Publication
Article
Article
Author(s):
IN BRIEF
Ambulatory oncology programs struggle with fragmented intake processes, variable clinic workflows, and diffuse communication channels—issues that slow access, increase rework, and frustrate patients and staff alike. Ambulatory Care Excellence (ACE) is a service-line model that standardizes roles, hardwires care-coordination time, and streamlines communication and benchmarking to match resources to demand. At Fox Chase Cancer Center, ACE convened more than 30 team members; identified more than 100 issues across patient access, navigation, and clinic workflows and translated them into 73 actionable countermeasures; and then piloted a future-state design within the breast service line. This article details the problem, 2-part scope (prearrival access and arrival-to-second-appointment coordination), methods (voice of the customer, empathy mapping, process mapping, root-cause analysis), intervention components (role clarity, service-line staffing, protected registered nurse care-coordination time, single-pool in-basket routing), implementation, control plan, and measurement framework.
Traditionally, oncology care has focused on the inpatient setting. In recent years, care delivery has shifted to the outpatient setting.1 Ambulatory care is increasing in complexity, requiring efficient processes, effective communication, seamless care coordination, and continuous collaboration among disciplines. An ambulatory care encounter for a patient may involve several events and multiple patient transitions between sites of services (eg, laboratory, imaging, diagnostic, procedural, and physician clinics) that necessitate communication and coordination among several clinicians, care team members, the patient, and, when appropriate, the patient's family or caregiver.2 However, ambulatory care in the United States remains highly fragmented, and 1 study demonstrated that this fragmentation results in approximately $1085 more in total adjusted costs per person per year.3 Often, ambulatory clinic operations exhibit inefficient processes, variations, repetitive work, and missing documentation—functional problems that impede throughput, increase access time to care, and degrade the experience for patients, staff, and providers.
Reimagining Our Ambulatory Care Model
The Ambulatory Care Excellence (ACE) Model was developed under the leadership of the chief nursing officer and vice president of nursing and patient care services at Fox Chase Cancer Center in response to growing gaps in care coordination and workflow inefficiencies across ambulatory clinics. The initiative aimed to transform the ambulatory care delivery model to meet the needs of a growing and diverse oncology population while promoting staff engagement, operational excellence, and high-quality patient outcomes.
The ACE Model was developed through a highly collaborative process. Over 30 team members from every part of the ambulatory ecosystem participated, with the following key stakeholder groups from multiple disciplines and leadership levels engaging to achieve a thorough and lasting redesign:
Methods
The development process followed a structured redesign framework grounded in systems thinking and process improvement methodologies, particularly Lean Six Sigma. This emphasis on a proven, structured approach instilled confidence in the team and ensured a systematic, effective process.
Scope of Work
The stakeholders defined 2 complementary workstreams to focus on:
A governance structure with clinical informatics was established to support the above workstreams. Decision tree audits with providers and navigation were conducted on a defined cadence to prevent triage errors and ensure scheduling algorithms reflect current pathways (Figure 1).
Emergence of the ACE Model
Using data-driven insights following the value-stream analysis, 5 high-impact opportunities were identified. The future state that was envisioned focused on reducing variation, eliminating non–value-added steps, and aligning service lines for balanced resource deployment. These standard practices became the core elements of the Fox Chase Cancer Center ACE model (Figure 2).
Clinic Role Delineation and Standardization
A baseline scope of work inventory was conducted in all ambulatory site locations to understand the workload of our clinic staff, including the RNs, MAs, licensed practical nurses, nurse navigators, and advanced practice providers. Results indicated variations in staff roles and responsibilities, role confusion, and role ambiguity resulting in task duplication, staff and provider dissatisfaction, and increased risk for gaps in care. A multidisciplinary workgroup was formed to clarify and delineate tasks by roles. Table 1 summarizes the standardized roles for MAs and RNs.
Protected RN Time for Care Coordination and Clinic Preparation
Many ambulatory clinics lack structured processes that allow nurses the administrative and coordination time needed to address patient needs beyond direct clinic sessions. The absence of dedicated care coordination roles can result in communication gaps, delayed follow-up, and inefficiencies that affect both patients and providers.
Nurses play a critical role in ensuring continuity and quality of care through timely coordination of diagnostic and supportive services and multidisciplinary collaboration. Benchmarking and workload modeling identified the need for protected nurse care coordination time hardwired into schedules to create predictable capacity for validation before visits, results management, and coordination between visits. Table 2 lists the standard RN tasks to prepare for the next patient visit. Care coordination tasks embedded in the clinic RN workload are listed in Table 3.
Structured Benchmarking and Resource Allocation
We developed our own framework using American Medical Group Association benchmarking to determine the appropriate number of staff members—both nurses and MAs—required per clinic session. In designing this model, we accounted for 15% indirect time, 4 hours of clinic preparation time per nurse each week, and 2 daily 4-hour sessions per nurse per week devoted to care coordination. These factors allowed us to assess our current staffing levels and identify the number of incremental full-time equivalents (FTEs) needed to achieve a full and balanced staffing complement.
Service Line Alignment
Patients often see multiple specialists and clinicians, which can sometimes lead to inconsistencies in care. RNs and MAs were assigned to a specific service line to enhance continuity of care and strengthen the nurse-patient relationship.
Standardized Clinical Communication Process
A standardized in-basket communication workflow was established to streamline the flow of messages coming from multiple sources, reducing the medico-legal risk and improving response tracking. Disease-specific nursing pools were created within the electronic health record (EHR) to streamline communication among the team and eliminate the use of emails and text messages for physician tasks and follow-up.
Measurement and Integrated Control Plan
To sustain performance, ACE embeds a formal control plan within routine operations—no separate appendix is required—so that each metric has 6 components:
The plan is reviewed in daily, weekly, monthly, and quarterly rhythms visualized via scorecards and control charts.
Metrics and Definitions
The ACE model measures of success span:
Records-specific key performance indicators include the percentage of tasks auto-triggered with facility-of-origin and slide retrieval turnaround time.
Ownership and Cadence
Each metric lists both an accountable owner and a process owner. Daily RN/MA huddles monitor backlog and time to first response. Weekly service-line reviews track access and/or readiness defects and record turnaround times. A monthly clinical informatics governance huddle audits decision-tree performance (eg, triage errors, change tickets, training adherence). A quarterly executive review validates targets, staffing benchmarks, and vendor service level agreements.
Targets, Thresholds, and Signals
Targets and thresholds are defined for each measure (eg, ≤ 10 days to first appointment, in-basket response time within policy, zero tolerance for incorrect provider assignment). Statistical bounds (eg, upper and lower control limits where applicable) and practical trigger thresholds identify signals such as rising backlog, delayed slide turnaround, or an uptick in readiness defects.
Standard Responses and Escalation
For each metric, standard actions are prespecified:
Decision-tree defects trigger an immediate audit, change control, micro-training, and verification in the next cycle.
Visualization and Governance
Operations dashboards visualize ownership, response times, backlog, and trend signals. Scorecards support weekly reviews, and control charts flag special-cause variation. Governance artifacts (eg, defect log, audit checklist, change tickets) are maintained by Clinical Informatics and service-line operations.
Pilot Implementation
Implementation of the ACE model was launched first within the Breast Service Line to assess its feasibility and scalability across the ambulatory enterprise. Operationally, the pilot encompassed the patient journey from the initial point of contact with the cancer center through the second clinic visit. Dedicated RNs and MAs were assigned to the service line with clearly defined roles, standardized workflows, and delineated escalation pathways. The ACE model clarified RN and MA responsibilities, established shared task ownership, and embedded structured communication processes.
Care coordination responsibilities were integrated into the clinic RN role, supported by protected time allocations (≈ 0.2 FTE/RN or 1.0 FTE/disease team) to ensure consistent follow-up, external communication, and clinic preparation coverage. Key performance metrics for success were identified, and compliance with the redesigned workflows was monitored through monthly data collection and performance review cycles.
Early Results
Early results from the ACE model pilot demonstrate promising improvements in coordination efficiency, staff engagement, and patient experience. Continuous monitoring using EHR data and satisfaction surveys provided actionable insights during the first phase of implementation. Data were reviewed monthly to evaluate adherence to standardized workflows and to identify opportunities for refinement.
Compliance with the standardized communication process was assessed through analysis of provider message volumes directed to service line–specific nursing pools (Figure 3). Clinic nurse efficiency in managing patient portal messages was reviewed monthly, focusing on responsiveness, message volume, and usage trends. Role-based message analysis revealed that physicians generated the majority of nursing pool messages. Across 807 physician-initiated communications, the average response time was 30.4 hours, confirming that all routine messages were addressed within the 2-day target. Message volumes and response patterns were tracked longitudinally to inform workload balancing and improve communication flow.
Following ACE implementation, post-pilot satisfaction surveys were distributed to participating service lines to assess perceived effectiveness, role support, and timeliness in responding to patient needs. Seventy-six percent of respondents reported greater ability to respond to patient needs promptly. Providers indicated increased support outside of clinic sessions, while nurses reported improved capacity to manage non-clinic responsibilities. These early outcomes highlight the ACE model's potential to enhance care coordination, operational efficiency, and staff satisfaction across the ambulatory enterprise.
Implications for Other Cancer Programs and Scalability
The development of this ambulatory care model has significant implications for cancer programs seeking to enhance care coordination and operational efficiency. Oncology practices face similar challenges with fragmented care delivery, limited nursing resources, and increasing patient complexity. The principles embedded in this model—consistent nurse assignment to defined disease sites, clear role delineation between nurses and MAs, and structured allocation of indirect and coordination time—can serve as a foundation for improving continuity of care in these settings.
The ACE model offers a scalable and flexible framework that may be adapted to various program sizes, patient volumes, and staffing capacities. Service line alignment with RNs and MAs embedded within disease-specific teams fosters stronger provider-patient relationships, reduces communication gaps, and improves both patient satisfaction and clinical outcomes. Benchmarking informs workforce planning. Allocation of indirect and coordination time supports sustainable workloads and mitigates burnout—an important consideration in programs where staffing is often limited.
The ACE model represents a strategic effort to improve continuity, efficiency, and patient outcomes in our ambulatory care setting, ensuring that services provided are not only clinically effective but also empathetic, accessible, and respectful of the patients' experiences. Implementation of the ACE model in a community cancer setting requires thoughtful adaptation to local context, including adjustments for smaller clinic sizes, resource constraints, and potential cross-coverage needs. These achievements culminated in national recognition when Fox Chase Cancer Center received a 2025 ACCC Innovator Award for excellence in ambulatory care transformation.
Fox Chase Cancer Center At-a-Glance
Part of the Temple University Health System, Fox Chase Cancer Center is a National Cancer Institute (NCI)-designated Comprehensive Cancer Center located in Philadelphia, Pennsylvania. Established in 1974, Fox Chase is among the nation's first cancer centers and remains a leader in cancer research, education, and clinical care. The organization has earned Magnet® designation for nursing excellence 6 consecutive times from the American Nurses Credentialing Center, reflecting a deep commitment to nursing professionalism, innovation, and quality outcomes. Ambulatory care at Fox Chase serves as the hub for comprehensive cancer management encompassing diagnosis, treatment planning, clinical trials, survivorship, and palliative care. Given the high acuity and complexity of this population, the ambulatory teams balance specialized clinical expertise with coordinated, patient-centered care delivery.
Tara DelGrippo, MSN, RN, OCN, NE-BC, is clinical director, Ambulatory Care, Supportive Oncology, and Direct Referral Unit; Disha Sawhney, MHA, FACHDM, CLSSGB, DHA(C), is operations manager, GI and GU service lines; Colleen Eroh, LSSBB, is director, service line operations; Sarah Porzig, MSN, RN, OCN, is clinical nurse manager, Ambulatory Care, Supportive Oncology, and Direct Referral Unit; Jordyn Lynn Biro, MBA, MPH, LSSGB, is operations manager, Breast and GYN service lines; and Anna Liza Rodriguez, MSN, MHA, RN, OCN, NEA-BC, is chief nursing officer and vice president of Nursing and Patient Services at Fox Chase Cancer Center in Philadelphia, Pennsylvania.
References
Additional Resources
