1. Utilization Of Lean Process Improvement During Introduction Of Stereotactic Body Radiotherapy And Radiosurgery To Decrease Patient Rescheduling Nitika Thawani Department of Radiation Oncology Assistant Professor, Department of Radiology Texas A&M College of Medicine Scott & White Healthcare System Sep 14, 2013

2. Overview Introduction- Why we needed this? Materials/Methods- How we went about doing this? Results- How it changed our practice? Discussion- How we compare to others? Future directions------------------------- 2

3. 3 Introduction Stereotactic Body Radiotherapy(SBRT) and Radiosurgery (SRS)- specialized forms of radiotherapy. High doses are delivered over a small number of treatment fractions Treatment requires extreme precision as very high doses of radiation are delivered over short period of time Potential for a high price to pay for small errors Multidisciplinary care mandated so that complex treatment modalities can provide safe and expeditious care to patients

4. 4 Introduction The Radiosurgery program at Scott and White Healthcare system was introduced in 4/2010 The patient need in Central Texas led to a high volume of patients over a short timeframe leading to a high rescheduling rate(RSR) High RSR can potentially lead to decreased patient and employee satisfaction, increased costs, poor outcomes and rework

5. 5 Introduction Lean thinking is a management philosophy developed from the manufacturing industry, initially pioneered and championed by Toyota Motor Corporation The objective is “ to deliver maximum value to the customer while consuming the fewest resources by eliminating waste and reducing lead time”

6. 6 Introduction- 5 steps of Lean Management

7. 7 Material/ Methods Data on rescheduling along with the reasons for rescheduling were collected on all patients Data from 5/2012 to 7/2012 was used to define the problem A team including scheduling, nursing, therapy (simulation and treatment delivery), physics and physicians, used A3 structured problem solving for each step of the workflow

8. 8 Materials/ Methods 1. Develop a Current state value stream map (CVSM) for the treatment flow. UDE( undesirable effects were recorded at each step) 2. Designed the Future state value Stream map(FSVSM) Kaizens- (continuous, incremental improvement of an activity to create more value with less muda) were recorded for each step 3. Detailed work plan was created for implementing the FSVSM. Each member of the team assigned specific tasks with timelines

9. 9 Materials/ Methods Data was collected from 9/2012- 12/2012 to assess improvement- 1.Rescheduling rates 2.Treatment start times ( time from patient check in to start of treatment)

10. Results- Initial problem statement 0% 20% 40% 60% 80% 100% Jan-MarAprilMayJuneJulyAugSeptOct SRS Patients w/o delays % cases w/o delaysGoal 95%

11. Results- initial problem statement

12. Current State

14. Physics Current State

15. Physics Current State Continued

16. Future State

17. Future State Continued

18. Physics Future State

19. Tools for standardization 19

20. Tools for standardization 20

21. Checklists 21

22. Results- rescheduling rates 22 RSR 5/2012- 8/2012 16/144(14.5%) RSR 11/2012- 0/13(0%), 12/2012- 1/18(0.05%)

23. 23 Results Treatment start time (check in time- start) 8/2012- 31 minutes( mean 27 min) 10/2012- 9 min( mean 3 min) Number of steps in the physics process decreased from 15 to 7

24. 24 Discussion Lean thinking application in the manufacturing sector has been very successful and reproducible We realized that our current system of operation was a fragmented process During this process of self discovery, we developed various tools to improve quality and standardize the process Biggest advantage- Eliminated the usual state where a quickfix/ workaround developed with each problem. Once a solution obtained- gets incorporated into the process and does not need rework

25. 25 Limitations- No before and after We improved while going through the process but difficult to obtain parameters to prove the success

26. 26 Conclusions Using Lean production principles, we improved our stereotactic radiosurgery process and decreased rescheduling of patients This improvement ( WE THINK!!!) has led to improved safety, quality, patient satisfaction and outcomes

27. 27 Future Directions Continuous reassessment and improvement Incorporate new technologies Institute the process for new sites

28. 28 Acknowledgements Entire Radiosurgery team- Front Desk- Courtney, Jessica Therapists- Ayeisha, Arlene, Jeni, Jessica, Nursing- Gabby Physics- Chris Cherry, Sangroh Kim, Andrew Morrow Department Support- Dr. Mutyala, Dr. Deb, Dr. Rangaraj Radiosurgery physicians- Dr. Maraboyina, Dr. Patel CLIP team especially Gretchen Davenport

29. 29 Questions???