1 hour and 29 minutes) Patients with breast cancer for chemotherapy 4 hours and 57 minutes 2 56.2 % of the total (2 hours and 47 minutes) 1.Arrival of the patient at the Hospital (START) 2.Entrance in doctor's office 3.Exit doctor’s office 4.Entrance in Prescription’s Endorsement Office 5.Exit Prescription Prescription’s Endorsement Office 6.Arrival at the pharmacy of National Organization for the Provision of Health Services (EOPYY) 7.Departure from the pharmacy of National Organization for the Provision of Health Services (EOPYY) (END) A-F: median times between steps Group of patientsMedian timeBest case scenario Patients with breast cancer for prescription 1 hour and 41 minutes14 minutes Patients with breast cancer for chemotherapy 4 hours and 57 minutes 1 hour and 56 minutes 1234567 Α(67)B(13)C(12)D(3)E(17)F(8) Chart 2: Main reasons for increased waiting times for prescription