Process improvements at MGH boost inpatient imaging service

Aug 9, 2007

In the hospital environment, enhancing the way staff work and patients are served is of crucial concern. But understanding work patterns, and then making them more efficient and transparent, can present a thorny challenge.

In a presentation at the 2007 American Healthcare Radiology Administrator (AHRA) meeting in Orlando, Pavel Rabiner, senior project specialist in the department of radiology's Quality Management and Education Committee (QME) at Massachusetts General Hospital (MGH) in Boston, and colleague Kathy Tabor-McEwen, formerly of MGH and now executive director of imaging at Boca Raton Community Hospital in Florida, offered their experience with a pilot effort to improve inpatient imaging service levels in MGH.

Rabiner, Tabor-McEwen, and colleagues on the QME, an internal consulting team for MGH's department of radiology, targeted pediatric inpatients for their initial assay. The project team included referring physicians, inpatient floor coordinators and nurses, radiology operations personnel (scheduling, MR, CT, and general radiography) and radiologists. The group focused on three particular process improvements: report turnaround time, exam predictability, and communication with all involved in and affected by a patient's care.

The group began by mapping the inpatient imaging process, which included receiving the request for an exam from a referring physician, scheduling the exam within the specific modality, imaging the patient, and generating the report, then making it available to the referring physician. It looked for "failure points" that impeded efficient outcomes, and listed people affected by the process, including patients and their families, referring physicians, inpatient floor personnel, patient transport staff, radiology operations personnel, and radiologists.

Where the ball drops -- and how to get it back in play

The QME committee found that the main sticking points in the imaging process included the following:

Interaction between inpatient floors and radiology operations and prioritizing exam requests from referring physicians
Scheduling exams within modalities
Coordinating between patient transport services and radiology operations
Prioritizing exams for radiologist interpretation and prioritizing requests by referring physicians
Interaction between inpatient floors and radiology operations and prioritizing exam requests from referring physicians

In the pediatric ward there wasn't a single point of contact to provide efficient scheduling and prioritize patients' radiology exams, so there were often conflicts in the patients' schedules, and miscommunication between the people involved in patient care.

"We found a breakdown of communication between inpatient floors and radiology operations," Rabiner said. "If an exam coordinator happened to speak to a nurse, that was good, but more often than not, radiology personnel would schedule an exam, and the nurse would go to prep the patient, then realize the patient had another appointment already scheduled. Two hours later, the referring physician would be calling about the exam that didn't happen, the parents would be complaining that their child hasn't eaten all day, and no one knows what's happening."

The QME committee recommended that the department create a centralized schedule for each patient and assign a single point of contact for exam scheduling. The centralized schedule could be high-tech, integrated via computer into the patient scheduling system; mid-tech, such as a worksheet located on a shared drive; or even a low-tech solution like a white board on the patient floor where nurses could list patient appointments.

Scheduling exams within modalities

When Rabiner and Tabor-McEwan began the process of evaluating inpatient imaging for MGH's pediatrics, they saw that there was a lack of defined inpatient appointment times, which created unpredictability in the timing of exams. The unpredictability was particularly hard for patients and families.

"Exam predictability is important for nursing staff and referring physicians," Tabor-McEwan said. "But it's also crucial for patients and their families. Knowing when an exam is going to occur gives everyone a sense of well being and calmness, and it's important customer service."

But setting aside exam time for inpatients can be tricky, since the demand volume is less predictable than it is for outpatients, the duration of exams is more variable, and the demand timing tends to correspond to referring physicians' work patterns (like ordering exams after rounds).

The group suggested that a hospital look over its historical daily inpatient volume to determine how much time to set aside for inpatient appointments. For example, if the average inpatient volume for CT Monday through Friday was 375 exams for 230 individual patients, this would translate to 75 exams and 46 patients per day; over a 16-hour work day, it would be three patients and five exams per hour. Since most requests for inpatient exams come in after physicians have completed their rounds, inpatient appointment times could be set aside after 10:00 a.m., Rabiner said.

"Having a scanner sitting empty tends to set temples pulsing in (hospital) administration," Rabiner said. "We tried to shoot for 75% utilization for our equipment to avoid waits, but also keep some appointment time open for inpatients."

Coordinating with patient transport

A major sticking point in the inpatient imaging process was that insufficient service-level agreements between patient transport services and radiology operations made patient transportation erratic. If there's not adequate patient transport service or if patient transport is decentralized, it's very difficult to improve inpatient imaging processes, Rabiner and Tabor-McEwan found. MGH has a central transport service for the hospital, as well as a mini-transport service just for radiology.

Rabiner and Tabor-McEwan wanted to be able to track transport patterns and to understand the dispatching system. As a result of their analysis, a paging system has been put into place for the patient transport service, as well as a more transparent dispatching and scheduling system.

Prioritizing exams

The QME committee at MGH discovered that the hospital's PACS worklist wizards couldn't separate inpatients from outpatients, so radiologists weren't able to prioritize inpatient exam readings. The committee rallied radiologist representatives from the hospital's referring practices to set acceptable priorities on reads and turnaround times, as well as IT staff to explore ways to modify the PACS to allow patients to be grouped by type (inpatient and outpatient).

As for prioritizing referring physicians' exam requests, the committee found that there was an inconsistent approach to prioritize requested exams, and a lack of clear expectations for report turnaround time also got in the way of prioritizing exams. In response, the committee worked to establish mutually agreed-upon priorities and patient/report turnaround times.

What makes a quality assurance process like this one effective? Three factors, according to Rabiner and Tabor-McEwan: Executive sponsorship from radiology, inpatient floor operations, and referring physicians; clear performance measures and success criteria; and representatives from each stakeholder group within the hospital (administration, nurses, doctors, transport staff, patients, and families).

Both Rabiner and Tabor-McEwan emphasized that for inpatient imaging processes to improve, there must be staff ownership of the solutions and willingness to implement them.

"These are all great ideas, but it's crucial to know who's actually going to do them (on the floors)," Tabor-McEwan said. "Administrators can't do it all on their own."

By Kate Madden Yee
AuntMinnie.com staff writer
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