Process Improvement: Real Methods that Work

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A single technologist at Columbus Regional Hospital acquires a CT, formerly a two-person job. Scans are now performed on outpatient-designated scanner. RIS screenshot (left) courtesy of Fujifilm.

Process improvement is a staple of high-quality care. With methodologies borrowed from manufacturers, hospitals are honing process improvement to a science, affixing it as a pillar of quality assurance and the fulcrum of improving care. As belts tighten, reforms hang in limbo and public and legal scrutiny reaches new heights, process improvement has become more valuable than ever.

Modern process improvement methods proceed from a common premise: large-scale improvements depend on bettering processes—not individual workers. Under this sweeping insight, poor performance and errors are predictable outcomes of imperfectly designed processes. This view can be traced back to the 1980s, with Lean and Six Sigma manufacturing methods' development in Japan and rapid adoption across industries and continents.

In healthcare, the shift is epitomized by a 1989 New England Journal of Medicine commentary by Donald M. Berwick, MD, MPP, contrasting the 'Theory of Bad Apples' and the 'Theory of Continuous Improvement,' wherein large scale improvements to quality depend not on rooting out bad apples but on eliminating inefficient processes. Consider:

  • To keep up with toughening competition, Columbus Regional Hospital in Indiana managed to increase CT volume by 600 studies per month, cut exam time by 33 percent and spur a 34 percent growth in CT reimbursements—all with fewer scanners and technologists. And they'll valet your car at no charge.
  • Akron Children's Hospital slashed MRI waiting time to get an exam from 28 days to three or fewer—generating a 25 percent increase in weekly exams and a $1.3 million increase in yearly revenue.
  • St. Elizabeth Healthcare in Northern Kentucky now communicates all critical radiology results directly to ordering physicians within 30 minutes of the finding.

Some powerful underlying modi are at work here. One of the more common overlapping methods arising out of Six Sigma is DMAIC—Define, Measure, Analyze, Improve and Control. Meanwhile, Lean prefers a simpler mnemonic (Plan-Do-Study-Act), but expounds a rigorous standard for healthcare: "Anything that occurs in a patient care process that does not provide value to patient care is considered waste," according to Ken Aakre, RT, quality coordinator and CT operations manager for Mayo Clinic's department of radiology in Rochester, Minn., and colleagues, in their February 2010 American Journal of Roentgenology article, "Process Improvement: What Is It, Why Is It Important, and How Is It Done?"

Aakre urges practices to make regular use of quality improvement advisors. Regardless of the size of the practice, a quality improvement expert can justify his or her position on the payroll. Moreover, effective programs demand methodical planning, monitoring and follow-up: time and data analysis should not be spared when paring away inefficiencies.

Down with dose

"In the fall of 2007, back before it was all over the media, our department started discussing the importance of attentive radiation exposure in children. We realized our protocols were not standardized, which was a really big gap and clearly where we needed to start," says Kelly Firestine, RT, CT manager and project leader for Memorial Hermann Healthcare System in Houston's CT radiation dose reduction program.

Firestine dug a bit deeper and found that few of the system's 11 hospitals, 37 CT scanners overall, had any standardized radiation dose protocols for children. Thus, she delineated the project's scope: "To reduce CT head and abdomen radiation dose in kids, without compromising image quality." The objective revealed its challenges immediately; Firestine went straight to the American College of Radiology's (ACR) website to begin to set the network's dose protocols. To her surprise, ACR offered only its recommendation for an abdominal CT scan of a five-year-old.

Enlisting Shannon Lutz, Memorial Hermann's director of performance improvement for retail services, the project got a boost from the Association for Medical Imaging Management (AHRA) and Toshiba, winning a Putting Patients First grant that enabled the radiology department to hold a kaizen, a one-day rapid improvement event aimed at soliciting staff and expert ideas about the project.

By then, Firestine and Lutz had collaborated with