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Background to the Project- Challenges | IR Lean Sigma Team Improves Patient Experience and Throughput
Background to the Project- Challenges | IR Lean Sigma Team Improves Patient Experience and Throughput
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IR Outpatient Delays | IR Lean Sigma Team Improves Patient Experience and Throughput
IR Outpatient Delays | IR Lean Sigma Team Improves Patient Experience and Throughput
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Delay Dashboard | IR Lean Sigma Team Improves Patient Experience and Throughput
Delay Dashboard | IR Lean Sigma Team Improves Patient Experience and Throughput
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Project Interventions & Improvements- Intake | IR Lean Sigma Team Improves Patient Experience and Throughput
Project Interventions & Improvements- Intake | IR Lean Sigma Team Improves Patient Experience and Throughput
anesthesiaattendingscallscenterchapterclinicalcliniciancoordinatorimplementedinsuranceintakeInterventionslabsNoneoutpatientpatientpatientsschedulesinghtriagetubeworkflow
Project Interventions & Improvements- Lab Reduction | IR Lean Sigma Team Improves Patient Experience and Throughput
Project Interventions & Improvements- Lab Reduction | IR Lean Sigma Team Improves Patient Experience and Throughput
biliarybleedingchaptercriticallygastrointestinalguidelinesimproveinterventionallabsneurosurgeryNonepatientprocedureproceduresrisksocieties
Project Interventions & Improvements- Prep & Pacu  | IR Lean Sigma Team Improves Patient Experience and Throughput
Project Interventions & Improvements- Prep & Pacu | IR Lean Sigma Team Improves Patient Experience and Throughput
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Project Interventions & Improvements- Floor Co-ordination | IR Lean Sigma Team Improves Patient Experience and Throughput
Project Interventions & Improvements- Floor Co-ordination | IR Lean Sigma Team Improves Patient Experience and Throughput
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Project Interventions & Improvements- Team Empowerment | IR Lean Sigma Team Improves Patient Experience and Throughput
Project Interventions & Improvements- Team Empowerment | IR Lean Sigma Team Improves Patient Experience and Throughput
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Project Interventions & Improvements- Patient e-Surveys | IR Lean Sigma Team Improves Patient Experience and Throughput
Project Interventions & Improvements- Patient e-Surveys | IR Lean Sigma Team Improves Patient Experience and Throughput
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Results  | IR Lean Sigma Team Improves Patient Experience and Throughput
Results | IR Lean Sigma Team Improves Patient Experience and Throughput
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Q&A Improving Patient Delays | IR Lean Sigma Team Improves Patient Experience and Throughput
Q&A Improving Patient Delays | IR Lean Sigma Team Improves Patient Experience and Throughput
anesthesiabedsidecenterchapterclinicalcoordinatecoordinatordelaysdocumentFellowsfloorguyshopkinshoustoninpatientinpatientsintakejefflabsmanagingmanpowerNonenursenursesoutpatientspackpatientpatientsphasephysicianphysiciansprocedureproceduresradiologyresourcescheduleschedulingsurveystriageturnaround
Transcript

good morning everyone today we have our team of frontline staff who conducted what we think is a really exciting qi project but Before we jump in if you would kindly please indulge us we have a question for you because we're curious how many others experienced similar

challenges so could we see please see a show of hands if in your departments you ever have issues with patient delays maybe your case is not starting on time patient 3-part anything like that show of hands okay that's a lot so this is

the project for you and even if it's not your challenge this is still a great example of a frontline team who worked together on a project that could really apply in sort of any setting or any qi situation so for this qi project we used

lean Sigma methodology so we used a systematic approach as we work through the project and our main areas of focus are patient delays and patient experience and these this is for our IR procedure outpatients so when I say

outpatients I mean our patients who go home the same day and also 23 our admissions our team is very excited to share our project with you today we were fortunate to be able to come up with some great and creative ideas and to be

empowered to be able to pilot and implement the ideas we even invented an app so the way that we decided oh sorry there we go the way that we decided to present our project to you today is to have eight members of our

multidisciplinary team each speak briefly to share a key aspect of our project our team will highlight some of our most valuable interventions such as the dashboard app the new smart East surveys the new bedside service

and also reducing a bunch of unnecessary pre-op labs that we were drawing and as I mentioned before this project was conducted by our frontline staff we definitely did not have a group of non clinician sitting in an office somewhere

deciding how to fix our problems and we honestly largely attribute the success of this project to the team to the frontline experts who are taking care of the patients every day and the trenches front-row seat to what's going on with

the daily operations and they really know where the pitfalls lie and importantly that our team was empowered and powered to truly be able to brainstorm freely come up with creative ideas and pilot and try new practices

and the leaders very much trusted this team this is just some brief background

on our IR department at Hopkins we have 11 procedure rooms all combined we see roughly 350 patients per week that includes everything outpatient

procedures inpatient procedures our bedside service and all of our consultation clinics so what prompted our project well there were two issues patient delays and patient complaints so for patient delays we were not always

starting our outpatient procedures on time we had three put problems we had some bottlenecks in prep and patio and we had patient complaints so patients are understandably not usually happy about being delayed for a long time

so we wanted to make improvements and we knew we needed to quantify the problem how many delays did we have how long were they but we had huge challenges with this that were not easy for this team to figure out so what were these

challenges there were three basic challenges one on I don't know about everyone else's schedule but on our EMR schedule we were not able to see the delays in real-time the patients were on this schedule but it just there was no

real visual or alert when patients were delayed so in the busy environment of the day the fact that mr. Jones is running two hours late could easily fall off our radar secondly we struggled with how we

were going to quantify the delays we knew we wanted automated data we were extremely determined to find a way to get that we knew we didn't want to use paper we have a lot of patience so we ran a report and that's what we often do

right we want some data we go to our EMR system and we run a report however it turned out we couldn't use the report and why was that well the report was wrong so why does this happen well what happens is let's say mr. Jones is

scheduled in room 6 at 10 o'clock room 6 starts running behind so we just sort of drag mr. Jones over into room 8 and say at 12 o'clock so he hit 2 hours too late when we run the report later this is not reflected because the act of dragging

mr. Jones from room 6 to room 8 on our schedule resets or reschedules his time in the EMR so the EMR system thinks that mr. Jones was scheduled for 12 o'clock start all along when in actuality he was 2 hours delayed we'll imagine running a

report with you know a thousand two thousand patients totally wrong so we weren't able to use that so we had to really get inventive third issue return rate for our patient surveys our old surveys were the paper type the type

that the patients needed to mail back to us and we would get maybe one a month I don't know how your returns are but we had very little virtually no patient feedback or any feedback was really mainly verbal incidental feedback from

the patients or maybe if there were severe delays from the patient relations department so this was really a challenge and this team was really determined to figure this out

okay so what were those outpatient

delays once we figured this out so I'm going to be transparent here as we collected data using the app the delay dashboard app that I mentioned we discovered that 28% of our outpatients were delayed more than 60 minutes past

their scheduled start time so this was like oh my gosh unbelievable that was 28 percent of our patients sitting on a stretcher in the prep area delayed more than an hour past their scheduled start time just waiting and waiting so

honestly once we figured this out this was worse than we expected we were really pretty surprised and more determined so we decided to initially tackle patients in the 60 minute delay category it seemed like at 60 minutes

that's when patients are getting extra nervous maybe upset you know they're like it's been over an hour what's going on so we wanted to tackle that group first and we decided that our initial goal would be to reduce those delays by

50% and these are just some snapshots of the methods that we use to collect our data we used the app to calculate the number of minutes each patient was delayed that was our key metric we used secret shopping to obtain some

observation data we used our patient survey responses and the nuit surveys were fabulous by the way and we performed some financial analysis so why do we have all of these delays what are the reasons our team identified numerous

reasons for delays populated on this fishbone diagram we have finna ties them into six major categories and I assume you guys can relate to some of these reasons maybe labs need to be drawn at the last minute or the procedure before

wasn't scheduled for long enough gaps in the schedule creating an efficiency may be pakis getting full and we need to see a doctor before we discharge a patient under scrubbed in and as we discussed previously just a general awareness of

the delays was huge for us so as you can see by this Fishburne full of delay reasons there were many moving parts in our department and we felt that we had a fairly daunting task as we started to

tackle these delays so now I would like to introduce dr. Andrew Dahmer who will share more about our delay dashboard app

Thank You Alyson so my name is Andrew Denver and one of the radiology residents in our ESI our program and I'm

the technology lead for our delay dashboard which you can see pictured here as was mentioned this is a key tool in our effort to improve the outpatient delay times we implemented this custom piece of software and the main benefit

it provided us one of the main benefits on top of our EMR was enabling us to track patient case status and delays in a real-time it consists of a dashboard with a web front-end that is visible just by typing in the URL that's

maintained by some of our tech savvy residents and fellows one of the the big things we like about the dashboard is the fact that we developed this color coding scheme as you can see in the key here that color coding scheme not only

allows us to kind of at a glance see how the day is running but also is used to trigger certain interventions when patient case delays reach a certain point so for example I the ideal world all of the cases are green with a smiley

face that doesn't happen so at a case turns yellow which is the delay of 15 minutes or more the prep nurse will acknowledge the delay to the patient and promise to keep them posted when a case turns orange which does delay of 30

minutes or more the prep nurse and the tech coordinator will convene and discuss a realistic timing for the case based on how the other cases in the lab are going that information is then passed on to

the patient if a case is delayed for 60 minutes or more interns read on the dashboard then a physician or physician assistant comes out to speak to the patient apologize for the delay over some insight into what's going on and

promise to keep them updated as the cases go on the dashboard is displayed prominently throughout our Center on several flat-panel screens that we've put out throughout the prep area the floor coordinator station and in the IR

intake center we did this as an effort to keep everyone no matter where they are in the lab updated to the case status for the day as well as to foster a culture of delay awareness a daily report for our delay dashboard is

emailed out to our staff each day in order to encourage discussion and troubleshooting for certain issues as well as to congratulate teams that were able to keep their delays down the previously mentioned color coding makes

it really easy to just add a glance and second see how the workflow went for that day and perhaps one of the most important reasons for using the delays dashboard is that it enables our technologists and staff to log reasons

for the case delays you can see an example list up here this information files back to our database and let's just collect and analyze the delay reasons across the lab the delay dashboard also allows us to get a quick

glance at trends either through the last day or two or across several months in order to try and evaluate further areas for improvement we can submit custom queries to our database if we're interested in interrogating a specific

aspect of what might be causing delays so real briefly I'll just talk about the underlying technology behind the dashboard and so basically it starts out by obtaining the information from our EMR those reports are then processed and

ingested into a custom database information from that database is used to not only help us run custom but also to filter through to the web dashboard that has displayed prominently throughout the lab and so now I'm going

to pass this over to Monique who is going to talk about some of the interventions that we did hi good

morning thank you Andrew hi everybody my name is Monique Dawson and I'm an RN patient care coordinator in the PCC

office here is a list of our team interventions and we implemented many many interventions for this project our team selected what we thought were some of the most important valuable interventions to share with you so what

is a patient care coordinator well the patient care coordinators our nurse known as a PCC that works in the intake Center and this intake Center is a central hub for the I our department I mean it literally sits in the center of

the department we have the prep and PACU on one side with the I our procedure lab on the other the intake Center houses nurses schedulers and insurance presearch staff the nurses responsibility is to include which

includes outpatient procedures we manage a variety of triage calls we lead rounds with the physicians in the teams for the next day we also make pre-op phone calls we do a lot of patient teaching and we see patients in the IR consult clinic

several times a week with our attendings and our pas the intake center I would say is fairly unique I call it the one-stop shop which makes it convenient for providers and patients to give you an idea of the intake center workflow

the clinician or provider calls the PCC directly they request an outpatient procedure so say for instance its patient were Marie who needs a single meda port placement for chemotherapy because she has breast cancer so we then

take this information and we confirm that we have a correct order in the system we also complete any clinical screening questions which would include labs any blood thinners

airway issues we're able to decide upfront at the patient needs general anesthesia or sedation we also get calls from the patients directly like my tube fell out or my tube is leaking which I'm sure some of you can relate to when the

nurse finishes the clinical piece we then hand off to the scheduler who verifies the demographics the insurance and does all the non nursing scheduling tasks and one of the things we really love about our own insurance presearch

staff is that they are experts in explaining indications for procedures to the insurance companies which then helps get things approved and on a short notice so so some of the improvements that we did and implemented in the

intake center just to mention a few was the pregame Huddle's so it's a PCC and the text would get together every week and talk through the next week schedule as indicated that's myself and one of the techs named John going through the

weekly schedule we look at case length equipments and resources that are needed and this helped us learn from each other and to schedule more effectively the other super exciting thing that we implemented was to stop using requiring

tons of labs unnecessary labs for the pre-op labs and to introduce and to tell you more about that I like to bring up dr. hardy Singh who's going to elaborate on our lab reduction initiative thank you

clicker okay hi so first I'm gonna do a

little survey to for everyone here does which groups do pre-procedure labs on everybody yeah okay so that's important right because that's one of the things that we really took a good look at to

see how we could improve throughput and improve patient satisfaction so Hopkins has a institution-wide initiative where they really want to look at how we can improve the patient experience and part of that is to reduce

unnecessary lab work we have patients that can come from a distance and that can really affect their interface with us over their experience so there's a choosing wisely initiative that allows practices to look at how they operate

and where they think they need to get labs versus where they may not be necessary labs that are drawn on the day of the procedure can cause delays as we wait for results if we have to send patients to a outpatient lab somewhere

that can also cause a significant inconvenience for them for getting labs that may not necessarily be needed so the Society of interventional radiology has a guideline that was first written in 2009 and updated in about 2012 where

they go through what they consider to be different types of procedures guidelines are always very good but guidelines are just that they're just guidelines and I think every practice should be critically evaluating what they're doing

and who they seem to have procedural issues with related to their to their labs so they break it down into low bleeding risk moderate bleeding risk and significant bleeding risk and you notice that the significant bleeding risk

procedures include any type of procedure where we're making a new hole in somebody for some reason whether it's into the kidney or the biliary system or into the arterial system particularly I would have to tell

you that there are lots of societies that are reeling the use of pre procedure labs just an example here from the Journal of neurosurgery this was actually published in 2012 they looked

s and one drawing their pre procedure labs they found that they had not a very good sensitivity and specificity and because of that if you looked at it critically you would save over eighty million dollars annually

with no difference in the bleeding rates during their procedures I will tell you that there actually have been other societies that have published papers since this one that actually are following that lead the most recent one

that I saw was the American Society of gastrointestinal endoscopy you know something probably a little closer to the types of procedures that we're gonna see and obviously neurosurgery is very different from what we see but you have

to look for things that might be more similar and I would suspect that that group has procedures that are more similar to ours particularly in the low risk group and they have stopped looking at their pre procedure labs most of

these papers have repeated over and over that the conversation with the patient and looking at what their pathway to your door has been as as important as the procedure itself okay with that I'd like to stop and I'll and invite Kerry

to come up and talk about improvements thank you

good morning I'm Kari prickle and I'm one of the nurses in the prep and patio and I wanted to share with you some of our interventions that have greatly

reduce our delays in the prep and patio the first one being afternoon rounds with the pcc patient care coordinator the ir fellow and a prep nurse we review all the outpatients and kind of come up with a game plan for the next day and

secondly our IR fellows for our first cases are now consenting at 6:45 before they go to morning conference and this ensures that the patients are on the table and ready to roll at 6:00 at 8 o'clock we also worked on registration

timestamps to ensure that the patient arrived time stamp was not forgotten in prep we really rely on this time stamp so this is what was happening the the patient arrived time stamp was not clicked we had no idea that the patient

was actually sitting in the waiting area the floor coordinator would put an in patient in that time split time and in that slot and as you can surmise it was disastrous for the whole flow of the room and it was disastrous for the

patient waiting in the waiting area so we invited a member from the registration staff to join our lean sigma team and I'm happy to report that that no longer happens and because we don't need as many pre-op labs we've

noticed a huge difference with reduction in prep time and also of course the dashboard is a visual and alerting us to patient delays in real-time and then we intervene based on the color changes one of the major barriers to throughput

in the prep and PACU areas was that the ir providers were scrubbed in and they were unavailable when we needed them we were able to reassign an ir physician's assistant to be embedded in prep and PACU on a daily basis and what a

difference this has made some of her roles include using ultrasound guidance for our difficult IV Stix consenting prep and PACU orders as well as pain medication orders central line removals and then she also facilitates throughput

by proactively using the dashboard for our 68 60-minute delays when the patient turns red on the dashboard she investigates through the delay she offers an apology to the patient and then updates the patient with an

estimated time now Jeff is going to tell us more about the floor coordinator role

right good morning my name is Jeff Andrus I'm one of the rad texts in the department and I function about once a week in the floor coordinator role

sometimes called the FC other places have different names such as an expediter or other names for it one of the things I do in the morning is to go up to the morning conference with all the physicians that includes all the

attendings the fellows the residents myself and whoever is the charge nurse for the day and we'll go through both the inpatients and outpatients to discuss what what the exam is and any sort of special equipment that might be

needed so we can kind of gauge how long these exams are gonna take after that we'll come downstairs and we'll lead the morning huddle and this is with all the texts and the nurses to kind of relay that information so we can kind of get a

idea of what our day is gonna be like and then throughout the day I act as the central hub I hold the phone I do a lot of coordinating between the different floors the icy use the emergency department anesthesia making sure

everyone is getting the support they need any sort of breaks or lunch coverage that's needed and also making sure that when the patients do come down they they're ready you know making sure they've got IVs that they've been NPO

trying to head off any sort of problems like that so everyone has different size departments ours is a a larger one there's 11 rooms altogether there's two neuro angio suites there's an

interventional CT room and interventional MRI and then seven body angio rooms every day one room is designated as an inpatient room between outpatients there might be gaps so if I know what those gaps are I can bring an

inpatient down to help get that get that going we do have piays that'll run one two two line rooms every day usually those are where we focus all of our outpatient line placements and then there is also a bedside service that is

managed by the chief techs and we'll talk about that later one of the things that we did start was we were using two Clint X we started using them as transporters because the hospital has one large pool of

transporters for the entire institution and sometimes that would cause delays you'd you know you're gonna have a room open in half an hour you put in for transport it might be an hour more before the patient makes it down so we

were using these two as transporters just to help expedite the process we found that we could also use them for room turnovers to help get the outpatients move through the department and overtime that role has evolved if

patients do get down to the department they can sit and watch the patients while we're getting the rooms ready like I said before they'll help with turning over so cleaning the area making sure that we're ready to accept the patient

when they come into the room if we need to send someone to the blood bank or the pharmacy to pick up chemo they are capable of doing that and also if we need supplies throughout the day if we need more linens or anything like that

they will communicate that with central storage so we can make sure we've got what we need for our patients you know I'm gonna introduce dr. Hong and you will talk about bedside and team empowerment thank you very much my name

is Kelvin Hong I'm the division chief of I are within the John's Hospital has across the health system I'm privileged to say that this represents just a snapshot of the team that we have both an operational side

but we utilize it within the Qi projects that we hold this is really a long-standing project for over almost four years now so I'm very very privileged and I'm very excited to share with you and obviously

I wanted to emphasize how this can be achieved and the concept of team empowerment is so critical most of our interventions and solutions in successors have been on the backs of really removing barriers and along

interventions to flow from front my staff in foreign we we do intervention team storming we really get the best ideas and solutions from by allowing everybody to be empowered and to speak up and to find solutions and that

transparency is critical to the success and not any operations but when you're trying to improve we free to you know point fingers and I think that it's important to recognize that I think it should be not just top-down but really

bottom-up and really the brainstorming comes from the best ideas and now we're standing then to form a bottom up to allow the physician leadership to go and get the resources negotiate and funding and I think we really need to think

outside the box from top and bottom and this was a an idea oops can someone advance this slide this one just logged off and so this is a one of the interventions I was born on really looking at the problems with increasing

delays and pressures over raw and under-resourced and I don't know if you have in your hospital but there's a increasing reliance on IR to do even minor procedures that traditionally was done you know by the bedside there's

sort of growing reluctance on many physicians do you do less and less at the bedside and rely on more complex interventions even notwithstanding we've had some Sentinel events with bad outcomes of patients been having

procedures at the bedside so there was increasing demand by the hospital for us to do more so this downward pressure of doing more procedures obviously contributes tremendous to patient delays and experience and so

we had increasing request by the hospital to do more more and increasing imaging almost didn't make sense to transfer the patient from the bedside the procedure suite increasing costs delays stresses amongst physicians just

as amongst the staff and we really just under-resourced an increasing complexity of patients doing support procedures for them so really in concept this is one of the interventions for us and to handle really to put together actually a

bedside service to do procedures where the patients were and to fund it and so that we can do the right procedure in the right place at the right time for the right patient in the right service and that there should be all housed

within IR and a1 team and safe for all so this was the intervention to really solution after key our analysis looking at transitioning a team to the bedside and not to do procedures at the suite Jim Bain and fun so that was the big

heavy lifting to fund five providers there were physician assistants who do procedures at the bedside themselves transfer only the sickest patients and to be centrally coordinated that we could coordinate all within the House of

IR so that they expeditiously this patient moves from the bedside to the procedure suite all evaluated and inappropriately to be done in the right place and the benefit obviously is tremendous improvement patient care

satisfaction we have a formalized backup so we really just get the patient to the right place and there's no question we've look at their reduce costs less wait time it's obvious if you don't need to do the procedure in the suite you're

doing at their bedside how that impacts length of stay denied days and some of these very hospital Jermaine Qi metrics that are very very important to Hospital workflows and efficient use of time appropriate use of time and not

importantly for skill procedures and avoid harm to the patient reduce signal veins so we actually had this funded and was and then the scope is some minor procedures you know Paris Toros complex IVs and is a major issue in amongst

hospitals as our patients get a lot of care ops unguarded and the foilage started to do less and less I'm sure you've seen some of these trends within your own hospitals we placed actually almost all the access

for dialysis and so the emergent procedures like shy leaves or non tunneled dialysis catheters are done by the base at the bedside by our IR a bedside service seem to mean as time on characters and so prior to formation of

this bedside service we had simple events that related to almost over a million dollars in claims and so this was but the backbone of the business plan to get this funded and since the inception of our team we actually

haven't had another signal vendor surrounding these procedures and notwithstanding there is actually revenue so and not having complications not having payouts for these risk management events as well as the

collection so we do get paid for this and this is important that you get something funded that you show the hospital that you can make this operationalized budget neutral and so we've analyzed this and shown that and

so what is the impact it sounds great to have this at least when they're not doing it in procedure suite for us actually we even looked at a survey distributed to people who consulted us smatterings of a variety of providers

physicians pas and nurse practitioners and looked at multiple departments how we were doing and we analyzed ourselves so we're always constantly not any improving but we analyzing and maintaining and the survey results in

blue and orange these are highly satisfied or strongly agree with all the turnaround times easy-to-access preventing admissions and and so this is a positive patient experience we really have made we shifted the bar some

negative perception of our service because there's delays to now positive perception of what we provide at the bedside in the suite and in truth from a physician here I'm just happy that there's a shift in in positive energy

and experience with us so this is critically and you know I'll be able to do it so you know we're tracking numbers and our volumes are steadily increasing the more more services are turning towards us and realizing that there's a

great way to to provide service at the bedside and where necessary concert and we'll make this session who needs to come to the ir suite is I think a really good way to also trace some of the patient delays doing

procedures at the right side so I'm going to turn you over to waipapa Dubourg who's on our end talk a little bit us about patient surveys good

morning I'm Molly Perdue ba I'm one of the procedure nurses and one of the best

things we ever did was to adopt this smart dynamic electronics patient surveys previously we used the regular paper service that most hospitals use and they were mailed to the patients about four weeks after the procedure and

I tell you no one ever mailed them back to us so we are lucky if we get one or two each month so we we never had a real patient feedback so we got lucky our hospital was starting a small pilot for this brand-new East surveys and they let

us join the pilot group it was really fascinating it turned out that these two doctors from North Carolina invented this and these are like short dynamic smart service that are texted or emailed to the patient the day after the

procedure so the survey consists of 10 quick questions in the free text box so no more paper no more snail mail and the patient's get the survey right away well it's still fresh in their minds and not four weeks later so on this slide are

our 10 current survey questions and one cool feature is that we can change these questions at any time and we can that we can pull from a large question Bank but for a clear project we use the same 10 questions so we had consistent pre and

post data they also have a great website that we can access so we can see the patient scores patient comments and they even have everything graphed with trends over time so we can see whether we have improved this slide all the patient

comments are emailed out to the multidisciplinary multi-departmental team every month so when I opened my email I see more than a hundred patient comments so the team is usually excited about

opening the email every month and you look for their names and staffer of often mention and compliment complimented by patients so for this graph it represents patient East Survey top box scores for the questions in a

timeliness category so we saw 24 percent improvement for the question my care team kept me informed of delays and we we also saw 36 percent improvement for the question my procedure started on time so now I'm gonna hand it back to

Allison to share additional project results in our conclusion

okay so just to continue on with our results and we were able to achieve a statistically significant reduction in on outpatient delays in the 60 minute

category by 53 percent so mission accomplished with our initial goal this graph depicts baseline interment post-intervention data and actually initially we really looked at the red and the blue as our pre in our post but

then what we did was start emailing out a daily snapshot of the delay dashboard for that day to the entire team I mean nurses Tech's physicians administrators everybody and after we started doing that we noticed we recalculated data and

noticed further improvement we also got it up on more flat screens in the department so for us it was really easy to see that the more we increased our transparency and awareness and got these delays on everyone's radar on a daily

basis the more we improved so in addition to the delays and the survey scores from the e surveys from the patients we also achieved some financial benefits one of those was related to our Hospital denied days or denied insurance

days has anyone ever heard of denied days before anybody know about that it really was not on my radar until we did this project and somebody asked me what we were going to do about our deny days problem and I was like I better figure

out what that is but anyway I don't know if you all can get to every impatient the same day that it's ordered but if you can't which we can't always get to the impatience and we may need to postpone for a day or two then the

insurance companies can often come in and say well this patient's just sitting there waiting around for their eye or procedure or maybe they need a line before they're discharged and we're not going to pay for that hospital day so

the central hospital and Finance Department started like keeping track of this and it turned out that we did have a problem and it was very costly problem so we were able with our improvements in our throughput we were able to reduce

that able to sort of show financial improvement a lot of times that can help us to justify resources that we need the

control phase so this is an important part of the lien Sigma process a lot of times when we do qi projects once the projects over and the group stops meeting the improvements can kind of go to the wayside so this is where we are

now we try to sustain the improvement or sustain the gain we wanted to find ways to hardwire our improvements under the fabric of our department so that we didn't lose our progress and how do we do this while visual management having

the dashboard upon flat screens in the department emailing this out every day we've continued this process accountability which is which happens and by emailing out to everybody again this has also been engaging for our

teams with team buy-in everybody wants the room with the green smiley faces in their room so everybody really is engaged and trying to keep things moving voice of the customer ongoing reporting of our patient comments and scores from

their electronic surveys emailed out again to all the team so everybody goes through looking for their names and kudos to each other that part's pretty fun and helpful when patients have suggestions and then finance is actually

developing an electronic dashboard with our denied days so we'll be able to really look at that and keep an eye on that so in summary our results include a reduction in hospital lost revenue associated with the dot deny days of

60-minute delays of 53 percent improvement in our timeliness patient experience scores of 24 and 36 percent and we're now seeing more efficient days

ending earlier subsequent reduction in staff overtime so our team concluded that Lean Six Sigma applications I our practice has a proven benefit to throughput and patient satisfaction and that the use of key metrics transparency

and key stakeholders including the frontline staff from each area are very critical parts of the process and thanks so much for your time and attention today and we're glad to take any questions you might have

good morning I don't know if this is on oh it is in terms of reducing delays in your department did you have to do any work around realistic scheduling of procedures putting standard procedure times around different procedures or how

to manage when procedures go and you know run long or you have difficulty managing that aspect of the schedule I'm sorry the audio is unclear it's a little fuzzy up here so you scale and we'll repeat it

yes we did a lot a lot of work around scheduling and that's really Monique in there with the intake Center talked in the intake center we are then we actually have the nurses schedule their procedures and then we hand off to the

schedulers to actually put them in but this way the nurse who's doing an intake can actually determine how long the procedure should be so it allows us to have clinical eyes on the length of the procedure so we modified sort of our

basic list of how long procedure should take we roll in 30 minutes of turnaround time and then we add another 30 minutes if it's an anesthesia case now if the case is going to say require a likely intervention and we can tell oh yes

that's gonna need more time than we schedule accordingly we add time so we really worked hard to make sure that we were scheduling accurate case lengths yeah we constantly analyze those case lengths and continuously try to improve

and recognize challenges hello I'm Nikki Jensen I work in a clinical resource mares clinical nurse specialist roll Mayo Clinic Rochester and I'm very curious about two things first thing is routine lab work and read reduction of

unnecessary labs we too have been doing this where we kind of have taken our own clinical practice expertise and compared with us IR guidelines and have reduced drastically our lab work needed have you guys created established guidelines to

help standardize your process or is this a physician to physician now we we do have a list of procedures that require certain labs for certain procedures again we have a nurse performing the intake so if there's a reason we have

sort of some exclusions so end-stage liver disease we are going to get the pt/inr but if it's a routine meta port placement or line placement we're not going to get pre-op labs so we kind of do a quick assessment in advance over

the phone oftentimes and we make a determination as to what's needed if there is any question then we do go to our physicians but yes we have a list of which procedures new labs and we really knocked out most of our PTI in ours and

then my second question is regarding your patient surveys I love those because us too we do not have really great patient satisfaction surveys available for radiology practice how did you find that is it a particular company

that you went through how did you get this yes so and I can give you more details if you'd like to email me but we because I said we had a we have a patient chief patient experience officer at

Johns Hopkins she was able to get us in on the ground floor of this little mini pilot the pilot was so hugely successful that we adopted it across much of Hopkins out patience and also 23 our Admissions

were allowed to use these the main sort of national surveys that need to there's a requirement that the inpatients have to receive those first you're not allowed to supersede with your own but this company actually was just recently

purchased by one of the major major Chris Kane these two doctors just invented this and all of a sudden now everybody really Press Ganey and talk by various thank you guys I don't know how they're rolling it out and whatnot but

hi I'm Marissa from Houston Methodist Hospital in your title did you write that phase two it says I our patient experience and throughput lean Sigma and Phase two is that is this your face too in your title is this our face Christo

and what was your face one phase one was reducing our procedure rim downtime the time between cases and interestingly for phase one we assumed that that would also reduce our patient delays but guess what at the end we found out it had

introduced our patient Dilys we had great success with you know getting our rooms running back-to-back better our patients back-to-back better but we were surprised so as the next steps on our phase one that was what we wanted to

work on patient delays okay and what's the approximate the corresponding cost of your project because it seems like it's an interdisciplinary what do you have a cost for the whole project sorry that makes just a little fuzzy on that

side so we really saved money for our department and our hospital by implementing this we are just all frontline staff we happen to have a radiology resident who knew how to write code so wasn't his day job

but he was really great I'm raining code and we ended up creating this delay dashboard so that's what I would say to everyone like you never know the strengths of the people who you have but to just ask questions

and brainstorm it's amazing what you can come up with so the the only thing that we really like spent money on would be the bedside service but that ended up being so the manpower for the Qi team is all in-house so we didn't necessary

invest specific but the projects that required hospital support was embedding a PA in the recovery area plus the bedside service and that totaled about you know seven eight hundred thousands it's a moving target but again if you

show metrics that validate why that that type of large number is validated and we it's find itself now but but strictly speaking a lot of the other initiatives were in-house in other but the East surveys was something the hospital was

going towards we just happened to tap into that so it's amazing how many resources you can get should you put the effort in but manpower wise the Qi entire team within IR what you see on front Chen this is just part of the

group is all in-house and not funded this is just part of our work thank you ask you about your inpatient who them on a daily basis who treats you in patients in patients so we have fellows and our fellows together with the four

coordinator like Jeff and add on the impatience but the fellows there's a ticket the fellows sort of is responsible for basically working up the impatient getting consents and then handing off and assisting the floor

coordinator or they had a conversation to determine where that we are and when that inpatient needs to so Jeff Jeff coordinates through the fellow and triage these cases and another question I have how do you schedule your

inpatient and outpatient s-- together in one day how do you differentiate the scheduling between inpatient and our patients how do we fit them into them so most of our rooms we schedule with outpatients

starting at the beginning of the day at 8 o'clock we have one room reserved for inpatients and sometimes we have another room reserved for inpatient lines that is a PA room so one or two inpatient rooms

the others are scheduled with outpatients and then as there are gaps in the schedule which we actually try to avoid those gaps now in patients can be popped in or can follow I see thank you I mean it strictly speaking if you or I

are inpatient come through in our consult fellow triage is it first once it's identified we're going to do a procedure then coordinates with our charge nurse or resource nurse plus the floor coordinator and then it's made to

happen so then the the mechanisms of appropriateness Labs prep is all done and consent done before the patient is transported down and then like Alison says we have a space a room dedicated for inpatients and then sometimes we'll

squeeze them in if it's more emergent origin if you don't mind Jeff can you can you just extent you know talk more about your role specifically what how do you communicate to the nurses upstairs when you coordinate the cases to come

down well every morning you know we get a list of known inpatients and then throughout the day the fellows will bring an add-on slips with pertinent labs and what we're doing when I know that I've got let me back up in the

morning will actually call all the units and speak to that patients nurse to say hey this is what we're gonna be doing are they NPO do they have an IV what kind of drips are they on so that way if the patient is not able to get their

procedure you know we can kind of head that off as a day goes on if I know I've got a room opening up in half an hour I'll call the nurse and say hey I'm sending transport up to get this patient this is what they're getting can you

and we'll just make sure that the patients ready so that way when transport gets there that the patient's ready to come down do you communicate these information to the a procedure nurse any sort of information that I get

there we do have the option to put notes in our EMR set the nurse can know that and a lot of times if if I'm able to I will walk down to the room and talk to the nurses and techs and whoever else needs to know that information and say

hey this is what we're doing what to prepare for and give them as much information as I can so they can be ready - got it thank you so much you yes I have some questions regarding the bedside service

that you guys offer how do you I guess I would say dictate or document the procedure where we are we used to have patients that we would go up to the floor and pull a line or change a tube or whatever and then our document

documentation system kind of got rid of that because we had to work around the computer system versus what was best for the patient so how do you document for those so part of the building of the team is critical is how you document and

importantly how you bill we need to make it financially viable so actually every procedure at the bedside we put into the radiology information system the accession numbers created and actually a before

those procedures are performed by physician assistants under the auspices of the attending on call and those are signed off as procedures then build in and so in that way we also document as well as make it billing compliant so

there's many advantages of actually doing that step and making sure that you get paid for what you do and not only that it's in the EMR exactly what happened and after they get I'm assuming you do some PICC lines bedside

chest x-ray after is that how they document this is how you verification some if it's our sign be verified or x-ray yep okay thank you hi I'm Heather from Sarasota Memorial I have two questions for your nurse intake person

and then the scheduler have you found that it's decreased your turnaround time and what is your turnaround time from receiving in order to proceed your time can you hear me so we receive there we have electronic

orders or they're in the EMR but when we do we require a lot of the providers to call us directly that communication piece is a big deal to be able to get all those questions answered and to get the patients scheduled appropriately so

as soon as they're putting in the order there a lot of them are calling us even as they're putting in the order so we I mean we receive lots of phone calls on a daily basis it's about five or six of us in the office at the same time answering

these phone calls so you have more than one nurse then that's fielding those yes yeah and the second thing for the bedside service do you send that PA or a mid-level person with a procedural person to assist in the room or is that

an expectation of the bedside nurse that they assist if needed that's a great question so there is you know some teething problems one of the problems you eliminated is doing procedures at the bedside you know how much do you

incorporate the the floor nurse involved with the case it's definitely become a little bit of a bone contention but we are managing it because the analogy the converse is that would be the internal medicine physician doing the procedure

and the nurse would be assisting anyway and sometimes it's just House staff internal medicine House staff doing it we're just doing it safer quicker so we've had to do a lot of Education with floor based nursing nursing leadership

to make everybody align that quickly turn around so we yeah but I think you raise a great point sometimes its resource at their bedside we right now we have one provider who goes with the ultrasound performs a procedure with

assistance of a clinic or the owners thank you last question please Fernando from Houston VA Medical Center can you hear me I have two questions so first question is do you guys see

schedule the same start time on all your I'd you sweets it can vary a little bit but we mostly start at 8 o'clock we have one day where we start at nine o'clock we sometimes start a room at eight o'clock except one day of the week which

is Thursday we start at 9:00 with education of anaesthesia our front land tech nurse physicians we all have our weekly education process from eight to nine so every day at eight except Thursdays at 9:00 standardized so then

we look at our first starts in that relation but so how many ones do you guys start all at the same time all the rooms and we start at 8 o'clock Oh second question so since the guys insert multiple drains in they are do you guys

primarily manage this drains including discharge instructions when patients are discharged can you apologize most of the time that would be yes there'd be a consult the primary team

would manage the patient's care be you know after the procedure going forward because they're usually managing their care for whatever problem there is for the abscess train or biliary drain now we our patients do pass through a pack

you the patients who are outpatients who are going to be going home or prior to admission oftentimes and the pack you will give basic instructions to ensure that the patient knows what to do with their drain before they go home

same thing with the intake so know as patient care coordinator nurses we're talking to the patient we're making sure that they have what they need or else we will help coordinate to make sure that they're getting what they need they know

what the plan is in patient often times they'll go back to the procedure room but it depends on whether they are have had anesthesia if they're off the sedation protocol they could go to pack you and then to their bed same-day

admission if the that's not ready pack you okay well thank you so much everyone and please feel free to contact us if you have additional and on behalf of Aaron avir I would like

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