Completing the imaging process for patients was causing continuous delay to patient flow through the department. The consensus among senior clinicians was that:
• CT’s and other urgent imaging were taking too long for some very ill patients
• No effective clinical prioritisation of patients who required imaging
• Ordering of imaging tasks and subsequent requesting of porters required manual and verbal handoff between Doctor, Nurse, Flow-Coordinator and Porter
• Tracking of patients was often lost or delayed due to miscommunication between staff and imaging
• No transparency on where a patient was on their imaging journey and how long it’s likely to take
There was no objective data or agreement between departments as to what the underlying issues of flow were. Partnering with Patienteer – an innovative IT platform, each step in the Imaging workflow was mapped and analysed. The biggest delay identified related to the transfer of patients to and from the imaging department. To address these issues a solution was implemented to:
• Automate the creation of portering tasks based on diagnostics orders
• Prioritise, track and manage the imaging workflow for every patient
• Allocate and manage the completion of all porter tasks within the department (imaging and other)
Soft intelligence suggested delays in patient imaging in A&E. Data identified by a Patienteer [a workflow analytics system (licensed by CHS A&E)] identified eight touch points or steps in an imaging workflow and objectively analysed use of time. Key learnings included:
• During the busiest times in A&E the time taken for a CT image and subsequent report took on average 2hrs 30 minutes from the time of the original request.
• Imaging tasks that required the patient to be transferred to imaging with the assistance of a Porter took three times longer than if the patient transferred on their own. Utilising this objective data, the Trust and A&E leadership teams commissioned the Patienteer solution to both manage the allocation of porters to tasks and provide real-time transparency on performance. This included:
• Enabling doctors to clinically prioritise in alignment with patient safety the order in which images are completed and reported
• Automating the creation of porter tasks based on diagnostic ordering in eMR
• Managing the allocation and tracking of porter tasks in real-time
• Providing real-time transparency of delays
The initiative was to apply lean manufacturing and best practice project management methodologies to clinical workflows. The key goals being measured by this initiative are:
1. Improve efficiencies by reducing the time to imaging
2. Improve patient safety by prioritising patients based on clinical need
3. Improve the 4hr target for patients requiring transfers to imaging
4. Ensure all patients requiring imaging are tracked and never lost sight of
After 3 months of utilising the solution the time to complete the imaging process reduced by 27%. During peak hours the time reduced by 22%. This outcome has had a direct link with faster decision making for patients within A&E. For patient requiring imaging and marked as high care priority by clinicians the median time to complete imaging is 38 mins.
These results have shown that by prioritising patients based on clinical need the overall safety of the department has increased. For patients requiring imaging there has been a small reduction in LOS against the baseline. This has been correlated with efficiencies generated within the workflows and the subsequent faster decision making.
The transparency generated by tracking each step of the imaging process has improved communication back to patients as clinicians have trust in the accuracy of when results will be available. The challenges in the first instance was getting clinicians to use the eMR ordering process correctly so that the patient would be put on the correct imaging workflow.
The key to this was communicating value (there is no need to remind or chase other stakeholders to ensure a transfer is completed) as which point the change was adopted.
An evaluation of the initiative was carried out in November 2018. The results from the evaluation, along with demonstrations of the solution have been continuously presented to hospital executive and senior medical staff across the hospital. Additionally, word of mouth on the success of the solution has cascaded to other departments via Senior Doctors.
The following initiatives are in place or planning as a direct result of the solution being employed within A&E:
• Porters workload and tasks are now fully managed in A&E by the electronic task list on Patienteer. • Prioritisation process is now being planned for implementation on wards using the same Patienteer solution, particularly for care needs of the patients during ward rounds
• Extending the priority-based system to include pathology diagnostics in both A&E and on wards.
• The prioritisation process of managing tasks, driven by physician, has now been adopted by the Medical specialty team in the new electronic medical take form which informs A&E of the tasks the Medical take team would like each patient to have done first before reviewing.
The objective data shows that the overall time for imaging has reduced and that those patients prioritised on clinical need are receiving their results quicker. There are tangible and intangible benefits from this. Moving to a fully electronic objective task list has reduced miscommunication and need to chase porters for transfer tasks increasing the overall job satisfaction for clinical staff.
Clinicians have full transparency on when their patient’s results are likely to be ready and no longer have to worry about informing flow co-ordinators about patient transport requirements. This creates a more seamless and efficient process.
In addition to creating efficiencies in daily A&E operations, the concepts and principles are stimulating a new way of thinking and challenging clinical teams to think differently and take back clinical control of process management and safe care of patients based on prioritisation and the urgency of care delivery.
This process has created a “pull” value and eliminated “non-value” time processes and duplications from the initial request. The Porter is now proactively presenting to the patient bedside ready to take the patient to imaging as opposed to waiting for instructions from a nurse, whose time can then be better released to caring.
The imaging process involves multiple departments and stakeholders. Endorsement was first sought and provided from senior medical and operational staff. These senior staff members championed the need for change and put patients at the centre of the initiative. The communication strategy centred on showing users how a new approach could elevate some of the pain points in their job and improve patient care. Staff were then engaged in PDSA cycles to developing the solution.
Over an 8-week period feedback from each user group was continually fed back into the design of processes, business rules, functionality and electronic views. For porters, illegible handwriting on white boards and missing information caused constant confusion. The incentive to improve the accuracy and clarity of information provided quick engagement from this group.
Doctors realised quickly that by completing the transfer method on the order it created an automatic and paper-less, person independent, porter transfer task, but when they realised that they could prioritise the order above other less clinically urgent orders this created greater engagement, and more importantly, enhanced safety for the ill patient.
The ability for nurses and flow coordinators to spend less time chasing tasks and have transparency on what a patient was waiting for, was a key driver for engagement within this group. Requests and feedback from staff continues to drive the tweaks and changes that are made to the solution. Fundamentally, through a value proposition, buy in from all stakeholder groups was secured and their engagement allowed full data availability to furnish and drive the solution forward.