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Improving Efficiency in the Angiography Suite

Kamran Ahrar, M.D.Elizabeth Ninan, PA-C

Jasmine NovoGradac, MBA,BSN,RNTerrell Evans, RT (R)(CT)(MR)

Division of Diagnostic ImagingSection of Interventional Radiology

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Background• Limited Capacity

– Total of 3 Angiography Suites at Alkek (Main Hospital)– 2 have up-to-date equipment, used routinely– 1 out-dated unit, used as an overflow room

• Increasing Demand for Angiography or Fluoroscopy Guided Procedures– Increasing number of patients with liver tumors receiving

liver-directed therapies– Alkek expansion project: Additional hospital beds– Anticipated 17% increase in overall volume for 2011

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AIMTo Reduce the

Inter-Procedure Time Interval in the Angiography Suite

by 20% by August 6, 2010

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Angiography Suite Turn Over Process D

efin

ition

sT

echn

olog

ist

Pro

cedu

re

Nur

seM

D Starts Next Procedure

Finishes procedure

(Gloves Come Off)

Transport Patient Out of the

Angiography Suite

N3 N5N4N1 N6N2

Bring Next Patient Into the

Angiography Suite

T2T1

N1-N6: Multiple tasks the procedure nurse has to complete before brining the

next patient in.T1-T2: Tasks the technologists has to

complete before bringing the next patient into the angio suie

Vacant Angio Suite

Inter-procedure Time Interval

Baseline DataSnapshot of Angiography Suite Utilization

May 24 to May 28, 2010

• Each box represents 10 minutes• Time intervals were rounded to the nearest 10-minute mark• Call cases are not included

Procedure in Progress

Vacant Angio Suite

• A-10 and A-11: High Quality Angio Suites• A-9 Old Equipment, used as overflow procedure room

1 -- 2 2 -- 3 3 -- 4 4 --5 5 -- 67 -- 8 8 -- 9 9 -- 10 10 --11 11 -- 12 12 -- 1

7 -- 8

A-09

5--27

5--28

A-11A-10A-09A-11A-10

8 -- 9 9 -- 10 10 --11 11 -- 12 12 -- 1 1 -- 25--24

5--25

A-11A-10A-09

5 -- 6

A-11

2 -- 3 3 -- 4 4 --5

A-11A-10A-09

5--26

A-10A-09

Baseline DataMetric: Inter-procedure Time Interval

Baseline DataMetric: Vacant Angio Suite (between procedures)

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PROLONGED INTERPROCEDURE

INTERVAL

POLICIES

PROCESSES

Site Marking

Scheduling

Transport

PATIENTS

Not NPOLab Results

Not Availalbe

Blood ProductsDelays

Arrived Late

EQUIPMENT

PICIS Connection Lost

STAFF

Cardiology Consult

RN Unavailablein post 8 to 9 am

RN Completing Tasksafter Procedure

Inadequate Nursing Staffing Related to Resources

Main Causes of Inefficiency

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PROLONGED INTERPROCEDURE

INTERVAL

POLICIES

PROCESSES

Site Marking

Scheduling

Transport

PATIENTS

Not NPOLab Results

Not Availalbe

Blood ProductsDelays

Arrived Late

EQUIPMENT

PICIS Connection Lost

STAFF

Cardiology Consult

RN Unavailablein post 8 to 9 am

RN Completing Tasksafter Procedure

Inadequate Nursing Staffing Related to Resources

Main Causes of Inefficiency

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Strategy to Improve Efficiency

• Make sure patients are properly worked-up and ready to be transferred to the angiography suite

• Make sure the angiography suite is clean and properly set-up to receive the patient

• Make sure there is a nurse available to transfer the patient into the angiography suite as soon as the suite becomes available

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Angiography Suite Turn Over Process: Main InterventionF

loat

Nur

seM

DT

echn

olog

ist

Pro

cedu

re

Nur

seD

efin

ition

s

Finishes procedure

(Gloves Come Off)

T2

Transport Patient Out of the

Angiography Suite

N6N1 N2

T1

N5

Bring Next Patient Into the

Angiography Suite

N3 N4

Starts Next Procedure

Receives Hand Off from Float

Nurse

Gives Hand Off to Procedure Nurse

Vacant Angio Suite

Inter-procedure Time Interval

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Other Interventions• Patient Preparation/Readiness

– Confirmations of appointments– MLP worked up of patients (blood products, pre-medications, consents)– Anticipate Cancellations– Improve Coordination with the OR for combined interventions– Dedicated Two Transport staff to IR

• Room Readiness

– The Charge technologist will assist to complete tasks– Medical Assistant will help clean up the room and set up new procedure tray

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• Each box represents 10 minutes• Time intervals were rounded to the nearest 10-minute mark• Call cases are not included

Procedure in Progress

Vacant Angio Suite

• A-10 and A-11: High Quality Angio Suites• A-9 Old Equipment, used as overflow procedure room

Final DataSnapshot of Angiography Suite Utilization

August 2 to August 6, 2010

A-11A-10A-09A-11A-10A-09A-11A-10A-09A-11A-10A-09A-11A-10A-09

1 -- 2 2 -- 3 3 -- 4 4 --5 5 -- 67 -- 8 8 -- 9 9 -- 10 10 --11 11 -- 12 12 -- 1

8--03

8--04

8--05

8--06

1 -- 2 2 -- 3 3 -- 4 4 --5 5 -- 68--02

7 -- 8 8 -- 9 9 -- 10 10 --11 11 -- 12 12 -- 1

Results Metric: Inter-procedure Time Interval

Testing for Statistical SignificanceInter-procedure Time Interval

Two-Sample T-Test and CI: Inter-procedure Interval

Two-sample T for Inter-procedure Interval

Period N Mean StDev SE MeanPost 47 47.7 20.4 3.0Pre 39 62.5 26.1 4.2

Difference = mu (Post) - mu (Pre)Estimate for difference: -14.8595% CI for difference: (-24.82, -4.89)T-Test of difference = 0 (vs not =): T-Value = -2.96 P-Value = 0.004 DF = 84Both use Pooled StDev = 23.1389

P-value <.05, so Pre and Post Means are statistically

significantly different at the 95% level

ResultsMetric: Vacant Angio Suite (between procedures)

Testing for Statistical SignificanceVacant Angio Suite(between procedures)

Two-Sample T-Test and CI: Vacant Room Time (between procedures)

Two-sample T for Vacant Room(between procedures)

Period N Mean StDev SE MeanPost 47 26.6 18.2 2.7Pre 39 39.8 23.6 3.8

Difference = mu (Post) - mu (Pre)Estimate for difference: -13.2295% CI for difference: (-22.21, -4.24)T-Test of difference = 0 (vs not =): T-Value = -2.93 P-Value = 0.004 DF = 84Both use Pooled StDev = 20.8484

P-value <.05, so Pre and Post Means are statistically

significantly different at the 95% level

Return on Investment• Pilot Period: 5 days, tracked over 70 patients, reviewed 47 Intervals

– 9.4 Intervals per day– Reduced Suite Vacancy by 13.22 minutes per interval

• Total Gain: 124.27 minutes per day– Anticipated Gains:

• Ability to accommodate additional patients and procedures– Increased patient satisfaction– Shorter length of stay– Additional revenues

• Ability to finish scheduled cases in a timely fashion– Less overtime– Higher job satisfaction, improved morale, better staff retention

• Unexpected secondary gain of charges from PA work up of patients the day prior to procedure

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Min (conservative) MaxCharges for 1 additional procedure

Charges for 2 additional procedures per day

Revenue 1 2Avg. CHARGE per Procedure 4,623.58$ 4,623.58$ Potential CHARGE per Day 4,623.58$ 9,247.16$ Total Work Days per Year 250 250Potential CHARGES per Year 1,155,895.00$ 2,311,790.00$ Additional CHARGES generated from MLP role expansion and billable/year 200,000.00$ 200,000.00$

Total Potential CHARGES per Year 1,355,895.00$ 2,511,790.00$

Costs

Cost of an additional RN 75,000.00$ 75,000.00$

Cost of an 0.5 MA 18,000.00$ 18,000.00$

Cost of an additional PA 85,000.00$ 85,000.00$

Total costs 178,000.00$ 178,000.00$

Net Potential Gain per Year 1,177,895.00$ 2,333,790.00$

Return on Investment: Most Optimistic

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Return on Investment: Most Conservative Min (conservative) Max

1 additional patient per day

2 additional patients per day

Contribution to Margin per Patient $200.00 $200.00

Avg. Procedure per Patient 2.40 2.40 Avg. Work Days per Year 250 250

Potential Revenue per Year $120,000.00 $240,000.00 Additional Charges generated from MLP role expansion and billable/year $200,000.00 $200,000.00

Total Potential Margin per Year $320,000.00 $440,000.00

Costs

Cost of an additional RN $75,000.00 $75,000.00

Cost of an 0.5 MA $18,000.00 $18,000.00

Cost of an additional PA $85,000.00 $85,000.00

Total costs $178,000.00 $178,000.00

Net Potential Revenue Gain per Year $142,000.00 $262,000.00

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Min (conservative) MaxNet Revenues for 1 additional procedure per day

Net Revenues for 2 additional procedures per day

Addional Procedure 1 2Avg. Revenue per Procedure 1,444.00$ 1,444.00$ Potential Revenue per Day 1,444.00$ 2,888.00$ Total Work Days per Year 250 250Potential Revenue per Year 361,000.00$ 722,000.00$

Additional Charges generated from MLP role expansion and billable/year 200,000.00$ 200,000.00$ Total Potential Revenue per Year 561,000.00$ 922,000.00$ Costs

Cost of an additional RN 75,000.00$ 75,000.00$ Cost of an 0.5 MA 18,000.00$ 18,000.00$ Cost of an additional PA 85,000.00$ 85,000.00$ Total costs 178,000.00$ 178,000.00$ Net Potential Revenue Gain per Year 383,000.00$ 744,000.00$

Return on Investment: Most Likely

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Moving Forward• Future Actions:

– The float nurse was a temporary solution we had pulled from our outpatient facility– As of now, we are not able to provide the float nurse function to keep the vacant angiography suite time to a minimum– We have requested additional nurses for 2011– If approved, a nurse will be assigned to the function tested in this pilot

• Maintained Actions:– Work-up of patients the day before (generating $ 200K E & M charges)– Confirming appointments–Charge tech helping with room turn over

•Quarterly Audits

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Conclusion

• Reduction in the Inter-Procedure Time Interval for the Angiography Suite by 24 %

• Reduction in the Vacant Angiography suite by 33%

Outcomes: – Accommodate additional patients

– Provide a better work environment

– Generate additional revenues

•Allocation of resources is justified

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Thank you.

Acknowledgements:M. D. Anderson CS&E Faculty and Staff

Tatiana Hmar-Lagroun, Project FacilitatorJames A. Terrell, Applied StatisticsMichael J. Wallace, MD; Sponsor