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1/13/2017
1
Improving Access to Pediatric MR performed under General
Anesthesia— Benefits of a Rapid Improvement Event (RIE)
N I Sarwani, MD, FRCR, FSARM A Bruno, MS, MD, FACR
S Mrozowski, MHA, NRP, CPPSCorresponding email: [email protected]
Disclosures
• N Sarwani – No financial disclosure• M Bruno - Book royalties Oxford University
Press and Elsevier• S Mrozowski – No financial disclosure
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Background
• Timely access to imaging services for our most vulnerable patient population – children – is a vital aspect of radiology care.
• For small children, MR imaging must often be performed under general anesthesia (GA) to allow diagnostic quality images to be obtained.
Background
• Organizing a combined service to provide MRI under GA requires a complex interplay between the referring physician and the departments of anesthesiology and radiology, and scheduling backlogs will result when demand exceeds supply.
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Background
• In December 2014, at our tertiary academic medical center, the backlog for the 1st, 2nd and 3rd available MRI appointment to be performed under GA was > 87 days. This resulted in significant “downstream” delays in patient’s clinic appointments, especially for Pediatric Neurology and Neurosurgery, as MRI results are required at the time of clinic visit.
Background
• A dedicated MR scanner was used to scan patients under GA, 5 days a week.
• An additional MR scanner was allocated one day a week to scan more patients
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Background
• As additional scanner time and technologists resources were redirected to help address the backlog of GA cases, there was less scanner availability for other MRI studies, creating a broader patient access problem.
Purpose
• Accordingly, our 3 SMART goals were as follows:
1. Increase throughput of pediatric, out-patient, GA cases through the MRI scanner
2. Reduce both the average time and the variability of patient contact times for each appointment slot
3. Reduce the GA MRI waiting list to < 30 days.
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Methods
• A Rapid-Improvement Event (RIE), also known as a kaizen event, was co-sponsored by the departments of Radiology and Anesthesiology and coordinated by the institutional process improvement team utilizing Lean methodology.
• Key stakeholders in attendance included radiologists, anesthesiologist, technologists, radiology nursing, radiology schedulers and image management (IT) personnel.
Methods
• RIE team members dedicated 5 continuous days to allow for an intense, focused effort to complete the process improvement exercise
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Methods
• The DMAIC process was used as follows:– Define
• Mapping of existing processes, identifying pain points of the process from all stakeholders (radiology, anesthesiology, scheduling and nursing), and value analysis
– Measure• The group performed Gemba walks to observe the
current processes, performed Takt-time analysis, and completed a waste inventory
Methods
• The DMAIC process was used as follows:– Analyze
• Brainstorming sessions were performed, with root cause identification, benefit and effort analysis
– Improve• Finalize action items, future state map, develop
implementation and roll-out plan, pilot solutions– Control
• Create 30 day action list, development of control plan
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Methods
• Additionally, a representative from radiology met individually with all stakeholders to further understand their processes, clarify available resources, explore options for improvement and coordinate efforts
Areas of Concern
• Lack of availability of Anesthesia resources• Large gaps between patients during the
workday, wasting MR scanner time• Not infrequent number of patient “no-shows”• Parents not following dietary instructions• Patients scanned by appointment times, with
no regard to the age of the patient being scanned.
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Baseline Data
• The average wait time for the 1st and 3rd available MR exam to be performed under GA in December 2014 was 87 and 107 days, respectively.
4335 39 42 41 36
4437 38
50 50 50 56 55 56 5851 45
54 58 63 6457
6450
64 64 7078
7178
5771 71
93
56
8779
71
4533
15
44
5244 41
48 43 4344
3744
50 50 5056 55 56 58
5145
5458
63 6457
64
50
64 6470
7873
79
64
7871
93
56
8779
71
45
33
15
44
57
5143
5150
4851
3944
52 50 50
57 56 56 5856
60
67 5864 64
6464
64
7164
70
7878
84
78
92 94
93
93
107
106
104
100
90
100
93
7-Apr 7-May 7-Jun 7-Jul 7-Aug 7-Sep 7-Oct 7-Nov 7-Dec 7-Jan
Anes Availability Pre RIE
Anes 1 Exam Anes 2 Exam Anes 3 Exam
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Intervention
• The resources made available by the department of anesthesia were not found to be limiting.
• We discovered that the throughput of patients was reduced, in part, by the presence of “blocks” in the radiology scheduling template, which severely limited the availability of the dedicated GA MR scanner. The MRI scheduling template was modified to remove these restrictions.
Intervention• We addressed the high number of “no shows” by
making changes to the content of the pre-procedure phone calls and by requiring radiology nursing to speak directly to the patient or relative and not merely leave a message.
• Frequent failure of parents to follow dietary instructions leading to delayed/rescheduled cases was addressed by a re-design of written dietary instructions that are mailed to the patient.
• These interventions were all implemented simultaneously in May of 2015.
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New Workflow
Clinics will be given an appointment date only at the time of scheduling, without an exact time of the scan.
New Workflow5 days prior to the scan date, the exact order in which the patients will be scanned will be determined by the Dept of Anesthesia.
This process will allow the triage of our youngest, most vulnerable and complex patients to be preferentially scanned earlier during the day, while allowing our older, more able patients to be scanned later in the day.
Patients/guardians will be contacted by nursing staff, following existing standard of practice (SOP). In addition to providing dietary instructions for anesthesia, they will be given their appointment time.
3 attempts will made to directly contact the patient/guardian.
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New Workflow
New Workflow• Patients/guardians will receive a standard
letter approximately 10 days prior to their scan, mentioning scan date, dietary requirements as well as a FAQ of what to expect.
• (10 day notice was difficult to do as appointment times were in the 2-3 day range)
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Results
• After implementation of our intervention regimen, the average wait time for the 1st and 3rd available MR exam to be performed under GA fell precipitously, ultimately reaching the current level of < 7 days, exceeding our target.
40
94 101 98 93 96 92 91 9078 85 85 78 71 72
1636
9 111 15 16 10 9
27 2413 21
40
94101 98
93 96 92 91 90
7885 85
7871 72
22
42
142
28 28 23 23 2829 28
1421
94
97101 100
96 9694 91 91
8585 92
8578 72
35
63
58
39
33 3732
25 2929 29
1924
0
50
100
150
200
250
300
350
Anes Availability Post RIE
Anes 1 Exam Anes 2 Exam Anes 3 Exam
1/13/2017
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37332925211713951
100
75
50
25
0
Observation
Indi
vidu
al V
alue
_X=30.6UCL=42.5
LCL=18.7
Pre Post
37332925211713951
60
45
30
15
0
Observation
Mov
ing
Ran
ge
__MR=4.48
UCL=14.63
LCL=0
Pre Post
111
1111111
11
111
11
1
11
Control Chart - MR with GA Wait Times
Results
• As part of the control phase of the process, the wait times were continued to be monitored and showed a long lasting beneficial result of keeping wait time for GA MRI to less than 7 days.
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40
94 10198 93 96 92 91 9078 85 85 78 71 72
1636
9 111 15 16 10 9
27 2413 21 16 15 17 14 9 4 9 9 2 82
40
9410198
93 96 92 91 90
7885 85
7871 72
22
42
142
28 28 23 23 2829 28
1421
16 16 17 149 8 9 9
282
94
97101100
96 9694 91 91
8585 92
85
78 72
35
63
58
39
33 3732
25 2929 29
1924
18 17 1815
9 12 10 16
792
2/2/
2015
2/9/
2015
2/16
/201
52/
23/2
015
3/2/
2015
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2015
3/16
/201
53/
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015
3/30
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54/
6/20
154/
13/2
015
4/20
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54/
27/2
015
5/4/
2015
5/11
/201
5*5
-18-
2015
5/25
/201
56/
1/20
156/
8/20
156/
15/2
015
6/22
/201
56/
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7/6/
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7/27
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8/31
/201
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7/20
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14/2
015
9/21
/201
59/
28/2
015
10/5
/201
510
/12/
2015
10/1
9/20
1510
/26/
2015
Anes Availability Post RIE
Anes 1 Exam Anes 2 Exam Anes 3 Exam
Conclusion
• RIEs are a useful tool to bring together stakeholders to review complex healthcare delivery processes such as MR exams performed under GA.
• Identifying sources of inefficiencies as well as scheduling template errors led to a marked decrease in wait times for pediatric MR exams performed at our institution.
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Conclusion
• Shared buy-in from stakeholders allowed us to maintain our gains by development of a novel scheduling technique for these cases, resulting in increased patient throughput on the MRI scanner by decreasing “wasted” scanner downtime, as well as decreased “no show” and last-minute cancellations.
Conclusion
• Delays and rescheduled cases due to patients not following dietary restrictions also decreased.
• To date, the improvement has been long-lasting and sustained, with current data showing a wait of 2-3 days for a GA MRI.