Professional Documents
Culture Documents
Charles Anderson, MD, PhD National Radiology Director, PCS December 17, 2007
000027
000028
000030
Performance Distribution
90 80
Number of Facilities
70 60 50 40 30 20 10 0
010
-3 20
Performance in Percent
000031
-3 20
-4 30
00 -1 90 0 -9 80 0 -8 70 0 -7 60 0 -6 50 0 -5 40
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.
000032
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.
000033
000034
Number of Facilities
000035
Inter-service Agreements
The requirement to approve studies may be facilitated by an interservice 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.
000036
10
Percent of Facilities
000038
12
Percent of Facilities
13
000039
Locally implemented
20
40
60
80
100
Number of Facilities
000040
14
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.
000042
16
000043
17
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 doesnt show for MRI the next outpatient usually hasnt 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 doesnt want study. Patient states physician didnt tell them they were having study. No-shows almost always dont show the second time if they are rescheduled.
000044
18
000045
19
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.
000046
20
000047
21
Number of nurses
Number of facilities
000048
22
000049
23
Number of Facilities
24
000051
25
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).
000053
27
28
29
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?
000056
30
000057
31
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.
000058
32
000059
33
000060
34
General Recommendations
Study and change your process, whipping doesnt 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. Dont put items on hold. Do todays 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. 35 000061 Right size your equipment and personnel.
36