Decreasing the Turnaround Time (TAT) of Intra-operative Imaging and Interpretation

of Potentially Retained Foreign Objects (RFO)

Joseph R. Steele, M.D., Janet Champagne MBA, Garrett L.

Walsh, M.D.UT MD Anderson Cancer Center

Overview

• RFOs after surgery can present considerable risk and potential patient harm

• The rate of RFO ranges from 1/5500 to 1/7000• Cima RR, et al. J Am Coll Surg 2008; 207:80-7• Egorova NN, et al. Ann Surg 2008;247:13-8

• Considered a sentinel event by the Joint Commission

Project Overview

• Joint venture between the Division of Surgery, Perioperative Enterprise and Division of Diagnostic Imaging.

• X-ray obtained if post-operative mismatched count occurs.

• The turnaround times (TAT) for intra-operative imaging of potential RFOs was felt to be unacceptable by the Division of Surgery, potentially jeopardizing patient care.

• A team consisting of OR staff, surgeons, radiologists, administrators and radiology technologists was organized to address and solve the problem.

AIM Statement

• The aim of this project was to decrease the average TAT for imaging and interpretation of potential RFOs to less than 30 minutes within 4 months. – The process begins when the OR calls Diagnostic

Imaging requesting an operative radiograph, and ends when the radiologist calls back to the OR with their report.

The RFO Saga

Phase 1: Baseline Data Collection

• Improving the RFO TAT was unsuccessfully attempted by a previous CS&E team.

• Because of pressure to immediately begin improvement efforts, their data were used as a baseline.

Problem #1

Phase 1: Baseline Data

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90

80

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60

50

40

30

20

10

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Imaging performed in OR for potential RFO

Min

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_X=43.0

UCL=91.3

LB=0

RFO TAT stage 1

Mean TAT = 43 minutes, Not consistent with OR experience

Potential RFO Imaging ProcessRoutine Hours: Monday – Friday 0600 - 1800

Retained Foreign Objects or Incorrect Counts – Routine Hours revised: 7 April 2010O

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1. OR discovers a RFO or incorrect

count

5. CT DI Service Coordinator

receives call from OR.

(Manual time collection).

10. Radiologist or Radiology resident is made aware of RFO or incorrect

count in OR

12. Rad Tech arrives in OR with

x-ray unit(Begin procedure time is collected)

9. CT DI Service Coordinator calls

Radiologist or Radiology resident

using call tree

13. Rad Tech obtains images

4.Prepares patientand room for

X-ray

6. CT DI Services Coordinator calls 713 794-1178 to

request technologist dispatch

15. Images uploaded to PACS

and enters info into RIS.

(End Procedure time is collected)

3. Provides patient name, MRN, md code, svc code, type of exam, surgical types and

locations, call back number and OR room number

7. Technologist is dispatched to OR.

8. CT DI Service Coordinator enters

requisition into CARE.

2. OR calls CT DI Service Coordinator at

713 745-5449.

11. Rad Tech Changes

procedure code in RIS to one of the

RFO codes

14. Do images cover defined

areas?

Yes

No14a. Inform

surgeon additional images required.

14c. Assist technologist with positioning under

sterile field.

14b. Can technologist

obtain additional images?

Yes

No

14d. Instruct tech to perform imaging after closing or in

PACU.

14e. Technologist obtains images in

pre-defined location.

1

Potential RFO Imaging ProcessRetained Foreign Objects or Incorrect Counts – Routine Hours revised: 7 April 2010 page 2

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16. Rad Tech calls CT DI Service Coordinator at 713 745-5449 and informs procedure is

complete

17. CT DI Service Coordinator notifies

GI Radiologist images are complete.

(Manual time collection)

19. Radiologist instructs CT DI

Service Coordinator to contact OR

21. Report communicated to Physician Team in OR * Standard Read Back

(Manual time Collection)

20. DI CT Service Coordinator contacts

OR with Radiologist on the phone at the phone

number provided earlier.

18. GI Radiologist reviews images

1

Phase 2: Initial Interventions (The Good)

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90

80

70

60

50

40

30

20

10

0

Imaging performed in OR for potential RFO

Min

ute

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_X=43.0

_X=39.6

UCL=91.3UCL=88.2

LB=0 LB=0

1 2

RFO TAT stages 1 and 2

TAT improved to 39 minutes and represents a lengthier, complete process. Since there were no complaints, the quality of the exams were assumed to

be excellent. (Problem #2)

BIG PROBLEM (The Bad)

Miscount following TRAM flap

Patient returns to EC

Phase 3: Re-engineering (The Ugly)

81736557494133251791

120

100

80

60

40

20

0

Imaging performed in OR for potential RFO

Min

ute

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_X=43.0

_X=39.6

_X=47.8

UCL=91.3 UCL=88.2

UCL=122.1

LB=0 LB=0 LB=0

1 2 3

RFO TAT stages 1, 2 and 3

Image acquisition segment of the project is redesigned, resulting in expected disruption. Mean TAT increases to 48 minutes with increased

variation.

RFO Redemption

Phase 4: Final Interventions (The Redemption)

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120

100

80

60

40

20

0

Imaging performed in OR for potential RFO

Min

ute

s _X=43.0

_X=39.6

_X=47.8

_X=38.9

UCL=91.3 UCL=88.2

UCL=122.1

UCL=83.2

LB=0 LB=0 LB=0 LB=0

1 2 3 4

RFO TAT by project stage

Mean TAT decreased to 38 minutes, and variation decreased.

Revenue Enhancement

• Additional technical charge (OR)- $1200/hr– Savings of approximately $100.00/case

• Additional anesthesia charge (OR)- $342/hr– Savings of approximately $28.50/case

• Additional professional anesthesia charge (OR) $648/hr– Savings of approximately $54.00/case

Revenue Enhancement

• Total annual savings$182.50 X 264 (est.) = $48,180.00

• Avoidance of a RFO and potential litigation

PRICELESS

Next Steps

• Since we failed to meet our aim the following steps will be undertaken:– Evaluate stage 4 data – Improve communication (OR and DI staff)– Decrease repeat imaging– Initial PDSA cycles until the 30 minute TAT goal is

accomplished

Conclusion

• Quality improvement is not for the faint of heart.– You don’t know what you don’t know. – Understand what is going on before trying to

measure it.– Don’t assume anything.

• You don’t need to win every battle to win the war.