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Improving accessibility to a non‐invasive brain stimulation treatment for depression
1Berenson
Allison Wang2, Antigoni Sinanis1, and Daniel Press1
Allen Center for Non-Invasive Brain Stimulation & 2Business Transformation at Beth Israel Deaconess Medical Center
1. Reason for Action
4. Countermeasures – Focused on Evaluation Phase
A.
The Berenson Allen Center for Non‐Invasive Brain Stimulation (BACNBS) is a world leading clinic that uses brain stimulation techniques to treat a
number of neuropsychiatric conditions, especially medication resistant depression. The Center has treated over 240 people over the course of 12
years. Transcranial Magnetic Stimulation (TMS) has been offered for 15 years as an off label treatment, but only achieved FDA approval in 2008 and
widespread insurance coverage in 2011 leading to a dramatic increase in patient intake. Patients with chronic depression experience delays of up to 17‐
114 days to start TMS treatment in the BACNBS. One of the challenges was a complex workflow that delayed patients getting treated.
1a
2. Current Patient Flow Process – Where are patient delays in process?
Approach:
A.
B.
C.
Decrease delays in evaluation phase to get to treatment faster ‐ Created a Patient Flow Dashboard to visualize bottlenecks and highlight areas to
focus on
Patient chart moves
through Patient Flow
Dashboard to visualize
where patients are in
process
# of patients
waiting as of
2/12/2014:
Gate with trigger to move patient chart forward (i.e. Move
when evaluations scheduled on specific date)
2nd
Clinical
Review
0
1st
Clinical
Review
Initial
Evaluation
1‐3
1st
Treatment
Last
Evaluation
2‐5
3‐6
Decrease delays in evaluation phase to get to treatment faster
Search for bottlenecks created if streamlined
Focus on increasing capacity for treatments as needed to serve faster incoming patients
4
Designated times for
MD – Patient
communication
Database’s
Excel docs/google
calendar
Increased
continuity of care
OMR
CCC
2
Patient referral
letters missing
information
Patient
Referral
3
P
2
Treatment Phase
Appointment
# of patients waiting as
of 10/2013:
5‐6
Non‐value add time:
Appointment
Initial
Evaluation
1st
Clinical
Review
Last
Evaluation
2‐4
3‐32 days
Value add time :
N
Delays treatment
>1 month
Evaluation Phase
L
A
Patients can’t
get into
evaluations
D
O
Patient referral
folder/chart
Delays treatment
>1 month
3‐5
4 min
4‐7 day
35 min
Problem
Delays in care
not visible
Appointments
Induction
Treatments
~#19 appts
Maintenance/
Taper
# appts vary
4‐7
0‐1
7‐14 day
25 min
Impact
Patient progress
hidden in
folders/charts
Appointments
1st
Treatment
2nd
Clinical
Review
2‐5
1‐27 day
2‐34 day
1
Appointment
4 min
4
0‐1
1 day
70 min
MD – Patient
communication
variable
7‐14 day
43 min
38 min
Anxiety over
next steps
Figure 1. Represents patient flow process from the point of patient referral received to when the first maintenance/tapering appointment occurs.
The process breaks down into two phases: Evaluation and Treatment. The countermeasures primarily focused on the Evaluation phase as it has the
largest patient delays. The purple boxes are the key problem contributors with connecting effects represented as red burrs. The major
countermeasures and results put in place to combat these problems are highlighted in figures 2‐5 with corresponding purple numbers (1‐4).
Goal: Reduce variation in lead time of a patient getting to treatment by 20%
The Team: Daniel Press, MD,
Charlene Saint Leger, Administrative
Clinical Director
Assistant
Antigoni Sinanis,
Clinical Coordinator
Zachary Gray,
Clinical Research Assistant
Andrea Vatulas,
Program Manager
Bonnie Baker,
Management Engineer, Business
Transformation
Allison Wang,
Management Engineer, Business
Transformation
Alice Lee, VP,
Business Transformation
3. Measure of Improvement
Metric
Total Lead Time (Referral to Treatment)
Lead Time (Referral to MD approval/denial to schedule evaluations)
Lead Time (MD approval to schedule evaluations to initial evaluation)
Lead Time (Initial evaluation to last evaluation)
Lead Time (Last evaluation to approval to schedule induction)
Lead Time (MD Approval/denial to schedule induction to 1st treatment)
Baseline
(10/13’)
17‐ 114 days
3 ‐ 32 days
2 ‐ 34 days
1 ‐ 27 days
4 ‐ 7 days
7 ‐ 14 days
Target (↓20%)
14 ‐ 91 days
2 ‐ 26 days
2 ‐ 27 days
1 – 22 days
3 – 5 days
5 – 11 days
Progress
(02/14’)
Data incomplete
0 – 13 days
2 – 27 days
0 – 33 days
0 ‐ 7 days
Data incomplete
Implemented a
standard
referral form
and process
Decisions on patient
referral letters made
immediately
3
Reduced # of phone
calls/emails made to
schedule patient
Added
evaluation
slots
Reduced # of
patients waiting
Week 5 – 2/12/2014
Figure 2. The Patient Flow Dashboard visually depicts where patients are located in the
evaluation phase. The board is split into 4 “Gates” each with designated criteria of what has to
occur before the patient folder can be moved forward (i.e. MD approval/denial to schedule
evaluations). Each gate has a maximum number of days the patient folder should wait in order
to highlight patient delays. The board is updated daily and huddled around weekly in order to
raise concerns over delays and problem solve in real time to get them to treatment.
Standard referral form
has reduced fetching for
missing information
Figure 3. In congruence with the standard referral process, a standard referral form was
created that has contributed to faster MD decisions to get patients to evaluations.
Placeholder for
when chart in
use
Type of Appointment
patient waiting for
Use patient
folder to signify
patient
Standard Facesheet to
track dates of progress
Maximum days shows how long
patient waiting in gate
Figure 4. The components of the Patient Flow Dashboard are
highlighted above. Existing patient folders were chosen to
signify the patient placed in a bucket under a gate. Standard
facesheets were created to document important dates in
order to track reductions in patient delays. Once the patient
folder hits maximum number of days in a gate, they are
tracked in the daily management system shown in figure 5
below.
1b
Implemented
a Daily
Management
System
Breaks down reasons
why patients
waiting
Tracks delayed
patients daily
Figure 5. Added a Daily Management System to the Patient
Flow Dashboard which captures patients waiting over the
maximum days to move forward. This visually shows trends
in areas where bottlenecks are occurring giving direction for
further investigations and improvements.
A 6. Standardize and Spread Processes
D Identify criteria for patient MD assignment once approval to
schedule evaluations received
J Create pathway to predict patients who are denied prior
authorization
U
Applying new system across potential satellite sites
S
For more information, contact
T
Allison Wang – Management Engineer, Business Transformation, Health Care Quality, aswang@bidmc.harvard.edu
5. Monitor both Results & Processes
S Decreases seen from referral to MD approval/denial to schedule
evaluations
T
Maintain gain and begin to breakdown bottlenecks seen from
U initial evaluation to last evaluation and last evaluation to
approval/denial to schedule induction
D
Y
Antigoni Sinanis – Clinical Coordinator, Berenson Allen Center for Non‐Invasive Brain Stimulation, asinanis@bidmc.harvard.edu
Daniel Press, MD – Clinical Director, Berenson Allen Center for Non‐Invasive Brain Stimulation, dpress@bidmc.harvard.edu
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Dublin Core
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Title
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Silverman Symposium
Description
An account of the resource
Each year the Silverman Symposium poster session offers BIDMC staff and affiliates the opportunity to share experiences and learn about efforts to improve Quality and Safety.
Date
A point or period of time associated with an event in the lifecycle of the resource
2021
Silverman Poster
Primary Contact
If you would like more information about this project, contact this person. Make email address clickable.
Antigoni Sinanis (<a href="mailto:asinanis@bidmc.harvard.edu">asinanis@bidmc.harvard.edu</a>)
Department
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Berenson Allen Center for Non-Invasive Brain Stimulation
Business Transformation
BIDMC Location
The BIDMC location where the poster team resides if identified in spreadsheet. If not identified, choose BIDMC.
BIDMC
Project Team
Daniel Press
Antigoni Sinanis
Charlene Saint Leger
Zachary Gray
Andrea Vatulas
Allison Wang
Bonnie Baker
Alice Lee
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Improving Accessibility to a Non-Invasive Brain Stimulation Treatment for Depression
Date
A point or period of time associated with an event in the lifecycle of the resource
2014
Format
The file format, physical medium, or dimensions of the resource
pdf
Efficiency
Patient and Family-Centeredness