Special radiology procedures can be some of the most difficult to manage in healthcare. Their production relies on the chorus of a multidisciplinary team working within a limited time frame. Ancillary department performance can directly affect outcome performance for the unit. Defects such as missing orders, missing history and physicals or problems with patient flow can develop into bottlenecks that hinder the efficiency of the unit.

In an effort to improve the efficiency of the Specials Radiology Department, Baptist St. Anthony’s Hospital in Amarillo, Texas, USA initiated an improvement project in May of 2006. The goals of this project were to improve start times, increase throughput, implement control mechanisms for continuous improvement and to provide feedback to ancillary departments concerning performance.

Identifying Issues and Resolutions

The project team began by scoping the subjective complaints of staff into a data collection tool and constructing a database. The DMAIC (Define, Measure, Analyze, Improve, Control) framework was utilized to accelerate the improvement process. Six Sigma tools were used in data analysis, Work-Out strategies were utilized in team meetings, and Lean was implemented for operational improvements. The team defined a defect as an event occurring to prevent the start of a procedure. The team further identified defects occurring within the department, and defects occurring outside the department. Defects occurring within the department were targeted for immediate improvement. Defects outside the department were compiled and reported back to the ancillary department to become future projects.

Initial data collection lasted four weeks using the team generated defect sheet. The team utilized a Pareto chart to prioritize the defects; see the charts below.

Next, zeroing in on the processes involving labs, patients and orders, process maps were used to segregate value-added and non-value-added steps. Once the stakeholders could visualize the bottlenecks involved with patient flow, team workouts resulted in viable options for throughput improvements.

Laboratory turnaround times averaged outside the allotted preparation time for patients on the day of the procedure. This was investigated and determined to be a result of the high volume of laboratory requests not only from the day surgery department, but the entire hospital during the early morning hours. The team worked to improve opportunities to perform laboratory work prior to the day of the procedure. By shifting the majority of requests to pre-admit department requests, this changed the lab requests from early morning day-of day surgery department requests to day-before pre-admit department requests. These requests also would become more normally distributed rather than skewed toward early morning. This involved altering the walk-in status of the pre-admit department to scheduled opportunities.

Improving the opportunity to pre-admit patients also provided staff with a patient contact point to increase patient compliance with procedures. Patients who, whether because of a mistake or a language barrier, might cause delays by failing to observe an NPO order (nothing to eat or drink prior to procedure), to bring a signed consent form, to arrive on time could be educated and procedures reinforced prior to the day of their procedure.

The physician order process was restructured to work incoming orders on the day the order was sent by the physician. Previously, orders were worked 24 hours prior to procedure, but this did not provide the time and opportunities necessary to provide complete and correct orders at the scheduled procedure time. Currently, the staff reviews the orders and sends a confirmation to the physician’s fax stating whether the order is complete or requires further information. Also, the ordering process was redesigned to take advantage of an electronic order/confirmation process to improve the hospital-physician communication. This allows ancillary departments to receive their order information from the radiology department versus a call back to the physician’s office.

Results Following Improvements

After implementing the solutions of the team, final project measurements were taken in October and tracking through the use of control mechanisms was handed off to the stakeholders. The table below outlines the results.

The percent of delayed cases dropped to 33 percent. Also, delays per case fell from 1.4 in May to .75 by October. Delays within the department decreased by 22 percent.

Orders missing/clarified in the Specials Lab dropped to zero for October. In redesigning the order process for the Specials Lab, all of outpatient radiology faxed orders were incorporated in the change process. Currently, the hospital receives orders from more than 500 physicians at an average rate of 250 orders per day. Thus, this one aspect of the project affects more than 90,000 orders per year.

Multiple physician offices were contacted prior to the close of the project to determine any improvements in customer satisfaction in regards to fewer call-backs on faxed orders. Every single one of the physician’s offices contacted reported satisfaction with decreased call-backs.

The Lessons Learned

Many hospital procedures require a multidisciplinary approach throughout the patient contact timeline, but are not engineered to provide team members feedback on their performance. This fosters the attitude that a defect can be passed down stream and fixed on the back end. With this misplaced vision, “back-end fixing” undermines teamwork and promotes the perception that team members are pushing mistakes to the next team member in line.

The hospital improvement team learned that customer contact begins the instant the physician attempts to send an order to the hospital, and it does not end until the patient has reached home safely. Seeing the first contact point as the physician sending the order provides the opportunity to fix any defects at the first opportunity. This is the moment the correction will cost the least and necessitate the minimum amount of effort.

The project empowered the department to identify the delays they were responsible for preventing, and identify the delays requiring feedback to ancillary departments. The control mechanisms also help identify which departments are best suited to address each category of delay. Finally, with control mechanisms in place, the team is able to recognize the efforts of each individual team member, and thus foster better teamwork.

By using data-driven tools and utilizing stakeholder teams, the project results at Baptist St. Anthony’s Hospital demonstrates how outcomes as well as culture can be changed for the benefit of customers.