university of michigan health systemioe481/ioe481_past_reports/f0811.pdf · university of michigan...

UH MRI Turnaround Process Improvement

Final Report Team 11

University of Michigan Health System:

Program and Operations Analysis Delivered to: Ann Cormack, Clinical Manager MRI, Department of Radiology

Catherine Brandon, M.D., MRI Attending Physician Susan Fisher, Administrative Specialist, Department of Radiology Sheri Moore, Senior Industrial Engineer, University Hospital POA

Submitted by: Michael Holody, IOE 481 Student Analyst Geoffrey Inch, IOE 481 Student Analyst Michael Kabcenell, IOE 481 Student Analyst Diane Schowalter, IOE 481 Student Analyst Date: December 8, 2008

Comment [O1]: To Do: List of Tables and Figures Table of Contents Add value stream map Formatting is standardized for all figures, tables,

etc Read over entire report for grammar, spelling, etc See comments in report

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EXECUTIVE SUMMARY University Hospital (UH) Department of Radiology personnel are concerned with inefficiencies in the current Magnetic Resonance Imaging (MRI) turnaround process creating long and widely varied turnaround times. Turnaround time is defined as the time from the end of a patient scan to the beginning of the next patient scan. The department asked the student team to analyze the turnaround process to identify areas for improvement and develop recommendations based on these findings. The primary goal of these recommendations is to reduce the current turnaround time. Key Issues The key issues behind this project are perceived inefficiencies in the current turnaround process that have not previously been evaluated. These inefficiencies are creating long turnaround times with high variations, the reasons for which were unknown prior to this project. Methodology Data collection began with initial observations of the current turnaround process. Each team member observed the MRI room and process for two hours to gather preliminary information and guide the development of the project plan. The team then interviewed three MRI technicians to understand how they perceive the turnaround process. To quantify the turnaround process, the team performed a time study, collecting data from 105 turnarounds. The team also performed a utilization study with assistance from the MRI technicians. This study produced a total of 2147 observations. Data from these studies helped quantify the turnaround process and develop recommendations from the findings and conclusions. Current Turnaround Process From the initial process observations and interviews, a high-level flow chart was developed. Figure 1 below shows this flow chart of the current turnaround process, with the major sub processes indicated.

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Figure 1: MRI turnaround process flowchart. (Data from observations and interviews)

Remove patient from scannerMRI scan ends Remove coil

from scanner Clear table

Setup table for new patient Get new coil Place patient in

scanner MRI scan begins





From the time study data, the current turnaround process was quantified and evaluated. Table 1 below shows averages for each sub process as well as the corresponding percentage of the process time and uptime. Table 2 shows a statistical summary of the turnaround process, differentiating between process time and non-value added time.

Table 1: A statistical summary of each step of the turnaround process from 105 observations

Process Steps Mean (m:s)

Standard Deviation (m:s)

Percent of Total Process Time

Percent Occurred

Tech enters room and removes patient from scanner 0:31 0:17 3.1% 100% Remove coil 0:39 0:26 3.8% 91% Transport patient out of room 1:34 1:30 9.3% 100% Remove pads and linens 0:46 0:36 4.5% 83% Setup contrast power injector 3:53 2:42 22.9% 21% Setup new linens 0:43 0:45 4.2% 85% Setup coil on scanner 0:47 0:39 4.6% 62% Patient arrives and lies on table 1:00 1:06 5.9% 100% Tech inserts contast IV 3:10 2:32 18.7% 21% Tech places coil on patient 1:14 0:50 7.3% 100% Tech slides patient into scanner 1:26 1:52 8.5% 100% Scan begins 1:13 1:24 7.2% 100%

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Table 2: A statistical summary of the turnaround process from 105 observations.

Overall Mean (m:s)

Standard Deviation (m:s) Percent of Total Time

Total Turnaround Time 26:46 20:47 100% Process Time 10:14 4:54 38% Non-Value Added Time 16:32 19:21 62%

Table 3 below shows the overall results from the utilization study. The percentages are stratified by value added time, non-valued added time (waiting), and MRI machine down. Within these general categories, the data is further divided by activity type.

Table 3: A statistical summary of MRI room utilization

Observations

Scan

ning

Not

Sca

nnin

g

Prep

ping

or S

ettin

g U

p Ro

om

Wai

ting:

No

Patie

nt S

ched

uled

Wai

ting:

Pat

ient

Lat

e/Ch

angi

ng

Wai

ting:

Pat

ient

Tra

nspo

rt

Wai

ting:

RN

Sed

atio

n

Wai

ting:

Can

cel/

No

Show

Wai

ting:

Inco

mpl

ete

Pape

rwor

k

Sche

dule

d M

aint

enan

ce

Une

xpec

ted

Mai

nten

ance

72.43% 7.45% 4.66% 7.08% 4.05% 2.28% 1.63% 0.23% 0.09% 0.00% 0.09%

Stratifications

Scanning/Prepping

2,147 Total Random Observations10/08/2008 (4:30pm) - 10/27/2008 (9:30pm)UH MRI Department

Possible States of MRI Room

Patient in Room Room Empty MRI Down

Waiting Maintenance

15.37%n = 2,147

0.09%OVERALL

84.54%

The data from both studies show that there is a significant amount of non-value added time (waiting) within the current turnaround process. Summary of Findings The following list summarizes the key findings from analysis of the time study and utilization study data:

• Total turnaround time for the night shift (11pm – 7am) is significantly greater than the day shift (3pm to 11pm).

• Total turnaround time and total non-value added time differ significantly between weekdays and the weekend.

• No significant average turnaround differences between MRI rooms. • Total turnaround variation for MRI room three is significantly greater than rooms one

and four. • Coil change does not significantly affect the total turnaround or process time. • The average turnaround time is significantly greater when wheeling out the MRI table. • Average turnaround time is significantly greater when either of the patients require

assistance to enter the MRI room.

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• Cancellation/ no show, patient changing, no scan scheduled, and RN sedation delays are the highest impact delays.

Summary of Recommendations The following list summarizes the recommendations resulting from this study:

• Optimize the scheduling practices to reduce scheduling delays. • Improve communication within the MRI department and between other departments. • Conduct a future study that investigates the four common delays found in this study. • Organize the materials needed for the turnaround process in each MRI room. • Investigate the layout of each individual room in order to optimize the new process steps

and reduce walking distances thus increasing efficiency. • Standardize the process steps and train the technicians based on the new set of turnaround

guidelines.

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Table of Contents

INTRODUCTION..........................................................................................................................7 BACKGROUND ............................................................................................................................7 KEY ISSUES ..................................................................................................................................8 PROJECT GOALS AND OBJECTIVES ....................................................................................9 PROJECT SCOPE.........................................................................................................................9 METHODOLOGY ......................................................................................................................10

Examine Current MRI Room Layout and Practices ............................................................10 Interview Key Personnel ..........................................................................................................10 Perform Time Study ................................................................................................................ 11 Perform Utilization Study .......................................................................................................12

CURRENT STATE ......................................................................................................................12 RESULTS OF DATA ANALYSIS .............................................................................................14

Data Stratications .....................................................................................................................14 Differences by Shift ....................................................................................................... 15 Differences by MRI Room ............................................................................................ 16 Differences by Time of Week ....................................................................................... 18 Differences by Coil Change ...........................................................................................19 Common Delays ....................................................................................................................... 20 No Scan Scheduled ........................................................................................................ 21 Patient Late/Changing .................................................................................................. 22 Patient Cancellation/No Show ...................................................................................... 22 RN Sedation ................................................................................................................... 23 Patient Transport .......................................................................................................... 23 Patient Needs ................................................................................................................. 24 Paperwork Not Available ............................................................................................. 24 IV Issue in MRI Room .................................................................................................. 24 Miscellaneous ..................................................................................................................25

RECOMMENDATIONS .............................................................................................................25 Process Improvement ...............................................................................................................25 Delays .........................................................................................................................................26

EXPECTED IMPACT.................................................................................................................26 APPENDICIES

Time Study Data Collection Form ..........................................................................................27 Utilization Study Data Collection Form .................................................................................28

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INTRODUCTION The University of Michigan Health System (UMHS) Department of Radiology at the University Hospital (UH) is one of the foremost medical institutions in the country with respect to magnetic resonance imaging (MRI). Three MRI machines are utilized within the Department of Radiology to deliver detailed internal body images to UH patients for diagnostic purposes. Operating these machines takes immense amounts of energy, a cryogenic cooling system, and a fulltime operations staff. As a result, the cost to operate a single machine has been estimated by an MRI physician to be $25 per minute; and a single scan can range from $900 to $3,000 in patient expenses. Thus, when used effectively, the MRI machines provide the health system with a significant profit, as more customers are billed for the service. Therefore, the efficiency of the MRI process and the turnaround time for each of the university’s MRI machines directly influence profits, making efficiency imperative. The Department of Radiology personnel believe that there are inefficiencies in the current process creating long and widely varied turnaround times. Therefore, the department asked the student team to analyze the turnaround process to identify areas for improvement and develop recommendations based on these findings. The team performed a time study on each step of the current process to quantify the room turnaround tasks. A total of 105 turnarounds were observed during this study. Additionally, a work sampling utilization study was conducted with assistance from the MRI technicians to determine the proportion of time the MRI room is in each defined state. This study produced a total of 2147 observations. The data from both studies was analyzed to establish a current state of the MRI turnaround process, identify turnaround delays, and recommend ways to improve the current process. The recommendations will lead to a new process that increases efficiency for the technicians, decreases patient wait time, and subsequently increases profits. The following report presents the project goals, methodologies, findings, conclusions, and recommendations aimed at reducing the MRI process turnaround time. BACKGROUND Turnaround time is defined as the time between patients or the time from the end of a patient scan until the next scan begins, including both value and non-value added time. The process time, however, includes only the time for each sub process of the turnaround (value-added time). The team’s initial observation and discussions with the MRI technicians, Senior Industrial Engineer, and Administrative Specialist, provided a general understanding of the department and the suspected reasons for the high variation of turnaround times. The team used the results of these discussions as a base for determining the current process and key issues.

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The current MRI turnaround process is as follows: 1. MRI scan ends. 2. Technician enters room and removes patient from scanner. 3. Technician removes straps, removes and unplugs coil, and returns the coil to the shelf or

leaves it on the table depending on the next patient’s scan. 4. Technician transports patient out of MRI room by either wheeling the table out or

walking the patient out. 5. Technician removes the linens and disposes of them, and removes the pads. 6. Technician sets up contrast power injector, if necessary. 7. Technician gets new linens and spreads them on the table. 8. If the paperwork for the next patient is available, then the next scan type is known and the

tech gets the new coil, plugs it in and sets it next to the scanner or leaves the previously used coil on the scanner. If the technician does not have the information for the next patient, then the room preparation cannot be continued until the information becomes available.

9. Patient arrives to the MRI room on a stretcher, in a wheelchair, or walking. 10. Patient lies down on the table. 11. Technician inserts the IV for the contrast agent, if applicable. 12. Technician places the coil in appropriate position for scan and straps it around the patient. 13. Technician slides patient into the scanner and leaves the room. 14. MRI begins.

These steps illustrate the extensiveness of the MRI turnaround process. Additionally, the steps reveal potential areas of variation that the team will investigate to improve the process and reduce room turnaround time. KEY ISSUES The current process stated above demonstrates the complexities of preparing the MRI room for another patient. As a result, the team identified the following preliminary issues. High MRI Turnaround Times and Variations The perception of department personnel is that average MRI room turnaround time is too high, resulting in poor utilization of the machines. Additionally, a significant amount of variability exists in the length of the turnaround process. For example, empty table time between patients may range from as low as 3 minutes, to as high as 100 minutes, as observed during the time study data collection. Steps in Turnaround Process Are Not Clearly Defined

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Each step in the MRI turnaround process is not clearly defined. Additionally, the timing of each process step has not been recorded or analyzed to identify potential delays. MRI Turnaround Process Has Not Been Evaluated For Efficiency Because the turnaround process has not been formally evaluated, it may be less than optimal and could include waste. Some of the contributing waste factors could involve patient delays (arriving late, awaiting sedation, filling out forms, requiring an X-ray), technician delays (helping other technicians, performing other responsibilities), protocol delays (protocol not prescribed, clarification request with radiologist in reading room), or a combination of all or some of the above. The exact causes and frequency of delays are not yet known, however, because the process has not been evaluated until this project. PROJECT GOALS AND OBJECTIVES To improve the turnaround process, the team defined both primary and secondary goals. The primary goals are as follows:

• Decrease MRI Room turnaround time • Decrease MRI Room turnaround time variation • Improve overall machine utilization and operating margin

By reaching the primary goals, the team achieved the following secondary goals:

• Decrease patient waiting time • Make each task easier for technicians and support staff • Improve overall MRI experience and increase patient satisfaction and safety • Provide insight into other outside factors that could delay the MRI process

PROJECT SCOPE This project assessed the MRI room turnaround time for the three UH MRI patient machines, detailing tasks performed by an MRI technician from when a scan ends to when the next scan begins (turnaround time). Consequently, the MRI division of the Department of Radiology and the MRI technicians and staff are the entities most affected by the project. The focus only included tasks performed when a patient was not being scanned. The scope excluded any turnaround activities related to the research scanner located at UH, the scanners at East Ann Arbor, and the scanners at Mott Children’s Hospital.

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Patient registration, patient scheduling, technician assignments, transfer of MRI protocols, and special physician protocols were considered only with regards to significant delays in turnaround time. Only the processes involved were considered, not the people performing these procedures. Although reducing MRI turnaround time and increasing machine utilization may provide cost reductions that can be quantified, this project does not include a cost-benefit analysis. Since this is an initial analysis of the MRI turnaround process, this project will provide a foundation for future projects to make specific improvements. METHODOLOGY The project team collected both qualitative and quantitative process data to analyze the current turnaround process and identify potential improvement areas to reach the project objectives. The following section summarizes this approach. Examine Current MRI Room Layout and Practices Each project team member initially observed the MRI turnaround process and patient room for two hours to gather preliminary information. This information helped the team develop the project plan and studies. The following is a list of outcomes from these observations:

• All turnaround process steps identified. • Data collection sheets developed. • All personnel involved in each turnaround process noted. • Significant sources of process variation examined. • A value stream map of the MRI turnaround process developed.

Interview Key Personnel The project team interviewed three MRI technicians, an MRI physician, and the clinical manager. These interviews allowed the team to:

• Understand how the people involved perceive the process • Understand their concerns with the current process • Obtain suggestions for process improvement • Gain a general understanding of the tasks performed in the turnaround process

This information was used to gain insight into the turnaround process and create the current process steps, a value stream map, and the high-level flowchart seen in Figure 2 below.

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Figure 2: MRI Turnaround Process Flowchart. Information collected by the project team from preliminary interviews and observations.









Perform Time Study To efficiently record turnaround times and delays, the project team developed data collection (See Appendix 2A). The team collected data from September 22 to November 3, which amounted to a total of 105 turnaround observations. These observations took approximately 150 hours of collection time. To produce statistically significant results, the team collected data across all stratifications of shift, day, and MRI room. The project team recorded the following information using the standardized data collection sheets:

• The total time required per turnaround (lead time). • The time when each sub-process started and finished (process time), noting all delays and

their causes, including the duration of the delay and who was involved (wait times within process steps, and wait times between process steps)

• The MRI room being studied • The staff involved in each of the process steps and when these staff members entered and

exited the process • Other significant factors that impacted the turnaround time

Perform Utilization Study To understand the long term state of the MRI room, the project team worked with the MRI technicians to perform a random sampling utilization study. This study used an electronic beeper, which was set to sound an average of 2.5 times per hour. When the beeper sounded, the technician recorded the current state of each MRI room, based on the explicitly defined room states provided on the data collection sheet (See Appendix 2B). Data was recorded during the entire day, though it was stratified by shift. Data was collected for three weeks, which amounted to 2147 observations.

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The team provided the technicians with three data sheets, clipboards, and beepers- one set of data collection materials for each scanner. The technician assigned to the scanner marked down its current state making the data collection less cumbersome for each technician. The possible states were as follows:

Patient in Room: • Scanning - Patient is currently being scanned. • Not Scanning - Patient is in room but not currently undergoing a scan.

Room Empty: • Prepping or Setting up the Room - No patient is in the room. A technician is tearing

down or setting up the room to prepare for the next patient. • Patient Transport - Delay is caused by UH staff in transporting an inpatient or

emergency patient to the MRI department. • Cancel or No Show - Delay is caused by a outpatient cancelling or not showing up for an

appointment. • RN Sedation - Delay is caused by the RN staff sedating a patient. • Incomplete paperwork - Delay is caused by incomplete paperwork. • Patient late or changing - Delay is caused by patient who is on the way to the MRI

department, but is late; or by the patient getting ready for the scan. • Other - Delay is caused by some other situation, which the technician will specify.

MRI Machine Down: • Scheduled - MRI is out of service for scheduled maintenance. • Unscheduled - MRI is out of service due to an unforeseen circumstance.

CURRENT STATE RESULTS The team assessed and quantified the current state of the MRI turnaround process using the utilization and time study data to confirm the perceptions of long, widely varied turnaround times. The average turnaround time calculated from 105 time study observations is 26 minutes, 46 seconds with a standard deviation of 20 minutes, 47 seconds. The average process time, however, is 10 minutes, 14 seconds, thus making 16 minutes, 32 seconds non-value added waiting time. Table 4 below shows a statistical summary of the overall turnaround process.

Table 4: Statistical summary of the turnaround process from 105 observations.

Overall Mean (m:s)

Standard Deviation (m:s) Percent of Total Time

Total Turnaround Time 26:46 20:47 100% Process Time 10:14 4:54 38%

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Non-Value Added Time 16:32 19:21 62% The long turnaround time shows that delays which holdup the overall turnaround process are present while the high standard deviation reveals a lack of process standardization. Furthermore, the team developed a value stream map to visualize the turnaround process, quantify how long each step takes, and display its impact on the total process (Appendix 3). In addition to the value stream map, Figure 3 below shows a graphical representation of the process steps as a proportion of the entire turnaround time. This graph shows the proportion of the turnaround process that is necessary to prepare for the next scan (process time) and the proportion of time that is non-value added (waiting).

Figure 3: Components of the MRI turnaround process (105 Total Observations).

Process Time, 38%Non-Value

Added Time, 62%

Sample Size = 105 Observations: September 22 to Novemeber 3UH MRI Department

This graph shows that the necessary steps in the turnaround process account for only 38% of the total turnaround time. The remainder of the turnaround time represents non-value added delays. The percentage of time in each state of the process including specific types of delays, is shown in Figure 4.

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Figure 4: Summary of MRI room states.

Scaning/Prepping85%

Waiting: No Patient Scheduled

7%

Waiting: Patient Late/Changing

4%Waiting: Patient

Transport2%

Waiting: RN Sedation2%

Waiting: Cancel/No

Show0%

Waiting: Incomplete Paperwork

0%

Maintenance0%

Waiting15%

Sample Size = 2,147 Observations10/08/08(4:30pm) - 10/27/08(9:30pm)UH MRI Department

Figure 4 verifies the presence of non-value added delays in the current turnaround process causing the inflated turnaround time average and high variation. DATA VALIDATION To verify the time study results, the team collected information from the MRI log books and analyzed the information in terms of percentages found from the utilization study. This in turn, validates the utilzation study results (percentages). Using the start and end dates of the utilzation study, the team calculated the total time (in minutes) that the study was active, and using the log books, found the total number of scans during that period. By simple division, the average time per scan, including the turnaround, is 92 minutes, 49 seconds, as seen below in Table 5.

Table 5: Validation data

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Utilization Study

Duration of studyStart Time 10/8/08 4:30 PMEnd Time 10/27/08 9:30 PMTotal Days 19.21Total Hours 461Total Minutes 27660Number of Beepers 3Total Min of Observation 82980

Number of Scans (From Dept Log Books)MRI 1 298MRI 3 303MRI 4 293Total Scans 894

Minutes Per Scan: 92.82Minutes Per Scan: 92:49

Then, using the scanning, process, and waiting percentages from the utilization study, the average time for each state was calculated, as seen below in Table 6.

Table 6: Time and utilzation study validation results

Scanning 72.43% 67:43Not Scanning 7.45% 6:04Prepping or Setting Up Room 4.66% 4:03Waiting: No Patient Scheduled 7.08% 6:04Waiting: Patient Late/Changing 4.05% 3:02Waiting: Patient Transport 2.28% 2:01Waiting: RN Sedation 1.63% 1:01Waiting: Cancel/No Show 0.23% 0:00Waiting: Incomplete Paperwork 0.09% 0:00Scheduled Maintenance 0.00% 0:00Unexpected Maintenance 0.09% 0:00

Overall UH MRI Machine Utilization

Poss

ible

Sta

tes

of M

RI R

oom

Patient in Room

Room Empty

MRI Down 0.09% 0:00

14:09

78:51

Minutes Per ScanPercentage of Total

84.54%

15.37%

The average process time, composed of the “Not Scanning” and “Prepping or Setting Up Room” states, is 10 minutes, 7 seconds. This is approximately equal to the average process time calculated from the time study data (10 minutes, 46 seconds). Additionally, the average wait time from the validation data is 14 minutes, 9 seconds. This is also approximately equal to the non-value added wait time calculated in the time study (16 minutes, 32 seconds). The disparity between the two wait times is reasonable given the high standard deviation of wait time compared to the relatively low standard deviation of the process time.

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Because this validation analysis verified the time study results, it thus follows that the utilization percentages are accurate. Due to the close relationship between the time study and utilization study results, the findings are presented by data stratifications and delay and supported concurrently by both studies. RESULTS OF DATA ANALYSIS Once the overall state of the MRI turnaround process was established from the time and utilization study observations, the data was further analyzed to determine the contributing factors and their impact on the total turnaround time. Data Stratifications To determine how the length and variation of the MRI turnaround time varies, the data from both studies was stratified to show the contribution of several factors to the overall current-state results. Differences by Shift. There are three work shifts within the UH MRI department (7am-3pm, 3pm-11pm, and 11pm-7am). These shifts can vary by volume of patients and particular types of scans. Findings The shift on which the turnaround was performed did contribute to a difference in total turnaround time. The 3pm-11pm shift has a mean turnaround time of 21 minutes, 53 seconds, which is significantly less than the mean value for the 11pm-7am shift of 33 minutes, 34 seconds. The 7am-3pm shift has a mean turnaround time of 26 minutes, 32 seconds, which is not significantly different from either of the other shifts. The percentage of time spent waiting is also significantly lower on the 3pm-11pm shift (only 11.1%) than either the 7am-3pm or 11pm-7am shifts, but is not significantly different between these two other shifts. The relative utilization levels for each shift can be seen in Figure 5 below. In addition, the variation within these total turnaround times is significantly lower for the 3pm-11pm shift. The value-added processing time, however, is consistent and does not significantly differ based on shift. The 3pm-11pm shift does have the lowest mean processing time at 9 minutes, 17 seconds; but the other shifts are only slightly higher with a mean processing time of 10 minutes, 25 seconds on the 7am-3pm shift and 11 minutes, 5 seconds on the 11pm-7am shift.

Figure 5: MRI Machine Utilization – Differences by Shift.

Comment [O2]: Sheri really liked the table we had that summarized the process, waiting, and total turnaround times for the MRI rooms. Add a similar table for the shift data. It will require editing the “findings” section so that you refer to the table instead of saying all the numbers.

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83%

17%

89%

11%

82%

18%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Scanning/Prepping Waiting

Perc

ent o

f Tim

e in

Giv

en S

tate

(%)


7a-3p 3p-11p 11p-7a 7a-3p 3p-11p 11p-7a


Conclusions Due to the fact that the process times are not significantly different based on shift, the difference in total turnaround time can be attributed to the amount of non-value-added delay time that occurs on a particular shift. Therefore, it can be concluded that the 3pm-11pm shift experiences less of an impact from delays than the other shifts. There are several potential delays that are contributing to the higher turnaround times for each of the other shifts, and these will be discussed in more detail in upcoming sections of this report. Differences by MRI Room. There are four MRI scanners within the Department of Radiology. This project, however, excluded the research scanner and therefore only analyzed rooms one, three, and four. Findings A statistical summary of the overall turnaround time, process time, and non-value added time for each MRI room is shown in Table 7 below.

Table 7: Summary of the turnaround process for each MRI room

Room 1 Mean (m:s)

Standard Deviation (m:s)

Total Turnaround Time 28:55 18:30

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Process Time 10:38 5:41 Non-Value Added Time 18:16 18:50

Room 3 Mean Standard Deviation

Total Turnaround Time 29:13 26:03 Process Time 10:57 5:22

Non-Value Added Time 18:15 23:38

Room 4 Mean Standard Deviation

Total Turnaround Time 23:07 15:15

Process Time 9:17 3:49

Non-Value Added Time 13:48 14:26 Though the turnaround time averages vary by room, there are no statistically significant differences. The total turnaround variability for room three, however, is statistically different than rooms one and four. The variability for room three is 26 minutes and 3 seconds, and significantly greater than rooms one and four which have a variability of 18 minutes 30 seconds and 15 minutes 15 seconds, respectively. Furthermore, the wait time (non-value added time) for MRI room three is significantly less than the wait time for rooms one and four, as seen below in Figure 6.

Figure 6: MRI Machine Utilization – Differences by Room.

82%

18%

87%

13%

84%

16%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Perc

ent o

f Tim

e in

Giv

en S

tate

(%)


Room 1 Room 3 Room 4 Room 1 Room 3 Room 4


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Conclusions As originally perceived by the Administrative Specialist and an MRI Physician, no significant differences exist between MRI rooms. Though a difference in variability was found, the team concluded that it does not result from differences between the actual rooms or the technicians working in the room. All three rooms are similar except for one key difference. MRI rooms one and three both have GE machines, while room four uses a Philips machine. Furthermore, the scanning table on the GE machines can be easily removed, making it more suitable for inpatients arriving on stretchers. The table on the Philips machine, however, is difficult to remove. Therefore, room three receives fewer inpatients and more outpatients than the other two rooms. Room three scans the most inpatients (34%), while room one and three scan 24% and 10% inpatients, respectively. The team therefore concludes that the extra time and delays associated with accommodating an inpatient are increasing the turnaround variation of room three. Furthermore, because room three receives only a small portion of inpatients, the wait time during the turnaround process is significantly less than the wait time for rooms one and four. Differences by Time of Week. The project team analyzed the turnaround process on weekdays (Monday through Friday) and weekends (Saturday through Sunday), in order to identify any differences that may exist based on the time of week that the turnaround is performed. Findings The time of week contributed to a significant difference in the total turnaround time between weekdays and the weekend. Weekday observations have a mean turnaround time of 25 minutes, 32 seconds, which is very close to the mean of all observations. The mean time for weekend turnarounds is 38 minutes, 29 seconds. These two means represent a statistically significant difference in total turnaround time based on time of week. Thus, it follows that the percentage of time waiting is significantly higher on weekends (22%) than weekdays (13%). The relative utilization levels can be seen in Figure 7 below. The process time, however, is not significantly different between weekday and weekend observations, with a mean of 10 minutes, 15 seconds for weekdays and 10 minutes, 1 second for weekends.

Figure 7: MRI Machine Utilization – Differences by Time of Week.

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87%

13%

78%

22%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Perc

ent o

f Tim

e in

Giv

en S

tate

(%)


Weekday Weekend Weekday Weekend


Conclusions Due to the fact that the process times are nearly identical based on time of week, the difference in total turnaround time can be attributed to the amount of non-value-added delays that occur on weekends rather than weekdays. Therefore, it can be concluded that the MRI department experiences less of an impact from delays on weekdays. There are several potential delays that are contributing to the higher turnaround times for each of the other shifts, and these will be discussed in more detail in upcoming sections of this report. Differences by Coil Change. To produce an MRI scan, a coil that emits a radiofrequency is placed over the area of the body that will be imaged. Within the turnaround process, the coil may be changed if the two patients involved require different coils. This is included as a process step within the turnaround process and was only quantified by the time study. Findings The initial perception was that high turnaround times were a result of the coil change step within the process. They believed that the technicians were having difficulty finding the coils needed and that setting up the coil was strenuous. The teams and time study data and observations, however, show otherwise. The average time for a coil change is 47 seconds, which accounts for only 4.7% of the total turnaround time and 7.7% of the total process time. Also, the total turnaround time and process time for the 56 observations where a coil was changed did not significantly differ from the 48 observations where the same coil was used.

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Conclusions Since no significant differences exist when a coil was changed or not changed, the team concluded that changing the coil is not a major factor contributing to the high turnaround times. Coil changes are part of the value-added turnaround process, which is consistent throughout all of the stratifications and has a small impact on the turnaround time in comparison to the time that delays contribute. Differences by Patient Characteristics. There are several patient-related factors that influence the MRI turnaround process. The project team collected qualitative data regarding patient characteristics along with the time studies and observations. Some of these factors include whether the previous patient is wheeled out of the MRI room on a table following the scan or if they walk out, whether the next patient needs assistance entering the room, and whether the patient is an inpatient or outpatient. This information was only quantified by the time study. Findings The manner in which the previous patient exited the room has a significant impact on total turnaround time. When the entire table was wheeled out of the room, the mean turnaround time was 36 minutes, 27 seconds compared to a mean turnaround time of 23 minutes, 46 seconds when the patient walks out of the room. Significantly higher variation in the total turnaround time is also present when the patient is wheeled out of the room (30 minutes, 1 second) than when the patient walks out (15 minutes, 40 seconds). The process time for cases in which the entire table is wheeled out, however, is not significantly higher than when the patient walks out. The total turnaround time is significantly higher when the next patient requires assistance entering the room. The mean turnaround time when the patient walks in the room is 22 minutes, 18 seconds, which is significantly higher than the turnaround time when the patient enters on a wheelchair (35 minutes, 53 seconds) and when the patient is sedated on a table (39 minutes, 44 seconds). No significant difference in mean turnaround time was found between observations that included an outpatient-outpatient sequence and those that included one inpatient. Observations that included an inpatient-inpatient sequence had a significantly higher mean turnaround time (73 minutes, 27 seconds) than other patient sequences with at least one outpatient. Conclusions The delay time is significantly higher as the level of patient assistance increases. When a patient is wheeled out of the room or requires a wheelchair to enter the room, the mean of the total turnaround time is higher. The fact that the value-added process time is not significantly different based on the different levels of patient assistance considered suggests that these patients

Comment [O3]: Long sentence. Break into 2+ sentences

22

do not necessarily take more time, but these situations result in more frequent and longer delays between patients and process steps. Common Delays The team used the data collected from the time study and utilization study to evaluate the impact of common delays. A delay is defined as any part of the room turnaround that does not contribute to the setup or tear down of the MRI room, or to the assistance of a patient. When a delay occurred, the team asked the technicians what the reason for it was in order to be able to see which types of delays create the biggest problems. The team determined the amount of delay time for each turnaround by calculating the difference between the overall turnaround time and the key process steps. The means and standard deviations of each type of delay were also calculated, along with the percentage of turnarounds in which each delay occurs. This information was used to determine each type of delay’s relative frequency and impact, and is graphically displayed in Figure 8 below.

Figure 8: Frequency and Impact of Delays

Comment [O4]: Should we include any of the other graphs? The distribution with the line perhaps?

23

0

10

20

30

40

50

60

0% 2% 4% 6% 8% 10% 12% 14% 16%

Mea

n Ti

me

of D

elay

(m

inut

es)

Frequency of Delay (%)

Cancellation or No-Show(2.9%, 50 min)

Patient Changing(14.3%, 11 min)Miscellaneous

(8.6%, 9 min)

IV Issue in Room(4.8%, 6 min)

Paperwork Not Available(4.8%, 15 min)

Patient Late(7.6%, 27 min))

Patient Transport(3.8%, 16 min)

RN Sedation(11.4%, 30 min)

No Scan Scheduled(11.4%, 39 min)

Sample Size = 105 Observations (79 Experienced Delay)September 22 to November 3

Patient Needs(5.7%, 15 min)

No Scan Scheduled. This delay is when the MRI room is empty because a scan is not scheduled immediately after the current one. Findings The delay of having no scan scheduled after the current one occurred in 11.4% of the team’s observations. The mean amount of delay time was 38.6 minutes, with a standard deviation of 26.2 minutes, showing a large variation in the impact of this delay on the turnaround time. This delay is more common in the 11p-7a shift than the other shifts. This is reflected in the utilization data, which shows that the 11p-7a shift experienced this delay 10.1% of the time while the other two shifts experienced the delay 5-6% of the time. Also, not having a scan scheduled is more common on the weekends (13.6%) compared to weekdays (5.1%). Conclusions This type of delay occurs frequently and has a high impact on turnaround times as shown in Figure 8. The main reason for the 11p-7a shift and weekends to have significantly higher percentages of delays is that the scheduling is not optimal, and the communication to bring down inpatients from other departments in the hospital is difficult. At times, a scan would end and there would be a significant amount of time before the next scheduled scan, but potential patients

24

from other places in the hospital were not prepped and on their way down to the MRI Department. This often meant there was not enough time for an inpatient’s scan to fit between two scheduled scans. Therefore, this type delay presents a significant opportunity for improvement. Patient Late/Changing. This delay is when a patient arrives late for the scan or is getting ready for the scan, so the staff must wait for the patient. From the team’s observations, the delays from a patient arriving late and a patient still changing are highly related. Most times that the patient is late to arrive to the MRI Department they are also late to change their clothes in preparation for their scan. Findings The delay of a patient arriving late occurred in 7.6% of the MRI room turnarounds and the delay for a patient changing occurred 14.3% of the turnarounds (21.9% combined). The mean delay time for a late arriving patient is 26.6 minutes, with a standard deviation of 14.9 minutes. The mean delay time for a patient changing is about 10.5 minutes, with a standard deviation of 7.4 minutes. The utilization study shows that these delays are similar across all stratifications, with the exception that the 3p-11p shift only had this delay for approximately 2.5% of the time and the other shifts were near 5%. Conclusions A patient arriving late has a moderate impact on the turnaround time and moderate frequency, as shown in Figure 8. This delay is difficult to address because much of it is beyond the control of the MRI staff. If a patient is late to arrive or to get ready for the scan, there is generally not much that the staff can do besides wait and perform any other tasks that do not require the patient. It is not clear exactly why the 3p-11p shift has a lower percentage of these delays, but there may be aspects of the 3p-11p shift that can be adopted by the other shifts to decrease the impact of these delays. Patient Cancellation/No Show. This is a delay caused by the cancellation of an appointment, or an outpatient not showing up for their scan. Findings The mean delay time when a patient cancelled or did not show up to their appointment was 50.1 minutes with a standard deviation of 36 minutes, making it high impact. This delay, however, occurred in only 2.9% of the observations, making it low frequency. Conclusions When a patient cancels an appointment or does not show up, the impact is very high as shown in Figure 8. This delay, however, does not occur frequently, and is out of the control of the MRI

25

staff. The focus for improvement with regard to this type of delay should be around scheduling so that in the event a patient cancels or doesn’t show up for an appointment, an inpatient could potentially be pulled to fill in the time slot before the next scheduled scan. RN Sedation. This delay is caused by the RN staff sedating a patient and the MRI staff must wait for the patient to be ready. Findings The delay caused from the RN staff sedating a patient occurred in 11.4% of the observed MRI room turnarounds. The mean delay time was 30.1 minutes with a standard deviation of 21.6 minutes. The delay time is highly varied, creating potential for a high impact on overall turnaround time. The utilization study showed that the 3p-11p shift had a much lower percentage of time dealing with this delay than the other shifts – 0.3% of the time, compared to 1.3% for the 11p-7a shift and 3.16% for the 7a-3p shift. Also, MRI Room 1 had a RN sedation delay 2.7% of the time – different than the other MRI rooms that were both close to 1% of the time. Conclusions The delay caused from RN sedation has a relatively high impact on MRI room turnaround times, as well as a high frequency of occurrence, as shown in Figure 8. The main issues causing this delay stem from the preparation of patients before the scan, and the timing of the RN sedation. As such, this delay type presents significant opportunity for improvement for the MRI department, and investigation into why the differences between shift and room are worthwhile. Patient Transport. This is a delay caused by UH staff in transporting an inpatient or emergency patient to the MRI department. Findings This delay occurred in 3.8% of the MRI room turnaround observed. The mean delay time was 15.7 minutes with a standard deviation of 12.8 minutes. The utilization study shows that MRI Room 1 experiences this delay 3.1% of the time, which is more than the other two MRI rooms, which both have this delay less than 2% of the time. Conclusions The delay caused by patient transport issues has a low frequency and relatively low impact on the overall MRI room turnaround process, as shown in Figure 8. While it is not the most important delay to address at this time, patient transport may become valuable to investigate once other issues are addressed and pulling patients from other departments in the hospital between scheduled outpatient scans becomes more frequent.

26

Patient Needs. This is defined as when a patient’s particular needs caused a delay in the turnaround process. For example, the patient may have asked a lot of questions to the staff, had issues with claustrophobia in the machine, or in one observed instance the patient was blind and required more assistance than an average patient. Findings The delay caused by patient need special attention occurred in 5.7% of the team’s observations. The mean delay time was 15.4 minutes with a standard deviation of 6.9 minutes. Conclusions This type of delay does a relatively low impact on the overall MRI room turnaround time and low frequency, as shown in Figure 8. Many times when the patient needs assistance, the amount of time it takes for the staff to help them is five minutes or less, which is not seen as a significant delay to the overall turnaround time. Paperwork Not Available. This delay is caused by the completed paperwork not being available to the technician in the MRI room. This means that the technician is forced to wait until all of the necessary patient information becomes available to continue to room turnaround process, or that the technician must obtain the information themselves. Findings The delay caused by not having completed paperwork available occurred in 4.8% of the room turnarounds. The mean delay time was 14.5 minutes with a standard deviation of 15.26 minutes. Conclusions This delay has a relatively low impact on the MRI room turnaround time and a low frequency, as shown in Figure 8. However, a large variation exists in the delay time, so methods of limiting that would potentially be useful to investigate. IV Issue in MRI Room. An IV issue means a problem occurred with administering an IV for a patient, while they are in the room. Typically this delay occurs once all other steps in the turnaround process are finished and the patient is on the MRI table. Findings The delay caused by an IV issue in the MRI room occurred in 4.8% of the observed room turnarounds. The mean time of delay was 6.14 minutes with a standard deviation of 4.53 minutes. Conclusions

27

This delay has a low impact on the turnaround time, as well as a low frequency of occurrence, as shown in Figure 8. Based on this information, this type of delay is not an urgent issue to consider for improvement. Miscellaneous. This category of delays holds all of the delays that did not fall into the above categories. Findings These various delays combined to account for 8.6% of the total turnarounds observed. The mean delay time was 8.7 minutes with a standard deviation of 4.5 minutes. Conclusions These types of delays can be considered “special case” delays. They have a low overall impact on the turnaround process, but a moderate frequency. Due to the fact that they are somewhat of outlying types of delays, immediate improvement in these areas may not be possible, and the focus should be kept on previously mentioned delays. RECOMMENDATIONS From the conclusions stated above, comprehensive set of recommendations was developed. Improvements: Delays The delay that impacts turnaround time the most is not having a scan scheduled. Therefore, the scheduling practices in the MRI department must be optimized in order to reduce this type of delay and decrease non-value added time in the turnaround process. To accomplish this, historic data pertaining to the length of time that each scan takes should be readily available to scheduling personnel. This information, along with the results of the time study (a ten minute process time average), would reduce gaps in the schedule. In the long term, the MRI department should continue working with Amy Cohen to optimize the overall schedule. Lack of communication between staff within the department is also a primary cause of delays in the turnaround process. Problems exist when technicians and other staff are not aware of the states of each room and when the status of a patient is not effectively communicated with the MRI department. This includes the Emergency Department (ED) as well as other units with inpatients who require an MRI scan. To improve communication in the short term, the MRI department should organize a small team to pilot different communication options. This could include ___. In the long term, the department should automate and standardize communication both within and between departments.

Comment [O5]: Any ideas?

28

Improvements: Process Based on the amount process variation shown in the time study data, there is potential to standardize the turnaround process for the MRI department staff. Though process time is consistent for each room, on all three shifts, during each day, there is opportunity for the process to be improved further. The following is a list of suggestions to improve the turnaround process:

• Organize the materials needed for the turnaround process in each MRI room. Such materials include coils, linens, and pads.

• Investigate the layout of each individual room in order to optimize the new process steps and reduce walking distances thus increasing efficiency.

• Standardize the process steps and train the technicians based on the new set of turnaround guidelines

EXPECTED IMPACT The overall goal of this project was to identify delays in the MRI turnaround process and recommend ways to decrease the total turnaround time. Currently, the average turnaround time is 26 minutes 46 seconds while the process time is only 10 minutes and 47 seconds. Therefore, the team believes that by decreasing the non-value added time and limiting it to 5 minutes of the turnaround process, total turnaround time can realistically decrease by up to 43%. The following is a further list of expected outcomes of implementing the team’s recommendations:

• Decrease turnaround variability • Increase communication within the Department of Radiology • Increase communication between departments • Decrease patient wait time • Increase machine utilization • Increase patient throughput

29

APPENDIX 2A: Time Study Data Collection Form MRI Data Sheet Date: MRI Room: Previous MRI Next MRI Technician: Technician: Procedure: Procedure: Coil Used: Coil Used: Type of Patient: TypePatient: Process Steps Start Time Notes 1. MRI ends 2. Tech enters room and removes patient from scanner 3. Tech removes straps, removes and unplugs coil and (return coil to shelf) (leave on table) 4. Tech transports patient out of MRI room: (wheel table out) (walk out) 5. Tech removes pads (places on shelving), and removies linens and disposes of them 6. Tech sets up contrast power injector 7. Tech done with room tear down 8. (Paperwork becomes available for next patient) / (Paperwork was already available) 9. Tech fetches new linens and covers the table with them 10. Tech gets new coil, plugs it in and sets it next to the scanner or on the table 11. Patient arrives: (sedated) (wheelchair) (self) 12. Patient lies down on table. 13. Tech inserts IV for contrast agent 14. Tech places coils in appropriate position for scan and straps it around the patient 15. Tech slides patient into the scanner and leaves the room 16. MRI begins Delays:

30

APPENDIX 2B: Utilization Study Data Collection Form Date: MRI Room: States of MRI Room 7:00a - 3:00p 3:00p - 11:00p 11:00p - 7:00a

Patie

nt in

Roo

m

Scanning

Not scanning

Roo

m E

mpt

y

Prepping or setting up room

Waiting: Patient Transport

Waiting: Cancel/No Show

Waiting: RN Sedation

Waiting: Incomplete Paperwork

Waiting: Patient Late/Changing

Waiting: Other (Specify)

MR

I Dow

n

Scheduled

Unexpected

31

APPENDIX 3: Value Steam Map of Turnaround Process

32

APPENDIX 4: Summary of Time Study Stratifications

Stra

tific

atio

ns

Tota

l Tu

rnar

ound

Tim

e (m

inut

es)

Tech

ent

ers

room

and

rem

oves

pat

ient

fro

m sc

anne

r

Tech

rem

oves

str

aps,

rem

oves

coi

l, u

nplu

gs c

oil

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oil

to s

helf

or

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e on

tab

le

Tech

tra

nspo

rts

pati

ent

out

of M

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oom

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ble

out,

or

paie

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alks

out

Tech

rem

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pad

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lace

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of t

hem

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ctor

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fet

ches

new

lin

ens

and

cove

rs t

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able

wit

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em

Tech

get

s ne

w co

il,

plug

s it

in

and

sets

it

next

to

the

scan

ner

or o

n th

e ta

ble

Non-

Valu

e Ad

ded

Time

(Be

twee

n Pa

tien

ts)

Pati

ent

is s

edat

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r wh

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hair

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by h

is o

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lf

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tab

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ins

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for

cont

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age

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app

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pre

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Time

(To

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Proc

ess

Time

Numb

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serv

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100%

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100%

-83

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%-

100%

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100%

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Patie

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Entir

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Self

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78

Whe

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Shel

f

Tabl

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77 6338424

Out-O

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Out-I

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In-O

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In-O

ut, O

ut-In

, or I

n-In

In-In

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