Team Leader: Eric Goodman
Team Sponsor: Jason Spaulding
Team Coach: Yvonne Cheung
Team Members: Heather LaPorte,
Nanci Adams, Paula Hebert
Douglas Goodwin J. Allen Graham
Project Information and Background
Fluoroscopic-guided MSK (Musculoskeletal) procedure are procedures in which patients are imaged using a fluoroscopic system while a needle is used to access the joint space either for
diagnostic or therapeutic purposes.
We perform these procedures in Diagnostic Radiology daily, and felt that we could improve the efficiency of our workflow. The number of MSK Procedures is currently high and growing and it
is important to be able to provide service to patients in a timely manner
Key Project Goals• Timely appointments without a long wait time
• Shorter duration of individual exam time
• Decrease the Physician time per procedure to allow for reading more examinations
• Standardizing workflow and supplies to optimize technologist time, and simplify examination procedure
By using the DMAIC process, we identified some root causes to prolonged total procedure time. We streamlined workflows by:
• Implementing standardized trays
• Standardized documents
• Limiting parallel scheduling conflicts by assigning a dedicated room for MSK procedures
DMAIC
Define
Key Points
SIPOC
• Project purpose and scope
• Obtain Info about process and customers
• Statement of the problem
Fluoroscopic-Guided MSK procedures were felt to take
too long.
Suppliers
• Patient
• Secretary
• Schedulers
• Radiology
Technologist
• Radiology
Resident
• Radiology
Attending
• Orthopedics
By reducing cycle time, it was hoped to lessen
patient’s time in the department.
This in turn will create increased access, and improved
ability for the department to accommodate add-on
requests
Measure
Key Points
 Situation
 Determine process performance vs.
requirements
 Summarize data regarding current process
The average patient spends:
63 minutes in 3T
21 minutes in the waiting room
38 minutes in the procedure room
10 minutes with the physician
6 minutes having the MSK procedure
Analyze
Key Points
 Determine potential root causes
 Confirm root causes with data
 Provide focused problem statement
4 key root causes:
•
Patient Communication
•
Procedural Issues
•
Clinic Communication
•
Space
Inputs
Process
• Order
• Demographic
Info
• Medications
• Physician
availability
• Register at
Front Desk
• Prepare Room
for patient
• Patient
Brought to
Room
• Consent
Patient
• Position
Patient
• Perform
Procedure
• Give After
Care
instructions
Outputs
Customers
• Treated
Patient
• Fluid for lab
study
• Patient
• Orthopedics
Patient Value Stream Map
Check
In
Waiting
Room
Tech
Pre-Procedure
Work
Rad
Consent
Tech
Post-Procedure
Work
Patient
Positioning
Procedure
Cycle
Time
0:03:18
0:20:30
0:03:00
0:04:18
0:04:36
0:05:42
0:00:54
Process
Time
0:04:24
0:20:30
0:07:24
0:04:18
0:04:36
0:14:30
0:07:18
Fishbone Diagram
PATIENT
COMMUNICATION
PROCEDURAL ISSUES
No standard positioning guide for techs
Lacking commonly requested
supplies in room
Patient Mobility
Issues
Proper supplies not
put on trays
Radiologist and Tech
having duplicate
conversations
Incorrect forms given to
patients by reception (e.g.
contrast sheets)
Lack of standardized
consent
Various attending
preferences
Patient does not understand
changing instructions, and is
not properly undressed for
the procedure
Referring Provider orders
incorrect examination or
wrong side
Referring Provider
does not order labs
(for aspirations)
Prolonged
Patient Time in
Fluoroscopy
No dedicated MSK
room/ no “overflow”
space to
accommodate addon cases.
CLINIC COMMUNICATION
GI/GU Procedures run
long
Slow room turn-over
SPACE
Improve
Key Ideas
Control
Key Ideas




• Standardized work & documents
• Education of support staff
• Dedicated MSK procedure room
• New C-arm to allow for “overflow”
into a non-fluoro room
• Switch to “OR-style” clean-up
process
• Standardized pre-made
procedure trays
 Maintain gains by standardizing
process
 Create feedback systems
 Monitor control plan
• Monitor system with repeat observation
• Allow the technologists, schedulers, and
secretaries to become owners of the
improvement process.
• Use PDSA cycles to target areas of
continued concern or weakness in the
process
Develop potential solutions
Test solutions
Develop future state
Actions eliminate or reduce
impact of the identified root
cause