Improving Efficiency in
the Angiography Suite
Kamran Ahrar, M.D.
Elizabeth Ninan, PA-C
Jasmine NovoGradac, MBA,BSN,RN
Terrell Evans, RT (R)(CT)(MR)
Division of Diagnostic Imaging
Section of Interventional Radiology
1
Background
• Limited Capacity
– Total of 3 Angiography Suites at Alkek (Main Hospital)
– 2 have up-to-date equipment, used routinely
– 1 out-dated unit, used as an overflow room
• Increasing Demand for Angiography or Fluoroscopy
Guided Procedures
– Increasing number of patients with liver tumors receiving
liver-directed therapies
– Alkek expansion project: Additional hospital beds
– Anticipated 17% increase in overall volume for 2011
2
AIM
To Reduce the
Inter-Procedure Time Interval
in the Angiography Suite
by 20%
by August 6, 2010
3
Angiography Suite Turn Over Process
Definitions
Inter-procedure Time Interval
Procedure
Nurse
Vacant Angio Suite
N1
N3
N4
N5
N6
Transport Patient
Out of the
Angiography Suite
Technologist
MD
N2
Bring Next Patient
Into the
Angiography Suite
T1
T2
Finishes
procedure
(Gloves Come Off)
Starts Next
Procedure
N1-N6: Multiple tasks the procedure
nurse has to complete before brining the
next patient in.
T1-T2: Tasks the technologists has to
complete before bringing the next
patient into the angio suie
4
Baseline Data
Snapshot of Angiography Suite Utilization
May 24 to May 28, 2010
5--24
5--25
5--26
5--27
5--28
7 -- 8
8 -- 9
9 -- 10
10 --11
11 -- 12
12 -- 1
1 -- 2
2 -- 3
3 -- 4
4 --5
5 -- 6
7 -- 8
8 -- 9
9 -- 10
10 --11
11 -- 12
12 -- 1
1 -- 2
2 -- 3
3 -- 4
4 --5
5 -- 6
A-11
A-10
A-09
A-11
A-10
A-09
A-11
A-10
A-09
A-11
A-10
A-09
A-11
A-10
A-09
•Each box represents 10 minutes
•Time intervals were rounded to the nearest 10-minute mark
•Call cases are not included
Procedure in Progress
Vacant Angio Suite
•A-10 and A-11: High Quality Angio Suites
•A-9 Old Equipment, used as overflow procedure room
Baseline Data
Metric: Inter-procedure Time Interval
Baseline Data
Metric: Vacant Angio Suite (between procedures)
Main Causes of Inefficiency
PATIENTS
PROCESSES
STAFF
Scheduling
RN Unavailable
in post 8 to 9 am
Transport
Arrived Late
Not NPO
Cardiology Consult
Lab Results
Not Availalbe
Blood Products
Delays
PICIS
Connection Lost
RN Completing Tasks
after Procedure
Inadequate Nursing
Staffing Related to Resources
PROLONGED
INTERPROCEDURE
INTERVAL
Site Marking
EQUIPMENT
POLICIES
8
Main Causes of Inefficiency
PATIENTS
PROCESSES
STAFF
Scheduling
RN Unavailable
in post 8 to 9 am
Transport
Arrived Late
Not NPO
Cardiology Consult
Lab Results
Not Availalbe
Blood Products
Delays
PICIS
Connection Lost
RN Completing Tasks
after Procedure
Inadequate Nursing
Staffing Related to Resources
PROLONGED
INTERPROCEDURE
INTERVAL
Site Marking
EQUIPMENT
POLICIES
9
Strategy to Improve Efficiency
•
Make sure patients are properly worked-up and ready to
be transferred to the angiography suite
•
Make sure the angiography suite is clean and properly setup to receive the patient
•
Make sure there is a nurse available to transfer the patient
into the angiography suite as soon as the suite becomes
available
10
Angiography Suite Turn Over Process: Main Intervention
Definitions
Inter-procedure Time Interval
Procedure
Nurse
Vacant Angio Suite
N2
T1
T2
N3
N4
N5
Receives Hand
Off from Float
Nurse
N6
Technologist
Transport Patient
Out of the
Angiography Suite
Bring Next Patient
Into the
Angiography Suite
Float Nurse
MD
N1
Gives Hand Off to
Procedure Nurse
Finishes
procedure
(Gloves Come Off)
Starts Next
Procedure
11
Other Interventions
•
Patient Preparation/Readiness
–
–
–
–
–
•
Confirmations of appointments
MLP worked up of patients (blood products, pre-medications, consents)
Anticipate Cancellations
Improve Coordination with the OR for combined interventions
Dedicated Two Transport staff to IR
Room Readiness
–
–
The Charge technologist will assist to complete tasks
Medical Assistant will help clean up the room and set up new procedure tray
12
Final Data
Snapshot of Angiography Suite Utilization
August 2 to August 6, 2010
8--02
8--03
8--04
8--05
8--06
7 -- 8
8 -- 9
9 -- 10
10 --11
11 -- 12
12 -- 1
1 -- 2
2 -- 3
3 -- 4
4 --5
5 -- 6
7 -- 8
8 -- 9
9 -- 10
10 --11
11 -- 12
12 -- 1
1 -- 2
2 -- 3
3 -- 4
4 --5
5 -- 6
A-11
A-10
A-09
A-11
A-10
A-09
A-11
A-10
A-09
A-11
A-10
A-09
A-11
A-10
A-09
•Each box represents 10 minutes
•Time intervals were rounded to the nearest 10-minute mark
•Call cases are not included
•A-10 and A-11: High Quality Angio Suites
•A-9 Old Equipment, used as overflow procedure room
Procedure in Progress
Vacant Angio Suite
13
Results
Metric: Inter-procedure Time Interval
Testing for Statistical Significance
Inter-procedure Time Interval
Two-Sample T-Test and CI: Inter-procedure Interval
Two-sample T for Inter-procedure Interval
Period N Mean StDev SE Mean
Post 47 47.7 20.4 3.0
Pre
39 62.5 26.1 4.2
P-value <.05, so Pre and Post
Means are statistically
significantly different at the
95% level
Difference = mu (Post) - mu (Pre)
Estimate for difference: -14.85
95% CI for difference: (-24.82, -4.89)
T-Test of difference = 0 (vs not =): T-Value = -2.96 P-Value = 0.004 DF = 84
Both use Pooled StDev = 23.1389
Results
Metric: Vacant Angio Suite (between procedures)
Testing for Statistical Significance
Vacant Angio Suite(between procedures)
Two-Sample T-Test and CI: Vacant Room Time (between procedures)
Two-sample T for Vacant Room(between procedures)
Period N Mean StDev SE Mean
Post
47 26.6 18.2
2.7
Pre
39 39.8 23.6 3.8
P-value <.05, so Pre and Post
Means are statistically
significantly different at the
95% level
Difference = mu (Post) - mu (Pre)
Estimate for difference: -13.22
95% CI for difference: (-22.21, -4.24)
T-Test of difference = 0 (vs not =): T-Value = -2.93 P-Value = 0.004 DF = 84
Both use Pooled StDev = 20.8484
Return on Investment
• Pilot Period: 5 days, tracked over 70 patients, reviewed 47 Intervals
– 9.4 Intervals per day
– Reduced Suite Vacancy by 13.22 minutes per interval
• Total Gain: 124.27 minutes per day
– Anticipated Gains:
• Ability to accommodate additional patients and procedures
– Increased patient satisfaction
– Shorter length of stay
– Additional revenues
• Ability to finish scheduled cases in a timely fashion
– Less overtime
– Higher job satisfaction, improved morale, better staff retention
• Unexpected secondary gain of charges from PA work up of patients the day prior
to procedure
18
Return on Investment: Most Optimistic
Min (conservative)
Charges for 1
additional procedure
Revenue
Avg. CHARGE per Procedure
Potential CHARGE per Day
Total Work Days per Year
Potential CHARGES per Year
Additional CHARGES generated from MLP
role expansion and billable/year
$
$
$
Max
Charges for 2 additional
procedures per day
1
2
4,623.58 $
4,623.58
4,623.58 $
9,247.16
250
250
1,155,895.00 $
2,311,790.00
$
200,000.00 $
200,000.00
$
1,355,895.00 $
2,511,790.00
Cost of an additional RN
$
75,000.00 $
75,000.00
Cost of an 0.5 MA
$
18,000.00 $
18,000.00
Cost of an additional PA
$
85,000.00 $
85,000.00
Total costs
$
178,000.00 $
178,000.00
Net Potential Gain per Year
$
1,177,895.00 $
2,333,790.00
Total Potential CHARGES per Year
Costs
19
Return on Investment: Most Conservative
Contribution to Margin per Patient
Min (conservative)
Max
1 additional patient
per day
2 additional patients
per day
$200.00
$200.00
2.40
250
2.40
250
Potential Revenue per Year
Additional Charges generated from MLP
role expansion and billable/year
$120,000.00
$240,000.00
$200,000.00
$200,000.00
Total Potential Margin per Year
$320,000.00
$440,000.00
Cost of an additional RN
$75,000.00
$75,000.00
Cost of an 0.5 MA
$18,000.00
$18,000.00
Cost of an additional PA
$85,000.00
$85,000.00
Total costs
$178,000.00
$178,000.00
Net Potential Revenue Gain per Year
$142,000.00
$262,000.00
Avg. Procedure per Patient
Avg. Work Days per Year
Costs
20
Return on Investment: Most Likely
Addional Procedure
Avg. Revenue per Procedure
Potential Revenue per Day
Total Work Days per Year
Potential Revenue per Year
Additional Charges generated from
MLP role expansion and billable/year
Total Potential Revenue per Year
Costs
Cost of an additional RN
Cost of an 0.5 MA
Cost of an additional PA
Total costs
Net Potential Revenue Gain per Year
Min (conservative)
Max
Net Revenues for 1
Net Revenues for 2
additional procedure per additional procedures per
day
day
1
2
$
1,444.00 $
1,444.00
$
1,444.00 $
2,888.00
250
250
$
361,000.00 $
722,000.00
$
$
200,000.00 $
561,000.00 $
200,000.00
922,000.00
$
$
$
$
$
75,000.00
18,000.00
85,000.00
178,000.00
383,000.00
75,000.00
18,000.00
85,000.00
178,000.00
744,000.00
$
$
$
$
$
21
Moving Forward
• Future Actions:
– The float nurse was a temporary solution we had pulled from our
outpatient facility
– As of now, we are not able to provide the float nurse function to keep
the vacant angiography suite time to a minimum
– We have requested additional nurses for 2011
– If approved, a nurse will be assigned to the function tested in this pilot
• Maintained Actions:
– Work-up of patients the day before (generating $ 200K E & M charges)
– Confirming appointments
–Charge tech helping with room turn over
•Quarterly Audits
22
Conclusion
• Reduction in the Inter-Procedure Time Interval for the
Angiography Suite by 24 %
• Reduction in the Vacant Angiography suite by 33%
Outcomes:
– Accommodate additional patients
– Provide a better work environment
– Generate additional revenues
•Allocation of resources is justified
23
Thank you.
Acknowledgements:
M. D. Anderson CS&E Faculty and Staff
Tatiana Hmar-Lagroun, Project Facilitator
James A. Terrell, Applied Statistics
Michael J. Wallace, MD; Sponsor
24