Smilow Cancer Hospital Town Hall | April 26, 2023

April 27, 2023

Hosted by Eric Winer, MD

Announcements- Kevin Billingsley, MD, MBA

Introduction to Access, Integration, and Regionalization- Eric Winer, MD; Lori Pickens, MHA

YNHHS/YM Access Initiative- Margaret McGovern, MD; Cynthia Sparer, MPA

Smilow Access Planning- Sarah Schellhorn, MD; Lisa Shomsky, MBA, BSN, CNML

Smilow Clinical Integration-Elizabeth Herbert; Jeremy Kortmansky, MD

Q&A Discussion

Information

ID: 9877
To Cite: DCA Citation Guide

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00:00I am absolutely delighted to welcome our
00:03community to our Smilow Cancer Hospital
00:06Town Hall here on April 26th, 2023.
00:11We have an absolutely packed and
00:14exciting agenda this evening and
00:16it's really a pleasure for me as the
00:18Chief Medical Officer to feature a
00:21roster of our senior Cancer Center
00:24and cancer hospital leadership as
00:27well as our health system leadership.
00:29And you can see from just looking at
00:32the agenda, we are going to cover a
00:35number of very high priority topics
00:37that are going to be some of the
00:40strategic and tactical elements that
00:42will drive our growth and development
00:45as an organization into the next
00:47generation of of SMILO in the Cancer
00:50Center in terms of national prominence
00:54and clinical and academic excellence.
00:57I have a few brief clinical announcements
01:00which really focus on our evolution
01:03into what we hope is a post COVID world.
01:07I'm really delighted to share that
01:09as of May 1st,
01:11we will cease across the system
01:14doing routine COVID testing for
01:17asymptomatic patients admitted for
01:20surgery procedures and direct admits.
01:23As you can tell from this list,
01:25there will still be a few isolated
01:28incidences where we do admission testing,
01:30but for the most part,
01:32we will be returning to normal clinical
01:35operations without routine testing.
01:38I'm also absolutely thrilled to
01:41share that our mask,
01:44our masking policies will continue to
01:46be in place, but will be less restrictive.
01:50We will. We will.
01:52Essentially in the use of routine
01:55masking in public areas,
01:56but we will continue to ask that our
02:00clinicians and our staff use masks in
02:03inpatient areas such as patient rooms,
02:06diagnostic and procedural rooms and
02:09when providing direct individual
02:11patient care and contact.
02:15Of course,
02:16we ask that staff will continue
02:18to adhere to all policies related
02:20to transmission based precautions
02:22and staff and visitors with any
02:24signs or symptoms of COVID should
02:26be advised to remain at home.
02:29So without any further commentary,
02:32I'm really pleased to take the agenda over
02:36to our Cancer Center Director and
02:38Physician in Chief Doctor Weiner and our
02:40Senior Vice President, Lori Pickens.
02:44Great. Thanks, Kevin.
02:46So we're going to talk about
02:48a number of items today,
02:51including patient to access.
02:52And we're going to talk about patient
02:55access both across the whole Health
02:57system and very specifically in Smilo.
03:00And then we're going to be talking
03:02about clinical integration.
03:04So first just in terms of access
03:05and then I'm going to turn it
03:07over to Lori in just a second,
03:08I think from our standpoint in Smilo.
03:13Patient access is really key,
03:15and I'm just going to speak
03:16to this for a minute.
03:17From a patient's standpoint,
03:19which is that, you know,
03:20when a patient has a new diagnosis
03:23of cancer and those are by,
03:25you know,
03:26far and away the majority of the
03:28people who are coming to us who have
03:30already had a biopsy or someone
03:31telling them that they have cancer
03:33or a high suspicion of cancer,
03:36getting in quickly is really important and
03:39it is hugely reassuring to the patient.
03:42We need to make sure that we are
03:45answering calls quickly and even
03:47more importantly that there is not
03:49a long lag before the appointment.
03:51And the truth is if there is a long delay,
03:54they'll just go elsewhere And we don't
03:57want that because we want to grow,
03:59but we also don't want that
04:00because we want to serve our our,
04:02our patient population.
04:03So I just think it's,
04:05it's really important and as you know,
04:09we sent out some guidelines.
04:13In the past week or two
04:14about what we think is,
04:15is a reasonable amount of time and
04:17and we'll go over that further today.
04:19So without further ado, Lori,
04:22thank you, Eric and I echo absolutely
04:24everything Doctor Reiner just shared.
04:26And you know we've been working on patient
04:30access within Smilo for a number of
04:33years and this work has been largely led
04:36by Doctor Shellhorn and Lisa Chomsky.
04:39They have. An amazing team of people.
04:42Many of you are out there hearing this
04:44and have participated in this amazing
04:46work over the last couple of years and we
04:49are very fortunate that the Health System
04:52and Yale Medicine have been doing the same.
04:55And they in fact brought a consultant in
04:59some of you may have heard named Guide House.
05:01I sometimes make the mistake
05:03of calling it White House,
05:04but it's Guide House.
05:06I don't know what I'm thinking, but anyway.
05:10So you know our work is really
05:13aligning beautifully with what the
05:15the health system and Yale Medicine
05:17are are seeking to achieve.
05:19And so we are very fortunate this
05:21evening for to have Cynthia Sper
05:23joining us to share a little bit
05:26about where the system and where
05:28Yale Medicine are heading with that.
05:31Cynthia is the president for our
05:33ambulatory work across the entire
05:35health system and she Co leads
05:38this patient access work with.
05:40Peg McGovern,
05:41who is the CEO for Yale Medicine
05:44and Doctor Churchwell, as we know,
05:45is our president for Yale New Haven Hospital.
05:48So Cynthia,
05:49I'm going to ask you to go ahead
05:50and give a preview,
05:51and then we'll have Sarah and and Lisa
05:55talk about how that ties in nicely
05:57with the work we're preparing to launch.
06:00Thank
06:01you so much, Laurie, and thank you, Eric.
06:03You teed it up perfectly.
06:04And good evening, everyone.
06:06It's really a pleasure to be joining
06:08you tonight to talk about something.
06:10That frankly, I'm quite passionate
06:12about and as Eric and Laurie, you said,
06:15clearly is a top priority for you know,
06:18medicine and the only event health system.
06:21And I am as as Laurie mentioned,
06:23representing my colleagues
06:25in this in this work,
06:27Peg McGovern has had the distinct.
06:30Actually dubious pleasure of being up
06:33in Hartford all day today since early
06:36this morning still up there or she
06:38would have been joining me tonight
06:40at today is the day we presented at
06:43the certificate of need hearings for
06:45the Prospect hospitals transactions.
06:47So Peg has been spending her day up
06:50there in Hartford and so anyway I I
06:54am representing both of them tonight.
06:57I want to just start by saying I
07:00am confident that everyone in this
07:02town hall is an expert at some level
07:05in the challenges around access,
07:08whether it's for their own personal health,
07:11a family member, a friend,
07:12a neighbor colleague, whatever.
07:15I think everyone is touched by and is
07:19in some way engaged in what turns out
07:22to be the workarounds around access.
07:25Because the truth is that we needed
07:30to and we have stepped back and
07:33looked at systems,
07:34the processes etcetera that we are
07:37utilizing with both in the health
07:40system and with in Yale Medicine.
07:42And recognized going back to
07:45last fall that we can do better,
07:48that we need to do better,
07:49that we have to do better and
07:52that the IT was not.
07:54Any one person or any one function
07:57or any one area that was that
08:00was somehow complicit and why we
08:02weren't where we needed to be.
08:03But in fact that we have too much of what
08:07gets done on behalf of our patients,
08:10always on behalf of our patients
08:12that are not supported as well as
08:14they might be by the systems that
08:16we are currently utilizing.
08:18And it's not for lack of trying.
08:20It's simply the fact that.
08:22We wanted to take a fresh set of eyes
08:24to this and as part of that work we
08:28put out an RFP to leading consulting
08:31firms in the country who do this
08:33work to see who might be in the best
08:36position to come in and help us.
08:37And as Lori mentioned,
08:39after a national search,
08:41we did select Guide House to
08:43help us with that work.
08:45The other fact of life is
08:46that we are not alone.
08:48When we talked to colleagues around the
08:50country at leading academic health systems,
08:52at academic medical centers,
08:54everyone is working on access.
08:57So it's not that we that
09:00people have perfected this.
09:02Colleagues again are are working on this,
09:05but the fact is that when Guide House
09:08came in and took a look at what we
09:10were doing collectively and rated
09:12us on essentially A1 to four scale.
09:15Looking at different elements from
09:18clinical coordination to scheduling to
09:20other mechanisms, financial reviews,
09:22other things that we were doing
09:25on a scale of one to four,
09:27we were running between A1 and A2.
09:31So a lot of opportunity for improvement
09:35and it it it's really been and this is very
09:38much a part of other things that that we
09:41see as themes that it is the commitment.
09:44To work together across the health system,
09:47across your medicine in a unified enterprise
09:50wide way that is going to create some of
09:53our best opportunity for doing this better.
09:57Here's where I'm going to pledge
09:59that you will not hear the words
10:01handoff come out of my mouth.
10:03There will be no more handoffs.
10:04We're going to work.
10:06Go away from handoffs, no handoffs.
10:08And that we are doing this in a
10:11unified way and unified approach.
10:14And so when Guidehouse came in,
10:16the first thing they did was they
10:18went into the enterprise and they
10:21spoke to over 70 individuals.
10:24They did mystery shopping,
10:26they visited sites of service.
10:28Milo was a part of that.
10:31And they assessed what what
10:33they were seeing and hearing and
10:35learning and looking at the data.
10:37And it it was not shocking,
10:41not surprising,
10:42but it was affirming that as to
10:45where we had these opportunities and
10:48they took their time to do that and
10:50they came to us after several months
10:53and presented a cogent approach to
10:55how we could make this pivot and
10:58how we could approach this work.
11:01And so again, it was impressive.
11:03It was comprehensive.
11:05And it was directionally important
11:07for us to look at it this way.
11:10What they've now put together is
11:12the next phase of this work which
11:15which is now launching,
11:17it is launching this month to really
11:20get underway with the work itself.
11:22And it's the sobering part of
11:26this is to really fully optimize
11:29the opportunities that have been
11:31identified is a three-year journey.
11:34But what we've also worked on with
11:36Guidehouse is that we needed to front
11:38load as in the first year of that
11:41three-year journey work that was
11:42going to be most impactful to make a
11:46difference in the patients that Smilo
11:49was serving and also across the enterprise.
11:52And when I,
11:53you know I'll give an example that I'm sure
11:56everyone on this call will understand.
11:58Yes, as Eric said, it is the patients
12:01who just got a diagnosis of cancer.
12:04That need desperately need
12:06immediate access to care,
12:08but it's also important to look
12:10at the feeders, cardiology,
12:12GI, neuro,
12:13urology,
12:13all the programs that if they're
12:17having access challenges,
12:19it's going to affect the ability
12:21to identify who are those patients
12:23that need access to smile.
12:26So it it's it really is important that we
12:29look at this across all of our services.
12:32So that for the people who are seeking care,
12:35they really can get in and get into
12:37that queue and get identified as
12:39and diagnosed appropriately in a
12:42timely way and then get the access
12:44to the to the care that they need.
12:46So that's the approach that we're taking.
12:48If the no one is opting out,
12:50everyone is all in and it will
12:53affect all of
12:54the aspects of care no matter where
12:57that occurs across the health system.
13:00So we're, as I said,
13:01we're getting underway this month.
13:03We have some structural aspects to this
13:06that we're putting in place and then it's
13:09it's really getting into the deep dive.
13:12What we expect is that somewhere by
13:15this fall we will be able to have a good
13:20line of sight to drive the consistency,
13:24the standardization,
13:25the coordination and alignment.
13:27Of all of the elements that can
13:30produce the change that we are seeking.
13:32So no, it isn't going to be overnight,
13:34but it's not going to be 3 years
13:36from now either.
13:37And I would expect that by the
13:39time we are rolling into the fall,
13:41we're going to do this in coordinated waves.
13:44So there'll be waves of of implementation
13:47that will get underway this fall.
13:49And what we have committed to our
13:53leadership to the board, etcetera, is.
13:57That we are going to see real
14:00change within this one year time
14:03frame that we've gotten underway
14:05with with God as His help.
14:07So I'm happy to go through any specific
14:11questions that people have about this.
14:14But what we're doing here tonight with
14:17all of you is really as Lori said,
14:19previewing what's coming and it
14:23will require change and that.
14:27Isn't always easy.
14:28In fact it often is not very easy to to,
14:31but it's going to be essential 2
14:34platforms and I think this is another
14:36key piece that I want to convey tonight
14:39is that 2 platforms for all of this work.
14:43The first platform is communication.
14:46The commitment to all of you is that you're
14:49going to get tired of hearing about access,
14:51but that's a good thing because
14:54we really have to make sure.
14:56That we're walking in lockstep together.
14:59This isn't something that you're
15:00hearing about tonight and then six
15:02months from now you'll get an update.
15:04You will be hearing a lot about
15:06this and I am commit.
15:08I'm confident that that
15:09commitment will be seen through.
15:11So communication throughout
15:12is going to be essential.
15:15No surprises.
15:16The other platform will be IT.
15:20All of this work is going to need
15:23the support of and be informed by.
15:26Our IT capabilities,
15:28you all know that we adopted
15:31EPIC 10 years ago,
15:33but we haven't fully utilized
15:34or optimized it in support of
15:36what we need to be doing here.
15:38And we've had different pilot
15:40elements etcetera.
15:41So I T is being pushed up to the
15:44front because we can't the size that
15:46we are and we have over 5,000,000
15:49interchanges with patients a year,
15:52it is impossible.
15:53To be able to really have a
15:56meaningful organized,
15:57coordinated way of doing this work if
16:00we're not leveraging IT as part of this.
16:03So that's going to be another
16:06platform element of all of this work.
16:08So again,
16:09I'm going to pause there and happy Eric
16:12and Laurie to open it up to comments
16:14that and our questions everyone may have.
16:17But that is sort of the that's
16:19the overview of how we got here,
16:21where we're headed.
16:22And what we're committed
16:23to doing in the weeks,
16:25months and it will be in
16:26some cases years ahead.
16:28Cynthia, thank you very much.
16:29And and I think that smile is ready to jump
16:32right in and and get going on this work.
16:35And I think if you're able to stay,
16:37you'll hear how we are poised to do that.
16:41There is a question in the chat that
16:44I think is an important question.
16:46And the question is will this mean
16:48phase three or what does this,
16:50I think this is what does this mean
16:52for the phase three of SMILO moving
16:55to the Ill Medicine access center.
16:57It's probably good to try to reconcile you
17:00know that because we have spent so much
17:03time in that space over the last few years.
17:06Can you help us with that?
17:08Certainly. So let me just say this,
17:12first of all, we are not.
17:15If you will, blowing up anything that exists.
17:18What we have to do is connect the
17:21dots and we have been too siloed.
17:24That is crystal clear and we have not
17:27had some of the wraparound efforts.
17:29Let me take a very basic example.
17:33If you go to a website,
17:36depending upon what portal of entry
17:38we use and let's say we're going to
17:41want to look and see Doctor Eric
17:43Weiner and have he is represented.
17:45Depending upon what website you go into,
17:47whether it's a health system website,
17:48a departmental website,
17:50a young medicine website,
17:53you could get different information.
17:59We're talking about fundamental issues here.
18:03So no, the last thing we want
18:05to do is is is go backward.
18:09But we have to do this go
18:10forward in a coordinated way.
18:12And so that that's the commitment.
18:14And so I understand the question.
18:16We're going to leverage things
18:18that are in place, the people,
18:20the resources that have been
18:22already been worked on.
18:24What I'm sure the team will
18:26be talking about tonight.
18:28We want to take what's good
18:30about what's been done,
18:32but we also have to recognize
18:34that it is siloed.
18:35And so this,
18:37this work is really about making
18:39sure that we connect the dots.
18:42So that the point of view of
18:44the of the consumer and the
18:45consumer definition in this
18:47case is obviously the patient.
18:49It's also the referring physicians if
18:52you want to get an earful about access,
18:55talk to people out there who have
18:59patients that they want to send
19:01us and experience a lot of the
19:03same frustrations our patients do.
19:05So consumer in this case is obviously
19:08first and foremost it's the patient.
19:10Also the referring positions
19:13and is it safe to say Cynthia that you
19:15know going back to what we've all been
19:18accustomed to preparing for around you
19:20know becoming the next phase if you
19:22will that there are there are a lot of
19:26things to leverage in the existing?
19:28Work that's been done and the
19:31infrastructure that is there that what
19:34we would hope to do with the the now
19:37the great help from Guide House and all
19:40of the participation that occurred in
19:42that effort is to really most adequately
19:45and appropriately leverage what we have.
19:48And I will just share for for those of you
19:51on that are out there that we were very
19:54involved in providing input and sharing.
19:57In that guide house process.
19:58So our voices were a part of
20:01the 70 that Cynthia mentioned.
20:04So you know,
20:05I think that they have taken into account
20:08not only what we shared but what a lot
20:10of other folks have shared as well.
20:12So thank you. All right.
20:17That was the question.
20:18That's the one question that came up.
20:19I think if there's anything else we we will.
20:23We'll catch it along the way.
20:24If that's okay,
20:25Cynthia,
20:26this is just such a perfect preview
20:29and perfect setup for what Doctor
20:31Shellhorn and Lisa Chomsky will
20:33now share with the group.
20:35It just ties in very nicely and
20:37really appreciate you being able
20:39to come and help us tee this up.
20:45The opportunity to present this
20:47update on our access initiative,
20:49I think first Doctor Shelhorn and I
20:51just want to acknowledge our small but
20:56mighty core patient access group that
20:58includes Jen Watkins, La, the Sudakar,
21:00Paula Pike and Mike Strait who are
21:03currently running off our team.
21:06We tend to pass
21:07over this slide in a lot of
21:10presentations, but as a reminder.
21:12Access is addressed at the very top.
21:15Yale New Haven Health enhances
21:17the lives of the people we serve
21:19by providing access to high
21:21valued patient centered care,
21:25right. This slide really reinforces
21:28that improving access is a firmly
21:30established goal for the entire health
21:32system as well as Yale Medicine.
21:35Executing a patient access
21:37strategy is a strategic priority.
21:40Patient access and navigation
21:42represent a Yale New Haven Health
21:44System strategic pillar and the
21:47university and the hospital share an
21:49aspiration for unparalleled access.
21:52These all represent different ways of
21:54saying timely access to care represents
21:57care that's truly patient centric
21:59and that when we improve access,
22:00we not only provide more timely care,
22:02but we increase patient engagement
22:04and patient satisfaction.
22:08OK, so our access goals center,
22:10I'm putting center,
22:11I'm putting the patient first.
22:13Our SMILO standard is to offer an appointment
22:16to new patients when then within three days,
22:19one to two when subspecialties are
22:21required or within four days when a
22:25multidisciplinary appointment is indicated.
22:28And it's important to note that our
22:30standard is a bit more ambitious than
22:32the Yale Medicine goal of seven days.
22:35Another goal is to follow the established
22:37Yale Medicine template standards.
22:39By doing this,
22:40we hope to improve access,
22:41clinical operations as well as
22:44the patient experience.
22:46We do realize that implementation of
22:48these goals might be a significant
22:50practice change in some areas and by
22:53moving to a patient centric model,
22:55we are changing our culture
23:01so. How did we approach this work?
23:04First, we created what we're calling
23:06the SMILO Access Dashboard to assess
23:09wait times by sight and by disease.
23:11We held to focus groups with multiple
23:14stakeholders that included RN coordinators,
23:17intake staff and physicians so that
23:20we can understand best practices as
23:22well as challenges and scheduling.
23:25Then we looked at the work queues
23:27across the SMILO enterprise to
23:28determine the number of new patient
23:30referrals that we were receiving.
23:32On a weekly basis and for our sites that
23:36are participating in Next Day Access,
23:39we reviewed scheduling codes to understand
23:41the reasons for the appointment delays.
23:44And finally,
23:45we began to review templates to
23:47determine specific challenges with
23:49scheduling and this work is ongoing.
23:54So Lisa's given a a nice
23:56overview of our process overall,
23:58but first we wanted to introduce
24:00our new dashboard that we've that
24:02we're using as the first step.
24:03It's important that we be able to measure
24:05the time to the first appointment.
24:07And so this was a dashboard developed
24:11over several months that has the
24:13following features and I want to point
24:15out that none of this is real data,
24:17but just so that all of you could
24:20take a look at what we're capturing.
24:22The first column is what percent of patients,
24:26according to site,
24:27are seen within three days.
24:30The second is within seven days.
24:32To align with the Yale Medicine standard,
24:38I'll I'll point out that the colors that
24:40we use in this dashboard are arbitrary,
24:43but green is good, red is bad,
24:45or green is better and red is bad.
24:48Greater this column is the the percentage
24:51of patients that were seen within
24:53more than with outside of three days
24:56for reasons other than their choice.
24:58So reasons being we don't have an
25:01appointment available would be captured
25:04here then median days to the new
25:06patient visit appointments and the total
25:08number of patients seen within that
25:10site in whatever time frame we use.
25:14It's important to remember that the
25:16time from the appointment being given
25:19to the appointment actually occurring
25:21is certainly important and that's
25:24what's been captured routinely.
25:25But the patient actually
25:28experiences a longer period.
25:30There's a that kind of.
25:32Processing time between the point that
25:34the referral is entered or called in to
25:37the point that the appointment is made,
25:38and that's a high anxiety period as well.
25:40So we're capturing that in a separate
25:43dashboard looking at time from the
25:45referral entry to the appointment made.
25:47And rather than show you multiple
25:49views of all of our dashboards,
25:52we wanted to summarize what
25:54we found in our first.
25:56Pass through with this dashboard,
25:58more than half of our patients
26:00aren't being seen within seven
26:02calendar days within solid tumors.
26:05That number does improve when we
26:07look at our top four disease sites,
26:09breast, GIGU and thoracic.
26:12Those patients with hematologic
26:14malignancy experience much longer wait
26:17times than patients with solid tumors.
26:20And patients with classical hematologic
26:22diagnosis are experiencing significant
26:25delays at nearly all of our sites
26:30Okay. So we conducted a
26:31couple of focus groups and you can see
26:34the feedback that we got on the left.
26:37Smile of physicians are flexible
26:39and accommodating new patients with
26:41malignancies and they often schedule
26:44outside of their templated time.
26:45Nursing outreach to patients prior
26:47to their appointment is key to
26:50immediate patient engagement and
26:51our R and coordinators report the
26:54patients expressed appreciation
26:56and relief when they call them.
26:58The presence of the intake team on site
27:01facilitates communication and triaging.
27:03Those hallway conversations among staff
27:05and physicians are really important and
27:08patients are grateful for the opportunity
27:10to schedule a timely appointment.
27:13We also identified some
27:14opportunities in blue.
27:15We heard again and again that
27:17there aren't enough open new
27:19patient visit slots and there's not
27:21enough return patient visit slots.
27:23There's a large volume of
27:25classical hematology patients,
27:26new patients and next day access
27:29slots are being taken by return
27:31and classical hematology patients.
27:33There's not enough APP return patient
27:36slots for active and longterm patients.
27:39And patients with scheduled six month
27:41and one year followup appointments
27:43are often rescheduled to accommodate a
27:45new patient and this happens sometimes
27:48more than once to the same patient.
27:50Obtaining necessary information is
27:52also causing delays outside records,
27:54especially diagnostic imaging
27:56and outside pathology,
27:58including heme pathology.
28:00Classical heme patients often have
28:02limited information in the referral.
28:04And staff spend time obtaining
28:07additional information to triage
28:08the appointment correctly.
28:10Cancer subspecialization is
28:12leading to longer waits.
28:13Next day.
28:14Access can't be offered if a
28:16subspecialist is not available.
28:18There may be openings,
28:19but not with the required
28:21specialized provider,
28:22and we anticipate that regionalization
28:24may reduce these wait times,
28:26allowing onboarding staff
28:28at multiple locations.
28:30To schedule at multiple locations
28:32would streamline the scheduling
28:34process and we do see this with our
28:36thoracic and our head and neck teams.
28:43Next slide, Sarah.
28:48OK, so to summarize the our current state
28:53greater than 50% of patients are not
28:55being seen within seven calendar days.
29:00Focus groups and scheduling codes confirm
29:02that new patient visit slots are not
29:04available when scheduling new patients.
29:09Trend and scheduling codes unfortunately
29:11shows a lack of new patient visit
29:14availability is increasingly common
29:19and template management varies
29:21widely across the organization.
29:24New patient slots are not
29:26consistently filled by new patients.
29:28And we're not following the YM
29:30policies on clinic and patient
29:32cancellations consistently.
29:37So our approach in in addressing our
29:39access issue first of all is to to
29:42look at the different contributors
29:44and the key drivers of delayed access
29:46to care and we can bucket these into
29:49four very large areas looking first
29:53at patient demand, clinician supply.
29:56Scheduling practices and the administrative,
30:01administrative approach.
30:04So I realize here and I apologize
30:08to everyone, I am using an old
30:10version of our slides.
30:11But in terms of our
30:13template optimization goals,
30:18let me come. I apologize everyone.
30:21I think in terms of the four buckets of of.
30:27Things that contribute to access
30:30patient demands are we seeing the we
30:33need to look at our referral numbers.
30:34We need to look at the frequency
30:36that patients are being seen.
30:38We need to look at the numbers of clinicians.
30:42Do we have the right numbers?
30:44Do we have the right lengths of sessions,
30:46the right availability of clinicians,
30:48the numbers of sessions,
30:50the distribution of templates
30:52across the morning and the
30:54afternoon and days of the week.
30:55In terms of the scheduling practices,
30:58what are the templates?
31:00What are the standards across
31:02the the system and are we
31:05complying with those standards?
31:06How are templates managed And make sure
31:09that that our management of those of of
31:11each of the schedules is standardized.
31:14And then looking at staffing of our
31:16onboarding associates and ensuring
31:18that we have the right number of people
31:20to do all of the work in advance of
31:23that first new patient appointment.
31:28Our goals for template optimization are
31:31first to follow the YM template standards,
31:36which is, as many of you have seen,
31:39a 240 minute session per 240 minute session.
31:43We recommend that in accordance with
31:46YM standards that that eight weeks
31:49notice prior to time out from clinic
31:52with a clear process for exceptions.
31:54Be developed for our group and
31:57protected new patient slots.
31:59We need to match the supply of clinicians,
32:01the availability of clinicians with
32:04the demand that patients have and we
32:08need to make templates reflective
32:10of our daytoday life.
32:12We are hoping to harness the power
32:15of the electronic medical record to
32:18allow for more efficient scheduling
32:20and improve our data collection.
32:23And improve the this will lead to
32:28improved efficiency in the clinical
32:30operations and we're hoping to
32:32balance appointments across the days
32:34of the week as well as mornings and
32:36night to kind of even out flatten
32:38the curve as it were of patients
32:41appointments throughout the day.
32:43And our our ultimate goal is as we've
32:45mentioned to ensure appointment
32:46availability within three days
32:47for every referred patient.
32:54I think. I think overhaul is
32:58probably an excessive word here,
33:00but we want to make sure that
33:03this is that templates are.
33:06Evaluated on a sitebysite basis,
33:10we'll be looking at the templates across
33:12the enterprise and we'll be developing
33:13a road map for template optimization,
33:15standardization and alignment,
33:16which will pilot in specific sites.
33:21We're going to look at visit types,
33:23the numbers of news and
33:24followups in the duration,
33:25and we'll look by areas of specialty.
33:31And we'll be optimizing our
33:33administrative processes,
33:34standardizing our template management
33:36and rolling out new and scheduling code,
33:40new scheduling codes to under to understand
33:43those patients who are referred to us,
33:46why they might not actually be seen.
33:49And we'll be doing some training and
33:51in servicing of all of our staff.
33:53We'll be standardizing our new
33:55patients record collection and we're
33:58hoping to develop and implement.
34:00Scripting to offer an alternative provider.
34:04I do have another slide in
34:07a newer version of this.
34:09You can speak to it, but if you
34:11would like to speak to it Lisa, that
34:13would be 1 sure if I just want to
34:17speak about what happens next,
34:18so as Cynthia. Stated earlier,
34:21we're going to be communicating
34:23Smilo's access goals in multiple
34:24forums over the coming weeks to
34:26make sure that everybody's on the
34:28same page and will utilize existing
34:30meetings like our clinical council
34:32meeting and we'll use some of the
34:34Smilo communications that go out as
34:36well as hopefully getting in front
34:38of the chairs at their meeting.
34:40We are also going to contact
34:42pilot site leaders,
34:44including clinical and administrative
34:45leads to set up a time to meet.
34:48And we're just asking that everyone
34:50please be flexible with your schedule
34:52so we can continue this important work.
34:55Our goal is to understand site and
34:57or team specific challenges and
34:59make recommendations for solutions
35:01including template optimization.
35:03And we're going to schedule training
35:05sessions for staff on use of the
35:08scheduling code algorithms that we've
35:09developed as well as the young medicine
35:12standards for work to management.
35:14And then after piloting in
35:15a couple of locations,
35:16we'll make any necessary modifications
35:18and then begin to meet with
35:20additional sites and team leads.
35:22So thank you.
35:28If I can make one comment,
35:30Lisa and Sarah, please.
35:32I think one of the things that
35:34often comes up and and you may have
35:37addressed this is filling up new
35:39patient slots with follow up visits.
35:41And while I will never say always or never,
35:44I think that part of the plan
35:46is going to have to be that if
35:49that's something we just don't do.
35:50I mean there there are going to be
35:52very rare situations where it happens,
35:54but if you build templates within disease
35:57programs that are meant to accommodate the,
36:00you know a given number of new patients then.
36:03We're just shooting ourselves in the
36:06foot if we if we eliminate those new
36:08visits to fill them with follow up
36:11slots and we have to figure out another
36:13solution for those follow up visits.
36:15So you got your work ahead of you.
36:18Yeah. And and I just add Eric that
36:21you know that is all part of the
36:23all part of the work that we have
36:25to do in front of us and I think.
36:27You know when Jeremy and Liz present the
36:30work we're doing around regionalization
36:33and and and sub specialization
36:35and integration and all that,
36:38those are bodies of work that
36:40help address other
36:44variables to the access challenges and
36:46that none of this is mutually exclusive.
36:50And so we do recognize that we have to be
36:53able to accommodate all of our patients.
36:56Whether there are new patients or
36:58are new patients who then become
37:00our return patients because we know
37:02that these patients are with us
37:04until they don't need to be with us.
37:06And that's a very long time.
37:08And it's really important that we are
37:11able to provide all of the services
37:13that are needed to to continue to
37:16take care of our cancer patients.
37:19And and I saw a question in the Q&amp;A.
37:22Around the staffing to support this,
37:24absolutely we have to make, we have to,
37:27we have to have everything aligned
37:30and and appropriately supported.
37:32But we need to understand that
37:34much better than we do right now.
37:36And I think that's the work that's
37:38in front of us and I think it's
37:39that's why it's so great that we
37:41have already started down this path.
37:43While the system and and Yale Medicine
37:45are prepared to roll out the the a lot of
37:48critical work that we're going to rely on.
37:51And so hopefully we will maybe be a
37:53little bit ahead of the game and we can
37:55take advantage of what's coming next
37:57from you know the health system in the
37:59school relative to to the broader efforts.
38:02But you know all of that's
38:04critically important.
38:04We have to make sure we have access
38:07for all of our patients and and and
38:10there was another question Eric in the.
38:13In the chat that maybe we can touch upon
38:15and anyone else who wants to jump in
38:17on this can and that was related to the
38:19the the lag time for breast cancer scans.
38:23I think that you know maybe we need a
38:26little bit more clarification on that.
38:28But we are aware that there there is,
38:32there is a delay sometimes in
38:34access within imaging.
38:36That aren't that support both our new
38:40patient and our existing patients and
38:43that is also work that is underway not
38:47just within Smilo that's obviously a a
38:50body of work that is you know for the
38:53entire health system and and School
38:55of Medicine and Yale Medicine to be
38:57working through and and Cynthia is probably.
39:02One of the most knowledgeable leaders
39:04in that work because she leads our
39:07ambulatory transformation work and
39:08radiology is a key part of that effort.
39:11And we are all at the table having
39:13those conversations and providing
39:15that input and helping I think
39:17to to address those issues,
39:19not just stay that it's a problem,
39:21but what can we all do.
39:23To help with that situation.
39:25So there is a lot of work that's being
39:27done and we all recognize that again
39:29none of this is mutually exclusive.
39:31Cynthia mentioned the importance
39:33of of this work touching on all of
39:36the other services that need to
39:38happen before we can even provide
39:41or even know that we have a cancer
39:43patient that needs our services
39:45and she referenced cardiology and.
39:47Other services where radiology is,
39:48is, is, is a big part of that.
39:50So you know I think that you know
39:52all of these are the important
39:54items that we need to understand is
39:56very complex but this is the work
39:58we're committed to and and we will
40:01be engaging everyone in this work.
40:04Well let me just say I'm hugely
40:06confident that we're going to fix
40:08this both system wide and and and
40:11and in smile up it'll be way better.
40:15612 months from now.
40:16And as Cynthia mentioned, I don't
40:18think we need to wait for three years.
40:21And if we if, if we do, all of us may
40:24not have as much hair as we do now.
40:27But Jeremy, you will.
40:29But but anyway,
40:33Lisa, Lisa and Sarah,
40:35really great work and you got
40:38all of our support.
40:39Yeah, great work.
40:40Yeah, great work. Thank you.
40:43Okay, should we transitioned,
40:46we should okay.
40:48So Eric, do you want to go
40:49ahead and introduce some?
40:51Sure. So yeah, so this is listen Jeremy
40:55I believe and and they're going to be
40:59speaking about two related topics and one
41:03has to do with regionalization within
41:06our broad system and the other is within.
41:12Medical oncology and hematology,
41:16the the need, the desire,
41:18the critical nature of moving
41:21toward a subspecialized care model.
41:25And by that we mean GI cancer doctors
41:28taking care of GI cancer patients,
41:31breast cancer doctors taking
41:32care of breast cancer patients.
41:33And the importance of it,
41:34I think is pretty obvious to most people,
41:36but cancer medicine has become
41:39so complicated that it is.
41:41Increasingly difficult for one person to
41:43be an expert across all disease subtypes.
41:46And so with that,
41:48I will turn this over to Liz and German,
41:52who have been working hard on this.
41:57Thank you, Eric.
41:58I'm going to share my screen.
42:02Whoops, and get it into the right mood here.
42:06Sorry guys, don't get dizzy.
42:08We're going to take a quick
42:09tour back through the the deck.
42:12So good evening everyone.
42:13I'm going to say a few words then hand
42:16the podium over to Jeremy Cortmanski.
42:18But we have been,
42:20Jeremy and I and many others listed
42:22on this slide have been working
42:24over the last year really on this
42:27notion of clinical integration,
42:29which we'll talk more about
42:30in the next few minutes.
42:32It really comes from the recognition
42:35that Smylo Cancer hospital so
42:38sorry is really quite an A very
42:40special place and we have you know
42:43clearly the clinical investigation
42:45and the Yale Cancer Center that
42:48whose home is in New Haven.
42:50But we actually have a very wide
42:52geographic reach throughout the state
42:56and what you what we're trying to
42:58actually work toward is to eliminate.
43:00Any distinction between New Haven
43:02and the rest of our enterprise.
43:05So you'll you'll notice tonight
43:07we're going to avoid using the
43:09word network or care centers or
43:10main campus that really what we
43:12have is the Smile Cancer Hospital,
43:14Yale,
43:15Yale Comprehensive Cancer Center that
43:17delivers academic the best in class
43:21cancer care access to clinical trials.
43:24But that we're able through
43:27our extensive sites,
43:28we have 16 sites across the state
43:31able to offer that care close to
43:33home which is very powerful from a
43:35population health and public health
43:37point of view and also tremendously
43:39extends the reach of our clinical trials.
43:45So before I hand it over to Jeremy to make
43:47the Segway here the the the a lot of the.
43:52Programs that are part of SMILO today were
43:54integrated and acquired over the last
43:5710 years and at the time that different
44:00practices were brought into SMILO,
44:02there was a lot of work done to integrate,
44:05to introduce care signature and to
44:09introduce an academic sub specialized.
44:12Mode for physicians.
44:14So really this work is intended to
44:16continue what was really kind of always a
44:19part of the DNA of the of the the smile.
44:21Oh, I'll use the word network,
44:23which you know Eric often says
44:27is actually pretty strong.
44:29Among cancer centers,
44:31there are very few.
44:32Eric often will say memorial.
44:34So Kettering is one that actually
44:36has achieved a high level of disease
44:39of specialization and academic.
44:41Faculty throughout their enterprise
44:42and we actually have a pretty
44:45strong basis and the work we want
44:47to do is to continue
44:48to evolve that. So
44:50Jeremy, I'm going to hand
44:51it over to you. Thank you.
44:55I'm hoping when all of this work is done,
44:57my hair does in fact grow back,
44:58but we'll see. So, you know, tonight's.
45:04Talk is not meant to deliver a
45:06finished product by any means.
45:08I think it is really meant to introduce
45:12the rationale for the the work that
45:15we're doing and also introduce the work
45:18that needs to be done and help our
45:23entire system to start the process of
45:26getting involved in that work I I think.
45:28Knowing the the size of our enterprise,
45:32it's important that there is
45:35involvement from everyone.
45:37But I think it's obvious that there has
45:40been some real transformative shifts
45:43in medicine and in cancer care in
45:47particular that have required some new
45:49new thinking about how we deliver that care.
45:52One is that there's this rapid increase
45:55in the complexity of the diseases and
45:57the treatments that we have for them
46:00with rapid emergence of immuno oncology,
46:03new drugs and therapeutics and multiple
46:06complicated clinical trial options,
46:08dependence on molecular profiling
46:11and targeted therapies,
46:13early introduction of genetic
46:15testing and genetic counseling,
46:18new technologies in radiation oncology.
46:22Interventional radiology, Thera gnostics.
46:26Increasing surgical specialization
46:28and expertise with robotic surgery,
46:31minimally invasive surgery,
46:33and then also the emergence of
46:36cellular therapeutics.
46:37And so the field has gotten very
46:40complicated in a very short period of time.
46:44On top of that, though,
46:46there is also a.
46:48A value imperative that the the
46:50payers for this care require that
46:53we don't just deliver a lot of it,
46:55but that we demonstrate the value
46:57in what we are doing that we try
47:01to reduce variability.
47:03And I think that that's also important
47:06that we try to reduce variability in
47:08what we deliver as a Cancer Center,
47:11so that there aren't great disparities
47:14depending on where within our
47:15system you're getting your care.
47:18And then making sure that
47:19people are still getting the
47:21right care at a location that is
47:24convenient and with a provider
47:26that is an expert in their field.
47:31And I think from the consumer side,
47:33from the patient side,
47:35patients and families really
47:38desire a research driven
47:41multidisciplinary expertise,
47:43but also want it to be close
47:45to home and convenience.
47:51And so when we think about
47:52the future of SMILO,
47:55it's really in these two areas,
47:57subspecialized care because the
47:59speed of change and complexity of
48:03care demands that and that it's
48:06offered with multidisciplinary
48:07expertise and integration.
48:09Because it does require a team.
48:11It's not just a hematologist
48:13or a medical oncologist.
48:14It is a surgeon and a radiation
48:17oncologist and imaging and pathology
48:19nursing and all of the supportive
48:22services that all have to be available
48:24to our patients wherever it is
48:25that they are getting their care.
48:32And so it really is at a point
48:35that achieving this state is
48:37critical and work that needs to
48:40be done now for the patients.
48:42It allows the the oncologists and
48:44hematologists that are treating
48:46them to be abreast and nuanced of
48:50the latest advances in their care.
48:53It allows the the physicians and clinicians.
49:00To have job satisfaction with that
49:03mastery of their area and getting
49:07stronger relationships with their
49:10partners in that care and better
49:13access and utilization of clinical
49:16trials and for our entire center,
49:19it allows us to reduce that
49:23variability and really create a
49:25distinctive signature of care.
49:27That not only separates us from
49:29our local competitors,
49:31but also on a national standpoint.
49:37So this is sort of the next
49:39two slides will sum up.
49:40But so the guiding principles that I think
49:43Jeremy has articulated are subspecialization.
49:46So the idea is that all
49:49physicians will progress towards
49:51subspecialty expertise such that.
49:54You know when we are kind of as we
49:57evolve a a the majority of patients
49:59will be taken care of by an expert in
50:02their tumor type and that access to
50:04clinical trials will be an emphasis
50:06and an important part of the program.
50:09One of the key ways that we see
50:12this subspecialization becoming
50:14manifest is through regionalization
50:17which we've alluded to.
50:19So one of the challenges in creating
50:22subspecialized practice is that.
50:24With the exception of breast cancer,
50:26they're really in small communities,
50:28there's not a large volume of cases and
50:31so it becomes hard to keep a Doctor Who's
50:35in practice 7 or 8 sessions a week busy.
50:37So we think that one of the ways we
50:40can mitigate that is to introduce
50:42the concept where physicians
50:44will practice in up to two sites.
50:47So I'll mention you know Waterbury
50:48and Torrington have already started
50:50down this path and are are working.
50:52On developing a model in which the
50:55physicians will practice at each site
50:57which will enable them more readily to
51:00become focused on a on a single disease.
51:04And that we know will take a lot
51:07of effort to mobilize changes in
51:09workflow and kind of rewiring how
51:11we do our business so that we can
51:14we can do that smoothly.
51:15And patient access,
51:16we just spent a lot of time
51:18on patient access.
51:19It continues obviously in
51:20this work to be a priority.
51:22And as Jeremy said,
51:24providing world class
51:25care very close to home.
51:28So just to wrap up the the general time frame
51:31is that between now and roughly July 2025,
51:34we will go through a process of retreats
51:37and engagement and organizing local
51:40work groups all kind of to manage
51:43the many changes and to get everyone
51:45engaged in making the changes that we
51:48required so that we wind up where.
51:51Each position is aligned with a
51:53subspecialty and is able to regularly
51:55attend tumor boards and other important
51:58center of excellence related meetings.
52:00Each has an academic portfolio of
52:02work and has access to mentorship that
52:05a PP's are a key part of the team
52:07and are optimally deployed in this.
52:09In this new model,
52:10the majority of patients are seen
52:12by a subspecialists,
52:13physicians working in up to two sites
52:15within a region we've redesigned workflows.
52:18And really importantly that we've
52:20engaged the referring community so that
52:23they understand the value proposition
52:25and are are comfortable with the way
52:27we will be functioning.
52:30So that ends our slides, we can pause
52:35and see what questions have been posed.
52:47So I will.
52:48I will take a step so that there's a
52:51question in the chat about how difficult
52:53that is to fit in patients currently
52:58and so and how that would be impacted if
53:01if a physician is in a different site.
53:04I I think that this the the ideas
53:08of sub specialization,
53:10regionalization and access all
53:12work hand in hand and to do that.
53:18It requires that we optimize
53:21how how everybody is used,
53:24how we utilize physicians APP's our
53:29nursing staff to to make that happen,
53:33how we right size the,
53:35the staffing that we need in
53:37certain places whether that's
53:39through additional hiring or better
53:42template management I think.
53:45That's why this work, you know,
53:48takes a couple of years to accomplish
53:50because it's not as simple as
53:53just moving someone from point A
53:55to point B for a session a week.
53:57It really involves all of the ways
54:00that patients are going to interface
54:02with the care that they're getting.
54:05And
54:05I would just add, Jeremy,
54:07that it also demonstrates the importance.
54:11Of recognizing that the work we do
54:13in the access efforts that was just
54:15presented and the work that you all
54:17just presented is really tied together.
54:20I mean we cannot work on these in
54:23silos And the timing for us to be
54:27doing both the patient access work
54:29and this work is not accidental.
54:34It it really needs to work
54:38together otherwise we will miss.
54:40Opportunities that we would
54:42not otherwise capture.
54:43And and I think in the chat around staffing,
54:47Lisa, you responded that you know
54:48this is this is important as well
54:50and it's part of work that we've
54:52done in in the analysis around
54:54what we call role harmonization.
54:57All of these have to be in place
54:59and have to be working together
55:01in concert and perhaps perhaps
55:04at a soon an upcoming town hall.
55:09We could do an update on the
55:11royal harmonization work as well.
55:13It's important for us to be able to
55:15keep everyone apprised of all of those
55:17moving parts and and making sure that
55:19everybody is is engaged in in that work.
55:26So look, it's it We,
55:28we we've sort of hit the hour and I
55:30think everyone's done a great job.
55:31I just want to say the, the goal here,
55:34the mission here is to provide absolutely
55:38outstanding multidisciplinary care
55:40in a research setting to patients
55:43with cancer and hemologic conditions
55:46in New Haven and around the state.
55:50We want to, we want people to feel like
55:53they have received the very best care.
55:56In all ways with a big hug and
56:00I think it's really,
56:01really important and I think you
56:04know we we have such potential
56:06and in many ways we're really,
56:09really close and we can do this.
56:12So everybody just you know bear with
56:14us as we as we take these steps
56:17and I I come as close as I can to
56:21promising that this is going to work.
56:25We have.
56:25Total support in this in this mission
56:29from both the CEO of the healthcare
56:33system and the Dean of the medical
56:35school and it's really going to be great,
56:38completely agree Eric And and
56:39actually there is one other
56:41question and I know we're at time,
56:42but I want to make sure we answer it.
56:45Will there be work on evaluation of
56:47frequency of provider slash patient visits,
56:49It seems to differ greatly between
56:51providers even for the same diseases
56:53and that is absolutely true.
56:55And we, yes, absolutely will
56:57be addressing that 100%.
56:59So yes, all right, this was great.
57:04I'm sorry the time is up.
57:06Sure that we could continue
57:07to talk about these topics.
57:09We will plan to bring I think this
57:12this back on a regular basis to
57:16keep everybody updated and we'll be
57:18adding more people to the panels,
57:20maybe some of you who are out there now.
57:23Will be on the screen helping to
57:26share some of the progress that
57:28is made that you are helping to
57:31to to lead and drive forward.
57:33So everyone have a great rest
57:37of your evening and we'll hope
57:39to see you all again very soon.
57:42Good night you.
57:43Bye bye.