A Lean Six Sigma Approach to Improving Radiology Total Turnaround Time (TAT)

by Jessica Higgins, JD, MBA Certified Lean Six Sigma Black Belt Director of Business Development Deisell Research Institute and Consultants and Michael Proscia, MBA/HCM, RT(R)(CV) Certified Lean Six Sigma Green Belt Director, Medical Imaging and Cardiovascular Services Regional Medical Center at Memphis and Robert Sumter, PhD Lean Six Sigma Black Belt Executive Vice President and Chief Operating Officer Regional Medical Center at Memphis Under ideal circumstances, when a patient receives orders that an X-ray, cat scan or MRI is needed, the patient will receive the prescribed procedure(s) and the doctor will follow up for treatment. However, at many hospitals, the total time needed to complete the medical imaging process (referred to as turnaround time, or TAT) exceeds patient expectations, causing frustration, delay and patient dissatisfaction. In emergencies, the extended TAT time hinders the ability of the doctor to complete medical imaging prior to treatment, forcing doctors to operate absent thorough diagnosis, creating increased risks to the patient of both mortality and post-surgical complications. Michael Proscia, Director of Medical Imaging at The Regional Medical Center at Memphis, under the direction of Dr. Robert Sumter, COO, developed the idea to join with the Lean Six Sigma innovation and quality improvement team at Deisell Research Institute and Consultants to improve the total TAT time across the medical imaging department. Through this data-driven process, TAT for medical imaging was reduced from 12.5 hours (751 min) on average down to 79 minutes: an 11.2 hour reduction per patient. The improved baseline has proven to be sustainable with no significant change in service time in the two years since implementation. Through this project, the Regional Medical Center at Memphis accomplished: Improved physician satisfaction

Improved patient satisfaction Reduced post-surgical complications Increased diagnosis accuracy Expedited treatment process Capacity to treat more patients Operational efficiencies Decreased operational costs

Although there is no one standard solution for all hospitals to improve TAT time, here are a few lessons that were learned which can apply to other hospitals in order to reduce TAT time across both radiology and surgical service lines: 1. Measure customers needs, expectations and desires. Every process should be centered on patients. Therefore, when determining the ideal TAT time for a service line, the process should begin with defining patient needs, expectations and desires. Although a patient may desire to not wait at all, most patients expect to wait for a certain amount of time. Determining this expected time is key for the patient population and demographic. When patient wait times exceed the threshold of expectations, patients become dissatisfied. In addition, results are needed by a certain time to provide a proper diagnosis. By defining this threshold point of patient expectations and needs, the ideal TAT is quantified as the lesser of: (1) The time patients expect to wait, or (2) The time by which results are needed for proper diagnosis Patient desires are then quantified as any amount of time shorter than the time patients expect to wait. This is an important point in Lean Six Sigma known as delight time, which can create the extra wow factor for hospital service delivery. At the Regional Medical Center at Memphis, customer expected wait times (measured at 2 hours) were set as the total TAT goal. For emergency situations when immediate response is needed, customer needs were set at roughly 6 minutes total TAT goal. By defining the TAT goal based on patient needs, expectations and desires, the TAT project is set to deliver 100% patient satisfaction and accurate diagnosis for the service line while still utilizing the maximum amount of expected wait time. 2. Differentiate and simplify non-emergency from emergency procedures to meet patient requirements. In the hospital setting, all patients are not created equal. Therefore, each service line should not be viewed from a holistic perspective. By differentiating critical from

non-critical patients, The Regional Medical Center at Memphis was able to exceed the target TAT for all patients through one service line by meeting patient needs and expectations via separate sub-processes. This concept is known in Lean Six Sigma as standard vs. exception processing. By mapping the total process as a sequence of steps, and then timing how long each step takes to be completed. The process of mapping allows an additional benefit. The department staff can see how each step interrelates to each other and the hospital as a whole, thus providing a feedback loop. The areas where processing time lags and bottlenecks occur become obvious. Any time that is not spent delivering value to the patient (in this case, a medical imaging diagnosis) should be simplified to reduce/eliminate the time spent on those non-value added steps. Think in terms of the steps required to: (1) deliver results and (2) meet regulatory requirements. The steps are then simplified until the total amount of time to complete all steps meets or exceeds the TAT goal for non-critical patients. If simplification of each step is not possible, the process should be innovated to define a simpler way of service delivery that meets the TAT goal. The result of simplification becomes the hospitals standard process for non-critical patients and personnel are aligned. The exception process is then developed by pulling the most critical steps from the above to create a fast track service line for critical patients. The TAT for this exception process should meet or exceed the TAT goal for critical patients. The prohibitive factor for not fast tracking all patients is that the critical patient process tends to be more costly and resource intensive. At the Regional Medical Center at Memphis, processing times made simplification impossible for this exception process, so the team designed and implemented a new system altogether based on a more costly point-of-care system. These two processes then operate in tandem: the standard process for all patients is followed unless an exception is triggered a critical patient. The exception process is then followed for that patient and the patient receives the fast track system. This allows the hospital to consistently meet customer expectations and dedicate those costly and resource intensive treatments to critical patients. The result is a simplified system where all patient needs and expectations are consistently met. 3. Develop a model of aligning physicians and staff to your patients; not the reverse. At the Regional Medical Center at Memphis, physicians were staffed to one day shifts for all physicians, from 8am to 4pm, five days per week. When analyzing the total process flow and staff utilization, the Lean Six Sigma team found a mismatch between peak processing times and staff utilization. Specifically, many of the medical imaging scans were coming in near the end of each day, just as physicians were leaving. This created the need for physicians to cover the previous days work at the beginning of the following days shift, and left a processing gap from Friday to

Monday because of no weekend physician coverage. Patients who received scans later in the day and all day on Mondays were not receiving physician validation of the scans until the backload of scans were analyzed from the previous day(s). For emergency situations, radiologists were proceeding without final diagnosis from a physician, increasing the risks to patients of improper diagnosis. By reengineering physician schedules around patient loads, the medical imaging department was able to reduce processing time dramatically. The team measured daily staffing needs by measuring patient volume throughout the day. The appropriate levels of day shift physicians were based on these measurements, and excess day shift physicians were reallocated to a 2nd and 3rd shift to allow for the department to be open 24 hours. This patient-focused method of process reengineering was so successful that the Regional Medical Center at Memphis developed excess capacity after reaching their target metric TAT time, and was able to sell this excess capacity to other nearby hospitals, thus creating an additional revenue stream. Simplified operations and customer alignment Dramatic reductions in TAT at The Regional Medical Center at Memphis were made possible through (1) customer focus, (2) customer differentiation and (3) customer alignment to hospital resources. Reengineering a service line is not impossible, and hospitals can achieve greater patient satisfaction and simpler operations while reducing total turnaround time by moving from what we have always done to putting patients first and then developing the service around patients. Actual project control chart of TAT, prior and post implementation:
Radiology Turnaround Time