A Pilot Study to Improve Workflow in an Academic Radiation Oncology Department

Abstract

The delivery of timely, effective and accurate therapy is requisite to maximizing tumor control in patients whose treatments include radiation therapy. Given the complex process associated with radiation treatment planning, systems-based approaches are needed to minimize delays in the initiation of radiation treatment. From December 2007 to September 2008, all patients treated at the Johns Hopkins Department of Radiation Oncology were prospectively coded to indicate whether radiation was initiated on a planned start date assigned at the time of simulation. Additionally, delayed patients were coded to categorize the reason for the delay. An intervention program was then piloted with three provider teams between December 2008 and March 2009 to reduce the incidence of physician-associated factors in treatment delays. The intervention plan included: (1) the initiation of a requisite weekly provider team scheduling conference, (2) reserved slots per provider for simulation, and (3) provider team accountability. Intervention data was prospectively gathered and statistical comparisons were performed using chi-square analysis. Over a 10-month period, 1,652 patients were treated with radiation and the initiation of radiation therapy was delayed in 491 patients (29.7%). Reasons for delays in the initiation of therapy were attributed to: (1) physician delay in the submission of treatment contours to dosimetry, 9.9% (or 33.3% of delayed patients), (2) physician request for patient delay, 7.8%, and (3) non-physician associated delays (i.e., physics/dosimetry initiated delays, patient requests for delay), 12.0%. After the initiation of a pilot intervention program with three provider teams over a 3-month period (n = 113 patients), the average number of patient delays in the intervention group decreased significantly from 29.7% to 15.1% (p = .00086). Patient delays in the intervention period attributable to physician-associated factors were significantly reduced (contour submission delays, 1.8% vs. 9.9%; p = 0.0042; physician request, 0% vs. 7.8%; p = 0.002), but delays associated with other causes were not significantly changed (13.3% vs. 12.0%; p = 0.699). Our data demonstrate that several factors contribute to delays in the initiation of radiation therapy at a major academic radiation department. Furthermore, a pilot program focused on decreasing physician associated delays helped to significantly improve the timeliness of radiation therapy initiation. Taken together, these results show that systems-based approaches can help solve a vexing problem in oncologic care by facilitating team-centered solutions that empower the physician provider. Further goals include the implementation of the interventions to all provider teams in the department.