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Department of Human Services

ToolkitRadiology

A toolkit of the Patient Flow Collaborative

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Toolkit Radiology


Introduction

Goals of the toolkit

Overview and strategy

Health service team

Processes

Data

Resources

Diagnostics and tools

Introduction

What is the radiology tool kit for?

The radiology toolkit has been designed to assist radiology teams and departments to resolve constraints to innovation in patient care.

Who should use the toolkit?

The tool kit provides ideas and solutions to possible constraints within radiology, anyone who is responsible for patent flow will benefit from using this tool.

What are the aims of the toolkit?

The Patient Flow Collaborative aims to remove unnecessary constraints or delays in patient flow by promoting a continuous flow of care. Radiology innovation is essential to providing a seamless efficient service to waiting patients.

How should we implement the concepts in this toolkit and change in our local context?

The toolkit will assist with provoking discussion and ideas, health service teams should operationalise any innovation idea to their local context.

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Toolkit Radiology



Introduction

The radiology toolkit is based on whole system thinking and includes a whole of hospital approach.

Goals

The specific goals of the toolkit are:

• Provide possible solutions to flow issues

• Build awareness of the management of capacity and demand

• Identify systematic methods to innovate in radiology

Your feedback

This first version of the radiology toolkit will stimulate discussion and innovation ideas and methods. The Patient Flow Collaborative welcomes feedback to enable subsequent versions of the toolkit.

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Introduction



Health service team

Processes

Data

Resources


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Toolkit Radiology


Whole system approach

A whole system approach is needed to effectively manage the variation in capacity and demand involved in radiology. Radiology is recognised to be a central point in this continuous flow of diagnosis and treatment for our patients.

Overview and strategyIntroduction



Health service team

Processes

Data

Resources


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Toolkit Radiology



Rigorous diagnostics

Agreed process

Access and

administration

Patient information

Organisational whole of hospital delivery

Radiology investigations and treatment modalities

Capacity and demand

Staff resource

AdministrationPolicy and leadership

Introduction



Health service team

Processes

Data

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Toolkit Radiology


Overview and strategyCapacity and demand

Staff resource


Capacity and demand

Staff resource


Capacity and demand

Staff resource

Administration

Policy and leadership

• Priority given to radiology services by board and local health community awareness of capital investment and issues.

• Identified board level report for radiology, leadership high priority for radiology management team.

• Policy stating maximum waiting times for emergency admitted and waiting patients.

• Essential data collected on capacity and demand for radiology services

• Staff resource plans undertaken regularly to promote, mentoring development and training. Roles redefined to maximise skill base and promote up-skilling of staff team.

• Administration systems in place which promote smooth allocation and booking of appointments and reporting results.

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Toolkit Radiology


Overview and strategyRigorous

diagnosticsAgreed process

Access and

administration

Patient information


Agreed process

Access and

administration

Patient information


Agreed process

Access and

administration

Patient information

• Capacity and demand, process mapping, tally chart data to be collected per diagnostic/treatment stream.

• High demand stream to be completed first.

• Once process is reviewed, redesign process to provide continuous process, advertise to staff/hospital as required.

• Advertise access timescales to all stakeholders.• Promote appointment system which pulls patients.• Agree date and time with patient.• Ask to confirm before appointment.• Manage DNA/FTA as per policy

• Provide patient information to promote quick appointment examination.• Make sure information given previous to attendance.

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Health service team

Processes

Data

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Toolkit Radiology


Health service teamIntroduction

Essential components of effective radiology services are skilled, trained and dedicated radiology staff. Teams who have clear roles, responsibilities, support and reporting lines will underpin effective patient flow.

Check list for radiology team

• Whole of hospital service strategy

• Executive sponsor for radiology team

• Clear reporting to supervisor or manager

• Skills recognised within whole team

• Opportunity for skill development

• Innovation champion

• Patient involvement champion

Clinical improvement team

It is important to identify a clinical and managerial lead for the Clinical Improvement team who will lead the innovations within radiology. A reporting line will be needed to an executive sponsor for the Patient Flow Collaborative executive team.

• Agree executive sponsor

• Agree clinical lead

• Agree managerial lead

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Toolkit Radiology


Processes

Appointment Administration

Triage

ReportingDNA/FTA TreatmentDischarge

•Plain film•Ultrasound•Mammograph•CT head and neck•MRI•Fluoroscopy•Nuclear medicine

Demand

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Example of simple process maps to start process

Processes

CONQUEST RADIOLOGY BOOKING PROCESS

REQUEST FORMS ARRIVE AT THE RECEPTION DESKVIA

INTERNAL POST EXTERNAL POST VACUUM TUBE HAND DELIVERY COURIER

DATE RECEIVED WRITTEN ON IT

SORTED INTO CATEGORIES

SPECIALS PLAIN FILMS

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Toolkit Radiology


Processes

REFERRALS ARE ONLYACCEPTED FROM MRALLEN OR ONCOLOGYCLINIC

REFERRALS RECEIVED INAPPOINTMENTS OFFICE

REFERRALS ARE CHECKEDTWICE A WEEK BYMAMMOGRAPHERS.PATIENT RADIOLOGYHISTORY CHECKED.FORM AUTHORISED

REQUEST FORMRETURNED TO PAT INAPPOINTMENTS FORBOOKING

PAT CHECKS WHETHERULTRASOUND SCAN ISREQUESTED AS WELL ASMAMMOGRAPHY

PAT CHECKS THE USAPPOINTMENT BOOK AND THEMAMMO APPOINTMENTSSHEET TO FIND SAME DAYAVAILABILITY

IF THIS MAKES APPOINTMENT TOOLONG TO WAIT FOR – SEPARATEAPPOINTMENTS ARE MADE

APPOINTMENT BOOKED ONCOMPUTER.DATE WRITTEN ON FORM

LETTER AUTOMATICALLYGENERATED AND SENT TOPATIENT

FORM FILED IN OFFICEUNDER DATE APPOINTMENTIS BOOKED FOR

ATTEMPTS TO FINDCONVENIENT DATE FORMAMMOGRAM ANDULTRASOUND TO BECARRIED OUT ON SAMEDAY

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Toolkit Radiology


Analysing the patient process

Processes

Having mapped the patient process, analyse by considering the following:

• How many steps are in the process?

• How many times is the patient passed from one person to another (hand-off)?

• What is the approximate time of each step?

• What is the approximate time between each step?

• What is the approximate time between first and last step?

• Where does the patient have a wait or have to queue?

• Where are there waiting lists in the system?

• How many steps add no value to the patient? (Ask patients)

• Where are there problems for patients – what do patients complain about?

• Where are there problems for staff?

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Toolkit Radiology


Identify referral entry points

Processes

• Single or multiple entry points?• Electronic or paper referrals?• All referrals to imaging room or reception?• Are there locations referrals could go to? That is, theatre, ED, other sites.• What work is done outside of normal hours that generates referrals?

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Toolkit Radiology


Develop a process map of the time it takes to see a patient

Processes

Check in – Undress – Preparation – Procedure - Reporting Method: • Identify start and end points of the procedure.• Agree how many activities in process. That is, check-in, pre check, consent,

discussion, patient changes, etc.• Identify the time it takes for each step. • Cross check with actual process.

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Toolkit Radiology


Process steps examples

Processes

Step Time per step

Patient checks in 2

Patient gets undressed 4

Consent taken 3

Patient positioned 2Scan 2

Patient get dressed 4

Patient waits 3

Post scan check 3

Patient leaves 2

Report on scan 10

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Toolkit Radiology


Process steps examples

Processes

Step Time per step

Colour code

Patient checks in 2

Patient gets undressed 4

Consent taken 3

Patient positioned 2Scan 2

Patient get dressed 4

Patient waits 3

Post scan check 3

Patient leaves 2

Report on scan 10

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Toolkit Radiology


Build your schedule

Processes

Use graph paper with one square per minute to sequence time scales per procedure.

1 MINUTE35 MINUTES

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Toolkit Radiology


Build your schedule

Processes

Transfer graph sequence timescales to chart clinic time.

9.00 am start12.00 pm end

Align steps to maximise use of equipment/radiology room/staff.

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Toolkit Radiology


Processes

Understand existing backlog Once schedules and processes have been reviewed, capacity and demand can be calculated for: • backlog and current demand• backlog = existing request still waiting• current demand = demand which will be made on service. Calculating backlog To calculate backlog you will need to use the previous time series calculations. • Identify time of request.• Identify from your sequence charts the time for this type of request.• Identify number of requests waiting.• Multiply time needed to do the procedure by number waiting. This will give you a measure of the time needed to clear your backlog.

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Toolkit Radiology


Processes

Current demand Daily demand calculations will promote effective management of radiology resources. Simple tally sheets can assist with this.

Referral type

Time to do

Referrals receivedM T W T F S S

e.g. CT

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Toolkit Radiology


Processes

Assistance with backlog

Options for assisting with backlog include:

• Waiting list telephone validation.

• Reduce inefficiencies – FTA rates, start times, cancelled sessions.

• Increase number of procedures in session by redesigning process and schedule.

• Introduce changes to working day; extended working days, evening sessions.

• Access capacity elsewhere.

• Use other resources/staff.

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Toolkit Radiology


Processes

Identity constraints that limit radiology equipment/specialists availability

Constraints may be due to:

• Waiting for portering

• FTA patients

• Short notice or cancellations (reasons?)

• Availability of clinical staff to prescribe and administer

• Availability of recovery areas or preparation areas

• Poor patient preparation

• Clinical staff performing no clinical duties

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Toolkit Radiology


• Appropriate imaging

– evidence based protocols

– registrar/consultant sign-off

– electronic prompts

– Easy consultation

• Process improvement

Imaging initiatives Appropriateness

Evidence based protocol

Consultant consultation

Personal consultation

Traffic light triage

Electronic prompts

ProcessesIntroduction



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Toolkit Radiology


Evidence Based Medicine

• Cervical spine injury?

• Head Injury

• Pulmonary Embolism?

• Deep vein thrombosis?

• 1st trimester bleeding

• Renal colic?

• Meningitis, Lumbar puncture or CT scan or treat?

Pulmonary Embolism and Evidence Based Medicine

Before

• 7 protocols

• 75% with PE have too many or too few tests

After

• one protocol

• 93% compliance




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Radiology Test Ordering (RTO)Traffic Light Guidelines

Clinical Indications must be on form

Red Tests Must be authorised by Specialist

Amber Tests Radiology form must be signed by a Registrar

Green Tests No restrictions on ordering All results must be checked before patient discharged

· Skull/Sinus/KUB· CT Chest/Abdo CT· Angiography/CT Angio· MRI· Paediatric CT· All radiology call backs

· AXR· T/L/S spine· CT Brain/CT C Spine· Abdo U/S· Pelvic US/O&G US· OPG/Facial Bones· F/B soft tissue· Renal Colic CT

· CXR· C-Spine· M/Skel. X-rays (excl. T/L/S Spine)· Pelvis

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Health service team

Processes

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Example from

Southern Health

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Measures

• Request to film completion

• Request to dictation complete

• Request until report typed

• Unreported cases at 5pm

• Protocol adherence

The Requesting Process

Nurse initiated

Faxing

Electronic

The consultation




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Toolkit Radiology


Filming/Scheduling Process

• Next waiting

• Reduced downtime

• Emergency AM slots

• Peripherally Inserted Central Catheter (PICC) story

• Porters story

• Responsiveness in CT, CXR

No Porters Data!

• 2 day audit was undertaken

• 22 observations of porters in room was made

• On 20 occasions between 1 - 5 porters were available in the porter’s room.




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Toolkit Radiology


Introduction



Health service team

Processes

Data

Resources



Example from

Southern Health

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Toolkit Radiology


Time from IP Request To Film5/03 3.40 HR (6.15)

(Max)

Time from ED Request to Film (average)

8/01 4.30 – 13.2 hours (23)

10/01 2.0 – 3.5 hours (11)

2/02 3/10 - hours (8)

5/03 1.0 - hours (3.3)

(Max)

Imaging Capacity AuditCT, 25days, no show 49/751

ED 2 days, 38%, 64% waiting




Health service team

Processes

Data

Resources



Improvements to time it takes Emergency Department patients to have radiology tests done

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Toolkit Radiology


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The Reporting Process

Hot reporting IP

Digital dictation

Weekend reporting

Evening reporting

Tele-reporting

Interims

Less priors

Before/After, % Typed 24 hours28/05/01 13/11/01 11/01/02 19/05/03

CT 79 100 100 100MRI 81 100 74 100NM 42 94 100 -ED 4 100 98 90US 80 100 94 100

Clerical Process

Digital dictation and dial-in

Interims

Remote reporting

Computer report distribution

Return films without reports

Eliminate report storage




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Toolkit Radiology


Data

Core data

Other Suggested Measures

Capacity and Demand

- Existing Capacity v Utilisation v Number Waiting

Did not Attend (DNA) rates per day/week

Cancellation rates (Hospital and Patient initiated)

Delays

- Monitor Radiology delays for one week to agree on the top 10 reasons. When this is agreed, 4 weeks data will be collected against the top 10 delays. Once 4 weeks of 10 delays have been gathered SPC charts can be produced. Time needs to be collected against each reason(s) per day, as the top ten offenders may not amount to the longest waste in time.

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Toolkit Radiology


Resources

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Change Concepts Redesign process to eliminate hands off, waste and complexity Implement ‘daily’ performance monitoring Redesign admin, booking and scheduling systems Increase scope and skills of radiology team, develop non-clinical staff as radiology technicians, develop consultant radiographer roles and extend scope of professional groups via development and protocols Develop electronic communication between primary care, in patient requests and radiology department Develop multi-skilled radiology administration and portering team Maintain permanent portering staff in radiology Develop and redesign request forms with supporting training, information and feedback

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Introduction



Health service team

Processes

Data

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Change Concepts

Rigorous diagnostic handbook

Data collection charts

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department of human services toolkit radiology a toolkit of the patient flow collaborative click...

Documents

radiology toolkit

toolkit overview

toolkit introduction

radiology innovation

radiology teams

radiology management

dedicated radiology

radiology tool kit