Clinical Safety &
Effectiveness
Rise & Shine:
Improving On-Time First
Case Starts in
Interventional Radiology
The Team
Team Members
Philip Abraham, MHA, MA
Department Administrator
Michael Clemings, RN, MBA, BSN, OCN
Assistant Manager, IR Nursing
Keenan Harris, RTR
IR Technologist Supervisor
Elizabeth Ninan, PA-C
Manager, IR Mid-Level Providers
Timothy Quinn, PhD
Division Performance Improvement
Alda Tam, MD, FRCPC, MBA
Assistant Professor, IR Faculty
Sponsor
Michael Wallace, MD
IR Department Chair
Background
• Institute for Personalized Cancer Therapy (IPCT)
– Rapid profiling of tumor molecular biomarkers
– Tailor therapy to each patient’s tumor type
• Image-guided biopsies in IR
– 4,000 procedures/year
– 40% of total IR procedure volume
– IPCT may increase demand +650% by 2016
• Need: Streamline IR’s workflow and evaluate resources
to meet this future growth projection
Roadmap
Optimal Procedure Room Utilization =
Room turnaround time
First case starts
Intra-day case starts
Procedure prep time variation
Procedure time variation
Cancellations & add-ons
Our project in CS&E 15
Definitions
• First Case:
– Patient procedures at start of each room’s daily
schedule
Monday
Tuesday – Friday
8:00 AM (if Anesthesia required)
9:00 AM (if Anesthesia not required)
8:00 AM
• On-time start:
– Patient in procedure room by scheduled time
Rationale
First cases
– Highest leverage point
– Easier to intervene
First-case delays
– Cascade effect
– Contribute to:
• Cancellations
• Overtime
• Dissatisfaction for patients, staff, and physicians
Aim Statement
Improve the fraction of
first cases starting on time
each day in Interventional Radiology
to 80%
by August 31, 2011
7
Analysis Tools & Plan
• Process flow mapping
• Brainstorming
• Fishbone diagram
• Baseline data collection (Jul 25 – Aug 3)
• IR staffing matrix
• Improvement Cycle 1 data collection (Aug 15 – 19)
• Improvement Cycle 2 data collection (Aug 22 – 24)
• Data analysis with bar charts, control charts
On-time Starts Baseline
120%
100%
80%
63%
60%
58%
38%
40%
Pretest (7/25 - 8/3)
20%
0%
n=16
_
n=12
_
n=13
_
Outpatient
Inpatient
Outpatient
ACB
Alkek
Only 54% of all first cases were on time
Flowchart of IR First Cases
Causes of Case Start Delays
PATIENTS
PROCESSES
Floor delays
Arrived Late/
No Show
STAFF
Scheduling
RN Completing Tasks
For Prep for Procedure
Transport
Not NPO
New Medical Issue
Blood Products
Delays
Lab Results
Not Availalbe
Anes Delay
Inadequate Nursing & Tech
Staffing Related to Resources
Delayed Procedure
start time
SBAR format
PICIS
Connection Lost
Consent
Imaging Equipment Malfuction
Universal Protocol Completion
EQUIPMENT
POLICIES
Courtesy of IR Team CS&E #13
Causes of Case Start Delays
31 Brainstormed Reasons
No Delay
Patient No Show or Patient Late
Schedued First Case Replaced-Case Moved Up
Patient not prepped - Difficult IV start
Patient not prepped - Waiting for IV team or PEDI IV
Patient not prepped - Waiting for PA to Consent
Patient not prepped - Waiting for PA - Other
Patient not prepped - Nurse Shortage
Consent Not Complete: Waiting for Translator
Patient not prepped - Medication Delay
Patient late due to transport
Case cancelled by Primary Team
Tech shortage
Room not ready - not Cleaned
Room not ready - Equipment Delay
Anesthesia Team not Ready
IR MD Not Ready
Patient not prepped - RN equipment prep
Case Rescheduled or Cancelled due to Unexpected change in
Medical Status
No Case Scheduled at 0800
Appointment not confirmed with patient
Labs
Universal Protocol Not Complete
Meeting Day
Consent Not Complete: MD/PA delay
Case move upNo Patient Scheduled
Floor Delay
IR Equipment Malfunction
Staff Delay
Not Recorded
19 Reasons for Checksheet
0 No Delay
1 Patient No Show or Patient Late
Case Rescheduled or Cancelled due to
2 Unexpected change in Medical Status
3 Case cancelled by Primary Team
4 Appointment Not Confirmed with Patient
5 Scheduled First Case Replaced-Case Moved Up
6 Labs
7 Floor Delay
8 Transport Delay
9 Patient not prepped - Medication Delay
10 Patient not prepped - IV problems
11 Patient not prepped - RN equipment prep
12 Universal Protocol Not Complete
13 Consent Not Complete: Waiting for Translator
14 Consent Not Complete: MD/PA delay
15 Nurse/NA Shortage
16 Tech/MA shortage
17 Meeting Day
18 Anesthesia Delay
19 IR Equipment Malfunction
Causes of Case Start Delays
WITHIN OUR CONTROL
12
Number of Patients
10
8
6
4
2
0
Patient Factors
Pt Transport &
RN Floor Factors
IR Factors
Anes
Improvement Cycle 1:
First Case On-Time Starts
(Aug 15 – 19)
Cycle 1 Interventions
WITHIN OUR CONTROL
1. MD Site Marking Policy:
Patient site marking must be
completed by 7:45 am
12
10
2. Staff Meetings Policy:
RNs/Techs/faculty to leave
meetings early enough to work
up first-case patients on time
8
6
4
2
0
IR Factors
3. Scheduling Rule: Patients with
incomplete medical work-up
and/or consent cannot be
scheduled as first cases
IR Staffing Matrix
Before
Hour
630
700
730
745
800
830
900
930
1000
1030
1100
1130
1200
1230
1300
1330
1400
1430
1500
1530
1600
1615
1630
1700
RN
Tech
RN
Tech
After
RN
Tech
Hour
630
700
730
745
800
830
900
930
1000
1030
1100
1130
1200
1230
1300
1330
1400
1430
1500
1530
1600
1615
1630
1700
RN
Tech
RN
Tech
RN
Tech
Cycle 1 Interventions
“The IR Matrix”
4. Align RN and Tech Shift Schedules:
•
•
Charge RN starts at 6:30 am with charge tech
Charge RN to call floor RNs for first-case hand-offs
–
–
Before floor RN shift changes
Remove charge tech as communication broker
Cycle 1 Interventions
5. Patient Transport: Assign
transporter to all inpatient
first cases by 7 am
12
10
8
6
4
2
0
Pt Transport
Anes
6. Coordination with
Anesthesia Teams: Increase
communication to minimize
delays and ensure timely
pre-procedure prep
Cycle 1 Interventions
7. Circulating Supervisor:
Presence of a circulating
supervisor to improve
communication among
the IR team
Outcome Measures
• Improvement Cycle 1
– First Case On-Time Start Percentage
– Late-Start Minutes by Location
Results: First-Case
Starts
At baseline, 54% of all first cases
(22/41) were on time
Post-intervention, 87% of all first cases
(32/37) were on-time
Results: First-Case
Starts
120%
100%
100%
90%
80%
80%
63%
60%
58%
Pretest (7/25 - 8/3)
38%
40%
Posttest1 (8/15 - 8/19)
20%
0%
n=16 n=10
_
Outpatient
ACB
n=12 n=8
_
_
Inpatient
n=13 n=10
Outpatient
Alkek
Outcome Measures
• Improvement Cycle 1
– First Case On-Time Start Percentage
– Late-Start Minutes by Location
Results: Late-Start
Minutes at ACB
Results: Late-Start
Minutes at Alkek
Improvement Cycle 2:
First Case On-Time Starts
plus
Room Turnaround Time
(Aug 22 – 24)
Cycle 2 Intervention
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
N5
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
FLOAT RN
Finishes
procedure
(Gloves Come Off)
Starts Next
Procedure
Courtesy of IR Team CS&E #13
Combining Interventions
• First Case On-Time Starts
– Our team’s 7 interventions
• Room Turnaround Time
– Float RN intervention from IR Project in CS&E #13
• Alkek location only
• Improvement Cycle 2 data collection (Aug 22 – 24)
Outcome Measures
• Improvement Cycle 1
– First Case On-Time Start Percentage
– Late-Start Minutes by Location
• Improvement Cycle 2
– First Case On-Time Start Percentage
– Late-Start Minutes by Location
– Room Turnaround Time
Results: First-Case
Starts
120%
100%
100%
90%
80%
80%
63%
80%
75%
58%
60%
Pretest (7/25 - 8/3)
38%
40%
Posttest1 (8/15 - 8/19)
Posttest2 (8/22 - 8/24)
20%
0%
n=16 n=10
_
Outpatient
ACB
n=12 n=8 n=5
n=13 n=10 n=4
Inpatient
Outpatient
_
_
Alkek
Outcome Measures
• Improvement Cycle 1
– First Case On-Time Start Percentage
– Late-Start Minutes by Location
• Improvement Cycle 2
– First Case On-Time Start Percentage
– Late-Start Minutes by Location
– Room Turnaround Time
Results: Late-Start
Minutes at Alkek
Outcome Measures
• Improvement Cycle 1
– First Case On-Time Start Percentage
– Late-Start Minutes by Location
• Improvement Cycle 2
– First Case On-Time Start Percentage
– Late-Start Minutes by Location
– Room Turnaround Time
Results: Angio Room
Turnaround Time
Results: CT Room
Turnaround Time
Summary of Results
• First Case On-Time Starts
– Achieved aim of >80% on-time starts by Aug 31
– Across 2 locations, inpatients, outpatients
– ACB average lateness reduced from 0.8 to -5 min, possible
increase in lateness variation
– Alkek average lateness reduced from 2.2 to -1.3 min,
lateness variation reduced by 57%
• Room Turnaround Time (TAT)
– Angiography room TAT reduced 18% to 25 min
– CT room TAT reduced 43% to 17 min
Exploit Anesthesia Prep
Time?
• Analysis Findings
– Anesthesia needs ~30 min prep time for intubated
cases
– IR Staffing Matrix showed more staff available in
AM
• Possible Capacity Increase
– Add a non-complex IR case to the daily AM
schedule
Increasing Capacity
Additional Procedures and Billable Charges
Location Procedures
Procedures/
Week
Revenue/
Procedure
Revenue/
Week
Revenue/
Year
Alkek
CT
3
$5500
$16,500
$858,000
Alkek
Ultrasound
2
$4500
$9000
$468,000
ACB
CT &
Ultrasound
5
$5700
$28,500
$1,482,000
TOTAL:
$54,000
$2,808,000
Next Steps
Optimal Procedure Room Utilization =
 Room turnaround time
IR project in CS&E 13
 First case starts
Our project in CS&E 15
 Intra-day case starts
 Procedure prep time variation
 Procedure time variation
 Cancellations & add-ons
Future IR projects
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