ed-ct exam turnaround time - loyola...

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ED-CT Exam

Turnaround Time

Lean Six Sigma Green Belt Project

CT Staff ED Staff

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Problem Statement:

From Jan – Jun 2012, the average turnaround time for Head CT exams

(without contrast) performed in the ED was 68 minutes. The average turnaround

time for Abdomen/Pelvis CT exams (with contrast) was 201 minutes.

Primary Measure: Turnaround time = order to preliminary report

Business Case:

By reducing turnaround time, we will improve patient throughput in ED,

increase patient engagement, and provide a better patient experience.

Scope:

Project Charter

D M A I C

In Out

CT exams performed in the ED:

• Head CT exams without contrast

• Abdomen / Pelvis (Abd/Pel) CT

exams with contrast

• All other CT exams

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Project Timeline (start dates):

Project Charter

D M A I C

Define Aug 15

Measure Aug 30

Analyze Sep 18

Resources:

• Champion: Dawn Csipo Assnt. Mng of ED, Kim Lenner Admin. Dir of Radiology

• Team Leader: Cliff Sissel Mgt of CT Rad

• Team: Radiology CT Techs, ED Nursing

• OpEx Practitioners: Sandy Chakonas and Jordan Erickson

Improve Sep 28

Control Nov 15

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High-Level Map (SIPOC)

D M A I C

Supplier Input Process Output Customer

ED MDs

ED RNs

CT Techs

Lab

Patient

Order

1. MD orders CT

2. Lab draws, prep

given

3. CT Tech transports

pt to exam room

4. CT scan completed

5. Pt returned to ED

room

6. Exam is reported to

MD

Images

Reports

Patient

ED MDs

Other

clinical

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Process Map

D M A I C

Process map highlighted:

• Big gap in communication between ED RNs and CT Techs

• Patients not informed

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360300240180120600

180

160

140

120

100

80

60

40

20

0

Turnaround Time (minutes)

Fre

qu

en

cy

CT Exams: Head(January - June 2012)

Mean

Baseline Data

D M A I C

N (exams) 995 25th Percentile 36

Mean 68 Median 59

StdDev 44 75th Percentile 91

Data source: RIS; Jan – Jun 2012;

removed TAT > 400 minutes (0.5% of exams)

Head: Turnaround time is skewed to the right

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25

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15

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Fre

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CT Exams: Abdomen/Pelvis(January - June 2012)

Mean

Baseline Data

D M A I C

N (exams) 251

Mean 201

StdDev 61

Abd/Pel: Turnaround time is much longer and more “bell-shaped”

25th Percentile 163

Median 200

75th Percentile 237

Data source: RIS; Jan – Jun 2012;

removed TAT > 400 minutes (0.5% of exams)

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Baseline Data

D M A I C

Turnaround times for Head and Abd/Pel are stable week-to-week

JunMayAprMarFebJan

Wk23Wk19Wk14Wk10Wk06Wk01

100

90

80

70

60

50

40

Me

an

Tu

rna

rou

nd

Tim

e (

min

ute

s)

CT Exams: Head(January - June 2012)

JunMayMayAprMarMarFebJanJan

Wk25Wk22Wk19Wk16Wk13Wk10Wk07Wk04Wk01

300

250

200

150

100

Me

an

Tu

rna

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Tim

e (

min

ute

s)

CT Exams: Abdomen/Pelvis (January - June 2012)

# of CT exams Min Median Max

Head 152 163 192

Abd/Pel 34 42 57

Monthly volume:

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Baseline Data

D M A I C

We divided each exam’s turnaround time into three segments:

1. Order to begin exam

2. Begin exam to complete exam

3. Complete exam to preliminary report

Then we calculated each segment’s percentage of the total turnaround time

for all Head and Abd/Pel CT exams:

Order Prelim Begin Complete

Turnaround Time


40% 16% 44%

Head CT Exams


70% 8% 22%

Abd/Pel CT Exams

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We brainstormed 27 potential causes to delays in turnaround time. We

affinitized these potential causes into 5 general categories:

1) Orders / Contrast (wrong order, MD examining pt

after placing order, PO contrast)

2) Protocoling (Rad Resident busy, conference)

3) Patients

(non-compliance, language)

4) Nursing / Ancillary (waiting for lab results, RN busy)

5) Other (Holding Trauma room, lack of communication)

Identify Potential Causes

D M A I C

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We voted on what we believed to be the 3 most influential root causes:

1) CT room held for traumas

2) Delay in PO contrast

3) Delay in lab tests

Table these for another project:

• Delay in protocoling

• ED busy

Determine Root Causes

D M A I C

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Suspected Root Causes Verification

1) CT room held for traumas 53% of traumas did not need CT

exam (56 out of 105 exams)

2) Delay in PO contrast Time from order to begin exam

consumes 70% of turnaround time

3) Delay in lab tests NOT a root cause

Verify Root Causes

D M A I C

120600

480

420

360

300

240

180

120

60

0

CT Order to Lab Result (minutes)

Tu

rna

rou

nd

Tim

e (

min

ute

s)

Turnaround Time vs Creatinine Lab Results

(Removed 4 extreme values: turnaround > 500 minutes)

(CT Exams: Abdomen/Pelvis, N = 106)

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We brainstormed possible solutions for each root cause. We voted on and

selected 3 solutions to implement:

Root Causes Solutions

1) CT room held Determine CT room hold time

for traumas ED notify Techs when trauma in-house

2) Delay in PO contrast Tech assumes active role in

CT preparations

Possible Solutions

D M A I C

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Determine CT room hold time

ED notify Techs when

trauma in-house

We met with Dr. Esposito (Dir of Trauma

to discuss data and agreed to

continue CT workflow without

holding the room through comm.

between Tech and trauma Chief

regarding pending exams

Future State

D M A I C

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Tech assumes active role in CT preparations

Future State

D M A I C

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We created a Gantt chart of the tasks that needed completion in order to

implement the solutions; the “go live” date was Nov 1

Pilot Plans

D M A I C

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Head CT exams are faster and more predictable (Before: Jun, After: Nov)

Results

D M A I C

*P-value = 0.04, two-sample t test **P-value = 0.03, Mann-Whitney test †P-value = 0.03, Levene’s test

Avg exams per month: 163

Hours saved per month: 30

40

30

20

10

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30

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Before


# o

f C

T H

ead

Exa

ms

After

CT Exams: Head(Before: Jun; After: Nov)

Median

Median

(minutes) N Mean StdDev Median IQR

Before 152 66 41 58 52

After 124 58 36 47 36

* 8 **

5 † 11

16

18

8

6

4

2

0

360300240180120600

8

6

4

2

0

Before


# o

f C

T A

bd

/Pel

Exa

ms

After

CT Exams: Abd/Pel(Before: Jun; After: Nov)

Median

Median

Abd/Pel CT exams are faster (Before: Jun, After: Nov)

Results

D M A I C

*P-value = 003, two-sample t test **P-value = 0.02, Mann-Whitney test †P-value = 0.52, Levene’s test

Avg exams per month: 42

Hours saved per month: 29

(minutes) N Mean StdDev Median IQR

Before 44 203 65 204 96

After 47 174 58 163 88

* 29 **

7 † 41

8

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Control Plan

D M A I C

What Who When

• Handed out education material to ED staff;

posted material in ED

Cliff 11/1/12

• Monitor turnaround times;

present results in ED and CT staff meetings

Cliff Ongoing

Educational Material

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• ED RN: It’s nice to see we are working hard as a team to make the

patient experience better by speeding up the processes.

• ED RN: “Went to check on a patient, they were drinking contrast, I

hadn’t realized a CT was ordered, saved about an hour and

a half of time on their length of stay in the ED”

• CT Tech: “The nurse’s seem to really like that we are involved it frees

them up to focus on other patients and not feel they are

ignoring the patient that we prep.”

• ER RN: When it is busy we will still prep the patient especially if we

know the tech is busy.

• CT Tech: I realized prepping my patient was the right thing when she

told me my explanation put her as ease and that she looked

forward to seeing me in a hour for the test.

Lessons Learned

D M A I C

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