An Innovative Redesign of the BC Cancer Agency Chemotherapy Booking System

Transcription

1 CHEMO SMARTBOOK An Innovative Redesign of the BC Cancer Agency Chemotherapy Booking System

2 Project Description The British Columbia Cancer Agency s (BCCA) Vancouver Cancer Centre delivers 15,000 chemotherapy treatments to over 2000 patients each year. Schedulers face significant challenges in arranging over 60 daily appointments while accounting for patient time preferences, laboratory, radiology and oncology appointments and pharmacy capacity, as well as balancing nursing workload, conforming to nursing shift schedules and avoiding overtime. Faced with increased patient volumes, new chemotherapy treatments and budget restraints, chemotherapy appointment scheduling had exhausted the capabilities of the manual paper-based system that was introduced in the 1990 s. The consequences included late patient confirmation times, considerable clerical rework, unbalanced nursing and pharmacy workloads, and heightened stress for patients and staff. To address these problems, the project team reviewed BCCA chemotherapy appointment scheduling processes and proposed a new flexible process with innovative customized scheduleplanning software (Chemo SmartBook) at its core. Implementation required process change, tightened protocol guidelines, information system modifications, software development, staff training, and communication of new practices to patients and staff. Attention to detail and carefully executed project and change management promoted organizational buy-in. The new system went live in June 2010, just 15 months after the study began. A comprehensive post-implementation evaluation showed a 58% reduction in late patient appointment notification and a waitlist reduction of 84%. Patient surveys confirmed heightened satisfaction with the appointment booking process, while staff feedback reported improved nursing workload distribution and reduced stress levels. The success of this project has heightened organizational awareness of the potential benefits of analytical solutions in other areas. CIHR Team in Operations Research for Improved Cancer Care 1

3 1. Issue Statement Chemotherapy, the administration of pharmaceutical agents usually by intravenous infusion is a critical part of treatment for many kinds of cancer. Treatment protocols vary greatly in frequency (daily to monthly), duration (.5 to 7 hours), number of treatments (one to indefinite) and side effects; protocols must be rigidly followed to achieve optimal results. The issue addressed by this initiative was inefficiency in the outdated chemotherapy appointment booking process at the Vancouver Centre of the British Columbia Cancer Agency (BCCA). Resulting problems adversely impacted patient satisfaction and stress levels, staff morale, treatment and administrative costs and, potentially, health outcomes. The following booking system was in place when the study began; A patient diagnosed with cancer was referred to the BCCA. If chemotherapy was required, an oncologist wrote orders specifying the drugs to be received and their frequency and dose. A booking clerk reviewed the orders to determine the required appointment length and checked the BCCA booking system to find an appropriate appointment or sequence of appointment times. If such times were available, appointments were scheduled; if not, the patient was waitlisted. An appointment card was mailed to the patient indicating the appointment times or waitlist status. Two days before the appointment date, a scheduling clerk based in the chemotherapy unit combined the list of pre-booked patients and waitlisted patients before creating the daily schedule. This task involved triaging patients, creating the daily schedule using the hand- written form in Figure 1, informing patients of their appointment times or changes by phone and assigning nurses to shifts. This secondary scheduling was onerous for clerical staff because they needed to: meet pre-specified appointment duration and workload guidelines, accommodate patient appointment time preferences or requirements, coordinate chemotherapy appointments with lab, radiology and oncologist appointments, balance workload and case complexity across nurses, and work within the pharmacy s drug preparation capacity. This system had become incapable of effectively managing 60 daily appointments, 200 different drugs or drug combinations to be administered, each requiring differing amounts of nurse, chair and pharmacy time, schedules of over 10 nurses attending 33 chemotherapy chairs, last minute cancellations and urgent new appointments. The manual scheduling process was time consuming, inflexible and required considerable managerial and staff input resulting in unbalanced workloads and inefficient resource utilization. Moreover, it was stressful for patients who frequently did not receive appointment time confirmation until the day before their appointments. Oncologists reported that frustrated chemotherapy patients frequently called their offices to obtain appointment information, adding to their workload. CIHR Team in Operations Research for Improved Cancer Care 2

4 Figure 1: Paper-based chemotherapy scheduling form. Cancer and chemotherapy can be physically and emotionally challenging for patients and their families. Uncertainty about appointment times was problematic because: Patients frequently needed to coordinate transportation with a family member, friend or ride services that required advance notice. Patients needed sufficient notice to take pre-treatment drugs if required. For patients living outside Metro Vancouver, uncertainty complicated travel plans and imposed additional financial burdens. The British Columbia Cancer Agency (BCCA) executive, management, clinicians and staff recognized the need for an updated scheduling system and welcomed a proposal by the CIHR Team in Operations Research for Improved Cancer Care (ORICC) to undertake a study of the BCCA chemotherapy appointment scheduling practices in Spring (Team details appear in Section 2.) The team s previous research had focussed on system improvement in radiation therapy. This focus expanded to chemotherapy at the suggestion of one of the team principal investigators who was familiar with the shortcomings of the chemotherapy scheduling system through the experiences of a family member. The team proposed a study to identify potential areas for improvement of the chemotherapy booking system; the proposed project received strong endorsement by the BCCA executive and the chemotherapy unit manager and was launched in April Methodology is described in Section 4. The expectation was that a new system would: reduce waitlists, increase the confirmation lead time between patient notification and appointment date, CIHR Team in Operations Research for Improved Cancer Care 3

5 reduce patient, family and staff inconvenience and stress, balance workload across nurses and within the pharmacy, and reduce clerical rework. The BCCA, an agency of the Provincial Health Services Authority (PHSA), provides a provincewide, population-based cancer control program for the residents of BC and the Yukon through five regional centres. BCCA s mandate covers the spectrum of cancer care, from prevention and screening, to diagnosis, treatment, and rehabilitation. The Agency s research, diagnosis and clinical care are driven by its mission to: reduce the incidence of cancer, reduce the mortality rate of people with cancer, and improve the quality of life of people living with cancer. BCCA s Vancouver Centre delivers over 15,000 chemotherapy appointments to more than 2,000 patients each year. With an aging population and the development of new diagnostic methods and therapies, appointment volumes will increase significantly. The BCCA mission makes it imperative to develop innovative ways to meet the current and future needs of patients receiving chemotherapy. Studies such as this reflect the BCCA mission and position it as a leader in cancer care systems improvement research. As an agency of PHSA, BCCA is committed to improve, its authority-wide lean health care initiative that seeks heightened staff engagement, enhanced care access and system sustainability. However, the lean methodology did not provide the tools or depth to make and evaluate the needed changes to the booking system. Complementary operations research (OR) methodologies including simulation and optimization were required to achieve project goals. A key mandate of the ORICC Team is to disseminate its research broadly. Study details have been communicated at Canadian and international professional meetings and universities. A case study ( has been developed for teaching UBC graduate health care system improvement courses. Journal submissions are in preparation. 2. Team Leadership This project was a collaborative effort of a working group representing the BCCA chemotherapy department, pharmacy, out-patient scheduling department, clinical trials unit, oncologists, management, and the ORICC team. The ORICC team planned, executed, managed and evaluated the project. Implementation and training evaluation was a joint effort of BCCA staff and ORICC team members. Weekly project meetings updated the working group, provided feedback on progress and resolved problems. This collaborative approach, together with close and ongoing contact with department staff, encouraged buy-in throughout the organization. CIHR Team in Operations Research for Improved Cancer Care 4

6 The ORICC team is a collaboration between the BCCA and the UBC Sauder School of Business. It seeks to improve the efficiency of cancer treatment through the development and use of new analytical tools from the field of operations research (OR). OR has been widely used by manufacturing and service industries to plan activities, allocate resources and schedule staff and equipment. The past decade has seen a resurgence in the application of OR in health care; the Sauder School has become an international leader in this field. The ORICC team, established in 2007 with funding from the Canadian Institutes of Health Research (CIHR), combines Sauder graduate students and faculty with BCCA decision makers, managers and clinicians. ORICC research includes: simulation studies of ambulatory care unit operations, strategic and operational radiation therapist scheduling, radiation therapy benchmarking and prostate cancer treatment decision making. The Chemo SmartBook project is the team s most extensive and significant project to date. The ORICC principal investigators are Professor Martin L. Puterman (Sauder) who provides operations research expertise and graduate student supervision, and Dr. Scott Tyldesley (BCCA) who provides a clinical practice and research perspective. John French (BCCA), Senior Director of Operations, Business and Strategic Planning at BCCA, provides managerial and operational perspectives and liaises with the agency executive. OR Scientist Pablo Santibanez (ORICC) manages the analysts, provides modelling input and works closely with agency staff. The OR Scientist and analysts are based at the BCCA. The team s on-site location was of primary importance for achievement of project goals. It enabled the team to respond to project needs in a timely fashion and to interact with working group and members both formally and informally. Project team members Name Job Title 1. Ruben Aristizabal Operations Research Analyst 2. Vincent Chow Operations Research Analyst 3. Kevin Huang Operations Research Data Analyst 4. Travis Nordin Operations Research Data Analyst 5. Pablo Santibanez Operations Research Scientist 6. Devon Poznanski Research Coordinator 7. Martin Puterman UBC Professor, Co-Principal Investigator 8. Scott Tyldesley Radiation Oncologist, Co-Principal Investigator 9. John French Senior Director Operations, Business and Strategic Planning 10. Nancy Runzer Clinical Nurse Coordinator, Chemotherapy Unit 11. Lindy MacKinnon Clerical Supervisor, Ambulatory Care Unit 12. Lynne Nakashima Professional Practice Leader, Pharmacy 13. Dennis Jang Pharmacy Coordinator 14. Susan D Alosio Clinical Trials Nurse Coordinator 15. Christian Kollmannsberger Medical Oncologist CIHR Team in Operations Research for Improved Cancer Care 5

7 Roles and Responsibilities Roles and responsibilities of project team members follow: Operations Research Analyst (ORICC) fulfilled the roles of project manager, lead analyst, team representative on the working group, the main link to the chemotherapy department manager and staff, training leader, and liaison with scheduling staff during implementation. Clinical Nurse Coordinator (BCCA) manager of the Ambulatory Care Chemotherapy Unit (ACCU), primary client and significant participant in all project aspects, provided in-depth knowledge of unit operations and challenges, ensured clinical and nursing guidelines were followed and provided leadership in bringing change to the chemotherapy unit. Operations Research Scientist (ORICC) formulated, developed and validated Chemo SmartBook optimization models and developed and managed project evaluation framework. Operations Research Data Analyst (ORICC) developed software tools, integrated software and process changes with existing information systems, and extracted and analyzed data. Professor of Operations (ORICC UBC) scientific and research leader expert on OR methodology and application, and leader in communicating results to the academic and research communities. Oncologist (ORICC BCCA UBC) provided clinical perspective, and liaised with other clinicians and medical research community. Senior Director of Operations, Business and Strategic Planning (BCCA) communicated with senior executive, and provided management perspective. Ambulatory Care Unit Clerical Supervisor (BCCA) managed booking clerks, and facilitated implementation, training and evaluation. Pharmacy Leader (BCCA) represented needs and requirements of pharmacy. Clinical Trials Coordinator (BCCA) represented needs of clinical trials units. Research Coordinator (BCCA) participated in the design and administration of evaluation surveys and interviews. CIHR Team in Operations Research for Improved Cancer Care 6

8 The Patient Role A primary objective of the booking system was to alleviate patient stress and uncertainty by reducing the likelihood of being waitlisted for an appointment, and increasing lead time between appointment time confirmation and appointment date. Patients were consulted in interviews conducted as part of a preliminary survey of patient satisfaction with the original booking system. The initial survey confirmed that uncertainty about appointment times and dates was a major stressor. One noteworthy finding was that patients with shorter notification lead times were less satisfied with the booking process. The survey also suggested that a one-week lead time would be considered reasonable. A post-implementation survey determined changes to patient satisfaction. Over 350 patients responded to each survey (Appendix 2). As noted above, one of the ORICC principal investigators had gained an in-depth understanding of the booking system and its shortcomings through the experience of a relative. He brought this patient/family perspective to project planning and execution. Work Processes Discovery: Reviewed appointment booking processes. Identified opportunities for process improvement. Interviewed staff. Observed chemotherapy unit and booking activities. Surveyed patients. Data Analysis: Analyzed 18 months of appointment lead time data. Developed and validated process maps for old system. Established performance metrics, set baselines and targets. Reviewed operations at other centres. Redesign and Simulation Modelling: Developed and reviewed process maps for new system. Developed and used computer simulation models to assess the effect of potential process modifications on performance metrics. Formulated appointment scheduling optimization model, determined its users and reviewed their requirements. Determined required information systems modifications. Developed and communicated implementation and change management plan. Implementation: Modified the Cancer Agency Information System (CAIS) to accommodate changes to the booking system. Reviewed clinical guidelines to set precise appointment flexibility windows. Reviewed and updated nursing time and treatment chair time requirements. Developed, tested and validated Chemo SmartBook software. Communicated process changes to patients and staff. Training: Trained first stage users on new booking process and CAIS changes. Trained chemotherapy unit users on Chemo SmartBook. CIHR Team in Operations Research for Improved Cancer Care 7

9 Evaluation: Developed evaluation framework. Obtained post-implementation appointment data. Conducted patient and staff follow- up surveys or interviews. Analyzed and interpreted data. Continuous Improvement: Updated Chemo SmartBook to meet newly discovered needs. Identified opportunities for additional system changes and research. Knowledge Transfer: Preparing research publications. Disseminated results at conferences and university workshops. Developed teaching case study. 3. Information and Analysis Data was extracted from the Cancer Agency Information System (CAIS) appointment module which records all patient appointment booking information, including cancellations and changes. Analysis of 19,000 individual chemotherapy appointment records for 2008 and 2009 revealed that over 40% of chemotherapy patients received appointment notification less than a week in advance. Further this analysis characterized demand by daily volume, nursing time requirements and treatment protocol, quantified daily waitlists, estimated resource utilization, summarized the time between the first appointment entry and its intended date, and developed detailed appointment booking process maps. The team observed operations and extracted and analyzed performance data from a comparable BCCA site. Some desirable practices at the other centre were incorporated in the redesign. Discussions with management at the Mayo Clinic, recognized for its innovations and patientfocused operations, provided other perspectives. No industry standards or best practice benchmarks have been established for appointment notification lead times or waitlists. The team found no relevant research on chemotherapy scheduling systems; guidelines from other medical areas proved inappropriate for chemotherapy scheduling. An initial patient survey provided baseline satisfaction data as well as patient input into reasonable notification lead times. These provided the targets for appointment lead times. Analysis focused on the written notes field of patient records which contained important appointment details including drug protocol, potential appointment conflicts, patient time preferences and travel requirements. The team developed standardized codes for the notes field that streamlined the booking process and simplified follow up analyses. Because nursing time represented the most critical and limiting system resource, treatment protocols were reviewed by chemotherapy nurses for accuracy, and specificity of nursing requirements. Prescribing oncologists were also consulted to determine the degree of flexibility in appointment schedules. This analysis showed that some treatments had to be given at precise intervals, while others could be delayed one or two days without any health detriments. Prior to this study, this information was not standardized or employed in the scheduling process. CIHR Team in Operations Research for Improved Cancer Care 8

10 A computer simulation model was used to evaluate waitlists and lead times on a what if? basis to find the optimal number of days in advance for confirmation of appointment times, and optimal number of appointment slots to reserve for new patients. The unprecedented range and depth of analyses performed during the project was made possible by the organization s support for change, and the ORICC team s analytical skills, in-depth its understanding of and access to CAIS data. 4. Implementation Process maps in Figure 2 provide a schematic representation of the original and redesigned booking processes. Taken together, they show the following changes to the booking process: New Process Stage 1 A maximum number of appointments is pre-specified for each day with a fixed number reserved for new appointments. For each appointment type, clinical guidelines specify a date tolerance. Depending on the clinic capacity and the protocol flexibility, the patient either receives a chemotherapy appointment date or is placed on a waitlist. No appointment time is assigned. New Process Stage 2 One week prior to appointment date, a chemotherapy unit clerk combines the list of prebooked patients and waitlisted patients to create the daily schedule. Using Chemo SmartBook the clerk and the chemotherapy unit manager o review patient records for accuracy, o triage patients, o modify nursing shift number or start times, o create the daily schedule, o review the schedule and modify it if necessary, and o generate the schedule and reports. The most significant improvement for patients is confirmation of appointment time at least one week prior to the appointment date. In place of the tedious and labor-intensive task of assigning 60 patients appointment times each day using a paper form, Chemo SmartBook now enables the user to simultaneously determine appointment times, assign patients to nurses, balance workload and case complexity across nurses, smooth pharmacy workload throughout the day, and accommodate patient time preference/requirements. CIHR Team in Operations Research for Improved Cancer Care 9

11 Figure 2: Original and redesigned booking process maps; changes are shaded. CIHR Team in Operations Research for Improved Cancer Care 10

12 Software development was essential to the implementation of the redesigned booking process. Chemo SmartBook is a customized and previously unavailable optimization software solution, that was envisioned and developed by the ORICC team to address BCCA s specific needs. Development of this software required the team s unique expertise in operations research, project management and optimization. Chemo SmartBook modules are depicted on Figure 3. Detailed screenshots appear in Appendix 1. Figure 3: Chemo SmartBook screenshots. Chemo SmartBook includes the following modules: Nursing Schedule Processor: Enables the unit manager to change shift start times or breaks, or add or remove nursing shifts to meet daily demand through a user-friendly interface. Patient Record Processor: Gives the user the ability to review all patient information including time preferences, other appointments, protocol and resource requirements. Potential problems or inconsistencies are flagged by the system for user correction. This information is downloaded automatically from CAIS prior to scheduling. Schedule Optimizer: Assigns patients to appointment times to simultaneously satisfy patient time preferences, balance workload and complexity across nurses, and limit the number of treatments that the pharmacy can prepare in any 30- minute period using an integer programming model. (An integer program is a mathematical model used to optimize industrial schedules or production plans taking into consideration resources limitations and conflicting objectives or constraints.) CIHR Team in Operations Research for Improved Cancer Care 11

13 Schedule Modifier: Enables daily fine-tuning to account for late appointment changes, urgent new appointments, cancellations or other unanticipated factors. A drag-and-drop interface facilitates these changes. Report Generator: Provides printed chemotherapy unit and pharmacy work schedules and selected managerial reports. Other team activities prior to launch of the redesigned system included modifications to the CAIS system, staff training in use of the new system and software, communication of appointment systems changes to patients, oncologists and staff. 5. Outcomes Results of a rigorous evaluation process determined that the project met and exceeded expectations. Evaluation Framework The ORICC team developed a comprehensive evaluation framework to measure project impact. Figure 4 schematically displays performance indicators. Quantitative measures were derived from appointment data; qualitative measures were derived from structured management interviews and patient and staff satisfaction surveys. quantitative qualitative Confirmation time Waitlist size Patients Satisfaction Reasonable conf. time, # changes Nursing workload Clerical rework Satisfaction Workload New process Staff Administration Utilization Capacity availability Pharmacy workload Transferability to other centres and clinics Figure 4: Evaluation framework showing analytical components relevant to each stakeholder group. CIHR Team in Operations Research for Improved Cancer Care 12

14 Impact with respect to quantitative factors was evaluated by; comparison of pre- and post- implementation data, and comparison to the previous years data from the same time period to eliminate seasonal effects. The team conducted patient surveys before (n=362) and after implementation (n=352) to assess patient satisfaction. Results were compared using formal statistical analysis; p-values are shown where appropriate. The Patient Perspective The evaluation determined that the system changes significantly improved the patient experience. Following implementation, the number of patients placed on the waitlist decreased by 83% from a daily median of 24 to 4 (Figure 5). In addition the number of patients who had less than seven days advanced notice of appointment decreased by 58% (Table 1). Chemotherapy Appointment Waitlist (1 week before) 60 Pre-Implementation 50 Post-Implementation 40 Waitlist Size Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Appointment Date Figure 5: Appointment waitlist pre- and post implementation. Horizontal dotted line indicates median for each period. Patient surveys revealed a significantly higher level of satisfaction with the new appointment booking process. They showed that The earlier the appointment date notification, the higher the patient satisfaction. Preimplementation, 68% of patients who had 5 or fewer days notification versus 99% of patients who had more than 5 days notification were satisfied with the appointment booking process (p<0.001). These findings were confirmed post-implementation. CIHR Team in Operations Research for Improved Cancer Care 13

15 After implementation, the number of patients who reported appointment date notification less than 5 days in advance decreased from 26% to 15% (p<0.001). After implementation, the number of patients who reported appointment time notification less than 5 days in advance declined from 42% to 22% (p< 0.001). Patients reported significant improvements in satisfaction as a result of the redesigned booking process: o Satisfaction with appointment date notification lead time increased from 91% to 97% (p = 0.008). o Satisfaction with appointment time notification lead time increased from 87% to 94% (p=0.014). Metric Post- Implementation 2 Pre- Implementation 1 Decrease Patients Confirmation time Appointments confirmed < 7 days (% appts. per day) 42 (11) 18 (6) 58% Appointments confirmed < 3 days (% appts. per day) 22 (21) 11 (10) 50% Waitlist size One day before appointment One week before appointment 6 (9) 24 (15) 3 (3) 4 (5) 50% 83% BCCA Appointment availability Pharmacy capacity Working days to first available appointment Days with appointment requests exceeding capacity (%) Daily treatment starts exceeding 15 capacity Daily preparations exceeding hourly capacity 11 (9) 76 9 (4) 65 (51) 5 (3) 48 5 (2) 45 (51) 55% 37% 44% 31% Table 1: Evaluation results; numbers are medians with inter-quartile ranges in parentheses. Evaluation timeframes: (1) Pre-implementation: June 29 to October 23; (2) Post-implementation: June 28 to October 22, The Staff Perspective Data in Table 1 showed a significant reduction in clerical workload due to: shorter waitlists throughout the booking process reducing the need for last minute scheduling changes, more available capacity increasing scheduling flexibility, and fewer time periods in which the pharmacy workload exceeded capacity. A structured interview with the chemotherapy unit manager revealed that the new processes: simplified clerical work and reduced staff frustration levels, allowed more time to respond to problems, provided accurate resource utilization estimates, and increased nursing time efficiency and flexibility. The pharmacy manager noted that the process and changes: balanced workflow and reduced chance of errors, CIHR Team in Operations Research for Improved Cancer Care 14

16 led to improved pharmacist and technician schedules, promoted collaboration and provided opportunity for broad input, and exceeded expectations for improving pharmacy operations. Scale-based questions administered to the chemotherapy, out-patient and pharmacy managers noted high satisfaction with the support provided, communication, and project execution and satisfaction with training and in achieving project expectations. The evaluation identified increased opportunity for managers to think strategically, rather than focusing most of their time on day-to-day operations. Examples include: optimizing shift scheduling, using resources more effectively, developing patient complexity scales, and identifying opportunities for further process improvement. Clerical staff also gave high marks to the redesigned process. Over 80% of appointment booking clerks preferred the new process, and over 40% noted a reduction in stress levels and in the amount of time required to book a patient; none reported increases in these measures. Nursing staff reported more balanced workload across shifts and days of the week. Clerical staff in the chemotherapy unit noted that the new scheduling system was easier to use and more efficient than the old system. Organization Perspective BCCA s strategic mandate is to: Ensure the provision and deployment of resources to achieve maximal organizational effectiveness and Establish the knowledge generation and application paradigm within the provincial cancer control platform, and to develop the knowledge transfer environments, forums, process and supports for innovation and adoption of new knowledge. The Chemo SmartBook project furthers these strategic directions by supporting BCCA s effort to improve organizational effectiveness, enhance efficiency, engage staff and develop innovative tools to gain new efficiency. The project exemplifies the transfer of new knowledge generated by advanced analytics into a clinical environment. The knowledge was successfully adopted by front-line care providers to improve patient care delivery, streamline organizational processes, and increase patient and staff satisfaction. These innovative approaches to problem solving are especially timely in the face of projected increased demands and costs for health services. BCCA now recognizes the potential for using advanced analytical methods to reduce workloads, meet performance targets, eliminate redundant tasks, enhance patient satisfaction, encourage strategic thinking and promote a culture of continuous improvement throughout the organization. CIHR Team in Operations Research for Improved Cancer Care 15

17 Transferability The processes and solutions developed in this project are applicable to a wide variety of complex scheduling issues in both in-patient and out-patient settings. Transferability of the process within the BCCA is being explored through planning for implementation of Chemo SmartBook at another one of BCCA s five regional treatment centres. The ORICC team continues to improve its Chemo SmartBook software by making it more flexible, faster, more comprehensive and better able to meet user needs. Linkages to patient notification systems and automated calling and reminder systems also are being investigated. Challenges to healthcare system efficiency will increase in response to an aging population, new therapeutic advances and rising costs. Chemo SmartBook and its implementation by the BCCA provides a proven model for the use of advance analytical tools to ensure a high quality and sustainable healthcare system. CIHR Team in Operations Research for Improved Cancer Care 16

18 Appendix 1: Chemo SmartBook Modules Figure 6: Nursing Schedule Processor module. CIHR Team in Operations Research for Improved Cancer Care 17

19 Figure 7: Patient Record Processor module; patient data is automatically loaded from the BCCA information system CAIS. CIHR Team in Operations Research for Improved Cancer Care 18

20 Figure 8: Schedule Modifier module; initial schedule created by optimization model. This replaces the paper-based schedule on Figure 1. CIHR Team in Operations Research for Improved Cancer Care 19

21 Appendix 2: Patient Survey Questionnaire CIHR Team in Operations Research for Improved Cancer Care 20

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