Screening Mammography Performance Improvement Team
Henry Ford Hospital and Health Network and Henry Ford West Bloomfield Hospital
Detroit Michigan
Work Plan
Aim
How would you like your
results - West Bloomfield
n=661
20%
Other
Phone
When to receive results - West
Bloomfield n=612
15%
19%
3%
24%
18%
24%
Same Day
<24 hrs
<48 hrs
<1 week
<30 days
Doesn't matter
26%
Same Day
<48 hrs
<30 days
Same Day - Willing to Wait
- West Bloomfield n=212
<24 hrs
<1 week
Doesn't matter
Same Day - Willing to Wait
- New Center One n=67
24%
38%
62%
76%
No
Yes
# Hours to Complete Quality Check and Process Letter
Before Improvements
Screening Mammography % of Studies Read within 72 Hours
*ABUS studies not included
120.00%
100.00%
154% Improvement for
studies finalized within 48 hrs
80.00%
60.00%
621% Improvement
for studies finalized
within 8 hrs
40.00%
20.00%
# of Hours
Before Improvements
After Impr ovements
72:00:00
70:00:00
68:00:00
66:00:00
64:00:00
62:00:00
60:00:00
58:00:00
56:00:00
54:00:00
52:00:00
50:00:00
48:00:00
46:00:00
44:00:00
42:00:00
40:00:00
38:00:00
14:00:00
12:00:00
8:00:00
10:00:00
6:00:00
4:00:00
0.00%
# of Hrs
Project Sponsors: Nancy Schlichting and Dr Manuel Brown - Chair of Radiology
Project Champion: Patricia Miller, MD (Director of Operations, Mammography Radiologist)
Samantha Tunnecliffe (Supervisor, Mammography)
Ewa Lacka, MD (Mammography Radiologist)
Rhonda Pate (Lead Technologist, Fairlane)
David Kastan, MD (Vice Chair Radiology)
Mary Kay Kimble (Lead Technologist, Lakeside)
William Sanders, MD (Vice Chair Radiology)
Nancy Doan (Lead Technologist, W. Bloomfield)
Jim Ciarelli (Radiology IT Supervisor)
Carmen Czajka (Lead Technologist, NCO)
Fran Hicks (Radiology IT)
Sandra Mitchell (Mammography Supervisor, W. Bloomfield)
Sheila Carriere (Radiology IT)
Karen Hunt , MD (Mammography Radiologist)
George Thomas (Film Room Supervisor)
Nassar Beydoun, MD (Mammography Radiologist)
Brooke Wessman (Project Manager)
Gina Fundaro, MD (Mammography Radiologist)
Phase Seven Action Plan:
•Present work to System Radiology Integration and
Alignment Team to spread these process
improvements across the system.
Results
% of studies finalized
Team
No
Time to Process Letters
compares May to July 2010 and 2011 data
includes both Screening and Diagnostic studies
120.00%
100.00%
80.00%
60.00%
40.00%
20.00%
0.00%
After Improvements
•Team Engagement was instrumental in obtaining drastic, positive results in a short
time period.
•Completing the larger task of eliminating both film jackets and paper was easier than
trying to create smaller steps to ease the new process change (printing orders to
substitute the jacket workflow).
•Entire team involvement (spanned all roles) in the current and future state process
design provided a clear understanding of the entire process and allowed development
of concise and realistic goals.
•Share your success with others in your department – process improvement is
contagious.
2:00:00
Yes
Phase Six Action Plan:
•Work with Marketing Manager to advertise same day
result appointments for screening mammography
studies.
10%
15%
Lessons Learned
•Decreased handling time for processing letters by over 20% and enabled letters to be sent out
one day earlier.
•MQSA standards require result letters to be sent to the patient within 30 days.
•Revised patient result letter with updated format and content to meet customer service standards.
•Reviewing phone and internet applications to deliver same day results to patients in addition to sending
letters.
Other
36:00:00
29%
Email/Text
When to receive results - New
Center One n=109
34:00:00
15%
Letter
32:00:00
2%
Phase Four Accomplishments:
•Piloted same day results at all clinics.
•Standardized Appointment Scheduling Process.
•Created 5 same day slots per day at all diagnostic
imaging locations.
•Most locations can offer same day result
appointments within a few days and offer same day
access for other screening mammography
appointments.
70%
Email/Text
30:00:00
Letter
28:00:00
Phone
Phase Seven:
Spread
Phase Five Accomplishments:
•Implemented Phone Results System to deliver
negative screening mammogram results to patients
within 1 business day of the clinic visit.
6% 4%
21%
26:00:00
16%
24:00:00
•Ensured that all process improvements were modeled after the
Institute of Medicine Aims (Safe, Effective, Patient-Centered,
Timely, Efficient, Equitable).
•Every process improvement used LEAN tools and was
implemented via the PDCA process. Pilots were identified,
changes were tested and discussed and then rolled out to the
other sites.
•Sub groups met weekly on improvements and then debriefed
with the entire team at monthly meetings.
Phase Six:
Advertise
How would you like your
results - New Center One
n=115
3%
60%
Cycles of Learning
Phase Five:
Implement Phone
Results System
Phase Two Accomplishments:
•Completed Patient Survey to understand needs.
22:00:00
•Solicited and unsolicited patient requests for change and continued customer
involvement throughout the process.
•Moved from analog to digital mammography technology.
•Recently digitized past 2 years of historical studies.
•The current batched paper workflow was no longer needed to drive the process.
Phase Four:
Implement Same
Day Results
Phase Three Accomplishments:
•Implemented electronic workflow for Radiologists to decrease turn around time from 2 days to just
over one hour.
•Volume remained stable throughout improvements.
Phase One Accomplishments:
•Developed overall goal.
•Created current and future state maps.
•Visited Elizabeth Wende Breast Center to benchmark same day
results.
•Developed action plan to achieve goals.
20:00:00
Key Indicators for Change
Phase Three:
Revise Work
flow
% of Time Quality Checked and Letter
Processed
To meet the patient’s preference by sending regular screening mammogram results
within 48 hours, same day or prior to the patient leaving the clinic.
Phase Two:
Identify Patients’
needs
18:00:00
Goal
Phase One:
Develop Team,
Overall Goal and
Scope Project
16:00:00
To give each patient the opportunity to receive their screening mammography results
in a timely manner that best suits their needs. Results will be delivered by patient’s
choice either same day via a phone call or same day prior to leaving the clinic and all
patients will receive results by letter.
•New electronic workflow
achieved a 621% improvement
which enabled the report turn
around time to drop from
over 2 days to under 2 hours.
•Same day results are now
provided and meet customer
expectations.
•Written results delivery to
patients decreased from 3.9
days to 48 hours.