Rationale and Objectives
To identify and reduce reasons for delays in procedure start times, particularly the first cases of the day, within the interventional radiology (IR) divisions of the Department of Radiology using principles of continuous quality improvement.
Materials and Methods
An interdisciplinary team representative of the IR and preprocedure/postprocedure care area (PPCA) health care personnel, managers, and data analysts was formed. A standardized form was used to document both inpatient and outpatient progress through the PPCA and IR workflow in six rooms and to document reasons for delays. Data generated were used to identify key problems areas, implement improvement interventions, and monitor their effects. Project duration was 6 months.
Results
The average number of on-time starts for the first case of the day increased from 23% to 56% ( P value < .01). The average number of on-time, scheduled outpatients increased from 30% to 45% ( P value < .01). Patient wait time to arrive at treatment room once they were ready for their procedure was reduced on average by 10 minutes ( P value < .01). Patient care delay duration per 100 patients was reduced from 30.3 to 21.6 hours (29% reduction). Number of patient care delays per 100 patients was reduced from 46.6 to 40.1 (17% reduction). Top reasons for delay included waiting for consent (26% of delays duration) and laboratory tests (12%).
Conclusions
Many complex factors contribute to procedure start time delays within an IR practice. A data-driven and patient-centered, interdisciplinary team approach was effective in reducing delays in IR.
The focus on quality in radiology is expanding rapidly and includes quality control of equipment, quality assurance (QA) of our imaging and processes, and increasingly, continuous quality improvement (CQI or, in short, QI) . To perform QI, every step in a workflow process is mapped, measured, and analyzed with the goal of improving a process and reducing systems errors . Methods and principles of systems engineering have been widely recommended as a means to improve health care delivery, from staff planning and resource capacity allocation, to improving patient flow and reducing wait times and delays . Medical literature on the improvement of on-time starts and delay reduction is widely available but mostly limited to the hospital’s surgical department setting .
The Radiology Department implemented a quality strategic plan with the following goals: 1) to foster a culture of quality, 2) to enhance patient satisfaction, 3) to promote standardization of workflow processes, and 4) to improve clinical quality and safety outcomes. Multiple projects were initiated to achieve these four goals. For instance, each of the 11 divisions within the department assigned a radiologist as quality officer to led efforts to monitor QA metrics and to develop practice quality improvement projects appropriate for their division. Next, we describe the creation and work of a QI project team in the interventional radiology (IR) and neurointerventional (NIR) divisions (together called “IR”) that resulted from this strategic plan with the following objectives: 1) to improve on-time procedure start times and 2) to reduce delays in patient care (and thereby improve patient satisfaction). The purpose of this article was to describe the process of building the QI team, collecting and analyzing the data, selecting QI interventions, and evaluating for improvement changes.
Materials and methods
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Initial Project Team and Team Building
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Data Collection and Analysis
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Workflow Process Times Report
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Table 1
Definitions of the Workflow Process Blocks
Process Block Definition Reception wait time Front desk check-in to PPCA arrival PPCA work-up time PPCA arrival to PPCA work-up complete PPCA wait time PPCA work-up complete to procedure room arrival Surgical site preparation time Treatment room arrival to completed prep of surgical site Preprocedure wait time Completed prep of surgical site to procedure start Procedure duration time Procedure start (puncture time) to procedure complete Postprocedure wait time Procedure complete to treatment room departure
PPCA, preprocedure/postprocedure care area.
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Room Utilization Report
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Delay Types and Duration Report
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Improvement Initiatives and Interventions
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Table 2
Top 10 Delays in Patient Care by Aggregate Duration at Start of Project
Delay Reasons Time (%) Count (%) Physician needed for consent, presedation, or order clarification 26.2 23.3 Miscellaneous (eg, IR room not available) 19.0 18.6 Laboratory testing and results delay 12.4 9.3 Anesthesia delay in room, with patient 7.4 7.9 IR room nurse not available 6.6 5.6 PPCA nurse assessment incomplete 6.5 8.4 Physician not available for call to order or start 6.4 7.4 Laboratory values abnormal 3.8 0.9 Patient request to use restroom, see family, and so forth 2.0 6.0 Anesthesia delay in preoperative assessment 1.5 1.9
IR, interventional radiology; PPCA, preprocedure/postprocedure care area.
The percent count represents the frequency of these delays.
Table 3
Improvement Interventions Implemented by the Project Team
Improvement Intervention Target Impact Area Date Implemented Checklist for PPCA to treatment room handoff Procedure start time (decrease PPCA work-up time and miscommunication) October 1st Transport from PPCA to treatment room not limited to IR treatment nurse Procedure start time (decrease PPCA “ready time”) October 14th Blood drawn in PPCA instead of sending patient to hospital laboratory Delays due to laboratory testing October 14th All IR fellows perform consents rather than one “consult” fellow of the day Delays due to consent process November 1st Internet access to outside laboratory results by PPCA nurses Delays due to laboratory testing/retesting November 20th
IR, interventional radiology; PPCA, preprocedure/postprocedure care area.
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Preimprovement and Postimprovement Interventions Statistical Analysis
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Results
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On-Time Room Starts
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Room Turnover and Turnaround
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Patient Workflow Wait Times
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Table 4
Interventional Radiology Workflow Process Blocks’ Patient Time Duration Before and After Project Improvement Interventions Were Implemented (Preinterventions/Postinterventions)
Statistic Before/After Wait at Reception At PPCA Wait for Room Prepped Ready for Puncture Procedure Leave Room All cases N 357/336 743/708 743/706 934/926 925/923 927/926 931/925 Median 27/17.5 45/42 23/15 20/19.5 10/8 42/37 10/10 Mean 38.2/27.1 51.8/48.6 40.1/30.6 23.4/21.8 11.8/10.3 53.9/50.7 12.7/12.5 SD 40.7/37.2 34.4/29.6 44.0/39.3 13.5/15.7 11.6/8.41 41.6/43.7 9.6/9.5P value<.01.06<.01.02<.01 .10 .61 First case of the day N 100/77 190/180 189/180 248/233 243/231 246/233 246/233 Median 12/13 50/41.5 18/10 20/19 10/9 41.5/35 10/10 Average 17.6/20.9 54.6/46.5 26.2/16.6 26.1/22.6 11.6/11.2 55.6/55.1 12.6/12.8 SD 18.6/51.1 28.9/23.2 28.5/15.7 17.2/13.7 8.17/9.10 44.3/53.6 7.8/10.7P value .56<.01<.01.02 .64 .91.05
PPCA, preprocedure/postprocedure care area; SD, standard deviation.
N is the number of cases. The median, mean, and SD are given in minutes. Both the mean and median were reported to demonstrate the data skew. Note that many of the mean times were significantly reduced as shown by the P values in the Table. The P values in bold indicate significance of at least 6%.
The “wait at reception” time is given for outpatients who did not require anesthesia; therefore, there were fewer cases in this time block. Similarly, “at PPCA” and “wait for room” times are given for patients (inpatients or outpatients) who did not require anesthesia. The P values were calculated using the t -test of the means before and after improvement interventions.
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Delay Types and Duration
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On-time OP Procedures and Average IP Order Cycle
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Discussion
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Study Limitations
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Conclusions and Next Steps
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