Quality Improvement Report: Improving Pre- and Postprocedure Care Area Workflows at a Busy Urban Academic Hospital Using Lean Management Principles.

Radiology procedure workflow is a summation of individual workflows for scheduling, precertification, preprocedure clinic visits, and day of procedure, representing a complex total process with many opportunities for inefficiencies and waste. At the authors' institution, a lack of standard work and communication gaps in a pre- and postprocedure care area (PPCA) workflow were identified as factors in bottlenecks, waits and delays, and staff and patient frustrations. Using "lean" process improvement tools, these workflows were targeted in a rapid improvement event (RIE). A cross-functional team was formed to work on the PPCA workflow RIE. Using lean management principles, process gaps were identified and changes were instituted to improve patient and information flow. Three projects were implemented over a course of 4 months. These included a 5S, a lean methodology of workplace organization to optimize supply cabinets; standardization of nursing preprocedure documentation and process; and standard work confirmation in daily management system huddles. At baseline, 45% of patients were prepared within 60 minutes of their arrival in the PPCA. After the RIE and instituting the changes from the RIE, 80% of patients were prepared within 60 minutes of their arrival in the PPCA. Implementing lean management strategies, such as daily management systems and huddles, and establishing standard work confirmation help to eliminate waste and create systems and teams that sustain and improve complex workflows. © RSNA, 2022.

Decreasing CT Acquisition Time in the Emergency Department through Lean Management Principles.

Background Emergency departments (EDs) rely on advanced imaging such as CT for diagnosis. Owing to increased ED volumes at the authors' institution, CT image acquisition became a significant bottleneck in ED patient throughput. Methods A multidisciplinary team was formed to solve this complex patient flow issue. Lean management principles were leveraged to identify process gaps and institute changes to achieve workflow improvements, remove process wastes, and improve patient throughput in the ED CT scanner. Process metrics such as percentage of CT examinations completed within 120 minutes and monthly median examination turnaround time (TAT) were tracked on a monthly basis. To measure impact, outcome metrics such as time savings from elimination of wasted steps were developed. Interventions Four projects including development of an ideal staffing model, a patient flow worksheet, revision of the CT patient screening form, and examination prioritization efforts were tested. Just-do-it activities such as revision of the CT angiography protocol ordering tool, optimizing scanner utilization, and improving communication and collaboration between the radiology department and ED were also attempted. Results After a phased rollout of changes over 6 months, the percentage of ordered ED CT examinations completed within 120 minutes increased by 10% (61%-71%); however, this improvement was sustained for only 6 weeks. Elimination of process inefficiencies resulted in a monthly median TAT reduction from 90-109 minutes to 82-106 minutes, and approximately 6 weeks (268 hours) of annualized full-time technologist time was saved. Conclusion Lean management tools can be leveraged to solve complex ED CT patient flow issues and reduce TAT. Online supplemental material is available for this article. ©RSNA, 2021.

Radiology Reading Room Huddles: Our Initial Experience.

OBJECTIVE. The objective of our study was to adapt the safety, methods, equipment, supplies, and associates, termed "S-MESA," communication tool from daily management huddles and implement it in radiology reading rooms to address the complexities of daily communications. We collected data on huddle logistics and perceived value from radiologists at an academic institution. MATERIALS AND METHODS. We constructed a 16-item survey composed of multiple-choice questions (single answer and multiple answers), statements requiring Likert scale ratings (from 1 [strongly disagree] to 5 [strongly agree]), and items requiring free text responses. The survey was distributed to 244 radiologists. Answers were collected over a 6-week period. RESULTS. The response rate was 41% (101/244). The majority of huddles were performed sometimes (59%) or daily or nearly daily (25%), and most lasted 5 minutes or less (83%), which was perceived as "just right" (87.5%). The components discussed more frequently in the huddle were availability (33.5%) and time goals (27%). Task review (19%) and miscellaneous (14%) were not as common. Huddles were valued for facilitating communication and better organizing the workday. CONCLUSION. Reading room huddles are feasible and perceived as useful. Moving forward, we are planning to integrate reading room huddles with multitier system huddles and include items that are of specific interest to radiology trainees.

Reducing STAT Portable Chest Radiograph Turnaround Times: A Pilot Study.

BACKGROUND: Our health system orders a high number of STAT priority portable chest radiographs (62%) compared to Routine (35%) and Today (3%). Retrospective chart review of 1000 chest radiographs ordered with the STAT priority revealed that 38% of studies did not indicate clinical urgency. Given the high number or STAT priority portable chest radiographs ordered, prioritizing acquisition and interpretation of true STATs has become challenging for technologists and radiologists, leading to process inefficiencies, long turnaround times (TATs), communication failures, and patient-safety errors. METHODS: A multidisciplinary team analyzed the current pathway for exam order to finalized report, identified failure modes of imaging order to completion process, and developed guidelines for what constitutes a true STAT examination. A new "urgent" order category meeting the definition of true STAT was designed, tested, and implemented over a 9-month period in participating intensive care units RESULTS: Since study implementation, 108 "urgent" examinations were ordered. Median TAT for a STAT examination from order entry to image acquisition dropped from 70 minutes preimplementation to 16 minutes for "urgent" examinations. Median TAT for exam completion to radiologist image interpretation dropped from 520 minutes preimplementation to 14 minutes for "urgent" examinations. Since implementation, "urgent" examinations were found to be more concordant (70%) with the status of a critically ill patient than STAT examinations (62%). CONCLUSIONS: The complexity of large multispecialty medical centers and lack of direct interaction of the radiologist with clinicians has led to underappreciation of the needs of ordering providers by radiology, and elucidated system limitations of radiology by ordering providers. By involving a team of frontline clinicians, our team standardized the process of identifying, ordering, procuring, interpreting, and communicating results of true STAT examinations. The process created by our team now serves as a template for implementation in other locations and service lines of our hospital.

Redesigning the Patient Observer Model to Achieve Increased Efficiency and Staff Engagement on a Surgical Trauma Inpatient Unit.

BACKGROUND: Provision of safe and efficient observer care to inpatients whose behavior puts them at risk for injury is a clinically challenging and costly endeavor for hospitals. At Massachusetts General Hospital (MGH; Boston), process improvement strategies were deployed to provide staff with an improved clinical model for patient observation, unit-based responsibility for allocating resources, and strategies to maintain a safer environment. METHODS: In a surgical trauma unit at MGH, a team of nursing leaders and clinicians created an innovative process to identify, assess, and develop best practices for ensuring patient safety in the hospital environment. Patients with delirium were identified as the most prevalent and concerning patient group, and specific interventions were developed to address their unique needs. From December 2012 through June 2014, the team successfully piloted the best practices (July 16, 2013-September 30, 2013) and implemented them. RESULTS: The baseline outcome metric of patient observer direct-care hours decreased from a median of 208 hours/week (January 1, 2012-July 13, 2013) to a median of 112 hours/week (July 14, 2013-June 28, 2014); a 46% decrease in utilization. Fall rate (falls per 1,000 patient-days) remained unchanged postimplementation, and staff satisfaction with the patient observer model increased from 9% to 72%, while costs associated with providing observer care remained stable. CONCLUSIONS: Providing the inpatient unit staff with the knowledge and tools needed to optimally manage patients with at-risk behaviors, including delirium, significantly decreased the number of staff hours spent at the bedside providing observation, did not negatively affect the unit fall rate, and increased staff engagement at no additional expense to the unit.

Health care failure mode and effect analysis to reduce NICU line-associated bloodstream infections.

OBJECTIVE: Central line-associated bloodstream infections (CLABSIs) in NICU result in increased mortality, morbidity, and length of stay. Our NICU experienced an increase in the number of CLABSIs over a 2-year period. We sought to reduce risks for CLABSIs using health care failure mode and effect analysis (HFMEA) by analyzing central line insertion, maintenance, and removal practices. METHODS: A multidisciplinary team was assembled that included clinicians from nursing, neonatology, surgery, infection prevention, pharmacy, and quality management. Between March and October 2011, the team completed the HFMEA process and implemented action plans that included reeducation, practice changes, auditing, and outcome measures. RESULTS: The HFMEA identified 5 common failure modes that contribute to the development of CLABSIs. These included contamination, suboptimal environment of care, improper documentation and evaluation of central venous catheter dressing integrity, issues with equipment and suppliers, and lack of knowledge. Since implementing the appropriate action plans, the NICU has experienced a significant decrease in CLABSIs from 2.6 to 0.8 CLABSIs per 1000 line days. CONCLUSIONS: The process of HFMEA helped reduce the CLABSI rate and reinforce the culture of continuous quality improvement and safety in the NICU.

Improving timeliness of antibiotic delivery for patients with fever and suspected neutropenia in a pediatric emergency department.

OBJECTIVE: There is a high risk for morbidity and mortality in immunocompromised patients with fever if antibiotics are not received in a timely manner. We designed a quality improvement effort geared at reducing the time to antibiotic delivery for this high risk population. METHODS: The setting was the emergency department in an academic pediatric tertiary care hospital that sees ~60,000 patients annually. We assembled a multidisciplinary team who set a target of 60 minutes from time of presentation to antibiotic delivery for patients with known neutropenia and 90 minutes for patients with possible neutropenia. Quality improvement methods were used to effect change and evaluate when the targets were not met. Improved communication between providers and patients and timely feedback were implemented. RESULTS: Mean time to antibiotic delivery in febrile oncology patients with known neutropenic status dropped from 99 minutes in the preimplementation period to 49 minutes in the postimplementation period, whereas it dropped from 90 minutes to 81 minutes in possibly neutropenic patients. The percentage of patients who met the targets for time to antibiotics rose from 50% to 88.5%. CONCLUSIONS: A multidisciplinary team approach and standardization of the process of care were effective in reducing the time from arrival to antibiotic delivery for febrile neutropenic patients in the pediatric emergency department.