1/13/2017

1

Improving Access to Pediatric MR performed under General

Anesthesia— Benefits of a Rapid Improvement Event (RIE)

N I Sarwani, MD, FRCR, FSARM A Bruno, MS, MD, FACR

S Mrozowski, MHA, NRP, CPPSCorresponding email: nsarwani@hmc.psu.edu

Disclosures

• N Sarwani – No financial disclosure• M Bruno - Book royalties Oxford University

Press and Elsevier• S Mrozowski – No financial disclosure

1/13/2017

2

Background

• Timely access to imaging services for our most vulnerable patient population – children – is a vital aspect of radiology care.

• For small children, MR imaging must often be performed under general anesthesia (GA) to allow diagnostic quality images to be obtained.

Background

• Organizing a combined service to provide MRI under GA requires a complex interplay between the referring physician and the departments of anesthesiology and radiology, and scheduling backlogs will result when demand exceeds supply.

1/13/2017

3

Background

• In December 2014, at our tertiary academic medical center, the backlog for the 1st, 2nd and 3rd available MRI appointment to be performed under GA was > 87 days. This resulted in significant “downstream” delays in patient’s clinic appointments, especially for Pediatric Neurology and Neurosurgery, as MRI results are required at the time of clinic visit.

Background

• A dedicated MR scanner was used to scan patients under GA, 5 days a week.

• An additional MR scanner was allocated one day a week to scan more patients

1/13/2017

4

Background

• As additional scanner time and technologists resources were redirected to help address the backlog of GA cases, there was less scanner availability for other MRI studies, creating a broader patient access problem.

Purpose

• Accordingly, our 3 SMART goals were as follows:

1. Increase throughput of pediatric, out-patient, GA cases through the MRI scanner

2. Reduce both the average time and the variability of patient contact times for each appointment slot

3. Reduce the GA MRI waiting list to < 30 days.

1/13/2017

5

Methods

• A Rapid-Improvement Event (RIE), also known as a kaizen event, was co-sponsored by the departments of Radiology and Anesthesiology and coordinated by the institutional process improvement team utilizing Lean methodology.

• Key stakeholders in attendance included radiologists, anesthesiologist, technologists, radiology nursing, radiology schedulers and image management (IT) personnel.

Methods

• RIE team members dedicated 5 continuous days to allow for an intense, focused effort to complete the process improvement exercise

1/13/2017

6

Methods

• The DMAIC process was used as follows:– Define

• Mapping of existing processes, identifying pain points of the process from all stakeholders (radiology, anesthesiology, scheduling and nursing), and value analysis

– Measure• The group performed Gemba walks to observe the

current processes, performed Takt-time analysis, and completed a waste inventory

Methods

• The DMAIC process was used as follows:– Analyze

• Brainstorming sessions were performed, with root cause identification, benefit and effort analysis

– Improve• Finalize action items, future state map, develop

implementation and roll-out plan, pilot solutions– Control

• Create 30 day action list, development of control plan

1/13/2017

7

Methods

• Additionally, a representative from radiology met individually with all stakeholders to further understand their processes, clarify available resources, explore options for improvement and coordinate efforts

Areas of Concern

• Lack of availability of Anesthesia resources• Large gaps between patients during the

workday, wasting MR scanner time• Not infrequent number of patient “no-shows”• Parents not following dietary instructions• Patients scanned by appointment times, with

no regard to the age of the patient being scanned.

1/13/2017

8

Baseline Data

• The average wait time for the 1st and 3rd available MR exam to be performed under GA in December 2014 was 87 and 107 days, respectively.

4335 39 42 41 36

4437 38

50 50 50 56 55 56 5851 45

54 58 63 6457

6450

64 64 7078

7178

5771 71

93

56

8779

71

4533

15

44

5244 41

48 43 4344

3744

50 50 5056 55 56 58

5145

5458

63 6457

64

50

64 6470

7873

79

64

7871

93

56

8779

71

45

33

15

44

57

5143

5150

4851

3944

52 50 50

57 56 56 5856

60

67 5864 64

6464

64

7164

70

7878

84

78

92 94

93

93

107

106

104

100

90

100

93

7-Apr 7-May 7-Jun 7-Jul 7-Aug 7-Sep 7-Oct 7-Nov 7-Dec 7-Jan

Anes Availability Pre RIE

Anes 1 Exam Anes 2 Exam Anes 3 Exam

1/13/2017

9

Intervention

• The resources made available by the department of anesthesia were not found to be limiting.

• We discovered that the throughput of patients was reduced, in part, by the presence of “blocks” in the radiology scheduling template, which severely limited the availability of the dedicated GA MR scanner. The MRI scheduling template was modified to remove these restrictions.

Intervention• We addressed the high number of “no shows” by

making changes to the content of the pre-procedure phone calls and by requiring radiology nursing to speak directly to the patient or relative and not merely leave a message.

• Frequent failure of parents to follow dietary instructions leading to delayed/rescheduled cases was addressed by a re-design of written dietary instructions that are mailed to the patient.

• These interventions were all implemented simultaneously in May of 2015.

1/13/2017

10

New Workflow

Clinics will be given an appointment date only at the time of scheduling, without an exact time of the scan.

New Workflow5 days prior to the scan date, the exact order in which the patients will be scanned will be determined by the Dept of Anesthesia.

This process will allow the triage of our youngest, most vulnerable and complex patients to be preferentially scanned earlier during the day, while allowing our older, more able patients to be scanned later in the day.

Patients/guardians will be contacted by nursing staff, following existing standard of practice (SOP). In addition to providing dietary instructions for anesthesia, they will be given their appointment time.

3 attempts will made to directly contact the patient/guardian.

1/13/2017

11

New Workflow

New Workflow• Patients/guardians will receive a standard

letter approximately 10 days prior to their scan, mentioning scan date, dietary requirements as well as a FAQ of what to expect.

• (10 day notice was difficult to do as appointment times were in the 2-3 day range)

1/13/2017

12

Results

• After implementation of our intervention regimen, the average wait time for the 1st and 3rd available MR exam to be performed under GA fell precipitously, ultimately reaching the current level of < 7 days, exceeding our target.

40

94 101 98 93 96 92 91 9078 85 85 78 71 72

1636

9 111 15 16 10 9

27 2413 21

40

94101 98

93 96 92 91 90

7885 85

7871 72

22

42

142

28 28 23 23 2829 28

1421

94

97101 100

96 9694 91 91

8585 92

8578 72

35

63

58

39

33 3732

25 2929 29

1924

0

50

100

150

200

250

300

350

Anes Availability Post RIE

Anes 1 Exam Anes 2 Exam Anes 3 Exam

1/13/2017

13

37332925211713951

100

75

50

25

0

Observation

Indi

vidu

al V

alue

_X=30.6UCL=42.5

LCL=18.7

Pre Post

37332925211713951

60

45

30

15

0

Observation

Mov

ing

Ran

ge

__MR=4.48

UCL=14.63

LCL=0

Pre Post

111

1111111

11

111

11

1

11

Control Chart - MR with GA Wait Times

Results

• As part of the control phase of the process, the wait times were continued to be monitored and showed a long lasting beneficial result of keeping wait time for GA MRI to less than 7 days.

1/13/2017

14

40

94 10198 93 96 92 91 9078 85 85 78 71 72

1636

9 111 15 16 10 9

27 2413 21 16 15 17 14 9 4 9 9 2 82

40

9410198

93 96 92 91 90

7885 85

7871 72

22

42

142

28 28 23 23 2829 28

1421

16 16 17 149 8 9 9

282

94

97101100

96 9694 91 91

8585 92

85

78 72

35

63

58

39

33 3732

25 2929 29

1924

18 17 1815

9 12 10 16

792

2/2/

2015

2/9/

2015

2/16

/201

52/

23/2

015

3/2/

2015

3/9/

2015

3/16

/201

53/

23/2

015

3/30

/201

54/

6/20

154/

13/2

015

4/20

/201

54/

27/2

015

5/4/

2015

5/11

/201

5*5

-18-

2015

5/25

/201

56/

1/20

156/

8/20

156/

15/2

015

6/22

/201

56/

29/2

015

7/6/

2015

7/13

/201

57/

20/2

015

7/27

/201

58/

3/20

158/

10/2

015

8/17

/201

58/

24/2

015

8/31

/201

59/

7/20

159/

14/2

015

9/21

/201

59/

28/2

015

10/5

/201

510

/12/

2015

10/1

9/20

1510

/26/

2015

Anes Availability Post RIE

Anes 1 Exam Anes 2 Exam Anes 3 Exam

Conclusion

• RIEs are a useful tool to bring together stakeholders to review complex healthcare delivery processes such as MR exams performed under GA.

• Identifying sources of inefficiencies as well as scheduling template errors led to a marked decrease in wait times for pediatric MR exams performed at our institution.

1/13/2017

15

Conclusion

• Shared buy-in from stakeholders allowed us to maintain our gains by development of a novel scheduling technique for these cases, resulting in increased patient throughput on the MRI scanner by decreasing “wasted” scanner downtime, as well as decreased “no show” and last-minute cancellations.

Conclusion

• Delays and rescheduled cases due to patients not following dietary restrictions also decreased.

• To date, the improvement has been long-lasting and sustained, with current data showing a wait of 2-3 days for a GA MRI.