Reducing Unproductive Visits for Thyroid Cancer Patients – Kaniksha Desai

The Problem:
Patients with thyroid cancer were often arriving for their follow up visits without necessary labs or imaging leading to an unproductive visit. This information would need to be reviewed at a later time asynchronously with the patient, leading to delays in treatment and inefficient workflow.

As we sought to understand the different causes of this problem, we prioritized having a patient advocate as part of the team. This was because patients were major stakeholders in this issue. Specifically, we sought to better understand patient-centered factors such as insufficient patient education that could have been contributing. 

Our 5 Why Exercise

Other causes identified included expired orders and delays in calling to schedule radiology imaging (leading to radiology appointments being scheduled after the visit with the physician). 

Finding Solutions: 
We believed that having a patient advocate on the team would help our team develop optimal interventions.  The key drivers the team identified included patient education about their disease, motivation to have productive visits, a reminder system for patients to have labs and imaging completed prior to the visit, and ensuring that orders were not expired.

After identifying the key drivers, we generated several interventions. The interventions included creating a new standard workflow for the PCC to check that active orders were present at the time patients made their follow up appointment, 3 weeks prior to the visit check that patients had labs and ultrasound imaging scheduled or completed and send patient reminders to have them completed. For patients with expired or missing orders, the PCC was to pend orders for the nurse. For patient education, patients were verbally told the follow up plan, and the plan was written in the after-visit summary and provided to the patient on my health.

Our Process Map

While implementing the PCC workflow, we heavily involved the PCC in order to have more effective PDSA cycles. Unfortunately, and despite this, during these early PDSA cycles, we did not document the standard workflows well, nor did we specifically analyze when the steps were happening or why. Because of this, we had some challenges in sustaining the intervention. After this was recognized, we did begin to document what you see above. Moving forward we will be including this documentation in future training of PCCs. 

Overall, these interventions proved to be very successful. They helped to improve the rate of productive clinic visits and led to a superior patient experience. From a provider standpoint the increase in clinical efficiency of practice would be expected to improve professional fulfillment and reduce symptoms of burnout. 

The outcome of this project actually surpassed our SMART goal. We remain limited however by our interventions being manual and dependent upon adequate staffing. Future work will be directed at creating more automated solutions. 

Reflection:
In reflecting on this project, we have emphasized several learning points: 

  1. We were successful at improving the percentage of productive visits. The majority of our interventions however relied on Level 1 or Level 2 sustainability.  We subsequently had difficulty with sustaining our new workflow and were unable to fully expand it out to other clinics. Sometimes level 1 reliability interventions will fall through and it’s really critical to consider that in your sustain plan. Recognize that level 1 reliability interventions are staff dependent. If you don’t have the staff or the staff doesn’t have the time, it won’t happen. When designing the intervention, try to make it as simple as possible. That way it’s actually easier for people to follow the process then to work around it. 
  2. The sustain plan did not account for major disruptions such as encountered during the COVID-19 pandemic. The pandemic caused resources to be stretched. We have now decided that we need to embed reviewing this process into our standard operations and will do this twice per year. 
  3. It is very important to document PDSA cycles. This includes what worked, what didn’t work and what you may have learned. The A3 is great for overall status of the project and initial problem solving, but isn’t great for this level of detail, so you’ll need something else for documentation. Make a point of documenting it somewhere!

Team Members: 
Katherine Wurdinger (RN), Susana Herrera (PCC), Robert Duffy (Patient Advocate), Sana Siddiqui (Medical Scribe)

Team Sponsor(s): 
Eva-Marie Alexander, Tim Morrison

Kaniksha Desai

Kaniksha Desai

Karen Frush, MD, is the former Chief Quality Officer at Stanford Health Care. She is a Clinical Professor of Emergency Medicine and Pediatrics. She also serves as a member of the Stanford Medicine Center for Improvement Advisory Committee.

Dr. Frush has been an MCHB funded researcher and helped lead an effort funded by the CMS Innovation Center to improve patient safety and quality across 70 small community and rural hospitals through the LifePoint Hospital Engagement Network. LifePoint was recognized with the John M Eisenberg Patient Safety and Quality Award in 2017 for this work. Dr. Frush has published peer review manuscripts in the areas of pediatric emergency care, patient safety and quality, teamwork, safety culture, interprofessional care, and quality improvement, and she has authored multiple books on these subjects, including Improving Patient Safety through Teamwork and Team Training, with Eduardo Salasin 2012. She is a Team STEPPS Master Trainer and served on the Department of Defense, Team STEPPS Technical Expert Panel (2008-2010). She is an alumnus of the AHA-NPSF Patient Safety Leadership Fellowship program, served on the American Academy of Pediatrics Steering Committee for Quality Improvement in Pediatrics(2006-2011), and has been named one of 50 experts leading the field of patient safety by Becker’s for the past five years. She served on the Board of Advisors and the Board of Directors for the National Patient Safety Foundation and currently serves as Chair of the Institute for Healthcare Improvement (IHI)Certification Board for Professionals in Patient Safety.

Former Leadership positions include Chief Patient Safety Officer of the Duke University Health System (2004-2018); member of the Board of Trustees, North Carolina Center for Hospital Quality and Patient Safety (2005-2012), and Vice President for Quality, LifePoint Health and Duke-LifePoint Healthcare (2011-2018). Dr. Frush received a BSN from the University of Pittsburgh School of Nursing and then attended the Duke University School of Medicine where she earned her MD.

Alice R. Georgitso, MPH, joins the SMCI Advisory Committee as our first Patient Partner. Alice has served as a Patient Partner with the Stanford Health Care (SHC) Patient & Family Partner Program for over 4 years and was appointed Chairperson of the Adult Congenital Heart Program Patient & Family Advisory Council in January 2020. She assisted in developing the Stanford Adult Congenital Heart Program’s Peer-to-Peer Program and serves as a Mentor to ACHD patients pre-and-post-organ transplantation. Alice has presented Stanford Health Care’s C-I-CARE framework for structuring best practice communications and developing relationship-based care approaches with patients and colleagues to 500+ Stanford Medicine Directors, Managers and Clinical Staff.

Alice is a Patient Relations Manager at Stanford Health Care. Within her role, she provides a channel for problem resolution to promote the highest quality of care and service excellence. Alice has also worked as an Unrelated Donor Search Coordinator with the Blood & Marrow Transplant at Stanford Health Care to coordinate allogeneic hematopoietic stem cell transplants through collaborative planning and partnership with the National Marrow Donor Program and SHC clinicians. Prior to her work with SHC, she was the Community Service Foundation Director at San Mateo County Medical Association where she partnered with local stakeholders and clinicians to expand county-wide community health programs to diverse populations. She has also delivered invaluable community health services through her work with the American Heart Association.

Alice earned her Bachelor of Arts in Sociology and Biology at Saint Bonaventure University in Olean, NY and her Master of Public Health from SUNY Buffalo in Buffalo, NY. Alice is a member of The Beryl Institute and Adult Congenital Heart Association professional associations, Donor Network West partner advocating for organ, eye, tissue, and blood donation, and remains an active volunteer with SHC. Alice continues to promote patient-and-family-centered care in both hospital and community settings to support precision health and improve the healthcare experience for patients, families, and clinicians.

John Shook learned about lean management while working for Toyota for 11 years in Japan and the U.S., helping it transfer production, engineering, and management systems from Japan to NUMMI and other operations around the world. While at Toyota's headquarters, he became the company's first American kacho (manager) in Japan. In the U.S., Shook joined Toyota’s North American engineering, research and development center in Ann Arbor, Michigan as general manager of administration and planning. His last position with Toyota was as senior American manager with the Toyota Supplier Support Center in Lexington, Kentucky, assisting North American companies adopt the Toyota Production System. Shook co-authored Learning to See, the book that introduced the world to value-stream mapping. He also co-authored Kaizen Express, a bi-lingual manual of the essential concepts and tools of the Toyota Production System. With Managing to Learn, Shook revealed the deeper workings of the A3 management process that is at the heart of Toyota’s management and leadership.
Shook is an industrial anthropologist with a master’s degree from the University of Hawaii, a bachelor’s degree from the University of Tennessee, and is a graduate of the Japan-America Institute of Management Science. At the University of Michigan, he was director of the Japan Technological Management Program and faculty member of the Department of Industrial and Operations Engineering.
Shook is the author of numerous articles, including "How to Change a Culture: Lessons from NUMMI"; Sloan Management Review, January 2010, which won Sloan’s Richard Beckhard Memorial Prize for outstanding article in the field of organizational development.

The Stanford Medicine Center for Improvement benefits from the diversity of its members and the richness of the experiences that they bring. Although the program continues to evolve from when it first launched in October 2019, we continue to reach out to improvers across Stanford Medicine in the School of Medicine, Stanford Health Care, Stanford Children’s Health, Stanford ValleyCare, UHA and PCHA. We welcome everyone from every discipline and recognize that we are stronger together as we value the contributions of every member of our teams.

Dr. Paul Maggio is the Chief Quality Officer of Stanford Health Care. Prior to being appointed the SHC CQO, he was Vice Chair of Surgery for Clinical Affairs, Associate Chief Medical Officer of Operational Effectiveness, and Associate Director of the Adult Intensive Care Unit. He trained in General Surgery at Brown University and obtained advanced training in Adult Surgical Critical Care and Trauma at the University of Michigan. He holds a Masters of Business Administration from the University of Michigan and is triple board certified in General Surgery, Critical Care, and Medical Informatics. In addition to being a clinician and surgeon, Dr. Maggio participates in the National Committee on Healthcare Engineering for the American College of Surgeons, and his research interests are focused on the delivery of high-value care.

Dr. Maggio received the SHC Board of Hospital Director’s Denise O’Leary Award for Clinical Excellence in 2013

Micah Duchesne joined Stanford Medicine in 2020 as a Principal Consultant project managing the deployment and operations of the Hospital Incident Command System (HICS) for COVID-19. He is now the Administrative Director of Performance Improvement at Stanford Health Care where he leads annual operations planning, improvement consulting, and capability development. Micah is also a Fellow at the Stanford Medicine Center for Improvement.

Before joining Stanford, Micah was an independent consultant for his company Silicon Valley Strategy Group, which partnered with Novartis and the Perelman School of Medicine at the University of Pennsylvania to commercialize cellular therapies. He led a team of clinicians from Europe, Japan, and Australia in designing a global logistics model and quality management system for Kymriah, the world's first approved CAR-T therapy, and helped create an international advisory board aimed at improving global capacity.

Prior to independent consulting, Micah was the Director of Performance Improvement at Kaiser's Santa Clara Medical Center, and he previously held improvement roles of increasing complexity within other health systems. Micah has both a Bachelor of Science in Accounting and Master of Health Services Administration from Mississippi College. He also holds certifications as a Lean Six Sigma Master Black Belt and Project Management Professional.

As a professional, Micah enjoys organizing complex stakeholder ecosystems, clarifying ambiguous goals, aligning visions, and driving high-stakes change. As a human, Micah just enjoys breaking a sweat. While he's not at work, he's at his very own gym in San Jose, CrossFit Moxie. You can find him there coaching olympic weightlifting or working out with his wife. He has a daughter in elementary school and two gym dogs.