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Image-to-report cycle drops to overnight
In earlier times, when transcribers took radiologists’ notes in shorthand, they could produce typed reports six hours later — so you’d expect electronic technologies to do better. But if layered on to existing processes, they can bog it down as much as seven to 10 business days. It happened at James A. Haley Veterans Hospital in Tampa, FL.
"The physicians were screaming about the delays," says Kaye Hixon, MS, RN, CPHQ, executive assistant for continuous quality improvement. They would have been happy seeing their routine X-ray results within two or three days."
When Hixon phoned other facilities seeking local benchmarks for Haley’s radiology reporting QI initiative, she learned that others had similar problems. A Haley team set internal customer wishes as the benchmark to beat: "The doctors wanted two- to three-day turnarounds, so we aimed for one to two days," she says.
Using criteria from the Malcolm Baldrige National Quality Award as the framework, the interdisciplinary team bumped the average image-to-report cycle from 7.8 business days down to same day, or overnight for notes submitted after 5 p.m.
Not only did the team wow its internal customers, the hospital won a Merit Award for improving customer service and saving tax dollars at the 1998 President’s Quality Award Program. The awards are based on the Baldrige criteria. (For a look at the time savings, see graph, above.)
As described on its Web site (www.baldrige.org), the Baldrige Criteria for Performance Excellence, named for former Commerce Secretary Malcolm Baldrige, are used worldwide by thousands of organizations to assess and improve their overall performance.
The criteria identify achievements and improvements made in seven key areas: leadership; strategic planning; focus on patients, other customers, and markets; information and analysis; staff focus; process management; and organizational performance results.
While it took less than two hours of active work to produce and deliver a final X-ray report, no one could account for the actual time lapse of 156 hours from image to report. "Nobody owned the process," Hixon explains. It was all too common for physicians to hunt for radiology reports by calling the radiology department, or the radiologist on the case. Often, patients were discharged before final reports ever caught up with their charts.
To track the long, mysterious journey of X-ray notes, the QI team flowcharted the process and uncovered several obvious time eaters. "Throughout the project, we challenged ourselves: Make it work better for the physicians, [the] end users of the radiology reports; but let’s not do a bad process faster," Hixon recalls. (See "Goal: Hard copy report available same day or less," p. 72.)
Two dramatic improvements came easily:
• Transcription cycle. "When I asked our transcription contractor what it would take to get the tapes transcribed faster, they said they could do it right away," Hixon says. "They said Would you like yours in four hours like the other hospitals? Nobody ever asked us, so we assumed you weren’t in a hurry.’ That taught us how important it is to partner with our suppliers."
• Elimination of stopover in transcription department. The team eliminated this step, probably a remnant of an old process, for a gain of 1.5 days. Other changes presented greater challenges than deleting a step or making a phone call.
Challenges to the new plan surfaced in these three areas to which the team applied fixes of new work tools and old-fashioned diplomacy:
1. Inpatient units opposed the prospect of having radiology reports uploaded to their overworked printers. Dedicated printers were installed on approximately 10 units. Hixon estimates cost, including the wiring, at $2,000.
2. Physicians chafed at the prospect of editing their reports on-line. The medical champion of the project talked trade-offs with his colleagues. When staff radiologist and associate professor of radiology at the University of South Florida, Edward Eikman, MD, showed how much they could gain by spending an extra hour or two self-editing, the radiologists warmed up to the idea.
The hospital went on to replace 1980s-vintage word processing programs with graphical software that was relatively easy to use. And they installed additional workstations so doctors could find a computer terminal anytime they had a few minutes for editing.
Hixon recounts, "The first few times the doctors got their routine X-ray results within one day, they thought it was an accident." Referring to Eikman’s involvement, she adds, "The most successful QI teams at our facility are the ones that have physician involvement."
Hixon underscores that timely X-ray reports are especially important in light of Haley’s 600,000 outpatient visits per year. "Now the physicians can be confident that the X-ray results will be there when they schedule a patient for a three- or five-day follow-up visit," she notes.
3. Legal requirements dictate that X-ray reports must have a radiologist’s signature. Each physician received a coded electronic signature that’s as valid as a handwritten one. Hixon observes, "Getting buy-in from the radiologists was a big accomplishment." Eventually Eikman assured them that the electronic signatures were valid and admissible in case the reports ever went to court.
Eikman costed out the new solutions, including physicians’ editing time. "It costs us an average of one dollar per report to cut six or seven days off the turnaround," he says.
The radiology QI project, like all the hospital’s efforts, used all seven Baldrige criteria. Hixon observes that the radiology reports project impressed them forever with the importance of two elements in the Baldrige model:
• Supplier partnerships. "Your internal initiatives are only as good as the cooperation and quality you get from your vendors, whether they’re doing a service like our transcription contractors or whether they’re supplying your equipment."
She concedes that while all supplier changes probably won’t be as effortless as that with the transcription service, "if they own part of the process, it will be easier."
• Customer satisfaction as improvement target. "The customers in this case were internal — the doctors." Indeed, the number of satisfied customers jumped 78% by project completion. (See pie charts, p. 72.)