CASE STUDY – This project in Brazil, part of a city-wide effort to improve patient flows, led to impressive results in the waiting time to access cancer care.

Words: Margarete Correa, Danilo Stanzani, Elitania Pontes, Joana Benjamin, and Carlos Frederico Pinto

In 2018, the 700,000-people city of São José dos Campos began to experiment with the creation of a hoshin plan for its healthcare system. Back then, thousands of patients were on the waiting list to receive care (some for as long as two years).

To try and speed up the flow of patients, the city’s healthcare authority invited Instituto de Oncologia do Vale (IOV), which is recognized as a successful lean healthcare organization, to help them set up and run four pilot projects in gastroenterology, cardiology, urology, and surgery. In this series of articles, we will explore some of the most successful projects that stemmed from these pilots.

In this article, we’ll tell you about the Previna Project, which aims to improve cancer care for São José dos Campos residents (in the city, cancer represents the second leading cause of death). In truth, initially the project focused on prostate cancer only, but it’s been so successful that it now applies to all types of cancer. What makes Previna particularly interesting is that at its core lies the effective collaboration among eight different organizations: the healthcare authority itself, primary care units, ERs, a pathology laboratory, blood test labs, two hospitals, and oncology centers (IOV).

Our intervention basically focused on queue management and daily management. We created several patients flow, setting priorities and opening treatment slots for each of them. With some flow redesign in the cancer center – similar to what IOV had done  – we managed to create a lot of room to treat patients. When the project began, we reorganized the queues based on the patients’ level of priority: high risk, medium risk, and low risk. High-risk patients (those who needed care right away) were fast tracked, while those who were likely not cancer patients had to wait a little bit longer.

For example, we know that patients with a high level of PSA (Prostate-Specific Antigen) in their blood tests are very likely to have cancer, so we fast-tracked them directly to biopsy (they didn’t really need a doctor to tell them they had to get one). When we fast-tracked those patients – there were around 200 of them, most of whom turned out to have prostate cancer – we immediately eased the pressure on the system.

The same thinking applied to those patients who weren’t eligible for surgery and should go straight to hormone, chemo, or radio therapy. By looking at their charts and scans, we were immediately able to see whether or not a patient could undertake an operation (the information was there all along, we were just not using it). When we started to send them straight to therapy, the number of people in need of consultation with the urologists dropped. That way our urologists could begin to focus on more surgical patients.

As a result of these changes, both the Urology and Cancer flows improved significantly.  Previously, a Urology patient with no priority had to wait around 400 days for a consultation, while today they are all seen within 20 to 40 days. In fact, around 95% of our cancer patients today are waiting less than 30 days to access care.

These are the four main actions that enabled the project:

• Process redesign to better connect the many providers engaged and allow the teams to engage in daily problem-solving. The use of visual management was extensive.

• Escalated Daily Management System, based on three key meetings. A daily huddle aims to move patients through the system (it is meant for the Previna team – including Joana, the doctor managing the cancer flow within the Healthcare Authority and the healthcare supervisors from the primary care units and hospital); a weekly huddle with all providers (to organize the work for the following week and allocate the work depending on slots available and demand); and a biweekly huddle for global performance within the City Healthcare Authority.

• Open communications channels, with specialized support by phone and a Hotline connecting the Flow Manager with 46 primary and secondary care units.

• Emergency access and flow, with the introduction of a standardized process for emergency access.

REASONS FOR SUCCESS

One of the greatest success factors in the Previna Project was that, to ensure the project ran smoothly, the City Healthcare Authority signed Service Level Agreements (SLAs) with the providers. They ask specific tasks of them, but the flow is managed centrally (an SLA, for example, might state that a provider is expected to guarantee 40 biopsy slots per month). Such requests are easy for providers to accommodate and didn’t require much internal change, except for the hospital – where a dedicated flow for cancer patients had to be created). The CHA also demanded every provider uses the same IT system, to ensure coordination and consistency in the data gathered.

Essentially, the SLAs ensured the data arrived when it had to arrive, while the IT system guaranteed they were gathered and analyzed in the same way. Another critical step was the introduction of a new role, the Flow Manager, within the City Healthcare Authority. Joana is tasked with scheduling patients and managing slots – with another person doing the same within the hospital, because that’s where around 80% of the surgeries take place.

We are now into our fourth year of implementation, and it’s great to see that every cancer patient in town is now being treated in a timely fashion. In 2015, the number of patients getting access to treatment within 60 days was 54%, while in 2020 it was 77%. Interestingly, over this time, the number of cancer diagnoses has doubled, as more patients accessed care and were screened. Our real demand is around 1,200 patients a year, which is still twice what we thought it was in 2015.

We are proud of the results we have achieved despite the spike in demand. This project has saved the Healthcare Authority a lot of money (treating cancer in the earlier stages is considerably cheaper) and, more importantly, it has saved countless lives here in São José dos Campos.

_{THE AUTHORS}

_{Joana Benjamin, City Healthcare Authority, São José dos Campos}