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Department of Radiology: ED/CT Patient Turnaround Time Improvement Project Mary Washington Hospital Background Fredericksburg, Virginia • 442 bed community hospital located in Fredericksburg, Virginia • 50 bed Emergency Department treating over 100,000 patients annually • Emergency Department using electronic charting software, Amelior. • Received Trauma II designation September 2008 Imaging Services Background • Full service Radiology department providing Diagnostic X-ray, Nuclear Medicine, CT, MRI, Ultrasound and Interventional Radiology 24/7 • On site Radiologist providing real time interpretation 24/7 using Powerscribe voice to text recognition. • Web based Philips iSite PACS accessible across organizational enterprise • Staffed with 162 FTE’s 24/7 to support over 190,000 procedures annually with 66,000 procedures originating from the ED. Kaizen Event Overview CT Department Overview ED/Radiology Improvement Team • A Kaizen Event is a team-based process improvement technique with the following characteristics: • Usually 3-4 full days in duration • Heavy bias towards change and action • Environment of trust, cooperation, transparency, and ownership • Uses a mix of very accessible techniques • Equipment Resources • Philips 64 slice • Siemens Sensation 16 slice • Philips MX 8000 4 slice • Siemens Duo 2 slice with CT fluoro (used primarily by Interventional Radiology. • Staff Resources – Department staffed 24/7 • CT Supervisor – 1.0 FTE • CT Technologists – 10.0 FTE’s • CT Assistants – 6 FTE’s • Team meets bi-weekly and consists of representatives from Radiology, Emergency Department, Information Systems, and Industrial Engineering. • Team’s charter is to bring forth and address operational barriers to success. • Members are assigned ownership of opportunities and report back to team with recommendations and solutions Thank you to the staff and physician members of the Mary Washington Hospital Radiology and Emergency Departments. These improvements could not have been made without the commitment of all involved. • Team comprised of Radiology and Emergency department physicians, management, and front line staff members to improve CT turnaround time through the use of LEAN methodology. • Target Turnaround times identified as: • 124 mins for CT with contrast (oral and/or intravenous contrast media) • 60 mins for CT without contrast • Turnaround time measured from order entry to results signed (ORE-RS) CT/ED Turnaround Time Goals and Objectives Summary • Applying LEAN methodology and maintaining engagement of the staff yielded the following improvements: • ED CT with contrast, average TAT decreased 16 mins and volume increased 24% over 2007 baseline data • ED CT without contrast, average TAT decreased 6 mins and volume increased 23% over 2007 baseline data • CT staff productivity averaging 104% 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 CT with Contrast 124 min 156 144 147 155 158 153 150 149 163 153 148 141 144 a) Order Placement to Begin Procedure 79 min 110 106 100 112 110 107 102 104 114 108 102 96 95 b) Present to Radiologist to Results Signed 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) Order Placement to Begin Procedure 25 min 48 46 48 56 55 54 47 48 54 49 49 41 38 b) Present to Radiologist to Results Signed 25 min 21 17 21 20 22 19 19 19 20 19 18 17 19 Radiologist Turnaround Time Non contrast target = 25 mins • Contrast target = 30 mins 2007 Baseline CT With Contrast Target TAT 124 mins CT Department Emergency Department SPAGHETTI DIAGRAM CT/ED PATIENT FLOW Total nursing and CT transport walking = 4 hours per day Total annual cost $35,000 CT with Contrast 2008-2009 TAT Target 124 mins CT FLOW MAP Identified Opportunities for Improvement • Patient location, • Pre procedure prep tasks, • Queuing congestion in CT Without Contrast Order to Results Sent With Contrast Order to Results Sent Process Improvements • CT oral contrast prep process changed: • Implemented Oral Omnipaque, prepared by CT Staff • Contrast refrigerator added to ED medication room • Par level established to decrease prep delivery time. • Cost Savings: $6.80 per patient, 2008 annual savings: $47,750 • Contrast waste ELIMINATED • PACS scanners on each CT computer to avoid bottlenecks • CT Assistant duties enhanced: • Obtain lab values • Complete medical history forms • Room preparation • Patient Transport • Patient positioning • Charge Tech assigned to manage workflow • CT Technologist staffing increased by 1.6 FTE’s January, 2009 • Added dedicated phone line in CT for ED use • Room turnover time decreased from 15 mins to 9 mins. • Added instant messaging technology using Primordial, a dedicated tool for communication between Technologist and Radiologist. • PACS icons added to Amelior terminals. • ED Physicians able to view PACS images “in progress”. • QC Technologist designated as Radiology’s point of contact for patient flow issues. • Modified Nursing orders for CT prep task completion. • Radiology Contrast administration algorithm provided. • Non acute patients for imaging studies placed in central location. Where Are We Now? • May 2009 - Rapid Improvement Team to decrease CT without contrast TAT to 60 mins by June 30, 2009 • Prioritized non contrast CT’s to MX8000 and Duo scanners • Negotiated with Lab to send patient to CT first 1Q 2009: 86 Minutes 2Q 2009: 77 Minutes -9 Minutes • With the work done by the RIT, the contrast CT’s were positively affected. Target 124 mins 1Q 2009: 155 Minutes 2Q 2009: 144 Minutes -11 Minutes • CT Associate overall job satisfaction improved 38% • Improving staff and physician access to software applications improved communication, patient location, medical history, imaging, and results • CT room turnover time decreased by 6 mins • Annual cost savings for oral contrast $ 47,750.00 in 2008 • Radiologist staffing pattern adjusted to support increasing ED volume Donna R. Morris, CRA, R.T. (R) (MR) Director, Radiology Mary Washington Hospital, Fredericksburg, VA

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Page 1: Department of Radiology: ED/CT Patient Turnaround Time ... · • Obtain lab values • Complete medical history forms • Room preparation • Patient Transport • Patient positioning

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

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