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Assessment, development, and evaluation of cancer programs
Assessment, Development, and Evaluation of Cancer Programs Luana Lamkin
A
RECENT SURVEY of 1,779 hospitals shows that nearly 50% intend to expand their oncology programs in the next 2 years. ~ Every oncology nurse working in those 886 hospitals will be affected by this development and can impact its outcome. The purpose of this article is to assist the oncology community to carefully plan, operationalize, and evaluate hospital-based cancer programs. As an advocate for cancer patients, the nurse is in an excellent position to lobby administrators to provide a full range of services. The nurses and nursing administrators must be prepared to answer the difficult issues of quality and concomitant cost containment through a process that is meaningful to the executives of the hospital. The nurse's knowledge of clinical issues must be combined with the skills to plan for a hospital strategy with specific business plans that will be successful. Fortunately, the nursing process has prepared the nurse to assess a situation, to plan for its solution, and to evaluate process and outcome STRATEGIC PLANNING
Nash and Opperwall 2 define strategic planning as "a process used to determine and evaluate alternatives for an organization to achieve its objectives and mission." A strategic plan usually spans at least 3 to 5 years. The process of developing the plan affords an opportunity for the multidisciplinary team, including employed staff and physicians, to develop a shared vision. The process itself can positively affect the growth of an organization, productivity, and morale. Apparently, the difficulty is in turning such a plan into action. "Perhaps 90% of all American companies have failed to successfully implement their strategies" according to some business leaders. 3 A strategic plan may state that the market share for a hospital for oncology in a defined geographic area will increase by 20% over 3 years, or that major efforts will be invested in oncology and orthopedics to create "centers of excellence." This strategy for success must be accompanied by sound business plans. A strategic plan not only sets Seminars in Oncology Nursing, Vol 9, No 1 (February), 1993: pp 17-24
organizational priorities for service lines and/or support services, but identifies (perhaps only by omission) what will not be pursued. The strategic plan sets forth direction for future decision making. Must one wait for a hospitalwide strategic planning effort to be mobilized to develop a service line plan? It may be more difficult to do independently, but it can be done. One must think like a hospital executive to achieve this success. Why would an executive be swayed to put special emphasis on developing oncology programs? Possible answers such as community need, service line identity, and positive financial outcome are listed in Table 1. If hospitalwide strategic planning is underway, the added pressure of competition with other service lines will play a major role. Figure 1 shows a bar graph depicting inpatient volume by service line by payor at a hypothetical community hospital. Data such as this will be combined with external assessment of growth potential to determine which service lines the organization will pursue. Many, if not most, oncology programs have developed one department at a time. An excellent business plan for luring chemotherapy infusions from the physician's office to a hospital-based outpatient department could backfire if, for instance, laboratory, pharmacy, and patient education services are not prepared for the new workload. A strategic plan that defines the sequence of development will avoid piecemeal growth. Likewise, a new oncology unit with the latest in technology does nothing for financial viability, image, or quality if there is not a companion plan to staff the new unit. The strategic plan requires sequential development of program components based on From The Queen's Medical Center Cancer Institute, Honolulu, HI. Luana Lamkin, RN, MPH, OCN: Executive Director, The Queen's Medical Center Cancer Institute. Address reprint requests to Luana Lamkin, RIV, MPH, OCN, The Queen's Medical Center Cancer Institute, 1301 Punchbowl St, Honolulu, HI 96813. Copyright 9 1993 by W.B. Saunders Company 0749-2081/93/0901-000455.00/0
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LUANA LAMKIN
18
Table 1. Why Develop Cancer Programs in a Community Hospital? A recognition that the community served by the hospital has a need A desire to distinguish the services of the hospital from competitors via a cancer program, and thereby improve the overall image of the facility A desire to positively affect the financial picture of the hospital by increasing profitable inpatient and outpatient oncology admissions A recognition that efficient, streamlined services should be developed in oncology to maximize profits from thirdparty payors
personnel availability, funds availability, and the physical plant. THE STRATEGIC PROCESS
The planning process must be clearly laid out. Identifying those to be involved in the process as well as the interim and final decision makers is of great importance. One employee champion and one physician champion are imperative. The involvement of great numbers of staff and physicians is ideal for future commitment but not practical for working meetings. One alternative is to involve a wide array of professionals, patients, and community agencies in focus groups to gather information and ideas and have a small (six to eight person) commission actually develop the plan. Each participant subsequently has an opportunity to review the plan before it begins the approval process. ASSESSMENTS
An internal assessment of present services, strengths, weaknesses, opportunities, and threats
(also known as SWOT analysis) is the first step. This should include supportive services such as laboratory, pharmacy, and diagnostics as well as all oncology services for inpatient nursing, outpatient capabilities, radiation therapy, and patient education. Personnel assessment should include the skill levels and general reputation of physician specialists, nurses, technologists, and therapists, to name a few. Assessment should also be made of the physical facility and its location, visibility, accessibility, parking, and expansion potential. A careful evaluation must be conducted with the financial departments of present workload, payor mix, cost, charges, and reimbursement for oncology care. 4 Very few organizations are capable of quickly providing detailed analysis by ICD-9 codes of both inpatient and outpatient services for the parameters listed previously. If estimates or extrapolations must be made they should be developed with the people who will be asked to attest to their validity, namely the financial and planning departments. Externally, a clear assessment should be made of the present cancer market in the service area, area demographics, the number of patients, where they are treated, and by whom. Patient satisfaction with the present care and services both internally and externally should be evaluated. Present programs and plans for expansion of other major providers should be taken into consideration. Projections for future workload and revenue are as difficult as they are imperative. Anticipated changes in practice patterns, reimbursement policies of third-party payors, technology, personnel
~NNN
Oncology Cardiac
OB
Ortho Gen Surg Gen Med Psych
Fig 1. Hypothetical inpatient admissions by payor by service line, for n 500-bad hospital FY 1991. El, contracted; I , charge based; I , Medicaid; I , Medicare,
CANCER PROGRAMS
19
policies, shifts to managed care, and changes in the roster of physicians practicing at the facility should all be detailed as footnotes to projections. FRAMEWORK
Henderson identifies both strategic fit and integration as necessary to achieve an interdependent business and information technology plan. 5 Waterman advocates that assessment and planning be performed using the McKinsey 7-S Framework6 (Fig 2). This theory revolves around the notion that a good strategy and the right organizational structure are not enough for success. The organization must also have strong systems for getting work accomplished day to day, a management style that reflects the strategy in action, a competent and available staff, and shared values and skill within the entire organization rather than within individual people. The strategic plan for the Queen's Medical Center Cancer Institute in Honolulu, HI, was originally developed in 1988 using the basic concepts outlined previously. Focus group meetings of 60 people were held, and detailed data was combined with internal and external assessments and projections. A seven-member planning commis-
sion then developed an eight chapter strategic plan: 1. Mission and Objectives 2. Physical Plant 3. Education and Research 4. Manpower 5. Reimbursement 6. Organizational Structure 7. Technology 8. Plan Sequence Each chapter defines a philosophy and a longrange goal. This plan covers 10 years, particularly in terms of the physical plant. Presentations regarding the plan were made to focus group participants, the Cancer Committee, Medical Center Board committees, and finally the Board of Trustees. The final chapter on sequencing was the most difficult to produce but perhaps the most helpful. Major program elements are defined for each year. A major tenet of The Queen's Cancer Institute plan is the development of a ten-story tower on the campus of the Medical Center that devotes five floors to consolidating oncology services. This physical realignment occurs in year eight of the plan, but every decision made regarding new programs in the interim is based on this long-range goal. PHYSICAL FACILITIES
Fig2. The McKinsey 7-S framework for strategi9 planning. (Reprinted with permission, s) From Journal of Business Strategy (New York: Warren Gorham Lamont), 9 1982 Research Institute of America Inc.
The need to renovate, expand, or build facilities is a major hospital commitment. Such decisions are based on an assessment that present facilities do not meet projected volume and consolidating and enhancing the present facility will fit with the overall strategy of the organization for the future. After determining that those two criteria are met, functional planning begins. Nowhere else can an articulate group of nurses have such impact. The basic question in functional planning is "what will be done in this area?" This planning should be done in small workgroup settings for different physical areas as first envisioned. Workgroup possibilities are inpatient nursing unit, intensive and/ or bone marrow transplant unit, outpatient infusion service, patient teaching, 23-hour clinic, radiation therapy, medical physics, physicians' office space, support services, and others. As the functions within each space become defined, some "areas" may be integrated into others. For example, it may be advisable to decentralize patient education
LUANA LAMKIN
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rather than consolidate teaching services in one physical area. Functional issues to be discussed are listed in Table 2. The battle cry of the nurse dealing with architects in planning is "form follows function." Simply put, the architect is told what function must be performed and then designs the form (space) in which to do it efficiently. By carefully defining the functions and the workload, the architect is provided the data from which to design the space. 7 Another important planning activity of clinicians is adjacency matrix building. Clinicians indicate how closely related new areas must be to one another. Is it more important for an outpatient infusion center to be adjacent to the inpatient oncology unit, the pharmacy, or patient parking? A matrix can be Table 2. Functional Issues in Facility Planning Department description Purpose Services Population served Educational programs Anticipated changes Current deficiencies Statistical activity Historical (3 years) Workload Inpatient days Average length of stay Number of discharges Staff FTEs by job description Total number of people Greatest number of people on duty at one time Projected (3 years) Workload Inpatient days Average length of stay Number of discharges Staff FTEs by job description Total number of people Greatest number of people on duty at one time Relationships (special and communication) Intradepartmental Interdepartmental Planning considerations Operational systems (ie, nurse call system, cart exchange, pneumatic tube) Major equipment and technology needs Unique design requirements Major spaces Patient rooms Nursing station Utility rooms and storage Education center Visitor facilities Staff facilities Abbreviation: FTE, full-time employee.
developed to define not only physical proximity but, alternatively, the need for two departments to be connected only by computer or only by pneumatic tube system. Figure 3 is part of an adjacency matrix from a hypothetical hospital. The legend tells if the two departments linked by the matrix must be contiguous, in proximity, or linked by communication systems. The architect uses the adjacency matrix to lay out "bubble drawings" that show contiguous departments horizontally and vertically. Many renovation or new construction projects have become mired in space details and have ignored systems planning. The systems by which people, medical records, supplies, food, and drugs are moved, ordered, and returned are critical to the smooth functioning of all clinical areas. There is no better time to realign systems than when planning new facilities. Traffic circulation considerations are crucial. From the functional plan, adjacency matrix, workload projections, and systems plans the architects develop initial space plans. This is when it is realized that planning has resulted in a 150,000 square foot structure when 75,000 square feet are available. The nurses' negotiating skills are tested at this point. Clinicians should have an opportunity to assist in planning the myriad details in their specific clinical areas also. Clinicians are probably best prepared to advise about outpatient treatment room configuration, including minor details such as where the intravenous fluid pump will stand and where the VCR controls should be placed for the convenience of the patient. The environment, or ambience, is extremely important to both patients and visitors as well as staff. Combining comfort and technology is a challenge, especially when infection control, cost containment, and other constraints are introduced. BUSINESS PLANS
The business of health care no longer takes place only in the Board room. If nurses can develop good ideas but cannot turn them into profit centers, they will be left behind. A good business plan is tied to a strategic plan. If the hospital strategy is to increase ambulatory oncology-related market share by 10% and profit by 10% in 2 years, one associated business plan may be to develop a breast health center.
CANCER PROGRAMS
21
RADIATION THERAPY BREAST HEALTH CENTER CLIN. NURSE SPED. ONDOLODY DIETITIAN EDUO. CONF* ERTENOSTOMAL THEN. PHYSICIAN EDUC. SP. MULTI-DISC* ONC. CLINIC ONCOL. DATA RED* PAIN MANAGEMENT
Fig 3. Facility planning adjacency matrix of a hypothetical hospital. Directions for use: To find the intended special relationship between two areas, follow their diagonals until they meet, similar to a mileage chart. For instance, the multidiscipiinary oncology clinic (eighth space down) should be adjacent to the oncology reception (fifteenth space down). This is evident because the box that connects these two spaces is solid black, which denotes adjacency.
PASTORAL EDUC. REHABILITATION .EGENI 9
ADJACENT TO
RESEARCH NURSES A HYPQTH~
HO~qTAL
ONCOLOGY RECPT'N. PNARM. SERVICES OFF. 2 MEDIUM TRAFFIC 3 LIGHT TRAFFIC
INPATIENT PHARMACY OUTPATIENT PHARM.
NO RELATIONSHIP
RETAIL BOUTIQUE SOCIAL SERVICES
INFORMATION EXCHANGE
The same kind of assessment of the internal and external environment and workload projections is necessary that was required for strategic planning but much more focused. Business plans are very detailed in terms of financial projections, time tables for milestones, and evaluation criteria. A variety of business plan formats are available. 8 A sample detailed business plan outline is shown in Table 3. Most hospitals have criteria for the development and approval of business plans. For instance, a detailed business plan must be completed if initial outlay is $10,000 or more. Approval criteria might be a positive cash flow in 36 months. As with a strategic plan, using the best internal and external resources makes the plan stronger. Know who the decision makers are and plan the presentation to meet their needs. Identifying market share is frequently a difficult task. Some states have required or voluntary volume-reporting regulations via the health department or hospital association. Even if such regulations exist, data rarely include such detailed reporting as "number of screening mammograms performed." Ideally, mammogram market share could be determined by dividing the number performed at the specific facility in a specified time by the total number performed in the service area during that same time. Sometimes the local unit of the American Cancer Society will have available in-
OUTP. ONOOLOOY CL/N.
formation such as a list of all facilities performing screening mammograms and charges or the American Cancer Society's estimate of the number of mammograms performed in a certain area. In projecting market share be sure to take into account the potential growth of the market. Market growth is the number of new mammograms that might be performed in future years because of the aging of the population, public education, changes in reimbursement regulations, or the marketing strategies used. For most oncology services, volume can increase by capturing the competitor's market or by identifying a new unserved population. If market share must be estimated or extrapolated from other data, document the assumptions made so at least the trends can be followed and over time the same assumptions will be used. Part of the business plan calls for routine assessment of the success of the operation in quality and financial terms. Reporting milestones usually relate to the hospital's fiscal year. If the new service resulted in a new cost center, the financial analysis currently performed will provide most of the data needed for monitoring expense and revenue. However, if the new service is to become part of an existing cost center (for instance, the breast health center expenses and revenue are reported as part of the aggregate analysis of the radiographic department) identification of exactly what data must be
LUANA LAMKIN
22 Table 3. Sample Business Plan Outline
Description Title Description of proposal Service objectives Relationship to strategic plan Assessment of competition in service area Degree of risk Financial Liability Implementation Time line of major planning and implementation milestones Responsibility and authority Resources required Human resources Capital expense (one time expense over $500 for items with a life greater than 2 years, such as computers, furniture) Operational expense (ongoing annual expenses such as personnel, office supplies, medical supplies) Space Evaluation Measures of success Reporting requirements Financial analysis Projected workload Projected market share Projected payor mix FTE requirements Supplies and expenses Capital expense-equipment Renovations Overhead cost (ie, housekeeping) Impact on other services (ie, admissionsl Rate setting, reimbursement forecast Pro forma income statement (3-5 years) Net present value analysis (3-5 years) Recommendation
collected, by whom, and at what intervals is crucial. Criteria for both quality and financial success should be set at the time of business planning. Do not be afraid to identify ancillary charges that the new service will produce. A good breast health center will, over time, result in additional localizations, biopsies, admissions, and surgeries. Attempt to establish systems so that clients who have such subsequent care can be tracked. If that is not possible, negotiate the percent increase in each of these subsequent care areas that will be attributed to the new service. It is wise to get written concurrence of such agreements with the financial analysis department. Finally, if one believes in the business plan but it does not meet the criteria for acceptance the first time it is evaluated, do not give up hope. Occasionally the community need or increased positive image for the medical center will outweigh finan-
cial advantage. Review all assumptions to determine if an unserved market has been ignored. Evaluate the possibility of starting out more slowly, and adding personnel and equipment incrementally. Try to sell the program as a 6-month or 1-year trial. EVALUATING A CANCER PROGRAM
As with all evaluation activities, success cannot be determined without establishing criteria for success. Evaluating a single program involves establishing criteria and reporting time frames during business planning. Do not overlook the "evaluation" that is already being performed for other related purposes. Look for staff performance appraisals showing an increase in productivity, team work, and independent learning; evaluate staff turnover as an example. Perhaps tumor registry data will help determine volume indicators. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is in the process of redefining quality. 9 JCAHO requirements establish continuous quality improvement measures that meet the institution's needs and theirs. Providers are increasingly being held accountable for measuring quality of care and demonstrating value for the consumers' health care dollars. This requires evaluation of both process and outcome of care, from the hospital's perspective and the clients, with a system's view. A basic tenet of continuous quality improvement is effective management, and support systems are equally important to the provision of quality care as are competent health care professionals. ~o Fortunately, evaluating a cancer program need not begin from scratch. The Association of Community Cancer Centers has developed standards for 23 separate cancer program activities. ]1 The categories range from the multidisciplinary team and the oncology unit to tumor board and cancer prevention and detection. The specificity of evaluation characteristics listed varies considerably, but this is an excellent document to use as a blue print for developing program goals and evaluation measures. These standards are currently being revised. The American College of Surgeons' Commission on Cancer is the only body that "approves" cancer programs. This approval is based on the services available, medical staff qualifications, residency programs, research, tumor conferences,
CANCER PROGRAMS
23
and the presence of a multidisciplinary cancer committee and tumor registry. 12 The College recognizes the vast array of cancer programs and approves eight separate categories. Many consulting organizations exist that specialize in evaluating cancer programs and making recommendations for expanding and improving quality, financial success, and market position. Such an assessment is particularly helpful if the internal assessment by staff, physicians, and administration is inconsistent. Most firms will be happy to help you write a business plan to contract for their services. Unfortunately, the guidelines available do not deal specifically with clinical outcomes or patient satisfaction. JCAHO is now testing oncologyspecific indicators that count items that deal mostly with medical care. 9 These indicators are discussed in more detail in the article by Ogorzalek elsewhere in this issue. Mortality rates by disease at specific stages of diagnosis provide an indication of care at a facility, but changes in practice are not recognized in such reporting for many years. The American College of Surgeons annually performs nationwide outcome studies (patient care evaluation studies) that provide data by which a facility can measure itself. 12 In addition to assessing services, volume, clinical outcomes, and financial success, patient evaluation is imperative. A patient's satisfaction should be measured in terms of both process and outcome. For example: Was your call light answered promptly? Were you prepared to care for yourself on discharge? A patient satisfaction scale developed specifically for cancer patients will result in the most usable information. Wiggers et all3 tested a 60item satisfaction scale to assess the "perception of 232 ambulatory cancer patients about the importance of and satisfaction with nine dimensions of patient care." Their data can be used to narrow a broad array of questions by acknowledging aspects of care most important to the patient. In their book, Morra and Potts advise patients,
"You do have a right to go to the hospital of your choice. ''14 They provide a five-page checklist for evaluating a hospital for oncology care. The criteria relate to size, teaching affiliations, accreditation, distance from the patient's home, and specific diagnostic and therapeutic services. The authors also point out, "Get to know the nurses who are involved in your care. They can be your best allies." A recent study of 20,000 patients' perceptions of quality care shows that a facility's tertiary care and census levels, teaching status, and employee salary rates are all correlated to a perception of high quality. 15 Another somewhat subjective but most enlightening measure of quality is to ask the staff. Given anonymity most staff are quite frank about the quality of their own care and that of their colleagues. They always have a long list of systems and communications concerns and frequently have solutions to suggest. Two questions particularly useful with staff (and physicians) are: 1. If you were in charge of all oncology services, what would you change? 2. If your mother (husband, child, etc) were to be admitted to your area for oncology care, what would you most closely monitor to insure their quality of care? Perhaps the biggest mistake made is to devise surveys, to ask people to take the time to complete them, and then to ignore the responses. Know that some action must be taken if suggestions are sought. CONCLUSION
Assessing a hospital-based cancer program and its potential, planning the long range strategy and the shorter term business plans, and evaluating their success can be a time-consuming and arduous task. However, only by doing this can it be assured that an integrated oncology program provides patients quality and value and provides staff professional satisfaction. The oncology nurse is in a unique position to combine clinical knowledge and business sense to impact patient care.
REFERENCES
1. Sandrik K: Oncology:Who's managing outpatient programs? Hospitals4:33-36, 1990 2. Nash MG, OpperwallBC: Strategicplanning: The practical vision. J Nuts Adm 18:12-18, 1988
3. BullerPF, TimpsonL: The strategicmanagementof hospitals: Towardan integrativeapproach.HealthCareManagRev 11:7-13,1986 4. BookbinderNF: Strategic planning, in Nathanson SN,
24 Lerman D (eds): Outpatient Cancer Centers Implementation and Management. Chicago, IL, American Hospital Publishing, 1988, pp 17-313 5. Henderson JC: Aligning business and information technology domains: Strategic planning in hospitals. Hosp Health Services Admin 37:71-87, 1992 6. Waterman RH: The seven elements of strategic fit. J Business Strategy, Winter: 69-73, 1982 7. Davis PB: Facility design, in Nathanson SN, Lerman D (eds): Outpatient Cancer Centers Implementation and Management. Chicago, IL, American Hospital Publishing, 1988, pp 63-91 8. Johnson JE: Developing an effective business plan. Nurs Econ 8:152-154, 1990 9. Joint Commission on Accreditation of Healthcare Orga-
LUANA LAMKIN
nizations (JCAHO): 1992 Accreditation Manual for Hospitals. Chicago, IL, JCAHO, 1992 10. O'Leary DS: Improving quality of care in an era of cost containment. Oncol Issues 5:8-9, 1990 11. Association of Community Cancer Centers: Standards. Rockville, MD, ACCC Publishing, 1988 12. American College of Surgeons Commission on Cancer: Cancer Program Manual 1991. Chicago, IL, American College of Surgeons, 1991 13. Wiggers JH, O'Donovan KO, Redmen S, et al: Cancer patient satisfaction with care. Cancer 66:610-616, 1990 14. Mona M, Putts E: Choices: Realistic Alternatives in Cancer Treatment. New York, NY, Avon, 1987 15. Boscarino JA: The public's perception of quality hospitals II: Implications for patient surveys. Hosp Health Services Admin 37:13-35, 1992
A
RECENT SURVEY of 1,779 hospitals shows that nearly 50% intend to expand their oncology programs in the next 2 years. ~ Every oncology nurse working in those 886 hospitals will be affected by this development and can impact its outcome. The purpose of this article is to assist the oncology community to carefully plan, operationalize, and evaluate hospital-based cancer programs. As an advocate for cancer patients, the nurse is in an excellent position to lobby administrators to provide a full range of services. The nurses and nursing administrators must be prepared to answer the difficult issues of quality and concomitant cost containment through a process that is meaningful to the executives of the hospital. The nurse's knowledge of clinical issues must be combined with the skills to plan for a hospital strategy with specific business plans that will be successful. Fortunately, the nursing process has prepared the nurse to assess a situation, to plan for its solution, and to evaluate process and outcome STRATEGIC PLANNING
Nash and Opperwall 2 define strategic planning as "a process used to determine and evaluate alternatives for an organization to achieve its objectives and mission." A strategic plan usually spans at least 3 to 5 years. The process of developing the plan affords an opportunity for the multidisciplinary team, including employed staff and physicians, to develop a shared vision. The process itself can positively affect the growth of an organization, productivity, and morale. Apparently, the difficulty is in turning such a plan into action. "Perhaps 90% of all American companies have failed to successfully implement their strategies" according to some business leaders. 3 A strategic plan may state that the market share for a hospital for oncology in a defined geographic area will increase by 20% over 3 years, or that major efforts will be invested in oncology and orthopedics to create "centers of excellence." This strategy for success must be accompanied by sound business plans. A strategic plan not only sets Seminars in Oncology Nursing, Vol 9, No 1 (February), 1993: pp 17-24
organizational priorities for service lines and/or support services, but identifies (perhaps only by omission) what will not be pursued. The strategic plan sets forth direction for future decision making. Must one wait for a hospitalwide strategic planning effort to be mobilized to develop a service line plan? It may be more difficult to do independently, but it can be done. One must think like a hospital executive to achieve this success. Why would an executive be swayed to put special emphasis on developing oncology programs? Possible answers such as community need, service line identity, and positive financial outcome are listed in Table 1. If hospitalwide strategic planning is underway, the added pressure of competition with other service lines will play a major role. Figure 1 shows a bar graph depicting inpatient volume by service line by payor at a hypothetical community hospital. Data such as this will be combined with external assessment of growth potential to determine which service lines the organization will pursue. Many, if not most, oncology programs have developed one department at a time. An excellent business plan for luring chemotherapy infusions from the physician's office to a hospital-based outpatient department could backfire if, for instance, laboratory, pharmacy, and patient education services are not prepared for the new workload. A strategic plan that defines the sequence of development will avoid piecemeal growth. Likewise, a new oncology unit with the latest in technology does nothing for financial viability, image, or quality if there is not a companion plan to staff the new unit. The strategic plan requires sequential development of program components based on From The Queen's Medical Center Cancer Institute, Honolulu, HI. Luana Lamkin, RN, MPH, OCN: Executive Director, The Queen's Medical Center Cancer Institute. Address reprint requests to Luana Lamkin, RIV, MPH, OCN, The Queen's Medical Center Cancer Institute, 1301 Punchbowl St, Honolulu, HI 96813. Copyright 9 1993 by W.B. Saunders Company 0749-2081/93/0901-000455.00/0
17
LUANA LAMKIN
18
Table 1. Why Develop Cancer Programs in a Community Hospital? A recognition that the community served by the hospital has a need A desire to distinguish the services of the hospital from competitors via a cancer program, and thereby improve the overall image of the facility A desire to positively affect the financial picture of the hospital by increasing profitable inpatient and outpatient oncology admissions A recognition that efficient, streamlined services should be developed in oncology to maximize profits from thirdparty payors
personnel availability, funds availability, and the physical plant. THE STRATEGIC PROCESS
The planning process must be clearly laid out. Identifying those to be involved in the process as well as the interim and final decision makers is of great importance. One employee champion and one physician champion are imperative. The involvement of great numbers of staff and physicians is ideal for future commitment but not practical for working meetings. One alternative is to involve a wide array of professionals, patients, and community agencies in focus groups to gather information and ideas and have a small (six to eight person) commission actually develop the plan. Each participant subsequently has an opportunity to review the plan before it begins the approval process. ASSESSMENTS
An internal assessment of present services, strengths, weaknesses, opportunities, and threats
(also known as SWOT analysis) is the first step. This should include supportive services such as laboratory, pharmacy, and diagnostics as well as all oncology services for inpatient nursing, outpatient capabilities, radiation therapy, and patient education. Personnel assessment should include the skill levels and general reputation of physician specialists, nurses, technologists, and therapists, to name a few. Assessment should also be made of the physical facility and its location, visibility, accessibility, parking, and expansion potential. A careful evaluation must be conducted with the financial departments of present workload, payor mix, cost, charges, and reimbursement for oncology care. 4 Very few organizations are capable of quickly providing detailed analysis by ICD-9 codes of both inpatient and outpatient services for the parameters listed previously. If estimates or extrapolations must be made they should be developed with the people who will be asked to attest to their validity, namely the financial and planning departments. Externally, a clear assessment should be made of the present cancer market in the service area, area demographics, the number of patients, where they are treated, and by whom. Patient satisfaction with the present care and services both internally and externally should be evaluated. Present programs and plans for expansion of other major providers should be taken into consideration. Projections for future workload and revenue are as difficult as they are imperative. Anticipated changes in practice patterns, reimbursement policies of third-party payors, technology, personnel
~NNN
Oncology Cardiac
OB
Ortho Gen Surg Gen Med Psych
Fig 1. Hypothetical inpatient admissions by payor by service line, for n 500-bad hospital FY 1991. El, contracted; I , charge based; I , Medicaid; I , Medicare,
CANCER PROGRAMS
19
policies, shifts to managed care, and changes in the roster of physicians practicing at the facility should all be detailed as footnotes to projections. FRAMEWORK
Henderson identifies both strategic fit and integration as necessary to achieve an interdependent business and information technology plan. 5 Waterman advocates that assessment and planning be performed using the McKinsey 7-S Framework6 (Fig 2). This theory revolves around the notion that a good strategy and the right organizational structure are not enough for success. The organization must also have strong systems for getting work accomplished day to day, a management style that reflects the strategy in action, a competent and available staff, and shared values and skill within the entire organization rather than within individual people. The strategic plan for the Queen's Medical Center Cancer Institute in Honolulu, HI, was originally developed in 1988 using the basic concepts outlined previously. Focus group meetings of 60 people were held, and detailed data was combined with internal and external assessments and projections. A seven-member planning commis-
sion then developed an eight chapter strategic plan: 1. Mission and Objectives 2. Physical Plant 3. Education and Research 4. Manpower 5. Reimbursement 6. Organizational Structure 7. Technology 8. Plan Sequence Each chapter defines a philosophy and a longrange goal. This plan covers 10 years, particularly in terms of the physical plant. Presentations regarding the plan were made to focus group participants, the Cancer Committee, Medical Center Board committees, and finally the Board of Trustees. The final chapter on sequencing was the most difficult to produce but perhaps the most helpful. Major program elements are defined for each year. A major tenet of The Queen's Cancer Institute plan is the development of a ten-story tower on the campus of the Medical Center that devotes five floors to consolidating oncology services. This physical realignment occurs in year eight of the plan, but every decision made regarding new programs in the interim is based on this long-range goal. PHYSICAL FACILITIES
Fig2. The McKinsey 7-S framework for strategi9 planning. (Reprinted with permission, s) From Journal of Business Strategy (New York: Warren Gorham Lamont), 9 1982 Research Institute of America Inc.
The need to renovate, expand, or build facilities is a major hospital commitment. Such decisions are based on an assessment that present facilities do not meet projected volume and consolidating and enhancing the present facility will fit with the overall strategy of the organization for the future. After determining that those two criteria are met, functional planning begins. Nowhere else can an articulate group of nurses have such impact. The basic question in functional planning is "what will be done in this area?" This planning should be done in small workgroup settings for different physical areas as first envisioned. Workgroup possibilities are inpatient nursing unit, intensive and/ or bone marrow transplant unit, outpatient infusion service, patient teaching, 23-hour clinic, radiation therapy, medical physics, physicians' office space, support services, and others. As the functions within each space become defined, some "areas" may be integrated into others. For example, it may be advisable to decentralize patient education
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20
rather than consolidate teaching services in one physical area. Functional issues to be discussed are listed in Table 2. The battle cry of the nurse dealing with architects in planning is "form follows function." Simply put, the architect is told what function must be performed and then designs the form (space) in which to do it efficiently. By carefully defining the functions and the workload, the architect is provided the data from which to design the space. 7 Another important planning activity of clinicians is adjacency matrix building. Clinicians indicate how closely related new areas must be to one another. Is it more important for an outpatient infusion center to be adjacent to the inpatient oncology unit, the pharmacy, or patient parking? A matrix can be Table 2. Functional Issues in Facility Planning Department description Purpose Services Population served Educational programs Anticipated changes Current deficiencies Statistical activity Historical (3 years) Workload Inpatient days Average length of stay Number of discharges Staff FTEs by job description Total number of people Greatest number of people on duty at one time Projected (3 years) Workload Inpatient days Average length of stay Number of discharges Staff FTEs by job description Total number of people Greatest number of people on duty at one time Relationships (special and communication) Intradepartmental Interdepartmental Planning considerations Operational systems (ie, nurse call system, cart exchange, pneumatic tube) Major equipment and technology needs Unique design requirements Major spaces Patient rooms Nursing station Utility rooms and storage Education center Visitor facilities Staff facilities Abbreviation: FTE, full-time employee.
developed to define not only physical proximity but, alternatively, the need for two departments to be connected only by computer or only by pneumatic tube system. Figure 3 is part of an adjacency matrix from a hypothetical hospital. The legend tells if the two departments linked by the matrix must be contiguous, in proximity, or linked by communication systems. The architect uses the adjacency matrix to lay out "bubble drawings" that show contiguous departments horizontally and vertically. Many renovation or new construction projects have become mired in space details and have ignored systems planning. The systems by which people, medical records, supplies, food, and drugs are moved, ordered, and returned are critical to the smooth functioning of all clinical areas. There is no better time to realign systems than when planning new facilities. Traffic circulation considerations are crucial. From the functional plan, adjacency matrix, workload projections, and systems plans the architects develop initial space plans. This is when it is realized that planning has resulted in a 150,000 square foot structure when 75,000 square feet are available. The nurses' negotiating skills are tested at this point. Clinicians should have an opportunity to assist in planning the myriad details in their specific clinical areas also. Clinicians are probably best prepared to advise about outpatient treatment room configuration, including minor details such as where the intravenous fluid pump will stand and where the VCR controls should be placed for the convenience of the patient. The environment, or ambience, is extremely important to both patients and visitors as well as staff. Combining comfort and technology is a challenge, especially when infection control, cost containment, and other constraints are introduced. BUSINESS PLANS
The business of health care no longer takes place only in the Board room. If nurses can develop good ideas but cannot turn them into profit centers, they will be left behind. A good business plan is tied to a strategic plan. If the hospital strategy is to increase ambulatory oncology-related market share by 10% and profit by 10% in 2 years, one associated business plan may be to develop a breast health center.
CANCER PROGRAMS
21
RADIATION THERAPY BREAST HEALTH CENTER CLIN. NURSE SPED. ONDOLODY DIETITIAN EDUO. CONF* ERTENOSTOMAL THEN. PHYSICIAN EDUC. SP. MULTI-DISC* ONC. CLINIC ONCOL. DATA RED* PAIN MANAGEMENT
Fig 3. Facility planning adjacency matrix of a hypothetical hospital. Directions for use: To find the intended special relationship between two areas, follow their diagonals until they meet, similar to a mileage chart. For instance, the multidiscipiinary oncology clinic (eighth space down) should be adjacent to the oncology reception (fifteenth space down). This is evident because the box that connects these two spaces is solid black, which denotes adjacency.
PASTORAL EDUC. REHABILITATION .EGENI 9
ADJACENT TO
RESEARCH NURSES A HYPQTH~
HO~qTAL
ONCOLOGY RECPT'N. PNARM. SERVICES OFF. 2 MEDIUM TRAFFIC 3 LIGHT TRAFFIC
INPATIENT PHARMACY OUTPATIENT PHARM.
NO RELATIONSHIP
RETAIL BOUTIQUE SOCIAL SERVICES
INFORMATION EXCHANGE
The same kind of assessment of the internal and external environment and workload projections is necessary that was required for strategic planning but much more focused. Business plans are very detailed in terms of financial projections, time tables for milestones, and evaluation criteria. A variety of business plan formats are available. 8 A sample detailed business plan outline is shown in Table 3. Most hospitals have criteria for the development and approval of business plans. For instance, a detailed business plan must be completed if initial outlay is $10,000 or more. Approval criteria might be a positive cash flow in 36 months. As with a strategic plan, using the best internal and external resources makes the plan stronger. Know who the decision makers are and plan the presentation to meet their needs. Identifying market share is frequently a difficult task. Some states have required or voluntary volume-reporting regulations via the health department or hospital association. Even if such regulations exist, data rarely include such detailed reporting as "number of screening mammograms performed." Ideally, mammogram market share could be determined by dividing the number performed at the specific facility in a specified time by the total number performed in the service area during that same time. Sometimes the local unit of the American Cancer Society will have available in-
OUTP. ONOOLOOY CL/N.
formation such as a list of all facilities performing screening mammograms and charges or the American Cancer Society's estimate of the number of mammograms performed in a certain area. In projecting market share be sure to take into account the potential growth of the market. Market growth is the number of new mammograms that might be performed in future years because of the aging of the population, public education, changes in reimbursement regulations, or the marketing strategies used. For most oncology services, volume can increase by capturing the competitor's market or by identifying a new unserved population. If market share must be estimated or extrapolated from other data, document the assumptions made so at least the trends can be followed and over time the same assumptions will be used. Part of the business plan calls for routine assessment of the success of the operation in quality and financial terms. Reporting milestones usually relate to the hospital's fiscal year. If the new service resulted in a new cost center, the financial analysis currently performed will provide most of the data needed for monitoring expense and revenue. However, if the new service is to become part of an existing cost center (for instance, the breast health center expenses and revenue are reported as part of the aggregate analysis of the radiographic department) identification of exactly what data must be
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22 Table 3. Sample Business Plan Outline
Description Title Description of proposal Service objectives Relationship to strategic plan Assessment of competition in service area Degree of risk Financial Liability Implementation Time line of major planning and implementation milestones Responsibility and authority Resources required Human resources Capital expense (one time expense over $500 for items with a life greater than 2 years, such as computers, furniture) Operational expense (ongoing annual expenses such as personnel, office supplies, medical supplies) Space Evaluation Measures of success Reporting requirements Financial analysis Projected workload Projected market share Projected payor mix FTE requirements Supplies and expenses Capital expense-equipment Renovations Overhead cost (ie, housekeeping) Impact on other services (ie, admissionsl Rate setting, reimbursement forecast Pro forma income statement (3-5 years) Net present value analysis (3-5 years) Recommendation
collected, by whom, and at what intervals is crucial. Criteria for both quality and financial success should be set at the time of business planning. Do not be afraid to identify ancillary charges that the new service will produce. A good breast health center will, over time, result in additional localizations, biopsies, admissions, and surgeries. Attempt to establish systems so that clients who have such subsequent care can be tracked. If that is not possible, negotiate the percent increase in each of these subsequent care areas that will be attributed to the new service. It is wise to get written concurrence of such agreements with the financial analysis department. Finally, if one believes in the business plan but it does not meet the criteria for acceptance the first time it is evaluated, do not give up hope. Occasionally the community need or increased positive image for the medical center will outweigh finan-
cial advantage. Review all assumptions to determine if an unserved market has been ignored. Evaluate the possibility of starting out more slowly, and adding personnel and equipment incrementally. Try to sell the program as a 6-month or 1-year trial. EVALUATING A CANCER PROGRAM
As with all evaluation activities, success cannot be determined without establishing criteria for success. Evaluating a single program involves establishing criteria and reporting time frames during business planning. Do not overlook the "evaluation" that is already being performed for other related purposes. Look for staff performance appraisals showing an increase in productivity, team work, and independent learning; evaluate staff turnover as an example. Perhaps tumor registry data will help determine volume indicators. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is in the process of redefining quality. 9 JCAHO requirements establish continuous quality improvement measures that meet the institution's needs and theirs. Providers are increasingly being held accountable for measuring quality of care and demonstrating value for the consumers' health care dollars. This requires evaluation of both process and outcome of care, from the hospital's perspective and the clients, with a system's view. A basic tenet of continuous quality improvement is effective management, and support systems are equally important to the provision of quality care as are competent health care professionals. ~o Fortunately, evaluating a cancer program need not begin from scratch. The Association of Community Cancer Centers has developed standards for 23 separate cancer program activities. ]1 The categories range from the multidisciplinary team and the oncology unit to tumor board and cancer prevention and detection. The specificity of evaluation characteristics listed varies considerably, but this is an excellent document to use as a blue print for developing program goals and evaluation measures. These standards are currently being revised. The American College of Surgeons' Commission on Cancer is the only body that "approves" cancer programs. This approval is based on the services available, medical staff qualifications, residency programs, research, tumor conferences,
CANCER PROGRAMS
23
and the presence of a multidisciplinary cancer committee and tumor registry. 12 The College recognizes the vast array of cancer programs and approves eight separate categories. Many consulting organizations exist that specialize in evaluating cancer programs and making recommendations for expanding and improving quality, financial success, and market position. Such an assessment is particularly helpful if the internal assessment by staff, physicians, and administration is inconsistent. Most firms will be happy to help you write a business plan to contract for their services. Unfortunately, the guidelines available do not deal specifically with clinical outcomes or patient satisfaction. JCAHO is now testing oncologyspecific indicators that count items that deal mostly with medical care. 9 These indicators are discussed in more detail in the article by Ogorzalek elsewhere in this issue. Mortality rates by disease at specific stages of diagnosis provide an indication of care at a facility, but changes in practice are not recognized in such reporting for many years. The American College of Surgeons annually performs nationwide outcome studies (patient care evaluation studies) that provide data by which a facility can measure itself. 12 In addition to assessing services, volume, clinical outcomes, and financial success, patient evaluation is imperative. A patient's satisfaction should be measured in terms of both process and outcome. For example: Was your call light answered promptly? Were you prepared to care for yourself on discharge? A patient satisfaction scale developed specifically for cancer patients will result in the most usable information. Wiggers et all3 tested a 60item satisfaction scale to assess the "perception of 232 ambulatory cancer patients about the importance of and satisfaction with nine dimensions of patient care." Their data can be used to narrow a broad array of questions by acknowledging aspects of care most important to the patient. In their book, Morra and Potts advise patients,
"You do have a right to go to the hospital of your choice. ''14 They provide a five-page checklist for evaluating a hospital for oncology care. The criteria relate to size, teaching affiliations, accreditation, distance from the patient's home, and specific diagnostic and therapeutic services. The authors also point out, "Get to know the nurses who are involved in your care. They can be your best allies." A recent study of 20,000 patients' perceptions of quality care shows that a facility's tertiary care and census levels, teaching status, and employee salary rates are all correlated to a perception of high quality. 15 Another somewhat subjective but most enlightening measure of quality is to ask the staff. Given anonymity most staff are quite frank about the quality of their own care and that of their colleagues. They always have a long list of systems and communications concerns and frequently have solutions to suggest. Two questions particularly useful with staff (and physicians) are: 1. If you were in charge of all oncology services, what would you change? 2. If your mother (husband, child, etc) were to be admitted to your area for oncology care, what would you most closely monitor to insure their quality of care? Perhaps the biggest mistake made is to devise surveys, to ask people to take the time to complete them, and then to ignore the responses. Know that some action must be taken if suggestions are sought. CONCLUSION
Assessing a hospital-based cancer program and its potential, planning the long range strategy and the shorter term business plans, and evaluating their success can be a time-consuming and arduous task. However, only by doing this can it be assured that an integrated oncology program provides patients quality and value and provides staff professional satisfaction. The oncology nurse is in a unique position to combine clinical knowledge and business sense to impact patient care.
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3. BullerPF, TimpsonL: The strategicmanagementof hospitals: Towardan integrativeapproach.HealthCareManagRev 11:7-13,1986 4. BookbinderNF: Strategic planning, in Nathanson SN,
24 Lerman D (eds): Outpatient Cancer Centers Implementation and Management. Chicago, IL, American Hospital Publishing, 1988, pp 17-313 5. Henderson JC: Aligning business and information technology domains: Strategic planning in hospitals. Hosp Health Services Admin 37:71-87, 1992 6. Waterman RH: The seven elements of strategic fit. J Business Strategy, Winter: 69-73, 1982 7. Davis PB: Facility design, in Nathanson SN, Lerman D (eds): Outpatient Cancer Centers Implementation and Management. Chicago, IL, American Hospital Publishing, 1988, pp 63-91 8. Johnson JE: Developing an effective business plan. Nurs Econ 8:152-154, 1990 9. Joint Commission on Accreditation of Healthcare Orga-
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nizations (JCAHO): 1992 Accreditation Manual for Hospitals. Chicago, IL, JCAHO, 1992 10. O'Leary DS: Improving quality of care in an era of cost containment. Oncol Issues 5:8-9, 1990 11. Association of Community Cancer Centers: Standards. Rockville, MD, ACCC Publishing, 1988 12. American College of Surgeons Commission on Cancer: Cancer Program Manual 1991. Chicago, IL, American College of Surgeons, 1991 13. Wiggers JH, O'Donovan KO, Redmen S, et al: Cancer patient satisfaction with care. Cancer 66:610-616, 1990 14. Mona M, Putts E: Choices: Realistic Alternatives in Cancer Treatment. New York, NY, Avon, 1987 15. Boscarino JA: The public's perception of quality hospitals II: Implications for patient surveys. Hosp Health Services Admin 37:13-35, 1992