May 2014 diagnostic imaging and regional nuclear medicine

• 1. Board Quality Committee Diagnostic Imaging & Regional Nuclear Medicine May 2014

2. Presentation Agenda General program information Program scorecard 2013-14 Goals Initiatives from the improvement board 2014-15 Goals Best practices Quality Assurance New Procedures Challenges 3. General Information Program Description Diagnostic Imaging Services: St. Marys General (SMGH) Computerized Tomography (CT) Scans Mammography (includes Ontario Breast Screening) General x-rays and fluoroscopy Ultrasound Regional Nuclear Medicine Services: St. Marys General (SMGH) and Grand River Hospitals (GRH) Imaging Procedures Non-Imaging Procedures Therapeutic Procedures 4. Program/Unit Scorecard QualityandSafety Procedures Starting On Time In The Morning (%) DRIVER 1 Percentage of time in CT that the morning exams start at the scheduled procedure time of 08:30am. Procedures Starting On Time In The Afternoon (%) DRIVER 2a Percentage of time in Ultrasound that the thyroid biopsy starts at 1300 hrs. DRIVER 2b Percentage of time in Ultrasound that the prostate biopsy starts at 1300 hrs. ER Exam Turn-Around-Time (%) WATCH 1 The percentage of time that the ER exam turn around time meets the 2 hour target for CT exams. WATCH 2 The percentage of time that the ER exam turn around time meets the 2 hour target for Ultrasound exams. ER Report Turn-Around-Time (%) WATCH 3 The percentage of time that the ER report turn around time meets the 1 hour target for CT and Ultrasound exams 5. Program/Unit Scorecard PatientandFamilyCentredCare Prospective Exam Wait Times (Days) WATCH 4 The number of days from phone booking to actual appointment date for certain exams in CT. WATCH 5 The number of days from phone booking to actual appointment date for certain exams in Ultrasound. WATCH 6 The number of days from phone booking to actual appointment date for certain exams in Xray (Gastrics and Specials). OurPeople Workload / Productivity WATCH 7 The average number of exams scanned by an Ultrasound technologist per day. FinancialStewardship Budget Variance WATCH 8 Monthly variance in the total monthly budget for all DI departments combined. 6. 2013/14 Goals Goals Status Strategic Direction - Quality & Safety Procure and install a shared PACs (image storage repository) with Grand River Hospital Begin preliminary planning for procurement of a new CT Strategic Direction - Patient and Family-Centered Care Patient Survey-expanded to include other modalities Strategic Direction - Our People Staff survey- Communication and Opportunities for staff to expand breadth of practice e.g. adjustments to the DI structure and cross training in Mammography, CT Strategic Direction - Financial Stewardship Reminder Calls-expand to include other modalities in diagnostic services 7. Initiatives from the Improvement Board 8. Initiatives contd 9. Initiatives contd Improving the patient experience for those having sentinel lymph node surgery. BEFORE AFTER 10. Initiatives contd St. Marys General Hospital Kitchener-Waterloo Regional Nuclear Medicine Program Subject: Standard Operating Procedure for Compounding in the Laminar Flow Hood Procedure: Compounding in the Laminar Flow Hood Review/Revision of Standard Operating ProcedureNuclear Medicine 11. Initiatives contd Ultrasound standard work for thyroid aspirations 12. 2014-15 Goals Goal 1: - To establish a monthly Unit Leadership Council (ULC) Description: To provide leadership to the unit by tracking key performance metrics, understanding problems and making improvements in support of the hospitals strategic directions. To provide a structure to address and improve unit level processes that will enhance staff work life Target Action Plan: Scheduled monthly meetings began as of January 2014. 13. First Project Central Portering Workflow mapping 14. 2014-15 Goals contd Goal 2: - The hospital goal to reduce the ED length of stay for at least 90% of admitted patients will be 8 hours Target Diagnostic Imaging has set a goal that 75% of ED patients from time exam ordered to exam completed will occur within 2 hours. Target The Radiologists have set a goal that 75% of ED patient reports will be available within 1 hour of exam completion (24/7). 15. Very positive early results for Radiologist report turnaround time for ED patients within the first few months of tracking! 16. CT and Ultrasound tracking from time the exam was ordered to when the exam was completed. 17. 2014-15 Goals contd Goal 3: - Improve communication Target In the recent staff survey, the team told us how important communication is to them. Action Plan: Introduce new Alert system 18. 2014-15 Goals contd Goal 4: - Tri Hospital Quality Assurance Program Target To introduce a quality assurance program that includes Radiologists conducting peer reviews to learn from each other and improve. Action Plan: The three hospitals will purchase Radpeer software. 19. Best Practices contd Nuclear Medicine is 45% complete in its review of best practice documentation (Society of Nuclear Medicine procedure guideline manual). Gastric Emptying Procedure Cardiac Half dose Procedures 20. Best Practices contd Radiologists regularly refer to best practice literature and make the recommendations for adjustments to CT protocols. CT High resolution imaging with reduced dose. Renal Protocol adjustment coming soon. 21. New Procedures New CT scanner coming soon 22. Quality Assurance Practices Tracking of In-Patients having multiple X-Rays Radiation Safety-lead aprons Ontario Breast Screening Program Accreditation Annual compliance audits (Nuclear Safety Commission) Monthly internal occupational health and safety audits 23. Challenges Quality of Care Review March 2013 911 Queens Blvd., Kitchener, ON N2M 1B2 (519) 749-6595 www.smgh.ca Prostate Biopsy 24. Challenges contd CT scanner planning and installation Minimize impact to patient care Maintain access to the Service Balance demand and capacity (in- patients, ED and out patients) 25. Challenges contd Technologist manpower issues. Radiopharmaceutical Supply 26. Reflections Shared PACS solution (Grand River & St. Marys Hospitals) PACS ED discrepant software 27. THANK YOU