«If the patient could decide»- diagnosis and treatment of breast cancer

Oslo University HospitalInnovation director Kari J. Kværner

Financed by the Norwegian Design Council (DIP-midler)the Norwegian Research Council

Challenges «Random» referrals• Several diagnostic «routes» for patients consequences for

waiting times• Often referrals with incomplete information

Non-standardized• Diagosis and treatment of breast cancer at Oslo University Hospital

followed several routes• Prolonged waiting times for pasients with «clinical problem-related

breast diagnosis»• Newspapers reported waiting times of 12 weeks or more

Several locations• Diagnosis and treatment both at Ullevaal and Radiumhospitalet• Postponed plans for Breast Cancer Center

Kilde: Rapport «Optimalt pasientforløp for pasienter med klinisk problem bryst i OUS.» Oppdragsgivere: Klinikkledere i KDI og KKT

Help from Service designers to provide «New Service»

Goal:• Reduce waiting times 75 %• Reduce diagnostic insecurity > 50 % • To create an understanding of the

concept « patient-centered care »• To create a model that can be

implemented and communicated in other hospitals

ApproachPatient focus:Patient interviews, not the «system-approach»

The total process as viewed by employees, management and patients. Employee interviews.

The stepwise project process

”The radiological answers are not completed by the time of the patient colsultations.”

”Now we have to perform several consultations because the procsedure and processing is unclear.”

”The bottleneck is not related to radiological examinations, but its result interpretation.”

”Patients and clinicians call us. Unfortunately the clinicians say ”call the radiologist directly for answers.”

”I do not want all the phone calls, I prefer working with the medical aspects of the disease.”

Employee insights…

Summing up employee insights

Noise and interruption disturb our working procedures

• Time spilled

• Prolonged waiting times

• Working conditions less satisfactory

Interpretative delays

• Work duplicates

• Follow-up of those who wait for answers

• Prolonged patient flow

Patient insights…

”I know others that have been through this… I have had recommendations from others that I need to follow-up thoroughly, otherwise I will get lost in the mass.”

” I called my husband and drove directly to Ullevaal with the X-rays – you simply cannot wait more than absolutely necessary…”.

”I have cheated to get the name of the person who schedules appointments.”

”You sit there all by yourself…”

”Under these circumstances 8th floor feels like the valley of death.”

”The waiting time prior to the first consultation feels so long – it is like my life stops completely.

Summing up patient insights

• The waiting time feels awful when you are uninformed.

• The first meeting with Oslo University Hospital is characterized by non-personal information, lack of contact and precision between professionals and the patient.

• The patient have confidence in the professional competence of the hospital, but feels responsible for the progression of her own patient care.

• Diagnostic transitions are the key bottlenecks.

• Once the cancer diagnosis is communicated, the patients report that follow-up and further communication is satisfactory and ”positive”.

The solution • One common referral center and

improve quality of referral information from GPs

• Radiologistsprioritize referrals verey day according to «severity score»

• The hospital takes responsibility for the patient from day 1 (informs GP)• The hospital call the patients for appointment within 1-3 days• All investigative procedures within one day• Agreement with private contractors in order to provide enough

radiological services (Aleris og Unilabs)• Pasient coordinator follow-up through treatment• Daily interdisciplinary meetind/video conferences between

Radiumhospitalet and Ullevaal

How to succeed while waiting for a national hospital referral system?

Postadresse:Oslo Universitetssykehus, Ullevål Henvisningskontoret for bryst og endokrinkirurgi Postboks 4956, Nydalen, 0424 Oslo

Direkte tlf nr 23 01 65 25 Telefontid: kl 8:30-11:00 og kl 12:00-14:00

Faks nummer til henvisningsmottaket: 23 01 65 35

Har du fått med deg at Oslo universitetssykehus har fått NY rutine for henvisning angående utredning og behandling av klinisk problem bryst?NYTT FOR FASTLEGENE:•Ett felles henvisningsmottak•På OUS nettsider finner du:

• Sjekkliste for henvisning av «klinisk problem bryst»• Direktenummer og faksnummer til henvisningsmottaket• Informasjon til pasienten DU kan skrive ut og gi under

konsultasjonen• Informasjon om etterkontroller

NYTT FRA OUS:•Pasienten ringes 2 - 3 virkedager etter mottatt henvisning•Alle nødvendige undersøkelser utføres samme dag•Tverrfaglig vurdering av ALLE behandlingskrevende funn•Videre behandlingsforløp avtales med pasient etter endelig diagnose

Hvor finner du dette?http://www.oslo-universitetssykehus.no/fagfolk/henvisningsrutiner/Sider/bryst--og-endokrinkirurgi.aspxKlikk deg inn via «henvisningsrutiner» på forsiden

Information sent all GPs and other referees

Henvisningsskjema utarbeidet av radiolog ved OUS

Mission completed?Reduce waiting times 75 %

• Waiting times is reduced from 12 to a maximum of 2 uker

• Mean waiting time is 7 days (Nov 2013 - Feb 2014)

Reduce diagnostic insecurity > 50 % • Diagnostic insecurity is hard to

measure, but the proportion of patients claiming that «this has been a straight-forward procedure from the day of the appointment at my GP», is increasing

The patient pathway was implemented November 2013

Waiting times has been reduced 90 per cent

«Design glasses» from the outside invaluable – but the professionals performed and carried out the difficulties of changing practice

What are the public measures of health care efficiency?

The department of health waiting time: from referral has been received to the onset of treatment

Patient waiting time: from the GP visit to the phone call from Oslo University Hospital with the scheduled appointment!

Lessons learned•Changing habits require

continuous improvement work and follow up

•We are impressed of the energy and responsibility of the professionals at our hospital

Success criteria• 1:1 contacts - it's all about people• Make alliances • Form networks to reduce "the silo organization"• The first idea is fertilizer for new ideas and innovations• Competitions and prizes• Communicate and share the good stuff!• Foster enthusiasts!• Share information and foster co-work:

a web-portal is very useful!• Assiduity• Resources is necessary!

Questions?Idépoliklinikken:https://www.idepoliklinikken.no/

Tlf: 23 02 70 23idepoliklinikken@ous-hf.no

A video of the project can be found here:https://vimeo.com/90355375