1. Faster Cancer Treatment: One Year On at Counties Manukau Health
Stephanie Easthope, Faculty Manager & Improvement Advisor, Ko Awatea
Executive Sponsor: Geraint Martin; Sponsor: Brad Healey; Programme Lead: Richard Small; Clinical Leads: Wilbur Farmilo & Anne-Marie Wilkins
Improvement Advisors: Stephanie Easthope (Lead), Thomas Epps, Earnest Pidakala, Nicholas Price, Sneha Shetty and Lawrence Wong
Background & Aim
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In October 2014 the NZ Ministry of Health
introduced a new health target: Faster
Cancer Treatment (FCT). This target states
that by July 2016, 85% of patients receive
their first cancer treatment (or other
management) within 62 days of being
referred with a high suspicion of cancer
and needing to be seen within two weeks.
The first publicised reporting period July –
Dec 2014 showed none of the District
Health Board’s (DHBs) met the faster
cancer treatment target, see the table on
the right. Our DHB, Counties Manukau
Health (CMH), was one of the worst
performing DHBs in the country with only
52% of patients receiving treatment by the
target of 62 days.
In response CMH formed a working team of the Service Manager for
Medicine, the Lead Cancer Nurse Co-ordinator and Improvement
Advisors from Ko Awatea. This team was deployed to working with
cancer pathways and diagnostic services to support these areas to make
improvements that would deliver more timely diagnosis and treatment,
as well as reduce the variability.
Current State & Opportunities
A rapid review of the 6 largest cancer pathways (76% of FCT patients)
was undertaken by the Ko Awatea Improvement Advisors. This involved
observations, data collection and interviews of staff involved in the
pathways. The information was then grouped into themes and overlaid
onto swim-lane process maps to give a comprehensive view of the
current state and opportunities for improvement.
Patient data was added to understand the average performance and
variation across the pathways. Key findings were presented to Executive
Leadership and improvement work streams were prioritised.
Improvements Made
Results to Date
Success Factors & Challenges
Next Steps
• Action plan to ensure sustainability of improvements –
moving from people-dependent processes and
micromanagement to standardisation and permanence
• Aligning patient needs and service design – not just faster
but better for patients
• Focus on handoff delays
• Addressing patient equity and access
• Seamless regional pathways and transitions of care
• Targeted improvement events in areas with on-going
variability in performance
• Implementing on-going monitoring and management
operating mechanisms to ensure performance is maintained.
Receive
Referral
Grade
Referral
First Specialist
Appointment
(FSA)
Diagnostics
Multi-
Disciplinary
Meeting
(MDM)
Decision to
Treat
First
Treatment
Performance has improved
When the targets were first announced,
performance was only 52% for the prior 6
months. Since starting the improvement
programme, the performance has lifted to a
mean of 76.4%. Work continues to close the
remaining gap in performance by focussing on
handoffs between services and ensuring
sustainability of improvements made (see
“Next Steps”).
There is reduced variation
In addition to the overall
performance improving, we
can also see that there is
significantly reduced var-
iation. The XbarS chart to
the right shows the variation
between patients in the time
to treat has gone down and is
more stable.
Biggest improvements seen from FSA to MDM
For individual cancer pathways, the most
significant improvements can be seen from the
time of the First Specialist Appointment (FSA)
until the Multi-Disciplinary Meeting (MDM).
This is reflected in the improvements made in the
timeliness of referrals between services and for
diagnostics (see “Improvements Made” above).
• Benefits to patients and their families
• FCT leadership structure with engaged Senior
Leadership team meeting fortnightly
• Operational meetings weekly with GM/Service
Managers sharing progress and identifying
additional opportunities for improvement
• Engaged Clinical Leadership speaking regularly
with peers to increase engagement and alignment
• High profile of target with performance of each
DHB published quarterly in media
• Improvement Advisor support and data analysis to
provide greater insights to work streams
MoH target gives it high profile with regular
publication in media
ChallengesSuccessFactors
• Competing targets and priorities within and
between services
• Variable clinical engagement
• System constraints (e.g. theatre and clinic
schedules, clinician rosters)
• Regional alignment on the pathway for patients
receiving services from more than one DHB
• Alignment on definitions of FCT
• Patient choice to delay treatment
• Inherent variability of pathways for patients with
differing clinical needs
• Some pathways have greater complexity but there is
a single target
• The ‘black hole’ of time (see “Improvements Made”)
Upper/Lower GI:
Referral to CT/MRI
done straight after
gastro/colon-oscopy
CT/MRI referrals
checked and booked
within 24hrs
Implementation of CanTrack (web based tracking system) to monitor patient progress through the pathway
Cancer Nurse Co-ordinators regularly review patient progress and alert clinical teams and diagnostic services where delays are occurring
Proactive holiday season management to ensure services continue to meet the needs of high priority patients
Agreed diagnostic
turnaround times for
FCT referrals
Nurse contacts
patient after
colonoscopy
E-grading
implemented across all
cancer pathways
48-hour grading target
agreed for all pathways
Identified ‘black hole’ in measurement of
pathway between decision to refer to
Auckland DHB for treatment and “Decision
to Treat” by Auckland clinician. Now
factored in to pathway timing.
Early alert sent to
Auckland DHB about
expected referrals for
treatment
Upfront PET
scan for Lung
patients
Surgical packs
sent electronically
to Auckland DHB
Dedicated clinics
for FCT patients in
some pathways
Work shift smoothing
in Histopathology to
improve turnaround
Standardisation of
MDM template
(Gynae)
GPs being trained to
do pipelles before
referring to secondary
Gynaecology service
Regional collaboration
and agreement on
timelines from referral
to treat  treatment
Days from FSA to MDM - Gynaecology