Abstract
A comprehensive cancer center is supported with an administrative infrastructure that facilitates the overall planning, management, and organization in the delivery of the center’s cancer care. This chapter explores the various administrative functions that are integral to the development and implementation of a comprehensive cancer center. Core administrative functions include, but are not limited to, strategic program planning and development, financial management, human resources management, operations management, space and facilities planning, compliance to regulatory and accreditation standards, and facilitation of access/intake functions for new patients entering the center for care. Depending on size of the cancer center and whether it is a freestanding institution, affiliated with an academic medical center, or part of a hospital or health system, the administrative infrastructure can vary in the extent to which operations are centralized versus decentralized. The optimal framework for administrative management can be scaled incrementally as the cancer center grows.
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Keywords
Strategic Planning
The capacity to develop a comprehensive cancer center varies with available resources such as human capital (providers, nurses, staff), facilities and equipment, and most importantly financial funding. The availability of such resources will dictate the services that can be provided. Sources of funding vary widely and can include national and subnational government funding; private user payments, either through health insurance or out of pocket, revenue-generating practices such as retail and parking, and philanthropic support from external donors. Strategic planning allows for a proactive approach in determining what populations can be served, what services can be delivered, the funding needs to grow the center, and developing and directing a short- and long-term business plan for expansion, implementation, and sustainability.
The long-term financial health of a cancer center ultimately determines its ability to effectively deliver quality cancer care services. Thus, another key component in strategic planning is the ability to understand the market intelligence and the ability to change as market conditions change. Changes in market conditions include changes in governmental funding; changes in private payer policies and practices; pricing changes for medical supplies, equipment, and personnel; and even scientific development and the subsequent delivery of new cancer treatments. The impact of such changes needs to then be evaluated within the context of the socio-demographics and health needs of the patient population that the cancer center is looking to serve. Effective planning and understanding of the culminating effect of these various factors will enable a cancer center to grow strategically in a manner that is fiscally responsible and positions it well for sustainability.
Space and Facilities Planning and Program Development
Strategic planning eventually transforms into program development and the operational execution of such plans to enable safe, quality, and efficient patient care. Administrative personnel are often responsible for the design of physical spaces as well as design of workflows and processes to move patients through the various steps in their care. If the strategic planning team can identify the volume of the patient population that needs to be served, then the administrative team can plan the type and number of resources needed to provide comprehensive cancer care:
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Number of inpatient beds
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Number of outpatient exam rooms
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Number of surgical suites
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Number of infusion chairs for outpatient treatment
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Number of radiation therapy machines
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Number of imaging machines
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Number of lab draw stations
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Number of waiting room chairs
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Number of parking spaces
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Time it takes for lab results
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Time it takes for chemotherapy to be prepared
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Time it takes for an inpatient bed to be turned
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Time it takes for an outpatient exam room to be turned
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Time it takes for a patient to enter/exit the cancer center (cycle time)
Coupled with human resource planning, such space planning is necessary to ensure that your cancer center facility is designed and built to efficiently manage the patient demand.
Financial Management
All cancer centers need administrative support and competent financial systems to monitor and manage revenues and expenses of the centers. Centers need competent financial and accounting systems that measure the collective productivity of the center – the units of service being administered, the number of patient visits, etc., and the relationship of expenses to incoming revenue for the delivery of such services.
Healthy revenue management and enhancement is maintained by instituting and improving policies and processes to assure all clinical services are billed accurately and timely, and that collections are pursued promptly and accurately. Retrospective analysis of charge capture, denial reasons, and reimbursement patterns can result in recommended actions to optimize the revenue return. Such action could include developing guidelines, providing feedback, and educating providers and staff on billing processes and practices that accurately reflect the level of service being delivered and that maximize the financial return for such service or even the movement or services to a lower cost setting or delivery of new services that may have more long-term reduction in health-care expense – all of which is also a factor of strategic planning.
Budgeting
Administrative support is also needed for the management of expenses – budgeting of personnel and non-personnel expenses for operating purposes and how they relate to anticipated patient volumes and revenue expectations. Capital budgets are needed for the planning of financial reserves for the larger capital purchases such as equipment, furniture, and maintenance, acquisition, or construction of facilities.
There may be instances where the patient revenue stream from private payers, governmental payers, or self-pay patients does not cover all the expenses necessary to deliver the needed health-care services. If such is the case, then alternative sources of revenue should be sought such as grants or philanthropic support from financial donors or even a form of subsidization from the larger institution or health system. In all cases, obtaining of such financial support typically requires the development of a business plan that explains to the investor(s) the mission of the cancer center, the long-term goal it aims to accomplish, and the level of investment and support needed to carry out such mission. Effective management of sponsored funds and philanthropic support require an additional level of accountability in complying and adhering the spending as per the conditions of the sponsor or donor.
Performance Management
A growing concern today is the overall cost of health care. There are changes occurring today to improve the “value” of health care begging to ask the question of “am I getting the best quality care at the best price?” A comprehensive cancer center needs an administrative infrastructure to measure the overall performance of the center – in quality and outcomes, patient volumes, patient satisfaction, workforce satisfaction, and financial performance . It is important to be able to measure quality outcomes in both acute and long-term setting. Acute quality measures for cancer hospitals typically include infection rates, length of stay, readmission rates, and mortality rates. Acute quality measures in the ambulatory setting are a bit more limited and are typically measured more by operational measures such as patient satisfaction (were the needs of the patient met?) and cycle time (measure of throughput for time the patient spends at cancer center and its various services). Overall, the healthcare industry is moving towards improved measures that measure overall health over the patient’s care continuum vs measuring episodic moments such as outpatient visits and hospital stays on an individual basis. This level of value-based care will require enhanced collaborations across various specialties beyond hematology/oncology to address the adverse health impacts that may come with the delivery of cancer treatments (cardio or neuro toxicities, for instance) as well as primary care in the survivorship setting, and marriage and family therapy to address the psychosocial and mental health impacts that come with cancer care. In this ever-changing market, administrative support is needed to be able to report on such performance outcomes so that centers can gauge their effectiveness and efficiency in the delivery of care and make internal adjustments as needed.
Regulatory and Accreditation Standards
Yet another component of performance management is the evaluation of the healthcare provider’s ability to provide safe and effective care of the highest quality and value per the standards of regulatory and accreditation agencies. Specially trained administrative support with regulatory knowledge is needed in a comprehensive cancer center to ensure compliance to regulatory and accreditation standards that are required for the provision of clinical services. Such accreditations can range from overall delivery, quality, and environment of health care – in the USA for instance, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is responsible for the accreditation of all healthcare organizations. However, cancer services may also require more specialized accreditations for services such as chemotherapy, radiation therapy, clinical laboratories, and transplantation and cellular therapy.
Human Resources Management
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Refining and developing the administrative structure that provides the necessary level of support services for the sustainable growth and success of the center
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Understanding and appropriately implementing the varied policies and procedures for providers and staff
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Generally overseeing personnel actions for providers and staff such as recruitment, selecting and hiring, training, performance management, promotions, succession planning, and terminations
Access Services
A core administrative service of any comprehensive cancer center is the access function – the intake or management of new patients into the cancer center via self-referrals or physician referrals. Referrals can come in from a variety of sources – telephone, fax, or internal via the electronic medical record system. Key administrative components of an access team include:
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Utilization of scheduling questionnaires/algorithms to appropriately triage patient
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Insurance verification
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Medical record collection
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Referral management (inbound and outbound)
Scheduling Questionnaires
Scheduling questionnaires ought to be developed to guide the scheduler through a series of questions designed to assign the patient to the right provider at the right time for an appropriate diagnosis. For example:
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1.
What is the reason for your call or visit? Is this a new diagnosis, existing diagnosis, a relapse or refractory diagnosis, a second opinion, or establishment of long-term follow-up care?
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For solid tumors, do you need to see a medical oncologist, surgical oncologist, radiation oncologist, or all three?
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3.
For blood cancers, do you need to see a hematologist/oncologist or do you need to see a stem cell transplant specialist?
The patient or referring physician’s office personnel may not always fully understand what services they are in need of given their unfamiliarity with the disease. In such cases, scheduling questionnaires can help guide schedulers through the appropriate questions to determine what services may be needed next. For example, does the patient have a definitive diagnosis from a pathology record? If not, has the patient been scheduled for a surgical biopsy to obtain a specimen for pathology to analyze and diagnose? Based on the information gathered, the scheduler utilizes the scheduling questionnaire and a diagnosis algorithm to assign them to an appropriate oncologist for that condition. Given the rapid and escalating potential of a cancer diagnosis, every effort should be made to have a patient seen timely; a goal of many comprehensive cancer centers is to offer patients an appointment in as soon as 72 hours or 7 days or less is another common goal. Some more chronic conditions can wait to be seen a bit further out, that is, a few weeks out. The challenge there is managing the anxiety that often comes with a patient waiting to understand their new condition and eager to learn what is next. Some cancer access teams utilize a nurse or patient navigator to help review the patient’s medical records to ensure if they can in fact wait to be seen, but a nurse in such role can help a patient waiting to be seen understand their condition and help them navigate what is often a complicated network of various specialties to diagnose, treat, and manage a cancer diagnosis.
Insurance Verification and Medical Record Collection
Depending on the financial clearance policies of your cancer center, protocols may need to be established to ensure that new patients have a financial plan to pay for their cancer services, whether that be through self-pay or through insurance . Uninsured or underinsured patients may need another mitigation strategy such as referral to another center that accepts their insurance, financial assistance from the center, or assistance in applying for governmental or foundational support for their care. Though not common, there could also be the scenario of a patient needing immediate emergency or urgent care – in such cases, the goal is to provide the appropriate clinical services to stabilize the patient while other financial options continue to be explored.
Assuming the patient meets the financial and medical clearance to be seen by the oncology team, various medical records are collected from the referring provider office and other medical offices that may have participated in the patient’s care over the years. The goal of such record collection is to ensure that the oncologist has as much comprehensive clinical information. Medical records that may or may not need to be collected in advance of the patient visit include:
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Physician notes
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History and physical
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Diagnosing or relapse pathology
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Cytogenetic reports
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Flow cytometry
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Lab results
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Imaging results (CT/MRI/PET/US)
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Screening results (mammography, colonoscopy, PAP smear)
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Chemotherapy flow sheets (hospital and clinic)
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Radiation treatment summaries
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Operative reports
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Medication list
Referral Management
Comprehensive cancer centers are becoming increasingly aware that access services are maturing from just scheduling to more enhanced referral management. Referral management is defined as the process by which patients are transitioned to the next step in their care. Normally, referral management takes place when a condition changes for the patient, thus necessitating a referral to a specialist but there are various cases in which care may also be appropriate to transition out or be shared, for example:
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Patients who are in remission and can be transitioned to a survivorship program or care with their primary care physician
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Patients who can receive part of most of their oncologic care closer to home
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Patients with complex conditions who may require various specialties in addition to hematology/oncology, that is, cardiology, neurology, rheumatology, endocrinology
The plan for when to make those transitions of care is planned by the oncologist, but a strong, clerical administrative group is essential in making these transitions back and forth across various care settings – it can often be a high-volume, busy function requiring the ability to multi-task and be organized in managing the various patients being referring in and out. This necessitates a key customer service ingredient – relationship management – the cancer center’s access and scheduling teams are often the first and the lifeline connecting the various medical offices, and thus it is critical to ensure smooth and efficient processes so as not to delay care. As more options present for cancer care, a strong referral base may choose to refer their patients elsewhere when cancer centers have processes and policies that make it difficult for patients to access.
Conclusion
In summary, a solid administrative infrastructure is necessary for a comprehensive cancer center to efficiently and effectively deliver cancer care. From intake/access functions to high-level strategic planning for the future, such administrative functions are needed to keep the cancer center solvent and well positioned to meet the needs of our cancer patients.
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Alcantara, G., Chao, N.J. (2022). Administrative Support. In: Aljurf, M., Majhail, N.S., Koh, M.B., Kharfan-Dabaja, M.A., Chao, N.J. (eds) The Comprehensive Cancer Center. Springer, Cham. https://doi.org/10.1007/978-3-030-82052-7_10
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