Improving Outcomes for Breast Cancer Patients Through Failure Mode Effects and Criticality Analysis

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Improving Outcomes for Breast Cancer Patients
Through Failure Mode Effects and Criticality
Analysis

• Breast Cancer Performance Improvement Team
• University Medical Center
• January 21, 2004

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Breast Cancer Project

• Reasons Breast Cancer was chosen as our 2002-2003
  Performance Improvement and Patient Safety
  Project
• Breast Cancer is one of our highest risk, most
  problem prone and highest incidence diagnosis
  within UMCs patient population
• - Breast Cancer is the second leading cause of
  death in women
• UMC was not satisfied with our performance
  related to early detection, diagnosis and
  treatment of Breast Cancer

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Breast Cancer Project

• Team Members Include
• Larry Dorsey Hospital Director
• Marilyn McLaughlin Nursing Director
• Dr. James Falterman Medical Director
• Dana Faul, RN Family Practice Clinic
• Cindy Vierra, RN Internal Medicine Clinic
• Marlene Michael, RN Central Clinic
• Jackie Bernard Mammography
• Kitty Bell, RN Surgery Director

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Breast Cancer Project

• Team Members Include
• Jessica Hanks Medical Records
• Gary Kuykendall Cancer Registry
• Diana Thibodeaux Laboratory Director
• Kelly Deranger, RN Oncology Unit
• MeJ Matte, RN Asst. DON Outpatient
• Julie Abshire, RNC Oncology Clinical Coor.
• Bridget Latiolais - Adminstration

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Plan
A multi-disciplinary team flow charted the entry
of women needing a screening mammography or
breast cancer treatment from each point of entry
into UMCs. All possible scenarios were
included. The identified scenarios included the
patient 1. Cancer free patient
2. Diagnosed Cancer patient 3. Surgery
Required 4.
Chemotherapy 5. Radiation 6.
Combination of Surgery,
Chemotherapy and Radiation We used the
Failure Mode Effects and Criticality Analysis
model to examine the process that a breast cancer
patient would have to travel to be diagnosed and
treated at UMC.
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What Do We Measure and Why?
P D C
A FMECA RCA
We utilize the FMECA in the planning phase of the
PDCA cycle so that we can proactively factor and
engineer out as many risks as possible to create
a safe patient environment
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We flow charted the hypothetical patients with
different scenarios through the system. We then
brain stormed potential failures that could
occur. We identified on the flow chart where
the failures could possibly occur and the effects
on the patient/system if the failures did
occur. We then assigned a failure rating of
Severity,
Probability
Detectability to the
areas of identified risk.
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• Each of the failure ratings is based on a scale
  of 1 to 5 with 1 being the lowest and 5 being the
  highest.
• This allowed us to prioritize the areas of risk
  so we would know where to begin improving the
  care that was given to the patients diagnosed
  with Breast Cancer.

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FMECA Improvement Results Breast Cancer

• Failure Modes Identified in Order of Criticality
• Physicians didnt see mammogram or pathology
  results because reports went straight to medical
  records
• Physicians were unaware of the findings until or
  if the patient showed up for a follow up
  appointment.
• Inefficient and ineffective mammography
  scheduling
• Risk of Residents ordering incorrect Cancer
  protocol
• 5. Failure of residents to discuss treatment
  options available due to discomfort of residents
  with this procedure

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1 - Physicians Unaware of Mammography
Pathology Results

• Changed reporting process so that Mammography and
  Pathology reports were routed back to the
  ordering clinic instead of Medical Records
• An additional RN was hired for each of the
  Clinics
• Pathology and Radiology reports were read by the
  RN
• Any report that was normal was put in the chart
• Any abnormal reports were given to the doctors
  for further follow-up

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2 Physicians Unaware of Findings

• UMC has improved from 0 of the reports being
  reviewed before being placed on the chart, to
  100 of the reports being reviewed by an RN, and
  appropriate physician if indicated, before being
  placed on the chart
• This improvement has prevented patients with
  potentially abnormal results from falling through
  the cracks

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3 Inefficient and Ineffective Mammography
Scheduling

• Lost mammography reports were rectified by the
  placement of a drop box in a central location in
  the Radiology Dept.
• A revised mammography requisition was developed
  and the required information was given
  appropriate prompts in order to consistently
  obtain the essential information needed to
  perform and interpret the mammogram. Staff
  education on the new form was done stressing the
  importance of the required information.

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3 Inefficient and Ineffective Mammography
Scheduling

• A computerized software program was developed for
  scheduling mammography appointments. The system
  eliminated duplication and scheduled patients
  within the recommended time frame according to
  age and risk category.
• This new program improved the efficiency of the
  mammography department. Wait times for screening
  mammography appointments have decreased from 2 ½
  years to 3.5 weeks.

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3 Inefficient and Ineffective Mammography
Scheduling

• Persons needing an appointment for a mammogram
  because of suspicious lumps can be handled within
  the week and sometimes that very day which is a
  drastic improvement.
• Screening mammograms have increased by 64 from
  2629 in all of 2002 to 4074 by June of 2003.
• Preprinted orders were developed to encompass the
  National Cancer guideline recommendations for the
  scheduling of mammograms by age and risk category.

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3 Inefficient and Ineffective Mammography
Scheduling

• These preprinted orders have helped to increase
  UMCs compliance with the mammography ordering as
  recommended by the American Cancer Society
  guidelines from 43 to 48 in a year.
• The Mammography Tracking system was upgraded
  allowing suspicious and highly suspicious cases
  to be entered and tracked monthly until follow-up
  is completed. If a problem exists the appropriate
  clinic is contacted and the patient is scheduled
  as needed.

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3 Inefficient and Ineffective Mammography
Scheduling

• UMC now tracks the number of lost requisitions.
  If the number rises above 1, we re-examine the
  system and revise as needed. Since our
  improvements to date we have no reports of lost
  requisitions.
• Incomplete requisitions are also tracked and
  returned to the appropriate clinic for the needed
  information. UMC has a 94 compliance with the
  completeness of the requisitions.
• UMC monitors the next available appt. for
  mammography. As of 10-1-03 it takes 3.5 weeks for
  screening mammograms.

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3 Inefficient and Ineffective Mammography
Scheduling

• In order to increase compliance with ordering
  mammograms as recommended by the American Cancer
  Society, UMC has developed monthly report cards
  for each physician to be used in the evaluation
  process for re-credentialing and reappointment of
  medical staff.

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4 Incorrect Ordering of Cancer Protocols

• Even though this was a low volume occurrence
  because of the nurses diligence in catching these
  failures before they became a reality, the
  multi-disciplinary team felt that the potential
  failures were very high risk.
• Potential reasons for failure to order proper
  protocols are the short period of time the
  residents are in the oncology rotation and the
  complexity of the protocols, along with the large
  volume of cancer patients progressing through the
  Oncology clinic in relationship to the number of
  Oncologists overseeing the orders that the
  residents were writing.

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4 Incorrect Ordering of Cancer Protocols

• Experienced Oncology nurses will continue to
  review all orders in ensure correct protocols are
  being followed.
• Another part-time Oncologist was hired to work
  with the residents so that the volume of patients
  will be more manageable and all the ordered
  protocols will be carefully scrutinized before
  the patient leaves the Oncology clinic. This will
  strengthen the safety net already in place.

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5 Inconsistent Discussion of Tx Options

• Many of the residents did not feel comfortable
  discussing treatment options with the patients.
  This caused inconsistencies in physicians
  discussion of treatment options with the patient.
• A team approach consisting of caregivers involved
  was adopted. Pastoral Care was involved whenever
  possible. The team discusses the options with the
  patient and makes sure that the patient
  understands the different options, and the impact
  of those options on the quality of life for each
  patient.

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5 Inconsistent Discussion of Tx Options

• The discussion of treatment options is documented
  and placed on the chart so that everyone knows
  the patient is aware of his treatment plan and of
  the options available. This action makes it
  easier for everyone to communicate and be
  comfortable that the patient is aware of the
  treatment options to be utilized.
• Concurrent review of all patient charts is
  conducted to verify documentation that the
  conversation has occurred.

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Hold the Gains

• All of the improvements discussed here have been
  fully implemented at UMC to allow to hold the
  gains in improvement that we have made this year
  in relation to Breast Cancer.
• The FMECA was an effective performance
  improvement tool that allowed us to truly look at
  our process and identify the inherent risks
  within the process and then re-engineer the risks
  out of our processes.
• We feel that we have made great strides of
  improvement for our Cancer patients and we are
  very proud of this.

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T I G E R S
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