Transitions of Care for Hematology Patients by Sarah Garrigues

By: Sarah Garrigues
Team Members: Anisia Dugala, Jennifer Hansen, Jillian Settlemire, Mohana Roy, Debbie Bergman, Michael Conte, Sarah Garrigues
Team Sponsor(s): Roni Brar, Vasu Divi

The Problem:
Patients with acute leukemia are some of our most vulnerable patients, especially shortly after discharge from the hospital when they are at risk of critically low blood counts.  When these patients do not have outpatient follow-up scheduled shortly after discharge, they are at increased likelihood for poor outcomes, many which require rehospitalization if not addressed in a timely manner.  Upon review of our patients’ discharge plans, we found many patients did not have a scheduled follow-up clinic or infusion appointments before they were discharged.

Primary Problem Causes:
Due to the pandemic and the fact that acute leukemia patients may be critically ill, Gemba walks were limited to two team members.  We supplemented Gemba with zoom interviews that revealed many contributing issues.  We found that there was neither a standard process nor an expectation to schedule prior to discharge an outpatient appointment in the Infusion Treatment Area (ITA) or the hematology clinic.  Access to ITA appointments is limited, and team members trying to coordinate patients’ post-discharge care didn’t have direct phone lines to the schedulers.  Outdated Epic pools and incomplete communication explaining a patient’s post-discharge needs contributed to messages being sent to the wrong people or requiring multiple back-and-forth messages to clarify scheduling requests.  One notable example revealed that discharge coordination took 34 inbasket messages before the patient’s appointment was scheduled in the desired manner.  Since the hematology service is run by housestaff who rotate frequently between services, if discharge care wasn’t successfully coordinated in the days leading up to a patient’s discharge, the scheduling of follow-up appointments slipped through the cracks and did not occur, leaving many patients vulnerable to clinical decline.

Our Solutions:
After our analysis we settled on a handful of key drivers including:

  • Standard process for discharge communication between in- & out-patient teams
  • Direct access to infusion treatment area (ITA) schedulers to secure appointments
  • Escalation pathways when no appointment slots appeared to be available
  • Education for the constantly changing trainees

The most impactful intervention was a customization of Epic’s discharge navigator to identify follow-up appointment needs and facilitate communication to the appropriate ITA and clinic pools to schedule post-discharge appointments. This Epic navigator can be viewed by multiple care team members and sends an auto-inbasket message with specific instructions to reduce back and forth messaging.

We also implemented new contact lists for each outpatient clinical team (sustained by a plan for continuous updates) and incorporated all new standard work into the resident and fellow training materials.

As a result of our interventions, we witnessed an increase in the percentage of acute leukemia patients who had outpatient follow-up within 5 days of discharge from 65% to 94%, and we have sustained this rate for 3 months.

The Outlook:
Though our key intervention did not launch until right after the CELT program concluded, we continued to collect data for 3 months to monitor the proportion of patients who had timely post-discharge care scheduled in clinic or the ITA.  We have witnessed sustained improvement far greater than the goal we set at the beginning of our project, which we credit to having implemented standard work and a technical solution that reduces EMR burden.  Since the discharge navigator intervention lives in Epic, no additional IT support is required to adapt this intervention for the four other hematology-oncology inpatient services.  The Cancer Quality Council has accepted the task of disseminating this intervention so that oncology patients on any of our services will have greater likelihood of timely outpatient follow-up.

In reflecting on our experience, here are our main takeaways:

  • There is no one solution to a complex problem: we identified inconsistent processes, incorrect contact lists, and limited ITA and clinic access. Our solution had to be multifaceted.
  • Inpatient teams often rely on rotating key players, who are often not connected to the outpatient teams (working in silos). Workflow standardization was one way we reduced variability in practice across all players.
  • Interventions that reduce EMR burden are most likely to succeed.

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.