PRACTICE POLICY AND QUALITY INITIATIVES
Note: This copy is for your personal non-commercial use only. To order presentation-ready copies for distribution to your colleagues or clients, contact us at www.rsna.org/rsnarights.
E18
Practice Policy and Quality Initiatives Improving Patient Access to an Interventional US Clinic1 Joseph R. Steele, MD, MMM Ryan K. Clarke, MHA John A. Terrell, MS Tonya R. Brightmon, MS, RT Abbreviation: CQI = continuous quality improvement RadioGraphics 2014; 34:E18–E23 Published online 10.1148/rg.341135062 Content Codes: From the Division of Diagnostic Imaging, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1479, Houston, TX 77030. Presented as an education exhibit at the 2012 RSNA Annual Meeting. Received April 15, 2013; revision requested June 6 and received July 1; accepted July 3. All authors have no financial relationships to disclose. Address correspondence to J.R.S. (e-mail: [email protected]). 1
Funding: The research was supported in part by the National Institutes of Health [grant number CA016672].
A continuous quality improvement project was conducted to increase patient access to a neurointerventional ultrasonography (US) clinic. The clinic was experiencing major scheduling delays because of an increasing patient volume. A multidisciplinary team was formed that included schedulers, medical assistants, nurses, technologists, and physicians. The team created an Ishikawa diagram of the possible causes of the long wait time to the next available appointment and developed a flowchart of the steps involved in scheduling and completing a diagnostic US examination and biopsy. The team then implemented a staged intervention that included adjustments to staffing and room use (stage 1); new procedures for scheduling same-day add-on appointments (stage 2); and a lead technician rotation to optimize patient flow, staffing, and workflow (stage 3). Six months after initiation of the intervention, the mean time to the next available appointment had decreased from 25 days at baseline to 1 day, and the number of available daily appointments had increased from 38 to 55. These improvements resulted from a coordinated provider effort and had a net present value of more than $275,000. This project demonstrates that structural changes in staffing, workflow, and room use can substantially reduce scheduling delays for critical imaging procedures. ©
RSNA, 2014 • radiographics.rsna.org
Introduction
Most experts agree that the rising cost of U.S. healthcare is unsustainable. Two options for immediate and direct cost savings are to lower payments or decrease services, neither of which necessarily results in better care for patients; hence, many experts have voiced a third option—eliminating waste (1). Total healthcare system waste has been estimated at $700 billion annually (2). One strategy that has proved effective in decreasing waste in industry and is being applied successfully to healthcare is continuous quality improvement (CQI) (3). We used CQI in our radiology department with great success to improve patient access to specific radiology services.
Background The neurointerventional ultrasonography (US) clinic at our cancer center is a specialty area that provides head and neck imaging and biopsy services. At a cancer center, these services are used to establish initial diagnosis, evaluate response to therapy, and monitor disease recurrence. In 2011, the clinic was unable to keep pace with the increasing patient volume, which resulted in marked scheduling delays for US-guided biopsies. Delays in patient access to the clinic also had the downstream effect of causing significant treatment delays across our institution (eg, at the melanoma, endocrine, and head and neck surgery centers).
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Figure 1. Ishikawa diagram identifies the primary and secondary causes of delays in scheduling US examinations and biopsies at a US clinic. The central horizontal line represents the main problem, the tangential lines extending from it represent categories of problems, and the arrows represent specific contributors. APN = advanced practice nurse, appts. = appointments, DIA = diagnostic imaging assistant, HTN = hypertension, NIR = neurointerventional radiology.
Problem Statement Progressive increases in institutional patient volume had resulted in a substantially increased patient volume at the neurointerventional US clinic. In 2011, the clinic had no additional patient capacity, and the wait time (time to next available appointment) for US examinations and biopsies had increased to 25 days. This wait time was considered unacceptable because of its effects on patient care at the referring centers.
Intended Improvement The purpose of this project was to improve patient access to the US clinic for diagnostic scans and biopsies. The specific aim was to decrease the mean time to next available appointment from more than 25 days to less than 5 days within 6 months.
Methods Planning Successful quality improvement efforts rely on the active participation of all individuals involved in patient care. A multidisciplinary team was formed that included a wide spectrum of personnel: three schedulers, two medical assistants, three nurses, eight technologists, and two physicians. The area manager was designated as the team leader, and the team met regularly to identify the causes of the long time to next available appointment for US examinations and biopsies, design potential improvements, and implement selected improvement strategies. Quality control tools, including an Ishikawa diagram, a process flowchart, and control charts, were employed throughout the project (4).
You are far more likely to identify problems, their causes, and effective solutions if you approach a quality improvement project systemically and use validated tools. After the first few meetings, the multidisciplinary team had created an Ishikawa diagram. Ishikawa diagrams (also called fishbone or causeand-effect diagrams) provide the structure necessary to effectively identify and organize the potential primary and secondary causes of a problem or event (5). An Ishikawa diagram frequently is used during the initial phase of improvement projects (6). To create an Ishikawa diagram, team brainstorming sessions are held to determine the possible causes of a named end result (in our project, the long wait time to next available appointment). Causes are grouped into categories (eg, scheduling, patients, procedures, and environment) that occupy the same branch of the diagram. Our diagram revealed a complicated problem with numerous potential contributing factors. Specific areas identified as potential causes were inefficient use of staff, difficult procedures for scheduling same-day add-on appointments, and poor use of clinic space (Fig 1). After the likely primary and secondary causes of the long wait times were identified, the team evaluated the entire care process and identified specific opportunities for improvement. One tool that provides a visual representation of the steps in a process is a flowchart (7). A flowchart shows the various steps in a process as a series of shapes connected by arrows. The shapes correspond to the type of activity; for example, ovals represent the start and end of a process, rectangles repre-
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Figure 2. Flowchart shows the entire process for completing a diagnostic US examination or US-guided biopsy after full implementation of the CQI project. Highlighted areas indicate the improvements made to appointment scheduling, patient check-in, and procedures. DI = diagnostic imaging, NIR = neurointerventional radiology, PSC = patient service coordinator, RIS = radiology information system.
sent generic steps, diamonds represent decision points, and parallelograms represent input and output. An accurate process flowchart helps visualize the workflow and its inconsistencies and identify areas of potential improvement. Our multidisciplinary team created a flowchart of the process for completing a diagnostic US examination and US-guided biopsy. Industrial engineers from the institution’s Office of Performance Improvement assisted the team and used direct observation to create the flowcharts. Do not rely only on opinions when creating a flowchart; ensure its accuracy by visiting the work area and observing the process in action. The steps involved in completing a US-guided biopsy were found to be quite complicated; the process from scheduling to completion of a biopsy included up to 47 discrete steps. With the complexity of the process documented and each step identified, it became easier to examine the need for each step and seek potential alternatives and efficiency gains. After examining the flowchart, the team tackled the problem of the long wait time to next available appointment through an integrated approach that addressed three key areas: scheduling, workflow, and room use. A simplified high-level flowchart of the im-
proved process is shown in Figure 2. The five highlighted areas represent improvements to the items that were identified on the Ishikawa diagram as causes of the long wait time.
Implementation Stage 1 (February through March 2011).—
Scheduling and room-use modifications were implemented to optimize the use of labor and capital resources. The initial analysis showed that staffing levels did not match the patient volume. A full staff arrived by 7 am, but the patient schedule was limited until 9 am. In the morning, there were more US technologists than patients; however, during peak hours, there were more patients than US technologists. In addition, patients reported a desire for earlier and later appointments. The scheduling template was changed to increase the number of patient appointments and expand the departmental hours of operation. Shifts for radiologists, technologists, patient service coordinators, and diagnostic imaging assistants were staggered to allow a continuous workflow. Two overlapping shifts were established to better utilize the facility, increase the number
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Figure 3. Run chart shows the weekly mean time in days to the next available appointment after implementation of the CQI project. The black squares represent the mean number of days to the next available appointment by week. The solid black line represents the median mean time in days to the next available appointment. The mean time to the next available appointment decreased from 25 days to 1 day by week 30. NIR = neurointerventional radiology.
of appointments available, and equalize provider workloads. For example, the US technologists’ new schedule matched the clinical appointment schedule; eight US rooms were staffed by eight US technologists only when eight appointment slots were available. A contracted receptionistscheduler was hired to accommodate the increased patient volume. Room use was scrutinized, and activities that did not require a US unit (eg, patient consent and education) were moved from the procedure room to a different area, thus optimizing the use of a limited resource. Patients completed all paperwork before entering the US room, thereby decreasing the amount of time spent with the US technologist. These improvements are highlighted in Figure 2 as “increase available appointments,” “patient begins filling out paperwork now,” “patient assessment done outside of US room,” and “patient escorted out of room for specimen review.” Stage 2 (March through April 2011).—Simpli-
fied procedures were implemented for scheduling same-day add-on appointments. Feedback solicited from the referring clinics indicated that the existing scheduling process was laborious and required too many approval steps. Managers and patient service coordinators worked closely with administrative directors from the referring clinics to further modify the workflow. A new process was instituted that eliminated the extensive communication required between the referring clinic and the US scheduler. Physicians and nurse practitioners were removed from the process of scheduling same-day add-on procedures unless a threshold of daily add-on cases was reached. If more than five appointments were added and overbooking was required, the physicians and nurse practitioners were consulted.
Historical data were used to calculate the average daily number of add-on cases, and a new scheduling template was created with designated slots for same-day add-on cases. Requirements for add-on cases were clearly defined on a checklist. The schedulers used the checklist to add cases without consulting the physicians and nurse practitioners. This improvement is highlighted in Figure 2 as “schedulers enable same-day add-on cases.” Whenever possible, create standard workflow processes to ensure consistent practice and a higher likelihood of long-term success. Stage 3 (July 2011 to the Present).—Stage 3
involved the designation of a local authority to optimize results. After the first two stages of the project were implemented, the time to next available appointment markedly decreased. To make the gains more permanent, a lead technician rotation was established in July 2011. Lead technicians were responsible for optimizing patient flow, staffing, and workflow. They were cross-trained to direct real-time problem-solving efforts, perform US examinations, and assist with biopsies if delays were encountered. Plan for the inevitable. Regardless of how well you have designed your process, it will fail at some point.
Evaluation The success of the interventions was measured as follows: (a) The time to next available appointment was measured using data gathered from the scheduling system. Although the time to third-next-available appointment typically is used, the time to next available appointment was used in this project because of the small clinic size. (b) The number of daily appointments available was evaluated by reviewing the templates in the electronic scheduling system. (c) Information
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Table 1: Effects of Quality Improvement Project on the Number of Available Daily Appointment Slots Month Type of Slot
January
February
March
April
May
June
July
US scan with biopsy US scan only Same-day add-on Total
10
10
10
14
16
16
16
18 10
18 10
23 10
24 12
25 14
25 14
25 14
38
38
43
50
55
55
55
Note.—The total number of available daily appointment slots increased from 38 to 55 (45%) from project implementation in February to project completion in July.
about room use, including procedure start and end times, was obtained from the radiology information system. Ensure that the data collection method is accurate, consistent, and preferably easy (eg, electronic capture of data).
Results Clinical Outcomes Implementation was completed in July 2011, and significant success was observed and measured. The mean time to next available appointment for diagnostic US and US-guided biopsy decreased from more than 25 days to 1 day, as shown in the run chart in Figure 3. A run chart, also known as a time series plot, allows any given data point to be compared over time (8), which helps determine the effects of changes made during an improvement effort. Run charts may not be as powerful as control charts (9), but they are easier to construct, are easy to interpret, and require no specific software. The data of interest are placed on the y-axis, with the time unit on the x-axis. In our project, the mean time to next available appointment for a given week was compared over time as modifications were made to the process. A run chart allows any given data point to be compared with the median. This is critically important in quality improvement because normal random variation must be differentiated from special cause variation. Special cause variation can reflect a potential underlying problem or a change in the process, and differentiation of special cause variation from normal random variation allows limited resources to be used more effectively (9). In a run chart, if many sequential data points are above or below but on the same side of the median, a special cause variation is indicated. In this project, the last 16 data points were below the median and represented nonrandom special cause variation. The special cause
variation was the result of the modifications made during the quality improvement project. The number of available daily patient appointments increased from 38 to 55 (Table 1). The total time required to schedule a patient, which included all precertification procedures, decreased from 25 minutes to 8 minutes. The mean time required to perform a diagnostic US examination, complete a US-guided biopsy, obtain preliminary pathologic interpretation, and perform postbiopsy education decreased from 90 minutes to 76 minutes.
Financial Return on Investment Because the demand for services was not sufficient to fill all of the new patient appointments created as a result of the intervention, project improvements resulted in only four additional US procedures performed each day. However, projected growth in patient volume will be more easily absorbed because of the efficiency gains from the quality improvement project. The neurointerventional US clinic will likely reach full patient capacity in 24–36 months. Supply cost and contribution margin calculations were performed at the procedural level using the institution’s cost accounting system, and the labor cost for team members was analyzed using a time-driven activity-based costing methodology (10,11). All calculations were based on the addition of four procedures per day (current caseload), not on the potential full capacity (future caseload). The initial labor cost for project development was $3905.85, and the sustained personnel cost was $0. The cost of the capital value used was very conservative to ensure that the net present value calculation would not be inflated. Thus, future revenues will be markedly discounted to be compared fairly to the current investment (Table 2). The project was both clinically and financially successful. The risk-adjusted return on invest-
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Steele et al E23
Table 2: Summary of Cost Calculations for Quality Improvement Project Year of Project Implementation Cost Factor
Year 0
Year 1
Year 2
Year 3
Cost of capital (%) Investments and costs ($) Benefits and revenue ($) Annual net benefit (revenue − costs) ($) Benefit and revenue, including soft savings ($) Annual net benefit (costs), including soft savings ($)
9.2 -3906 0 -3906
NA 0 120,919 120,919
NA 0 120,919 120,919
NA 0 120,919 120,919
0
120,919
120,919
120,919
-3906
120,919
120,919
120,919
Note.—With an initial investment of less than $4000, an annual revenue increase of more than $120,000 was obtained. NA = not applicable.
ment (net present value total benefit/net present value total cost) was 6959%. The internal rate of return (based on the rate of expected return) was 3906%. The net present value for 3 years was $275,722.78.
Conclusion
Significant financial and clinical benefit was obtained through the application of a CQI project. For an investment of less than $5000, we successfully implemented a project with a net present value of more than $250,000. Our success was predicated on three key points: (a) Approach quality improvement methodically. Have a broad representation; apply structured quality tools, such as Ishikawa diagrams and flowcharts; and measure outcomes with run charts or control charts. (b) Identify a critical path or limited resource and design the schedule to maximize it. We increased the number of daily patient appointments by 45% by implementing staggered shifts and moving nonprocedural activities from the procedure room. (c) When possible, standardize processes and create checklists to help team members function at the upper range of their skill set. By modifying the process of scheduling same-day add-on cases, we allowed physicians and nurse practitioners to focus on patient care while schedulers communicated with the referring clinics. Physicians do not need to solve every problem. Empower front-line supervisors to make realtime decisions and provide the flexibility to deal with uncertainty. The lead technician rotation was created to enable a local authority to adjust the schedule, modify the workflow, and poten-
tially cross-cover cases to ensure daily success in an ever-changing environment. Acknowledgment.—The authors acknowledge Stephanie
Deming for her help in preparing the manuscript.
References 1. Berwick DM, Hackbarth AD. Eliminating waste in US health care. JAMA 2012;307(14):1513–1516. 2. Kelley R. Where can $700 billion in waste be cut annually from the U.S. healthcare system? https:// healthleadersmedia.com/content/241965.pdf. Published 2009. Accessed June 25, 2013. 3. McLaughlin CP, Johnson JK, Sollecito WA. Implementing continuous quality improvement in health care: a global casebook. Sudbury, Mass: Jones & Bartlett Learning, 2012. 4. Kruskal JB, Reedy A, Pascal L, Rosen MP, Boiselle PM. Quality initiatives: lean approach to improving performance and efficiency in a radiology department. RadioGraphics 2012;32(2):573–587. 5. Ishikawa K. Guide to quality control: industrial engineering & technology. Tokyo, Japan: Asian Productivity Organization, 1976. 6. Breyfogle FW. Implementing Six Sigma: smarter solutions using statistical methods. 2nd ed. Hoboken, NJ: Wiley, 2003. 7. Tague NR. The quality toolbox. 2nd ed. Milwaukee, Wis: ASQ Quality Press, 2005. 8. George ML. The lean Six Sigma pocket toolbook: a quick reference guide to nearly 100 tools for improving process quality, speed, and complexity. New York, NY: McGraw-Hill, 2005. 9. Cheung YY, Jung B, Sohn JH, Ogrinc G. Quality initiatives: statistical control charts—simplifying the analysis of data for quality improvement. RadioGraphics 2012;32(7):2113–2126. 10. Albright HW, Feeley TW. A cancer center puts the new approach to work. Harv Bus Rev 2011;89(9): 61–62. 11. Kaplan RS, Anderson SR. Time-driven activity-based costing. Harv Bus Rev 2004;82(11):131–138, 150.
Teaching Points
January-February Issue 2014
Practice Policy and Quality Initiatives Improving Patient Access to an Interventional US Clinic Joseph R. Steele, MD, MMM • Ryan K. Clarke, MHA • John A. Terrell, MS • Tonya R. Brightmon, MS, RT RadioGraphics 2014; 34:E18–E23 • Published online 10.1148/rg.341135062 • Content Codes:
Page E19 You are far more likely to identify problems, their causes, and effective solutions if you approach a quality improvement project systemically and use validated tools. Page E20 Do not rely only on opinions when creating a flowchart; ensure its accuracy by visiting the work area and observing the process in action. Page E21 Whenever possible, create standard workflow processes to ensure consistent practice and a higher likelihood of long-term success. Page E21 Plan for the inevitable. Regardless of how well you have designed your process, it will fail at some point. Page E22 Ensure that the data collection method is accurate, consistent, and preferably easy (eg, electronic capture of data).
Note: This copy is for your personal non-commercial use only. To order presentation-ready copies for distribution to your colleagues or clients, contact us at www.rsna.org/rsnarights.
E18
Practice Policy and Quality Initiatives Improving Patient Access to an Interventional US Clinic1 Joseph R. Steele, MD, MMM Ryan K. Clarke, MHA John A. Terrell, MS Tonya R. Brightmon, MS, RT Abbreviation: CQI = continuous quality improvement RadioGraphics 2014; 34:E18–E23 Published online 10.1148/rg.341135062 Content Codes: From the Division of Diagnostic Imaging, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1479, Houston, TX 77030. Presented as an education exhibit at the 2012 RSNA Annual Meeting. Received April 15, 2013; revision requested June 6 and received July 1; accepted July 3. All authors have no financial relationships to disclose. Address correspondence to J.R.S. (e-mail: [email protected]). 1
Funding: The research was supported in part by the National Institutes of Health [grant number CA016672].
A continuous quality improvement project was conducted to increase patient access to a neurointerventional ultrasonography (US) clinic. The clinic was experiencing major scheduling delays because of an increasing patient volume. A multidisciplinary team was formed that included schedulers, medical assistants, nurses, technologists, and physicians. The team created an Ishikawa diagram of the possible causes of the long wait time to the next available appointment and developed a flowchart of the steps involved in scheduling and completing a diagnostic US examination and biopsy. The team then implemented a staged intervention that included adjustments to staffing and room use (stage 1); new procedures for scheduling same-day add-on appointments (stage 2); and a lead technician rotation to optimize patient flow, staffing, and workflow (stage 3). Six months after initiation of the intervention, the mean time to the next available appointment had decreased from 25 days at baseline to 1 day, and the number of available daily appointments had increased from 38 to 55. These improvements resulted from a coordinated provider effort and had a net present value of more than $275,000. This project demonstrates that structural changes in staffing, workflow, and room use can substantially reduce scheduling delays for critical imaging procedures. ©
RSNA, 2014 • radiographics.rsna.org
Introduction
Most experts agree that the rising cost of U.S. healthcare is unsustainable. Two options for immediate and direct cost savings are to lower payments or decrease services, neither of which necessarily results in better care for patients; hence, many experts have voiced a third option—eliminating waste (1). Total healthcare system waste has been estimated at $700 billion annually (2). One strategy that has proved effective in decreasing waste in industry and is being applied successfully to healthcare is continuous quality improvement (CQI) (3). We used CQI in our radiology department with great success to improve patient access to specific radiology services.
Background The neurointerventional ultrasonography (US) clinic at our cancer center is a specialty area that provides head and neck imaging and biopsy services. At a cancer center, these services are used to establish initial diagnosis, evaluate response to therapy, and monitor disease recurrence. In 2011, the clinic was unable to keep pace with the increasing patient volume, which resulted in marked scheduling delays for US-guided biopsies. Delays in patient access to the clinic also had the downstream effect of causing significant treatment delays across our institution (eg, at the melanoma, endocrine, and head and neck surgery centers).
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Steele et al E19
Figure 1. Ishikawa diagram identifies the primary and secondary causes of delays in scheduling US examinations and biopsies at a US clinic. The central horizontal line represents the main problem, the tangential lines extending from it represent categories of problems, and the arrows represent specific contributors. APN = advanced practice nurse, appts. = appointments, DIA = diagnostic imaging assistant, HTN = hypertension, NIR = neurointerventional radiology.
Problem Statement Progressive increases in institutional patient volume had resulted in a substantially increased patient volume at the neurointerventional US clinic. In 2011, the clinic had no additional patient capacity, and the wait time (time to next available appointment) for US examinations and biopsies had increased to 25 days. This wait time was considered unacceptable because of its effects on patient care at the referring centers.
Intended Improvement The purpose of this project was to improve patient access to the US clinic for diagnostic scans and biopsies. The specific aim was to decrease the mean time to next available appointment from more than 25 days to less than 5 days within 6 months.
Methods Planning Successful quality improvement efforts rely on the active participation of all individuals involved in patient care. A multidisciplinary team was formed that included a wide spectrum of personnel: three schedulers, two medical assistants, three nurses, eight technologists, and two physicians. The area manager was designated as the team leader, and the team met regularly to identify the causes of the long time to next available appointment for US examinations and biopsies, design potential improvements, and implement selected improvement strategies. Quality control tools, including an Ishikawa diagram, a process flowchart, and control charts, were employed throughout the project (4).
You are far more likely to identify problems, their causes, and effective solutions if you approach a quality improvement project systemically and use validated tools. After the first few meetings, the multidisciplinary team had created an Ishikawa diagram. Ishikawa diagrams (also called fishbone or causeand-effect diagrams) provide the structure necessary to effectively identify and organize the potential primary and secondary causes of a problem or event (5). An Ishikawa diagram frequently is used during the initial phase of improvement projects (6). To create an Ishikawa diagram, team brainstorming sessions are held to determine the possible causes of a named end result (in our project, the long wait time to next available appointment). Causes are grouped into categories (eg, scheduling, patients, procedures, and environment) that occupy the same branch of the diagram. Our diagram revealed a complicated problem with numerous potential contributing factors. Specific areas identified as potential causes were inefficient use of staff, difficult procedures for scheduling same-day add-on appointments, and poor use of clinic space (Fig 1). After the likely primary and secondary causes of the long wait times were identified, the team evaluated the entire care process and identified specific opportunities for improvement. One tool that provides a visual representation of the steps in a process is a flowchart (7). A flowchart shows the various steps in a process as a series of shapes connected by arrows. The shapes correspond to the type of activity; for example, ovals represent the start and end of a process, rectangles repre-
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Figure 2. Flowchart shows the entire process for completing a diagnostic US examination or US-guided biopsy after full implementation of the CQI project. Highlighted areas indicate the improvements made to appointment scheduling, patient check-in, and procedures. DI = diagnostic imaging, NIR = neurointerventional radiology, PSC = patient service coordinator, RIS = radiology information system.
sent generic steps, diamonds represent decision points, and parallelograms represent input and output. An accurate process flowchart helps visualize the workflow and its inconsistencies and identify areas of potential improvement. Our multidisciplinary team created a flowchart of the process for completing a diagnostic US examination and US-guided biopsy. Industrial engineers from the institution’s Office of Performance Improvement assisted the team and used direct observation to create the flowcharts. Do not rely only on opinions when creating a flowchart; ensure its accuracy by visiting the work area and observing the process in action. The steps involved in completing a US-guided biopsy were found to be quite complicated; the process from scheduling to completion of a biopsy included up to 47 discrete steps. With the complexity of the process documented and each step identified, it became easier to examine the need for each step and seek potential alternatives and efficiency gains. After examining the flowchart, the team tackled the problem of the long wait time to next available appointment through an integrated approach that addressed three key areas: scheduling, workflow, and room use. A simplified high-level flowchart of the im-
proved process is shown in Figure 2. The five highlighted areas represent improvements to the items that were identified on the Ishikawa diagram as causes of the long wait time.
Implementation Stage 1 (February through March 2011).—
Scheduling and room-use modifications were implemented to optimize the use of labor and capital resources. The initial analysis showed that staffing levels did not match the patient volume. A full staff arrived by 7 am, but the patient schedule was limited until 9 am. In the morning, there were more US technologists than patients; however, during peak hours, there were more patients than US technologists. In addition, patients reported a desire for earlier and later appointments. The scheduling template was changed to increase the number of patient appointments and expand the departmental hours of operation. Shifts for radiologists, technologists, patient service coordinators, and diagnostic imaging assistants were staggered to allow a continuous workflow. Two overlapping shifts were established to better utilize the facility, increase the number
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Steele et al E21
Figure 3. Run chart shows the weekly mean time in days to the next available appointment after implementation of the CQI project. The black squares represent the mean number of days to the next available appointment by week. The solid black line represents the median mean time in days to the next available appointment. The mean time to the next available appointment decreased from 25 days to 1 day by week 30. NIR = neurointerventional radiology.
of appointments available, and equalize provider workloads. For example, the US technologists’ new schedule matched the clinical appointment schedule; eight US rooms were staffed by eight US technologists only when eight appointment slots were available. A contracted receptionistscheduler was hired to accommodate the increased patient volume. Room use was scrutinized, and activities that did not require a US unit (eg, patient consent and education) were moved from the procedure room to a different area, thus optimizing the use of a limited resource. Patients completed all paperwork before entering the US room, thereby decreasing the amount of time spent with the US technologist. These improvements are highlighted in Figure 2 as “increase available appointments,” “patient begins filling out paperwork now,” “patient assessment done outside of US room,” and “patient escorted out of room for specimen review.” Stage 2 (March through April 2011).—Simpli-
fied procedures were implemented for scheduling same-day add-on appointments. Feedback solicited from the referring clinics indicated that the existing scheduling process was laborious and required too many approval steps. Managers and patient service coordinators worked closely with administrative directors from the referring clinics to further modify the workflow. A new process was instituted that eliminated the extensive communication required between the referring clinic and the US scheduler. Physicians and nurse practitioners were removed from the process of scheduling same-day add-on procedures unless a threshold of daily add-on cases was reached. If more than five appointments were added and overbooking was required, the physicians and nurse practitioners were consulted.
Historical data were used to calculate the average daily number of add-on cases, and a new scheduling template was created with designated slots for same-day add-on cases. Requirements for add-on cases were clearly defined on a checklist. The schedulers used the checklist to add cases without consulting the physicians and nurse practitioners. This improvement is highlighted in Figure 2 as “schedulers enable same-day add-on cases.” Whenever possible, create standard workflow processes to ensure consistent practice and a higher likelihood of long-term success. Stage 3 (July 2011 to the Present).—Stage 3
involved the designation of a local authority to optimize results. After the first two stages of the project were implemented, the time to next available appointment markedly decreased. To make the gains more permanent, a lead technician rotation was established in July 2011. Lead technicians were responsible for optimizing patient flow, staffing, and workflow. They were cross-trained to direct real-time problem-solving efforts, perform US examinations, and assist with biopsies if delays were encountered. Plan for the inevitable. Regardless of how well you have designed your process, it will fail at some point.
Evaluation The success of the interventions was measured as follows: (a) The time to next available appointment was measured using data gathered from the scheduling system. Although the time to third-next-available appointment typically is used, the time to next available appointment was used in this project because of the small clinic size. (b) The number of daily appointments available was evaluated by reviewing the templates in the electronic scheduling system. (c) Information
E22 January-February 2014
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Table 1: Effects of Quality Improvement Project on the Number of Available Daily Appointment Slots Month Type of Slot
January
February
March
April
May
June
July
US scan with biopsy US scan only Same-day add-on Total
10
10
10
14
16
16
16
18 10
18 10
23 10
24 12
25 14
25 14
25 14
38
38
43
50
55
55
55
Note.—The total number of available daily appointment slots increased from 38 to 55 (45%) from project implementation in February to project completion in July.
about room use, including procedure start and end times, was obtained from the radiology information system. Ensure that the data collection method is accurate, consistent, and preferably easy (eg, electronic capture of data).
Results Clinical Outcomes Implementation was completed in July 2011, and significant success was observed and measured. The mean time to next available appointment for diagnostic US and US-guided biopsy decreased from more than 25 days to 1 day, as shown in the run chart in Figure 3. A run chart, also known as a time series plot, allows any given data point to be compared over time (8), which helps determine the effects of changes made during an improvement effort. Run charts may not be as powerful as control charts (9), but they are easier to construct, are easy to interpret, and require no specific software. The data of interest are placed on the y-axis, with the time unit on the x-axis. In our project, the mean time to next available appointment for a given week was compared over time as modifications were made to the process. A run chart allows any given data point to be compared with the median. This is critically important in quality improvement because normal random variation must be differentiated from special cause variation. Special cause variation can reflect a potential underlying problem or a change in the process, and differentiation of special cause variation from normal random variation allows limited resources to be used more effectively (9). In a run chart, if many sequential data points are above or below but on the same side of the median, a special cause variation is indicated. In this project, the last 16 data points were below the median and represented nonrandom special cause variation. The special cause
variation was the result of the modifications made during the quality improvement project. The number of available daily patient appointments increased from 38 to 55 (Table 1). The total time required to schedule a patient, which included all precertification procedures, decreased from 25 minutes to 8 minutes. The mean time required to perform a diagnostic US examination, complete a US-guided biopsy, obtain preliminary pathologic interpretation, and perform postbiopsy education decreased from 90 minutes to 76 minutes.
Financial Return on Investment Because the demand for services was not sufficient to fill all of the new patient appointments created as a result of the intervention, project improvements resulted in only four additional US procedures performed each day. However, projected growth in patient volume will be more easily absorbed because of the efficiency gains from the quality improvement project. The neurointerventional US clinic will likely reach full patient capacity in 24–36 months. Supply cost and contribution margin calculations were performed at the procedural level using the institution’s cost accounting system, and the labor cost for team members was analyzed using a time-driven activity-based costing methodology (10,11). All calculations were based on the addition of four procedures per day (current caseload), not on the potential full capacity (future caseload). The initial labor cost for project development was $3905.85, and the sustained personnel cost was $0. The cost of the capital value used was very conservative to ensure that the net present value calculation would not be inflated. Thus, future revenues will be markedly discounted to be compared fairly to the current investment (Table 2). The project was both clinically and financially successful. The risk-adjusted return on invest-
RG • Volume 34 Number 1
Steele et al E23
Table 2: Summary of Cost Calculations for Quality Improvement Project Year of Project Implementation Cost Factor
Year 0
Year 1
Year 2
Year 3
Cost of capital (%) Investments and costs ($) Benefits and revenue ($) Annual net benefit (revenue − costs) ($) Benefit and revenue, including soft savings ($) Annual net benefit (costs), including soft savings ($)
9.2 -3906 0 -3906
NA 0 120,919 120,919
NA 0 120,919 120,919
NA 0 120,919 120,919
0
120,919
120,919
120,919
-3906
120,919
120,919
120,919
Note.—With an initial investment of less than $4000, an annual revenue increase of more than $120,000 was obtained. NA = not applicable.
ment (net present value total benefit/net present value total cost) was 6959%. The internal rate of return (based on the rate of expected return) was 3906%. The net present value for 3 years was $275,722.78.
Conclusion
Significant financial and clinical benefit was obtained through the application of a CQI project. For an investment of less than $5000, we successfully implemented a project with a net present value of more than $250,000. Our success was predicated on three key points: (a) Approach quality improvement methodically. Have a broad representation; apply structured quality tools, such as Ishikawa diagrams and flowcharts; and measure outcomes with run charts or control charts. (b) Identify a critical path or limited resource and design the schedule to maximize it. We increased the number of daily patient appointments by 45% by implementing staggered shifts and moving nonprocedural activities from the procedure room. (c) When possible, standardize processes and create checklists to help team members function at the upper range of their skill set. By modifying the process of scheduling same-day add-on cases, we allowed physicians and nurse practitioners to focus on patient care while schedulers communicated with the referring clinics. Physicians do not need to solve every problem. Empower front-line supervisors to make realtime decisions and provide the flexibility to deal with uncertainty. The lead technician rotation was created to enable a local authority to adjust the schedule, modify the workflow, and poten-
tially cross-cover cases to ensure daily success in an ever-changing environment. Acknowledgment.—The authors acknowledge Stephanie
Deming for her help in preparing the manuscript.
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Teaching Points
January-February Issue 2014
Practice Policy and Quality Initiatives Improving Patient Access to an Interventional US Clinic Joseph R. Steele, MD, MMM • Ryan K. Clarke, MHA • John A. Terrell, MS • Tonya R. Brightmon, MS, RT RadioGraphics 2014; 34:E18–E23 • Published online 10.1148/rg.341135062 • Content Codes:
Page E19 You are far more likely to identify problems, their causes, and effective solutions if you approach a quality improvement project systemically and use validated tools. Page E20 Do not rely only on opinions when creating a flowchart; ensure its accuracy by visiting the work area and observing the process in action. Page E21 Whenever possible, create standard workflow processes to ensure consistent practice and a higher likelihood of long-term success. Page E21 Plan for the inevitable. Regardless of how well you have designed your process, it will fail at some point. Page E22 Ensure that the data collection method is accurate, consistent, and preferably easy (eg, electronic capture of data).
