Process Improvement for the Long Haul

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 - Process Improvement
It's easy, or at least relatively so, to uncover an anecdotally successful imaging project. We've all heard a fair share of impressive success stories about departments that increased patient satisfaction or reduced MRI wait time. All too often, the data associated with these stories are soft, unsustained or unmeasured. Or the project simply fizzles after six months. In contrast, Health Imaging presents a collection of truly successful data-driven process improvement case studies.

Genuine process improvement, and the variety every organization demands, is data-driven, sustained and measurable. Process improvement success stories are flush with metrics, such as:
  • A revised coronary CT angiography (CTA) protocol at Gundersen Lutheran Health System in La Crosse, Wis., trimmed radiation exposure from 21 to 15 mSv for 260 patients annually;
  • A CT turnaround project slashed room turnaround time at Columbus Regional Hospital in Columbus, Ind., from 22 to 13 minutes and maintained the new standard for four years (and counting); and
  • Advocate Condell Medical Center in Libertyville, Ill., increased patient satisfaction from the bottom quartile to the top quartile, and sustained the gain.

Despite the varied results, a number of common factors pervadet these success stories, including a solid grasp of data, committed leadership, organizational coherence and consistency, staff engagement and solid metrics and assessment. Many embrace Lean, a system of process improvement that originated in manufacturing, which seeks to eliminate waste by involving frontline staff, identifying wasteful steps, focusing on customer priorities and standardizing processes.

The first step in any process improvement project is data gathering. Without data, it's nearly impossible to accurately assess current operations and set meaningful goals. "You don't know what you don't know [without data]," says Deanna Welch, system director imaging services at Intermountain Healthcare in Salt Lake City.

In 2009, Intermountain completed an organization-wide strategic plan and imaging services has used those data as a springboard to drive 13 strategic initiatives, each of which have multiple improvement projects. "The strategic plan highlighted a number of areas where performance could be improved, or were not measured regularly or effectively. The data analysis gave us our marching orders," says Dave Monaghan, assistant vice president.  

Rocket science…or not?

"If this were easy, every hospital would do it," shares Airica Steed, RN, MBA, EdD, vice president of professional services at Advocate Condell Medical Center. Steed and her colleagues spearheaded a downright transformation, nurturing impressive gains in an array of metrics including patient satisfaction, report turnaround, profitability, no-show rates and much more.

Everyone, observes Steed, loves to see positive results. She and her team have amassed more than a few, including reducing report turnaround time by more than 75 percent, cutting patient wait time by more than 65 percent and increasing staff and physician satisfaction by more than 50 percent. "The simplest part of process improvement is identifying what's broken and identifying the best practice to fix it. The difficult part is selling that change throughout the organization."

The challenges originate on multiple fronts. The sheer volume of data at Intermountain illustrates the complexity of the planning and improvement processes. The extensive strategic plan analyzed 2.7 million data lines, entailed 500 interviews and surveys and required more than 2,000 man-hours.

Data gathering and analysis, however, are the mere starting point. Every organization is comprised of multiple players who will question and resist the need for change. "Getting everyone to share the same vision is the most complex aspect of a Lean program," Steed asserts.

In fact, Advocate Condell struggled in its initial process improvement efforts because the medical center had not thoroughly established the infrastructure for change. "We had a lot of starts and stops and actually experienced breakthrough success in many respects, but we didn't have the leadership strength to sustain the new and improved level of performance. It was very easy to fall back on what we had always done, which was to operate with a lot of weight, redundancies and inefficiencies," Steed says.

For example, an early process improvement project in the ambulatory surgery program focused on integrating a service culture. The medical center was able to tackle the challenge and raise patient satisfaction scores from the single digits to the 90th percentile. However, when it shifted focus to its next priority, scores once again plummeted. "It was a matter of learning how to keep all the balls in the air," Steed says.

The answer—leadership development—sounds deceptively simple. "We didn't have leadership developed to hold associates accountable for change," Steed admits.

Leadership…the essential ingredient

Leadership has made its mark at Columbus Regional Hospital. The hospital has a nearly seven-year track record with Lean and has completed 145 projects. Its organizational chart is liberally peppered with Lean expertise and includes a director of Lean and six Lean black belts, master practitioners with advanced training in Lean tools, such as data collection, data analysis and Lean operations.

Columbus Regional has infused Lean throughout the organization. "We are dedicated to using Lean Six Sigma as a method for improvement, standardizing change and maximizing our value proposition," explains Doug Sabotin, MBA, director of Lean Six Sigma.

The hospital has devised a value proposition formula and applies it to assess projects and ensure that projects maximize value to customers. The formula is: quality + safety + satisfaction/cost.

The goal, says Sabotin, is to maximize quality, safety and satisfaction, while minimizing cost. Columbus Regional measures quality, safety and satisfaction via multiple lenses, including regulatory bodies and patient and employee satisfaction surveys.

As the hospital established its Lean program, it adhered very closely to the Lean structure and its value formula. One of its earliest imaging projects focused on CT throughput.

The project tied directly to the value formula as it focused on reducing costs and increasing revenue, with patient satisfaction as an added metric, explains Bill Algee, radiology manager at Columbus Regional. "The primary component," adds Sabotin, "is denominator-related, but there is a patient component as we can accommodate work-ins and enable more rapid treatment, which addresses the quality, safety and satisfaction perspectives."  

When the project originated in 2007, outpatient CT room turn-around time averaged 22 minutes per patient.

"We tracked everything with flow charts and found that we spent a lot of non-revenue generating time in the room. The only time revenue is generated in the CT suite is when the patient is on the scanner," says Algee.

At the time, Columbus Regional had two CT suites, booked solid through two shifts. Algee gathered a group of stakeholders, including CT staff, the Lean team and schedulers, to analyze the situation and determine which processes that occurred in the CT suite could be relocated to other areas. The list included patient history, labs, IV starts and oral contrast prep. After relocating those steps, room turnaround time dropped to 13 minutes.

Equally impressive, the hospital has sustained its new threshold. "We followed that process for 18 months to make sure that the new process was hardwired among staff," explains Algee.

Similarly, when Advocate Condell developed a process to follow revised processes and ensure that changes held, it found that it could maintain improvement.

"We initiated a leadership development institute program that empowered leaders to support change," says Steed. Leaders support change by:
  • Allocating resources;
  • Serving as champions and spokespersons;
  • Providing education and training to frontline staff;
  • Learning Lean tools;
  • Holding the team accountable;
  • Removing barriers and obstacles; and
  • Providing recognition and celebrating the wins.

In addition, the medical center organized teams of stakeholders to devise change. "We tried to keep leadership off of the teams because we wanted staff to feel empowered and comfortable to test out new ideas and concepts in a safe environment. The approach builds ownership and lets staff know that it is acceptable to take risk and possibly fail," says Steed.  

Imaging project teams included radiologists, referring physicians, practice managers from referring physicians' offices, frontline staff, representatives from service areas such as outpatient nursing and cardiology and patients and family members. The medical center assigned teams to specific projects, for example, pulling patients, family members and registration staff to address the waiting room experience, rather than involving a larger team that might not fully appreciate the details of the challenge.

The teams refer to the organizational vision—"to be a healthcare ministry delivering best health outcomes and exceptional patient experience every time"—and check to ensure that each process stays true to the vision, explains Steed.

From vision to data

Similarly, Intermountain wed data analysis with organizational goals. "For example," says Monaghan, "we're evaluating optimization of the delivery of care in a shared accountability environment. We developed priorities based on what we need to do to prepare for that delivery model, such as reviewing and managing utilization and CPOE with appropriateness criteria. These imaging focal points tie in with organizational goals."  

At the same time, Intermountain established imaging-specific priorities. The strategic plan revealed that imaging services' referral rate and referring physician satisfaction were not as high as expected. The revelation informed the decision to hire six physician liaisons and a manager to determine how to grow market share and better meet physician needs.

One key to successful process improvement is to determine which projects will generate the most significant impact.

For example, Advocate Condell understood that it did not provide an ideal patient experience and wanted to differentiate its service, which was aligned to the organizational vision of the hospital. "We put a lot of eggs in that basket, which had a significant impact," reports Steed. "We were able to reduce patient wait time by 50 percent and increase patient satisfaction from the bottom quartile to the top quartile."

Similarly, Gundersen Lutheran Health System also tackled the low-hanging fruit in its CT dose reduction project. The effort was organizationally consistent and staff-driven, explains Mary Ellen Jafari, MS, radiation safety officer and medical radiation physicist.

When the hospital installed a dual-source CT system in 2006, cardiologists expressed concerns about dose. "They wanted to estimate how much dose we were exposing patients to. This tied in with an overall strategy of providing high-quality services and a goal of improving patient safety," Jafari says.

The project launched with a baseline assessment. Jafari and her team used the vendor's protocols to scan 50 patients and calculated dose for the pilot group. With an average dose exposure of 21 mSv, the team decided to modify the protocol to reduce dose and successfully trimmed dose to 15 mSv.

In many cases, once an organization and its staff experience a successful process improvement project, it gains momentum. That's exactly what occurred at Gundersen Lutheran. The staff was inspired to further tweak the protocol and employed a modified kVP for patients with a lower body mass index to further curb radiation exposure to 5 mSv for patients weighing less than 180 pounds.

In addition, Jafari explains, "CT technologists and radiologists became more dose-conscious." They also aimed to monitor dose and expand the project to record dose data and widen the scope beyond CT angiography to all CT protocols.

As the hospital expanded its initiative, Jafari and her colleagues  focused on high-impact exams. "There is limited staff and time at any hospital, so it's important to look at exams where you can make the biggest change or benefit the most patients." These include traditionally high-dose exams, such as CT angiography, or studies of patients who require extra protection such as children, pregnant women or patients required to undergo repeat scanning for chronic conditions such as renal or ureteral calculi.

Gundersen Lutheran's team employed this approach as it implemented additional projects. For example, a low-dose renal stone protocol for patients with known renal or ureteral calculi undergoing follow-up imaging reduced effective dose 64 percent, from 12.2 mSv to 7.8 mSv. And a CT topographic bone growth protocol reduced effective dose by 26 percent, from 0.22 mSv to 0.16 mSv, compared with the department's conventional radiographic bone growth study.

Sabotin of Columbus Regional agrees that success breeds success. As the staff recognizes results of these projects such an enhanced service, improved ability to meet patient needs and increased revenue, they become eager to participate in future projects. "It all goes back to the value statement. Once staff start seeing the results of projects and realize that it makes their work simpler, they start sharing the success story with colleagues. This helps break down resistance," explains Linda Sneed, MBA, Lean SixSigma Black Belt at Columbus Regional.

Algee recalls that staff was slow to embrace the initial CT throughput project, partially because the plan left one of the department's two scanners unscheduled and open for inpatients and ER patients. However, they soon realized that the reinvented processes helped the department run like clockwork.

"We created a job for each person in CT. Two technologists operate the scanner and one tech is a runner who preps the patient. Another tech acts as coordinator for the day by answering the phone and managing workflow. It's more of an assembly line process." The streamlined process added $1.7 million to the bottom line in its first year without any additional investment in full-time employees, Algee says.

Columbus Regional employs multiple checks to ensure that revised processes stick. Lean Black Belts, like Sneed, work with department managers to identify metrics and design and assess projects and closely monitor results for a minimum of two years after the project.

Organizational commitment is essential, Steed concurs. "You can get a project off the ground without leadership, but you can't sustain it." She advises organizations to do a gut-check prior to a process improvement initiative and ask the following questions:

  • Is the organization ready to lay out a foundation for change?
  • Has the hospital developed a learning system to make change widespread throughout the organization and ensure that all stakeholders are on the same page?
  • Is there a system for accountability?

"At that point," says Steed, "you can apply best practices." She notes the methodology is not prescriptive; it does not tell an organization what to do or how to complete a project, but provides a process for devising improvement.

Experience pays

After an organization thoroughly understands Lean methodology, the system can be adapted. Take for example Columbus Regional, which has tweaked Lean to meet its needs and value formula.

The hospital's current approach is a rapid, three-day process improvement boot camp. The Lean team has met with every department to develop and implement standardized processes, which translates into more efficient management. Sabotin explains, "We identified the most important tools to efficient operations." The tools include standard work instructions, control plan summaries (which identify key steps in the process to measure or monitor to ensure standard processes are followed) and process boards to assess metrics in real-time and over time.

"Standardization is important," says Algee, "because if staff isn't performing the job in the same way, outcomes will be different." It also helps when the department hires new staff as the instructions encompass everything from protocols to where to find supplies.

These rapid improvement projects are not for the faint-hearted or inexperienced, Sabotin says. The hospital followed Lean methodology rigidly in its early years, honing internal expertise before modifying the method to launch the rapid projects. Rapid projects also are designed for straightforward processes, such as standardizing work, not significant changes.

The hospital addresses complex projects, such as patient hand-offs or inter-departmental work, in projects that stretch to nine months or longer. "We are seasoned enough in our understanding to take the time we need to solve the problem," says Sneed.  
Concurrent projects in Columbus Regional's radiology department tackle the measurable metric of on-time starts for patient exams.  

The department set a goal of starting 85 percent of exams within 10 minutes of the appointment and uses a process board to track metrics. Staff record on-time start three times daily at 11 a.m., 3 p.m. and 10 p.m. For four months, it has met its 85 percentile goal, shares Algee.

The next step is to use these metrics to drive further improvement. Every time an exam is not started within 10 minutes, staff records the reason for the delayed start. Some situations, such as a late patient arrival, are beyond the department's control. Beginning in 2012, the department will examine the data to look for patterns. For example, it will examine whether no-shows received or responded to automated reminder phone calls.

Lessons from the field

Sustained process improvement is not easy, but it is doable. Successful organizations can offer a wealth of advice to help others launch their programs.
  • Leadership development, says Steed, is the most important ingredient. Without committed leadership to guide and support projects, it is nearly impossible to sustain success.
  • Don't charter a project without metrics and monitor those metrics for a minimum of two years after the project to ensure that it sticks and that the data support the project, says Sneed.
  • Know who you are and who you are not, says Sabotin. At Gundersen Lutheran, tying the CT dose project to the organizational emphasis on high-quality care helped ensure buy-in among staff. This was critical, says Jafari, as the hospital relied on in-house expertise to provide training for technologists and educational programs for referring physicians.
  • Tie projects to organizational goals and make sure that central leadership is aware of imaging's contributions to the enterprise, says Monaghan. In the past, Intermountain, like other organizations, viewed imaging as an ancillary service line. However, imaging is a significant contributor to the bottom line. "Imaging departments can influence their futures by gathering and sharing these data with senior leadership."