Systems thinking for cancer centers: lessons from the trenches
At a roundtable session that took place at the inaugural LeanTaaS Transform virtual event in June 2021, cancer center leaders and infusion managers gathered to discuss how their facilities could apply systems thinking to finally address fundamental challenges and improve their operations, as well as experiences for patients, clinicians, and staff. This write-up summarizes session leader Ashley Joseph’s key points. For further live insights on improving infusion operations, register to attend or view Transform on December 7-8, 2021.
Over the past six years, our team engaged with the day-to-day operations of hundreds of cancer centers across the country. It became clear we couldn’t focus on one oncology function, in this case infusion scheduling, in a vacuum. Scheduling solutions worked better when the whole infusion center made smart operational choices and all its interlocking needs were accounted for. The operation of the whole “system”, from the clinics to the pharmacy to the lab and beyond, could make or break an infusion center’s success.
The first point: what is “systems thinking” for cancer centers and why does it matter?
Systems thinking is based on the idea that a system’s component parts will act differently when isolated. So, though individual nodes in the system may perform well alone by all objective measures, overall system results can still suffer. In cancer centers, this means each department and function might appear to be already optimized, while patient satisfaction, nurse satisfaction, and overall center metrics are poor.
What does an operational “system”, or the lack of one, look like in a cancer center?
Patients who arrive at a cancer center that operates on systems thinking should have a seamless experience after initial check in:
- Each clinician and staff member the patient interacts with throughout the day knows exactly what has happened at every previous step
- Procedures and visits are all within a few minutes of scheduled appointment times
- All team members involved in the visit have all the approvals and information needed to complete their tasks with the patient efficiently and cheerfully
- The patient leaves at the scheduled time – and so does the cancer center staff
Instead, the patient often:
- Arrives at the cancer center, checks in individually for their blood draw, clinic visit, diagnostic imaging, then finally their infusion or radiation treatment
- Must constantly update staff on what has and has not already happened in the day, or what they have been told will happen next
- Endures long waits in various departments and clinics, sometimes getting to their next scheduled appointment late or missing it completely
- Leaves much later than expected, as staff work overtime and stay past their department’s scheduled close
Cancer centers tend to either accept these problems as inevitable or else struggle to address them. But actually solving them requires an overhaul in approach, one that addresses the entire system, which most traditional approaches fail to do.
How have cancer centers traditionally approached solving problems, innovating, and improving the patient experience?
Cancer centers commonly try to address problems and improve patient experience through benchmarking, focusing on process issues, or investing — or wishing they had the budget to invest — in new technology or automation.
These approaches don’t solve root causes or address dependencies and therefore aren’t effective. Cancer centers must instead approach innovation as an entire ecosystem, where every component has an influence and impact. This includes reassessing the commonly held “truths” that keep them attempting the same ineffective solutions.
How can cancer centers approach problems instead — what are the “truths behind the truisms”?
Cancer centers run on premises that are assumed to be true and unchangeable. But from a systems thinking perspective, these “true” problems are often falsely defined. The truth behind the truisms presents both solvable problems and the solutions themselves.
Truism 1: The lab will always be behind and make downstream departments run late.
Actual Truth: Problems in the lab are often manifestations of systemic problems outside the lab. “The lab” becomes an excuse that keeps systems-based problem solving from happening.
Truism 2: Drugs can’t be premixed because unused drugs are wildly expensive.
Actual Truth: The vast majority of regularly-used drugs can be premixed. A study of the previous year by day would indicate the absolute minimum needed, meaning that the cancer center can premix to that amount. Using premixing as a tool can dramatically reduce wait times and unlock infusion capacity.
Truism 3: Unwanted tasks must always be spread out evenly among everyone.
Actual Truth: Clinicians and staff members have their own favorite and least favorite tasks, and assigning daily tasks as if these are all the same only leads to bad days for everyone. Nurses and staff are asked about their real preferences and then tasks are allocated fairly.
Truism 4: Doctors will do what they want to do — their behavior can’t be changed.
Actual Truth: Doctors should understand the full systemic impact of their behavior. For instance, explaining the downstream impact of an unsigned order on patients and colleagues can be more effective than reprimanding or ignoring the doctor who habitually leaves orders unsigned.
Truism 5: Decisions based on safety can never be reassessed.
Actual Truth: Safety constraints sometimes turn out to be strong preferences or driven by something other than safety. Pushing back on a perceived safety decision can reveal a different issue, which can then be resolved at its source.
Truism 6: Excellent patient service means giving patients exactly what they ask for all the time.
Actual Truth: Often a patient’s request for a specific appointment time or last-minute reschedule causes issues downstream, leading to a longer wait time for that patient and worse service for all patients. The best systemic outcome for the patient’s day overall can mean they are told “no” upfront.
Truism 7: Late patients, early patients, no shows, and overbooks are the reasons why schedules get behind and wait times are long.
Actual Truth: Daily occurrences are not a sufficient reason or an excuse. The systems thinking approach entails looking at the numbers of these over time, and building systems and processes that realistically account for them. The result is schedules that efficiently already factor in unscheduled occurrences.
Truism 8: It’s impossible to predict how long a doctor will take with a specific patient, so this can’t be factored in schedules.
Actual Truth: While appointment times vary overall, individual doctors are very consistent in how long they typically take with a patient. Recognizing how each doctor’s time impacts the entire system allows centers to schedule downstream activities accordingly.
Overall, taking a systems-based approach means:
- Identifying the real problem — not the perceived problem
- Recognizing how the problem reverberates throughout the system
- Communicating with every person involved to find and implement the most effective solutions
Why is adopting “systems thinking” in cancer centers such a challenge?
Change management simply isn’t easy, especially in a system as complex and interlocking as a cancer center. Many centers give up before they really get started.
Cancer centers are deeply hierarchical, and achieving true cooperation between levels is rare. Front line staff, whose views are critical, are perceived as the lowest rung and not worth listening to. “Quality” is often conflated with micromanaging, and those in control are afraid to let go of the reins in case they’re held responsible for poor results. Leaders may be inclined to write off a new idea as something that’s already been tried and failed, even if the idea is actually different.
Piloting any change in this environment may seem like an overwhelming challenge. But even a simple, inexpensive change can be implemented within one day and still yield long term results. If the change doesn’t work, then the center is no worse off.
How can cancer center leaders perceive these issues and solutions today?
Just as patients view their cancer center as a single unified system, cancer centers must see the touch points throughout the patient journey as one system as well. This requires top-down structural and cultural change. Frequent and consistent messaging to staff across all silos is needed so all functions are aware of decisions being made and the implications upstream and downstream are well understood.
Technology is not a solution in itself, especially if the actual problems are not being acknowledged in address. But the right software can support a change on this level. Visit iQueue for Infusion Centers to learn more, or join Transform, December 2021, for real-time updates from leading cancer centers.