2. 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

3. 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

4. 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.

5. 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.

6. The RFO Saga

7. 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

8. Phase 1: Baseline Data Mean TAT = 43 minutes, Not consistent with OR experience

9. Potential RFO Imaging Process

11. Phase 2: Initial Interventions (The Good) 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)

12. BIG PROBLEM (The Bad)

13. Miscount following TRAM flap

14. Patient returns to EC

15. Phase 3: Re-engineering (The Ugly) Image acquisition segment of the project is redesigned, resulting in expected disruption. Mean TAT increases to 48 minutes with increased variation.

16. RFO Redemption

17. Phase 4: Final Interventions (The Redemption) Mean TAT decreased to 38 minutes, and variation decreased.

18. 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

19. Revenue Enhancement Total annual savings $182.50 X 264 (est.) = $48,180.00 Avoidance of a RFO and potential litigation PRICELESS

20. 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

21. Conclusion Quality improvement is not for the faint of heart. – You don’t know what you don’t know. – Understand what is going on before trying to measure it. – Don’t assume anything. You don’t need to win every battle to win the war.