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Understanding the Design for The Quality Improvement Project at Emory Healthcare | Improving Throughput in Interventional Radiology: A Collaborative Approach
Understanding the Design for The Quality Improvement Project at Emory Healthcare | Improving Throughput in Interventional Radiology: A Collaborative Approach
advancedarticlesboardchangechapterchargeclinicalcliniciancreateengagedengagementfrequentmeetingsmodelNonenursenursespatientplanprojectstafftechtrackingurgencyvision
Building the Radiology Nurse Dashboard | Innovation and Application of Real Time Nursing Dashboards
Building the Radiology Nurse Dashboard | Innovation and Application of Real Time Nursing Dashboards
accomplishalignbuildbuiltcapturecategorychaptercovercreatedatadesigneddisplayeddocumentationengagementintentjeannejourneymeasuresmetricsmodalitiesmultipleNonenursenursesnursingpendingproductradiologyrealrelevantselectedstaffingsystemteamunderstandworkflow
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
Q&A- Risk in All The Right Places | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
Q&A- Risk in All The Right Places | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
awarenessbehavioralbluntcenterchapterchecklistchemoculturedependingerroreventeventsfocushospitalinvolvedmanagementmanagerNonenursespatientphysicianpractitionerpractitionersprocedureprogramreportreportingriskroundssafetysharpstaffsupportsystemtalksvenueswrong
Overview of Diagnostic Errors | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
Overview of Diagnostic Errors | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
academyadversechapterdiagnosticeducationalerrorhospitalizationsmedicineNonenursespatientproceduralsafety
Q&A Bleeding Risks | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
Q&A Bleeding Risks | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
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Studies into Equipment | Respiratory Compromise: Use of Capnography During Procedural Sedation
Studies into Equipment | Respiratory Compromise: Use of Capnography During Procedural Sedation
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Just Culture Concept | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
Just Culture Concept | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
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Dashboard Drill Down Report | Innovation and Application of Real Time Nursing Dashboards
Dashboard Drill Down Report | Innovation and Application of Real Time Nursing Dashboards
chaptercomponentdatademonstratedinterpretNonenursingpatientreporttimeline
Signs of Burnout | Burnout in the Radiology Setting?
Signs of Burnout | Burnout in the Radiology Setting?
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Dashboard Component- Nursing Case Volume per Hour | Innovation and Application of Real Time Nursing Dashboards
Dashboard Component- Nursing Case Volume per Hour | Innovation and Application of Real Time Nursing Dashboards
callschaptercolorcoupledatadocumentationinterpretMRINonenursenursingpacemakerspendingphonevolumeworkup
Combining Guidelines with What You Know | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
Combining Guidelines with What You Know | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
anticoagulationchapterdysfunctionfloraguidelineguidelinesheparinlovenoxmultidisciplinaryNonenursenursespatientpatientsprocedureradiologistrestartedscreeningserviceworkup
Data- The Story Behind the Numbers | Innovation and Application of Real Time Nursing Dashboards
Data- The Story Behind the Numbers | Innovation and Application of Real Time Nursing Dashboards
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Introduction to Establishing Periprocedural Screening Guidelines to reduce bleeding risk associated with Image-Guided Theraputic and Diagnostic Procedures | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
Introduction to Establishing Periprocedural Screening Guidelines to reduce bleeding risk associated with Image-Guided Theraputic and Diagnostic Procedures | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
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The Dashboard Implementation | Innovation and Application of Real Time Nursing Dashboards
The Dashboard Implementation | Innovation and Application of Real Time Nursing Dashboards
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Q&A- Success, Case Add-Ons | Innovation and Application of Real Time Nursing Dashboards
Q&A- Success, Case Add-Ons | Innovation and Application of Real Time Nursing Dashboards
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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
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Organizational Strategy | Innovation and Application of Real Time Nursing Dashboards
Organizational Strategy | Innovation and Application of Real Time Nursing Dashboards
alignchapterdailydartmouthdatadevelopfrontleadersmeaningfulmetricsNoneorganizationalorganizationspacemakerspatientsradiologyseniorstaffstrategiesstrategytranslate
Q&A- Respiratory Compromise | Respiratory Compromise: Use of Capnography During Procedural Sedation
Q&A- Respiratory Compromise | Respiratory Compromise: Use of Capnography During Procedural Sedation
adverseanesthesiaanesthesiologistcathchapterguidelinesinstitutionintubatedlistsNonenursenursespatientpatientsprocedurequestionsafetysedationultrasoundversuswaveform
Q&A PET/MRI  | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
Q&A PET/MRI | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
apronsbodychaptercontrastDialysisdischargeinjectinstitutioninstructionslinedminutesMRINonepatientpatientspediatricpediatricsportionprotocolsradiationradiologistrequirescanstechnologist
Background to Nursing Burnout | Burnout in the Radiology Setting?
Background to Nursing Burnout | Burnout in the Radiology Setting?
chaptercontinuumdifferenceemotionalfallNonenurseradiologyspecialtytalk
Clinical Workflow for PET/MRI | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
Clinical Workflow for PET/MRI | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
arrivesbloodchapterchartcheckcontrastdoseflowgadoliniumglucoseimaginginjectinjectedinjectinginjectionmonitorMRINonenursepatientpatientspneumaticpresencepriorradiologistrobescanscannerscanningscreeningworkflow
Delay Dashboard | IR Lean Sigma Team Improves Patient Experience and Throughput
Delay Dashboard | IR Lean Sigma Team Improves Patient Experience and Throughput
centerchaptercodingcolorcoordinatorcustomdatabasedelaydelaysdisplayedInterventionsNonepatientphysicianprepreasonstechupdatedworkflow
The Journey Together | Gold Medal Lecture - Health of Technologists and Nurses and the Role of Compassion in an AI Focused World
The Journey Together | Gold Medal Lecture - Health of Technologists and Nurses and the Role of Compassion in an AI Focused World
albanybaltimorechaptergrantedknowledgeNonepatientperfusionphysicistsradiologyrisksshared
Q&A- Documentation, Before and After results, Leadership, Culture | Innovation and Application of Real Time Nursing Dashboards
Q&A- Documentation, Before and After results, Leadership, Culture | Innovation and Application of Real Time Nursing Dashboards
accomplishchapterculturedatadocumentationdocumentinginterventionalleadershipmanagermodalityNonenursenursesnursingpatientphysiciansprojectprojectsradiologyroundingteamtechnologisttechnologists
How We Established our Practice Guidelines | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
How We Established our Practice Guidelines | Risk Mitigation: Periprocedural Screening and Anticoagulation Guidelines to Reduce Interventional Radiology Bleeding Risks
anticoagulationcallschapterclinicaldatabaseguidelineslivermayomedicationNonenursespanelpatientpatientsphysiciansprocedureradiologistradiologistsspecialtytriagevalues
Transcript

basically and a lot of projects you'll see like pre and post but here we had a little bit a little bit of a mix of a

lot of different project pieces so we did lean methodology and that's where we had our data collection tool and Eddie's going to go over our sheet about how we measure time and then we wanted to measure the arrival time to the

procedural time that that's the part that we really focused on our focus groups so we had frequent staff meetings so every Wednesday every Wednesday of every month we had something going on so we would either

have a one-to-one like nurse to nurse or tech to nurse or tech to leader or we had the techs all meeting together on one Wednesday I know the nurse is all met on another Wednesday and then on a third Wednesday we everybody met and we

talked about our findings like what what we thought was going to work the the big thing that we accomplished in these staff meetings was roll clear if it we all knew who was responsible for what and then our implementation plan is

that's when we optimized our tracking board because the doctors were the ones that came forward and said hey I want the insertion site on the tracking board and the nurses said I want that I want the name up there so that they know

who's doing the case as far as the medications on the tracking board everybody wanted to know that so we got some input from everyone and allergies was huge - and then we started the charge nurse role where the nurses were

we I had a group of the nurses and said who wants to be a charge nurse because I knew they wanted they were on the clinical ladder and the way our clinical ladder works is that the nurses start at the clinical level then they could

become an advanced nurse clinician then they go to an instance north clinician - and then a nurse scholar and then a chart and then a shift nurse manager so if you're an advanced nurse clinician - or a scholar you can be a charge nurse

so I had quite a few of those so I said who wants to be a charge nurse because they had lots of experience five of them stepped up and said they wanted to be the charge nurse so because I wanted to be able to show the vision to the to the

to our staff we use Carter's change model and in Cotters change model we started to create a sense of urgency and the reason why we use and so I have the Carters on the it's on the it's on the left right-hand side and on the

left-hand side I have the framework so create a sense of urgency that's where we had the unstructured workflow roles and responsibilities confusion and patient safety concerns especially with when the patient would come down about

the Eliquis or did you eat but those are important things that we needed to know and that those are things that kind of like delayed the cases build a guiding coalition number two and that's where the interprofessional team members all

the doctors the APB's and the nurses were involved involved I was the executive sponsor for the project but we also had to address our other stakeholders which were the nurses in dialysis

and the nurses in the ARU because that's where our patients are coming from them and going back to them and some of the nurses on the floors we had to form a shared vision for change and that's where we we had our staff meetings we

have lots of handouts we had some posters if we had a new change model which you'll see what we did have one we posted it on the wall and in the bulletin boards so that the nurses knew this is what we were doing so it was a

constant reminder remove all communicate the vision so that's where we researched the literature and then we shared the findings and so when we were researching the literature we would sit down and we have access to the library at Emory and

we would find articles that would pertain to our project and we went to a ORN they we used a lot of their work because of the Ori and the Perry OP which really gave us a lot of clarification and some safety guidelines

that we liked then then I printed out the articles for the other nurses and they had part of their project was they had to take the article articles home and read them on their spare time and come back and share at the next staff

meeting what they learned and then we designed the role the charge nurse but here it was the nurses that once I was like super busy so I gave him these articles like I want you guys to look these up they looked and printed them

out they came back and said this is what we want our charge nurse to look like and we also improved our communication methods are tracking board our daily Huddle's and we had lots of pictorials to help and then this way our nurses

were completely engaged and so as a staff so when the staff engagement survey came out because we use like these words if you're a leader in the room we'd say you're so engaged and then when they get that questionnaire do you

feel engaged then they're gonna say yes so your staff engagement scores go up so it was kind of a win-win for everybody and then the remove barriers that's where you empower the staff so basically that's where I was this leader where the

staff would say this isn't working and even though like I kind of had an idea it was gonna work they needed to either find out or if they did something and it didn't work as planned I was never punitive I'm like okay so plan a

didn't work let's try Plan B and because I had that that mindset my staff really trusted me another piece that worked for us is that we we did the PDSA model and we would plan it study it do it and act on it and we kept doing that over and

over and over with a lot of the pieces that we changed in our project then we had the create short-term wins so we had a quality and bulletin board and every month on the quality on bulletin board we would have a data for the impatience

the outpatients and the and then total and we measures like how the patients were going on a like a Ana tracking I forgot what I called that anyways it's a it's a time measurement scale and then we had then we said the next one is

sustain never let up so that's where we always had the constant reminders we kind of had nurses starting to champion different roles we had nurses say to one another like hey you aren't doing it right like the and they were like they

respected each other you're like you okay right I'll go back and change it and they didn't like talk about each other or something didn't work right and then anchor the change is that's where we had our frequent staff meetings we

always did an evaluation houses working we kept our workup sheets in a drawer so we can go back and on it if we had to and then we and then everybody met their performance appraisal criteria and like I said earlier for nurses advanced on

the plan so this was one of the this is one of our biggest breakthroughs is when we changed our leadership model care delivery when I first started it was the doctor and the I our radiology tech makin all the decisions like the nurses

was completely out of it so after we did these different things the doctor was in charge of the clinical treatment so anything that had to do with the patient care he he decided what we're gonna do the are in charge she was in charge of

clinical decisions daily operations and throughput so she basically was the air traffic for IR and then the lead tech which was the IR supervisor previously we changed the role to called to lead tech and they

were responsible for the IR sweeps all the supplies inventory and the IR technologist she cheated their schedule and then we changed it to our interprofessional model so where everybody was important and equal and so

so what is it like to be a nurse in radiology all four of these boxes represent the essential part of radiology nursing workload and staffing speaks to how our rit nurses cover all seven modalities in radiology in a

variety of functions these functions include but are not limited to sedation IV therapy triage recovery education and emotional support for our patients regarding staffing this requires deploying nurses in multiple locations

at one time to ensure that the patients are receiving the best care at the right time for us the challenge was how do we adequately deploy the staff to multiple areas while being efficient fiscally responsible but continue to provide

compassionate care the next box epic which is our electronic medical record centers around orders and documentation as Cris mentioned earlier in 2015 we went live with radiant and epic plugin specific

for radiology workflow the radiant functionality was exam specific and less patient flow specific this presented a problem for nurses who cover patients and all modalities and had more documentation requirements than the

technologist did and the last box engagement as we know is so important our nurses felt like they were getting pulled in multiple directions and often time misunderstood by the other modalities and radiology that really are

just focused on their modality and it risks nursing job satisfaction and increased our burnout rate right so as Jeannie described to you that was the current state that our nurses we're facing and as we designed or created the

dashboards we had to understand how we could create meaningful metrics for the nurses to address all these different issues that they were facing our nurses and dartmouth-hitchcock radiology did not just cover interventional radiology

so they were covering MRI CT fluoro so they were all over at the department and it was really hard to capture all of that work and really help them understand how to align their staffing to cover all these multiple modalities

and that also made it difficult for engagement sometimes as they interacted with different staff across the department so we have to consider all of this on top of the complexity with documentation in our EMR system we had

to combine all of these factors as we designed the dashboard so fortunately for us we did not follow Dilbert's boss's philosophy we had much more intent international intent as we design our dashboards so when it came to build

in the radiology nurse dashboard if we could sort of break down the steps we took we would go over these three categories the first category is identifying what measures were relevant for the nurses given the current

situation that they were facing the second category was where that information lived and how we could pull this in to the dashboards meaningfully and the last is how that data needs to be

displayed on the dashboard so going to our first category here which is what measures are relevant we have two main goals the first goal was to select measures that could help our nurses monitor their performance in real-time

so again this was part of our journey around competency building and sustainability across the department and we knew that for our frontline staff including our nurses they were not used to looking at data especially data in

real-time to make decisions and a lot of their description about their day was very variable and really driven by perception of what they were feeling at any given moment so our objective or our goal around monitoring real time for

performance was to create an objective understanding across the board around how the day went so if someone said that they were really busy what did that actually mean so trying to make sure everyone speak in the same language

using data and objectively understanding their performance the second goal around our measures was to help the nurses be more proactive around decision making so as a part of this journey we wanted our frontline

staff to be better problem solvers and be empowered to make decisions around their workflow and so we wanted the measures to be relevant around helping them make more proactive decisions to be more efficient around their daily work

to the left here as an example of some of the metrics that we selected Gina will go into more details around to the dashboard but that's just a real quick snap short of some of the metrics that we selected and a lot of those metrics

are showing pending work for our nurses and a lot of what that does for them is decide how they can align their staffing on a daily basis to accomplish a lot of the pending work that they have so that's just an example of some of the

measures that we selected to accomplish those goals so moving on to the second category here which is where the information lives as Chris and Jeannie both mentioned and I'll mention it again because it was a real pain when we went

live with radiance in 2015 it wasn't great for nursing it didn't capture a lot of the nursing work accurately and because our nurses covered so many different modalities it was difficult for them to see all of their work in one

place in a way that made sense so part of our journey or one of the biggest things as we built the dashboard was to create nurse resources within radiance that helped us accurately capture all of the nursing work and described it in a

way that was easy for them to understand and differentiate between the different kinds of work that they did in radiology and then we am partnered with epic to participate in a cojito project cojito is a branch of epic which builds

dashboards almond does analytic reporting so this was a paid engagement where we told them what we wanted and they had their analytic team built and designed the dashboards within the epic system the engagement took about 12

weeks to complete and that was not just for the nursing dashboard we had about 17 different dashboards that we were building across radiology and so all that entire engagement took about 12 weeks to complete and so that was how we

partnered or that was where we partnered with the epic cojito team to actually build those dashboards within the EMR system and then finally in our process of building the radiology nursing dashboard we had to figure out how the

data needs to be displayed so again we were dealing with frontline nurses who are not used to looking at data and at first we're really opposed to looking at it because they didn't really understand what it meant to them and so we had to

make sure that the data was simple and easy for them to to understand especially in real time for the dashboards it has to be something that they would look at it would be visually appealing and they could really get

enough context in real time to make a decision around their workflow so we had to juggle all of these different pieces as we built and design our radiology nurse dashboard and in a minute you will go over what that actually looked like

when we're done but before that I wanted to show you a prototype of what we started with as we embarked on the cojito project so this is just a PowerPoint template or design that we shared with the Epico hero

team when we started this was our way of sharing or showing our vision of what we wanted on the dashboard we knew that there were a team of analytic people who didn't necessarily understand our operations of workflow so we wanted to

make it easy for them to understand what we needed and we also had to do some shadowing and training in real time with the analytics team as they embarked on this project to build our dashboard but of course when we presented this to them

we knew that our actual product would would the result of the final product would be constrained by what they had in the system so for example they did not have as many callers in their color palette to create a dashboard and so as

Jeanne goes over our final product you might not see as many beautiful colors in there that was their upgrading to more colors and that was great but we knew that as we move forward we would have to be restricted by what they

actually had in the system for a final product or outlook but I just wanted to share this just to give you if you're thinking of embarking on their journey to build dashboards you can start simple just create a wait just have a way to

share your vision with the with whoever the Analects analytics team is that is built in the dashboard you don't have to know what it would look like exactly on the system itself so now Jeanne is gonna walk you through

our actual dashboards and how we apply them in real time thanks to me

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

questions a question comment I'm

Canadian I work in a Canadian hospital and I would say my hospital has an excellent just culture this is a practice so the other day we had a bunch of unusual things happen to begin with and I made the first error and it was a

medication error I forgot to order chemotherapy page went into the room they filled out their interventional procedure safety checklist and someone checked off all the equipment I need for this procedure as present checked it off

he did a time out in the room completed it the doctor started the case when he got the catheter in the right place that's when they discovered there was no chemo because I had forgotten to order the chemo that was the first mistake and

so we have an RLS reporting and learning system I filled it out etc and my manager was 100% supportive that art Swiss cheese lined up and you know the three things that should have caught it did not so this the safety procedure

checklist failed and so did the timeout but the ultimate one in my opinion and I wrote this in my report was that the doctor should never have started a case if he didn't know everything was ready and my my or

zatia was extremely supportive of everything I did but that doctor still thinks it's my fault that we didn't do the case and you know I'm not a new grad obviously and I'm you know he's wrong and I don't care

I fully own my mistake but he's wrong in that the whole thing was my fault so sometimes your organization will 100% support you but you might have people that are not in the just culture part and they're just looking to blame you so

you know I feel like I've done my thing I've learned I've set arow and I'm changing the situation and so it's important to remember that part of your just culture and and not focus on the people are trying to say it's your fault

to stop you from reporting in the future not really a question sorry no that's alright that's great because I think that illustrates that anatomy of the error in healthcare with that blunt end of the system and the sharp end so he's

kind of stuck in the sharp end isn't he he's blaming at you thank you very much because errors are made and they're devastating not just for the patients they're devastating to a practitioner so I think we have to look beyond the just

culture and there's something called second victim and you need second victim support and I'm trying yet actually where I work to have a program instituted sort of like a Rapid Response Team when an error is made so that you

can have the support and it goes beyond changing a policy or procedure or doing a root cause analysis but you need emotional and psychological support for the practitioner that made that error and came forth to report that error so

just wondering also how many people have a second Victim Support Service at their institution see there very little I think we have to really look at that and look forward and implement maybe something like that I

agree and we are one of those institutions that have the second victim and and that in itself is kind of a it's a topic but absolutely and and that does go hand in hand with that just culture to support because it is very

devastating when you have that air and depending on the patient safety event that occurs you know if it results in a patient death that really sticks with you and also events that we don't just stop there with ours so we have a

psychologist that's on board that talks with our physicians and then we have a liaison in our Employee Assistance Program that's also psychology based for our staff so that they can have further follow-up but even even if it's a

devastating event where there wasn't anything that was done wrong it's just that we were gonna stop that train that was rolling with this patient you know how devastating sepsis can be you just sometimes aren't going to stop

that train and and the patient is going to pass but the practitioners that were involved in that care are are moved by that most recently we had a three-year-old who passed and they had they were septic had a cleft palate and

they had a abscess that had formed after the surgery so you know that can be very devastating we do we pull our practitioners into that and that from risk management we're able to initiate that so we absolutely ask when a serious

patient safety event occurs or one that we can pick up that there's some a lot of emotion wrapped around it we'll ask them how they're doing and then a we can self-refer a person and then EAP we'll reach out to the staff member and

our psychologist we'll reach out to the physician if we if we really feel that they need just a little helping hand so yeah it's a good program I kudos to you to get that started so much for your talk today I just wanted to reach back

to you and ask you how your organization or other organizations support the exposure of those events within your hospitals I happen to be from Vanderbilt University Medical Center and we have been in the national news recently and

so there's been a lot of conversation with my staff and you know you you pull your team together and you have conversations and and the event occurred in 2017 and I'm facing them in 2018 2019 and they're like how come we don't know

these things happen in our organizations and you know there's a lot to learn from patient error and Sentinel events and I'm just curious to learn from you how how do you expose your nurses within your organization to those very private

things that go through risk management can you share with me sure sure thank you that's a great question so we do out of patient safety and risk management we do Grand Rounds and we do one once a quarter and in that way and

we will on some sensitive issues because some of it can be wrapped up in legal if there's lawsuits pending and stuff so you you really can't share some of that and I think that that might be some of it a little bit of the disconnect that

staff have because they may or may not know the players involved which gets to be a little tricky so so time helps but we we do let them know that the event happened here and that's that's the title of our

Grand Rounds and we bring those patient safety events but will de identify them quite a little bit and change some of that to protect the practitioners involved and also to focus more on the on the patient safety event and again

focus on the system so on the on the blunt end rather than so much on that sharp end because that sharp end it's sharp for a reason and it could hurt so it can hurt our clinicians describe to me who all is involved in your Grand

Rounds and where that takes place so we have we have a couple of different venues in our Hospital depending on how large we anticipate it to be so we actually have a an auditorium that has the auditorium seating because we're an

academic Medical Center so we have that that luxury we also have some smaller venues depending on what's happening so depending on what the event is we may have outside people come in and talk about that in fact we had the one of the

big things that we're working on right now is sorry the burt behavioral emergency response team so and awareness awareness wrapped around that so one of the things that we're actually looking at is bringing in the the nurse who

speaks from the del noir event to come to the hospital and speak about issues she presented very well very strategically and just to kind of heighten that behavioral awareness that we don't want our nurses to be you know

subjected to that so so depending on what's happening we may pull in outside most of the time we will involve people from our own departments throughout the hospital depending on what the event is so we've we've had some we had a wrong

patient that was they had a procedure done not a wrong patient we had the wrong the wrong procedure was done on the right patient and we actually brought in from ultrasound and from I are including the

physician involved with the case and then a risk management person and made up a panel for people to we presented and then fielded questions now that actually went really well we standing-room-only so okay that was good

so that's some of the strategy that we use thank you you're welcome because we have a computerized reporting and learning system our system sends out a monthly report on just the trends so if we're seeing a rise in a certain

thing and sometimes it's just you know Falls so remember to look at your Falls where whatever but sometimes it's more specific so there have been you know a mixup on this drug in this drug and and pharmacy is doing this to try and

alleviate that and so well it's not everything and it's obviously not any that are illegal it does give you a sort of months a month overview of what kinds of things people are doing wrong and the best part about it is these were all

reported independently so you can it's showing us as people that someone listened to our report and that something's being done about it right very good point and that's some of what we hear too is that these systems allow

you to anonymously submit a report which is fine we're interested in the event we want to hear the the event it's helpful when we have a name because if if I as the MIS managers that's looking at this report if I have a question I'd like to

go back to the person who put the report in to kind of find some more information out but it is not necessary and we're like I said we're more interested in the event but we we to send out a report that kind of aggregates our involvement

but it what our top five reports are for the month but we hear a lot of disconnect that our staff don't hear about what's happening what the report is I put that I put that record in and I don't hear anything about it well did

you give us a name so because the manager the unit manager also sees that and that's why we encourage our managers to use some of those reports that they're seeing as a patient safety during their event during their

department meetings get that word out and what they're doing about it because leader leadership so does do some effect some change but staff might not realize it's connected to the event that they turned in I was just curious amongst us

all who when you get new hires or new employees who talks about what to do you know if there's an air or just the whole process of that because I know the facilities that I worked at nobody has ever done it until the time that it's

happened so what education are we providing from the get-go that maybe change practice further down absolutely so we risk management speaks at nursing orientation for us anyone else do they have just to talk about oh sorry that's

okay Dartmouth Hitchcock Medical Center up in New England and we have an error prevention training class that's required by all new staff but we also have made a huge push that all veteran staff have to go as well and we're like

at 90% it's a two-hour training and it talks about all different types of error prevention and then it also talks about our reporting system we also are starting to look at code lavender if anyone's heard about that but that's the

second victim so we're supporting our nurses through errors and doctors you know technicians technologists but we have a really great just culture I mean sometimes of course it's thought to be punitive but I actually as a nurse

manager do all of the reporting systems for quality and safety for the whole department and we have at 9:30 we have a daily safety brief and everyone from the hospital every department comes and reports out any safety issues and then

oftentimes in real time we're actually getting together with the different parties to say okay what can we do what was the failure we also have a very robust our see a root cause analysis or when we

have something that goes to a report that's pretty serious we will have that we get a lot of people in the room including the people that were involved in it and it's to look at where do we systems failure where is that and then

after that oftentimes we'll do a cap so we'll grab a group of working together to say we need to change our policy or change the standards in which we're working because it's it's not ever proof it's fabulous thank you so much for

sharing that okay thank you all very much I appreciate you coming [Applause]

thank you for joining me this morning as we talk about patient safety and risk management we're gonna touch on a number of different things but for starters can I see how many of bedside or procedural room nurses CTM our procedural room excellent okay all right okay all right

any leaders charge nurses directors awesome all right by chance are there any physicians in the crowd all right okay cool welcome thanks again for coming okay so just to note I have no financial or educational conflicts of

interests all right so today we're going to be talking about and discussing some key patient safety influencers in health care we're going to take a look at something that's called human factors engineering we're going to look at

educational and global human error reduction strategies and we're going to take a look at the just culture concept and its impact on patient safety Event Reporting so according to some statistics from this year for patient

safety week which was March 10th through March 16th so just a few days ago there are about that occur due to patient due to adverse events and 10 to 20% just to highlight a

few 10 to 20% during medical examiner cases they find that there have been some misdiagnosis during that so arriving at an accurate diagnosis is fundamental to the practice of medicine yet according to the 2015 Institute of

Medicine report most patients will experience at least one diagnostic err in their lifetime this report will also note that diagnostic errors contribute to about 10% of patient deaths and account for up

to 17% of adverse events during hospitalizations so currently we have about 41% of Americans who say that they've experienced a medical error either in their own care or that of a loved one or a friend and the National

Academy of Medicine and just a word about the National Academy of Medicine the IOM in July of 2015 changed their name to the National Academy of Medicine so this statistic comes post July of 2015 and they're

suggesting that 5% of US adults who seek care in outpatient settings experience a diagnostic error so that's the reason why we're here today so when we're

going to open it up to any talks or questions great great question great question so

her question was do we share these guidelines with her inpatient nursing staff yes I did a clinical Grand Rounds where we kind of over viewed but no expecting them to remember this and understand it no but it is available

online within our my own Mayo Clinic intranet for them to refer to but then that also comes down to our nurses calling the flora nurse - because they're really screening these patients and then calling and having that

conversation with our floor nurses and then just prior to Kerri and I travelling here these guidelines are also being shared across our enterprise for enterprise conversion so Arizona Florida and Rochester the referring

clinician yes yes yes so that's why okay so that's why it's really important to have that physician to physician disgusting yes our radiologists are not putting through these orders to hold these medications

that's a very good point to make that is where our radiologists will be calling the ordering clinician and determining hey I really strongly encourage you to hold this medication on this patient if you disagree what are your objections

and then they discuss the plan going forward from there our microphone isn't working hello yes yep so you you want to take that yes we do have like I shared I would love to be

doing these phone calls a week in advance we have not gotten that far but that's something that we're looking to you can explain the company we run into this on a daily basis yes and you know with all the health systems and we have

so many people ordering these procedures that don't understand what we do what our coagulation guidelines are a lot of our physicians in the Health System and other parts of the clinic have access to that ask Mayo expert which which does

follow that guideline so it is available but a lot of times we are finding patients that are getting added a day or two before and the bulk of our pre procedure phone calls are done the night before the procedure so when that

happens and we call the patient and they say oh yeah I just had a stent placed in my Hospital in Montana a week ago then that's the point at which we have to turn it over to the radiologist and say can you look into this and we have

fellows often that will look into that the night before and the procedure may be rescheduled it may be delayed or it you know been depending on the patient condition they may have that risk-benefit conversation and decide to

proceed yes so yes and no so in our practice a lot of these patients are all patients strictly outpatients so a lot of these patients are not even sent to an AM admits they come directly to radiology

they report right to our desk but with the phone calls the we what we use epic how many of you guys use epic so scheduling we do have scheduling triage is yes so our scheduling triage right now

because I can't give them all these guidelines we've put in our big hitters we have them ask are you taking any new blood thinning medications do you take warfarin that's the one medication that we do call out so yes sorry

yep I've misunderstood what you're asking it does yeah yeah you know your exact yep so good point and when we first rolled these out I sat down with our scheduling supervisor and we updated all of our

triage is to reflect because we did have it in all of our procedures and then we removed it from some [Music] they need it for the semen we say Menards

yeah okay and you [Music] yeah mm-hm yeah it's so good what world

you know and I would like to add so what we're trying to do now that we have a Peck we've just recently rolled it out so we're trying to optimize it trying to create BPA so that it can pull these medications and give an alert to the

ordering clinicians boat and then you run into alert fatigue and things like that but that's that's our next step in this problem we do where you know we're fortunate so that yeah okay do you want to we share that we share

that tub so her question was when you have when you do identify in a patient's chart when you're doing a review that the patient is on one of these medications who has that conversation with the ordering clinician and we're a

little bit spoiled in that we typically have residents and fellows and so our staff radiologists might not want to have that conversation but we do tend to have a fellow who sort of triage is all those problems both in the late

afternoon and in the morning before we get started so they can call providers and have those conversations and if it's at the point where the patient is already there then it's too late for that conversation so then that becomes a

you know supervising radiologist and patient discussion all right yes I uh I'm full disclosure we do not get all of our pre-procedure phone calls done we do the best we can and we prioritize it and oftentimes we're doing

it up until eight o'clock at night and we are pretty selective about who we call we're not if we have a lot of cases we're not going to call low risk procedures we're not gonna call the repeat biopsies if they've had a biopsy

in the last few months yeah repeat procedure call and and and so that's where we differ - so in our practice we do not use moderate sedation for any of our ultrasound guided procedures or even our deep organ

biopsies shouldn't say any we yeah right never say any board's question but uh very rarely do we local only no blocks yeah but those are for our low-risk bleeding procedures or our deep organ kidney

livers pinks oh yeah oh all that's in there patient appointment guide also it's mailed to them but then also we have a Mayo Clinic app so they can just click where their

appointment is and the map we're spoiled because there's big infrastructure but if any of you guys have any questions please feel free to reach out to a carrier myself again it's in your handouts so thank you all

physiology knowing that we want to measure true ventilation let's kind of dive deeper into the equipment issues so looking at some studies here this is a

study that compared the different techniques for interfacing capnography with adult and pediatric supplemental oxygen masks in really the main finding of this study was regardless of the measuring device that was used this

signal for the of the entitled carbon side it varies as the oxygen concentration varies especially in very high levels so levels and adults that are less than 15 if you have a good location of your sampling you're going

to get a pretty accurate sample of your carbon dioxide but what this study found is an extremely high flow rates and that's adults greater than 15 liters per minute and in Pediatrics greater than 8 liters per minute that's when you're

gonna start to see some data quality decrease and I'm gonna tell you a little secret if you have an adult that's on 15 liters per minute and you're having oxygenation issues your problems are bigger than that okay no one should

really be on that much oxygen right you know there's a certain point where you have to change the ventilation or maybe they have a perfusion mismatch or they need peep or they need some other physiologic intervention camp Nagato

masks they provide really stable measurements without significantly breathing with commonly used oxygen flows and these are capnography masks that were designed for that not the rigged up ones that we sometimes you'll

have creatively used in the past and because and if you've seen some of the masks coming by some of because of the open design the carbon dioxide measured with the High Flow oxygen rates if we need to use higher flow rates you make

it artificially lower readings a greater again greater than 15 liters per minute and they may not reflect adequately like that gradient may be much bigger than compared with lower flows so using a standard o2 mask the one we pick up off

the shelf in combination with our you know nasal oral scope monitor can provide us with really good monitoring because it's going to be right close to the patient where they're exhaling but you have to watch the risk of patients

rebreathing okay so this is a little bit of a change in practice because we've recommended this for a long time now you put your sampling line on you use your regular oxygen but just by doing these studies we've found that

patients are rebreathing carbon dioxide more than we thought just something to be aware of you're looking at your baseline and if your monitor is calibrated appropriately and I've been doing

for 15 years and I've never seen a Capon ography monitor you know when you turn it on and it calibrates itself where the baseline was not zero okay so usually it's something related to the patient rebreathing and such so again food for

thought this is just the comparisons okay so when we have patients that are breathing I know it's a little hard to see from the back so we're comparing the end tidal co2 concentration between devices and at our supplemental oxygen

rates as we're going up on our flow rates so with patients that were normal ventilating their co2 on a blood gas was 39:39 on the monitor so very very little change and that's actually true for the cap one mask the oxy mask and the

different capital lines that's what they looked at they looked at for when they went up to five liters per minute 38 plus or minus point five 38 plus or minus point seven and then no change for the capital line the two different

capital lines so again nothing's statistically significant as far as using five liters per minute and same thing with ten liters per minute with normal ventilation really no change in the monitoring from no oxygen to oxygen

where you start to see some changes in normal ventilation with using all four of those the cap one the oxy mask and the capital lines very very little difference even at 20 but when you looked at the regular oxygen mask that

wasn't designed for it that's when you see the statistic differences and certainly the same goes true for patients who are a hypoventilating and hyperventilating to using the proper equipment again with normal flows and

even higher flows you really don't see a whole lot of changes and this is just a this in a graphical form here so we have patients with a simple mask on the first column cap one and then the oxy mask and you can see the simple mask between no

flow and flow there's a difference in our siege of co2 readings where the cap one and the oxy mask not as much of a difference right and then the same things when we I'm sorry I'm the right when we

turn the oxygen on and the flow rates go up minimal difference in the concentration that we're monitoring there so careful attention to positioning the mask where the mask is located on the patient the inspired

concentration of carbon dioxide and the waveform itself right the quality of the waveform should be looked at very carefully and then looking at the location the gas sampling should be right over where the patient is exhaling

right you want to avoid having any distance between the two of those which I know can be a challenge in the environments that you're working in so

culture concept so the single greatest impediment to err prevention in the

medical industry is that we punish people for making a mistake we should learn right we should really learn so what comes to mind when you think about it the term just culture right she's being able to

report something and not having having punitive actions from that Lane free fair open and honest trustworthy supportive nice place to work yes so two nurses select the wrong medication from a dispensing system

one dose reaches the patient causing him to go into cardiac arrest and the other is caught at the bedside before causing harm do we treat these nurses in the same way no we should but oftentimes we don't right

right right so an active failure versus more the latent failure right so upon further investigation it showed that the two vials that these nurses pulled were very similar the vials was very similar to something that wears a different

medication so we needed some separation from pharmacy so so a little systems intervention right in our Omni cells so and maybe you know maybe there's some human factors that were involved there too that you know one nurse caught it

and the other one didn't but rather than punishing we need to work on consoling and supporting and look at the system and find what's happening what's going on what's the root cause a nurse loses custody of yet an unlabeled specimen but

chooses not to report the incident at a fear of discipline do we fur grit forgive the breach given the nurses fear no no so we really can't but we shouldn't come down on her like a hammer you know or on them doesn't have

to be heard on them because this can actually be a sentinel event if if you have to go back and get another sample that's a set a little bit so that's a Joint Commission never event so that that's not that's not a good thing plus

it's an extreme inconvenience to the patient and also we're opening that patient up to further harm because we have to get another sample so you have to ask why did the nurse behave this way why did she choose not to report it

honest honest disclosure without fear of retribution that's an important characteristic of the just culture hmm yes it does doesn't it that's an excellent point thank you very much for

sharing that excellent point certainly she said that you also have to look at leadership because a lot of times leadership has favoritism so you've got to work on the favoritism so it has to be fair and that's also part

of the just culture and that's a very good point as a learning experience and we're gonna cover some of that too so we have a radiology team that defends skipping the timeout on the basis that no adverse event occurred

so do we condone this no no no so we we don't condone it and it is it is a Joint Commission requirement but and although this incident didn't end in an adverse event we could certainly see where it might so again we need to engage our

leadership we need to engage people at the bedside including our physicians as to you know why we blew right through the timeout so a fair and just culture is is a culture that refers to values supportive model with shared

accountability um it's also an integrated pattern of individual and organizational behaviors based upon shared beliefs and values that continuously cease to minimize patient harm that may result from the processes

of care delivery so culture is the outcome of how our organization responds it's the outcome so if we have a just culture we will have people who will report those events those near misses and will work and not hide them and do

what's right that's why we need it because if we don't have it only two to three percent of errors would be reported most hospitals would be unaware of what errors they had health care workers would report only what they

could not hide and airs as viewed by hospital workers and the media are indicators of carelessness which is not true in fact it's farthest from the fact

so last is a drill down report so as Tommy mentioned we've kept the dashboard simple for the nurses to easily interpret the data so we really we needed it to be like a quick visual

however there are times when nurses might need more context in detail behind what they are seeing in the dashboard this shows a drill down report as you can see behind each dashboard component that we just spoke about that can

provide some additional details so example this report shows the actual time stamps and it's a little squished because it's a long thing but these are the actual time stamps and that's how we generated the data for the scorecard and

this is a great tool during huddle time to quickly investigate and answer more specific questions about the patient timeline so remember when the first one I showed you with the red boxes and for like nine minutes late or whatever

well with this drill down you're able to kind of see whether the patient got there on time so where they the patient might came thirty minutes before their appointment said a sixty or what was the holdup and you can actually see was it

the nursing that's running behind or or the physician or whatever so it really helps to drill it down so you can get to this drill down report by clicking on this icon on each dashboard component so this was the nurse casing buffer time

indicator and as you can see there's a couple of tabs up here and this right here can get you down to this drill down report one things I wanted to mention is that this report can also be manipulated to run data historically and over larger

timeframes it's sort of how Tommy got the information for the scorecards by using this drill down report and then she could also pull it for like I said daily Huddle's at the end of the day we can look at a particular case and say

why was it late and what do we r and so really fixing things in real time so this completes the formal part of our presentation on our journey to create meaningful nursing dashboards at D H and just to review our objectives so we hope

that you were able to make the connection that Chris spoke about between the different leadership boxes and the importance of lining across aligning across different levels of the organization remember

strategy is ineffective if you can't be rolled down to the front lines second Tommy discussed and we demonstrated how data is an important part of driving high quality patient care and that behind every number there is a story and

every story there is a number thirdly we hope you learn some useful ideas for building and designing your own nursing dashboard and lastly we demonstrated the practical application of the dashboard for the frontline staff using the look

interpret apply and assess model so

burned out so if you chose not to do the survey you can certainly go through this and see how many

you can say yes on so are you constantly sick and tired do you ever find yourself struggling to keep your eyes open even when you're out with friends or is it getting harder to get out of bed than it used to be physical exhaustion is one of

the earliest warning signs of burnout but don't we all attribute it to the stressful day that we just had that we're busy with the kids we're taking them to soccer we're taking them here I don't have children but I have very sick

elderly parents so for me it's the other way but when I was feeling exhausted I just I'm just tired it's busy it's busy but it can truly be one of the first signs that you're getting past stress and into burnout so burner can also

cause physical symptoms including headaches insomnia stomach upset weight loss or gain and it can make you more susceptible to illness do you have those people in your department that are always flippin sick do you wonder if

maybe they're burned-out and that's why they're always sick it's a really good question I was talking to the people I currently work with and even though I happen to work at a phenomenal organization right now and it's the best

job I've ever had it's still stressful I was shocked out of the 12 of us seven of them said they suffered from insomnia seven I think that's higher than usual so we had that conversation of you may be starting to burnout you may need to

help you know pull back a little bit so it definitely is an issue so if you're constantly sick or tired and I'm not making a joke on that one even though I could please seek out medical attention to find out if there is a medical reason

maybe your hypothyroid your vitamin D is low because surprisingly most of us are there may be a medical reason that you're always exhausted but if you've ruled that out it may be that you're going past stress into burnout warning

sign number two and I love this one because I can come up with every single day where I feel just a little underappreciated but this is warning sign number two and I love that cartoon is that not adorable

and yes stress can kill you it's easy to feel underappreciated on a given day what we do we do so much stuff all at the same time and most of the time our patients and our supervisors don't even see

what we do let's be honest we do but we're so busy doing it we don't feel all the good that we do if you start to seriously feel underappreciated you need to kind of take stock and why am I so upset

is it me am I having some issues is it I don't have good communication with my supervisor is it an issue with my coworker and maybe I need to sit down with them and work on our relationship it's okay to say no to extra assignments

I know that's a tough one no is the hard word for me those of you that know me yes I am the chair of the Planning Committee I am also one of the master faculty they teaches the review course to study for your certification exam

I'm also the state chapter president I have a hard time saying no I get so passionate about getting involved that I realize I'm under a mountain I learned how to say no ask Pauline we were at a meeting the other night and they asked

someone to step up and do something and my answer was I'm sorry but I have to say no I have to figure out how and when I have enough it's okay to do that you just have to do it professionally and not snarky which as you can tell by my

personality I sometimes have troubles with I did say no I was very proud of myself I waffled a bit but I said no and yes and it's a hard thing to do especially when you want to help okay do you spend your drive home chastising

yourself on how you handled a certain situation I know I sure as heck do so I'm in a couple of slides I'm gonna share with you how I process that information and I'm finding it's being very helpful in moving me down that

burnout scale okay sign number three dreading going into work I just love the guy over on the right I had so much fun with these people okay nobody wants to work on a holiday or a weekend but if your stomach is getting tied up in knots

when you wake up going oh crap I have to go to that job again it's probably a sign that it's more than just stress okay but we don't want you to just soldier through this is your body's Way of

telling you this is not just stress this is abnormal okay now it's gonna happen to all of us some days granted if I had to work that next day or after I worked my 21 hour shift do you think my stomach would have

been in knots getting up absolutely but it shouldn't be consistent okay I loved the third one if an unsupportive nurse manager or co-workers from hell do you have any of those are making your work life a living nightmare it might be

time to look for another job I'm being honest for me that was it that was my solution I was so uncomfortable in the situation I was in feeling like I wasn't getting the support even when I shared with the person that I would realized

how burned out I was I got no support for my well-being and for my marriage it was time to find a new job but it doesn't have to be if you have a supportive group you can come back from it and stay in a job that you love it is

possible okay so if you're not ready to leave the do job try picking up a new skill or taking a class so let's say you always work in IR maybe you go to your boss and say hey can I start picking up a few shifts in CT just to do something

new to challenge myself with a new task it's a great way to refresh that passion for what you do without leaving the job if that makes sense okay our fourth sign does anybody remember what that blow-up guy was from airplane I love Tim so

warning sign number fours you're going through the motions okay so here's my question were you inspired and motivated after nursing school where you went into your shift and you were so excited to go in and take care of that patient and I

can tell you after I got that leadership job I went in everyday all excited on how I could make a difference but do you see that now you're almost trying to avoid the interactions with your patient and you may not and I hope you don't but

there have been times even now as I'm healing that I'm thinking in my head I just wish this patient was shut up please be quiet and then I have the other side you know the devil and the angel

and then the angel goes Lauren take a deep breath it is not your patients fault you're having a bad day you love what you do go back to that take a deep breath and go back but it happens it happens to all of us and it's not that

we're bad people and that we don't care anymore we just we're overstimulated is the best way I can describe it okay all right and our last sign is that you're becoming insensitive to your patients and the the situation I just just

described and it admitted to which I can tell you is an embarrassing thing to have to admit but I admit it you you can absolutely become insensitive to your patients how they're feeling what they're going through this meta port

I've done seven of these today I'm frustrated I want to go home I have a headache I don't feel well but you forget that for this patient this is life-changing probably in the last week their life has been turned upside down

with a million procedures and new diagnoses so it's taking that deep breath and refocusing okay so if you can and that happens take that deep breath try and take a break which I know is hard some of us don't even get lunches

but even if all you do is I've actually turned around and faced the corner and done three deep breaths and my staff because I've shared with them the struggles that I'm going through if they see me facing the corner they just let

me be because they know I just need five seconds to compose myself okay burnout is not a moral failing I struggled with this a lot because I kept thinking like that okay so now we're

this is nursing case volume per hour so

staffing is a consistent challenge as I mentioned before having dashboards helps to make real-time decisions to help allocate nursing resources during high-volume times so this dashboard indicator

identifies the distribution of nursing workload over the course of the day I love this one for me especially as a nurse manager especially since me knows Tommy says they they feel like oh my god it's so busy it's so busy it's so

chaotic and you're trying to help them you know well of course I understand why it is now so I actually have data to understand their story and help them to see the data and why they feel it's chaotic so again with the help of color

coding the ability to look and interpret the data is simple so here since I've taken you through a few I thought I'd throw it out to everybody and see what if you wanted to kind of take a stab at using our model so if showing or if

anyone wants to raise their hand so what are you seeing here in this dashboard a lot of what you owe to our cases yeah anything else are you seeing yes correct there's nothing happen at 8 o'clock anything else right yep

sort of a lull here correct so what might you interpret from that in other words so what would you kind of see your say about this I'm sorry can be allowed a long time oh yes yep exactly right and so so then

what action might we take here to help sort of get rid of sort of the high volume times yes exactly so here's where you would shift the staffing to help cover the high volume areas and so I'll just take you through what how since

it's what we do at D H I'll take you through so exactly right I think someone pointed out that you have nurse cases except for say at 8 and at 6 and 6 generally we're just doing recovery at that point we don't need any more cases

going through interpret wise so we have this Pio nurse as you can see in the magenta and I'll tell you a little that's our MRI nurse to specific for MRI doing Pio sedates as Chris mentioned we have an MRI nurse there and we also do

cover pacemakers as well and those that's her caseload as far as non sedation we actually just have we sort of as people aren't busier in between rooms is when they might go you know give lasix for a year gram or you know

port access or what have you so what I'm looking as interpret I have a Pio nurse available seven several times a day so only in the magenta is she busy or he and then the best times may be for IR addons is between like say 11 and 12

here I would potentially my action would be to say hey this pio nerves could actually come and help get cases started and get them on time and then also come and maybe relieve lunches that's another I'm sure probably an issue for everyone

is like you're down a couple staff during that time but we're still running our rooms great that was a great job very good okay so a couple more to just kind of quickly show the pending patient workup documentation so this gives the

ability of the frontline RN to have instant visuals of the electronic medical records documentation that needs workup and phone calls that are needed to be completed for future patients so again let's use our model

so look there are a lot of workup phone calls pending and remember this is real time so in this case if you were looking this is just a snapshot but say today is March 4th okay going around so the first thing I'm saying yep there's a lot of

cases I've got 14 here and it shows a couple of days worth obviously you can see how the numbers add up I'm looking at the high number of same-day pending work for procedures so you can see here three four five six work ups and I have

nine phone calls to be made and I'm looking at the MRI work up calls and right now there are a couple days out so I'm opening less concerned about that so how would I apply and what action would I take well first I would clarify that

these same day workup and phone calls are actually pending sometimes they might have been done or someone missed hitting the icon on our computer and then I would prioritize completion of pending work so I might say to a couple

nurses that are in between rooms or whatever can you make a couple of phone calls we've missed this and we need to get contact with the patient and then of course I would obviously prioritize the I our work ups before the MRI ones

because there are a couple days out okay

and I'm gonna let Carrie go over a case study with you all we printed and gave you one of those and this is just gonna

kind of really show you the importance of yes let's have established guidelines to help guide nursing practice but then let's also take into consideration what we know so I'll just give you all a minute to look over the the patient I'm

not going to read this all to you what's the journal was 28 to the right is right here June 2018 volume 37 number 237 number 2 June 2018 and it's bolded in our reference side - so here's the time for audience feedback if you are a

nurse and you saw this patient what are some things that might concern you about them heading into a procedure there's microphone if anybody wants it or you can just call out liver dysfunction when we were looking

at this patient and this is you know an actual patient that I saw doing a workup and said hmm this is a really complex patient what are we going to do with this person they are having a lowest procedure as Nicky points out so that is

good to note in this patient was actually admitted following a stroke while anticoagulation was being held for another low-risk procedure so that's definitely something that caught our attention and we looked at our lab

values again the INR pretty normal they were taking lovenox at home but they're currently in the hospital they're on IV heparin and a lot of our procedures come up at the last minute so this is it's not uncommon

for us to show up in the morning have half of our day filled and have cases added as the day goes on and I would imagine that's pretty much the standard for most of you so and they wanted this today this was more of a therapeutic

procedure but they really did want it for the patient so we got out our nursing guideline we looked at what medications are they on what's their history what does our guideline tell us and I've included the low-risk procedure

and it tells us IV heparin hold for four hours so normally the nurse would call the floor and say can you have a discussion with your service would you know can they hold the heparin per our procedural guidelines in this case we

didn't feel like it was a good idea to have that nurse to nurse conversation this is a case where we went directly to the radiologist and said here's the patient here's what our guidelines tell us could you please call the service and

have a conversation with them and they did they talked about the risks and benefits you know in our practice we do occasionally do procedures with IV heparin running it's been known to happen it's definitely not preferred but

again it's that risk benefit decision in this case the service felt it would be okay to hold the heparin for four hours the radiologist agreed that they would be okay with and so the heparin was turned off the

flora nurse called us when they turned it off we verified it in the medical record transport order was put in the patient was brought down at exactly four hours and the procedure was performed successfully the patient was returned

directly to the floor and the heparin restarted but we just picked this one as just an interesting patient to look at because it does show we have these guidelines they encourage nurses to look at these things while we're screening

patients but we also need to think critically and say you know does this warrant a little bit of extra consideration should the radiologist and the service have this conversation or is the service managing the patient going

to do what our recommendations say so we do run into this kind of thing quite often and they did say at the session this morning nurses want a guideline but there's no cookbook for these patients and I think that emphasizes that we can

make all the screening guidelines in the world they're very helpful for streamlining triaging patients getting patients in but ultimately we're going to have a lot of these multidisciplinary conversations where radiologists are

talking to the service that's managing the patient and flora nurses radiology nurses everybody is getting involved in the conversation so it's really kind of a collaborative approach even though we do have these guidelines they don't

apply for every situation

as Chris described to you we really walked this journey around bridging the data gap from our front lines all the way to our senior leaders and we thought

this was very important because we didn't think we could drive a sustainable organization if everyone was not on the same page or even in the same book so we had to start helping the staff understand the story behind the

numbers and help them understand that every number actually has a story and is connected to their work it's not just random numbers these are things that also define patient care and can help us improve the way that we take care of our

patients and so the scorecards were really key in creating that alignment across the organization because as you can see on this chart here the senior leaders the radiology mid-level leaders and the

frontline staff all review the scorecards so AB monthly staff meetings the radio radiology leaders review the scorecards with the frontline staff and then we have our radiology director and our clinical chair review the scorecards

with the institutional senior leaders as well so all across the organization everyone had the same understanding around performance and if there was a strategy strategic vision that our senior leaders had they could easily see

how we could accomplish that based on the numbers that we had on our scorecard and then when it came to the dashboards these were as Chris mentioned more real-time frontline tools that were applied by our staff and but the metrics

on the dashboards were also included on the scorecards as well so when we designed the dashboard we pulled some metrics from the scorecards and thought about which which of these metrics would be more relevant in real time for our

frontline staff and so that way we restraints where we were continuing to build that competency for our frontline staff to help them to understand how to use data to drive decision-making in real-time and finally when it came to

the strategic plan we still have our senior leaders design strategic plans but our radiology leaders were able to move that strategic plan through our strategy to deployment program to define more specific strategies for radiology

and then roll that down to our frontline staff through their one on one performance management goals so this really helped us to start to create the same level of expectation across the organization as Chris mentioned we might

have senior leaders say well we have our strategic vision of increasing or falling by 10 percent over the next year and for our frontline staff that might be difficult because if they to them their work might be chaotic and they

think they cannot possibly do any more volume but when we presented the scorecard for example on s Chris showed in I arm at a 65 percent utilization everyone could see that if our benchmark was 80 to 85 percent we still had more

capacity in our rooms to be able to service more patients and on the same scorecard we could see our on-time start rate which was actually kind of low around 50% and so that helped us engage in conversation

with our frontline staff to help them understand that our issue was not necessarily a capacity issue we had the capacity to increase volume but the way that we were managing our workflow as you can see from an on-time start was

not great and so this helped them to start to identify projects that they could lead to help to manage their workflow better and with the dashboards they could actually see real-time improvement or real-time changes as they

made decisions around their workflows so again our goal to this journey or our journey to this one box was around bridging the data gap and to really create a sustainable organization where each frontline staff was empowered to

solve problems and have the data that they needed to do that objectively so now Jeanne will go over the current state of our nurses as we embark on that next steps of up - specific dashboards for them thanks to me

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

I'm Nikki Jensen Nicole is what my mother calls me but that's alright thank you all for joining us today I am the clinical resource nas I work in a clinical nurse specialist position I graduated in May so I'll finally be called the clinical nurse specialist

after I passed my boards in nonvascular radiology so at Mayo Clinic Rochester we are kind of split up between I are in our IR practice where we have non vascular procedural Center CT MRI ultrasound guided procedures we'll go

over a list of our standard perform procedures as well as our neuro interventional and vascular interventional practice so Kerri and I work in the non vascular so we do not do any neuro interventional or vascular

vascular interventional procedures so these guidelines are going to focus on your LR CT or ultrasound guided procedures how many of you went to the combined session this morning great this is going to be an overview because what

we saw presented there really reiterates what we are have brought into our practice but then we're also going to share how we created nursing guidelines and how we rolled that into our practice this is Carrie Carrie is a staff nurse

in our department I worked as a staff nurse for seven years prior to this position I've been in this position now for four years and really enjoy it I do want to give a little shout-out to Carrie and I presented or sorry we

published an article in the June 28th volume 37 issue - that really coincides with our presentation today so I would encourage you to read that publication and then you'll get additional information on how we did this yes all

right we have nothing to disclose unfortunately or fortunately right so the purpose of this presentation is to help you all understand the importance of creating reviewing the literature

understanding your for one your coagulation casket as well cascade as well as anticoagulants that are out there or new up-and-coming medications and understanding that yes it's very important to establish and create these

guidelines so that within your practice you don't have differing radiologists that have differing opinions if you're working with doctor so-and-so today you need to worry about these labs if you're working with you know dr. Johnson

tomorrow he doesn't care about the labs we did this to help standardize that to help reduce the amount of questions our nurses have how many times we're interrupting our radiologists but then also we need to take into consideration

the importance of the patients and their different disease processes and we'll be going over that too so it's nice to have established guidelines but then also we need to take into consideration why patients are on certain medications this

here is our list of objectives I'm not going to read them for you you can all read them and we've provided you all with handouts too but really we want to just help kind of explain mechanism of actions and different medications and

how we established our guidelines this here is where Kari and I come from full disclosure we do have snow on the ground so these pictures were not taken before we came we are really enjoying this nice warm weather but for those of you who

are not familiar with the history of Mayo Clinic in Rochester who we have a hundred and fifty plus year tradition of implementing evidence-based care to assure the needs of our patient come first we are divided up into one

downtown campus but we have three different main areas so we have our st. Mary's Hospital this is where Kerry is based out of this is this houses most all of our ICUs as well as most all of our inpatients so we do a lot of

inpatients but we also see outpatients in this hospital Rochester Methodist Hospital this is where our he mock patients typically are we do have one ICU within Hospital as well but then right here my

office is right there this is our Mayo downtown campus so this is where most of our patients come for outside procedures or outpatient diagnostic imaging exams this here is the group that I'm part of the clinical nursing specialist group

within our clinical nursing specialist group there are 77 of us there are five like myself clinical resources as we have not graduated as of yet I'm right there in the middle w

that work in over 70 ambulatory areas in 58 inpatient areas we also support some areas in our Arizona and Florida campuses and then we have Mayo Clinic Health System hospitals that are scattered throughout Iowa

Wisconsin in Minnesota as well I am the only one in radiology across all of our

so are you ready here's the final project product tada that's what our d-h radiology nursing dashboard looks like today so as Tommy mentioned the goal of

our dashboard is to help the frontline objectively understand their performance and be proactive about making decisions to help their run day their day run smoothly all of these metrics on the dashboard work together to achieve those

goals so for example at the top right here the procedural workup pending and calls pending help to see the volume of pending workup and phone calls that need to be completed over the next few days another exam

well here on the bottom left the nursing case volume that's another it helps us to sort of see the different levels of nursing resources needed by hours of the day the dashboard is not just for nurse managers and for supervisors but for the

frontline users as well we had to teach your nurses how to use this information in real time what we have learned that by using actual data to drive decision-making nurses are able to deliver patient care more consistently

and in compliance with standard practice they are also able to manage variation and optimize utilization of resources the dashboard proves to be an easy tool to apply and capture meaningful metrics around the radiology nursing workflow

this is the framework we use to educate the frontline nurses on the real-time application of the dashboards we broke it down into four simple steps look so looking at the data interpret and gain insight 3 apply and maybe take action

and for what are the results and how are we assessing those results the next few slides will look at some specific components of the indicators on the dashboard and demonstrate how we use this model look interpret apply and

assess to increase the utilization of the frontline staff in their everyday work this is one of the dashboard components that you saw on the dashboard called buffer time the buffer time is the amount of time left till the patient

scheduled appointment time so for example the patient's appointment time is at 12:00 you can see the check-in time generally what we have found that it takes about 60 minutes from the time the patient checks in to get them into

the procedural room so based on that we have the appointment time at 12 12 o'clock the patient checked in at 10 11 and we have a buffer time you have 21 more minutes to go until there a scheduled appointment

time so let's use the look interpret apply and assess model to help better understand how this dish board indicator works so look as you can see we have multiple patients that have checked in interpret we have three patients

highlighted in red that indicates their past their appointment time and then we have four patients in green indicating time left till scheduled appointment time so what action can we take on this well first I'd look at the red patients

since they're late and I would determine next steps there's an ir case in room two that's nine minutes late and then we have an MRI our nurse that is also nine minutes late and it looks like we have a CT case that has nineteen minutes late

oftentimes I know this just because it's our area but if I was to look at this in our nurses too we would confirm that the CT three case really needed a nurse and generally we don't do procedures in our CT room three as far as the green

patients are concerned we would look at the we'd look at both these two twenty one minute buffer times and say and confirm that the pre-work is on track that we're ready to go and we're going to be able to get those patients in as

far as these two patients you can see they checked in way early then there's 60-minute time and at this point I wouldn't do anything else for that and then as far as assessing generally that's done sort of like later in the

day to discuss in the huddle future actions that needed to be taken maybe to prevent this okay let's try another component of it of our dashboard this here is our procedural patient workup turnaround time so here the first box is

the time in which it takes the RN to do her workup so that might be checking the patient in verifying labs vital signs placing an IV etc and then this middle box is the total workup time which includes the fizz

since time as well so a si and Malley mallampati assessment consent that kind of thing and then the third box is the total time the patient was in the pre room so let's apply our model again so as we can look the RN pre workup is

taking 22 minutes on average the pre procedural workup time total is taking 39 and the total patient time 65 so what can we gather from that as I mentioned earlier we give about us it's about 50 minutes generally when we've done a lot

of audits but we give a 60 minute window so that's why we asked our patients to come in 60 minutes before their before their actual scheduled appointment time so what can we interpret from this so as I'm looking the RN process time is

within 30 minutes so we're good there the total workup time was is in within the 50 minute expectation and we still have our 10 minute buffer remember however the total time in pre exceeds the 60 minute expectation so what action

might we take as a frontline either charge nurse or the any of the nurses say what should we do next so here what I might do is talk to the charge tech who sort of does all the orchestrating of the rooms and say so what's the

possible bottleneck because we've got our patients ready to go within 39 minutes to gain on time start but however it looks like we're stuck I will tell you that there is some of those variations like we had a stroke come in

or a trauma that actually bumps cases we get that piece but why are the rooms running what can we do can we maybe make a person that was scheduled going to room to go into our overflow room in five if say a power authorities like are

less acuity room so those are type of things that we can talk about in real time to get patients moving and so we don't continue to have late start delay so we'll move on to the next one

we're happy to open up the floor for questions you want to use it maybe a mic for them yeah sorry oh let's use a microphone then everyone can hear Thanks

can you hear me on this one yeah so I think your question was how successful were we thank you for this presentation so I used to be six feet tall so I will tell you that the journey was very difficult and it's not for the faint of

heart it takes a lot of people to really make this happen and as I mentioned in 2013 we were working with the value Institute and that's where I grabbed Thome from I stole her shamelessly and you know we did some projects and I'll

say the first few were not successful and what we learned from that and I mentioned in my speech is that they don't understand data unless you put it and you present it in a way that's meaningful and that was hard for us and

and so yes it was hard so my so my point is that that this is really incredible and how I would use this and based on your experience how helpful was this to to increase your efficiency and for the nurses to actually look at this and say

oh my god you know this is what we have to meet and we're not meeting it so yeah so I will tell you and the journey was real I mean the perseverance was I mean it really was driven by Chris and Tomi they didn't give up and we met like even

when we started with the scorecards we met weekly with all of the supervisors in all modalities because we didn't just do this for IR Nursing we did it for all modalities and it was it was really hard in the beginning because I kind of felt

like that's where we talked about stories and numbers you know and I I talked about Nursing being a very story driven you know the frontline nurses want to help for their patients and when you show them numbers they start telling

you that all you care about is your volume and your data and you're just going to keep driving us until we get driven down into the ground and so it's no honestly and so it was how do we make that connection and I think to your

question we started with the scorecards as those were less impactful to the frontline staff but once we started using the dashboards and we just we slowly like rolled it out we started with

Huddle's first and we had like the charge check and the charge nurse talked about it and then other nurses and text would be around in the core and they would sort of listen in and maybe chime in about why a case was laid and what

have you and so we started doing the Huddle's and then once we rolled out the dashboards now we have actually a big screen up that runs the dashboard is visual um in the core of the IR a suite and it's really great we have there

actually it's so funny we have them an on-time start like glitter posters so it's on your like it gets posted on the outside of your door and everyone's involved before it was like the techs were much more driven about getting the

cases on time the nurses were less but now we've really actually the teamwork the competition of it and the teamwork it's hilarious I love seeing it they're like yes I've got like all my cases were on time today and they ran like room to

like a clock and so it's it's been very good and they've really utilized that the other thing I love is you know the work up stuff so after the day sort of you know winds down and they're trying to figure out like what were cups they

have to do or whatever I watched the charger she'll put up on there and say like we need you know we need to get this done or whatever so it's really helping to to show them like what work they still have to do so no

one's just standing around going I'm not sure what I'm supposed to do now you know the other thing I'll mention though that was important to getting there was so we took all the lead techs in every modality we call them education

coordinators in our modalities and Tommy did classroom work with them so they would come they would come every two weeks and sit in a classroom and Tommy would speak specifically to the reporting metrics and what it meant and

it did two things it not only taught them how to read data it also engaged them with each other and we cross kind of crossed the modalities where they were siloed in their work before it really built some teams among the

technologists and the nurses and Tommy spent a lot of time teaching them and it it it was very impactful so I would I would absolutely recommend that you have to have some kind of classroom work for this do you want

I think she um great presentation like this is quite inspiring you know it's really nice to see that you've able to build this up in accomplished and everything you did my question is more on a Don cases so when

it's scheduled its predictable you can try and work work things so that you hit everything on target but how do you deal with a Don cases cuz we I feel like in our in our area ninety percent of the cases I add ons so how do you how have

you been dealing with it are important and that was a lot of why we started this journey because a lot of what we would get is oh we have another add-on case and now the world and the sky's fallen over it was a lot of that

reaction to everything that was thrown on a frontline staff so I'll start from the scorecard let me start from the scorecards so on the scorecards we have the utilization numbers which shows how much of our

capacity were using and that was the first step for the team or for everyone to start to understand how much work can we actually do and how much of it have we and how much over that we utilize in today so if we are at a 50 or 60 percent

utilization we're not really at a high capacity utilization rate but then who still had frontline staff who thought add-ons were very chaotic and so it wasn't necessarily about the volume of work it was how we were managing it so

starting to break it down in this way helped everyone start to understand okay maybe it's not that we're doing too much it's how are we managing what we have so that was why the numbers were important to set that objective level of

understanding in the first place and then when it comes to the stat to the dashboards which is more frontline information because they have so we don't have the I our interventional radiology dashboard here

on that dashboard we can see the utilization in each room so we can see how much how much capacity there is to actually manage to add on more cases into each room so that's something that when they make decisions on add-ons they

look at each room and say what is the utilization currently do we have enough time to actually add on one or two more cases and then as Jeanne showed you in the nursing on the nursing dashboard with the caseload by hour of day they

can make decisions around what time of day is the best time to add on this case because we see we already have five at 8:00 a.m. maybe we should add this case on at 1:00 p.m. so it's really helping people make more objective objective

decisions around the add-ons or around their workload vs. reacting to everything that comes up so you talked

how do I become a cath lab nurse or RT and so the traditional route really was you know if you worked in as an arti worked really general radiology or you worked interventional radiology or if you were a nurse you could come from ICU

or the emergency room pack uor or PC you are progressive care and work with your preceptors get that on-the-job training and so again there's that whole you know rich waiting you know maybe bad behaviors and creating shortcuts etc and

then you have your cath lab staff so really the early beginnings to our program kind of was twofold so we had an existing virtual program which was basically some modules online working with one of the textbooks that we have

and really working with the preceptors so then we decided how can we create this pipeline for new RTS because we're having a huge shortage of RAD techs and so initially our program was six weeks and then we kind of as we whittled it

down we can went into this three week program now and it's basically an adjunct to their orientation program it doesn't take the place of it it just adds into it and so now the other thing too is what we're looking at is how does

this look like in the future and how do we really truly impact our patient care outcomes so now when someone says how do I become a cath lab RN or RT we have again the traditional route but now we've added in this systemized the

standardized cath lab Academy working with our preceptors and now we have staff our cath lab staff and so in

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

so before we get into the dashboards which I know you're all interested in

hearing about I'm going to talk a little bit about organizational strategy and how it really does align with our frontline workers so we all know that senior leaders have a responsibility to create a vision and a strategy for our

organizations they do this using benchmarks cost margins revenue in order to position our organizations to deliver high-quality care but also to position ourselves in ever-growing markets which I'm sure you're all aware of so as

organizational leaders develop these strategies for future development it is really important that the front line that the mid-level leaders are able to take these strategies and translate them down to the front lines so when you read

a story or you watch a movie you just assume that the cast of characters and the plot are going to follow along and if they don't we lose interest or we become disengaged so in this case can you trace the CEOs sorry can you trace

the CEOs vision for his strategy and how he asks the mid-level leaders to take down to the front line probably not and this is what all organizations struggle with because we know that the whole is always greater than the sum of all the

parts so now we're going to show you some boxes and these boxes represent the front line the mid-level and the senior leaders let's have a show of hands today for how many of you in the audience consider yourself to be frontline staff

do we have any mid-level leaders great how about senior leaders great well today our dashboard presentation is going to mostly apply to the frontline staff so we know that when organizations build strategies and they ask our

mid-level leaders to take them down to the frontline staff that sometimes the translation of that information creates chaos and disruption at the front lines and an example of that is at Dartmouth our senior leaders had a strategy for

improving access for care for an underserved population of patients that had pacemakers and needed MRIs Fordyce diagnostic studies we felt we could take the volume so we embarked on imaging patients with pacemakers and what we

found is that the number of patients that had pacemakers was outpacing the resources that we had at the frontline and this created chaos and it made the good intention of the strategy lost on the frontline nurses so it's really

important that we not only take strategy down to the frontline but that the mid-level leaders take the reaction of the staff and how it affected their work back to the senior leaders so in 2013 at Dartmouth we began our journey to bridge

this gap and we did some process improvement projects and we soon found that the data that we were presenting wasn't really accepted or understood or trusted by the staff that we were working with we discovered

that at the front lines that sometimes perception is not always reality so our job was to help the staff objectively understand how to work on a daily basis how their work on a daily basis impacted our organizational strategy in 2015

you'll see we went live with the radiant product that epic has for radiology and when I began looking at the reporting metrics that epic presented I saw that it didn't really translate into radiology language and it really didn't

translate into nursing language at all so we needed some metrics and we needed a way to be able to give the nurses meaningful actionable information that they would be able to work on and that we could really turn them into

data-driven problem solvers so this is when I engaged with Thome our quality specialist and I asked her to help us develop a strategy for how we could empower the staff to become more data-driven problem solvers what we

decided was that we first had to build build competencies and understanding around data and how Thome decided to do this was to develop these monthly scorecards the scorecards our performance scorecards that the leaders

in the organization in our department can use to kind of measure their success so we first met with the leaders in each modality and this was the radiology directors it was our technologists lead our nurse's leads and Thome sat down and

said what would be meaningful for you to understand so that you can talk to your staff about the business that you are running so this is an example of one of the scorecards that Thome built and at the same time we decided that we would

align our organizational strategies and our department strategies with these scorecards this is an example of an IR scorecard and you'll see that they chose quality and safety operational excellence and

sustainability this was a way to look at what their monthly volumes were and when we were asking them maybe to move that needle a little bit and give us some more and they felt maybe that they couldn't because the staff was saying

that they were too busy we could show them that the utilization in one of their rooms was 65% and maybe there was indeed some opportunity to move that number a little bit after we were successful with the scorecards and we

felt we had built the competency on the department the section director level Thome began working on dashboards and these are real-time metrics that our frontline staff can use every day to see how well they're processing their

patients through our system we also developed daily Huddle's where they take these dashboards the charge tech nurse tech the radiologists staff if they're interested and we talk about what went well what maybe didn't go so well we

talked about action items opportunities for improvement and maybe some projects that we could start around things that they identify that are impacting their workflow so now I'm gonna turn this over to Tommy who's gonna talk to you about

how she used that data to get us to our dashboards thank you Chris all right so

so I actually work mostly in

interventional radiology in CT and ultrasound which is actually on a different floor that where we have our cath lab and I our stuff upstairs so that I our doctors are each going between two floors and one of my biggest

concerns is when we're doing moderate sedation the nurses are down in CT and ultrasound it doesn't matter how many comorbidities the patients have the aasa' is always three or less because they want to justify doing it downstairs

with just one nurse and the procedure list and I just and then you have somebody who obviously needs to be having anesthesia involved and now the anesthesiologist or the nurse anesthetist they get a circulating nurse

with them and I'm just wondering is there a cut-off that anesthesiologists or nurse and necess use for saying okay the a SA when it's this you have to consult with an anesthesiologist before you proceed with a nurse just giving

sedation that's a great question and that's institution unfortunately that's one of those things that is like institution dependent policy and procedure politics finances you know sometimes you'll see patients who really

are in a sa three four or four and a half that are made to be an a sa to write you know so they could be done during off-hours without anesthesia unfortunately it's a symptom so the organization's ever sit together and say

let's look at this globally for the patient safety and if we're doing sedation in this scenario we should still have somebody there who's trained to do the backup for that person I can't speak to your organization's policies

because I don't know them I know that they recommend catalog' Rafi I do know that the avenues to look at would be the Joint Commission in the anesthesia patient safety foundation you know for guidelines and again guidelines are just

that they're guidelines they're not mandates especially you know when institutions develop policies procedures protocols and such I do know on the third bullet down is we have a whole implementation project that we've rolled

out so one of the questions in addition to technical questions we get is how do I go to my institution and kind of change practice a little bit and usually the question is like implementing capnography but it it's a three-part

series that we did on how to implement change in an organization who are the stakeholders who are the champions who can you really talk to that would create change and whether it's the chief of anesthesiology is the person who's your

roadblock or your best friend is it the VP in nursing is it the safety committee you know cuz it takes one adverse event one Sentinel event unfortunately sometimes to change culture it takes more than that I know I know we're

trying a little at a time though but think it was a great comment in question was just made in our institution anesthesia kind of hit at this because the nurses were concerned about what she was just saying and so they worked with

the directors of like IR cath lab the medical directors to you say let's come together and figure out you know if it's a four it doesn't mean that every four needs to be you know it can be given sedation can be given by nurses but at

least get an assessment or things like that and in our institution nurses are able to if they feel like they needed anesthesia consult they can do the anesthesia console it doesn't mean they're gonna have anesthesia but

anestis you can tell you what to give and what not to give mm-hmm but that's that's what they're trying to do they have done for cath they're doing it for IR too and that is I forget them term for it but that's a team collaboration

and so and I must said where we work we actually screen the charts ahead of time because we have some really remote places and some not as remote and it's like the litmus test you know somebody with a BMI 55 is not going to be done

down the street they're gonna be done where emergent resuscitation is right upstairs if needed and same thing holds true like in our institution like anybody can call a patient safety stop meaning like I don't

feel comfortable with this let's not go forward and and again the procedure lists are another list of those champions because procedure lists they care about their pain you know they don't want to see adverse outcomes and

they're so focused sometimes on what they're doing that they kind of black you blank out on some of the peripheral factors and no one wants to see something bad happen on their watch so the procedure lists can be

instrumental in getting better monitoring or advocating for advanced levels of care or at least support for the nurses to have there's another question in your experience are the waveforms the same as far as a

ventilated patient versus a non ventilated patients have you seen any discrepancy in the actual performance that waveform itself yes and no okay so so I'm ventilated patients somebody who's really hyper dynamic I mean I've

seen like you could see sometimes their heart beating you know like just some of the little fluctuations or oscillations for the most part no difference if the non-invasive ventilation patient is getting monitored really right where the

gas is being exhaled like right here you may see some other you know and somebody is intubated so if there's secretions you might see like a little you know blip and such but when things are perfectly working the way they should be

working in both the intubated patient or the patient with an artificial airway versus not the waveform should be spot-on but if you're not seeing that is it a COPD or is it somebody who's got you know bronchitis in there yeah if

you're not seeing that full square waveform the question should be why not is my equipment not working good question great questions did the sign-in sheet make its way I know the spiral bound notebook is over

here but please do make sure that you put your name your email address and you'll be emailed because so you could fill out an evaluation and make sure that you get c e for attending this opportunity today I hope you guys

enjoyed it I hope you took something out of it I hope this just wasn't the basics for you today I hope that there was some value added in to coming today please do hang around we'll be here we'll be in the exhibit hall I know that there's

going to be many more events that are have this afternoon but the rest of the team will be here and we really do look yeah I love working with nurses that are providing sedation's I feel like you're the you're my people you know but you're

the people that are doing this day in and day out and you really are that that patient safety advocate and I feel like when I speak to a roomful of people that you guys go out and teach your precept ease and create change that's going to

impact patient safety so thank you for your attention today and thank you for attending [Applause]

guidelines so what I did when I created these was try to really simplify them Terry and I have given all this information to our staff nurses we've

this was a two and a half year project we took in feedback from our radiologists obviously went on off of their clinical best practice and their clinical experience this table here is a table for our low-risk bleeding

procedures I've already given you the list but within our guidelines I've created hot links where they can just click on whatever procedure they're doing in it it'll bring them to the appropriate table but as you can see for

our lowest bleeding procedures we currently we are no longer really gathering much from our patients we've deemed that it is safe for these patients to have this procedure this is also in the journal article so I would

recommend that you guys read that here's our moderate to high risk procedure again like I shared earlier we've decided to combine moderate to high risk versus having two separate tables so this one is where we also need to take

into consideration our patients and their disease processes and why they're on certain medications but this allows for our nurses to look at this list for these patients and determine how we triage this patient next it allows for

these pre procedure phone calls and our pre procedure screenings assessments that we're doing to be more expedited

if we had less blame we'd have more patient event reporting and from there

we can do more to look at our systems in our organizations and really affect patient care it helps so increased reporting helps to prevent future patient harm it provides an indication of human and system performance so again

we're working on the system not the person it guides performance improvement and it also provides an opportunity to identify risks it also provides a culture of safety so we go from blaming the equipment and the other person to

looking at owning some of our own air and then ultimately when we know that we have not followed a policy as we should have because we know that we're gonna our leadership is going to look at that and find out why we didn't do what we

were supposed to according to policy sometimes those policies are written by people who aren't at the bedside or they're so old that they're not up-to-date they don't have best practice in them and so we'd need to be conscious

of those so you know every three years we're supposed to be updating our policies and procedures and that includes our departmental ones too and we need to be looking at best practice and listening to our staff to really

prevent patient safety errors so if you look at your system design and behavioral choices if you spend 80% of your son time there you could really reduce your human errors in your adverse events that's

what a just culture and a culture of safety brings you but in order to do that you have to have organizational trust so management needs to be trusted management needs to trust the staff and staff needs to trust management so all

that is cyclic elana just culture you would have that so how do we get there I

I'm the FDG is have a radio pharmacy located on the second floor no New York State does allow nuclear medicine

technologist and nurses to inject the con the FDG isotope I know in other states one in particular is is New Jersey the the nurses are not allowed to inject isotope and the technologist has to do it also in addition certain

isotopes and certain scans the ducts have to inject the contrast like the the cervical Lin scintigraphy and some so my question has to do with discharge instructions so just like you give them that little card that they keep with

them so they trigger some radiation alarm and a bridge or on a highway do you give them discharge instructions about if there's small children at home that they're not sitting in their lap for extended period what kind of

instructions do you give on discharge after these patients so we when they come in coupled with the screening forms that they fill out we have some instructions attached to it and does that does have

the discharge instructions but we reiterate to them you know if they have small children or babies and pregnant women and just try to keep their distance for the next 12 to 24 hours just to until the really activity has

wear off so the FDG is like two hours almost for the half life FDA FDA has 60 minutes 116 minutes half life and usually by 12 hour by the 12 hour period they're mostly background radiation okay thank you

we had they have a written instruction like it's like a packet that we give into the market that we do to the patient and the patient have accessed to the web portal that they have and they can be the instructions from there

this is correct so betta bar is still investigational for the most part the only way you can build for it is two different scans you build for a pet and you build for our mr so you've got to get approval for both what you are not

going to get reimbursed for is the registration and that's where it gets a little bit challenging because then you need a radiologist who is both certified uncredentialed to read a pet and an mr so right now most institution bill it as

two different procedures so that's why you that's how we get the approvals just a little information on the side I went back to this case study because I forgot to tell you that in order for the PET CT to have as clear image as the pet MRI

the pet portion I mean the city portion and the pet city would have to be done diagnostically and that this would expose the patient to radiation three times that's why they prefer the pet MRI because yeah the reason why we do it if

we do it mostly for for for pediatrics and it's it and it's because of radiation because you know like our my team is saying you you are going to have this patient have constant follow-up so if you can reduce the amount of

radiation they have from a younger age as we all know it work in radiology DNA injuries occur when you're younger then more is more severe than than later our MRI the pet MRI injection they're all lined with lead and our MRI the pet

MRI room is actually lined with lead so we don't really have Needham let aprons we don't know we don't have wear aprons they are allowed to go to other appointments after they are pet MRI usually with the FDG most of the

radiation after the Tessa's finish is gone they're not more than what not more than radioactive than background radiation so they are are safe to be around people yes that's more for precautionary

measures yes no they go straight to the PACU so we our MRI table is detachable we have an area for where we keep our inpatient bay area we have a structured ready for them to go into right after the test and the

anesthesiologist and if they are Pediatrics the pediatric nurse is with them and they go straight to pack you do like probably like probably less than ten a week right now some weeks we are busy we do for how we do that much some

it varies like we'll do three or four but we are trying because the reimbursement that's one of the big issue our institution is actually eaten eating the cost for some of these to provide a patient with less radiation

especially or pediatric population we have one pet MRI machine for the whole institution three at the main campus we have two we have multiple and other regional sites so the yes

no less than 15 GFR except for the EU vist less than 30 then we notified the radiologists eeeh this is harder to so you this is the it's a linear contrast as opposed to the Catalan bettervest which is

macrocyclic so it's easier for the body to get rid of well there yes well they're only they're already getting dialysis so it's really not much of a harm yes we do patients on dialysis but we make sure the dialysis is done within

24 hours after receiving the contrast yes um sometimes you know you just have it to have it we don't require it for all the tests if you have it we have it we check if it's already in the chart we

acknowledge it you know we don't require for outpatient we don't require but in patients we do all right anything okay so Bernie pet/ct the scanning time for pet/ct is about 30 minutes to 45 minutes Patsy pet/ct is about 30 to 45 minutes

with the pet MRI sometimes they they order dedicated pet MRIs so that is a little longer you have to take note that we do a whole body scan whole body scans for even just for a regular MRI is at least an hour so we try to eliminate

just you know having them have to have to or point to different appointments and just one waiting room one waiting time so that cuts down the response for the patient themselves yes we do for adults it's 12 for the

whole body and then for the pet brain it's about 10 if I'm not mistaken and then plus or minus 10% and then the pediatric doses are cultured calculated base of their height and their weight and there are all protocol by a

radiologist because we have a lot of whole-body protocols we have the bone survey actually that's about 30 or 40 minutes and yes that's an hour and then we have longer whole body protocols diseases

specific and sometimes they try to depends on what the patient's diagnosis is we have whole body scans where they have to check the bone marrow and that needs to be from tips of the toes and tips of the fingers and that can be a

challenge especially if the patient is tall because that has to be in sequest sequestered and sequential patient and positioning is also a challenge alright thank you so much thank you thank you so much

[Applause]

heard the title of my presentation is what we burn out in radiology yes we do just like every other nursing specialty and every other first responder that you

can think of some a lot of the research that I found was for police officers because they have the same give your 110 percent all the time every day on every shift and it burns you out okay so yes we do have it in the radiology setting

but in our case nurses are the fabric that hold the healthcare system together who sees the patient more than anybody else in their stay it's us okay so normally when I give this presentation to a smaller group this is a bit of a

big group so we're not gonna do this as an activity but I want you to just think back why did you become a nurse in the first place what led you to do it anybody brave enough to give me a story cuz if not

I'll give you mine okay I'll give you mine I was unfortunate enough to have to be in the hospital at 13 for surgery the hospital I was in did not allow mom to stay overnight put me in a two bedded room

with a spanish-speaking only woman that had just had a hysterectomy and was screaming III all night okay so here I am terrified and the evening nurse came in and said I'm gonna give you a pain shot

and then I'm gonna sit with you until you fall asleep that was it and I know I'm gonna get teary here and there so please excuse me I knew right then and there I wanted to do that I wanted to make a difference so anybody

else brave enough okay what you got Thank You Joanna PO did everybody hear her do you need me to repeat that I do hear a lot of my mother was a nurse and I saw how much she cared my sister was a nurse my father was a nurse or a doctor

there's a lot of that that happens but ultimately it always comes down to now granted you're gonna have those few and far between people and I hope they're few and far between but say they went into nursing because you can get into it

with an associate's degree and make a decent amount of money and it's all about the money there are some in our career and I've even met some that I even to this day I became a nurse so I could meet a doctor

and quit working not kidding I am hoping that that's few and far between honestly most of us it's because we want to make a difference we wanted to help we wanted to show compassion for someone else but the problem with burnout is we get into

compassion fatigue which if you made Kathy Brown's lecture the other day I only made half of it so I may repeat some of what you said but that's where we get when we're burned out okay so that's what we're gonna talk about today

okay the objectives for today it's very simple this is going to be a very relaxed this is not stressful I want everybody to just sit back relax and I want you to reflect and think if taking notes helps you great

but just enjoy this one okay so at the end of the lecture I want you to be able to define the difference between stress and burnout because I can tell you just ten years ago I wouldn't have known the difference so we're gonna talk about

that understand where you are as far as a burnout level and that's the activity we're gonna do you all have an opportunity to take a burnout survey and you will get that I can email it to you if you want to take it back to your

peers to see where you fall on that continuum because no matter where you fall on the continuum even if you're at a low risk you want to stay at a little risk so it's good to know where you are so we're gonna do that we're gonna

describe a little bit about the topic of emotional intelligence I'm not gonna go into it a lot I could talk eight hours on emotional intelligence alone because it happens to be one of my passion but it really feeds well into this so we're

going to talk about what emotional intelligence is and it's one of the few things that you can actually increase and improve and change so we're going to talk about that just a little bit and then I want you all to be able to walk

away with one thing that you can do to alleviate or mitigate burnout okay so

workflow for pet MRI upon arrival the patient have to fill out questionnaires the MRI screening for contrast and allergy assessment pet screening form

the RT will review MRI screening for after he checked that the patients at MRI safe and no presence of a Mia Ferris fragments or anything he would give the paper to the RN the patient then will be escorted through the change room and

asked to put on robe and non slip shots this is these are the responsibilities of the nurse in our clinical workflow for pet MRI RN to review pet screening form and contrast questionnaire if patient have to receive gadolinium check

kidney function EGFR below 15 you notify the radiologist except for a of s below 30 you notify the radiologist check for allergies if allergic make sure patients is properly pre-medicated

check for Medicaid presence of medication patches and implanted infusion pumps now also you have to check for patient's blood glucose monitoring I have one but I would but I don't go inside the scanner so I'm safe

check for pregnancy status with pediatric patients we have a special process to follow the iron then obtains blood glucose and record if blood glucose is 70 to 199 we proceed with the scan anything above 200 we follow the

glycemic management with PET imaging flow chart and here's how our PET imaging flow chart looks like it looks complicated by its color coded it's three pages but I would like to show you some key points like the administration

of insulin is also based on the level of BMI you see on the arrow says BMI below 25 and there's another flow chart is if it's above 25 after that the patient will be brought back to the pet designated injection room

remember our pet MRI is located in zone three of the MRI area so prior to that the RT would the screen the patient again the patient would pass through the wall-mounted metal detector and nobody could go into song free without escorted

by the IRT or a nurse you have to swipe your ID to open the door mission when the patients in the hot room are in would obtain the height in centimeters and weight in kilos after that the RN now could do IV access once

secured you call the range of pharmacists that you're ready to inject so we wait until and the FDG dose would come up through the pneumatic children this is how our hot lab looks like the pneumatic tube to your left above is the

shower and we have the hoop to prepare for the dose or check for the dose and the wash station and once the those arrives the nurse injecting and the RT is scanning or the RT assisting just always two artists in one machine in our

MRI Department we have four magnets and only one is for MRI PET MRI it's always two artists in each machine so one RT is assisting you and with the patient so once the FDG arrives we do a patient identification using two patient

identifiers we check the label and the dose if it's correct the FDG then will be injected to the patient once injected we tell the patient they have to wait for 40 minutes during this time we instruct them to stay still not stay

still but limit movement and stimulation and inform them that we have a camera inside that room and the nurses in a and the nurses could monitor them in the nurse's station one RT will set up the scanner and computer

and patient will be screen and wondered prior to so on for so you get wandered twice check for ferrous presence patient then will be positioned on the scanner table by the pet mr technologies it takes 15

to 20 minutes for setup you have seen how the patient is position the whole body is covered by the coils and head is covered by another coil as anybody among he works in the institution who requires time out prior to injection raise your

hand please at ms KCC we do this is done by the injecting nurse and the RT is scanning the RT is reading information directly from the monitor not anywhere in the monitor while the nurse is comparing and listening into the using

the documents on hand this is done to ensure the five rights the right patient the right scan the right area your scanning the right contrast those and rate and method of administration as you all know is either given IV push or by

the dynamic or the injector timeout will be done if patient will be receiving gadolinium once the scan is finished IV access will be removed our artists are trying to remove and inject also so they are capable of removing the IV the

radiation card will be handed to the patient and paste after that patient would be assisted to the change room and discharge there is good thing when you change the patient into the robe and the non-skid

sucks because just in case there's a spill you're not sending that patient into the paper outfit they're not gonna be happy at all now I'm gonna bring you

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

thank you very much for this you know Irish people aren't great at taking compliments it's just not something we do you know and the more we like somebody the worse the things we say about them it's sort of unlike how we communicate with each other you know we

say terrible things about each other like I was watching television one night and this Irish journalist goes mother Teresa not a great nun you know it's like the kind of people we are so um so thank you for this I'm really honored

and I guess it means I'm old if this kind of thing is starting to happen so I'm going to talk about our health and our well-being and I'm going to talk about compassion which is often the most important thing that we do a good

bedside manner you know shaking somebody's hand feeling their pulse and this over-emphasised role of AI in radiology which you don't have to worry about given what you do you will be fine because you practice medicine

so we're going to talk about that I want to thank all the people I've worked with through my career you know Albany med was so good to me letting me into radiology and when I moved from Ireland to the u.s.

Albany was a in the matchbook so I applied there first and they took me I couldn't believe it you know so I've been very lucky always with the people that I worked with and often my techs and nurses you know when my kids were

young and my son had an imaginary friend you know I'd say to one of my nurses it's just normal they go yeah Kieran don't worry about it so it wasn't just the fact that I was working with folks every day this is a

photo of a photo this is my team at Hopkins who we shared enormous risks together and this issue of shared risk is really important you know the patient the procedure the risks the thing we see the stress this this this shared risk is

a huge element in the community that we have when we practice together and you know we work in these highly technical environments if you took physicists like Albert Einstein and you shared with them what you take for

granted they would think that you deserved the Nobel Prize because of your physics knowledge which he didn't have with your knowledge of ultrasound which our knowledge of MRI flipping protons are on the place creating images cone

beam CT the the physics of of you know CT perfusion CT a the physicists who created the quantum field movement the atomic bomb would think you were all greater than them as physicists because of the knowledge you take for granted

every day so this is the group I work with in Toronto there are about as respectful and irreverent as the group in in Baltimore and it's a great place it's very different the patient never sees a bill ever it's a phenomena that's

quite incredible the cost of the healthcare is not part of the patient getting better like when I have my aortic valve replaced and I was in hospital for about three months I never saw a bill I still be dealing with

co-pays and things you know if I was in Baltimore a better title for this talk

about you rolled out the radiant in 2015 and all of this data is great but it's reliant on the nurses documenting it in

all their different areas so how did you did you actually when you built this dashboard did you leave blanks because you just didn't have the data available or did you circle back around and hold the nurses accountable how did you do

that trying to motivate them and engage them rather than it looking like a disciplinary action because you're showing that they're not documenting appropriately yes and that's part of our journey from 2013 we started all these

projects it became evident that document documentation was important when it came to the data and so we actually started training from our technologists and and then to our nurses we created standard work for how they documented time stamps

I'm at different points in the process we audit we audited that for a while to make sure that they were compliant with that documentation so so we embarked on a lot of projects and I did a to greenbelt projects I did one in

interventional radiology and I did one on beginning complete because you really have to start at the ground and if people's reporting is not good you have to fix it so we have a definition for beginning complete for our

technologists which cleaned their data up then we did a project with Jeannie's nurses around and Tommy did some auditing around the time stamps in their system and that took a long time so yes you have to clean your data up first

and that takes projects in order and we also did Tommy led all of us to look at our data and a data validate sort of like Gilbert's thing you know so is it really valid and so we did a lot of work around that as well

the nurses do with themselves and the nursing supervisor did it as well to make sure and the technologists help you with that because what we found is when we handed the data to the nurses and we had them do their audits it was more

impactful than when we did it how would you say your start times improved from pre project pre dashboard to current how did you measure that was the time yes so that was actually interesting especially in interventional radiology because it

it when we started rolling off the Huddle's and the dashboards we had some participation in the with the technologists and the nurses and the providers doing their Huddle's and looking at the information and then

there was a period of time when they stopped doing that and they actually and they actually saw a drop in there on time starts so when we started up they were around maybe 40% on-time start and then when they consistently did their

Huddle's and looked at the - would I use the information they quickly jumped to 60 65 percent so and when they stopped dropped again so it was sort of it proved that that the tools actually worked and now they're actually going

back and owning the work of their own to continue T their Huddle's and use the dashboards in real time yeah rome wasn't built in a day and would you say that this is significantly impacted employee engagement yes I will definitely say it

has previously we had a real sort of segmented nursing work you know silo's and now we have like this cohesive team of nursing and and physicians and technologists working together in IR I will say also part of

our leadership team crisp as part of this as well our senior leaders we did a job we did a change in sort of our leadership structure so before it was like the physicians they led their physicians the technologists led their

technician technologists and the nurses led theirs well we in got a team together so we have a nurse manager the chair of interventional radiology the nursing supervisor and the nursing technologist

and supervisor and we lead as a team now and so we look at volumes together we look at budgets together we look at staffing together so it's not no longer just leading in silos so with that consistency in that that that sort of

got them all together and then so then they see that you can't hit a technologist against a nurse in a physician against a nurse or a technologist because we're all one team and that was a big part of helping this

out yeah sorry before that I was just going to talk about how important leadership was in this so Chris is our operations manager and I would say she made all of this perseverance tommy's the brains I'm the Brawn so I

would like to ask you give more details on the culture like what you were just describing about becoming a multidisciplinary team sure um that's a good vision but practically how did you accomplish so the culture was really

really hard and my Greenbelt project that I did back in 2013 was not successful because of the culture and what we learned was that we had to do something about the culture Jeannie alluded to the fact that our our

department chair dr. chair Toth and our administrative director Karen Buttrey talked to me about this and and they decided it was important that they had leadership teams in each modality so every modality and radiology has a

leader it is the division director the technologists lead and if there's a nurse a nursing lead they meet once a month tommy's does the score cards for them they bring their score cards they bring their a3 reports on

their strategic plan and they sit as a group I sit with them as well and we talk about how they're aligning their strategy to their work what the culture is like and do we need help sometimes we bring HR in if we think we need help

and geney's done a lot of leadership training with the nurses she's very good at it we have Conaty so we've partnered with Dartmouth and we send different teams to Conaty to learn leadership training this

has been really this all started really in 2013 and it continues today and we work just as hard on it as we did in 2013 Neverending yeah and I was part of that Conaty training and it was phenomenal so

it was two of the IR physicians myself the business manager and another radiology technologist supervisor and so really we had to work on a project together and it really brought us together to understand each other's work

and for um I feel like probably the strongest you know asset I have is relationships and and making those connections and nursing wasn't my first career I did practice management and so I worked for a doctor's office and I

kind of know that you have to sort of make sure that everyone understands that we're all trying to get we're all trying to take care of the patient and we all have different responsibilities to do so and there's a crossover if we fight

against each other then nothing's going to work and so that was where I I feel like I probably did the best these again you know brains and brawn and I was just sort of like let's make it all work together people with it so

was that something that you had to work into the amount of hours that it takes to maintain the new task that was being asked for yes so the documentation is part of their work to take care of the patient so for a technologist for

example when they go get the patient from the waiting room they start the beginning the exam in Radian those are things they need to do - as part of the EMR to actually accomplish their work so that was by design already part of their

workflow we just had to make sure that they were all doing it at the same point in time so for example before we standardized the definitions we would have some technologists who would begin the exam when they went to go again the

patient some will do it after they had set up the rooms so we have to standardize all of it so the data was measuring at the same points and for the nurses as well as part of their documentation as they work up the

patient so it's all part of the flow the other thing we do that I want to mention quickly because we're out of time is rounding so rounding is really important so I am the operations manager I probably around three times a day in

every modality and as an example I was just in mr and I saw a red button on their dashboard and I said why aren't we 19 minutes behind and somebody had forgot to complete the exam and everybody was there and they were

talking to me about it and they said yep and they ran back and they you know so I stay engaged the supervisors Jeanne I have two other supervisors tomy rounds you have to keep the conversation going you can't just build these and think

they're gonna take care of themselves because they're not you have to really do that disciplined rounding work so thank you everyone very much yeah thank you and just some related articles that

other other institutions have used for healthcare dashboards I found really really great so I don't know if this is true but I think they're going to send the slides after yeah conference oh yeah yeah afterwards we're happy to stay here

thank you

do anesthesia for some of our cases mostly to our pediatric patients but we are also capable of doing it through the adults they need some anesthesia clearance patient is asked to be NPO

after midnight we have equipment available that are MRI compatible such as the monitors the IV pumps and the anesthesia ventilator machine when we set up the the patient inside the scanner we have to be wary of the lines

the table does move in and out during the test we don't want any of those IV tubing's get snagged we've done pretty good job in securing these lines usually by taping it on top of the coils after the pet MRI with

anesthesia is done they go to the PO 70 anesthesia care unit for recovery and I

establish our guidelines this was something this was a question that we got when we did publish our journal article because you'll see when you do

see our guidelines we are not 100% in alignment with SAR that is because we used SAR in a detailed literature review and examined both of those sources but then we also have our own homegrown radiology database our nurses are

instrumental in collecting this data every biopsy patient we collect their medication list as well as their current lab values we've been doing this since 2002 and we currently have over 50 000 patients within that database so we pull

from that database to identify what is best what trends are we seeing what medications are we seeing that are causing issue in our practice so we're taking from our own clinical expertise and then we also have a great panel

within Mayo Clinic it's called ask me Oh expert this panel is made up of multiple physicians we have physicians from Department of Laboratory Medicine physicians from our anticoagulation practices we have our liver physicians

can need lots of different doctors we have two radiologists that also sit on that committee so it's a combined specialty panel so we take we took into consideration all of these factors to establish our guidelines our nurses use

these guidelines when they are performing pre-procedure phone calls so I love to the presentation yesterday from Johns Hopkins I believe where they're doing pre procedure phone calls but often times a whole week before we

don't have that yet but I would love to get to that point but right now our nurses are doing pre procedure phone calls within a few days prior to a patient's procedure and we are going through these guidelines to identify

what medication or risk factors these patients have and we're alerting our radiologists to see if there's any type of considerations that we may need to take if for example a patient has not stopped warfarin and

then they also look for if within our guidelines the patient needs lab values we determine if there's lot values ordered or if they have any within the medical record we want them within 30 days except for if the patient has known

or suspected liver disease we do want them more recently within 14 days or if a patient's on chemotherapy or one of those anti antagonists this is something I really need to stress to our nurses and I think I've gotten the point across

to you that these are guidelines only clinical decisions are made by the supervising radiologist so we've we've put this right in all of our guidelines in that yes these are guidelines that we can use those nurses to help triage our

patients and move and streamline our assessment process but sometimes it does further critical thinking and then discussion you want to go into what you

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