Measure Target Baseline Current

(improved)%

Improvement

% of SSU cancer cases sent to Cancer Registry within 1 week of visit 80%

0%(12/31/14)

70%(4/6/15)

70%

Weekly hours of SSH and SSU re-work tracking down information needed by the Cancer Registry

1260 hours per week

18 hours per week 70%

Clinical Integration

IMPROVEMENT BULLETINSpecialist practices eliminate waste and improve information flow to South Shore Cancer Registry

Start Date: September 4, 2014

Sponsors: Suniti Nimbkar, MD, South Shore Hospital; Joe Cahill, President and COO, South Shore Hospital; Luke O’Connell, MD, South Shore Urology (SSU), HPSO Chair

Team: Nancy Hinchliffe, Manager (SSH); Laura Goldman, Registrar (SSH); Elizabeth Ledwell, Coordinator (SSH); Sandy Swanson, Office Manager (SSU)

Background: South Shore Hospital (SSH) cancer patients must be registered in the SSH Cancer Registry as a regulatory requirement. Non-compliance can result in loss of accreditation. The current state process to enter Cancer Registry information for patients who had biopsies or office visits outside of SSH, Partners, or Atrius, takes up to 1 month (versus 2 hours for a patient from within those practices). This re-work for Registrars and office staff in specialist practices is costly and frustrating for staff, and can put us at risk of losing our accreditation.

Goal: Increase the % of SSU patients’ pathology and visit information received by the Cancer Registry within one week of visit or procedure, from 0 to 80%, saving 1 hour of staff time per case.

Progress: Almost to the goal of 80% of cancer cases within SSU.

Next Steps: •Continue spread to all SSU providers to achieve 80% target.•Spread to other specialist practices in the south shore community.

IMPROVEMENT METRICSIMPROVEMENT METRICS

Health Provider Services Organization

Questions? Contact Luke O’Connell at Luke_O’Connell_MD@sshosp.org

See page 2 for information on the process improvements that were made.

Task Impact When

SSU – continue spread to all SSU providers, to achieve at least 80% of their cancer cases; sustain

Save an additional 6 hours of staff time, weekly April 15

Spread and standardize the improved process to Dermatology and GI practices in the south shore

X # of patient cases tracked by Cancer Reg August 31

Identify other specialist practices in the south shore to adopt the improved process

X # of patient cases tracked by Cancer Reg Sept. 30

Next StepsNext Steps

Clinical Integration

IMPROVEMENT BULLETINThe table below is a summary of the process improvements that were made.

Problem Causes Countermeasures Results Next Steps

SSU providers were not aware of the need to send patient pathology and visit information to the SSH Cancer Registry

• Workaround using letters, emails, and phone calls to request information was accepted by staff

• Identify the re-work (letters and phone calls) as “waste”

• Informed providers about the Registry process and waste

• All SSU providers are now aware

• Reminders as needed

SSU lacked an easy way to send their patients’ pathology and visit information to the SSH Cancer Registry

• No one had identified this as a need, so a process was never created

• SSU developed a way to Cc the SSH Cancer Registry via fax for each patient visit or procedure, within their EMR

• Attached reminder notices to providers’ PC monitors

• SSU providers are now using this for 42% of patient cases

• Saving 25 hours weekly of staff time

• Continue to monitor weekly at SSU and the SSH Cancer Registry

• Sustain improvements with visual management

Variation in use of the new process - some SSU providers still not using the new process for most of their patients. Some are at less than 20%

• The new process is still not familiar or standard to all providers, so they may forget

• Providers with less frequent cancer cases may have a harder time remembering

• Remind less frequent users

• Share weekly results with SSU providers, showing performance by provider -- % of patient cases CC’d to SSH Cancer Registry

• In Study phase • Study and Act on results

Health Provider Services Organization

Find more bulletins on the Clinical Improvement Corner on the Medical Staff website.Email us at: hpso@sshosp.org. For internal distribution only.

Rev date here