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End of section Introduction Introduction What is the radiology tool kit for? The radiology toolkit has been designed to assist radiology teams and departments to resolve constraints to innovation in patient care. Who should use the toolkit? The tool kit provides ideas and solutions to possible constraints within radiology, anyone who is responsible for patent flow will benefit from using this tool. What are the aims of the toolkit? The Patient Flow Collaborative aims to remove unnecessary constraints or delays in patient flow by promoting a continuous flow of care. Radiology innovation is essential to providing a seamless efficient service to waiting patients. How should we implement the concepts in this toolkit and change in our local context? The toolkit will assist with provoking discussion and ideas, health service teams should operationalise any innovation idea to their local context. Goals of the toolkit Overview and strategy Health service team Processes Data Resources Diagnostics and tools Back to menu

End of section Goals of the toolkit Introduction • Introduction • The radiology toolkit is based on whole system thinking and includes a whole of hospital approach. • Goals • The specific goals of the toolkit are: • Provide possible solutions to flow issues • Build awareness of the management of capacity and demand • Identify systematic methods to innovate in radiology Your feedback This first version of the radiology toolkit will stimulate discussion and innovation ideas and methods. The Patient Flow Collaborative welcomes feedback to enable subsequent versions of the toolkit. Goals of the toolkit Overview and strategy Health service team Processes Data Resources Diagnostics and tools Back to menu

Overview and strategy Introduction Goals of the toolkit Whole system approach A whole system approach is needed to effectively manage the variation in capacity and demand involved in radiology. Radiology is recognised to be a central point in this continuous flow of diagnosis and treatment for our patients. Overview and strategy Health service team Processes Data Resources Diagnostics and tools Click to continue Page 1 of 4 Back to menu

Overview and strategy Introduction Organisational whole of hospital delivery Goals of the toolkit Policy and leadership Capacity and demand Staff resource Administration Overview and strategy Health service team Processes Radiology investigations and treatment modalities Rigorous diagnostics Agreed process Access and administration Patient information Data Resources Diagnostics and tools Click to continue Page 2 of 4 Back to menu

Overview and strategy Introduction Policy and leadership • Priority given to radiology services by board and local health community awareness of capital investment and issues. • Identified board level report for radiology, leadership high priority for radiology management team. • Policy stating maximum waiting times for emergency admitted and waiting patients. Goals of the toolkit Overview and strategy Capacity and demand Health service team • Essential data collected on capacity and demand for radiology services Processes Staff resource Data • Staff resource plans undertaken regularly to promote, mentoring development and training. Roles redefined to maximise skill base and promote up-skilling of staff team. Resources Administration Diagnostics and tools • Administration systems in place which promote smooth allocation and booking of appointments and reporting results. Click to continue Page 3 of 4 Back to menu

End of section Overview and strategy Introduction Rigorous diagnostics Goals of the toolkit • Capacity and demand, process mapping, tally chart data to be collected per diagnostic/treatment stream. • High demand stream to be completed first. Overview and strategy Agreed process • Once process is reviewed, redesign process to provide continuous process, advertise to staff/hospital as required. Health service team Processes Access and administration • Advertise access timescales to all stakeholders. • Promote appointment system which pulls patients. • Agree date and time with patient. • Ask to confirm before appointment. • Manage DNA/FTA as per policy Data Resources Patient information Diagnostics and tools • Provide patient information to promote quick appointment examination. • Make sure information given previous to attendance. Back to menu

End of section Health service team Introduction • Clinical improvement team • It is important to identify a clinical and managerial lead for the Clinical Improvement team who will lead the innovations within radiology. A reporting line will be needed to an executive sponsor for the Patient Flow Collaborative executive team. • Agree executive sponsor • Agree clinical lead • Agree managerial lead • Introduction • Essential components of effective radiology services are skilled, trained and dedicated radiology staff. Teams who have clear roles, responsibilities, support and reporting lines will underpin effective patient flow. • Check list for radiology team • Whole of hospital service strategy • Executive sponsor for radiology team • Clear reporting to supervisor or manager • Skills recognised within whole team • Opportunity for skill development • Innovation champion • Patient involvement champion Goals of the toolkit Overview and strategy Health service team Processes Data Resources Diagnostics and tools Back to menu

Processes Introduction Goals of the toolkit • Plain film • Ultrasound • Mammograph • CT head and neck • MRI • Fluoroscopy • Nuclear medicine Appointment Administration Triage Demand Overview and strategy Health service team Processes DNA/FTA Treatment Discharge Reporting Data Resources Diagnostics and tools Click to continue Page 1 of 25 Back to menu

Processes Introduction Example of simple process maps to start process Goals of the toolkit Overview and strategy Health service team Processes Data Resources Diagnostics and tools Click to continue Page 2 of 25 Back to menu

Processes Introduction REFERRALS ARE CHECKED REFERRALS ARE ONLY TWICE A WEEK BY Goals of the toolkit REFERRALS RECEIVED IN ACCEPTED FROM MR MAMMOGRAPHERS. APPOINTMENTS OFFICE ALLEN OR ONCOLOGY PATIENT RADIOLOGY CLINIC HISTORY CHECKED. FORM AUTHORISED Overview and strategy ATTEMPTS TO FIND PAT CHECKS WHETHER Health service team PAT CHECKS THE US CONVENIENT DATE FOR ULTRASOUND SCAN IS APPOINTMENT BOOK AND THE MAMMOGRAM AND REQUESTED AS WELL AS MAMMO APPOINTMENTS ULTRASOUND TO BE MAMMOGRAPHY SHEET TO FIND SAME DAY CARRIED OUT ON SAME AVAILABILITY DAY Processes Data REQUEST FORM IF THIS MAKES APPOINTMENT TOO APPOINTMENT BOOKED ON RETURNED TO PAT IN LONG TO WAIT FOR – SEPARATE COMPUTER. APPOINTMENTS FOR APPOINTMENTS ARE MADE DATE WRITTEN ON FORM BOOKING Resources Diagnostics and tools FORM FILED IN OFFICE LETTER AUTOMATICALLY UNDER DATE APPOINTMENT GENERATED AND SENT TO IS BOOKED FOR PATIENT Click to continue Page 3 of 25 Back to menu

Processes Introduction Analysing the patient process Goals of the toolkit • Having mapped the patient process, analyse by considering the following: • How many steps are in the process? • How many times is the patient passed from one person to another (hand-off)? • What is the approximate time of each step? • What is the approximate time between each step? • What is the approximate time between first and last step? • Where does the patient have a wait or have to queue? • Where are there waiting lists in the system? • How many steps add no value to the patient? (Ask patients) • Where are there problems for patients – what do patients complain about? • Where are there problems for staff? Overview and strategy Health service team Processes Data Resources Diagnostics and tools Click to continue Page 4 of 25 Back to menu

Processes Introduction Identify referral entry points Goals of the toolkit • Single or multiple entry points? • Electronic or paper referrals? • All referrals to imaging room or reception? • Are there locations referrals could go to? That is, theatre, ED, other sites. • What work is done outside of normal hours that generates referrals? Overview and strategy Health service team Processes Data Resources Diagnostics and tools Click to continue Page 5 of 25 Back to menu

Processes Introduction Develop a process map of the time it takes to see a patient Goals of the toolkit • Check in – Undress – Preparation – Procedure - Reporting • Method: • Identify start and end points of the procedure. • Agree how many activities in process. That is, check-in, pre check, consent, discussion, patient changes, etc. • Identify the time it takes for each step. • Cross check with actual process. Overview and strategy Health service team Processes Data Resources Diagnostics and tools Click to continue Page 6 of 25 Back to menu

Processes Introduction Process steps examples Goals of the toolkit Overview and strategy Health service team Processes Data Resources Diagnostics and tools Click to continue Page 7 of 25 Back to menu

Processes Introduction Process steps examples Goals of the toolkit Overview and strategy Health service team Processes Data Resources Diagnostics and tools Click to continue Page 8 of 25 Back to menu

Processes Introduction Build your schedule Goals of the toolkit Use graph paper with one square per minute to sequence time scales per procedure. Overview and strategy Health service team 1 MINUTE 35 MINUTES Processes Data Resources Diagnostics and tools Click to continue Page 9 of 25 Back to menu

Processes Introduction Build your schedule Goals of the toolkit Transfer graph sequence timescales to chart clinic time. Overview and strategy 9.00 am start 12.00 pm end Health service team Processes Data Resources Align steps to maximise use of equipment/radiology room/staff. Diagnostics and tools Click to continue Page 10 of 25 Back to menu

Processes Introduction • Understand existing backlog • Once schedules and processes have been reviewed, capacity and demand can be calculated for: • backlog and current demand • backlog = existing request still waiting • current demand = demand which will be made on service. • Calculating backlog • To calculate backlog you will need to use the previous time series calculations. • Identify time of request. • Identify from your sequence charts the time for this type of request. • Identify number of requests waiting. • Multiply time needed to do the procedure by number waiting. • This will give you a measure of the time needed to clear your backlog. Goals of the toolkit Overview and strategy Health service team Processes Data Resources Diagnostics and tools Click to continue Page 11 of 25 Back to menu

Processes Introduction Current demand Daily demand calculations will promote effective management of radiology resources. Simple tally sheets can assist with this. Goals of the toolkit Overview and strategy Health service team Processes Data Resources Diagnostics and tools Click to continue Page 12 of 25 Back to menu

Processes Introduction Goals of the toolkit • Assistance with backlog • Options for assisting with backlog include: • Waiting list telephone validation. • Reduce inefficiencies – FTA rates, start times, cancelled sessions. • Increase number of procedures in session by redesigning process and schedule. • Introduce changes to working day; extended working days, evening sessions. • Access capacity elsewhere. • Use other resources/staff. Overview and strategy Health service team Processes Data Resources Diagnostics and tools Click to continue Page 13 of 25 Back to menu

Processes Introduction Goals of the toolkit • Identity constraints that limit radiology equipment/specialists availability • Constraints may be due to: • Waiting for portering • FTA patients • Short notice or cancellations (reasons?) • Availability of clinical staff to prescribe and administer • Availability of recovery areas or preparation areas • Poor patient preparation • Clinical staff performing no clinical duties Overview and strategy Health service team Processes Data Resources Diagnostics and tools Click to continue Page 14 of 25 Back to menu

Appropriate imaging evidence based protocols registrar/consultant sign-off electronic prompts Easy consultation Process improvement Appropriateness Processes Introduction Imaging initiatives Goals of the toolkit Evidence based protocol Consultant consultation Personal consultation Traffic light triage Electronic prompts Overview and strategy Health service team Processes Data Resources Diagnostics and tools Click to continue Page 15 of 25 Back to menu

Cervical spine injury? Head Injury Pulmonary Embolism? Deep vein thrombosis? 1st trimester bleeding Renal colic? Meningitis, Lumbar puncture or CT scan or treat? Evidence Based Medicine Processes Introduction Pulmonary Embolism and Evidence Based Medicine Goals of the toolkit Before • 7 protocols • 75% with PE have too many or too few tests After • one protocol • 93% compliance Overview and strategy Health service team Processes Data Resources Diagnostics and tools Click to continue Page 16 of 25 Back to menu

Radiology Test Ordering (RTO) Introduction Traffic Light Guidelines Example from Southern Health Clinical Indications must be on form · Skull/Sinus/KUB Goals of the toolkit · CT Chest/Abdo CT Red Tests · Angiography/CT Angio · Must be authorised by · MRI · Specialist Paediatric CT Overview and strategy · All radiology call backs Health service team · AXR · T/L/S spine Amber Tests · CT Brain/CT C Spine Processes · Radiology form must be · Abdo U/S signed by a Registrar · Pelvic US/O&G US · OPG/Facial Bones · F/B soft tissue Data · Renal Colic CT Resources · CXR Green Tests · C-Spine · · No restrictions on ordering M/Skel. X-rays (excl. T/L/S Spine) · Diagnostics and tools All results must be checked · Pelvis before patient discharged Click to continue Page 17 of 25 Back to menu

Request to film completion Request to dictation complete Request until report typed Unreported cases at 5pm Protocol adherence Measures Processes Introduction The Requesting Process Goals of the toolkit Nurse initiated Faxing Electronic The consultation Overview and strategy Health service team Processes Data Resources Diagnostics and tools Click to continue Page 18 of 25 Back to menu

Next waiting Reduced downtime Emergency AM slots Peripherally Inserted Central Catheter (PICC) story Porters story Responsiveness in CT, CXR Filming/Scheduling Process Processes Introduction No Porters Data! Goals of the toolkit • 2 day audit was undertaken • 22 observations of porters in room was made • On 20 occasions between 1 - 5 porters were available in the porter’s room. Overview and strategy Health service team Processes Data Resources Diagnostics and tools Click to continue Page 19 of 25 Back to menu

Example from Southern Health Introduction Goals of the toolkit Overview and strategy Health service team Processes Data Resources Diagnostics and tools Click to continue Page 20 of 25 Back to menu

Introduction Example from Southern Health Goals of the toolkit Overview and strategy Health service team Processes Data Resources Diagnostics and tools Click to continue Page 21 of 25 Back to menu

Introduction Goals of the toolkit Overview and strategy Health service team Processes Data Resources Diagnostics and tools Click to continue Page 22 of 25 Back to menu

5/03 3.40 HR (6.15) (Max) Time from IP Request To Film Processes Introduction Improvements to time it takes Emergency Department patients to have radiology tests done Goals of the toolkit Time from ED Request to Film (average) Overview and strategy 8/01 4.30 – 13.2 hours (23) 10/01 2.0 – 3.5 hours (11) 2/02 3/10 - hours (8) 5/03 1.0 - hours (3.3) (Max) Health service team Processes Imaging Capacity Audit CT, 25days, no show 49/751 ED 2 days, 38%, 64% waiting Data Resources Diagnostics and tools Click to continue Page 23 of 25 Back to menu

Introduction Goals of the toolkit Overview and strategy Health service team Processes Data Resources Diagnostics and tools Click to continue Page 24 of 25 Back to menu

Hot reporting IP Digital dictation Weekend reporting Evening reporting Tele-reporting Interims Less priors End of section The Reporting Process Processes Introduction Clerical Process Goals of the toolkit Digital dictation and dial-in Interims Remote reporting Computer report distribution Return films without reports Eliminate report storage Overview and strategy Health service team Processes Data Resources Diagnostics and tools Back to menu

End of section Data Introduction Core data Other Suggested Measures Capacity and Demand -Existing Capacity v Utilisation v Number Waiting Did not Attend (DNA) rates per day/week Cancellation rates (Hospital and Patient initiated) Delays -Monitor Radiology delays for one week to agree on the top 10 reasons. When this is agreed, 4 weeks data will be collected against the top 10 delays. Once 4 weeks of 10 delays have been gathered SPC charts can be produced. Time needs to be collected against each reason(s) per day, as the top ten offenders may not amount to the longest waste in time. Goals of the toolkit Overview and strategy Health service team Processes Data Resources Diagnostics and tools Back to menu

End of section Resources Introduction Change Concepts Redesign process to eliminate hands off, waste and complexity Implement ‘daily’ performance monitoring Redesign admin, booking and scheduling systems Increase scope and skills of radiology team, develop non-clinical staff as radiology technicians, develop consultant radiographer roles and extend scope of professional groups via development and protocols Develop electronic communication between primary care, in patient requests and radiology department Develop multi-skilled radiology administration and portering team Maintain permanent portering staff in radiology Develop and redesign request forms with supporting training, information and feedback Goals of the toolkit Overview and strategy Health service team Processes Data Resources Diagnostics and tools Back to menu

End of section Diagnostics and tools Introduction Change Concepts Rigorous diagnostic handbook Data collection charts Goals of the toolkit Overview and strategy Health service team Processes Data Resources Diagnostics and tools Back to menu

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