Department of Radiology: ED/CT Patient Turnaround Time Improvement Project

Mary Washington Hospital Background

Fredericksburg, Virginia

• 442bedcommunityhospitallocatedinFredericksburg,Virginia

• 50bedEmergencyDepartmenttreatingover100,000patientsannually

• EmergencyDepartmentusingelectronicchartingsoftware,Amelior.

• ReceivedTraumaIIdesignationSeptember2008

Imaging Services Background• FullserviceRadiologydepartment

providingDiagnosticX-ray,NuclearMedicine,CT,MRI,UltrasoundandInterventionalRadiology24/7

• OnsiteRadiologistprovidingrealtimeinterpretation24/7usingPowerscribevoicetotextrecognition.

• WebbasedPhilipsiSitePACSaccessibleacrossorganizationalenterprise

• Staffedwith162FTE’s24/7tosupportover190,000proceduresannuallywith66,000proceduresoriginatingfromtheED.

Kaizen Event Overview

CT Department Overview

ED/Radiology Improvement Team

• AKaizenEventisateam-basedprocessimprovementtechniquewiththefollowingcharacteristics:

•Usually3-4fulldaysinduration •Heavybiastowardschangeandaction •Environmentoftrust,cooperation,

transparency,andownership •Usesamixofveryaccessibletechniques

• EquipmentResources •Philips64slice •SiemensSensation16slice •PhilipsMX80004slice •SiemensDuo2slicewithCTfluoro(used

primarilybyInterventionalRadiology.

• StaffResources–Departmentstaffed24/7 •CTSupervisor–1.0FTE •CTTechnologists–10.0FTE’s •CTAssistants–6FTE’s

• Teammeetsbi-weeklyandconsistsofrepresentativesfromRadiology,EmergencyDepartment,InformationSystems,andIndustrialEngineering.

• Team’scharteristobringforthandaddressoperationalbarrierstosuccess.

• Membersareassignedownershipofopportunitiesandreportbacktoteamwithrecommendationsandsolutions

ThankyoutothestaffandphysicianmembersoftheMaryWashingtonHospitalRadiology

andEmergencyDepartments.Theseimprovementscouldnothavebeenmadewithoutthecommitmentofallinvolved.

• TeamcomprisedofRadiologyandEmergencydepartmentphysicians,management,andfrontlinestaffmemberstoimproveCTturnaroundtimethroughtheuseofLEANmethodology.

• TargetTurnaroundtimesidentifiedas:

•124minsforCTwithcontrast(oraland/orintravenouscontrastmedia)

•60minsforCTwithoutcontrast

• Turnaroundtimemeasuredfromorderentrytoresultssigned(ORE-RS)

CT/ED Turnaround Time Goals and Objectives

Summary• ApplyingLEANmethodologyandmaintainingengagementofthestaffyieldedthefollowing

improvements:• EDCTwithcontrast,averageTATdecreased16minsandvolumeincreased24%over

2007baselinedata• EDCTwithoutcontrast,averageTATdecreased6minsandvolumeincreased23%over

2007baselinedata• CTstaffproductivityaveraging104%FYTD

June July Aug Sept Oct Nov Dec Jan Feb March April May June TaRGET 2008 2008 2008 2008 2008 2008 2008 2009 2009 2009 2009 2009 2009

average Time - TaT for CTwith Contrast 124 min 156 144 147 155 158 153 150 149 163 153 148 141 144

a)OrderPlacementtoBeginProcedure 79 min 110 106 100 112 110 107 102 104 114 108 102 96 95

b)PresenttoRadiologisttoResultsSigned 30 min 28 25 30 26 29 26 27 24 29 26 25 23 25

average Time - TaT for CT without Contrast 60 min 81 74 83 90 93 91 82 83 90 84 83 75 73

a)OrderPlacementtoBeginProcedure 25 min 48 46 48 56 55 54 47 48 54 49 49 41 38

b)PresenttoRadiologisttoResultsSigned 25 min 21 17 21 20 22 19 19 19 20 19 18 17 19

Radiologist Turnaround TimeNon contrast target = 25 mins • Contrast target = 30 mins

2007 Baseline CT With ContrastTarget TaT 124 mins

CTDepartment

Emergency Department

SpaGHETTI DIaGRaMCT/ED paTIEnT FlOW

TotalnursingandCTtransportwalking=4hoursperday

Totalannualcost$35,000

CT with Contrast2008-2009 TaT

Target 124 mins

CT FlOW Map

IdentifiedOpportunitiesforImprovement•Patientlocation,•Preprocedurepreptasks,•QueuingcongestioninCT

Without ContrastOrder to Results Sent

With ContrastOrder to Results Sent

process Improvements• CToralcontrastprepprocesschanged:

• ImplementedOralOmnipaque,preparedbyCTStaff• ContrastrefrigeratoraddedtoEDmedicationroom• Parlevelestablishedtodecreaseprepdeliverytime.• CostSavings:$6.80perpatient,2008annualsavings:$47,750 • ContrastwasteElIMInaTED

• PACSscannersoneachCTcomputertoavoidbottlenecks

• CTAssistantdutiesenhanced:• Obtainlabvalues• Completemedicalhistoryforms• Roompreparation• PatientTransport• Patientpositioning

• ChargeTechassignedtomanageworkflow

• CTTechnologiststaffingincreasedby1.6FTE’sJanuary,2009

• AddeddedicatedphonelineinCTforEDuse

• Roomturnovertimedecreasedfrom15minsto9mins.

• AddedinstantmessagingtechnologyusingPrimordial,adedicatedtoolforcommunicationbetweenTechnologistandRadiologist.

• PACSiconsaddedtoAmeliorterminals.

• EDPhysiciansabletoviewPACSimages“inprogress”.

• QCTechnologistdesignatedasRadiology’spointofcontactforpatientflowissues.

• ModifiedNursingordersforCTpreptaskcompletion.

• RadiologyContrastadministrationalgorithmprovided.

• Nonacutepatientsforimagingstudiesplacedincentrallocation.

Where are We now?• May2009-RapidImprovementTeamtodecreaseCTwithoutcontrastTATto60minsbyJune

30,2009

• PrioritizednoncontrastCT’stoMX8000andDuoscanners

• NegotiatedwithLabtosendpatienttoCTfirst 1Q 2009: 86 Minutes 2Q 2009: 77 Minutes -9 Minutes

• WiththeworkdonebytheRIT,thecontrastCT’swerepositivelyaffected.Target124mins 1Q 2009: 155 Minutes 2Q 2009: 144 Minutes -11 Minutes

• CTAssociateoveralljobsatisfactionimproved38%• Improvingstaffandphysicianaccesstosoftwareapplicationsimprovedcommunication,

patientlocation,medicalhistory,imaging,andresults• CTroomturnovertimedecreasedby6mins• Annualcostsavingsfororalcontrast$47,750.00in2008• RadiologiststaffingpatternadjustedtosupportincreasingEDvolume

DonnaR.Morris,CRA,R.T.(R)(MR)Director,RadiologyMaryWashingtonHospital,Fredericksburg,VA