Center improves X-ray wait, patient satisfaction

Study found scheduling to be the problem

Alegent Health Immanuel Medical Center in Omaha, NE, had a major problem when it came to processing patients through its X-ray department. Waits could range from 20 minutes to an hour, and no one could explain why.

Patient satisfaction, as expressed on a 1993 Press, Ganey survey, was in the 37th percentile, an unacceptably low score to hospital managers. As the wait in the X-ray department repeatedly surfaced as a reason for discontent, it was targeted for improvement.

Using the Press, Ganey survey as an external benchmark and then gathering data on best internal practices, Alegent managers sought the root of their problem. They found that the radiology department needed stepped-up coordination through the use of a more efficient scheduling system.

In 1993, the hospital was just implementing the Juran quality improvement methodology (developed by post-war economist Joseph Juran) system-wide, and the radiology department looked to be its first big test. It was a successful one. Seven months later, the radiology team introduced the new radiology management system that reduced the logjam, dropping patient time for chest X-rays to less than 15 minutes. Press, Ganey scores almost doubled, climbing to the 67th percentile.

"We basically reorganized," said Deb Fuchser, RN, manager of perioperative services at Alegent, a 300-bed hospital. "Although I think I am a little biased, the Juran method makes sense. It consists of simple steps. This is not rocket science. It is a data-driven system, which was a new method for us. In the past, we handled the problem which ‘squeaked’ or complained the loudest."

The Juran model relies heavily upon a scientific approach, with six distinct steps:

• Develop a mission statement, which identifies the project and uncovers opportunities.

• Gather data to establish project parameters (benchmarking both internally and externally).

• Diagnose the cause of the problem.

• Remedy the cause through discovery and evaluation of different solutions.

• Enhance the solution by ongoing review and adjustment.

• Replicate in similar settings.

When radiology’s logjam was tackled at Alegent, the Juran system was simply too novel. "When we started, Juran was just being instituted," said Kevin Miller, the Juran facilitator on the Alegent team. "Everyone had hours in training, from top management down, which was usually a two-day seminar. We also used just-in-time training."

Despite the training, it took time before the staff felt comfortable using Juran methodology. And too, while Alegent’s senior management embraced the Juran approach, mid-level managers were slow to buy into the system. Less than full support from department managers crippled the quality process, Alegent team members discovered. And most considered the seven-month implementation process too long.

At the onset, the hospital assembled a five-member team to coordinate the project. The team was composed of Fuchser, Miller, a supervisor from radiology, a physician, and a scheduler. The team met weekly.

Once the team was operational, it devised a mission: to improve the waiting time for chest X-ray patients. This provided a clear focus for the project. Then the team decided on the data it needed: scheduling methodology, wait times, and patient and staff input.

The team collected its data over several weeks, using flow charts, fishbone diagrams and surveys to determine the exact nature of the problem.

The data showed that the lag was at the end of the X-ray process. Patients lost the most time after tests were done, not before.

The internal research also dismissed a wrongly suspected culprit: re-takes. They were inconsequential, occurring only once in about 300 cases. Above all, the team found that there was no process in place to track patients or record their time accurately.

To speed up the reading and reporting of X-rays, the team developed tracking and routing forms that ensured the timely handling of the films. For example, the scheduling system now includes a wall board, which lists the physicians available to read the X-rays, thus enhancing overall coordination. Concurrent with this, the team revised the scheduling system to show where each patient was within the process, so that any problems that developed were readily apparent.