How to Reduce Imaging Wait Times

Charles Anderson, MD, PhD National Radiology Director, PCS

December 17, 2007

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Reason for Monitor

• Preliminary data showed imaging wait times are a problem. • Improving wait times will result in better patient care.

– Disease will be diagnosed at a less advanced stage. – Communication and follow-up will be more likely. – Patients will be more satisfied.

• Collecting wait time data across VHA allows us to study the problem and reach coordinated, evidence-based solutions.

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Definition of Imaging Wait Time

• Time: – From desired appointment date as entered by provider – to date patient arrives and study is registered.

• Very similar to clinic wait time definition, except radiology clerk can not enter or correct date desired.

• Only outpatient US, CT, MRI, Nuc Med, Nuc Cardiac, Mammography is monitored – Inpatients are not scheduled. – Plain film mostly walk-in. – IR procedures are consults.

• Data collected automatically in radiology package of VistA. • Performance can be monitored as needed by management reports

in radiology package.

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First Year Baseline Performance

• Initial observation is tremendous variation in performance across medical centers.

• Often facilities will perform well in all modalities or poorly in all modalities, suggesting that some facilities have adopted superior processes.

• CT and Nuclear Medicine are closest to meeting the measure. • Other modalities have wait times well beyond 30 days.

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Performance Distribution

0

10

20

30

40

50

60

70

80

90

0-1020-30

20-3030-40

40-5050-60

60-7070-80

80-9090-100

Performance in Percent

Num

ber o

f Fac

ilitie

s

CT

MRI

Mammo

NM

Cardiac

US

Large number of facilities

have >30 day MR and US

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Process Steps

• Provider enters order for procedure and for labs. • Order prints in radiology, and appears on Pending Log of VistA. • Clerk collects orders periodically and brings orders to radiologist. • Radiologist reviews orders for safety and appropriateness, special

instructions and contrast. • Clerk calls/mails out appointment.

– Patient calls to change appointment. • Clerk or automated message calls patient to remind them of

appointment. • Patient appears for appointment.

– If patient fails to appear, order cancelled and provider notified. • Safety check, labs, IV, premedication as needed. • Informed consent. • Study performed.

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Order Entry

• Providers often do not specify a desired date, or else specify the date in the history section. There may be hundreds of such orders per month. These orders must be cancelled and re-entered properly. Date entry will be mandatory in the next version of CPRS.

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MR & CT orders should be reviewed by radiologist before scheduling

• To reduce last minute cancellations after the patient has arrived. – Often because study was unsafe or unnecessary.

• To specify protocol in advance. – Protocol defines length of schedule slot. – Ensure patient is given appropriate instructions (e.g. NPO). – Arrange for labs in advance. – Patient might need to arrive early for blood draw or IV start.

• Each radiology service should have a policy defining which procedure orders need to be reviewed.

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Do radiologists review MR and CT orders before scheduling?

0 10 20 30 40 50 60 70

Never

Sometimes

Often

Always

Number of Facilities

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Inter-service Agreements

• The requirement to approve studies may be facilitated by an inter-service agreement.

• An inter-service agreement defines who can order what for what indication and with want prior approval.

• Radiology inter-service agreements are usually clinical practice guidelines and as such should be approved by the medical staff.

• However the radiologist or physician supervising the injection is still obligated to review patient for safety before contrast administration.

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Examples of Inter-service Agreement Provisions

• Back Pain: Obtain plain films unless: – There are neurological abnormalities or reasonable concern for

infection or malignancy. Neurological abnormalities include bowel/bladder dysfunction, motor weakness, root distribution sensory loss, and radiating lower extremity pain.

– Plain films do not explain back pain of greater than six weeks duration

• Joint Pain – Obtain plain films for suspicion of degenerative joint disease or

fracture. – Do not order MRI for patient with DJD being referred to

Orthopedics. • Altered Mental Status

– Obtain non-contrast CT – MRI may be ordered by neurologist/neurosurgeon, or else

approved by neuroradiologist • Intracranial MRA/CTA

– May only be ordered by neurology attending 000037

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Facilities with Inter-service Agreements

0% 20% 40% 60% 80% 100%

Orthopedics

Cardiology

Neurosurgery

Neurology

Speech Pathology

Pulmonary Medicine

Percent of Facilities

Yes

No

Don't Know

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Facilities that Require Imaging before Patient Seen by Specialist

0% 20% 40% 60% 80% 100%

Pulmonary Medicine

Cardiology

Neurosurgery

Neurology

Speech Pathology

Orthopedics

Percent of Facilities

Yes

Rarely

No

Improving orthopedic clinic wait times may increase imaging wait times.

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How should ordering decision support be implemented?

0 20 40 60 80 100

Locally implemented

Nationaly implemented system withlocally modified guidelines

Nationaly implemented system withnational appropriateness guidelines

Number of Facilities

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Establish a Centralized Imaging Scheduling Desk

• There should be a central point of contact within radiology department for patients and ordering physicians.

• Staffed all day with a scheduling clerk. – Technologists should concentrate on the patients and keeping

the work flowing. Technologists should not interrupt study to answer scheduling phone, nor should patient calls roll over to recording – phone tag.

• Clerks should be located in department and trained: – as to how long procedures take. – what preparation instructions to distribute. – what orders require radiologist review.

• If a patient or physician calls to request an appointment time and the order has not yet been reviewed by a radiologist, go ahead and give a provisional appointment.

• Appointments should be placed both in the radiology scheduling package and the clinic scheduling package (inefficient).

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Scheduling Process

• Ideally, physician will send patient to central scheduling desk to get appointment on the day order is written before patient leaves the hospital. – This is not possible if order is written after patient is gone or

order is written from satellite clinic. – If so, mail out appointment with number to call to reschedule.

• Call patient to notify them of appointment. • Automated telephone reminder night before appointment.

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Monitor the pending log

• Require all orders to be reviewed and appointment assigned within 7 days.

• A supervisor should run the pending log for each modality every day. Discuss with clerks why log extends beyond 7 days as needed.

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No-shows

• No-shows rates should be kept below 10%. This parameter should be tracked by the supervisor. – It is very difficult to recover from a no-show. For example, if a

patient doesn’t show for MRI the next outpatient usually hasn’t arrived and there is no time to call a inpatient from the ward. The equipment stands empty.

• Top reasons for no-shows: – No transportation. Often this depends on time of day. – Patient doesn’t want study. – Patient states physician didn’t tell them they were having

study. • No-shows almost always don’t show the second time if they are

rescheduled.

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Cancel no-show orders

• If a patient doesn’t show, doesn’t call to say they can’t make it, and if no-show isn’t explained by weather: – Then cancel the order and notify the ordering physician to

contact patient and evaluate whether the study should be reordered.

– Perhaps one-half are reordered.

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Radiology Nurses

• Nurses should be assigned to CT and MR. • Nurses keep the workflow moving by:

– Arranging for lab tests, or perform point of care creatinine – Screening patients for safety – Medication reconciliation – Pre-medication of patients – Starting IVs – Assisting with informed consent – Medical record documentation – Detecting and responding to complications and allergic

reactions – Entering allergies in VistA – Credible liaison with wards and units

• A nurse will help you deal with contingencies without delaying schedule.

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Nurses should understand imaging

• Nurses who are assigned primarily to radiology are most capable of speeding workflow.

• Experienced radiology nurses can assume much of the workflow process.

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Most facilities have no nurses in the imaging service

0 10 20 30 40 50 60 70

Four or more

Three

Two

One

None

Num

ber o

f nur

ses

Number of facilities

• Do not know how these nurses are deployed in services. • If one nurse, probably covers IR only.

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Create a holding/prep area

• Patients monitored by nurse or health aid. • Location for blood draw or IV start. • Patients often need bi-carb or NS infusion. • Recovery area, does not tie up room. • You will be less reliant on timely escort. • Make best use of open slots in event of no-show. • The fact that inpatients wait several days implies we are not

managing open slot opportunities efficiently.

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Inpatient Waiting Times

0 20 40 60 80 100

> 3 Days

3 Days

2 Days

1 DayDa

ys to

Com

plet

e 90

%

Number of Facilities

CTMRI

MR slots are twice as long as CT slots; harder to accommodate add-ons.

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Make radiologists available

• Study should be approved and protocol written before patient arrives.

• Radiologist should be promptly available to consult with technologist or nurse, for signature consent, to sign orders, to check images before the patient leaves if needed.

• Ideally, radiologists work in a common reading room near the acquisition equipment.

• However waiting for radiologist will slow down the workflow and will decrease over-all service productivity.

• Nurse can reduce “radiologist delay” to a minimum.

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Factors that Influence VA Radiologist Productivity

• Each additional hour of MR schedule decreases each radiologist’s productivity by 11 wRVU/yr. While not a large number it shows we are inefficient since increasing studies should increase productivity.

• Adding a nurse to a VA radiology service increases the productivity of each radiologist by 346 wRVU per year, equivalent to adding ½ of a radiologist to an average size VA!

• Each additional FTE devoted to patient coordination increases each radiologist’s productivity by 306 wRVU/yr. Patient coordination includes:

– Consult triage – Pre-visit reminder call – Provide patient education, pre and post procedure – Follow up calls for patient no-shows/cancellations – Coordinate patient care with social workers, home health, and others – Clerical support during normal workday – Assistance during minor procedures & 3D reformations – Radiation Safety Officer for radionuclide therapy support 000052

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CT Equipment Capacity

• Hospitals with one CT scanner have difficulty in meeting monitor if they perform more than about 2000 studies per quarter or 8000 studies per year (where study is defined as number of CPT codes).

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Performance for Hospitals with One CT Scanner

0

0.2

0.4

0.6

0.8

1

1.2

0 1000 2000 3000 4000

Total Studies per Quarter

Frac

tion

of O

PT S

tudi

es P

erfo

rmed

W

ithin

30

Days

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Performance for Hospitals with One MRI Scanner

0

0.2

0.4

0.6

0.8

1

1.2

0 500 1000 1500 2000 2500

Total Studies per Quarter

Frac

tion

of O

PT S

tudi

es

Perf

orm

ed w

ithin

30

days

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MR Equipment Capacity

• Hospitals with one MR scanner have difficulty in meeting monitor if they perform more than about 1300 studies per quarter or 5200 per year.

• The large variation in MR performance suggests services are unable to manage schedule exceptions. – Too many no shows? – Studies delayed to resolve problems that should have been

addressed earlier, like claustrophobia? – No one available to D/C pump or start IV? – MR in remote location? – Slots too long? – Protocol performed is not protocol projected? – Remote contract radiology staff order just-in-case sequences?

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Keep the equipment busy!

• Two staff per CT/MR, one to run machine, another to prepare patients.

• Provide for timely escort. • Optimize location of waiting and changing rooms. • Do patient prep in prep area. • Nurses for patient prep, IV, complications, documentation, order

entry queued for radiologist signature. • 3D reconstructions should not compete with acquisition. • Keep inpatient carve outs to minimum. • Overbooking is a poor idea and results in angry patients. Key to

patient satisfaction is good communication with patients in waiting room. Keep them informed of any delays.

• Extend the work day.

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Mammography

• Just 33 facilities perform their own mammography. • There is little data on mammography because many of these

procedures are outsourced, or the reports are not placed in the radiology package. [34% of facilities report that some or all of their contract and Fee study reports are not placed in the radiology package. Some reports are entered as notes.]

• Types of mammography: – Screening: once per year or every other year. – Diagnostic: if a lesion is suspected.

• Prioritize Diagnostic Mammography under 30 days as your first goal.

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Nuclear Stress Tests

• Note that not all cardiac stress tests involve nuclear imaging. So not all cardiac stress tests are measured by this monitor.

• Also note that not all nuclear cardiac imaging is performed as part of stress test.

• If procedure is jointly performed by Cardiology and Imaging, then meeting the monitor requires close cooperation of the two services. Services should meet and write out workflow steps together. Simplify.

• Often it is better to place one service in charge of the schedule.

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Work Down Backlog

• Extend the work hours – but not into late evening, patients won’t come and there is no

support staff. • Stagger staff hours. • Stagger work days Sun-Thurs, Tues-Sat. • Cross train staff (e.g. CT and MR). • Contract technologists temporarily. • Evaluate order queue and develop plan to resolve the queue of

orders never acted on.

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General Recommendations

• Study and change your process, whipping doesn’t work. You will only see a lasting change if you have identified and corrected your bottlenecks.

• Write out your process steps. – Identify limiting steps (e.g. waiting for lab result). – How do you respond to exceptions in workflow (IV line

infiltrates)? – What is your contingency plan (tech calls in sick)?

• Simplify your workflow. Deal with contingencies as they happen. Don’t put items on hold. “Do today’s work today.”

• Assign a supervisor to monitor pending log and no-shows. • Assign central schedulers. • Nurses! • Discuss your wait time performance, workload, no-shows and

other identified parameters in QA meetings. • Right size your equipment and personnel. 000061

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PCS National Solutions

• Make entry of Date Desired mandatory in CPRS, projected for release in February.

• Collect best practices. Analyze data for trends. • Distribute benchmarks.

– Staffing – Equipment – Utilization

• Modify radiology package to better incorporate reports from outsourced procedures.

• ? Write directive that defines ordering and scheduling process, including orders never acted on and no-shows.

• Build national decision support system for imaging procedure order-entry.

• Propose clinical practice guidelines.

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