Effective Scheduling of Inpatient Echocardiographic Testing

1. Effective Scheduling of Inpatient Echocardiographic Testing No Delay in Diagnosis Performance Improvement Leadership Development Program University of Missouri Health Care February 2011

2. Members of the Team Kathy Brady Margaret Calaluce Debra Glodoski Susan Vollrath Annamalai Senthilkumar Koby Clements, Advisor Les Hall, Advisor Megan Tregnago, Advisor Mike Lambert, Executive Sponsor

3. Our 4E Partners Lori Mann Lynn Wheeler Cheryl Overton Sarah Hall Russell Becker

4. DiagnosticCardiology Non-invasive diagnostic cardiology services ~ 14,000 patients annually Types of testing ─ EKG/Holter ─ Exercise treadmill ─ Tilt table testing ─ Echocardiographic Imaging (48% of annual patient volume) ▪ Transthoracic Echo (TTE) ▪ Exercise stress echo (ESE) ▪ Dobutamine stress echo (DSE) ▪ Transesophageal echo (TEE)

5. It’s an Orchestration

6. Current State Outpatient focus ─ Last decade all about efficiency, throughput, and outpatient growth ─ Our echo imaging, scheduling, ops process focused on outpatient volume (57% of total patient volume) Outpatient schema ─ “Just say YES!” ─ Same day access ─ Double booking Inpatient demand variability

7. Outpatient Service 3.1 hours Inpatient Service 5.9 hours Customer View of TAT Is this Service Excellence?

8. Problem Statement Inpatients experience delay in receiving echo imaging due to current outpatient schema and inpatient demand variability.

9. The Work Begins

10. High-Level Flow Chart inpatients, outpatients, ordering physicians, outpatient scheduler, clinic staff, office support staff, unit clerks, transporters, sonographers, floor nurses, unit nurses, advanced study nurses, exercise physiologists, cardiology fellows, interpreting cardiologists, patient diagnosis, discharge process

12. Patient Voice ▪ Inpatient survey on echo experience ▪ 30/75 (40%) forms completed ▪ Majority of patients from 4East ▪ Alarming # of patients (17%) unaware of scheduled echo imaging procedure ▪ Impetus for development of 4E signature PFCC program

13. Finger Pointing 13 • Transporter • Unit Clerk • Interpreting Physician • Diagnostic Cardiology

14. Baseline 75th Percentile 174 Minutes Intervention

15. Aim Statement By February 11, 2011, we will minimize delay for inpatient echocardiographic imaging so that 75% of our patients have their echo procedure started within 120 minutes of procedure order entry. (relative to the current time of 174 minutes August – October 2010)

16. Process Flowchart Focus on Echo Order Entry to Transport Order Entry to Echo Start Time

17. Why are the floor patients worse? Focus on High Acuity Floor Patients are brought to Diag. Card. What can we do to make Diag. Card. more accessible given inpatient variability?

18. 45.7%

19. Silent Brainstorming

20. Interventions Considered designated inpatient ultrasonographer emphasize to outpatients they must arrive on time stop double/triple booking especially in morning better transport system take pending discharge patients first better communication between patient’s nurse and diagnostic cardio department take inpatients as ordered (first in, first out) schedule patients per room or per tech techs stop doing prelim reports schedule patients thru lunchtime do more inpatients at bedside two staff arrive at 0630 get our own courier have a room on 4East to do echos nurses from originating floor call to schedule their patient’s testing originating floor unit attendants bring patient to our department get more machines, more echo techs send studies thru immediately don’t repeat fellow studies

21. Six Columns of Excellence Engage PEOPLEin a high-performing team to attain patient- and family-centered care Enhance SERVICE byexpediting diagnostic testing Minimize delay in diagnosis to improve QUALITY Align GROWTHby epitomizing patient- and family-centered care related to echo imaging Alleviate potential discharge delays and achieveFINANCIALexcellence Best serve the COMMUNITYwith effective and sensitive health care 21

22. Value 22 IT’S ALL ABOUT THE PATIENT!!!!!

23. Driver Diagram Aim Key Drivers Interventions Scheduling • Eliminate 0830 outpatient ADL slot • Eliminate double booking before 1000 • Reserve afternoon slot for inpatients 120 minutes Staffing • 3 sonographers staffed at 0700 • Dedicated patient transporter • Designated inpatient sonographer Patient Education • 4E Pilot Program • Quarterly patient survey

24. Interventions Chosen H Yield L L H Effort

25. Intervention Go-Live January 3, 2011 Goal = 120 Minutes

26. Problem and Goal Communicated To Staff CMS/Snow Vollrath Effect Intervention

27. 4E PFCC Pilot Program ─ Identification of inpatients with echo imaging orders ─ Unit clerk notification of nurse ─ Nurse prompt leads to patient education ─ Educated and prepared patient

30. % Improvement of 75th Percentiles Baseline (Aug – Oct 2010) to Intervention (Jan 3 – Feb 11th 2011)

31. Patient VoicePost-Intervention ─ 10/24 (42%) completed surveys ─ 50% of patients report they were aware of ordered procedure ─ All patients aware of ordered procedure were told by physician ─ 40% were also informed by nurse

32. Lessons Learned Data! Data! Data! ─ Data speaks for the patient and the process ─Don’t finger point until data is collected and problem truly identified Our Project Specialist is our friend ─Seek early intervention for database development

33. Next Steps ▪ Sustain improvement: Engage staff in data management ▪ Ongoing monitoring and quarterly reporting using new database tracking system ▪ Hospital-wide implementation of signature PFCC echo imaging/patient education program

34. Summary Our participation in the PI-LDP program promoted an understanding of an evidence-based framework for organizational improvement in a complex environment with change based on facts that focus on results and create value. The excellent guidance of Koby, Les, and Megan helped to change our paradigm of “numerical naivete” to one of true understanding so that we may hear the voice of the customer as well as the voice of the process. Enhancement of our PFCC service value resulted in an improvement trend of reduced inpatient echo imaging delay and our ongoing commitment to P(lan)-D(o)-S(tudy)-A(ct).

36. % Improvement of 75th Percentiles Baseline (Aug – Oct 2010) to Intervention (Jan 3 – Feb 11th 2011)

38. 38

39. Baseline Data CollectionTime of order entry ▪ September 1, 2010 – September 15, 2010 ▪ Total of 114 Patients ▪ 51 (45%) of the total had an Order Received Time of 6:30 AM University of Missouri Health Care Performance Improvement Leadership Development Program

40. Baseline Data