ICCN 17

Training for outpatient treatment procedures

Anne Gross – Dana Farber Cancer Institute, Boston, USA




Tell us about safety in the outgoing oncology setting.

In the outpatient setting, most patients receive chemotherapy and other treatments for their cancer. So much of that has moved from the inpatient setting to the outpatient setting and it’s critical that we get every step of that process correct from the ordering of it by the practitioner to the dispensing of the medication by the pharmacy and then the administration of the drugs by the nursing staff. It’s a high risk, high volume activity and an area that we constantly focus on to ensure that our patients get the right drug, the right dose, the right time, the right day.

Tell us about teamwork and team training, discussed in your presentation.

It’s an approach that has been very successfully implemented in the aviation… a pilot implemented in the aviation industry in the United States and nuclear industries. Again, these industries are very risky and involve teams working together in order to complete their work so it’s an educational intervention that teaches team behaviours, deals with issues of hierarchies in the team. Certainly in our medical culture we have those issues and it flattens the hierarchy and focusses each team member on the patient and what we’re doing. So the person that has the most recent information or has the patient with them is really the leader of the team at that time. We took those principles and applied them to our setting; they had never been applied in an outpatient setting before where the challenges of geography are huge, the team members are not always located in the same place and so it really requires excellent communication and systems in place and agreements on how practitioners and staff will communicate with each other to care for the patient safely.

What about the structure and content of the training?

The training is a train the trainer type of methodology. The content, as I said, involves these principles of teaching team behaviours and what we did is took our disease centres, we have our clinical care divided by teams that treat different cancers, so we took each team together and with a physician and nurse leader we trained them to train their staff in these concepts. So they would look at their way of practising and our main focus was initially to look at the whole chemotherapy process and we made certain agreements around assuring safety when there is, for example, a patient’s treatment for the same day is going to be altered, we made agreements that those kinds of changes would be verbally communicated between the practitioner ordering the chemotherapy and the nurse administering and the pharmacist. So we put interventions like that into place, each disease group had their own areas of concern and risk and so through using these team behaviours and then sitting together and looking at their areas of risk, they made agreements of how they would work together and then we developed the tools and changed the systems for them to be able to do that. So around that communication for chemotherapy change orders, we gave all of our nursing staff telephones so that the ordering provider could call them directly if they were going to change the order for the day to be sure that the right order was understood by the pharmacy who was mixing the drug and the nurse that would be administering.

What are process meetings?

Those process meetings were where each team, having learned the concepts of team training, would sit down and say to each other, “OK, what are the things in our group that challenge us?” So, for example, many of them came up with an idea to implement team huddles once a week because they’re all going in many different directions and not all in the clinic at the same time treating the patient, that they would have a huddle together once a week and go through all the patients who were coming in, making sure the proper scans and X-rays and tests were ordered, making sure the right chemotherapy regimen was in our system for the patient for that day, the right lab tests were ordered and then a check back following that huddle on the actual day of treatment to be sure all was in place.

How did the staff perceive the post intervention evaluation?

Our initial aim was to mitigate any risk for error but in fact along with that we had an added benefit of the teams really feeling, number one, that the interventions that they applied in their teams did increase patient safety but also increased the satisfaction of the team members and their respect for one another. Because one of the other concepts that is taught in the training is skills around conflict resolution and different methods of communication and so with those new tools people felt that the practice environment had improved, there was better communication amongst the team, better respect and better staff satisfaction. In addition, we have been measuring patient satisfaction in terms of patients’ perception or feeling that their team was working together well to take care of them. We’ve seen a steady increase in that over the 2½ years now that we’ve been measuring that.

How has this been implemented?

We’ve implemented it across our adult service, outpatient service, at Dana Farber which is twelve different disease centres and then we have four satellites in the community where we have also implemented the training and the concepts and now are working on a training session between our inpatient teams and the outpatient teams around the transfer of patients from the outpatient, admitting outpatient to inpatient. There are several hand-offs that need to occur safely and clearly in that exchange so that’s our current area of focus.