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May 2014 diagnostic imaging and regional nuclear medicine
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May 2014 diagnostic imaging and regional nuclear medicine


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  • PLEASE READ THESE TIPS CAREFULLY BEFORE CRAFTING YOUR PRESENTATION: Tips:Where possible, use simple lay person terms (remember not everyone in the audience is a clinician or has a healthcare background). Where this is not possible, provide a high level explanation of what the medical term means.Avoid use of acronyms– please state it in full form both in the webex and during Q&A at the meeting itselfStick to key items/points you would like to bring across– You can’t tell them everything. What are the most important items that fall within the 4 strategic directions? Try to tell a story to the board and be sure to incorporate the “patient perspective” Where possible- show outcomes/measurements before and after the improvement/initiative– a picture in the form of a photo, run chart or other chart such as pareto chart is worth a thousand wordsYou can verbally say more than is on the slide to convey your thoughts– avoid having everything you want to say written on the slide. Simple slides that convey the problem, solution(s) and outcome are best (goal--- improvement initiative– outcomes/measurements)Although you are encouraged to celebrate and communicate your successes over the past year, the board wants to hear about your challenges. Their role is to provide guidance and direction (through Q&A) so you can be successful in the great work you do.When you finish creating each slide, ask yourself, “Am I bringing it back to the patient?” What is the impact on the patient? How do they feel about this? Ground your presentation wit the patient.
  • Thank you for the opportunity to speak about Diagnostic Imaging and Regional Nuclear Medicine. The agenda will include program information, scorecard detail, our goals for 2013/14, a review of some initiatives from the improvement board, 2014/15 goals, best practices, quality assurance initiatives, some new procedures and a review of some of the challenges we’ve experienced.
  • Diagnostic Imaging Services include: Computerized tomography (CT), Mammography which includes the Ontario Breast Screening), General Xray & FluoroscopyNuclear Medicine Services for the region are operated by St. Mary’s with service being offered at both St. Mary’s & Grand River Hospitals.Nuclear medicine includes a full range of imaging, non-imaging and therapeutic procedures
  • The scorecard for diagnostic imaging was developed to track and monitor metrics that mattered to the staff as well as aligning with hospital goals. Metrics were established that relate to the following 4 categories: quality and safety, patient & family centred care, our people and financial stewardship.The metrics being monitored are divided into what are called:DRIVERS:These metrics are closely aligned with the hospital’s priorities and will drive performance.All DRIVERS will have plans in place to reach targets, with ‘ ‘work plans’ identified to improve performance.The staff identified our first two driver metrics as something that impacts their quality of work life, quality of service, and has a financial impact if running late and overtime is accrued.Both drivers track the percentage of time the first appointment of the morning in CT and the first appointment in the afternoon for ultrasound begin on time. We began with collection of baseline data and are now into regular daily tracking. For CT baseline data indicated the first procedure started on time only 57% of the time. We are now starting on time 93% of the time. Tracking will continue to ensure sustainability. For ultrasound, the first afternoon appointment of the day for both prostate biopsy and thyroid biopsy begins on time did not meet the target of 75% of the time. The team in ultrasound created a work plan (also called an A3) and identified a number of reasons as to why the procedure did not begin on time one example includes the patient was scheduled to arrive at the same time that they procedure was to begin. This did not allow enough time to register and prepare the patient. Currently the team is looking at things they have control over changing e.g. having the patient arrive 15 minutes early.WATCH METRICS:Are important metrics to understand department performance.Performance on these metrics is also monitored monthly.We will “watch” for adverse trends in performance, at which time the metric may become something we actively work to improve if it is decided that action needs to be taken. Watch metrics may turn into Examples of our watch metrics are:The first two watch metrics involvetracking turnaround time (the time from when the exam was ordered to the time when the exam was completed. A report has just been written by decision support that will allow us to begin track baseline information.Watch #3 report turnaround time which measures the time from when the exam was completed to when the report is available to the Emergency department. I’ll speak in a bit more detail on our current performance in a later slide.
  • Also being watched are the length of time patients are waiting to have their procedures. Specifically measured is the time from when the booking is taken to the date the patient is having their procedure. This is being monitored for all modalities.Another watch metric relates to workload in ultrasound. We want staff to work at a steady pace without risk of injury.The final monthly watch metric of budget variance relates to our financial stewardship.
  • Under the Quality & Safety Goal for 2013/14The shared PACS system with GRH was installed in Feb 2013. Patient images and documentation are available from either site.The CT procurement negotiations are almost complete-details relating to the turnkey construction remain.Under the Patient & Family Centred goalPatient surveys are being conducted for nuclear medicine and ultrasound.Under the Our People goalA staff member (CT technologist) cross trained in mammography.Under the Financial Stewardship goalReminder calls are being conducted to remind patients of their procedures. Calls are being conducted for all modalities.
  • During 2013-14, the huddle boards in DI were redesigned (DI was one of four pilot areas to participate). Staff create a ticket which contains a new idea. During huddles, the staff use a pick chart to identify whether the idea is easy to implement and has high impact , easy to implement with low impact, difficult to implement or whether the team does not wish to work on the ticket at all. Each modality within DI has color coded idea tickets so that we can easily track which area is working on an idea. Nuclear medicine will be updating their lean boards and will be partaking of additional lean training starting in September 2014.
  • The team in X-Ray identified an improvement suggestion to assist patients in changing into a gown. A simple picture with set of instructions was created and made available in each patient change room.
  • Patients having sentinel node breast surgery were arriving as early as 8 hours prior to their surgical time. During this time, patients travelled to nuclear medicine for a sentinel lymph node imaging procedure, to radiology for a needle localization and finally to surgery (not always in the same order). After speaking with patients who experienced this process staff gathered the following quotes:ExcruciatingLongest Day of my lifeTerrifyingThis improvement initiative required that staff from Day Surgery, Radiology and Nuclear Medicine work closely together to shrink the time from patient arrival to surgery. Process launched in April 2013 reduced the patient’s stay by 4 hours.100% of Sentinel Node Breast Biopsy patients have the injection first, followed by the Needle Localisation before arrival to back to Nuclear medicine for the images.
  • Nuclear medicine technologists, on a daily basis, compound and prepare radiopharmaceuticals that are used to administer radioactive tracers to patients having nuclear procedures at either site of the regional program (GRH or SMGH).A nuclear medicine student identified at huddle that during her radiopharmaceutical compounding training,not all of the preceptor technologists were following the SOP in the same manner. Although a step by step procedure had been created, it still left room for some technologist decision-making and variation and this could prove confusing to students and new staff. The staff gathered and reviewed the current SOP. They consulted with expert peers (commercial radiopharmacy), performed a literature review, and subsequently altered the SOP as a result. Students do make a difference to the workplace and keep us all on our toes!
  • The team in ultrasound identified that not all staff were following the same patient flow for thyroid aspiration procedures. There was variation in flow from the radiology nurse to the ultrasound technologist to the radiologist. The goal of this initiative was to provide a consistent patient experience through standardization of the thyroid aspiration process. The process standard work provides step by step guidance from initial greeting of the patient, through patient preparation , explanation, consent, scan, aspiration by radiologist, patient assessment by nurse and on to exam completion. In addition to improving the patient experience, the process standard work document will also serve as a training tool for new staff member. Once the standard work document has been completed and communicated to all staff, it will be implemented and audited periodically for sustainability.
  • What is your data/metrics currently telling you that your department/unit needs to work on? Where are you going next with your unit goals?What goals is your unit/dept expected to work on to contribute to organization strategy/priorities?This year we have established a Unit Leadership Council who’s purpose is to:To provide leadership to the unit by tracking key performance metrics, understanding problems and making improvements in support of the hospital’s strategic directionsTo provide a venue for communication between the Nursing Advisory, Professional Advisory Committees & clinical units.To provide a structure to address and improve unit level processes that will enhance staff work life
  • Here is an example of a staff member’s idea that will aim to improve service levels for portering of patients as well as improve work life for staff. A huddle board ticket was submitted by a central porteringstaff member identifying that the portering team was having difficulties in delivering patients to their destinations within the hospital in a timely manner. This could potentially cause unnecessary delays to ED, nursing units and the various programs and services. The team decided that the ticket was not a simple fix but instead a larger project involving multiple programs and services. As a result the ticket was taken to the Unit Leadership Council. A multidisciplinary group had their first meeting in April to begin mapping out the process. The group will meet regularly to work their way through identification of the root cause and begin to identify solutions.
  • The hospital has set a goal to reduce the ED length of stay for at least 90% of admitted patients will be ≤8 hours.Diagnostic imaging has set a target that 75% of ED patients from time of exam to exam completed will occur within 2 hours. It is important to note that both CT and ultrasound exams do have required patient preparation e.g. CT patients often need to have barium administered 1.5 hours prior to the procedure and ultrasound patients must begin to drink water 1.5 hours prior to the procedure. Once it is identified that the patient requires a CT or ultrasound, the preparation begins while the patient is still in ED. A report is being written by decision support that will allow us to begin to capture baseline data.Radiologists have set a goal that 75% of ED patient reports will be available within 1 hour of exam completion 24 hours a day, 7 days a week.
  • The shared PACS installation impacted workflow for the technologist as well as the radiologists. Prior to the PACS installation, ultrasound technologists would image the patients, then wait until they had a batch of completed patient studies before they walked the paper files to the radiologist for interpretation. Now after each patient’s images are completed, all documentation is scanned into the PACS, the study is identified as “S” for stat in PACS. CT and X-Ray are also following the same method for identifying ED patient studies. Immediately the interpreting radiologist is able to view the studies on their workstation and they are identified as ready to interpret. To make the flow even more efficient, the radiologists adjusted their daily work schedules and are now assigned to a specific modality e.g. CT, Ultrasound or X-Ray . Current data shows that 90% of the time reports on emergency patients are available to the ED physician.
  • Currently we have collected 2 months of baseline data. CT procedures on ED patients involve patient preparation (drink barium 1.5 hours prior to images being taken. The clerks in ED enter the request for the procedure, the nursing staff in ED begin to administer the barium. When it is time, the patient is transported to CT for the procedure. It is important to note that CT is available on an on call basis from midnight to 0700 daily. ED physicians wi;; not request to call a technologist in unless it is urgent. There are some studies that the ED physician will opt to wait until the day shift begins at 0730.Ultrasound procedures from the ED involve patient preparation so patients are given water 1-1.5 hours prior to their scan.
  • The new alerts will be used to communicate new procedures, changes or new policies. The alerts will be place in a consistent place, and will contain space for each staff member to sign the communication once they have read it. This alert system was piloted within X-Ray and will be rolled out during 2014-15 in other modalities.
  • Recently in place is a Tri-Hospital Chief of Radiology . Dr. Darren Knibutat serves as the Chief for St. Mary’s, Grand River and Cambridge Memorial Hospital. Medical Lead Radiologists are in place at each institution (Dr. Chad Lavallee is the Lead for SMGH). The Tri Hospital Radiologist Quality Committee has begun to meet and their first shared project is to introduce peer review. The objective of a peer review process is to learn and improve. Software will be purchased that will allow images to be assigned anonymously to a peer for review. The second “review” of images is compared to the original interpretation. The outcome of each peer review presents opportunities for the group to learn from each other and strengthen expertise.
  • The SNM procedure guideline manual contains best practice documentation. An 18 month project to review all nuclear medicine procedures, compare them to the gudielines and make the necessary adjustments to the protocols. -Gastric emptying is a study where a patient consumes a meal containing a radioactive tracer, then they are imaged. In the past there was so much variability throughout the world that institutions were creating their own protocols and creating their own databases. The SNM developed a standard process which has been adopted worldwide. Now each patient receives a standardized meal, undergoes a standardized imaging protocol, and standardized image processing plus quantitation for results. Now nuclear physicians can more confidently sort normal from abnormal and the images have a higher diagnostic value-Cardiac half dose protocolA literature review of new trends and protocol refinement pertaining to our cardiac dedicated ultrafast nuclear medicine camera took place.The new protocol allows a patient specific balance between ultrafast imaging and lowering patient radiation dose administration maintaining high quality imaging- every patient is assessed by the technologist and assigned a relative priority between rapid imaging and importance of lowering administered radiation dose- patient’s clinical condition and compliance, age, history of multiple prior (or future need of) medical imaging procedures are factors taken into account- The outcome is a significant improvement in radiation safety profile of cardiac MPI patients; many patients receive ~ 50% of otherwise standard departmental weight based dosing- ultrafast imaging in selected patients improves image quality in patients with a poorer clinical condition or lesser compliance- significant patient specific improvement in overall safety, quality and comfort compared to the prior standard dual head MPI procedure
  • Radiologists regularly refer to best practice literature and make the recommendations for adjustments to protocols and specifically this year with CT protocols. The altered CT protocols are built directly in the CT scanner and the changes communicated to the CT technologists.. The new protocol is immediately available for selection by the technologists.The radiologists have combined the high resolution portion of the lung imaging with the routine imaging in order to reduce radiation dose to the patient.  They are also working on formulating a combined renal protocol with a goal to reduce dosage to the patient.
  • The hospital has just purchased a new CT scanner that will lower the radiation dose to the patient as well as decrease the time required for imaging. The scanner will perform the full complement of CT procedures currently offered at St. Mary’s but also will be able to perform cardiac CT. Cardiac CT is a heart-imaging test that uses CT technology with or without intravenous (IV) contrast to visualize the heart anatomy, coronary circulation, and blood vessels (which includes the aorta, pulmonary veins, and arteries). This procedure will be new for St. Mary’s.
  • -In response to a staff member’s observation on quantity of xrays some patients seemed to be having, the number of in-patients having multiple X-Rays during their stay was tracked. The data identified that there were a number of patients who had a high volume of Xrays. The charts are currently being reviewed by a physician and the quality team to ensure each of the X-Rays was required.-Staff and physicians wear lead aprons to reduce exposure to radiation during diagnostic imaging procedures. Lead aprons are in use in many areas of the hospital (radiology, nuclear medicine, catheterization laboratory, operating room) and there has been no easy way to keep track of the aprons. Although we were adhering to legislative requirements to perform fluoroscopy on each apron to ensure there were no holes or cracks, it was difficult to ensure we maintained a complete inventory. Wanting to keep our staff and physicians safe, we arepurchasing a new identification system using computer software and barcoding. Every apron will have a barcoded button that can be scanned during visual or fluoroscopic inspection. -Early in 2014, we completed and submitted all of the required documentation to maintain our accreditation standing with the OBSP. -Nuclear medicine must comply with the regulations set out by the CNSC. Annually there is a compliance audit submitted and an on site inspection.-In both Diagnostic Imaging & Nuclear medicine staff conduct internal OH&S audits to be proactive in identification of safety hazards.
  • In response to a patient complaint relating to a patient who underwent a prostate biopsy, during a quality of care review, it was identified that providing patients with verbal instructions just wasn’t meeting the needs of our patients. This particular patient experienced some bleeding post procedure and felt ill prepared to know what to do. The radiology nursing staff, along with a hospital educator, developed information pamphlets for patients having interventional procedures. Patients now have information relating to what will happen, before, during and after their procedure.
  • Once a decision has been made to replace an important piece of equipment, we must carefully plan the installation. The planning goals will be to minimize the impact to patient care, maintain access to the service, and to balance demand and capacity in a predictive manner but in an unpredictable environment (meaning the daily juggling of bookings for in-patients, out patients and emergency patients).
  • Manpower availability has proven a challenge this year in successfully securing qualified staff on a PT or casual basis. For example, the inability to find staffing has impacted the wait times for ultrasound. As of Apr 21st we are training our newest staff member and after a period of 4 months, we are finally fully staffed in ultrasound and able to return to typical capacity.Radiopharmaceutical supply continues to be an issue with drugs and kits on backorder or available only through Health Canada’s Special Access Program. The unavailability of drugs will impact hospital costs e.g. one lung scan radiopharmaceutical now has a single North American supplier and the cost increase was close to 500%. We will adjust the ordering patterns to save delivery costs and utilize the product as efficiently as is possible.
  • The shared PACS system has decreased repeat exams and allows for more accurate comparison of previous studies. Along with the shared PACS solution came ED discrepant reporting. Emergency physicians regularly review xray images and will record their preliminary results in the PACS system. The preliminary report is immediately available to the Radiologist who will in turn review the results. If the radiologist review identifies a discrepancy in results, the radiologist will electronically notify the ED of the discrepant result. The ED physicians are working in collaboration with the PACs vendor to adjust/enhance some of the functionality of the software.
  • Transcript

    • 1. Board Quality Committee Diagnostic Imaging & Regional Nuclear Medicine May 2014
    • 2. Presentation Agenda • General program information • Program scorecard • 2013-14 Goals • Initiatives from the improvement board • 2014-15 Goals • Best practices • Quality Assurance • New Procedures • Challenges
    • 3. General Information Program Description • Diagnostic Imaging Services: St. Mary’s General (SMGH) • Computerized Tomography (CT) Scans • Mammography (includes Ontario Breast Screening) • General x-rays and fluoroscopy • Ultrasound • Regional Nuclear Medicine Services: St. Mary’s General (SMGH) and Grand River Hospitals (GRH) • Imaging Procedures • Non-Imaging Procedures • Therapeutic Procedures
    • 4. Program/Unit Scorecard QualityandSafety Procedures Starting On Time In The Morning (%) DRIVER 1 Percentage of time in CT that the morning exams start at the scheduled procedure time of 08:30am. Procedures Starting On Time In The Afternoon (%) DRIVER 2a Percentage of time in Ultrasound that the thyroid biopsy starts at 1300 hrs. DRIVER 2b Percentage of time in Ultrasound that the prostate biopsy starts at 1300 hrs. ER Exam Turn-Around-Time (%) WATCH 1 The percentage of time that the ER exam turn around time meets the 2 hour target for CT exams. WATCH 2 The percentage of time that the ER exam turn around time meets the 2 hour target for Ultrasound exams. ER Report Turn-Around-Time (%) WATCH 3 The percentage of time that the ER report turn around time meets the 1 hour target for CT and Ultrasound exams
    • 5. Program/Unit Scorecard PatientandFamilyCentredCare Prospective Exam Wait Times (Days) WATCH 4 The number of days from phone booking to actual appointment date for certain exams in CT. WATCH 5 The number of days from phone booking to actual appointment date for certain exams in Ultrasound. WATCH 6 The number of days from phone booking to actual appointment date for certain exams in Xray (Gastrics and Specials). OurPeople Workload / Productivity WATCH 7 The average number of exams scanned by an Ultrasound technologist per day. FinancialStewardship Budget Variance WATCH 8 Monthly variance in the total monthly budget for all DI departments combined.
    • 6. 2013/14 Goals Goals Status Strategic Direction - Quality & Safety Procure and install a shared PACs (image storage repository) with Grand River Hospital Begin preliminary planning for procurement of a new CT Strategic Direction - Patient and Family-Centered Care Patient Survey-expanded to include other modalities Strategic Direction - Our People Staff survey- Communication and Opportunities for staff to expand breadth of practice e.g. adjustments to the DI structure and cross training in Mammography, CT Strategic Direction - Financial Stewardship Reminder Calls-expand to include other modalities in diagnostic services
    • 7. Initiatives from the Improvement Board
    • 8. Initiatives cont’d
    • 9. Initiatives cont’d Improving the patient experience for those having sentinel lymph node surgery. BEFORE AFTER
    • 10. Initiatives cont’d St. Mary’s General Hospital Kitchener-Waterloo Regional Nuclear Medicine Program Subject: Standard Operating Procedure for Compounding in the Laminar Flow Hood Procedure: Compounding in the Laminar Flow Hood • Review/Revision of Standard Operating Procedure–Nuclear Medicine
    • 11. Initiatives cont’d • Ultrasound standard work for thyroid aspirations
    • 12. 2014-15 Goals Goal 1: - To establish a monthly Unit Leadership Council (ULC) •Description: To provide leadership to the unit by tracking key performance metrics, understanding problems and making improvements in support of the hospital’s strategic directions. •To provide a structure to address and improve unit level processes that will enhance staff work life Target – •Action Plan: Scheduled monthly meetings began as of January 2014.
    • 13. First Project Central Portering Workflow mapping
    • 14. 2014-15 Goals cont’d Goal 2: - The hospital goal to reduce the ED length of stay for at least 90% of admitted patients will be ≤8 hours Target – Diagnostic Imaging has set a goal that 75% of ED patients from time exam ordered to exam completed will occur within 2 hours. Target – The Radiologists have set a goal that 75% of ED patient reports will be available within 1 hour of exam completion (24/7).
    • 15. • Very positive early results for Radiologist report turnaround time for ED patients within the first few months of tracking!
    • 16. • CT and Ultrasound tracking from time the exam was ordered to when the exam was completed.
    • 17. 2014-15 Goals cont’d Goal 3: - Improve communication Target – In the recent staff survey, the team told us how important communication is to them. • Action Plan: Introduce new Alert system
    • 18. 2014-15 Goals cont’d Goal 4: - Tri Hospital Quality Assurance Program Target – To introduce a quality assurance program that includes Radiologists conducting peer reviews to learn from each other and improve. • Action Plan: The three hospitals will purchase Radpeer software.
    • 19. Best Practices cont’d • Nuclear Medicine is 45% complete in its review of best practice documentation (Society of Nuclear Medicine procedure guideline manual). • Gastric Emptying Procedure • Cardiac Half dose Procedures
    • 20. Best Practices cont’d • Radiologists regularly refer to best practice literature and make the recommendations for adjustments to CT protocols. • CT High resolution imaging with reduced dose. • Renal Protocol adjustment coming soon.
    • 21. New Procedures • New CT scanner coming soon
    • 22. Quality Assurance Practices • Tracking of In-Patients having multiple X-Rays • Radiation Safety-lead aprons • Ontario Breast Screening Program Accreditation • Annual compliance audits (Nuclear Safety Commission) • Monthly internal occupational health and safety audits
    • 23. Challenges Quality of Care Review March 2013 911 Queen’s Blvd., Kitchener, ON N2M 1B2 (519) 749-6595 Prostate Biopsy
    • 24. Challenges cont’d • CT scanner planning and installation Minimize impact to patient care Maintain access to the Service Balance demand and capacity (in- patients, ED and out patients)
    • 25. Challenges cont’d • Technologist manpower issues. • Radiopharmaceutical Supply
    • 26. Reflections • Shared PACS solution (Grand River & St. Mary’s Hospitals) • PACS ED discrepant software
    • 27. THANK YOU