ª15

THE VOICE OF EXPERIENCE

Fifty Percent Reduction in Time BetweenPatient Check-In and Needle Stick for ThyroidFNA Due to Workflow RedesignCourtney C. Moreno, MD, Claire Travis, William C. Small, MD, PhD, Michael Bowen, NP,Jianhai Li, William E. Torres, MD, Pardeep K. Mittal, MD, Bobbie R. Hollis, RDMS,Marilyn E. Dickerson, MPH, RDMS, Kimberly E. Applegate, MD, MS

INTRODUCTIONOptimizing workflow efficiency iskey to improving the performance ofany system.Optimized workflows inhealth care benefit patients by re-ducing unnecessary waits and delays.Additionally, optimized workflowsbenefit health care organizations byallowing the production of moreunits during a fixed period of timeand with fixed resources.In our practice, our workflow

for ultrasound-guided thyroid fine-needle aspiration (FNA) was anobvious target for a workflow re-design. Patients would dutifullycheck in at our department’s frontdesk. Then, sometimes 2 or 3 hourslater, their procedures would occur.Our patients were understand-

ably frustrated and unhappy withthese wait times. Additionally, theunpredictability and inefficiency ofthe system made it difficult toknow how many elective pro-cedures we could reasonably addon in a day. We therefore decidedthat for the betterment of our pa-tients’ experiences and to lessenfrustration levels among our staffmembers, we would undertake aredesign of our ultrasound-guidedthyroid FNA workflow.

HOW WE DID ITFor ourworkflowproject, we followedoperations management steps as out-linedbyOndategui-Parra et al [1].Themembers of our team were radiolo-gists, a nurse practitioner, nurses, andsonographers. We also solicited inputfrom departmental administrators,

2014 American College of Radiology

46-1440/13/$36.00 � http://dx.doi.org/10.1016/j.jacr

institutional policies, and The JointCommission. None of our primaryteam members had any specific busi-ness training or consulting experience.

Learn the Current WorkflowThe first step in our workflowredesign was to learn the details ofour current workflow. A text docu-ment was generated and circulatedamong all teammembers, includingnursing staff members, ultrasonog-raphers, and physicians. A physi-cian initiated the document withher understanding of the presentworkflow. Through in-person verbalcommunication and e-mail commu-nication, other team members wereencouraged to modify the docu-ment. The document was modifiedusing the track changes function inMicrosoft Word (Microsoft Cor-poration, Redmond, Washington)and circulated electronically.In mapping out this workflow, we

were as granular and detailed aspossible. For example, we tried toinclude all decision-making steps andcommunications. It was also impor-tant to include all team members sothat allworkflow stepswere included.For example, physicians were largelyunaware until this project thatdepartment nurses were needlesslyfilling out a moderate sedation ass-essment trifold document for thyroidFNA patients. Our initial thyroidworkflow before this project began isillustrated in Figure 1. As noted inthis figure, the initial workflowincluded 16 steps from the time apatient checked in at the radiologydepartment front desk to the time

.2013.11.005

the patient was walked to the ultra-sound suite for the procedure.

Look for BottlenecksThe next step in our workflowredesign was to evaluate for poten-tial bottlenecks. It quickly becameapparent that a potential bottleneckwas space availability in the pre/postprocedure care area (PPCA) forthe consent process. The rooms ofthe PPCA are used for a variety ofpurposes, including obtaining in-formed consent for outpatient andinpatient procedures, completingnursing evaluations for patients whomay require conscious sedation, andmonitoring patients as they recoverfrom conscious sedation and inter-ventional radiologic procedures.

The PPCA consists of 16 patientrooms and is staffed by an average of5 nurses, including a charge nurse.Patients going to or from interven-tional radiologic procedures in ourultrasound (1 or 2 procedure rooms),CT (1 or 2 procedure rooms), angi-ography (5 procedure rooms), andfluoroscopy (1 procedure room)divisions all pass through the PPCA.

A second bottleneck was thetiming of the scheduled daily thy-roid FNA. Historically, thyroidFNAs were scheduled for 1:30 PM.Our team decided that the earlyafternoon was often a busier periodof the workday, with a convergenceof CT, ultrasound, and fluoro-scopic procedures and diagnosticstudies requiring interpretation.

Investigate SolutionsWe focused our efforts on (1)movingthe consent process from the PPCA

1

Fig 1. Previous workflow for ultrasound-guided thyroid fine needle aspiration.

2 The Voice of Experience

to the ultrasound suite and (2)changing the appointment time forour thyroid FNA patients. Movingthe consent process out of the PPCAwould eliminate the PPCA spacebottleneck and would also eliminatethe need for steps 4 to 10, 12, 13, and16 of our workflow. Additionally,step 9 (nursing assessment) was eli-minated, as our thyroid patients donot receive conscious sedation.Beforewecouldmove theconsent

process out of the PPCA, we had todetermine if obtaining consent forthyroid FNA in the ultrasound suitewould be in compliance with insti-tutional policies as well as The JointCommission. We accessed theEmory University Hospital healthcare policy for consents and aftercareful review determined thatmoving consents to the ultrasoundsuite would be in compliance withEmory University Hospital healthcare policy. Through direct verbal

Fig 2. New workfl

communication with a Joint Com-mission representative, we learnedthat moving the consent processto the ultrasound suite would alsobe in compliance with The JointCommission.Additionally, we briefly consid-

ered whether direct phone calls toupdate team members regardingpatient status (eg, “arrived”) wouldbe more efficient than relying onteam members to identify changesin patient status in the patient elec-tronic tracking system. However, itwas our experience before imple-mentation of the electronic trackingsystem that relaying of phone mes-sages among team members wasinconsistent and contributed todelays. We have anecdotally foundthat the electronic tracking systemis a more efficient way for all teammembers to know a given patient’sstatus at our institution. Addi-tionally, our ultrasound suite does

ow for ultrasound-guided thyroid fine ne

not have a coordinator who couldreceive such a phone call. Theultrasound suite phone is answeredby sonographers when they arebetween scanning patients. Wethought that the creation of a coor-dinator position who could answersuch phone calls was beyond thescope of our project.

Develop and Solicit Feedbackon New WorkflowThe proposed new workflow thatwe drafted is presented in Figure 2.The primary change in this newworkflow was moving the consentprocess from the PPCA to theultrasound suite. This new workflowwas 8 steps shorter than our orig-inal workflow. We also changedthe primary appointment time forour thyroid appointments from1:30 PM to 8 AM. If the 8 AM slot wasunavailable or if patient preferencediffered, thyroid FNAs could also be

edle aspiration.

The Voice of Experience 3

scheduled at other times during theday.Our next step was to circulate this

proposednewworkflowamong teammembers for feedback. We had face-to-face discussions with our sono-graphers because the new workflowwould potentially affect them themost. The proposed new workflowalso was e-mailed to other teammembers, including faculty radiolo-gistswhoperformultrasound-guidedthyroid FNAs, and was discussed atdivisional meetings.Our sonographers’ primary

concern was that shifting the con-sent process to the ultrasound suitewould create a newbottleneck in theultrasound department, especially ifa physician or nurse practitioner wasnot immediately available to obtaininformed consent. We thereforeadded information at the bottom ofthe protocol document indicatingthe order in which individualsshould be paged to obtain consent(resident first; if resident unavai-lable, then nurse practitioner; ifnurse practitioner unavailable, thenattending physician).

Rollout of New WorkflowWe selected October 1, 2012, as thedate to roll out the newworkflow. In-person discussions were held with ourultrasonographers regarding this start

Fig 3. Mean time interval (minutes) b

date. Group e-mails were sent to ourdivisional faculty members. Targetede-mails also were sent to individualfaculty members who were scheduledto work on October 1 and the daysimmediately thereafter.The rollout was not without

glitches. On day 1, a thyroid pa-tient was taken to the PPCA. Welearned that we had not done anadequate job of communicatingthe new workflow to the PPCAstaff. By day 2, our thyroid patientswere being consented successfullyin the ultrasound suite.An additional glitch was the in-

structions that were given to ourthyroid patients at the time ofscheduling. We were unaware thatschedulers were telling patients toarrive 1.5 hours before theirappointment times. Several pa-tients checked in well before theirscheduled appointment time of8 AM, the earliest checking in at6:06 AM. Although our front deskstaff members were there to recordthe patient’s check-in, we were notfully staffed to perform thyroidFNAs at that early hour. As soonas we were aware of this problem,we contacted our schedulers andinstructed them to change patientinstructions to request that patientsarrive 30 minutes early to allowtime for parking and check-in.

etween patient check-in and first needl

Assessment of New WorkflowAnecdotally and subjectively, the newworkflow seemed to be an improve-ment. To more formally assess theimpact of our new workflow on pa-tient wait times, we obtained institu-tional review board approval toretrospectively review our thyroidcases. A waiver of the requirement forinformed consent was granted.

We obtained a list of all 298thyroid FNAs performed betweenApril 1, 2012, and April 1, 2013,in our ultrasound department. Pa-tient check-in time at the frontdesk and the image time stampfrom the ultrasound image fromthe first needle pass were collected.Elapsed time between these twotime points was computed.

Time intervals for the old and newworkflows stratified by appointmenttime are reported in Figure 3. Themean time interval between check-inand first pass was 167min for the oldworkflow and the 1:30 PM appoint-ment slot. With the new workflow,the shortest time interval betweencheck-in and first pass occurred forthe 8:30 AM appointment slot andwas 80 minutes. This 80-minutetime interval with the new work-flow was a >50% reduction com-pared with the old workflow andthe 1:30 PM appointment time.This 80-minute time interval is not

e pass for old and new workflows.

4 The Voice of Experience

entirely a wait, as the patient is con-sented during this time and changesinto a gown, diagnostic images areobtained, the site is marked, the pa-tient is prepped in sterile fashion, thetransducer is prepped, the skin isnumbed, and the cytopathologyteam is paged and then arrives.We also noted that the time

interval between check-in and firstpass grew longer with the newworkflow as we approached thelunch hour and decreased slightlyearly in the afternoon. The roomwe use for thyroid FNA is also usedfor other procedures, as well asinpatient diagnostic ultrasoundscans. We speculate that when athyroid FNA was not the first caseof the day, thyroid patients mayhave experienced longer waits ifother preceding cases were delayed.

LimitationsA limitation of our project was thatwe did not directly measure patient

satisfaction related to thyroid FNAworkflow before and after the newworkflow. We intend to directlymeasure patient satisfaction beforeand after any future workflowredesigns.

Follow-UpWe continue to use this newworkflow at the Emory UniversityHospital. Our head-and-neck radi-ologists have also adopted thisworkflow for their ultrasound-guided neck lymph node FNAs.We have also adopted this workflowat another hospital in our health caresystem.

LESSONS LEARNED

� Get the facts directly from theprimary source. This applies tolearning the details of the workflowdirectly from involved team mem-bers. It also applies to institutionalpolicies and Joint Commissioninformation.

� The system is more complexthan you realize. We learnedthis lesson when writing the de-tails of the old workflow andalso after rollout of the newworkflow.

� Communicate, communicate,communicate. Despite worryingthat we were on the verge ofovercommunication with multi-ple face-to-face and e-mail com-munications, in the end, wehad not communicated enough,in particular with PPCA staffmembers regarding the rolloutdate of the new workflow.

� Be persistent. If this process weresimple or easy, all of our work-flows would already be opti-mized. Don’t give up.

REFERENCE

1. Ondategui-Parra S, Gill IE, Bhagwat JG, et al.Clinical operations management in radiology.J Am Coll Radiol 2004;1:632-40.

Courtney C. Moreno, MD, Claire Travis, William C. Small, MD, PhD, Michael Bowen, NP, Jianhai Li, William E. Torres, MD,

Pardeep K. Mittal, MD, Bobbie R. Hollis, RDMS, Marilyn E. Dickerson, MPH, RDMS, and Kimberly E. Applegate, MD, MS, are

from the Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia.

Courtney C. Moreno, MD, Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 CliftonRoad NE, Atlanta, GA 30322; e-mail: courtney.coursey@emoryhealthcare.org.