Identifying delays in care for patients with NSCLC using value-stream mapping.

Abstract

136 Background: Value-Stream Mapping (VSM) was employed to evaluate non-value added activities focused on minimizing time between pathological diagnosis and first treatment (Time-To-Treat or TTT). Objective is to identify unnecessary delays in care for NSLC patients treated at a large academic medical center. Methods: A total of 253 patient records were examined between 1/15/2015 and 7/19/2016 and divided into stages: Stage I (Non-Surgical), Stage I-II (Surgical), Stage III, and Stage IV. Selection criteria required a min. of 50 patients/stage, including internally and externally diagnosed patients. A VSM was developed for each stage. Spreadsheets were used to detail dates and sequences of events, including consults, E&M visits, imaging, procedures, and testing. Results: Overall TTT results by stage (median days) are as follows: Stage I (Non-Surgical) = 46 days (n = 55), Stage I-II (Surgical) = 35 days, n = 50), Stage III = 34 days (n = 71), Stage IV = 19 days (n = 77). Consults were reviewed among 4 specialties (Med/Onc, Rad/Onc, Surgical, Pulmonary), revealing Pulmonary Consults most common regardless of stage, 38%, 40%, 49%, 29%, respectively. It was found consults among specialties were rarely coordinated (stage III: 11/70 patients had consults same day between 2 specialties). Bronchoscopy procedures were most common method of Dx; sampling (n = 60, all stages) revealed MD orders are placed within 1 median day for each stage (15% ≥ 5days), but lead time to procedure ranged 7-12 median days depending on stage. Comorbidities for surgical patients (n = 46) were reviewed and found TTT delays correlates with number of comorbidities and FEV1 test results. Interventions included weekly, multi-disciplinary identification and review of patients across the 4 specialties, development of a TTT visual dashboard, and creation of communication standards across specialties. Conclusions: A VSM will identify areas where excessive delays occur. Opportunities exist to combine activities (same-day appointments/consults), reduce delays between activities, and/or improve communication. Decision-making can be accelerated when time between events (consults, staging, procedures, and tests) is minimized, regardless of diagnosis origin.