In the past, patients who needed outpatient infusion treatments for non-cancerous conditions might have to wait weeks for an appointment at Yale New Haven Health’s outpatient infusion centers.
The reasons for the delays and patient backlog are complex. New medications for conditions such as Alzheimer’s disease have increased infusion demand. Physician referral and scheduling processes have been inconsistent across different practices. It can take up to two weeks for insurance companies to approve infusion treatments after a physician prescribes them.
The oncology infusion area has also faced patient throughput challenges. As with other oncology programs nationwide, Smilow Cancer Hospital patients had wait times the day of their appointments. In addition, balancing the workload among staff was difficult, particularly during peak times.
In response, staff within the oncology and non-oncology infusion areas each created multidisciplinary teams focused on two main goals: to more efficiently use infusion chairs, thereby increasing capacity and improving patient access.
“The solutions the teams developed to meet each area’s unique needs are different, but there have been opportunities to share best practices and collaborate,” said Elaine Whitney, Smilow program manager.
YNHHS infusion centers provide highly specialized diagnostic and clinical care and perform more than 36,000 treatments annually for allergy and immunology conditions, rheumatoid arthritis, inflammatory bowel disease, multiple sclerosis, lupus, Alzheimer’s disease, osteoporosis and other non-cancerous conditions.
Many of these treatments are the only options for patients with previously untreatable conditions. Increasing available treatments is a boon for patients and requires creating the necessary capacity.
Last year, a multidisciplinary team from Nursing, Pharmacy, Digital Technology Solutions, Financial Clearance and other departments began exploring ways to streamline access to infusion chairs at YNHHS outpatient infusion centers. After analyzing barriers to timely patient access, they worked with community physicians to improve communications and streamline referrals. The team is also working with YNHHS providers to facilitate scheduling at sites across the health system to provide more care closer to home and is piloting an Epic tool to improve patient scheduling.
“We have been able to get more patients in on a more timely basis,” said Stephanie Kane, RN, senior manager, Neurosciences, Orthopedics and Spine Services.
Smilow Oncology partnered with LeanTaaS and offered new scheduling software called iQueue that uses predictive analytics and artificial intelligence (AI). This has helped Smilow’s infusion sites reduce patient backlog, create capacity for more patients and better balance staff’s workday. Smilow Cancer Hospital Trumbull piloted the program, with leaders engaging staff.
“Our staff were part of every step. They gave input, and we kept listening and learning from their experiences, tweaking the process along the way,” said Lisa Shomsky, RN, regional director, Smilow Cancer Hospital at the Bridgeport and Greenwich delivery networks.
Many factors contribute to long wait times for patients the day of their chemotherapy infusions. First, patients have different infusion treatment plans, ranging from 15 minutes to six hours. With appointments available 8 am – 5 pm, peak demand is 10 am – 2 pm. This is often connected to a physician or advanced practice provider visit, when the number of patients can exceed the number of chairs or nurses available. Nurses can feel overwhelmed with the backlog, as can pharmacists who compound individualized medications.
Adding infusion chairs isn’t always the answer. “We needed to improve scheduling to decrease wait times and improve workflows,” Shomsky said.
The LeanTaaS digital platform uses AI to study the infusion center’s patient and staffing data and predictive analytics that help staff plan for patient volume days in advance instead of in the moment. While the software helps build a steady patient flow, the other part of the solution rested with the way nurses practice.
Before LeanTaaS, the charge nurse reviewed patients scheduled for the day and the number of nurses available. After gauging each patient’s complexity, the charge nurse assigned patients to a nurse. If a nurse’s patient was late, other patients had to wait.
While nurses are assigned to patients in advance, patients remain in the waiting area until the nurse indicates “ready for infusion,” after chart review and are then “pulled” to infusion. The nurses then take the next patient in line once they have indicated the patient is ready for infusion.
“This was a big culture shift,” Shomsky said. “This modified pull system enables nurses to practice with autonomy and complete more comprehensive chart reviews on their patients. Additionally, this provides greater nurse and patient satisfaction as nurses can build relationships with their patients while maintaining continuity of care.”
Staff have seen shorter patient wait times and efficiencies that increased the number of treatments. Staff have a more balanced caseload and greater control over their practice so they can focus on the patient in front of them.
After being piloted at Smilow Trumbull and on Yale New Haven Hospital’s NP 8, LeanTaaS has expanded to 14 of the hospital’s 15 centers.
Shomsky’s advice for making successful changes: “Listen to your staff and have an open mind. Be ready to make changes if something isn’t working.”
