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Improving Your Image: Timely Access to Radiology Services

Project Added:
19 August 2015
Last updated:
21 August 2015

Improving Your Image: Timely Access to Radiology Services

Summary

Imaging departments across NSW are struggling to balance emergency, inpatient and outpatient care with resources. The increasing demand for medical imaging (MI) presents further difficulties in meeting expected timeframes, particularly for examination and reporting turnaround times. The radiology department will assist referring clinicians in making the patient’s journey through the hospital as efficient as possible by minimising delays, and improving timely access to medical imaging services.

Download a poster from the Centre for Healthcare Redesign graduation, August 2015. 

Aim

To improve timely access, efficient and safe care of patients requiring medical imaging services.

Benefits 

  • Improved patient experience by reducing waiting time for examinations.
  • Increased collaboration and improved relationships between MI staff and referring clinicians / departments
  • Improved staff morale in medical imaging department (MID)
  • Improvement in emergency department (ED) targets (including Emergency Treatment Performance [ETP]) 
  • Minimising inpatient bed days
  • More efficient and cost effective imaging services
  • Nepean Hospital has an opportunity to take a lead role in setting state benchmarks by sharing lessons learnt and outcomes achieved
  • Shorter waiting time for outpatients which will maximise revenue for the hospital
  • Time saved can be redirected to enhance other activities such as education
  • Manage appropriateness of referrals (clinical necessity)

Project status

Project started: July 2014 

Project status: Implementation - some solutions of the initiative have been implemented, others are currently being implemented.  Some long term solutions are in early pilot stage.

Background

Radiology has been identified by many referrers as a major barrier to timely diagnosis and treatment of their patients, particularly in the ED, following implementation of the National Emergency Access Target (NEAT), now called Emergency Treatment Performance (ETP).

However, if radiology only focuses on emergency patients, longer wait for exam and reporting times for inpatients may lead to longer hospital stays, and a decrease in revenue from outpatients.

The number, type and complexity of examinations have increased, in addition to the acuity of patients. Non-reporting activities (e.g. multidisciplinary team meetings, consultations, teaching and research) need dedicated time so that patient care and service to referring clinicians can be optimised.

Appropriate referrals need to be presented to radiology for all examinations. Requests with inappropriate or poor history, duplicate requests or those with insufficient patient information reduce productivity and waste valuable resources.

Radiology needs to find ways to improve customer service to patients and their referrers. Referrers need to be mindful of the ever increasing volume of examinations undertaken in radiology and determine how they can assist in streamlining the patient flow through radiology.

Implementation

Solutions 

1. Medical imaging department provided prep sheets, factsheets and checklists for referrers

Development of plain film, CT and contrast factsheets, with the plan to have available on hospital intranet. In addition, contrast checklist from ACI and prep / recovery sheets are being developed. Informed consent and complete patient preparation by referring clinicians will soon be piloted in selected inpatient wards.

2. Medical imaging department staffing and rostering changes

All departmental groups reviewed, piloted and implemented effective rostering changes.

3. Emergency department referral process for non-prep CT head and c-spine

Eliminate the need for approval from radiology trainee if the ED provides appropriate clinical history and an agreed referral pathway.

4. Transport staff rostered in emergency department

New transport assistant positions allocated to transporting patients to and from the ED to radiology.

5. Equipment purchase and upgrades

Equipment and resources were reviewed and appropriate purchases made, such as a dedicated wheelchair for emergency medical imaging room.

6. Establishment of an allocated waiting area for ambulatory emergency department patients

Use of a waiting bay near emergency CT and x-ray, for ambulatory ED patients to wait for their examination (eliminates need to search for them around ED).

7. Role clarification for staff

Review roles of all staff in radiology to determine the most appropriate person for each task and how the team can best work together.

8. New communication channels

Share updated contact details between MID and referring departments regularly.  Regular fortnightly meeting with ED. A variety of communication methods were used including emails, newsletters, flyers, workshops and regular meetings.

9. Improve information technology interfaces

Enhanced communication between Cerner and the radiology information system. New consult process for urgent reporting of selected plain films from the ED.

Knowledge sharing

A literature search was conducted to inform implementation working groups of the work already done in this area internationally. 

Progress on this project has been shared with clinicians and managers from other ACI Medical Imaging Committees during the project timeframe.

Consultation with other sites has also occurred to exchange ideas.

Implementation site

Nepean Hospital, Nepean Blue Mountains Local Health District.

Partnership

ACI Centre for Healthcare Redesign. 

Evaluation

Hospital and local health district key performance indicators focus on timely access to radiology services which is becoming increasingly difficult. ACI Medical Imaging Committees (Medical, Radiographic, Nursing, Business Management) have been discussing the impact on MIDs of increased demand, particularly from ED due to ETP for several years.

As we are still in implementation phase for many of our solutions, significant improvements are not yet evident.  Evaluation of the solutions will occur through measuring the turnaround times against the project objectives.   Daily data is currently being collected in order to move to “exception reports” so that root cause analyses can occur on a daily basis.

Some improvements have been seen in the turnaround times for examinations (requested to reported), particularly for emergency CT patients. There is still a long way to go to reach the target however these small improvements are encouraging.

Qualitative data will be gathered by repeating the initial staff (MID and referrers) and patient surveys to see whether the desired changes are occurring.

The addition of transport staff to deliver emergency patients to and from imaging has resulted in MID staff being able to concentrate on patient flow and care, particularly in CT.

The simple communication channel upgrades have resulted in a greater understanding of the various roles and issues within both medical imaging and the emergency department. Improved relationships have resulted in early problem solving and less stress among hospital staff members.

A major issue identified in the project was the difficulty for MID staff finding ambulatory emergency patients as they often wander off. By establishing a waiting bay close to MID, time is saved in looking for them and there is greater flexibility in prioritising available patients.

Previously unknown issues between the ED and MID IT systems have been discussed and mostly resolved. These issues had caused a great deal of time wasting and stress among staff of both areas.

Implementation and evaluation will be ongoing and improvements will be continued into other modalities and other MID services.

Lessons learnt

The greatest challenge, as in most projects, is effective communication among stakeholders. There are many referrers into Radiology and the scale of communication makes it difficult. A variety of methods were used including emails, newsletters, flyers, workshops and regular meetings. Communication within medical imaging and among other hospital departments will continue to be improved into the future.

The executive sponsor (general manager of the hospital) was essential in the implementation to ensure engagement and commitment of high level clinicians for a project instigated by radiographic staff.

Teamwork, mutual respect and understanding had to start within MID before it could be enhanced with external stakeholders. A working party was established with representation from all staff in the MID. This group will continue building upon positive culture and teamwork within MID.

The MID could not implement these solutions without collaboration with the emergency department and the neurology ward (inpatient pilot).

Dedicated resources are critical to the success of any clinical redesign process. The volume of work in radiology often gets in the way of implementing changes when resources are tight.

It became evident as the project implementation phase progressed that all solutions could not possibly be implemented during the allocated time frame.  The original scope of the project has proven to be far too ambitious.

A major objective change occurred during the implementation phase as it became clear that the objective was unachievable within existing resources. It also became evident that the allocation of these resources (if possible) would not provide sufficient benefit to either patients or referrers to justify additional expense.  Specifically, the turnaround goal for plain film reporting for emergency patients was originally an additional one hour after examination completed. In order to meet ETP, it was agreed that ED clinicians can usually make a decision to admit or discharge their patient based on the image being available and reviewed, not the report. A system is being trialled to use a ‘consult’ function in Cerner FirstNet so that if the ED clinician is unsure of the image, they can request a ‘consult’ (actually a report) on that particular patient.

This initially was seen as a negative; however it soon led to a more practical, efficient and cost effective solution which has the potential to be applied to other sites/departments.

Contacts 

Andrew Teece
Chief Radiographer, Nepean Hospital
Nepean Blue Mountains Local Health District
Phone: 02 4734 2422
Andrew.Teece@health.nsw.gov.au

Michelle Carpenter
Senior Radiographer, Nepean Hospital
Nepean Blue Mountains Local Health District
Phone: 02 4734 1855
Michelle.Carpenter@health.nsw.gov.au

Annie Hutton
Manager, Radiology and Nuclear Medicine Networks
Agency for Clinical Innovation
Phone: 02 9464 4624
Annie.Hutton@health.nsw.gov.au

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