Background

Four trusts in the Kent and Medway Imaging Network have recently undertaken a project to address the constraints leading to poor flow in CT. Among the constraints identified was a lack of formal training for radiographers in service improvement, and an absence of real-time data needed to demonstrate service flow. A key requirement to the long-term success of the programme therefore was to build in-house improvement capability skills. This has been achieved through the development of an online foundation Health Care Operations Management Programme targeted at radiology service managers. The learning from this approach will enable others to improve their access to CT by following a structured methodology and creating in-house capability.

Figure 1: diagnostic vitals chart (DVC)

This is a dashboard updated and presented to the CT teams weekly so they can monitor service performance in near real-time over the previous 6 months.

Benefits seen at Kent and Medway

• each team developed a CT diagnostic vitals chart® (figure 1) which demonstrates the relationship between weekly referrals, activity, work in progress/backlog (WIP), cancellations and referral-to-scan lead times
• all teams worked to remove their policy constraints (time traps, batching and carve out) and, with no additional cost, this led to the reduction of WIP and reductions in lead times for routine scans down to 14 days and cancer lead times to less than 14 days
• 1 team eliminated their annual outsourcing costs (over £360k p.a.) and reduced their overtime costs for elective CT
• 3 teams review their DVCs every week, enabling them to react quickly to changes to proactively prevent issues
• in-house improvement capability has been developed for the long term, with 5 radiology staff being trained in the health care systems engineering improvement methodology

The steps to improve access to CT

1. Project setup

• pull together a multidisciplinary CT team including clinical and non-clinical staff
• produce a stakeholder map to identify who needs to be involved in the project
• arrange to meet weekly to map, measure and model the service before testing any changes

2. Map the CT Service

• map the processes in the current CT pathway from referral to scan including the patient and the information flows (see figure 2 below)

Figure 2: process map showing the stages and estimated timings for the day of the appointment

Example CT Pathway

1. Patient attends appointment fully prepared (1 minute).
2. Receptionist books patient on radiology information system (RIS) (1 minute).
3. Patient waits in waiting room.
4. Radiology department assistant (RDA) shows patient changing room (1 minute).
5. Patient changes to gown (5 minutes).
6. RDA inserts I/V Venflon for contrast (5 minutes).
7. Radiographer consents patient (5 minutes).
8. Radiographer calls patient to scanning room (5 minutes).
9. Radiographers and RDA position patient on scanner (1 minute).
10. Radiographer scans patient (5 minutes).

3. Measure the flow metrics

• request analytical support to capture weekly RIS validated data. This will enable a dynamic flow dashboard to be established (see figure 1 above)
• the project team can use the data to establish a baseline and to monitor the service data weekly. This will enable the team to understand if changes are leading to improvement
• measure the CT utilisation:
  • measure the CT cycle time for every patient for a full week, from opening to closing. The sum of all the CT cycle times for each day is called the CT load
  • CT utilisation is calculated by dividing the total CT load by the CT operating hours per day (see figure 3 below). This is presented as a percentage
  • note: CT activity is not a measure of CT utilisation
    

Dashboard should include

1. Weekly referrals, activity, and cancellations.
2. Weekly work in progress (backlog) – examinations waiting to be performed.
3. Lead times (request to scan) by date of scan.

Figure 3: utilisation chart comparing daily load (sum of cycle-times) to the operational hours (CT resource-time available)

4. Measure the cycle time

• CT activity is governed by the CT cycle time which is defined as “the time from when the patient enters the scanner, to when the staff and resources are ready to scan the next patient (including preparation and cleaning)”

5. Measure patient flow and wasted time

• use a Gantt chart to make the patient flow and wasted time visible
• The Gantt chart (see figure 4 below) measures every step in the process for all 15 patients scanned over a 4-hour period
• each process step is a different colour, with red squares showing the wasted time where patients are waiting

Figure 4: Gantt chart, and key, showing the breakdown of 15 patient’s cycle times, from arrival at reception to the actual scanning

6. Diagnose the flow constraint

• using the system flow map, process map, data dashboard, CT utilisation analysis and Gantt charts, identify the constraints to flow. The issues identified will be different for different sites and scanners. These could be:
  • policy constraints – where certain tacit and explicit ‘rules’ for managing the demand, activity and booking unintentionally cause longer delays for patients
  • resource-time constraints – where there is insufficient resource/staff time to meet the demand, in particular non-clinical workforce including:
    • booking clerks
    • porters
    • RDAs
  • diagnose the problem before testing any changes and use the data to show the impact of any changes before reflecting on how to embed the changes
  • invest in a solution to remove any flow constraint identified. For example, Kent and Medway Imaging Network invested in more booking clerks, porters and RDAs

Overcoming challenges at Kent and Medway

Figure 5: access to CT driver diagram

Links and resources

• Full Kent and Medway CT case study: www.journalofimprovementscience.net
• Radiology GIRFT: www.gettingitrightfirsttime.co.uk
• Foundations of Health Care Operations Management: www.fhcom.uk
• How to create a Gantt Chart: www.ganttchart.uk
• To speak to someone about this project, project please contact richard.flood@nhs.net at Maidstone and Tunbridge Wells.
• Further resources on diagnostics can be found on the National Diagnostics Transformation FutureNHS page. An NHS email address will be required to access the page.