The document summarizes updates on access to MRI and CT scans in Ontario. It discusses how wait times have improved through increased capacity, improved efficiencies, and stable or decreasing demand. Key strategies included empowering patients, increasing health system capacity using a single provincial wait time information system, and obtaining feedback from clinical stakeholders. MRI and CT scan rates per capita in Ontario have increased and are now comparable to international benchmarks. Wait times have decreased significantly from initial highs in 2005 through targeted investments and process improvement initiatives.

1. Access to Care: MRI/CT Ontario Update
Meeting: Taming of the Queue
Date: March 29, 2012
Julian Dobranowski, MD, FRCPC
Provincial Lead ATC MRI/CT
Provincial Lead Cancer Imaging Program CCO
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2. Source : Wait Time Alliance report 2011
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3. Overview in 3 parts
Add images
CT PET/CT MRI
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4. Wait Time Strategy Key Elements
Empowering patients and demonstrating
accountability to the public
Increasing health system capacity
Using a single provincial wait time
information system
Obtaining feedback and recommendations from
clinical stakeholders
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5. Ontario’s Wait Time Strategy
MRI & CT Scans
Cancer Surgery
Key Health Services Cataract Surgery
Targeted
Hip & Knee Replacement
Cardiac Procedures
Expansion to major Surgical
Areas
Ontario’s Wait Time Strategy was introduced by the
Ministry of Health and Long-Term Care in November 2004. Perioperative Efficiencies (SETP)
The Wait Time Strategy was developed to improve access
to five key health services by reducing wait times, and then
expanded to include wait time data for major surgeries as
well as perioperative efficiencies. 5

6. MRI CT Wait Times-Approach
Expert panel
2005
2006
2010
2012- ATC DI subcommittee
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7. MRI CT Approach- Quality dimensions
Safe
Effective Efficient
VALUE FOR
MONEY
Accessible Equitable
Integrated Responsive
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8. MRI CT Approach – Change Management
Data/Information
Knowledge
Performance
Management
Knowledge Transfer
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9. MRI CT Approach
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10. Ontario MRI CT Targets 2005
MRI 62 per 1000
CT 114 per 1000
P4 90th percentile
80 days
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11. PART 1
CT 2004 2005 Starting out
96 CT scanners hospitals
4 CT in IHF’s
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12. CT 2005 How did we compare? (OECD)(CIHI)
CT Scan Rate per 1,000
2005 2006 2007
population
Ontario 79.4
Canada 101.6
Australia 88.6
France 111.1
United States 194.8
Denmark 71.4
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13. Provincial Wait Time Trend: CT
• CT wait time has been relatively stable since late 2010 at just above the 28 days priority 4
target.
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14. CT scans ordered and completed by Fiscal Year
171 scanners (base 94)
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15. CT scan rates per 1,000 population
Data Source:
2008-2011 – Wait Time Information System, Cancer Care Ontario
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16. CT Scan Rate per 1,000 population –comparison (OECD)(ATC)
CT Scan Rate per 1,000
2007 2008 2009 2010 2011
population
Ontario --- 78.3 81.5 79.7 78.5
Canada --- 119.0 125.4 --- ---
Australia 88.6 93.4 93.9 --- ---
France 120.3 130 138.7 --- ---
United States 227.9 --- --- --- ---
Denmark 73.6 83.8 --- --- ---
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17. CT what changed?
Capacity- bulk buy
incremental funding
Demand-
Completed Scan
Volume
YEAR CT Population
2008 1,012,868 12,919,572
2009 1,065,470 13,050,754
2010 1,053,540 13,193,809
2011 1,050,597 13,349,125
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18. CT- 2012 current wait time P4
February 2012 – P4 Wait time 90 percentile = 29 days
Increased capacity
Improved efficiencies
Stable or decreasing demand
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19. PART 2
PET/CT
1999 OANM - Request for Provincial funding for PET
2000 ICES- Review of Evidence
2001 ICES- Report- Health Technology Assessment of PET
“despite the availability of PET scanning for almost three decades, the number of
methodologically high quality studies (and the numbers of patients within these
studies) is distressingly small.”
Institute for Clinical Evaluative Sciences. 2001 (May) Health Technology Assessment of
Positron Emission Tomography (PET) – A Systematic Review. An ICES Investigative
Report.
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20. PET/CT
Approach to PET key elements:
-Access to PET through high quality clinical trials
-Access to PET through registry studies
-Access to PET through the PET Access Program
-Quality assurance standards for PET
-Ontario’s PET infrastructure
-Coordination of the PET program
-Communications
Evidence based approach to PET/CT
Evidence to support all demand
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21. PET/CT
2009- OHIP funded indications – 9
2010 CCO Oversight of non-funded PET/CT scan
PET Access program
PET Registry
Clinical trials
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21

22. 22

23. Recommendations by PSC for Change
Insured Uninsured
Insured Indications Additions OCOG Trials Registry Indications PET Access
• Solitary pulmonary Nodule • PET REC • Pancreatic • Case-
cancer by-case
• Thyroid cancer • Melanoma
• Germ cell tumours • Testicular
Cancer
• Colorectal cancer • PET LACE
• Lymphoma
• Non-small cell lung cancer
• Stage III non-small cell lung ca
• Limited disease small cell lung ca
• Myocardial viability
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23

24. 24

25. PART 3
MRI 2004 2005 Starting out
52 MRI scanners in hospitals
5 MRI in IHF’s
257,042 total scans
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26. MRI 2005 How did we compare? (OEDC) (CIHI)
MRI Scan Rate per 1,000
2005 2006 2007
population
Ontario 27.4
Canada 30.7
Australia 20.2
France 38.2
United States 84.3
Denmark 27
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27. Provincial Wait Time Trend: MRI
• Wait time for MRI scans peaked on October 2010 at 127 days but has since decreased to 87
days by January 2012.
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28. Comparison of MRI Orders Received & Scans Completed
91 scanners (base 52)
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29. MRI scan rates per 1,000 population
Data Source:
* ** MRI 2005/2006 to 2006/2007 data: You, J., Venkatesh, V. and Laupacis, A. (2009). Better access to outpatient magnetic resonance imaging in Ontario – But for whom?. Open
Medicine, Vol 3, No 1. Outpatient MRI Utilization only.
2008-2011 – Wait Time Information System, Cancer Care Ontario
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30. MRI Scan Rate per 1,000 population –comparison (OECD)(ATC)
MRI Scan Rate per 1,000
2007 2008 2009 2010 2011
population
Ontario --- 38.7 41.2 43.7 47.5
Canada --- 40.6 43.0 --- ---
Australia 20.2 21.4 23.3 --- ---
France 44.2 48.4 55.2 --- ---
United States 91.2 --- --- --- ---
Denmark 36 37.8 --- --- ---
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31. Removing variability
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32. Provincial Wait Time Trend: MRI and CT
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33. Backlog
time
demand capacity
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34. 34

35. 35

36. Looking at the MRI backlog
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37. Backlog management- The Blitz
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38. MRI Blitz: Impact on Overall Provincial Wait Times
 Participating hospitals were notified of their additional volume allocations in November 2010, December 2010, January 2011
 Provincial wait times closely followed wait times for blitz hospitals
 Participating hospitals reached the lowest wait time of 93 days in June 2011, 3 months after receipt of funding
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39. MRI – System improvement
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40. PIP Outcome Indicators
Data Captured in Weekly Performance Dashboards by MRI-PIP Hospitals
Outcome Indicators
Time between requisition received and exam completed
• By priority
1. MRI Wait Times • By body division
• By hospital site (for multi-site facilities)
• By contrast/non-contrast
1. MRI Report Turnaround
Time between exam completed and report verified
Times
Number of exams requested (i.e. demand)
1. MRI Exams Requested • By priority
• By body division
Number of exams completed
• By priority
1. MRI Volumes Performed • By body division
• By hospital site (for multi-site facilities)
• By contrast/non-contrast
1. Planned Operating Hours [Sum of actual scanning time for pre-booked patients/Sum of operating hours
Utilization dedicated to pre-booked patients] *100
1. Unplanned Operating [Sum of actual scanning time for unscheduled patients (e.g. inpatients and
Hours Utilization emergency) /Sum of operating hours dedicated to unscheduled patients] *100
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41. Process Indicators
1. Requisition Completeness [Number of complete requisitions / Number of requisitions received] * 100
2. Booking Turnaround Time Time between requisition received and appointment booked
3. Booking Volumes Number of appointments booked
4. Booked Time Utilization [Sum of hours planned time of booked exams/Sum of operating hours available to be booked] *100
[Sum of hours of incoming requests/Sum of hours in scheduling template] *100
3. Requisitions Received •By priority
Relative to Time Allocated •By body division
•By contrast/non-contrast
[Sum of actual scanning time/Sum of hours in scheduling template] *100
3. Actual Hours Performed •By priority
Relative to Time Allocated •By body division
•By contrast/non-contrast
3. Protocolling Turnaround Time Time between requisition sent for and received from protocolling
3. No Show Rate [Number of no shows / Number of appointments booked] * 100
3. No Shows Filled [Number of no shows filled / Number of no shows] * 100
3. On-Time Scan Starts [Number of early and on-time exams / Number of exams completed] * 100
3. Patient Prep Time Time between registration and scan start
3. Room Turnaround Time Time between patient 1 exiting scan room to patient 2 entering
Planned scan time – Actual scan time
3. Planned Scan Time Accuracy
•By procedure
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42. MRI PIP Wait Times Improve in London
St. Joe’s MRI Wait Time
300
Patients Getting Needed MRIs Sooner
250
Number of Days
The London Free Press. Aug 2010 MRI PIP
187
200 177 172
The improvements mean 780 more patients can be scanned 156 151 145
each year with MRI at St. Joseph’s, said Glen Kearns, 150 128
integrated vice president, clinical support services and 113
94
information technology services at St. Joe’s and London 100
56 56 63
Health Sciences Centre (LHSC).
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As part of a project with Ontario’s Health Ministry, St. Joe’s
dissected every MRI process, assessed what worked and 0
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what could be tweaked, then put the process back together
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more effectively for patients and staff.
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The results:
•An average 50 days’ wait for semi-urgent patients (down
from 104 days a year ago) and 60 days (down from 149) for
non-urgent patients; LHSC MRI Wait Time
•212 MRI exams each week, or 15 more a week than a year 300
ago.
250
Number of Days 215
MRI PIP
LHSC is in the middle of a similar process, one made more 195 187
complex by the wider range and type of MRI services offered 200 162
144 146 152 150
for inpatients and outpatients. So far, the waits there have 135
150 120
dropped to an average 86 days, from 150 as recently as six
months ago. That pace of improvement means 1,000 more 100
86
75
patients can be scanned each year, he said.
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0
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07
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43. MRI PIP Wait Times Improve in Ottawa
TOH MRI Wait Time
400 352 349 347 348
Improving Equitable Access to Imaging
J American College of Radiology. Aug 2010 307 MRI PIP
Number of Days
300 263
237
The Ottawa Hospital Rapid Improvement Event team was
assembled and completed a 4-day review of the booking process 188
and scheduling in MRI. They then delineated additional steps 200
that could be initiated to potentially reduce wait times. This was 117
96
undertaken using Lean methodology brought forth by the Ontario 65
100 58
government to evaluate process improvement and patient
throughput at all stages of navigation through the system . Some
of the main goals and strategies of the Lean project include the 0
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following:
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•Improving efficiency of each scan
•Improving patient flow and throughput
•Improving booking process
•Evaluating the patterns of unfilled spots and adjusting the Montfort MRI Wait Time
schedule commensurately 400
•Reducing physicians’ redundant ordering of diagnostic imaging
tests through education on appropriate indications
Number of Days
300
MRI PIP
193 202
200 163
90 82 84
76 75 76
100 63 63
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0
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44. Impact of all interventions on Provincial Wait Times
(data as of February 2012)
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45. Summary of the Ontario Approach
1. Capacity building through additional MRI/CT scans
2. Capacity building through system and process redesign to
improve efficiencies “Value for Money”
3. Managing demand by decreasing the backlog
4. Managing demand through appropriate referrals
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46. Next steps:
Maintain equilibrium
-Appropriateness
-Point of care decision support
-Capacity
Sustainable backlog management
-focus on LHINs with greatest backlog
-continue collecting data on demand
-determine best practices related to backlog management
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47. Next steps:
Process improvement -
-Optimising the ordering process- dated examinations and booking
optimization
-CT
Disease specific wait times
Revisiting the benchmarks
-National benchmarks
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48. Questions?
Thank You
Access to Care
ATC@cancercare.on.ca
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