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A Classic Healthcare Improvement Story
by Ralph Smith
A while back a friend of mine who is a hospital COO gave me a challenge- find and facilitate 3-5 game-changing process improvement projects. Nothing was off limits, but each project had to deliver >$1 million improvement to the bottom line. In the midst of my search, I stumbled across some interesting data.
The MRI department had a six-week backlog to get an appointment, yet the daytime utilization of their scanners was just over 50%. (They had to repeat that three times before I was sure I heard it right!). This looked like a project that checked all the boxes- management commitment, good data on the existing process, knowledgeable subject matter experts… it had it all. What about financial opportunity? Well, this was a children’s hospital. That meant a significant percentage of the patients had to be put to sleep for their scan- tough to tell a 5-year-old to hold still for 45 minutes. That made the average charge per patient over $5,000. We set a reasonable target of 70% utilization, which basically meant adding 4 scans per day- roughly one per scanner. That’s $20,000 per day… it adds up.
Every project is unique. One of the things that made this one unique was the presence of senior leadership on the team, mixed with front-line personnel. It’s tricky to pull that off unless you have the right chemistry- we did. Great leaders that knew when to chime in and when to listen. And because the leaders were there, we got buy-in as we went along. When we wanted to make changes, we had the authority to do it- we didn’t have to waste time getting approvals.
What did the team do? Analyzed the process, collected data, performed cause analysis, etc… all the things a lot of process improvement teams do. But this team was interesting in that the range of lessons learned fell into a lot of common categories:
Don’t make assumptions: For months the team kept saying they had two fast machines and one slow one. As an outsider, I assumed the slow one was slow because it was older / not state of the art. I finally asked one day, and got the unexpected answer that it was slow because it took smaller images and had to be reset to do larger area scans. Once that was on the table, someone suggested using the “slow” scanner primarily for brain scans, as they were small enough to be taken in one shot. The team therefore turned the “slow” scanner into a third “fast” one.
When everyone shares responsibility for communication, then no one is responsible: Multiple functional areas were assuming someone else was telling the parents their kids couldn’t eat before coming in for an MRI (because they would be going under anesthesia). Many times that meant they weren’t told at all. The kids-that-ate-at-McDonalds-on-the-way-in rate was much higher than it should have been, leaving utilization gaps. Nursing took accountability for this and the problem went away.
Metrics that don’t tell the whole / right story: The hospital kept track of no shows for years, and had multiple reminder mechanisms in place to prevent them. Nothing wrong with that, since the no show left a gaping hole in the schedule and hurt utilization. But no shows weren’t the whole story. When a patient cancelled or rescheduled within a day or two of the appointment, there wasn’t enough time to get a substitute patient through the insurance process and fill the slot. So late-stage cancels and reschedules had the same scheduling impact as no shows, and they happened far more often. Changing the metric to “lost slots” gave the team a bigger-picture view of the schedule, and led to modifying the timing on the reminder process so we could head off late changes before they became a problem.
We’ve always done it this way: Every organization has processes that have been around since the dawn of time, and people often assume incorrectly that they cannot be changed. In this case the Radiologists would order certain scans and the techs would run them. The problem was that often the orders weren’t specific enough, causing the techs to either a) chase down the Radiologist and ask questions, b) run the sequences they thought were necessary, creating rework when they were wrong, or c) running everything that might be needed, wasting scanner time. The team wanted to approach the Radiologists with the idea that they should protocol specific scans for each patient for the following day before leaving the night before, but assumed there would be massive pushback. Luckily, one of our team members was a senior Radiologist, and he pitched the idea. The rest of the Radiologist group had been frustrated with interruptions / questions from techs and periodic rework, and adopted the process change immediately. The % of scans protocolled was over 90% within a month, and utilization interruptions dropped measurably.
What were the results? Well, the first round of changes enabled the hospital to burn through the entire backlog in one month, dropping time-to-be-seen from six weeks to under a week. This led to improved quality and speed of patient care, and big gains in parent satisfaction.
And while a picture may only be worth a thousand words… it turned out it was also worth several million dollars.