aldo rolfo, national clinical development manager, genesis cancer care, australia - cancer care...

Cancer Care Service of the FutureGC UK Clinical CollaborativeNovember 2016

Genesis CancerCare is the largest private provider in Australia

‒ Provides radiotherapy services at 27 sites, with 55 linear accelerators across all major Australian states

‒ Medical oncology services in WA and NSW (11 chairs)‒ c.700 full time employees (incl. doctors)‒ c.340k attendances p.a.

(1) Includes shared care arrangements in Victoria.

GenesisCare is the leading provider of essential, high quality cancer services in the Australian market

Strong reputation for clinical excellence

‒ Achieved through continuous improvement and innovation in technology and treatment

‒ Well-established and defined clinical governance framework ‒ Focus on delivery of quality patient outcomes

Commitment to research

‒ c.47 clinical trials currently in progress ‒ Contribution to over 1,000 peer reviewed publications‒ Partnership with TROG Cancer Research, a leader in radiotherapy

research

Strong public sector relationships

‒ Partnering with government to deliver unique solutions‒ 8 State Government public private partnerships(1)

‒ A number of additional PPP opportunities identified

4

What is the CCSOF about? The Cancer Care Service of the Future (CCSOF)

─ A program that seeks to redefine best practice across the drivers of our business (Quality, Access and Efficiency) in order to deliver on our vision of “Innovating Healthcare. Transforming Lives.”

The project provides a platform to:

─ Ensure sustainability & growth of the network despite declining reimbursement

─ Enhanced service offering to patient and referrers

─ Better and more engaging place for our staff to work

─ Provide opportunities for leaders to live our vision and values

─ Development of our brand around quality, outcomes and research

─ Support the development of a globally scalable service model into regions of need

CancerCareService of the Future

Quality

AccessEfficiency• Innovative, low-

cost operations• Easy access for all

• High-quality, evidence-based care

Our vision for the CCSOF is informed by overseas centres of excellence who are innovating service delivery

Outcomes ReportingMcLaren / Karmanos

Detroit, USA

Rapid AccessSunnybrook Hospital

Toronto, Canada

Care PathwaysLaval Integrated Cancer Centre

Montreal, Canada

Research & QualityThe Christie

Manchester, UK

Automation & Throughput

Private Radiotherapy CentreMetz, France

Adaptive RT & EPID Dosimetry

Lake Constance Radiation Oncology CentreSingen, Germany

CCSOF Vision: What does success look like in 3 years?

Patient satisfaction 90%+ NPS

Patient outcome reporting (Staging, intent, QOL, control) for key tumour streams

5% of patients enrolled in clinical trials

100% NSQHS and RO Practice Standards accreditation

Avg. radical case wait time 5 business days from RFC

Support existing and pioneer introduction of new treatment modalities: e.g. DIBH, SRS/ SBRT, Dose guided RO, MRI Linac

Develop Wellness / Survivorship / Allied Health programs

High utilisation of VMAT and IMRT treatments

Improved Linac utilisation

Clinical productivity improvement

Shared services costs decrease as % of revenue

Performance reporting to key referrers (wait times, patient satisfaction, outcomes)

Reduction in Other costs (Equip., medical, rent, OH, etc.) as a % of revenue

Leadership development program for Staff and Doctors

Employee engagement 70%

GenesisCare Foundation to support R&D and Access

Rapid Access Palliative Service (“See, Plan, Treat”)

Standardised care pathways for 90% of courses

Measure and report adherence to clinical guidelines (NCCN, EviQ)

Comprehensive marketing, communications and education program to share key messages on services and outcomes

CancerCare Service of the Future case studyAdvances in technology and workflow are delivering on Quality, Access and Efficiency

Comparison of treatment options Situation: 84 y.o. Italian man with extensive metastatic cancer, widespread pain and a poor quality of life

Outcome: The patient received VMAT palliative treatment at GenesisCare less than 2 days after referral

Public facility GenesisCare facility

Technique Photons & Electrons

VMAT

Planning time 2 Weeks, manual 30min, automated

Quality Assurance time

1 week 1 day

Dose distribution

Non personalised Highly personalised

Normal tissue avoidance

Difficult to achieve

High level of avoidance

Time on couch 40min/day 5min/day

Doctor satisfaction

“The VMAT plan on this patient is better than the IMRT plans we see on our curative patients….” – Dr. M

Complex disease, conformal treatment

Lungs, Heart, Spinal Cord all protected from higher doses

The world needs a high quality, efficient radiotherapy provider to improve access to care for billions of people

26.511.9

10.9

10.4

4.5

1.5

0.5

4.5

3.5

0.5

0.5

0.5

1.5

0.5

1.5

0.9

1.9

4.8

5.8

4.9

2.8

1.8

0.9

3.80.8

0.9

0.8

0.9

8.8

5.3

0.7

7.7

0.3

3.7

3.7 4.7

0.7

1.7

2.3

1.7

1.3

0.3

1.7

0.3

0.7

7.3

7.6

2.6

0.6

6.6

6.0

2.4

1.4

0.40.4 0.00.0

2.41.0

0.0

0.2

1.2 0.2

0.2

0.20.2 0.2

0.20.1

6.1

0.10.1

0.1

1.1

1.1

7.1

0.1

4.1

0.1

0.10.1

0.1

Linacs per million population (2015)Number of linacs per million population in selected regionsNumber of linacs per million population in Australia Region

Country

Note: “West” defined as North America, Western Europe, and Southern & Western Pacific (ANZ); Blanks are where linac data unavailable; GDP figures normalised (PPP).Source: World Bank 2015 population and GDP data; IAEA Directory of Radiotherapy Centres (2015)

0

2

4

6

8

10

The "West"

8.4

Rest of World

0.7

0

2

4

6B

The "West"

0.04B

Rest of World

5.39B

0

10

20

30

40

$50K

The "West"

$47K

Rest of World

$12K

Linacs per million people(2015)

People without Australian levels of access(2015, billions)

GDP per capita(2015, USD PPP)

Reimbursement (Andrew Saunders) Communication (Amy Hallam) Procurement (Finance – Peter Moore)

Leadership & Culture (Natasha Winton, Monica Lonergan)Business intelligence (Mike McFadden) IT Platforms (Thomas Pinn, Denise Hunt, Fraser Hughes)

CCSOF SteerCo: Keith Hansen (Chair), Aldo Rolfo, Andrew Saunders, Mike McFadden, Project Leads, HR, IT, CC project mgr.

8 key CCSOF workstreams to deliver the program, with several key supporting enablers

Patient Experience Access & Engagement

Centre Structure, Mgmt. & Tools

Care Pathways & Outcome Reporting

Planning Room of the Future Research & Trials Quality & Safety Physics Service of

the Future

Key Driver Access Access Efficiency Quality / Efficiency Efficiency Quality Quality Quality / Efficiency

Project Leads Ada Ryan Andrew Saunders Kate Evans Aldo Rolfo Aldo Rolfo & Mike McFadden

Peter O’Brien & Sophie Mepham

Peter O’Brien & Joan Sheppard

Aldo Rolfo & Brendan Hill

Key projects / initiatives

• Best practice patient experience (“Just Start” projects)

• Patient journey mapping and gap analysis

• Enhanced physical environment (Wembley refurb)

• Partnerships with consumer groups

• Patient portal • Wellness / Survivorship

• Project Destiny (education & comms.)

• Best practice referrer communication, including performance reporting

• Referrer portal• Service differentiation• GP education• GC Foundation

• Org. structure• Role structure, clarity,

re-design• Leadership training • Performance Mgmt. &

Dev.• Throughput• Site mgmt. tools• Lean process review• Dashboards• Playbook & Training• Rapid access workflow• PS/nursing w’flow

• Care pathways• RO Portal• IQ Scripts and

standardized workflows

• Minimum data sets by tumour stream

• Outcomes data reporting

• VMAT implementation• SMART Planning

validation and implementation (GenPlan, DVP+, GenPrinter, GenReconciler)

• Sim-to-QA workflow• Auto contouring • Planning quality

benchmarks • Best practice planning

room

• Clinical trials engagement

• GC Foundation• Expanding the role of

Radiotherapy• Partnerships (TROG,

Elekta, ECU etc)

• NSQHS accreditation• RO practice standards • Automation of auditing

• New technology assessment (e.g. PerFraction)

• RS reporting and governance

• Role in planning • Daily patient specific

QA (e.g. EPID)

Key KPIs Patient satisfaction % sites offering

wellness services Partnerships Testimonials

• Linac utilisation • Growth in courses• Performance reporting • Referrer satisfaction• Letters out in 48hrs

• Time to Tx • Linac utilisation• DLH / Tx• Non Dr Rem %

Revenue• Staff engagement

• Guidelines adherence • Data capture • Outcome reporting• Care path utilization• IMRT / VMAT rates

• Time to Tx • Plan quality• Planning times /

efficiency • Adaptive treatments

• % patients enrolled in clinical trials

• Abstracts accepted• Papers published• Grant $$$

• Accreditation• Workforce efficiency • WHS compliance

• IMRT / VMAT rates• Workforce efficiency • Time to Tx • Plan quality

1 2 3 4 5 6 7 8

ab c

d e fEnablers

9

KPI: Patient satisfaction 90%Engaging more deeply with our patients is having a meaningful impact on patient satisfaction

0

20

40

60

80

100%

Patient satisfaction Net promter score

2014

70

Sep-16

87

Goal

90

People & Culture

Distinctly positive

experience

Coordinated Care

Expedited Time to

Treatment

Wembley refurbishment

and multi-disciplinary pod

model

“Just Start” initiatives and deep patient engagement

KPI: Patient outcome reporting and care pathwaysDrives continuous clinical improvement

GC UK DataBase

Input of Clinical/Administrative data(Manually / Automatically)

Insightive software with a dynamic analysis of data(Varian & GenesisCare algorithms)

Input of patient data by the patient(Manuually / Automatically)

GC UK DataBase

Input of Clinical/Administrative data(Manually / Automatically)

Insightive software with a dynamic analysis of data(Varian & GenesisCare algorithms)

Input of patient data by the patient(Manuually / Automatically)

Care Pathways & Outcomes Reporting

Platform

Clinical consensus on

treatment protocols

Automated Care Pathway via the

Electronic Medical Record

Collate structured

patient data (internal & external)

Collect patient reported

outcomes via portal

Structured big data accessible in

real time

http://www.google.com.au/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwidlsiu5ZTNAhUIMaYKHZ00AfEQjRwIBw&url=http://crossing-technologies.com/big-data-analytics/&bvm=bv.123664746,d.dGY&psig=AFQjCNEcn7D_ApCotwpN-z3lA6_SnbCKhg&ust=1465350271294826

KPI: GenesisCare Foundation to support R&D and AccessGenesisCare board have approved the establishment and launch of the GC Foundation

Our new partners CRG and Macquarie Capital have kindly donated $5m of seed funding to commence the GenesisCare Foundation• Commitment from GC Board to provide further annual funding• Foundation will be established to receive tax-deductible gifts

Foundation will have two main focus areas of health promotion:• Research: Support a strong clinical trials program • Access to Care: Committed to supporting disadvantaged patients receiving

access to care

More details will be shared in the coming months on this fantastic initiative!

KPI: 100% NSQHS and RO Practice Standards accreditationWe are building a culture of Quality and Safety

0

20

40

60

80

100%

GenesisCare Employee Culture Survey Percent of positive respondents

My team consistently delivers high

quality patient care.

2014 2015

84 86

Safety risks, once identified, are

dealt with promptly and appropriately.

70

76

The organisation has appropriate

processes in place for me to raise safety issues.

72

84

We are willing to speak out about

safety risks.

81

87

Accreditation achieved at NSW, QLD; others to be completed by late 2016

Self-assessment completed across GCC against the Tripartite Standards

All Practices using Riskman to report and manage clinical and organisational risks

Risks reported monthly to Board, Clinical Leaders Forum and state-based Clinical Management Committees

KPI: Leadership development program for Staff and DoctorsLeadership development for doctors and leadership across practices is underway

Doctor Development ProgramEnrich, support, encourage and challenge doctors

to be better leaders

GC Leadership & Mgmt. DevelopmentProvide training and tools for our leaders and staff

to develop

CC Leadership Team ChallengeExperiential learning to help leaders reflect, coach,

manage, lead and engage

“Benefits of the DDP [include]:• Empowering others and giving them responsibility• Being more proactive with [performance management] and

rewards.• Accepting that I am GenesisCare, [and] I really want

GenesisCare/myself to be successful” - Radiation Oncologist

LEAD program

Management Essentials

Program (MEP)

Performance development & management

training

Project management

training

Resilience & Comms. Training

Watch this space for future programs…

CT Sim Contouring Planning RT Plan QA Physics Plan QA

KPI: Avg. radical case wait time 5 business days from RFCAutomated tools will support increasing VMAT penetration while shortening the work day

CT Scan Simulation for treatment planning

Delineation of tumour and organs at risk

Plan checking / QA - Performed by RT

Generation of the optimal treatment plan

Plan QA - Performed by Physics

Leverage commercially available auto-segmentation software tools MIM Maestro

which uses Atlas based contouring tools

GC scripts drive a automated treatment plan through the Pinnacle Treatment Planning

system

Developed in house plan checking tools (DVP+,

Reconciler and Printer)

Facilitate a simple traffic light report for RT review

Automated Phantom free IMRT QA through direct

measurement of dose on the EPID Panel

Automated; • Dose capture • QA processing • Alerts

GC Automation

Projects

20%

30%

40%

50%

60%

70%

80%

31/01/2016 29/02/2016 31/03/2016 30/04/2016 31/05/2016 30/06/2016 31/07/2016

Total Target (month end)

KPI: High Utilisation of VMAT and IMRT treatmentsTeams around the network have mobilised to shift patients to the best treatment protocols available

“In my public centre I struggle to get 3DCRT plans for my palliative

patients. I would love to have VMAT but it seems years away”

Doctor

“Moving to IMRT/VMAT has allowed us to reduce patient Out of Pocket costs by up to ~20% (depending on

treatment type, course length, etc.)”Patient Services Officer

“I can produce a high quality plan in 30 minutes with VMAT.

3D CRT would not even get close!”

Planner

Case study: South Terrace ST3

% VMAT Treatments

Average tx time

Combining Quality (more personalised), Access (greater capacity) and Efficiency (faster treatment times)

KPI: Support existing & pioneer new treatment modalitiesWe continue to invest in a wide range of new treatments, including DIBH, SRS/ SBRT, Dose guided RO and MRI Linac

First MRI Linac in Asia• Supporting Hypofractionation & New Indications

(Pancreas, Liver, Sarcomas)

Roadmap to Adaptive Radiotherapy• Quality Assurance (QA) for every patient, every day• Ensures personalised targeting and dose delivery

Deep Inspiration Breath Hold (DIBH)• 1 site in July 2015, 100% in April 2016

SRS/SBRT treatments• 2 sites in 2014, 50% in April 2016

2015 - 2016 2017 and beyond

KPI: Develop Wellness / Survivorship / Allied Health programs

Live Life Get Active FREE Exercise programs with Olympian Jane Flemming in x3 locations

Cancer Council NSW FREE 8 week survivorship program launched at Hurstville

Working with PCFA on a trial to investigate the benefits of exercise for people with cancer

(ECU) Health and Wellness Institute’s exercise clinic at GenesisCare, Shenton House.

KPI: Comprehensive marketing, communications & education program to share key messages on services and outcomesInteractive educational content, available via web /ipad, and integrated in the care pathway

‘Informed consent’ online tool for doctors to walk patient through a radiation therapy

treatment consultation

A patient resource website to expand on radiation therapy treatment information

provided during consultation, to help make it easier for patients

+

Interactive educational content for patients, their families and carers

Available on a variety of formats

Integrated as part of the care pathway• Used by doctors, nurses, patient services to assist

with engagement around key aspects of care coordination

• iPads, web, mobile

• Patient stories: actual patients telling it like it is• Pathway videos to demystify the treatment process

KPI: Employee engagement 70%We recognise how important staff engagement is to the patient experience, and we are committed improving it

0

20

40

60

80%

CancerCare Employee Engagement

Health & Comm. Services 44%

2014

45

2015

52

Target

70

Health & Comm. Services 44%

Employee engagement is trending upwards

67% of CancerCare employees are proud to

work for GenesisCare

57% of employees believe GenesisCare is a great place

to work

65% of employees agree that GenesisCare’s new

vision of “Innovating HealthCare. Transforming

Lives.” resonates with them

Why does this matter? There is clear proof that this improves patient satisfaction

50

60

70

80

90

100%

25 35 45 55 65 75%

Net engagement score: % Engaged minus % Disengaged (Oct 2015)

Patient Net Promoter Score (Apr-Sep 2015)

NSWROV

CWAARC

HCWA

OPT

ACP

HCP

CCQHCV

HCP removed from regression due to low number of responses to patient survey

R2 = 0.50P values < 0.05

CC

HC

Legend

KPI: Clinical productivity improvement of 30%Improving our processes to allow us to work “smarter not harder” will provide faster access to treatment for patients and allow us to improve clinical productivity

PATIENT SERVICES AUTOMATIONReplacing manual processes with automation to allow for

greater productivity and better patient experience

BEST PRACTICE PLANNING ROOMEnsuring quick turnaround of plans so that no patient is

delayed for non-clinical reasons

PLAYBOOK / LEAVE PLANNER / BI TOOLSRegular, consistent approach for our leaders to

review & improve operations

Practice Playbook

Leave planner

BI dashboards

One team’ approach to

planning through VPR

RO engagement

Quality and efficiency KPI management

Enabled by SMART planning tools and

automated QA

EMDAT Notification Manager

Validation Engine PBRC automation

“A lot of administrative time is saved by using EMDAT which will result in more time spent on patient services and efficiency in running a busy practice.”

Patient services team CWA

Workstation model Integration with ePathology

CURRENT STATE

8am-5pm~75-80% Utilisation

3 RT FTE

FUTURE STATE

8am-3pm~95-100% Utilisation

3 RT FTE, with ½ day Planning / Training /Project

WHAT IT WILL TAKE

Smart SchedulingNo gaps in day, PSOs own bookings

Review treatment rostersWorkstation model for treatment staff

Activity codes Phase1Matching scheduled treatment times to actual treatment time

National Best Practice Tx timesLEAN review of treatment process

Utilisation managementDashboards, CL ownership

KPI: Ave. Linac utilisation 45 patients / machine / dayEnsuring our machines are fully utilised and have high ‘throughput’ to provide timely access to all patients

Improving our treatment times by just 1 minute per patient would provide ~24 hours of additional time across the network every day leading to: Capacity to treat over 100 more patients within our current working hours More time for project work/research Enhanced patient experience (less time on the couch)

WHY?

KPI: 10% reduction in Other costs as a % of revenueThrough better coordination and innovation, we are taking advantage of our national scale to deliver better service and cost savings

• Global procurement deal for linear accelerators

• Improved EMR service

Equipment procurement

• Group ordering of key medical consumables

• 3D Printing of electron shields & wax blocks to reduce dependence on the need for mould rooms

Medical consumables

• Telstra contract renegotiation

• Concur Expense Management

• BidEnergy energy bill consolidation

• Travel• Other national procurement

initiatives

National procurement initiatives

Efficiency:Innovative, low cost

operations

Quality:High-quality,

best in class shared services

Culture:CollaborationCompassionInnovation Outcomes

Access:Easy access

for all

Payroll processing accuracy > 99.61%

Shared service feedback score > 8/10

Mosaiq uptime 99.99% (from 99.86%) Shared services costs as % of revenue

4.5% (from 5%)

Automated, self-service site-based P&L’s and per patient cost of delivery

Month end close of 3 days (from 15 days)

HBO Cost per employee $2,000 (from $2,700)

BI: dashboards for activity reporting, time-to-treat, HC quality data

Comprehensive clinical outcomes reporting

Insights and analytics for the top 200 actual and potential CC referrers and 20,000+ HC referrers to enable increased share of wallet

Labour utilisation reporting to drive Non-Dr Labour cost as % of revenue 21% (from 32%)

Patient satisfaction 90%

Leadership development program for Staff and Doctors

Staff engagement 80%

Service Desk response & resolution time met 95% of SLA

Finance Accuracy rate 9/10

Performance reviews undertaken for 100% of staff

New Finance System (ERP). HR Systems (HRIS)

BI Project Management (PM)

KPI: Shared services costs decrease by 15% (as % of revenue)Project Monarch will deliver improved service levels, efficiency and scalability for Shared Services

Thank-you

This year’s Collaborative is about showcasing the efforts that all of you are making to drive the CCSOF

Patient Experience Access & Engagement Centre Structure,

Mgmt. & ToolsCare Pathways &

Outcome Reporting

Planning Room of the Future Research & Trials Quality &

Safety Physics Service of the

Future

Key Driver Access Access Efficiency Quality/Efficiency Efficiency Quality Quality Quality/Efficiency

Project Leads Ada Ryan Andrew Saunders Kate Evans Aldo Rolfo Aldo Rolfo & Mike McFadden

Peter O’Brien & Sophie Mepham

Peter O’Brien & Joan Sheppard

Aldo Rolfo & Brendan Hill

Presentations • An Oxford-based case study on the initial clinical and patient experience of the Information-Guided Care Coordination (IGCC) system

• Consumer Engagement Journey & Wembley re-development case study

• Improving patient care through resilience training for staff

• Spanish Cyberknife experience in Stereotactic Body Radiation Therapy

• DIBH in Victoria: 12 months post implementation review

• 11.40am The development of an iPad application to educate paediatric cancer patients about radiation therapy

• AccessiBull radiotherapy for Central Queensland Patients

• Sequence Reversal: Preoperative Radiotherapy for Breast Cancer patients

• Prone Breast technique implementation and the verification of medial breast dose

• Rapid Access at Nambour – our experience so far and future directions

• From Rock Bottom to Rock Stars: The effect of improving workplace culture on patient satisfaction

• Stress, satisfaction and burnout amongst Australian and New Zealand Radiation Oncology trainees: what next?

• Breaking New Ground: Reflections from our first Cancer Care Nurse Consultant

• Managing increasing patient numbers with decreased time slots

• Collaborative Continuing Professional Development

• New Paradigm in Leadership: non-RT Centre Leaders “The good news is, great minds don’t think alike…”

• Improving communication between Physics, Engineering and RTs

• RO Portal Demonstration and Care Pathways

• Breast Hypo-fractionation and Breast Care Pathways

• A Demonstration of MIM Maestro

• Planning room of the future – Centralized Planning in action

• GenPlan - The Next Generation

• Audit of Palliative VMAT utilization at St Vincent’s Sydney from 2008

• How can we evaluate advanced MIM modules using deformable image registration applications? Any ideas?

• Cost minimalisation analysis (CMA) comparing adjuvant radiotherapy (RT) with endocrine therapy (ET) in elderly patients with oestrogen-receptor positive, low risk, early breast cancer.

• MRI for Breast Lumpectomy Cavity Delineation: CT Comparison and Sequence Variation

• An update on the prospective analysis of SpaceOAR hydrogel rectal spacing and rectal toxicity in the treatment of prostate cancer at Genesis Cancer Care Victoria

• A Comparative Analysis of FB-IMRT to DIBH-IMRT Left Breast Irradiation: Exploring Cardiac and Lung Dose

• Impact of research on workspace culture

• Zooming in on Clinical Governance

• Training of future Physicists at ARC/GenesisCare

• PerFraction - EPID based IMRT/VMAT QA of the future

• Treatment planning QA models

• Moving to standardization for acceptance and commissioning for Elekta linear accelerators

• Clinical case study with implementing deformable dose accumulation strategy: An example of 4D evaluation in the case of liver SBRT

• Physicists in the planning room – insights from a 3-month placement

• Why do we “Care”? Insights from quantum cosmology and applications in the CancerCare Physics Service of the Future

1 2 3 4 5 6 7 8

Appendix