Lean Team

Find out how one hospital reduced turnaround time for CT exams on ER patients from 2 hours and 52 minutes to 2 hours and 15 minutes.

These days, patients who visit Tampa General Hospital’s emergency room—which received more than 76,000 visits in 2009—are more likely to receive more efficient treatment because of a “lean process” initiative undertaken from March to June this year that focused on decreasing turnaround times on wet reads on CTs.

Keith Aldahondo, RT(R)(CT)(MR), the hospital’s CT/MRI manager, and his cross-functional team included his coleader, Elizabeth Richard, MBA, MHS, director of decision support; emergency room physicians and radiologists; nurses and other staff from the emergency room and radiology departments; CT technologists; a financial analyst; emergency room transport personnel; and consultants from the Center for Transformation at the University of South Florida.

The lean process methodology, originally implemented in the manufacturing industry, focuses on eliminating resources that fail to create value for the end customer. In the case of Tampa General Hospital, the team mapped out in detail their process for providing wet reads for CT exams to emergency room patients and then tried to eliminate as many as possible of the steps that didn’t help them to deliver timely results.

“For us, it’s about ensuring that the patients get through the emergency department in a timely manner,” said Aldahondo. As is the case in any emergency room in any hospital, a stroke patient at Tampa General Hospital will be attended to first. But the patient who comes in with a hurt ankle can be accommodated, too, because of Aldahondo and his team’s sustained effort.

The Problem

“Patients shouldn’t be waiting in the emergency room for a long time,” said Rajendra Kedar, MD, a radiologist and director of CT and body imaging at Tampa General Hospital. “What’s important is satisfaction for patients and emergency room physicians—and good turnaround times on exams. We wanted to make sure that referring physicians were happy. They had been frustrated because they had ordered a CT and it took more time than they thought it would.”

“All of our patients are important, but what tends to happen is when you have a really big emergency and you’re not looking at your workflow, the biggest emergencies get the most time,” said David Orban, MD, chief of emergency medicine.

According to Orban, who agrees that medical staff tend to focus on the patients with the highest acuity, the above scenario happens when you don’t pay attention to the steps you take when providing patient care. Orban admits that he was once pretty critical of the time it took to receive wet reads on his patients’ CT exams, but, once he discovered that the radiology department would be undertaking a lean process to reduce turnaround times, he became a supporter.

Scope It Out First

One of the first things the team at Tampa General Hospital did was establish the scope of their project, a process that led them to determine their customers (emergency room physicians, patients, staff, and other physicians), their complaints (delays on wet reads for CT exams), and their needs (timely turnaround on CT exam wet reads), and identify what outcome would satisfy their needs, which led to their problem statement: emergency room physicians were frustrated by CT turnaround times that were greater than their expectations of 120 minutes. (Why? Long emergency room CT turnaround time can lead to longer emergency department lengths of stay—and that can lead to unhappy physicians and patients.)

Aldahondo and his team then needed to determine a metric whereby they would determine success: Reduce the turnaround time on wet reads for CT exams for emergency room patients to less than 120 minutes. Successfully meeting this goal would lead to improved emergency room physician, patient, and staff satisfaction.

Focus on Quality

One of the first things the team determined was that some CT exams were just going to take longer than 120 minutes. This was definitely the case when the team was dealing with a CT with an oral contrast that required a preparation time of 90 minutes. That said, the team was able to shave 30 minutes off the preparation time to ensure more efficient wet read results.

That was one area, in particular, where Kedar was instrumental. “As lead radiologist, I wanted to make sure that the quality of exams wasn’t compromised—like with abdominal CTs,” said Kedar. “Patients need to drink an oral contrast, and then they need to get the oral contrast down. My goal was to ensure that there were fewer false diagnoses or repeat scans. But I also wanted to do what I could to improve turnaround time and make sure radiologists and radiology residents were accountable and aware.

“Many times, we as radiologists do things and we’re not aware,” continued Kedar, who, along with the rest of the hospital’s radiologists, now reads emergency room exams first. What helped to ensure success was Kedar communicating with radiologists and residents to let them know that any exams that took more than an hour would result in a call from him.

“Communication was extremely important and essential,” said Kedar, who also knew he needed to get emergency room physicians on board. “We had to make sure emergency room physicians understood the process. Certain exams can’t be done immediately. Some patients need IV contrasts or oral contrasts.”

Trystorming

One of the tools used in the lean process is trystorming, which essentially means trying what you brainstorm.

“Our first trystorm was a designated emergency room transporter,” said Aldahondo. “We originally thought that having our own transporter to bring patients [from the emergency room to the CT scanner] would help us decrease our turnaround times. What we found out in our data is that we had so many outliers, it was hard to see the benefit of the transporter in our processes, though we may look into bringing a transporter into our process again to see if it could reduce our turnaround time.”

As a result of their six successful trystorms, the team decided to:

• Extend hours for the CT scanner in the imaging center;
• Use the CT scanner in the cardiovascular center on a routine basis;
• Use a visual queue board to track emergency room CT exam wet read turnaround time by the hour;
• Ensure follow-up with radiologists and radiology residents if there were delays on wet reads;
• Maintain a structured approach to managing exams when contrast is required;
• Reduce preparation time for exams requiring contrast from 90 to 60 minutes.

“Trystorms gave this team the ability to try things without committing resources—and they had autonomy,” said David Johnson, manager of process improvement. “It was okay if it didn’t work. It was okay if they were going to fail, as long as they learned from it.”

“The biggest thing is metrics,” said Aldahondo, who admits that having a transporter take patients from the emergency room to the CT scanner “felt good,” but that feeling of success wasn’t reflected in their numbers.

The “Show Me” Approach

Physically, the visual queue board is just a 36″ x 48″ dry erase board on the wall of the CT technologists’ work area. But it’s the function it plays that makes the visual queue board so powerful. The board, the result of one of the team’s six successful trystorms, is used to illustrate wait times for CT exams for emergency room patients by less than an hour, between 2 and 3 hours, between 3 and 4 hours, and 4 hours and longer.

Here’s how it works: When the CT technologists receive a printout of an order for a CT exam, a team member now puts that patient’s initials in the less-than-an-hour column. If that patient’s CT wet read results are available within an hour, their initials are removed from the board—mission accomplished. If that patient’s results aren’t available within an hour, the initials are removed from the less-than-an-hour column and written in the 2- to-3-hour column, which automatically triggers a phone call to determine why the patient was waiting and this reason is then documented.

(A notable exception to this workflow would be all abdomen/pelvis CTs, which are automatically entered in the 1- to 2-hour column because the contrast preparation for these patients is 60 minutes—but reduced from an original 90 minutes over the course of this initiative, again, as the result of a successful trystorm.)

If that phone call didn’t resolve the issue, one of the CT technologists would call the emergency room physician and inform them of the delay and then they would get involved as well. Aldahondo found that his team members were so “on board” that they would send him e-mails to let him know about excessive delays and difficulties they encountered. That information would then be shared with physicians or emergency room management to avoid future issues.

Cross-functional Team Approach

Everyone on the team played a very important role, says Aldahondo. “It was important to have senior administration involved and showing support for this project. Our CT department runs 24 hours a day, 7 days a week—and we had to ensure that we had a team member to cover all of our shifts.”

Equally important to the success of the initiative was the ability of Richards’ team to extrapolate data in a digestible and timely way, Kedar’s leadership and support for the project, feedback from the emergency room physicians—and a structured approach with the lean process, which was gleaned from Mo Kasti, MS, MBB, MCA, and Lou Rhodes, MBA, MBB, chief transformation officer and partner, respectively, at the University of South Florida’s Center for Transformation.

Aldahondo attributes a great deal of the success achieved to having a great team. “Staff involvement was huge,” he said. “The most important part of [achieving success] was having the staff’s buy-in for this project. That’s our emergency room staff, our nurses, our technologists. Everyone did a fantastic job.”

Success, Culture Change, and Next Steps

Back in February, Tampa General Hospital’s baseline for a CT exam for an emergency room patient was 2 hours and 52 minutes from order entry to wet read. Contrast that with the average wait time for a wet read over the lean process initiative: 2 hours and 15 minutes.

Orban, who believes that he’s now able to focus more on caring for patients, says that the lean process is key to addressing workflow challenges that can impede the efficient delivery of high-quality health care.

With the success of this project, “there’s been a cultural shift at Tampa General and this team is leading the way,” said Johnson in process improvement. “The hospital is really adopting ‘lean’ as their project methodology, and we’re using this story to communicate success throughout the hospital.”

Aldahondo is now focused on sustainability on this project and wants the team to continue to decrease outliers from 4 hours to 3 hours and the turnaround time on wet reads from 1 hour to 40 minutes.

“Why should we stop?” asks Aldahondo. “We’ve had so many successes. Let’s keep it going.”

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Aine Cryts is a contributing writer for Axis Imaging News.