Adult and Pediatric radiology faced different challenges with a common theme: how to improve patient care and patient (and provider) experience by decreasing wait time from image to interpretation.
Adult radiology focused on the emergency department. Nearly half of emergency department visits require imaging* and since decision-making in the emergency department rests heavily on image interpretation, delays can have serious consequences. At UCH, efforts to tackle turnaround times began with a 2014 Institute for Healthcare Quality, Safety and Efficiency (IHQSE) ED turnaround time initiative, involving teams from the emergency, radiology and process improvement departments. Team members included Gerald Dodd, MD, James Borgstede, MD, Kristen Nordenholz, MD, Denise Snuttjer and Stephanie Prevost, RN.
(Pictured left to right: Prevost, Nordenholz, Borgstede, Snuttjer and Dodd)
Dr. Borgstede is professor of radiology and vice chair of clinical operations and quality at UCH. He explains that his team’s initial goal was to shave ten minutes off the process for CT scan requests.
“We actually managed to save 25 minutes,” he said. “This is a significant achievement from a financial perspective – the project is estimated to have saved the ED millions of dollars annually – but also represents a significant opportunity to improve patient satisfaction.”
The project at UCH involved two parts. The first focused on the ED, measuring the time from when the CT scan was requested to the time it was performed.
A dedicated transporter was allocated for CT patients in the ED with significant positive impact. The team also made better use of the CT tech assistant. “We realized it was better for CT tech assistants to act like air traffic controllers,” Dr. Borgstede said. “They now ask, ‘Is the patient ready for the CT?’ ‘Do they have an IV in place?’ ‘Are they appropriately clothed?’. This helps avoid having patients arrive at the CT scanner unprepared.”
The second stage of the UCH project focused on the radiologist’s interpretation of the exam, measuring the time from exam to final report. “Here the key was awareness,” Dr. Borgstede said. “Our technicians needed to send scans to the radiologists for prompt interpretation and the radiologists needed to interpret them promptly. The result was something of the Hawthorne Effect, where the team knew their efficiency was being monitored and so became more efficient.”
Dr. Borgstede and his team have also made other improvements, such as developing a “patient ready for radiology” notification in the electronic medical record, and reorganizing the levels of priority for radiological exams.
“Previously we had two levels of prioritization: stat and routine,” Dr. Borgstede explained. “But of course, everything came through as ‘stat.’ If everything is urgent, nothing is urgent, and so soon we will have nine levels of priority, from a trauma patient through to a patient who will be seen several months later.”
At Children’s Colorado, John Strain, MD, professor of radiology (Pictured at right) explained that a fall-off in turnaround-times spurred the team to act. “Our quality metric related to the percentage of cases we manage to turn around in under 45 minutes, from when the exam is started to when the formal report is signed by the radiologist,” he said.
“When we had only five radiologists, we all read a broad range of imaging. It was relatively easy to support a rapid turnaround time because everyone took responsibility for all of the imaging.
In an effort to improve and enhance the relevance of our practice, we began to sub-specialize. We now have subspecialists in Cardiac Imaging, Chest, MSK, Neuro and Body, and Fetal. In addition, each radiologist maintains a modality interest such as CT, MRI, or Nuclear Medicine. Sub-specialization improved our collaboration with specialty colleagues and added expertise to our practice. We did indeed add relevance to specialty care in pediatrics.
“Over time, however, our report turnaround times dropped from 95% to around 88%.” Given that between 85 and 90% of radiologic exams at Children’s Colorado are read by specialists, it was easy for the radiologists to become engrossed in their specialty and forget to assist with the more routine imaging. To ensure the turnaround times remain below 45 minutes, Dr. Strain and his team needed to boost accountability.
“We have a great team in that we act on consensus,” he said. “When we identify a problem, we all agree to address it. Then we collectively find a solution.”
“Our most significant and enduring improvement came when we assigned ED coverage to single radiologists in 1.5 hour time slots throughout the day. When everyone was accountable for achieving a report turnaround time, no one was specifically accountable. As soon as we made one individual accountable during his or her time slot, we started to see the metric improve, and we’ve since been consistently above 95%.”
Dr. Strain adds that it is important for the group to work as a team. “Our accountability measures are effective but we still need everyone’s cooperation to make it work. We still release ED cases to the whole group so that if one person happens to be busy, someone else can follow up.”
The key to success is teamwork. Dr. Borgstede said. “There’s been a real team approach to this project and it’s been great to see a rapport growing across departments. Everybody wants to improve the patient experience, and we hope everyone involved in the project, especially the transporters and tech assistants, see how much we value and appreciate all they do for our patients.”
*46.8%, according to http://www.cdc.gov/nchs/ahcd/web_tables.htm#t2014