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MRIDU SINGH

PGDM – HEALTHCARE MANAGEMENT

GOA INSTITUTE OF MANAGEMENT , GOA

BUSINESS PROCESS REVIEW-MRI , IMAGING DEPARTMENT,HINDUJA HOSPITAL

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WHY Business Process Review ?

Business process review/ analysis is an assessment tool to identify the bottlenecks in the existing business system and the opportunities for improvement in the same. It generally comprises of three stages namely review, proposal for change and implementing change.

This tool can be applicable to both simple , small level processes as well as the large and complex businesses.

It provides both the 360° panoramic overview and in depth understanding of the existing system which is necessary for considering improvements.

Thorough understanding of the existing system

Identification of the roadblocks/bottlenecks

Identification of scope of improvement and designing of the appropriate intervening tools

Assessment of the impact of implementing change

EXPECTED OUTCOMES

Reference :cics-ppu@sheffield.ac.uk

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PURPOSE OF PROJECT

To conduct the business process analysis of MRI section , Department of Imaging , P.D. Hinduja Hospital and Medical Research Centre and to assess the impact of changes implemented.

SCOPE OF PROJECT

This summer project includes all the three stages of business process analysis and additionally assess the implemented changes intended for improvement of the existing business process.

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PROJECT PLAN - GANTT CHART PNG File

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UNDERSTANDING WORK PROCESS-WORK SHADOWING

Waiting area

MRI Room

Doctor’s room

Console room

IN SEQUENCE

Registration desk Changing room

Waiting area Nursing

station

Technical Room

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THE WORK FLOW APPOINTMENT TAKEN

– SLOT ALLOTED

PATIENT ARRIVAL CONSENT

FORM FILLING,

CHECKLIST

MARKING AND

MAKING PAYMENT

PATIENT HISTORY TAKEN ( MRI

REQUEST FORM IS USED) DRESS

CHANGE

PREPARAT

ION (IN CASE OF GA/CONT

RAST STUDY)

STAY IN WAITING

AREA

MRI EXAMINATION ( PRECEDED BY TECHNICIAN’s

INSTRUCTIONS AND SETTING TIME TAKEN)

RECEIVING

REPORT

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Facts about the department •For appointment ,scheduling and payments , a module of CARE 2000 is used for the MRI Department. During appointment following details are filled:-

•Patient no. ( HH No. /EX NO. )

•Name

•Telephone No.

•Service provided (based on the prescription submitted)

•Sex/ age

•Time allotted

•Status

•Remarks ( any further specifications )

•The allotments are given certain status like tentative ( yellow ), confirmed ( red ), purple , light blue ( available ), pink ( holding ) , grey ( OT book )

•Instructions are conveyed to patients orally as displayed on the desktop screen

Philips Ingenia-1.5 T & 3 T

1 slot= 45 minutes (total 20 per machine

per day )

UNDER GA – 8:30 AM TO 1 PM

APPOINTMENT SYSTEM

WORKING HOURS - 7 AM TO 11 PM

TIME TO WALK FROM MRI TO CONSOLE =5

SECONDS

2 PATIENT TROLLEYS – USED FOR PREPARATION &

RECOVERY

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The record files that are maintained – inventory of medicines and consumables ( weekly indent ) , post anesthetic care ( recovery room data ), crash cart , working of suction and O2 supply , pharmacy enquiry ( to be charged separately from the patient ), contrast checking , thermometer checking , daily consent forms record, anesthesia charge sheet Claustrophobia or other unprecedented factors making patient uncomfortable delays the scan time

Patient seems highly dissatisfied due to long waiting time

Real time communication is missing to patients’ relatives

Patient flow is not uniformly distributed over different time of day and across days in a week

For every patient, one folder is used for keeping report ; a sticker with the patient details is printed and pasted on it.

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The intrusion of emergency cases creates the backlog of already scheduled slots Location next to emergency and in front of the patient lift –transportation time minimum for both inpatient & casualty casesAround 3 -9 minutes it takes to shift IPD patients to patient table / change the patient table in case of Breast MRISometimes , staff’s absence for a short while or being busy with other patient adds to the waiting time for the respective patient

Unidirectional movement of patient in the department setup – not present

Schedule for IPD & casualty patients directly handled by technicians

Examination protocol for different kinds of studies followed by technicians

Consent form is not explained in detail

Third party option may be used while making voucher if the patient is employee of organization mentioned on the panel ( for reimbursement)

System for formal feedback/complaints not present

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THE TEAM …human resource •The number of staff present in a shift – 2 technicians, 1 resident radiologists, 1 nurse , 1attendant , 2 registration desk staff

•Working hours : for technicians & registration staff – 7 to 3, 3 to 11

•For nurses – 8 to 4, 2 to 10 (reliever from CT scan dept from 2 to 4

•Pager system for nursing and attendant staff ( only used in emergency)

MRI STUDY

OF PATIENT

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PHASE 1 – REVIEW & ANALYSIS

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Mapping the Process …

The process map included here shows the patient flow throughout the process of MRI

Adobe Acrobat Document

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DATA COLLECTION METHODOLGY

TIME MOTION

STUDY FOR SAMPLE SIZE 150

OPEN ENDED INTERVIEW WITH ALL

STAKEHOLDERS ( ALL STAFF & PATIENTS)

OBSERVATIONS

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QUANTITATIVE ANALYSIS

QUALITATIVE ANALYSIS

Results from data

Microsoft Office Excel Worksheet

Microsoft Office Excel Worksheet

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PARAMETER GA CASES NON GA CASES

Average MRI examination time( time taken for one scan)

46 MINUTES 51 MINUTES

Average turnaround time( time taken from when patient arrives till patient exits )

193 MINUTES 104 MINUTES

Average preparation time( time taken to prepare the patient for MRI scan )

41 MINUTES 35 MINUTES ( OPD)13 MINUTES ( IPD)

Average recovery time 49 MINUTES 43 MINUTES

Average idle time 12 MINUTES 8 MINUTES

Average waiting time 116 MINUTES 80 MINUTES

KEY HIGHLIGHTS

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% above 45 minutes 59 MINUTES 56%

% within 45 minutes 35 MINUTES 45%

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Average no. of examinations per dayAverage no. of working hours per week

31 examinations

96 hours

Average access time ( time duration between appointment request and allotment )

1 DAY ( VARIABILITY 1 TO 22 DAYS)

% of IPD cases 16%

% of OPD cases 84%

% of walk in appointments 7.6%

Utilization rate 73.8 %

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Types of studies conducted

MRI Brain plain 25.17%

MRI Angiography abdomen 6.99%

MRI Angiography brain 2.09%

MRI Cervical plain 4.89%

MRI musculoskeletal 13.98%

MRI Lumbar spine 12.58%

MRI Brain spectroscopy 0.69%

MRI RT planning pelvis 6.99%

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MRI Brain with contrast 10.48%

MRI Dorsal spine 4.19%

MRI Neck with contrast 1.39%

MRI Enterography 0.69%

MRI Cochlea 2.79%

MRI Para nasal sinuses 0.69%

MRI Breast MRI 0.69%

MRI MRCP 1.39%

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RACI analysis Functions\Roles Receptionist Nurse Technician Resident DoctorAnesthetist Attendant Radiologist  

appointment R C I

reminder/ information call to patient R I

consent & other forms R I A/C C

transferring the patient folder A I Rpayment R I

change into patient dress C I C A SELF

consent for anesthesia* R A I Cpatient history I A R Cpreparation R C Ipharmacy billing R

machine set up & instructions Rprocessing I R Ctransportation I A C Rrecovery / IV removal R A I C

patient's dress change C A SELFreport making I Rreport bringing C I Rreport dispatch R Imaintenance of linen I A C R

maintenance of films & blank CDs I R A

maintaining file records R

maintaining pharmacy supplies R A

*only for certain patients

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CAUSE & EFFECT ANALYSIS JPEG File

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1

2

2

3

3

Interaction at registration desk

staff not availablestaff busy with other patientstaff busy on phone callpatient arrives late

Pediatric patient start from 8:30 , anes-thetist might be late

.

1%

2%

3%

Patient arrival

patient arrives lateprepond emergency case

22

3

4

5

6

7

changing room

dresses not available in changing room

not in the stock

size not available attendant not available to pro-vide dress

changing room occupied

very old immobile patient

patient not in-formed

1

1

4

preparation

nurse not available nurse busy with other patient

coordination amongst staff not timely,

anesthetist not available

problem of finding the patient's vein ( GA)

fasting instruction not followed

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22

2

45

6

patient history

not asked before imaging

need repetitive in-teraction

unable to convey the problem

files not brought

not taken at this time

relative not available

files missing by doctor

1

3

4

setting time

technicians' time to plan the scan

non cooperation / claustrophobia

instruction of metal removal not followed

attendant not available

3

5

7

8

scanning

machine's potential (technical)non cooperation / movementtest not done completelyrepeat scan relatives not in-formed

15

5

6

9

IV removal / recovery

nurse not available nurse busy with other patient

instruction not fol-lowed to press for 5 mnts

nurse busy with her own errands

patient not well dur-ing recovery

1

3

4

exit report receiving info not given

IPD patients file update

may have query about the report receiving

further discussion by doctor

attendant not available

23Cause & effect analysis result

Problem Cause Solution

Overall delay due to the delay in changing room

•Patient dress not available• stock over •patient not asked well in time to change

All patient dresses kept in the changing room with shelves properly labeled

Patient forgets to bring previous records or do not fast properly

Instructions are communicated orally only

Brochure be given at the time of appointment

With high patient flow , task becomes chaotic

Less organized method of handling forms

All forms kept together as set

Patient enquires often to technician & nurse about reports

Patient does not have enough information

Report collection information displayed for patients .

Patient may not follow all instructions properly

Patient information is not sufficient

Certain posters/labels in changing room

Extension of study – more waiting for next patient

Many reasons responsible like patient movement

Informing patient before 30 minutes (reminder calls)

C:\Users\win\summer project\presentation\

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PHASE 2 –IMPLEMENTATION OF CHANGE

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PROBLEM ADDRESSED CHANGE / SOLUTION STATUS

DELAY IN ARRANGING AND SENDING CONSENT AND REQUEST ( PATIENT HISTORY ) FORMS

THREE FORMS IN TOTAL CLUBBED TOGETHER (CONSENT FORM , SCAN REQUEST FORM & MRI CHECKLIST ) AS DIFFERENT SETS

ALL GA PATIENTS ARRIVED AT 8:30 AM

2 PATIENTS CALLED AT 8:30 AM,

NEXT TWO AT 9:00 AM AND REST OTHER PATIENTS CALLED AT 10:00 AM ONWARDS

THE CHECKLIST OF CHANGES IMPLEMENTED YET TO BE DISCUSSED

TO BE IMPLEMENTED SOON

ON HOLD

IMPLEMENTED* STATUS

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PATIENT DRESSES NOT AVAILABLE FOR SEVERAL PATIENTS AS ONE PIECE KEPT AT A TIME

• SHELVES LABELLED• ALL PATIENT DRESSES

KEPT IN CHANGING ROOM

DIRECTIVE COMMUNICATION FOR PATIENT IS MISSING IN CHANGING ROOM

THREE ADDITIONAL SIGNBOARDS DISPLAYED

PATIENTS MAY NOT BE CLEAR ABOUT REMOVAL OF ALL METALLIC ITEMS

POSTER TO INFORM PATIENTS REMOVAL OF METALLIC THINGS

MANY ENQUIRIES ABOUT REPORT COLLECTION

NOTICE FOR REPORT COLLECTION INFORMATION

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SOME PATIENTS GET DELAYED IN ARRIVING - CURRENTLY PATIENTS CALLED 15 MINUTES BEFORE THE ALLOTTED TIME

● CALLING PATIENT 30 MINUTES BEFORE THE ALLOTTED TIME

COMMUNICATION NEEDS TO BE MORE EFFICIENT BETWEEN TECHNICIAN , DOCTOR AND FRONT DESK STAFF

● ON THE CHECKLIST , TO BE MENTIONED WHO IS INFORMED ABOUT THE PATIENT NEXT IN TURN

FEEDBACK FORMS FOR ANY COMPLAINTS AND COMPLIMENTS FROM PATIENTS

● FEEDBACK FORM TO BE CREATED FOR RADIOLOGY DEPARTMENT ( AS ALREADY USED IN HEALTH CHECK AND OPD)

TECHNICIAN BEING INVOLVED IN PATIENT CARE - LEADS TO ADDITIONAL DELAYS

● JOB ENHANCEMENT - TASK OF PATIENT BEING SET ON PATIENT TABLE DONE BY ATTENDANT ONLY

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CLEAR DESCRIPTION OF WORK CAN HELP STAFF BE ORGANISED

● SOPs FOR ALL STAFF BE DISPLAYED ON NOTICE BOARD INSIDE CONSOLE ROOM ( FOR THEIR OWN REFERENCE)

NEED OF MAKING PATIENT MORE INFORMATIVE

● BROCHURES TO BE GIVEN AT THE TIME OF APPOINTMENT

COORDINATION BETWEEN THE STAFF HOLDS POSSIBILITY OF IMPROVEMENT AND THUS OCCASIONAL FRICTIONS CAN BE AVOIDED

● MOTIVATING REWARDS AND PROFESSIONALISM ENHANCEMENT (LEARNING/TRAINING SESSIONS FOR STAFF)

FOR SOME PATIENTS VERY LONG WAITING TIME (SPECIALLY WALK IN WITHOUT ANY REFERENCE)

● STANDARDISED DURATION OF WAITING , ACCESS TIME EXAMPLE - NOT MORE THAN 30 MINUTES , 2 DAYS RESPECTIVELY

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CERTAIN TIMES SCHEDULING ITSELF IS NOT PROPER DUE TO MIS-COMMUNICATION ( OPDs HANDLED AT REGISTRATION & IPDs HANDLED BY TECHNICIANS DIRECTLY )

● ALL SCHEDULING BEING DONE BY SINGLE PERSON

CERTAIN PATIENTS NEED APPOINTMENT URGENTLY

● PREFERENCE BASED ON URGENCY OF THE CONDITION AND NEED OF THE PATIENT

PATIENT NEEDS TO BE MENTALLY WELL PREPARED - TO INCREASE THE POSSIBILITY OF COOPERATION DURING MRI SCAN

● AUDIO - VISUAL TO BE SCREENED IN THE WAITING AREA

● ALL THE INFORMATION CONTENT IN BROCHURE AND DEMO VIDEOS BE UPLOADED ON WEBSITE

REAL TIME COMMUNICATION AMONG STAFF CAN BE IMPROVED WITH TECHNOLOGICAL INTERVENTION

● USE OF RFID AND OTHER NEW TECHNOLOGIES FOR TRACKING INVENTORY ( LINEN , DRUGS AND OTHER MEDICAL SUPPLIES ) AND STAFF

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The “CHANGES” implemented in the department The signages that are being used now in MRI department.

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PHASE 3 – EVALUATION

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FURTHER PLAN – Data collection methodology and analysis results

TIME MOTION STUDY FOR N=150

OBSERVATION

RESULTS

Microsoft Office Excel Worksheet

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COMPARATIVE DATA – GA CASES

MRI EXAMINATION TIMEIDLE TIME

0

20

40

60

80

100

120

140

160

180

200

4641 49

12

193

116

68

20

53

9

161

97 AVERAGE 1AVERAGE 2

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EXPLANATION MRI EXAMINATION TIME PREPARATION TIME

RECOVERY TIME

IDLE TIME

TURNAROUND TIME

WAITING TIME

MORE CASES OF MRI BRAIN THAN OTHER SMALLER STUDIES

PREPARATION TIME SIGNIFICANTLY GOT DECREASED BY 51.2 %

RECOVERY TIME WAS MORE THAN EARLIER ; REASON PATIENT SPECIFIC

IDLE TIME ( TIME GAP BETWEEN COMPLETION OF SCAN OF 1 PATIENT AND START OF ANOTHER) DECREASED BY 25%

TURNAROUND TIME DECREASED BY 16.58 % PROBABLY DUE TO THE DECREASE IN PREPARATION AND TURNAROUND TIME

WAITING TIME DECREASED BY 16.37%

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COMPARATIVE DATA – NON GA CASES

MRI E

XAMIN

ATIO

N

PREP

ARAT

ION T

IME

IDLE

TIM

E

TURNAR

OUND TIM

E

WAI

TING T

IME

0

20

40

60

80

100

120

51

35

8

104

8052

2111

98 99

AVERAGE 1AVERAGE 2

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EXPLANATION

MRI EXAMINATION TIME PREPARATION TIME

IDLE TIME

TURNAROUND TIME

WAITING TIME

MRI EXAMINATION TIME IS ALMOST SIMILAR

PREPARATION TIME SIGNIFICANTLY DECREASED BY 40%

IDLE TIME HOWEVER WAS INCREASED BY 37.5% PROBABLY DUE TO LESS PATIENT FLOW ON CERTAIN DAYS OF THE STUDY THAT LED TO HIGHER VANANT TIME

TIME DECREASED BY 5.76% DUE TO THE REDUCTION IN PREPARATION TIME

WAITING TIME INCREASED BY 23.75% DUE TO HIGHER NUMBER OF WALKIN PATIENTS

( SEASONAL IMPACT)

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SPECIFIC OBSERVATIONS DURING EVALUATION STUDY•Attendant had to be asked to keep patient dresses in changing room . some of them needs to be more responsive to the patient needs

• Scheduling becomes difficult if many walk in patients are there- longer waiting time for them and more clarity required in communication between technician and front desk staff in this regard.

• Once ventilator was found to be not working properly when patient had been already taken for MRI – maintenance should be more robust to avoid such incidences

•Sometimes no staff is present in waiting area

In certain instances , scan could not be done ; reasons were metal stents inside body, no fasting before GA (ICU patient) , patient could not lie down comfortably

Some days both the machines were vacant for more than 30 minutes owing to less patient flow

Number of lockers given for patients’ use be increased to 4 instead of 2

Absence of billing staff makes the patients go to the first floor for payment specially during lunch breaks ; probable reason is shortage of staff

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CONCLUSION THE PROJECT UNDERTOOK THE ANALYSIS,

IMPLEMENTATION AND EVALUATION THE ANALYSIS PART LED TO THE THOROUGH

UNDERSTANDING OF THE BUSINESS PROCESS AND IDENTIFICATION OF THE EXISTING GAPS

THE IMPLEMENTATION ( RESEARCH , DESIGN AND APPROVAL) IS AN ONGOING PROCESS ; ONLY CERTAIN RECOMMENDATIONS COULD BE IMPLEMENTED DUE TO THE TIME CONSTRAINED FEASIBILITY

THE IMPLEMENTED CHANGES THAT WERE CONFINED TO THE FRONT DESK AND GUIDING THE PATIENTS THROUGH SIGNAGES SHOWED THE RECUCTION IN TIME SPENT FOR PREPARATION

THE SCHEDULING CHANGES DROPPED THE WAITING TIME ALSO HOWEVER THE DATA MAY SHOW SLIGHT IMPACT OF SEASONALITY OF DEMAND

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REFERENCES:-• “Introduction to business process review and implementation”; cics-ppu@sheffield.ac.uk• “ The business process review”, Pennington Dennis P. , Total resource Management

ACKNOWLEDGEMNT :-

Due gratitude is conveyed to Dr. Swapnil Kharnare for guiding throughout the project and the whole MRI staff for helping achieve successful completion of the project. Further , gratitude is also extended to Dr. Preeti Goraksha for providing this opportunity and Mr. Deepak S. Kuvlekar for providing requisite support from Marketing department.

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THANK YOU