Decreasing the Turnaround Time (TAT) of Intra-operative Imaging and Interpretation
of Potentially Retained Foreign Objects (RFO)
Joseph R. Steele, M.D., Janet Champagne MBA, Garrett L.
Walsh, M.D.UT MD Anderson Cancer Center
Overview
• RFOs after surgery can present considerable risk and potential patient harm
• The rate of RFO ranges from 1/5500 to 1/7000• Cima RR, et al. J Am Coll Surg 2008; 207:80-7• Egorova NN, et al. Ann Surg 2008;247:13-8
• Considered a sentinel event by the Joint Commission
Project Overview
• Joint venture between the Division of Surgery, Perioperative Enterprise and Division of Diagnostic Imaging.
• X-ray obtained if post-operative mismatched count occurs.
• The turnaround times (TAT) for intra-operative imaging of potential RFOs was felt to be unacceptable by the Division of Surgery, potentially jeopardizing patient care.
• A team consisting of OR staff, surgeons, radiologists, administrators and radiology technologists was organized to address and solve the problem.
AIM Statement
• The aim of this project was to decrease the average TAT for imaging and interpretation of potential RFOs to less than 30 minutes within 4 months. – The process begins when the OR calls Diagnostic
Imaging requesting an operative radiograph, and ends when the radiologist calls back to the OR with their report.
Phase 1: Baseline Data Collection
• Improving the RFO TAT was unsuccessfully attempted by a previous CS&E team.
• Because of pressure to immediately begin improvement efforts, their data were used as a baseline.
Problem #1
Phase 1: Baseline Data
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90
80
70
60
50
40
30
20
10
0
Imaging performed in OR for potential RFO
Min
ute
s
_X=43.0
UCL=91.3
LB=0
RFO TAT stage 1
Mean TAT = 43 minutes, Not consistent with OR experience
Potential RFO Imaging ProcessRoutine Hours: Monday – Friday 0600 - 1800
Retained Foreign Objects or Incorrect Counts – Routine Hours revised: 7 April 2010O
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1. OR discovers a RFO or incorrect
count
5. CT DI Service Coordinator
receives call from OR.
(Manual time collection).
10. Radiologist or Radiology resident is made aware of RFO or incorrect
count in OR
12. Rad Tech arrives in OR with
x-ray unit(Begin procedure time is collected)
9. CT DI Service Coordinator calls
Radiologist or Radiology resident
using call tree
13. Rad Tech obtains images
4.Prepares patientand room for
X-ray
6. CT DI Services Coordinator calls 713 794-1178 to
request technologist dispatch
15. Images uploaded to PACS
and enters info into RIS.
(End Procedure time is collected)
3. Provides patient name, MRN, md code, svc code, type of exam, surgical types and
locations, call back number and OR room number
7. Technologist is dispatched to OR.
8. CT DI Service Coordinator enters
requisition into CARE.
2. OR calls CT DI Service Coordinator at
713 745-5449.
11. Rad Tech Changes
procedure code in RIS to one of the
RFO codes
14. Do images cover defined
areas?
Yes
No14a. Inform
surgeon additional images required.
14c. Assist technologist with positioning under
sterile field.
14b. Can technologist
obtain additional images?
Yes
No
14d. Instruct tech to perform imaging after closing or in
PACU.
14e. Technologist obtains images in
pre-defined location.
1
Potential RFO Imaging ProcessRetained Foreign Objects or Incorrect Counts – Routine Hours revised: 7 April 2010 page 2
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tech
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CT
DI
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Co
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16. Rad Tech calls CT DI Service Coordinator at 713 745-5449 and informs procedure is
complete
17. CT DI Service Coordinator notifies
GI Radiologist images are complete.
(Manual time collection)
19. Radiologist instructs CT DI
Service Coordinator to contact OR
21. Report communicated to Physician Team in OR * Standard Read Back
(Manual time Collection)
20. DI CT Service Coordinator contacts
OR with Radiologist on the phone at the phone
number provided earlier.
18. GI Radiologist reviews images
1
Phase 2: Initial Interventions (The Good)
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90
80
70
60
50
40
30
20
10
0
Imaging performed in OR for potential RFO
Min
ute
s
_X=43.0
_X=39.6
UCL=91.3UCL=88.2
LB=0 LB=0
1 2
RFO TAT stages 1 and 2
TAT improved to 39 minutes and represents a lengthier, complete process. Since there were no complaints, the quality of the exams were assumed to
be excellent. (Problem #2)
Phase 3: Re-engineering (The Ugly)
81736557494133251791
120
100
80
60
40
20
0
Imaging performed in OR for potential RFO
Min
ute
s
_X=43.0
_X=39.6
_X=47.8
UCL=91.3 UCL=88.2
UCL=122.1
LB=0 LB=0 LB=0
1 2 3
RFO TAT stages 1, 2 and 3
Image acquisition segment of the project is redesigned, resulting in expected disruption. Mean TAT increases to 48 minutes with increased
variation.
Phase 4: Final Interventions (The Redemption)
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120
100
80
60
40
20
0
Imaging performed in OR for potential RFO
Min
ute
s _X=43.0
_X=39.6
_X=47.8
_X=38.9
UCL=91.3 UCL=88.2
UCL=122.1
UCL=83.2
LB=0 LB=0 LB=0 LB=0
1 2 3 4
RFO TAT by project stage
Mean TAT decreased to 38 minutes, and variation decreased.
Revenue Enhancement
• Additional technical charge (OR)- $1200/hr– Savings of approximately $100.00/case
• Additional anesthesia charge (OR)- $342/hr– Savings of approximately $28.50/case
• Additional professional anesthesia charge (OR) $648/hr– Savings of approximately $54.00/case
Revenue Enhancement
• Total annual savings$182.50 X 264 (est.) = $48,180.00
• Avoidance of a RFO and potential litigation
PRICELESS
Next Steps
• Since we failed to meet our aim the following steps will be undertaken:– Evaluate stage 4 data – Improve communication (OR and DI staff)– Decrease repeat imaging– Initial PDSA cycles until the 30 minute TAT goal is
accomplished
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