The Path of Least Resistance: Is There a Better Route?

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By Ann Loree, Marcia Maihack and Marge Powell

Driven by nationwide technologist shortages, an industry-wide focus on quality and rising consumer demand, healthcare is feeling the pressure to deliver more with less. Given this challenging environment, some organizations have come to the conclusion that taking the path of least resistance may not be the best approach.

For many, delivering quality patient care is non-negotiable and the ability to function at the highest level of efficiency while doing so is seen as a necessity…not a choice. Realizing and responding to this quandary a few years ago, California's Stanford University Medical Center decided to aggressively work toward a solution and overcome resistance by approaching it with evidence.

Developing One Clear Vision
In May 2000, the radiology department at Stanford University Medical Center embarked on a five-year journey toward complete digitization, partnering with GE Medical Systems to make this transition. While the end goal was known, there was much less certainty about the steps involved along the way. Initiating any large-scale change within an academic medical institution presents a unique set of challenges, and a sweeping technological transformation clearly impacts traditional workflow and inherent cultural barriers.

To smooth the transition, Stanford worked with GE's team to implement Six Sigma process improvement methodologies and related change management techniques, making the steps toward a digital environment much clearer and easier to follow. The methodical and evidence-based framework of Six Sigma significantly organized the process of "going digital" by breaking it into manageable projects with clear objectives.

Change management techniques used in conjunction with Six Sigma were equally instrumental in helping the team at Stanford gain acceptance among staff for the changes introduced into the system. Combining technical and cultural strategies helped to pave the way during Stanford's journey toward digitization, and illustrated the importance of addressing the human side of the equation through workflow and behavior modification.

Identifying and Overcoming Roadblocks
As the process began, key stakeholders within Stanford's radiology department sought to identify and focus on the most significant issues impacting productivity within the radiology department. Appropriate selection and scoping of projects on the front end is a critical aspect of the Six Sigma approach. Stanford identified five key areas where improvement could be made that would have a major impact on the organization: MR outpatient throughput, CT inpatient throughput, CT outpatient throughput, report turnaround time and Lucile Packard Children's Hospital CR/Ortho throughput and digitization. These five areas became the initial Six Sigma projects at Stanford, and the CT project is presented in this article.

To represent key stakeholders, projects were assigned team members comprised of management, staff and radiologists. Over a period of six to twelve months, each project team typically met two to three times per month to review progress and plan next steps. For Stanford, committing time and resources to this endeavor proved to be challenging given the number of staff vacancies and contracted technologists utilized as a result of those vacancies. Workforce shortages are being felt industry-wide, but the high cost of living in the Palo Alto area has made recruitment and retention of technical staffing especially difficult.

Such resource constraints were taken into consideration as Stanford began the Six Sigma initiative. Although labor-intensive, collecting radiology data manually is often the best way to obtain the level of detail required, unless there is a robust RIS in place with solid data integrity. To gather the necessary information without unduly impacting staff and workflow at Stanford, the consultants working onsite handled the actual observation and recording of data.

Gaining Momentum in CT
Kicking off in September 2001, the CT Six Sigma project focused on increasing throughput and decreasing the outpatient-scheduling backlog. In the initial phases of the project, scheduling backlog was reported at 16 days. Even more frustrating was the increasing number of patients who missed appointments, which is not unusual when patients and referring physicians are waiting more than two weeks for a CT appointment.

One of the first steps in understanding and improving capacity was to collect throughput data at Stanford's Blake Wilbur Outpatient Center. There were numerous factors affecting the data gathering process, and in this situation the onsite consultant observed and recorded the times involved with providing CT services and moving patients through the system.

Prior to the project, CT appointments were scheduled every 30 minutes during the day shift and every 45 minutes on the evening shift. The staffing pattern on the day shift was 1.0 FTE CT technologist and 1.0 FTE technical assistant. The evening shift was staffed with 1.0 CT technologist, but no technical assistant, which was the rationale for the longer appointment times. Radiology nurses handle the IV access, and cover both MR and CT at the outpatient facility.

The CT throughput data was analyzed and the results were presented to the team for recommendations. The data revealed that the mean CT exam in-room time was 16.9 minutes with a standard deviation of 7.8 minutes representing 46 percent of the mean. It was obvious that the evening shift in-room times were comparable to the day shift and that extended appointments were not necessary. One of the first changes to be implemented was to convert the 45-minute appointment times to 30 minutes, resulting in a gain of 28 potential appointments per week. This adjustment was the first of numerous design solutions that were implemented in CT at the Blake Wilbur Outpatient Center.

Total appointment capacity was the next area of study. With an ever-increasing outpatient backlog, both physicians and patients were feeling the frustration of delays in service and diagnosis. Since it is a widely renowned academic facility, Stanford University Medical Center draws patients not only from its own geographic location, but also through referrals traveling long distances to seek care. Encountering additional delays in treatment or diagnosis can have a serious impact on the patients and family involved.

One of the factors affecting appointment backlog related to the availability of staff. There were unused or blocked appointment times during lunch and break periods, which had a significant impact on throughput. There were five appointment times blocked each day for a total of 35 "lost" potential appointments. California law strictly prohibits employees working through lunches and breaks unless they are compensated for each lunch or break missed at a higher pay.

The long-term solution was to add a third CT technologist to provide coverage and allow staff to take the necessary lunches and breaks, while increasing appointment capacity. The potential to build revenue by adding appointments offset the financial impact of bringing in an additional FTE.

As it turned out, some of the same problems were also impacting the MRI department. When MRI scheduling backlog was first measured, the wait time for an appointment was 27 days. The team decided to focus on solving impending issues in this area as well.

The Road to Recovery
Throughout this initiative, Stanford University Medical Center was committed to the improvement process and received strong support from Gary Glazer M.D., the professor and chairman of Stanford's radiology department. Most of the project teams included radiologists, who were in attendance at the majority of the meetings. Initially, there was a certain amount of skepticism from this group, and comments such as "we have already tried that…and it didn't work." They had to be persuaded that this was a team effort and several notches above previous improvement initiatives in healthcare such as TQM and CQI.

The scientific rigor in the methodology and the validity of the data proved to be the most convincing argument. Previous attempts to initiate change had been presented primarily with anecdotal or experiential documentation. The key difference this time around involved data analysis that demonstrated process capability, correlation of factors and elements that were determined not to be statistically significant.

The skepticism subsided in light of the evidence and the team came together through change acceleration techniques to participate in the performance improvement process. Some of the changes introduced through Six Sigma may appear, at least on the surface, to be common sense. It is only by presenting clear evidence in terms of data, however, that the improvements can actually be implemented and accepted.

While certainly not an overnight cure, the changes at Stanford have had a positive and cumulative effect. By converting all appointments to 30 minutes and expanding operating hours of operation, Stanford was able to boost diagnostic imaging productivity, volume and revenue. With the ability to scan over lunch breaks and rest periods, potential appointment capacity increased by 140 CT scans per month.

Another best practice was established in both CT and MR departments. More IVs are started prior to the patient entering the scan room, which reduces the total "in room" time and thereby increases throughput. Stanford has substituted water for oral contrast on a significant portion of routine abdominal scans. This decreased turnaround time and raised patient satisfaction, with no adverse impact on exam quality.

All of these changes greatly contributed to the impressive results. Overall, the CT project increased potential for outpatient appointment capacity by nearly 75 percent and projected over $1.5 million in additional annual gross revenue.

Addressing 'No Shows'
The impact of patients not showing up for their exams was both frustrating and difficult for staff and management. The "no show" rates averaged over 10 percent in both CT and MR. Usually, by the time it was apparent that a patient was not going to arrive, there was not enough time to arrange another patient to fill that slot. Within the hospital setting, it is more likely that an inpatient or emergency patient was available to take the slot, but the outpatient center did not have this option. The loss in productivity and empty table time were important throughput issues and the teams began to collect data to determine what they could learn about this issue from an analytical standpoint and how it could be addressed.

Standard operating procedures required the scheduling department to place reminder calls to patients prior to their scheduled appointments. This process was not working perfectly; however, since it turned out the calls were being placed four days prior to the appointment during daytime hours when many people were not at home. The first recommendation from the team was to place reminder calls closer to the scheduled appointment times and to call during evening hours when direct contact was more likely to occur.

Over a period of time, the team collected "no show" data and analyzed the information to reveal trends and patterns by site, modality, day of week, time of day and the age of the patient. The highest group of "no shows" was young adults scheduled for CT-sinus on Saturday mornings. This was good information for the staff when they were faced with having to add-on or double book.

Addressing "no shows" requires ongoing effort, and improvement is often noted as scheduling backlogs decrease. Contacting patients in person and close to the appointment time is essential. The ability for patients to cancel appointments quickly and easily allows staff time to revise schedules and fill in vacant appointments. To accomplish this, Stanford implemented a "Cancellation Hot Line" for CT with a 24-hour voicemail system. This allowed patients to cancel anytime without having to go through the typical phone call process to the department.

The Path to Sustaining Change
The complex process of moving toward a digital radiology department at Stanford demonstrates that healthcare cannot be healed by technology alone. The ability to optimize patient services revolves around a combination of leading edge technology, dedicated and well-trained staff and careful examination of processes and productivity as exemplified by the CT project.

Referring physicians and patients are beginning to feel the improvement, and the reputation of long scheduling delays is gradually changing. Stanford plans to continue using the operating mechanisms and dashboard developed during this project and to monitor progress monthly to ensure the benefits are maintained.

"In spite of all the obstacles and pressures facing healthcare today," noted Dr. Gary Glazer, "providers have an obligation to explore every opportunity for improvement. The changes we've implemented at Stanford have had a positive effect on patients and staff." In this case, taking the path of greater resistance proved to be the most productive and beneficial.

About The Authors
Ann Loree joined GE Medical Systems in 1999 as a systems engineer with CT. Today she is a consultant with GE's Performance Solutions group. Loree earned a bachelor's degree in engineering with a minor in business from McMaster University in Hamilton, Ontario, Canada. She is currently based in Fremont, Calif., and may be contacted at ann.loree@med.ge.com.

Marcia Maihack has been director of radiology at Stanford Hospital and Clinics in Stanford, Calif., for the last 27 years.

Marge Powell joined GE Medical Systems in 2000 and currently serves as a consultant with GE's Performance Solutions group. Prior to joining GE, she was the director of radiology services at St. Joseph's Hospital, a member of Covenant Healthcare in Milwaukee, Wisc. Powell has published articles on DRGs and bar code tracking of x-ray film jackets and contributed to the Radiology Policy and Procedure Manual published by the AHRA Midwest Region in 1992. She has a bachelor of science degree in management from Cardinal Stritch College and is a graduate of St. Joseph's Hospital School of Radiologic Technology. Powell is currently based in Brookfield, Wisc.

This Article Reprinted with Permission from Radiology Management
September/October 2003 Issue

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