#21
PROJECT NAME: Interventional Radiology
Throughput Optimization: 15 month follow up
Institution: University of Texas Southwestern Medical Center
Primary Author: Seth Toomay, MD
Secondary Author: Ikponmwosa Iyamu MD, Minesh Patel MD, Frank
Vaughan, James Collins, Michael Estabrooks RN
Project Category: General Efficiency
Purpose
In late 2011 the interventional radiology section at Parkland Memorial Hospital
(Dallas, TX) was experiencing unacceptable wait times for elective outpatient
procedures resulting in poor access to care for a vulnerable segment of Dallas
county residents. This problem was the subject of a CS&E project “Interventional
Radiology Throughput Optimization” presented at the 2012 CS&E Building the
Bridge conference1. The purpose of this abstract is to provide15 month follow up
from the project’s inception (1/2012).
Aim:
“To reduce wait times for outpatient interventional radiology procedures by 50% by
June 2012”
Tools and Measurement:
The original project included process mapping and redesign, pareto analysis,
fishbone diagram, no-show quantification, case volume and room utilization, as
well as evaluation room turnaround times and patient transport times1. It is
important to note that the initial pareto analysis revealed that outpatient mediport
placements represent 13% of the total volume (50% inpatient and 50% out patient)
and for the purposes of this project are used as a proxy for all outpatient exams.
The 15 month follow up is shown as a control chart (FIGURE 1) that plots the
average time from the ordering of the mediport to its placement (in days) with 3
sigma control limits per month. In addition the monthly volumes (ports/month)
placed by the interventional radiology service and by the surgical service are
superimposed. Also the duration of the CS&E class in displayed. The display of
these four variables illustrates nicely how the increase in surgical placed ports
helped decrease the backlog of cases while the scheduling template re-work was
implemented to increase the capacity in the interventional radiology section. This
data was not available at the time of submission of last year’s abstracts. It also
shows that the changes to the process have been durable since initiation.
Intervention and Improvement
Updates to interventions that were discussed in the initial abstract:
1. Additional IR procedure room
a. Apparent early on that procedure rooms were not rate limiting.
b. Project canceled with $700,000 capital savings
2. Lobbied surgical services to use extra OR capacity for mediport
placement.
a. Additional capacity helped reduce the scheduling backlog.
i. This data was not available to our project until this spring.
ii. See FIGURE 1.
b. This added capacity required additional work to coordinate and
was transient in nature.
3. Prep & recovery room capacity identified as a serious limitation
a. Currently 11 recovery beds for 3 IR rooms, 1 CT room, and 1 US
procedure area. (2.2 beds per procedure resource)
b. Society of interventional radiology practice guidelines for clinical
practice recommend a ratio of up to 4.0 rooms per procedure
resource2.
c. Approval of $650,000 remodel to recovery room to add 3 beds
and 6 recliners for a total of 20 prep/recovery spaces (4 beds/
procedure resource)
d. New nursing administration deemed recovery recliners not
appropriate for a prep/recovery area and canceled the project.
i. $650,000 savings.
Subsequent interventions:
1. Adjustment of the procedure scheduling template
a. Implemented May 2012.
b. Adjusted procedure length to reflect actual procedure time from
“patient in the room” to “patient out of the room”.
c. Booked cases into the under utilized procedure room two ½ days/wk.
i. Room was originally intended for Nuero IR cases only but
quantifying process inadequacies eliminated political
resistance.
d. Appears to have doubled mediport throughput for IR section as noted
in FIGURE 1.
e. Procured additional visit types from the hospital information
resources.
i. A visit type must be associated with an order.
ii. Visit types specify what room a case is scheduled in and how
long the case will take.
iii. Initially had only two 1 hour visit types
iv. Requested 100 additional visit types for a 1:1 ratio of visit
types to procedures.
v. Delays due to strong resistance from hospital IT to creation of
new visit types.
1. Only 29 visit types were generated.
Intervention Results:
At the worst in November 2011 outpatient mediport wait times was 40.5 days. By
the end of the CS&E course in June 2012 the wait time had decreased to 23 days
(43% reduction) which was near the aim statement goal of 50%. With additional
time it has been possible to calculate values for a control chart that show the preintervention monthly median wait times of 35 days and the post intervention wait of
18 days. This represents a 48% decrease. It is worth noting that this decrease has
been durable over the past year. (FIGURE 1)
After the completion of the CS&E course mediport procedures performed by the
surgery service returned to their pre project values. This was due to the additional
manual effort required to coordinate the transfer of the workflows between
established radiology and surgical workflows. The surgery service current volume
of mediport procedures does not appear to be a contributor to the continued
decrease in wait times (FIGURE 1).
The volume of outpatient mediport procedures performed by IR has nearly doubled
since the adjustment of the scheduling templates and scheduling into the
underutilized procedure room. The magnitude of this effect was not anticipated. It
is noteworthy that the two interventions that were actually able to be implemented
required no capital investment. The main impediment was political in nature
(Resources claimed but not utilized by another group and the hospital information
technology’s reticence to allow the creation of additional visit types for unknown
reasons).
Revenue Enhancement /Cost Avoidance / Generalizability:
Initial hypothesis of a fourth IR room was proved null by results of this project
(approximate cost of $700,000). The approved expansion of radiology recovery
space was rescinded (approximate cost of $650,000). In total, this project has
saved the PHHS radiology department nearly $1.35 million.
Optimizing the scheduling and IR room turnaround time has been critical to the
success of this CS&E project, and these two facets require no capital expenditure
and are generalizable to other locations.
(1) Interventional Radiology Throughput Optimization Seth Toomay MD, Frank Vaughan, James
Collins, Michael Estabrooks RN. 2012 Building the Bridge CS&E Conference.
http://www.utsystem.edu/hea/buildingbridge/files/2012%20Presentations/Interventional%20Radiology%20
Throughput%20Optimization.docx
(2) ACR-SIR-SNIS Practice Guideline for Interventional Clinical Practice. Society of Interventional
Radiology and Americal College of Radiology 2009 r24:
http://www.acr.org/~/media/0C8928B2A2EE42ACB640083C7D3DEF2F.pdf
Figure 1. Median Mediport Volume and Wait Times Before, During, and After CS&E Project.
Green control chart shows the pre-CS&E median wait time of 35 days relative to the post –CS&E median
wait time of 18 days. Superimposed over this is the monthly volume of ports placed by surgery (blue) and
by interventional radiology (red). The Y-axis is in days for the control chart and ports/month for the IR and
Surgery line graphs. The superimposition of these graphs with the CS&E class duration nicely illustrates
how the two successful interventions (surgical capacity for port placement and altering the scheduling
templates to increase IR capacity) contributed to the decreased wait times.
Figure 2. Cancelled Radiology Prep & Recovery Area- Light blue area represents the addition of 5 preop chairs, an IV station, and three recovery bays. This is in addition to the current 11 recovery bays for a
total capacity of 19 patients, plus an IV station. This project was cancelled after new nursing
administration concluded that the additional recliners were not appropriate for a prep/recovery area and
additional beds could not be placed in the area due to new space requirements.