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Click here to continue. End of section. Introduction. Introduction. What is the radiology tool kit for? The radiology toolkit has been designed to assist radiology teams and departments to resolve constraints to innovation in patient care. Who should use the toolkit?

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End of

section

Introduction

Introduction

What is the radiology tool kit for?

The radiology toolkit has been designed to assist radiology teams and departments to resolve constraints to innovation in patient care.

Who should use the toolkit?

The tool kit provides ideas and solutions to possible constraints within radiology, anyone who is responsible for patent flow will benefit from using this tool.

What are the aims of the toolkit?

The Patient Flow Collaborative aims to remove unnecessary constraints or delays in patient flow by promoting a continuous flow of care. Radiology innovation is essential to providing a seamless efficient service to waiting patients.

How should we implement the concepts in this toolkit and change in our local context?

The toolkit will assist with provoking discussion and ideas, health service teams should operationalise any innovation idea to their local context.

Goals of the

toolkit

Overview and

strategy

Health service

team

Processes

Data

Resources

Diagnostics

and tools

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End of

section

Goals of the toolkit

Introduction

  • Introduction

  • The radiology toolkit is based on whole system thinking and includes a whole of hospital approach.

  • Goals

  • The specific goals of the toolkit are:

  • Provide possible solutions to flow issues

  • Build awareness of the management of capacity and demand

  • Identify systematic methods to innovate in radiology

Your feedback

This first version of the radiology toolkit will stimulate discussion and innovation ideas and methods. The Patient Flow Collaborative welcomes feedback to enable subsequent versions of the toolkit.

Goals of the

toolkit

Overview and

strategy

Health service

team

Processes

Data

Resources

Diagnostics

and tools

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Overview and strategy

Introduction

Goals of the

toolkit

Whole system approach

A whole system approach is needed to effectively manage the variation in capacity and demand involved in radiology. Radiology is recognised to be a central point in this continuous flow of diagnosis and treatment for our patients.

Overview and

strategy

Health service

team

Processes

Data

Resources

Diagnostics

and tools

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Overview and strategy

Introduction

Organisational whole of hospital delivery

Goals of the

toolkit

Policy and

leadership

Capacity

and demand

Staff

resource

Administration

Overview and

strategy

Health service

team

Processes

Radiology investigations and treatment modalities

Rigorous

diagnostics

Agreed

process

Access

and

administration

Patient

information

Data

Resources

Diagnostics

and tools

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Overview and strategy

Introduction

Policy and

leadership

  • Priority given to radiology services by board and local health community awareness of capital investment and issues.

  • Identified board level report for radiology, leadership high priority for radiology management team.

  • Policy stating maximum waiting times for emergency admitted and waiting patients.

Goals of the

toolkit

Overview and

strategy

Capacity

and demand

Health service

team

  • Essential data collected on capacity and demand for radiology services

Processes

Staff

resource

Data

  • Staff resource plans undertaken regularly to promote, mentoring development and training. Roles redefined to maximise skill base and promote up-skilling of staff team.

Resources

Administration

Diagnostics

and tools

  • Administration systems in place which promote smooth allocation and booking of appointments and reporting results.

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End of

section

Overview and strategy

Introduction

Rigorous

diagnostics

Goals of the

toolkit

  • Capacity and demand, process mapping, tally chart data to be collected per diagnostic/treatment stream.

  • High demand stream to be completed first.

Overview and

strategy

Agreed

process

  • Once process is reviewed, redesign process to provide continuous process, advertise to staff/hospital as required.

Health service

team

Processes

Access

and

administration

  • Advertise access timescales to all stakeholders.

  • Promote appointment system which pulls patients.

  • Agree date and time with patient.

  • Ask to confirm before appointment.

  • Manage DNA/FTA as per policy

Data

Resources

Patient

information

Diagnostics

and tools

  • Provide patient information to promote quick appointment examination.

  • Make sure information given previous to attendance.

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End of

section

Health service team

Introduction

  • Clinical improvement team

  • It is important to identify a clinical and managerial lead for the Clinical Improvement team who will lead the innovations within radiology. A reporting line will be needed to an executive sponsor for the Patient Flow Collaborative executive team.

  • Agree executive sponsor

  • Agree clinical lead

  • Agree managerial lead

  • Introduction

  • Essential components of effective radiology services are skilled, trained and dedicated radiology staff. Teams who have clear roles, responsibilities, support and reporting lines will underpin effective patient flow.

  • Check list for radiology team

  • Whole of hospital service strategy

  • Executive sponsor for radiology team

  • Clear reporting to supervisor or manager

  • Skills recognised within whole team

  • Opportunity for skill development

  • Innovation champion

  • Patient involvement champion

Goals of the

toolkit

Overview and

strategy

Health service

team

Processes

Data

Resources

Diagnostics

and tools

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Processes

Introduction

Goals of the

toolkit

  • Plain film

  • Ultrasound

  • Mammograph

  • CT head and neck

  • MRI

  • Fluoroscopy

  • Nuclear medicine

Appointment

Administration

Triage

Demand

Overview and

strategy

Health service

team

Processes

DNA/FTA

Treatment

Discharge

Reporting

Data

Resources

Diagnostics

and tools

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Processes

Introduction

Example of simple process maps to start process

Goals of the

toolkit

Overview and

strategy

Health service

team

Processes

Data

Resources

Diagnostics

and tools

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Processes

Introduction

REFERRALS ARE CHECKED

REFERRALS ARE ONLY

TWICE A WEEK BY

Goals of the

toolkit

REFERRALS RECEIVED IN

ACCEPTED FROM MR

MAMMOGRAPHERS.

APPOINTMENTS OFFICE

ALLEN OR ONCOLOGY

PATIENT RADIOLOGY

CLINIC

HISTORY CHECKED.

FORM AUTHORISED

Overview and

strategy

ATTEMPTS TO FIND

PAT CHECKS WHETHER

Health service

team

PAT CHECKS THE US

CONVENIENT DATE FOR

ULTRASOUND SCAN IS

APPOINTMENT BOOK AND THE

MAMMOGRAM AND

REQUESTED AS WELL AS

MAMMO APPOINTMENTS

ULTRASOUND TO BE

MAMMOGRAPHY

SHEET TO FIND SAME DAY

CARRIED OUT ON SAME

AVAILABILITY

DAY

Processes

Data

REQUEST FORM

IF THIS MAKES APPOINTMENT TOO

APPOINTMENT BOOKED ON

RETURNED TO PAT IN

LONG TO WAIT FOR – SEPARATE

COMPUTER.

APPOINTMENTS FOR

APPOINTMENTS ARE MADE

DATE WRITTEN ON FORM

BOOKING

Resources

Diagnostics

and tools

FORM FILED IN OFFICE

LETTER AUTOMATICALLY

UNDER DATE APPOINTMENT

GENERATED AND SENT TO

IS BOOKED FOR

PATIENT

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Processes

Introduction

Analysing the patient process

Goals of the

toolkit

  • Having mapped the patient process, analyse by considering the following:

  • How many steps are in the process?

  • How many times is the patient passed from one person to another (hand-off)?

  • What is the approximate time of each step?

  • What is the approximate time between each step?

  • What is the approximate time between first and last step?

  • Where does the patient have a wait or have to queue?

  • Where are there waiting lists in the system?

  • How many steps add no value to the patient? (Ask patients)

  • Where are there problems for patients – what do patients complain about?

  • Where are there problems for staff?

Overview and

strategy

Health service

team

Processes

Data

Resources

Diagnostics

and tools

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Processes

Introduction

Identify referral entry points

Goals of the

toolkit

  • Single or multiple entry points?

  • Electronic or paper referrals?

  • All referrals to imaging room or reception?

  • Are there locations referrals could go to? That is, theatre, ED, other sites.

  • What work is done outside of normal hours that generates referrals?

Overview and

strategy

Health service

team

Processes

Data

Resources

Diagnostics

and tools

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Processes

Introduction

Develop a process map of the time it takes to see a patient

Goals of the

toolkit

  • Check in – Undress – Preparation – Procedure - Reporting

  • Method:

  • Identify start and end points of the procedure.

  • Agree how many activities in process. That is, check-in, pre check, consent, discussion, patient changes, etc.

  • Identify the time it takes for each step.

  • Cross check with actual process.

Overview and

strategy

Health service

team

Processes

Data

Resources

Diagnostics

and tools

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Processes

Introduction

Process steps examples

Goals of the

toolkit

Overview and

strategy

Health service

team

Processes

Data

Resources

Diagnostics

and tools

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Processes

Introduction

Process steps examples

Goals of the

toolkit

Overview and

strategy

Health service

team

Processes

Data

Resources

Diagnostics

and tools

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Processes

Introduction

Build your schedule

Goals of the

toolkit

Use graph paper with one square per minute to sequence time scales per procedure.

Overview and

strategy

Health service

team

1 MINUTE

35 MINUTES

Processes

Data

Resources

Diagnostics

and tools

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Processes

Introduction

Build your schedule

Goals of the

toolkit

Transfer graph sequence timescales to chart clinic time.

Overview and

strategy

9.00 am start

12.00 pm end

Health service

team

Processes

Data

Resources

Align steps to maximise use of equipment/radiology room/staff.

Diagnostics

and tools

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Processes

Introduction

  • Understand existing backlog

  • Once schedules and processes have been reviewed, capacity and demand can be calculated for:

  • backlog and current demand

  • backlog = existing request still waiting

  • current demand = demand which will be made on service.

  • Calculating backlog

  • To calculate backlog you will need to use the previous time series calculations.

  • Identify time of request.

  • Identify from your sequence charts the time for this type of request.

  • Identify number of requests waiting.

  • Multiply time needed to do the procedure by number waiting.

  • This will give you a measure of the time needed to clear your backlog.

Goals of the

toolkit

Overview and

strategy

Health service

team

Processes

Data

Resources

Diagnostics

and tools

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Processes

Introduction

Current demand

Daily demand calculations will promote effective management of radiology resources. Simple tally sheets can assist with this.

Goals of the

toolkit

Overview and

strategy

Health service

team

Processes

Data

Resources

Diagnostics

and tools

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Processes

Introduction

Goals of the

toolkit

  • Assistance with backlog

  • Options for assisting with backlog include:

  • Waiting list telephone validation.

  • Reduce inefficiencies – FTA rates, start times, cancelled sessions.

  • Increase number of procedures in session by redesigning process and schedule.

  • Introduce changes to working day; extended working days, evening sessions.

  • Access capacity elsewhere.

  • Use other resources/staff.

Overview and

strategy

Health service

team

Processes

Data

Resources

Diagnostics

and tools

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Processes

Introduction

Goals of the

toolkit

  • Identity constraints that limit radiology equipment/specialists availability

  • Constraints may be due to:

  • Waiting for portering

  • FTA patients

  • Short notice or cancellations (reasons?)

  • Availability of clinical staff to prescribe and administer

  • Availability of recovery areas or preparation areas

  • Poor patient preparation

  • Clinical staff performing no clinical duties

Overview and

strategy

Health service

team

Processes

Data

Resources

Diagnostics

and tools

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Appropriateness

Appropriate imaging

evidence based protocols

registrar/consultant sign-off

electronic prompts

Easy consultation

Process improvement

Appropriateness

Processes

Introduction

Imaging initiatives

Goals of the

toolkit

Evidence based protocol

Consultant consultation

Personal consultation

Traffic light triage

Electronic prompts

Overview and

strategy

Health service

team

Processes

Data

Resources

Diagnostics

and tools

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Evidence based medicine

Cervical spine injury?

Head Injury

Pulmonary Embolism?

Deep vein thrombosis?

1st trimester bleeding

Renal colic?

Meningitis, Lumbar puncture or CT scan or treat?

Evidence Based Medicine

Processes

Introduction

Pulmonary Embolism and Evidence Based Medicine

Goals of the

toolkit

Before

  • 7 protocols

  • 75% with PE have too many or too few tests

    After

  • one protocol

  • 93% compliance

Overview and

strategy

Health service

team

Processes

Data

Resources

Diagnostics

and tools

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Radiology Test Ordering (RTO)

Introduction

Traffic Light Guidelines

Example from

Southern Health

Clinical Indications must be on form

·

Skull/Sinus/KUB

Goals of the

toolkit

·

CT Chest/Abdo CT

Red Tests

·

Angiography/CT Angio

·

Must be

authorised

by

·

MRI

·

Specialist

Paediatric CT

Overview and

strategy

·

All radiology call backs

Health service

team

·

AXR

·

T/L/S spine

Amber Tests

·

CT Brain/CT C Spine

Processes

·

Radiology form must be

·

Abdo U/S

signed

by a Registrar

·

Pelvic US/O&G US

·

OPG/Facial Bones

·

F/B soft tissue

Data

·

Renal Colic CT

Resources

·

CXR

Green Tests

·

C-Spine

·

·

No restrictions on ordering

M/Skel. X-rays (excl.

T/L/S Spine)

·

Diagnostics

and tools

All results must be checked

·

Pelvis

before patient discharged

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Measures

Request to film completion

Request to dictation complete

Request until report typed

Unreported cases at 5pm

Protocol adherence

Measures

Processes

Introduction

The Requesting Process

Goals of the

toolkit

Nurse initiated

Faxing

Electronic

The consultation

Overview and

strategy

Health service

team

Processes

Data

Resources

Diagnostics

and tools

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Filming scheduling process

Next waiting

Reduced downtime

Emergency AM slots

Peripherally Inserted Central Catheter (PICC) story

Porters story

Responsiveness in CT, CXR

Filming/Scheduling Process

Processes

Introduction

No Porters Data!

Goals of the

toolkit

  • 2 day audit was undertaken

  • 22 observations of porters in room was made

  • On 20 occasions between 1 - 5 porters were available in the porter’s room.

Overview and

strategy

Health service

team

Processes

Data

Resources

Diagnostics

and tools

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Example from

Southern Health

Introduction

Goals of the

toolkit

Overview and

strategy

Health service

team

Processes

Data

Resources

Diagnostics

and tools

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Introduction

Example from

Southern Health

Goals of the

toolkit

Overview and

strategy

Health service

team

Processes

Data

Resources

Diagnostics

and tools

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Introduction

Goals of the

toolkit

Overview and

strategy

Health service

team

Processes

Data

Resources

Diagnostics

and tools

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Time from ip request to film

5/033.40 HR(6.15)

(Max)

Time from IP Request To Film

Processes

Introduction

Improvements to time it takes Emergency Department patients to have radiology tests done

Goals of the

toolkit

Time from ED Request to Film (average)

Overview and

strategy

8/014.30 – 13.2 hours(23)

10/012.0 – 3.5 hours(11)

2/023/10 - hours (8)

5/031.0 - hours(3.3)

(Max)

Health service

team

Processes

Imaging Capacity Audit

CT, 25days, no show 49/751

ED 2 days, 38%, 64% waiting

Data

Resources

Diagnostics

and tools

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Introduction

Goals of the

toolkit

Overview and

strategy

Health service

team

Processes

Data

Resources

Diagnostics

and tools

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The reporting process

Hot reporting IP

Digital dictation

Weekend reporting

Evening reporting

Tele-reporting

Interims

Less priors

End of

section

The Reporting Process

Processes

Introduction

Clerical Process

Goals of the

toolkit

Digital dictation and dial-in

Interims

Remote reporting

Computer report distribution

Return films without reports

Eliminate report storage

Overview and

strategy

Health service

team

Processes

Data

Resources

Diagnostics

and tools

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section

Data

Introduction

Core data

Other Suggested Measures

Capacity and Demand

-Existing Capacity v Utilisation v Number Waiting

Did not Attend (DNA) rates per day/week

Cancellation rates (Hospital and Patient initiated)

Delays

-Monitor Radiology delays for one week to agree on the top 10 reasons. When this is agreed, 4 weeks data will be collected against the top 10 delays. Once 4 weeks of 10 delays have been gathered SPC charts can be produced. Time needs to be collected against each reason(s) per day, as the top ten offenders may not amount to the longest waste in time.

Goals of the

toolkit

Overview and

strategy

Health service

team

Processes

Data

Resources

Diagnostics

and tools

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Resources

Introduction

Change Concepts

Redesign process to eliminate hands off, waste and complexity

Implement ‘daily’ performance monitoring

Redesign admin, booking and scheduling systems

Increase scope and skills of radiology team, develop non-clinical staff as radiology technicians, develop consultant radiographer roles and extend scope of professional groups via development and protocols

Develop electronic communication between primary care, in patient requests and radiology department

Develop multi-skilled radiology administration and portering team

Maintain permanent portering staff in radiology

Develop and redesign request forms with supporting training, information and feedback

Goals of the

toolkit

Overview and

strategy

Health service

team

Processes

Data

Resources

Diagnostics

and tools

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section

Diagnostics and tools

Introduction

Change Concepts

Rigorous diagnostic handbook

Data collection charts

Goals of the

toolkit

Overview and

strategy

Health service

team

Processes

Data

Resources

Diagnostics

and tools

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