Update on clinical changes in the Holden Comprehensive Cancer Center

As you all know, we are currently in a period of transition.  A number of faculty have recently retired and others have left or will be leaving this academic year for attractive positions at other institutions.  We have had recent significant changes in our clinic staffing.  Health care reform is resulting in major (and unpredictable) changes in Iowa and across the country.

At the same time, positive changes are taking place at multiple levels the will help us provide better care for our patients.  We thought it would be a good time to summarize and update you on many of these changes.

1.    Faculty Recruitment  Our current faculty are working incredibly hard, and there is a clear need for recruitment.  Aggressive efforts are underway in faculty recruitment in Medical Oncology, Gynecologic Oncology and Pediatric Oncology with a focus on specific areas of clinical need.  We are looking for faculty with enthusiasm for our clinical research and teaching missions who will strengthen our Multidisciplinary Oncology Groups.  A number of faculty candidates will be making their first visits shortly, and others are returning for second visits. These potential new faculty members have all been impressed with the quality of our institution, collaborative spirit, and “can do” attitude of our faculty and staff.  Overall, the pool of faculty candidates is extremely strong and we are confident that we will be adding 8-12 outstanding new faculty members with a strong clinical oncology and clinical research focus beginning July 1, or soon thereafter.

2.    Clinic Staffing:  With support from the Hospital, we have seen significant enhancement in clinic staffing, including development of a patient centered triage team.  We have replaced members of the front line team who have departed in the last year and are hiring additional staff that will function as our CCC triage team.  This group will take calls regarding prescriptions, symptom management, and any other care related question or concern.  The team, consisting of nurses, MAs, and clerks will move the question or concern through the system in the most efficient and effective way.  As the triage team gets implemented, we will identify other ways this team may be able to benefit the center.  We have hired Ben Tvedte as our front line supervisor and Julie Kurt as our Revenue Cycle Supervisor.

3.    Scheduling  With the hiring of Ben, as well as other front line staff, we are in the process of making significant improvements in our ability to schedule patients for the Clinic and Infusion.  We expect this will markedly improve our efficiency as we triage patients, schedule them for various appointments, and move them through their visits more efficiently.  Scheduling for our patients is extremely complex, very patient specific, and often includes multiple physician specialties, labs, radiology, and treatment.  We are working on approaches to improving various aspects of the entire system.  We know “moving through your visit” is not currently one of our strengths in the area of patient satisfaction, and are confident we can address this through enhanced staffing, improved operations and additional faculty.

4.    Support from the Hospital and Departments  The University of Iowa Hospitals and Clinics has been working with the Cancer Center and Departments to ensure that support for our faculty is competitive with other academic Centers.  This includes enhanced support for both current faculty and funds to recruit additional faculty as referred to above.  We are very appreciative of the support the Hospital has provided.  In addition, we are making excellent progress in discussing a longer term Cancer Service Line that would focus on the key departments that provide much of the cancer care at the Holden Comprehensive Cancer Center.  The goal of such a plan would be to align incentives so that everyone is working together to provide the best possible care and do so in a way that is financially viable in moving forward.   These groups have never been this well aligned before which speaks well for our future clinical efforts and our ability to serve our patients.

5.    EPIC Improvements – We are working closely with HCIS to identify those areas where the EPIC System can be more efficient for our faculty and staff.  Dr. Abu-Hejleh is leading a committee that addresses issues with Epic and Beacon that meets on a regular basis.  The Epic Access and Revenue Cycle has been postponed and will no longer be going live in May.  This will provide us additional time to get our background documents completed, templates built and staff trained.  Transitions are always difficult, but the opportunity to work within one system will bring several opportunities for improved communication, coordination and efficiency.

6.    Clinical Research  Dr. Raymond Hohl has accepted the position of Cancer Center Director at Pennsylvania State University.  We soon will be initiating a search for an Associate Director for Clinical and Translational  Research at The Holden Comprehensive Cancer Center.  This search will come with an outstanding package of support and will provide us with the opportunity to recruit a world class clinical investigator to The University of Iowa.  We will be seeking input from all the faculty and staff in order to recruit the best possible candidate for this position.

Change is a challenge, but it is also a time of great opportunity.  All the pieces are in place to strengthen our clinical mission and do an even better job serving our patients.  We remain open to your suggestions and look forward to your input and continued commitment in the exciting times ahead.

Thanks for all you do every day…


Earth Date 10-7-13, Iowa – the “HCCC Deputy Director’s Log”

Verbal Orders

These dreaded words.

I have asked my team to help me explain what are verbal orders.

Verbal orders can be for diagnostic tests, treatments, medication and care that we as clinicians deliver verbally to the other members of our team. We frequently provide verbal orders at the conclusion of our clinic assessment and pass these on to our nursing team for entry into the Epic system.

Who can give verbal orders? Licensed practitioners who can give verbal orders include physicians and dentists, physician Assistants (PA), advanced registered nurse practitioners (ARNP) and optometrists who have been granted clinical privileges by UIHC.

Who can receive verbal orders? This depends on if the verbal order is for medication. For medication, personnel who are approved to accept verbal orders in both inpatient and outpatient settings (and related to their scope of practice) are: registered nurses, licensed practical nurses, registered pharmacists, registered dietitians, respiratory therapists, radiology technologists, and nuclear medicine technologists.

Those who can accept a verbal order for nonmedication include: registered nurses, licensed practical nurses, medical assistants, registered pharmacists, physical/occupational/speech therapists, registered dietitians, radiology technologists, nuclear medicine technologists, respiratory therapists, psychologists, sonographers, laboratory technicians, and social workers.

And for us in the clinic setting for verbal medication orders, staff approved to accept verbal medication orders may accept a verbal order in the ambulatory setting for an order set in which the drug name, dosage, route, frequency, and indication are defined and there is no option to edit any of these discreet data fields. Additionally, no verbal medication order may be given or accepted for an initial dose of sedation. For chemotherapy, verbal orders are only acceptable in the case of a dose modification.

So why all the fuss over verbal orders? Safety. Safety. Safety. When we use verbal orders there is more room for error than orders that are written and/or then sent electronically. We all know the classic telephone game of passing on what we heard. It is not only the interpretation of what someone else says that can be inherently problematic because of different accents, dialects, and pronunciations. Background noise, interruptions, and unfamiliar terminology often can compound the transmission of verbal orders. Once received, verbal orders must be transcribed as a written order, which adds complexity and risk to the ordering process.

That said, according to our hospital bylaws, the use of verbal orders for medications should be minimized as per Bylaws Article VIII, Section 4 and be utilized in cases of emergent situations. Currently, we as the Cancer Center Clinic are outliers in the number of verbal orders each week that are given and accepted. There are a variety of reasons for this and I want to recognize our outstanding nursing and care teams who have been tremendously adaptable in our use of verbal orders. At the same time, in addition to the attention and scrutiny of the UIHC practice committee in our non-emergent use of verbal orders, I believe too by reducing verbal orders we can improve work flow efficiency of our clinic. So how can we do that without changing are practice styles?

Let me share some facts about our use of verbal orders. Last week there were a total of 6,971 verbal orders. Of these, our top 5 verbal orders given were for 1) CCC Follow-up; 2) CBC; 3) automated differential; 4) creatinine; and 5) bilirubin, total; clearly important for our workflow and honestly not so high up on the safety issues.

You might have all noticed me walking around clinic watching you practice. Right I am keeping a keen eye on how you are doing it. It is not rare that I observe a physician wait up to 10 minutes for a nurse to be free to then tell the nurse to order follow-up labs and a return visit. I have seen fellows do it and PA’s. Typically, this is a standard AVS follow-up and could have been completed by the physician in two minutes. Where’s the problem? This is an easy fix.

I have also found that when I enter my own orders, I am able to assist in the justification of the peer-to-peer requests that are often requested for diagnostic imaging. By doing my own Ct-scan ordering I provide enough rationale that prevents a peer-peer review on the back end. I am sure you all find them fun to do.

I will be doing my part helping all of you with this by providing other interesting ways of reducing our ordering, and I welcome your opinions.

  1. Protocols for smart sets – We can access these faster and improve efficiency.
  2. Nurses will pend orders for you to sign, this will help reduce verbal ordering and add a step toward the safety of the patient by letting you review the order set first.
  3. Please share your thoughts as well.



Earth Date 9-9-13, Iowa – the “HCCC Deputy Director’s Log”

“Got Rhythm?”

You might think of this title as: What is Mo all about today? I have been talking this week to many of you and sharing our experiences in the clinic. And, at the same time, the theme of leadership has been on my mind, and I’m asking myself what it means to be a leader.

It’s like music. A maestro conducting an orchestra and trying to figure out how to make each person play their instrument well. And then Steve Lentz says to me, “It’s about rhythm, Mo.” So, I decided to share.

Let’s define the rhythm that I am talking about. It is the regular recurring motion of the clinic day—our flow, if you wish. Our days in clinic are in constant motion. We are all moving, and our patients are moving through all this motion and activity. The clinic is in constant movement, moving to check-in, moving to sit down, moving to the clinic room. The list goes on.

The clinic has its own cadence, flow, and pace for each of us. What we all experience each day has what could feel like a harmonious aria or like that punk rock radio station that your teenager left on high volume last time she borrowed the car.

I would like us all to find our funk and enjoy our time in our clinics. I have been doing some things to help remove some of the major distractions around you so you can find your tune.

A leader always starts with himself as an example. How do I find “Mo’s flow” on my clinic days? For starters, I like it busy. I like my days full, and I want everything happening at once. I want my team to be engaged and not stressed. I want them to be able to get their tasks done and not be stressed. So I started paying attention to their roles.

For Alicia, the MA: What can get in her way to slow her down? For Wendee, the nurse: How much time does the phone demand for her to conduct her work? For Michelle and Deb, the PAs: How does working in an alternating fashion dovetail with my efforts? The template that I have for these scenarios is asking: Is it accommodating or crippling?

I want to hear about your teams and your thoughts. As you know, I will be inviting you all to comment on your team dynamics. But to make this work you all have to comment.

There are many pieces to the operations of the clinic, and it takes all of us, coordinating our individual parts, to create the whole. Like sections in an orchestra, we each have our roles as we deliver the care to our patients. Please see George’s latest blog post as he eloquently underscores the importance of all the moving parts of our cancer center and all our roles in the provision of this care.

I extend my heartfelt thanks and appreciation to all of you who are making it happen! All these pieces are required and create the rhythm that we experience daily in our clinic.


I have received tremendous input from the pizza huddle: thumbs up, fist bumps, and you name it. The suggestion board and box have served us but it is your individual input that is re-vitalizing the clinic flow.

We all recognize that having more money, more people, and more space are all important and necessary for our continued growth and success. At the same time, using the resources we have to our fullest and most efficient uses will enhance the rhythm of our clinic. There are times that our cupboards are not as full as we would like, and we end up making a really good dinner! Having more of something doesn’t necessarily create the most effective outcome. Thinking about this in terms of a chef or conductor, balance is the key to efficient harmony.

One of the themes from the suggestions I received is to improve your work areas. For example, creating standing clerical workstations, taking off the arms from the office chairs on the first floor, and replacing the chairs in the workrooms would all improve your work areas and enhance how we move in our clinic space.

As your maestro, I want to create an environment where you are comfortable and supported in how you achieve your rhythm in the clinic. These suggestions are not big and costly things, however they are important and allow us all to be in sync and enhance our individual feeling of being “in flow.”

So Young People, let’s find our rhythm.


Earth Date 8-20-13, Iowa – the “HCCC Deputy Director’s Log”

Young people, I want to share additional thoughts with you today and provide transparent data as we explore our practice from all its angles. This is “Mo’s wish list.” I would like to highlight on my wish list the issue of wait times in our clinic.

Patient Satisfaction

I know we are all working hard to get patients in to clinics and working overtime means a sacrifice in our scores. For the month of July 2013 we experienced our lowest score on patient satisfaction related to “likelihood to recommend.” The way I look at this data means we are working hard. In July we were at an overall score of 92.7. Our high score over the last 12 months was 96.7. As I reviewed the July comments from our patients, the lower score was related to the wait times experienced in our clinic this last July. So I think, besides increasing our existing staff how can we do better? I applaud your effort in maintaining the clinic efforts in seeing patients when they need to be seen. It’s a clear reflection of the hard work you all do.

I get that our wait times are influenced by several factors and often opposing forces. As I mentioned, we are making progress in our recruitment efforts to have more faculty providers. This will improve the number of slots we can offer and thus reduce the double and sometime triple booking that we all experience on our clinical days. I hope you have all noticed the elbow room that the clinic now has given the Gynecology Oncology move to Women’s Health.

Our collective work on the Epic scheduling templates will help. In my initial view of the scheduling templates, I believe there are some quick wins that we can coordinate to make some incremental improvement in the daily flow of patients through our clinic. I learned by reviewing my own Epic templates, that simply understanding how the schedulers were scheduling versus how I thought they were scheduling had added value in finding some quick wins. Also, I learned more about some standard rules that we can review about holding AM slots for chemo and treatment or 3 month sooner returns and my new and return visit ratio. Something that we all expected but sure need to educate those who schedule our clinics.

I am confident that these and other tactics to reduce our patient wait times will succeed. As we know, there is not one “silver bullet” – recruiting takes time, working through our templates requires iterative discussions and understanding our practice patterns (and possibly changing them). It is a process of careful consideration, as we hold our patients and their needs as our ultimate goal.

Recognizing that reducing our wait times is a work in progress, I ask for your help in brainstorming with me about how we might ease this time that our patients do wait. Some ideas that I have heard thus far fall into two broad categories: a) diversion and entertainment options and b) patient communications regarding their wait time. I recognize that with both of these, there are pros and cons to consider. There is some evidence that shows patient perception about wait time is lessened when they have information about the amount of time for the wait and the reason why they are waiting. While you expect others to explain your lateness or your clinic flow, getting actively involved is crucial. I have found by walking and just stopping in a patient’s room to explain delays has done wonders for the patient understanding of how this clinic really flows.

I have received a few suggestions in terms of patient diversion and entertainment, for example, we could offer patients DVD movie players (with headsets) or iPads. At the time of check-in and when we know the wait time is greater than 1 hour, we could offer patients the option of having a DVD or iPad. We also want to consider the logistics of this, in addition to the expense of the devices, as this would involve some additional effort for our staff to coordinate patients’ use of the devices and return.

I have received some suggestions to enhance the communications about wait times to patients. For example, handing out text pagers to patients at check-in and periodically updating them with text messages on the wait period remaining. Other variations on this idea relate to a potential automated method to send updates to a patient’s smartphone device, perhaps even before their scheduled visit check-in. There are software vendors out there that provide these types of services, and we need to explore further Epic’s capability in automated text and/or voice communications. Here too, we want to be aware of the additional staff effort or possible efficiency that could be created with a change in how we communicate wait times to our patients.

Looking for Your Input

What ideas do you have? What do you think of these suggestions? Are they worth trying? Please let me know as I want to explore all possible options. Please email me, talk with me (reminder pizza lunch tomorrow) or put a note in the suggestion box. You have to communicate back to me or else you leave me in a darkness hard to navigate alone. It’s a two-way street, so communicate. I believe it is the small things that we can do that will ultimately make the big difference for our patients.

This Saturday I will be riding in the Courage Ride, and I just wanted to send a thank you to all who are participating in this event and for your support!

Best regards,


Earth Date 8-06-13, Iowa – the “HCCC Deputy Director’s Log.”

I have always viewed practice changes as something that I could never understand; even the lingo—RVU’s, payor mixes, etc.—just makes my head ache. As a doc, I would come to clinic and just see patients. I have taken a step forward in my new role to take a deeper look at the meaning of “practice.” I get a chance to look in the mirror and, for a change, listen to my critiques.

I want to share these thoughts with you, making this process transparent and allowing us to really explore a “sound” practice from all its angles. I’d like to call it “Mo’s wish list.” It should encompass our best practices.

Headache #1

Our biggest headache was scheduling as you all realized, and I am slowly ironing out the curls. Templates are next on the chopping board, and I need your help and you’ll need ours.

During the next few months my team will be meeting with all the providers to review their scheduling templates. So let’s be visible, creative and opportunistic. Let’s enhance clinic throughput, making it our ultimate goal to have this be seamless for patient and provider.

I have put my team on trial and as your lawyer have asked these important questions in your defense: How do I balance the mix of my schedule between new and return? What resources are needed if I were to shift this mix? What does a potential change mean to my patients? Do we have capacity in our infusion suite for additional new patients?

You Want Answers?

I ain’t got all the answers for sure. I would like to share what I have learned thus far on this topic.

We are team players, and we have to step up and call ourselves that. It’s not Dr. Milhem clinic, it’s the Mo team. Yes, I know you all have heard me say this expression before, I plan on changing my scheduling front to represent my team. A patient coming through our solar system would simply say, “I am here to meet the Milhem Melanoma team!” In its simplicity it would allow us the freedom to assign patients to faculty or a physician assistant who would confer with me on the treatment plan. Or you can do it differently. What are your thoughts? Comments are welcome.

Another metric that you commonly hear about is the percentage of new patients seen within 14 days. How do you think we do? Best in the house! However, in achieving this metric, we set ourselves for failing in another one (“My Doc is always not on time”). Has this become our norm then, and how do we break free from this?

I think we have set the expectation of being late, so how can we make our teams perform better, fixing multiple issues at the same time? I have been slowly piloting a change in my new to return mix utilizing my physician assistants to help see patients as a team. This is helping me increase my new patient mix and has helped strengthen my academic mission of providing state-of-the-art treatment in my clinical trials.

Our compassion drives us to see our patients regardless, at least I know mine does and our philosophy has been to accommodate our new patients into already busy schedule days—really would a patient with a cancer diagnosis really want to wait? Would I as a doctor want my patients to wait? Our mission to provide excellent care can burn us out. I know we all have been working hard at keeping things together, as a team, and your efforts do not go unnoticed.

Introducing “Hot Facts”

Over the next few weeks, I will be building a “Hot Facts” section–(you’ll find this on the right hand side of the blog too). Here I will include data that helps us track our metrics and focus on facts that you may or may not be aware of. One such Hot Fact that I was unaware of was the difference in wRVU values in seeing a new patient and a return patient. Depending on the level of visit, the wRVU for a new patient ranges from a little above 1.5 to 2.5 times that of a return patient. This fact alone helps me to balance my productivity and allocation of time as I am thinking about my new and return mix.

Our operations excellence team and finance folk are still analyzing data to provide similar Hot Facts on the total revenue and cost per new and return patients seen in the clinical cancer center. Not that we will be making clinical decisions per se on financial and productivity data, though this certainly helps to inform me about an important impact of the new to return mix. Another Hot Fact is our new visit percent as compared to total visits at the clinical cancer (see table below). Here we can see for the Hem/Onc service, we have a heavily weighted return visit practice. I will be working to understand this better and to solicit comparisons with other comprehensive cancer care clinics and the impact to our infusion services.


Signs of Improvement

The Division of Hematology/Oncology is actively recruiting three new Hem/Onc faculty positions and two new BMT positions. Please spread the word, we are looking for excellent physicians to augment our practice. Our current demand for services is strong. This is a good thing!

While relief is on its way, let us know how we can help you maintain your current loads and possibly continue expanding. I am offering a 30-minute tutorial on “How to Command Dragon- according to Mo” and can teach you some short cuts to documentation and being more efficient. Help your nurse, do after-visit summaries, order sets not verbals—not hard. You can meet with the EPIC folks for an hour. I am working on seeing if we can get Dragon for all the Cancer Center members.

And please comment………………..Feedback has been the best thing I have learned yet.


Earth Date 7-24-13, Iowa – the ‘HCCC Deputy Director’s Log’

Like the captain’s log in Star Trek, this blog is my way of sharing with you our adventures and discovery in clinical operations at Holden Comprehensive Cancer Center (HCCC). Join me regularly for a “Hitchhiker’s Guide to the HCCC.” Bear with me, though, as I navigate; it is my first time as the Deputy.

I will be writing approximately twice a month, telling you what I have learned at our clinical operations, the do’s and don’ts in our practice, and letting you hear about the amazing people who have really made an impact to help patients get the best care at HCCC. We value collaboration, creative ideas, universal sharing, and innovation. Let this be a platform for us to communicate and for us to understand how to improve on our mission.

I have included other sections along the right-hand column for additional information and points of interest. I will be including announcements, milestones, and recognition as it relates to HCCC. I hope to be as inclusive as possible and as relevant to our academic mission. Duplication and repetition in this fast-changing world are welcome.

18 Months Young

Can you believe it? The new clinic space in Pomerantz has been open now almost 18 months, and our efforts are centered on making the entire HCCC process transparent and efficient. Thanks to the faculty, nurses, and all the staff of HCCC, we are improving the patient experience, as our patient satisfaction scores continue to improve (see diagram of mean scores below). Our scores reflect improvement and at the same time highlight our need to continue to focus on the patient experience in moving through the visit.

Slide1 (Click image to enlarge.)

Let’s take a moment and not work ourselves up over these stats, though I admit it’s hard to do. I think we should practice in a no-fault system, i.e., no one is to blame. Consider these as objective ways of improving our system. Think of them as a means to an end—ultimately the excellent care we provide for our patients. We all remember Tuesday right after the 4th of July holiday when we reached our record high volume day seeing almost 330 patients. The lesson: anticipate, prepare, and you will be ready.


Let us know what works and what doesn’t. You have our ears. They may not be Spock’s, but I am no Vulcan. And. yes. for all those who know me. I am a little spacey. Doctor Who-ish or just Mo-ness will do.

We have excellent support from our engineers through the Operations Excellence team. They have helped to identify future projects to focus on our patient throughput. And boy am I learning words like engagement, simple, solutions, and data-driven. I need your help and input on these projects as we gather more information to create an easier path for all of us to practice.

An Epic Journey

One such project that I will be highlighting is the Epic template review. During the month of August, Denise, Geri, and I will begin meeting with each of the faculty providers to review their Epic scheduling templates. This is your chance to fix your clinic. Tell us how you practice. See if we get it right!

We really want to learn more about the needs of our providers in the clinic and see where we might have opportunities to improve clinic flow based on understanding the unique and varied scheduling templates. Our goal is to seek improvements in moving our patients through their visit, efficiently and with compassion. I will have more updates next time on the Epic template review.

I not only welcome your ideas and input in making the clinic the best experience for our patients, I empower you to do that. I believe that you all are truly the people of HCCC—its lively community. If we don’t do it, who will?

I need your best ideas for making it better. Send your ideas my way. I hope you soon begin seeing some of the changes you have asked for. I’ve got a great team in Denise and Geri. They even want you to fill up their suggestion/idea box, which will be placed in the lounge on the second floor. It’s a tool for staff and faculty to be innovative, anonymous, and creative on how we can improve.

And we’re off……………….

milhemfinalMo Milhem, MD
Deputy Director for Clinical Operations
University of Iowa Holden Comprehensive Cancer Center

Learn more about Mo