No Delay in Diagnosis Performance Improvement Leadership Development Program

University of Missouri Health CareFebruary 2011

Effective Scheduling of Inpatient Echocardiographic Testing

No Delay in Diagnosis

Performance Improvement Leadership

Development Program

University of Missouri Health CareFebruary 2011

University of Missouri Health CarePerformance Improvement Leadership Development Program


2

Members of the TeamKathy BradyMargaret CalaluceDebra GlodoskiSusan VollrathAnnamalai SenthilkumarKoby Clements, AdvisorLes Hall, AdvisorMegan Tregnago, AdvisorMike Lambert, Executive Sponsor



Our 4E Partners

Lori Mann Lynn Wheeler Cheryl Overton Sarah Hall Russell Becker



4

Diagnostic CardiologyNon-invasive diagnostic cardiology services

~ 14,000 patients annuallyTypes of testing

─ EKG/Holter─ Exercise treadmill─ Tilt table testing─ Echocardiographic Imaging (48% of annual patient volume)

▪ Transthoracic Echo (TTE)▪ Exercise stress echo (ESE)▪ Dobutamine stress echo (DSE)▪ Transesophageal echo (TEE)



5

It’s an Orchestration



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Current StateOutpatient focus

─ Last decade all about efficiency, throughput, and outpatient growth

─ Our echo imaging, scheduling, ops process focused on outpatient volume (57% of total patient volume)

Outpatient schema─ “Just say YES!” ─ Same day access─ Double booking

Inpatient demand variability



7

Customer View of TAT

Outpatient Service3.1 hours

Inpatient Service 5.9 hours

Is this Service Excellence?



8

Problem Statement

Inpatients experience delay in receiving echo imaging due to current outpatient schema and inpatient demand variability.



The Work Begins



10

High-Level Flow Chart

inpatients, outpatients, ordering physicians, outpatient scheduler, clinic staff, office support staff, unit clerks, transporters,

sonographers, floor nurses, unit nurses, advanced study nurses, exercise physiologists, cardiology fellows, interpreting

cardiologists, patient diagnosis, discharge process

Order Schedule Perform Interpret Report





12

Patient Voice

▪ Inpatient survey on echo experience▪ 30/75 (40%) forms completed▪ Majority of patients from 4East▪ Alarming # of patients (17%) unaware of

scheduled echo imaging procedure▪ Impetus for development of 4E signature PFCC

program


Transporter Unit Clerk Interpreting Physician

Diagnostic Cardiology

13

Finger Pointing



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Order Received to First Frame (All Inpatients)Weekly 75th Percentile

75th %ile Target 75th %ile

Week Of

# of

Min

utes

Intervention

Baseline 75th Percentile174 Minutes



15

Aim Statement

By February 11, 2011, we will minimize delay for inpatient echocardiographic imaging so that 75% of our patients have their echo procedure started within 120 minutes of procedure order entry.

(relative to the current time of 174 minutes August – October 2010)

16

Process FlowchartFocus on Echo Order Entry to Transport Order Entry to Echo Start Time



0

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100

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350

Order Received to First Frame Time (Unit vs. Floor Inpatients)Weekly 75th Percentile

Floor - 75th Unit - 75th Target - 75th

Week Of

# of

Min

utes

Why are the floor patients worse?

1. Focus on High Acuity2. Floor Patients are

brought to Diag. Card.

What can we do to make Diag. Card. more accessible given

inpatient variability?


0601-0630

0631-0700

0701-0730

0731-0800

0801-0830

0831-0900

0901-0930

0931-1000

1001-1030

1031-1100

1101-1130

1131-1200

1201-1230

1231-1300

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1431-1500

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Inpatient Volume by Order Received Time(Aug - Oct 2010)

Floor Unit

Order Received Time

Inpa

tient

Vol

ume

18

45.7%


Silent Brainstorming

Interventions Considereddesignated inpatient ultrasonographer emphasize to

outpatients they must arrive on time stop double/triple booking especially in morning better transport system take pending discharge patients

first better communication between patient’s nurse and diagnostic cardio department take inpatients as

ordered (first in, first out) schedule patients per room or per tech techs stop doing prelim reports

schedule patients thru lunchtime do more inpatients at bedside two staff arrive at 0630 get our own

courier have a room on 4East to do echos nurses from originating floor call to schedule their patient’s

testing originating floor unit attendants bring patient to our department get more machines, more echo techs send studies thru immediately don’t repeat

fellow studies



2121

Six Columns of ExcellenceEngage PEOPLE in a high-performing team to attain

patient- and family-centered care

Enhance SERVICE by expediting diagnostic testing

Minimize delay in diagnosis to improve QUALITY

Align GROWTH by epitomizing patient- and family-centered care related to echo imaging

Alleviate potential discharge delays and achieve FINANCIAL excellence

Best serve the COMMUNITY with effective and sensitive health care



22

ValueIT’S ALL ABOUT THE PATIENT!!!!!

120 minutes

Scheduling

Driver Diagram

Staffing

Patient Education

• Eliminate 0830 outpatient ADL slot• Eliminate double booking before

1000• Reserve afternoon slot for

inpatients

• 3 sonographers staffed at 0700• Dedicated patient transporter• Designated inpatient sonographer

• 4E Pilot Program• Quarterly patient survey

Aim Key Drivers Interventions



24

Interventions ChosenEliminate 0830

outpatient ADL slotEliminate double booking before

10003 sonographers staffed at 0700

4E Pilot Progra

m

Quarterly patient

survey

Reserve afternoon slot for inpatients

Designated inpatient

sonographerDedicated patient

transporter

Effort

Yie

ld

H

L

HL



Intervention Go-Live January 3, 2011

Goal = 120 Minutes



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ntion

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75th %ile Target 75th %ile

Week Of

# of

Min

utes

Problem and GoalCommunicated

To StaffVollrath Effect

CMS/Snow

Intervention

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ntion

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# of Tests 75th %ile Target 75th %ile

Week Of

# of

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utes

# of

Tes

ts



27

4E PFCC Pilot Program

─ Identification of inpatients with echo imaging orders

─ Unit clerk notification of nurse ─ Nurse prompt leads to patient education─ Educated and prepared patient



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tion

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Order Received to First Frame Time (4E vs. Not 4E)Weekly 75th Percentile

4E - 75th %ile Target Not 4E - 75th %ile

Week Of

# of

Min

utes



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Interven

tion

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4E Order Received to Transport Order Entry TimeWeekly 75th Percentile

75th %ile

Week Of

# of

Min

utes


Order Received to Transport Order Time (in minutes)

Order Received to First Frame Time (in minutes)

Baseline Intervention % Improvement Baseline Intervention %

Improvement

All Inpatients 201.5

(n = 343)127.5

(n = 147)

36.7% 174(n = 724)

152(n = 324)

12.6%

4 East 184.5 (n = 139)

105 (n = 49)

43% 206 (n = 169)

143 (n = 61)

30.6%

% Improvement of 75th PercentilesBaseline (Aug – Oct 2010)

to Intervention (Jan 3 – Feb 11th 2011)


Patient VoicePost-Intervention

─ 10/24 (42%) completed surveys─ 50% of patients report they were aware of ordered

procedure─ All patients aware of ordered procedure were told by

physician ─ 40% were also informed by nurse



32

Lessons Learned

Data! Data! Data!─ Data speaks for the patient and the process─ Don’t finger point until data is collected and

problem truly identified

Our Project Specialist is our friend─ Seek early intervention for database development



33

Next Steps

▪ Sustain improvement: Engage staff in data management

▪ Ongoing monitoring and quarterly reporting using new database tracking system

▪ Hospital-wide implementation of signature PFCC echo imaging/patient education program


Summary Our participation in the PI-LDP program promoted an

understanding of an evidence-based framework for organizational improvement in a complex environment with change based on facts that focus on results and create value.

The excellent guidance of Koby, Les, and Megan helped to change our paradigm of “numerical naivete” to one of true understanding so that we may hear the voice of the customer as well as the voice of the process.

Enhancement of our PFCC service value resulted in an improvement trend of reduced inpatient echo imaging delay and our ongoing commitment to P(lan)-D(o)-S(tudy)-A(ct).


Order Received to Transport Order Time (in minutes)

Order Received to First Frame Time (in minutes)

Baseline Intervention % Improvement Baseline Intervention % Improvement

All Inpatients 201.5

(n = 343)127.5

(n = 147)

36.7% 174(n = 724)

152(n = 324)

12.6%

Floor Only 202.3(n = 340)

130(n = 141)

35.7% 209.3(n = 412)

183(n = 185)

12.6%

Units Only N/A N/A 127.5(n = 312)

121.25(n = 139)

4.9%

4 East 184.5 (n = 139)

105 (n = 49)

43% 206 (n = 169)

143 (n = 61)

30.6%

Not 4 East 212 (n = 204)

156.25 (n = 98)

26% 164 (n = 555)

153.5 (n = 263)

6.4%

% Improvement of 75th PercentilesBaseline (Aug – Oct 2010)

to Intervention (Jan 3 – Feb 11th 2011)


Outpatient Echo Imaging Volumes

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150

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300

FY'10

FY'11


38

7:00 8:00 8:30 9:00 10:00

10:30

11:00

13:00

14:00

14:30

15:00

15:30

7:00 8:00 8:30 9:00 10:00

10:30

11:00

13:00

14:00

14:30

15:00

15:30

Kept

27 5 29 116 88 32 119 138 90 11 87 18

Cancelled

4 NaN 7 23 18 14 28 27 12 NaN 19 NaN

% Cancelled

0.12903225806451

6

0 0.19444444444444

8

0.16546762589928

1

0.16981132075471

7

0.30434782608695

7

0.19047619047619

4

0.16363636363636

4

0.11764705882353

0 0.17924528301887

1

0

1030507090

110130150170

3%

8%

13%

18%

23%

28%

33%

Outpatient Cancellations by Scheduled Time (Aug - Oct 2010)

Scheduled Time

Vo

lum

e o

f Sc

hed

ule

d A

pp

oin

tmen

ts

Per

cen

tage

of

Can

celle

d A

pp

oin

tmen

ts



39

Baseline Data CollectionTime of order entry

▪ September 1, 2010 – September 15, 2010▪ Total of 114 Patients▪ 51 (45%) of the total had an Order Received Time of 6:30 AM


Baseline Data

MeasureOrder Received –

First Frame(minutes)

Order Received – Report Signed

(minutes)

Collection Period August – October 2010 August – October 2010

N 726 728

Median 83.5 245

75th Percentile 173.75 358

Maximum 584 2821 (47 hours)

Average 118.88 293.88Standard Deviation 121.59 215

Documents

No Delay in Diagnosis Performance Improvement Leadership Development Program