Decreasing the Turnaround Time (TAT) of
Intra-operative Imaging and Interpretation
of Potentially Retained Foreign Objects
(RFO)
Joseph R. Steele, M.D., Janet
Champagne MBA, Garrett L. Walsh,
M.D.
UT MD Anderson Cancer Center
Overview
• RFOs after surgery can present considerable
risk and potential patient harm
• The rate of RFO ranges from 1/5500 to 1/7000
• Cima RR, et al. J Am Coll Surg 2008; 207:80-7
• Egorova NN, et al. Ann Surg 2008;247:13-8
• Considered a sentinel event by the Joint
Commission
Project Overview
• Joint venture between the Division of Surgery,
Perioperative Enterprise and Division of Diagnostic
Imaging.
• X-ray obtained if post-operative mismatched count
occurs.
• The turnaround times (TAT) for intra-operative imaging
of potential RFOs was felt to be unacceptable by the
Division of Surgery, potentially jeopardizing patient
care.
• A team consisting of OR staff, surgeons, radiologists,
administrators and radiology technologists was
organized to address and solve the problem.
AIM Statement
• The aim of this project was to decrease the
average TAT for imaging and interpretation of
potential RFOs to less than 30 minutes within
4 months.
– The process begins when the OR calls Diagnostic
Imaging requesting an operative radiograph, and
ends when the radiologist calls back to the OR
with their report.
The RFO Saga
Phase 1: Baseline Data Collection
• Improving the RFO TAT was unsuccessfully
attempted by a previous CS&E team.
• Because of pressure to immediately begin
improvement efforts, their data were used as
a baseline.
Problem #1
Phase 1: Baseline Data
RFO TAT stage 1
UCL=91.3
90
80
_
X=43.0
70
Minutes
60
50
40
30
20
10
0
LB=0
1
5
9
13
17
21
25
29
Imaging performed in OR for potential RFO
33
Mean TAT = 43 minutes, Not consistent with OR
experience
37
Potential RFO Imaging Process
Retained Foreign Objects or Incorrect Counts – Routine Hours
revised: 7 April 2010
5. CT DI Service
Coordinator
receives call from
OR.
(Manual time
collection).
6. CT DI Services
Coordinator calls
713 794-1178 to
request technologist
dispatch
8. CT DI Service
Coordinator enters
requisition into
CARE.
Radiologic technologist
Radiologist
CT DI Service
Coordinator
Routine Hours: Monday – Friday 0600 - 1800
9. CT DI Service
Coordinator calls
Radiologist or
Radiology resident
using call tree
10. Radiologist or
Radiology resident
is made aware of
RFO or incorrect
count in OR
7. Technologist is
dispatched to OR.
11. Rad Tech
Changes
procedure code in
RIS to one of the
RFO codes
12. Rad Tech
arrives in OR with
x-ray unit
(Begin procedure
time is collected)
13. Rad Tech
obtains images
14. Do images
cover defined
areas?
No
14e. Technologist
obtains images in
pre-defined
location.
14a. Inform
surgeon additional
images required.
Yes
15. Images
uploaded to PACS
and enters info
into RIS.
(End Procedure
time is collected)
Operating Room
1
14b. Can
technologist
obtain additional
images?
3. Provides patient name, MRN,
md code, svc code, type of
exam, surgical types and
locations, call back number and
OR room number
Yes
1. OR discovers a
RFO or incorrect
count
2. OR calls CT DI
Service Coordinator at
713 745-5449.
4.Prepares patient
and room for
X-ray
14c. Assist
technologist with
positioning under
sterile field.
No
14d. Instruct tech
to perform imaging
after closing or in
PACU.
Potential RFO Imaging Process
Radiologist
19. Radiologist
instructs CT DI
Service Coordinator to
contact OR
CT DI Service
Coordinator
17. CT DI Service
Coordinator notifies
GI Radiologist
images are complete.
(Manual time
collection)
20. DI CT Service
Coordinator contacts
OR with Radiologist on
the phone at the phone
number provided
earlier.
16. Rad Tech calls CT
DI Service Coordinator
at 713 745-5449 and
informs procedure is
complete
Operating
Room
18. GI Radiologist
reviews images
Radiologic
technologist
Retained Foreign Objects or Incorrect Counts – Routine Hours
1
21. Report communicated
to Physician Team in OR
* Standard Read Back
(Manual time Collection)
revised: 7 April 2010 page 2
Phase 2: Initial Interventions
(The Good)
RFO TAT stages 1 and 2
1
UCL=91.3
90
80
2
_
X=43.0
70
UCL=88.2
_
X=39.6
Minutes
60
50
40
30
20
10
0
1
7
LB=0
13
19
25
31
37
43
49
Imaging performed in OR for potential RFO
LB=0
55
61
TAT improved to 39 minutes and represents a lengthier, complete process.
Since there were no complaints, the quality of the exams were assumed to
be excellent. (Problem #2)
BIG PROBLEM (The Bad)
Miscount following TRAM flap
Patient returns to EC
Phase 3: Re-engineering
(The Ugly)
RFO TAT stages 1, 2 and 3
1
2
3
120
100
UCL=91.3
Minutes
80
_
X=43.0
UCL=88.2
UCL=122.1
_
X=47.8
_
X=39.6
60
40
20
0
1
9
LB=0
LB=0
17
25
33
41
49
57
65
Imaging performed in OR for potential RFO
LB=0
73
81
Image acquisition segment of the project is redesigned, resulting in
expected disruption. Mean TAT increases to 48 minutes with increased
variation.
RFO Redemption
Phase 4: Final Interventions
(The Redemption)
RFO TAT by project stage
1
2
3
120
100
UCL=91.3
Minutes
80
_
X=43.0
UCL=88.2
UCL=122.1
_
X=47.8
_
X=39.6
4
UCL=83.2
_
X=38.9
60
40
20
0
1
11
LB=0
LB=0
LB=0
21
31
41
51
61
71
81
Imaging performed in OR for potential RFO
LB=0
91
Mean TAT decreased to 38 minutes, and variation decreased.
Revenue Enhancement
• Additional technical charge (OR)- $1200/hr
– Savings of approximately $100.00/case
• Additional anesthesia charge (OR)- $342/hr
– Savings of approximately $28.50/case
• Additional professional anesthesia charge (OR)
$648/hr
– Savings of approximately $54.00/case
Revenue Enhancement
• Total annual savings
$182.50 X 264 (est.) = $48,180.00
• Avoidance of a RFO and potential litigation
PRICELESS
Next Steps
• Since we failed to meet our aim the following
steps will be undertaken:
– Evaluate stage 4 data
– Improve communication (OR and DI staff)
– Decrease repeat imaging
– Initial PDSA cycles until the 30 minute TAT goal is
accomplished
Conclusion
• Quality improvement is not for the faint of
heart.
– You don’t know what you don’t know.
– Understand what is going on before trying to
measure it.
– Don’t assume anything.
• You don’t need to win every battle to win the
war.