University of Michigan Health System. Program and Operations Analysis. Room Scheduling Analysis for Interventional Radiology.

University of Michigan Health System Program and Operations Analysis Room Scheduling Analysis for Interventional Radiology Final Report To: Matthew Rall, UMHS Radiology Admin Susan Fisher, Special Project Coordinator - Department of Radiology Andrei Duma, Management Engineer Program and Operations Analysis Whitney Walters, Lean Coach Michigan Quality System Mark Van Oyen, Associate Professor of Industrial and Operations Engineering From: IOE 481 Project Team 1IR Turnover, Programs and Operations Analysis Nasrin Kaniz Joshua Pigula Mike Dendrinos Garrett Spindell Date: April 17th, 2012

EXECUTIVE SUMMARY The Department of Interventional Radiology (IR) at the University of Michigan Health Systems (UMHS) currently faces difficulties achieving a flowing, efficient schedule to treat patients. IR treats both inpatients and outpatients, however, outpatients sometimes wait for over four hours to be treated if an emergency inpatient cases arise. In addition, the IR system may be underutilizing both physicians and room equipment. Therefore, the administration wants to know what issues are causing these suboptimal conditions. To gain a better understand the IR department, the team observed 34 outpatient cases over three weeks in February collecting procedural data on the scheduled start and end time, patient checkin, arrival to and exit from the procedure room times, doctor start and stop times, clean-up, and prep time. The observations helped pin-point the issues of the current system. The team s data was also used to verify the data recorded in the Operating Room Management Information System (ORMIS). After verifying the ORMIS data, the team developed an Excel-based scheduling tool to be used by IR s schedulers. The scheduling tool uses previous ORMIS data to optimize the scheduling of outpatient procedures BACKGROUND The IR Department at the University of Michigan Hospital has five rooms available for use per day. During each procedure, approximately two nurses and two technicians work with the physician to clean the room and prep the patient. These nurses and technicians are considered the crew for the procedure. Three crews and two physicians are staffed daily in IR. The physicians are the most constraining resource in the IR department; they are the most expensive staff resource. Other staff includes the schedulers, who are responsible for assigning appointments to outpatients, and the boardrunner, a nurse responsible with managing the daily schedule. The current problems the IR is facing are: 1) IR rooms contain expensive equipment that remain idle between procedural cases, 2) patients sometimes wait for over four hours beyond their scheduled appointment start time, 3) delays in subsequent cases are caused by variation in procedure durations from the scheduled times, and 4) physicians are not being fully utilized. The goals of this project were to develop recommendations to improve IR outpatient scheduling, to reduce patient and physician waiting times, and to increase room and physician utilization. The scope of the project pertains only to IR outpatient cases performed within the five IR rooms. METHODS The team performed four types of tasks to evaluate and improve the scheduling process for outpatient IR cases. Interviewed Hospital staff. First, the team interviewed 20 nurses and technicians to better understanding the problems of the current system and scheduling process. These interviews were conducted during the data collection period in February. The team also 2

toured and interviewed staff of the Cardiovascular Center (CVC) Cath Lab to see how that department operates because both IR and CVC perform similar procedures. Collected data by observing IR procedures. For three weeks in February, the team performed time studies of procedures done in IR. A total of 34 cases were observed during this period. The data collection sheet used by the team is shown in Appendix II. Verified ORMIS data. The team compared the data collected during observations to the recorded ORMIS data. Analysis was then performed to verify the ORMIS data. Analyzed ORMIS data and created a scheduling tool to be used by IR schedulers. The team developed an Excel spreadsheet to calculate the optimal percentile at which to schedule each procedure. The tool sums the amount of idle time and delay time for the physician by each percentile for each case type, then finds the minimum expected wasted time, which correlates to the optimal procedure schedule length. FINDINGS The following findings are from the ORMIS data and observation period. Schedulers and boardrunners lack standardized methods. No uniform standards exist for the boardrunners to follow. Also, lack of communication is common between the scheduler and boardrunner. For observed cases, only 30 of 34 cases had data recorded. IR could adopt methods of CVC Cath Lab. The Cath Lab has the goal to start the first case on time 90% of the time. Additionally, they rotate and overlap physicians between procedure rooms to minimize physician idle time. IR whiteboard schedule is unorganized and difficult to update. Cases are not organized chronologically, leading to difficult reading. Located in the central hallway of IR, the whiteboard creates a lot of unnecessary traffic. The two IR electronic boards are being used minimally, if at all. Both boards are located in the corners of IR and are rarely updated in a timely manner. 80% of outpatient cases are scheduled for longer than necessary. This creates idle time for physicians. Additionally, 60% of cases were scheduled for 30+ minutes longer than necessary. 85% of cases start later than scheduled. Only 15% of cases start on-time or before the scheduled start time. The ORMIS data from July 2011 to January 2012 is recorded with a 6.5% error. The historical data was deemed accurate for use in future analysis. CONCLUSIONS The following conclusions are based on the findings from the observation period and ORMIS data. The physicians and rooms are being underutilized. During the observation phase the team noticed physicians waiting for patients to arrive and to be prepped. The whiteboards currently being used to show the daily schedule of patients are inefficient and unorganized. The staff uses the whiteboard to keep up with the status of 3

cases complete throughout the day. However, often times the whiteboard is not updated, such as cases marked not started that are already underway or even complete. The two electronic scheduling boards are underutilized. The electronic boards provided a quicker and more accurate way to updated patient status compared to the whiteboards. The current estimated times used to schedule outpatient cases are overestimated. As stated in the findings, 80% of cases are scheduled for longer than necessary. This leads to idle time for all staff and equipment in IR. RECOMMENDATIONS The following recommendations are based on the observation period, findings from the ORMIS data, and Excel scheduling tool. Improve communication within IR and to outside departments. Through the observations and interviews the team found that communication between the staff in IR is poor. Cases get backed up due to poor communication; for example, physicians and nurses do not always know if the patient has arrived to the room. Use only electronic boards. As seen in the Cath Lab, electronic boards are extremely useful for creating an efficient, flowing process. By having the whiteboard, cases are not updated automatically, nor in a timely manner. Overlap back-to-back procedures. The team recommends that IR overlaps scheduled procedures between two rooms when back-to-back; increasing room utilization as well as decreasing physician idle time. The same number of cases can be completed in less time when compared to the current system. The figure below shows an example of the current schedule vs. a schedule with the proposed changes. Reduce the current scheduling times of select procedures. The team developed an Excel scheduling tool that minimizes idle and delay time for patient procedures conducted in IR. In the output, schedule length times for various cases were reduced. The figure below shows an example of the current schedule vs. a schedule with the proposed changes. 4

TABLE OF CONTENTS INTRODUCTION 1 BACKGROUND 1 Key Issues 2 Goals and Objectives 2 Project Scope 3 METHODS 3 Conducting Interviews 3 Receiving ORMIS data 4 Verifying ORMIS data 4 Analyzing ORMIS data 4 Creating Excel Scheduling Tool 4 FINDINGS 5 Findings from Interviews and Observations 5 Findings from ORMIS Data and Excel Scheduling Tool 6 CONCLUSIONS 7 Conclusions from Interviews and Observations 7 Conclusions from ORMIS Data and Excel Scheduling Tool 8 RECOMMENDATIONS 8 Recommendations from Interviews and Observations 8 Recommendations from ORMIS Data and Excel Scheduling Tool 9 EXPECTED IMPACT AND OUTCOME 9

Impact on Patients 9 Impact on IR Staff and Department 10 FUTURE WORK 10 Communication between Nurses and Physicians 10 Communication between the Boardrunner and Technicians 10 Communication between Boardrunner and Pre-op Area 10 Communication between Boardrunner and Anesthesia Department 10 Use of Electronic Boards and Software 11 Standardizing the Cleaning of Rooms Post-procedure 11 APPENDIX I: CURRENT SCHEDULING CHEAT SHEETS 12 APPENDIX II: DATA COLLECTION SHEET 15 APPENDIX III: BOARDRUNNER SCHEDULING SHEET 16 APPENDIX IV: SCHEDULER SCHEDULING SHEET 19 APPENDIX V: SAMPLE FUTURE SCHEDULING 22

TABLE OF FIGURES AND TABLES Figure 1. Outpatient Schedule Length Overestimation 6 Figure 2. Outpatient Start Time 7

INTRODUCTION The Department of Interventional Radiology (IR) at the University of Michigan Hospital conducts minimally invasive surgical procedures, on areas such as the heart, using advanced body imaging technology. IR treats both inpatients, those already admitted to the hospital, and outpatients, who arrive to the hospital based on a scheduled appointment. The IR often gets backed up when emergency inpatients arise, resulting in outpatients waiting extended periods for treatment. UMHS Radiology reports that outpatients sometimes wait in excess of four hours past their scheduled time to begin a procedure. The emergency procedures, which take priority over outpatients, are near impossible to predict, so delays are inevitable. However, the current scheduling of outpatients may also contribute to procedure delays. Potential scheduling problems also lead to physician, room, and equipment underutilization. Therefore, the hospital administration wanted to know what underlying issues are causing the current suboptimal conditions. To better understand the current system, the IR department proposed a student project for the Industrial and Operations (IOE) 481 Practicum in Hospital System. The IOE 481 team began the study by observing procedures in the IR and interviewing staff members which included physicians, nurses, and technicians. Next, the team collected procedural time data for three weeks to verify the data recorded by IR staff using the Operating Room Management Information System (ORMIS). The team observed 34 outpatient cases collecting procedural data on the scheduled start and end time, patient check-in, arrival to and exit from the procedure room times, doctor start and stop times, clean-up and prep time. The purpose of observing procedures was to verify the ORMIS data so historical data could be used in statistical analysis with confidence. Finally, the team used historical ORMIS data and the feedback from interviews and observations to create a scheduling tool to improve physician utilization. The purpose of this final report is to present the team s methods, findings, conclusions, recommendations, and expected outcomes, as well as some future works for the IR department. BACKGROUND The IR Department at the University of Michigan Health Systems has five rooms available for use per day. Each of the five procedure rooms contains near identical machines; Room 5 contains a CAT scan machine for special procedures. In the IR central hallway exists three boards displaying the current patient schedule for the day. A whiteboard and two electronic flat screen boards each display the patient name, procedure type, scheduled start and end time, and patient status (i.e. checked-in, in recovery, etc.). The whiteboard requires manual update and takes up much more space than the electronic boards. The electronic boards can be updated instantly via computer in multiple areas of the hospital. Each day there are two to three physicians and a combination of seven to nine nurses and technicians in the IR department. The number of physicians available for procedures makes them the most constraining resource in the IR department. The hospital administration has previously discussed hiring more physicians, but financial constraints made that infeasible. During each procedure, approximately two nurses and two technicians work with the physician. These nurses and technicians are considered the crew for the procedure. Three crews work on staff in IR 1

each day. The responsibilities of the crews include room prep, room cleanup, patient prep, patient transfer to the discharge area, recording procedural data, and assisting the physician during the procedure. Currently, upon completion of the physician portion of a procedure and before the next, the crew exits the patient to recover, cleans the room, preps the room for the next procedure, and carts the next patient to the same room. Back-to-back procedures are scheduled in the same room rather than utilizing the benefits of using all rooms available. The idle time for physicians between procedures is 20 to 30 minutes using the current scheduling methods. Other employees critical to daily IR operations are the boardrunner and appointment schedulers. Each day, IR has one nurse working as the boardrunner; this individual rotates each day. The responsibilities of the boardrunner are to manage the day s schedule using the electronic boards and whiteboards and to fit inpatient procedures between scheduled outpatient procedures. The boardrunner is in constant communication with the physicians, nurses, schedulers, and outpatient check-in area. The schedulers work both in IR and in an additional office area in Radiology. The responsibility of the IR schedulers is to assign appointments for approximately 20% of outpatient procedures, and all inpatient procedures with a 24 to 48 hour advance notification. The schedulers in Radiology assign appointments for all remaining outpatient procedures. All schedulers make appointments using information provided by the physicians and cheat sheets provided by IR, as seen in Appendix I. The IR administration expressed that many of the outpatient procedures may be scheduled for longer than necessary. When procedures are completed ahead of schedule, the boardrunner sometimes attempts to fit in a non-emergency inpatient procedure or an outpatient who arrived ahead of schedule. In theory, these added procedures reduce idle time for staff, but more often, they cause delays for the next patient. The delays are caused by either the staff underestimating the procedure length or emergencies that emerge mid-procedure extending the procedure length. In general, when the outpatient, who must fast prior to the procedure, is delayed, he or she becomes dissatisfied with the hospital s service. The complaints received by IR administration from upset outpatients were the initial reason for this project. Key Issues The following key issues were important in all aspects of this project: IR rooms contain highly expensive equipment. When the IR system is idle, this equipment and investment is being wasted. Patients sometimes wait in excess of four hours past their scheduled appointment time before beginning their procedure. Procedure durations vary from the estimated scheduled times, creating delays for subsequent procedures. Physicians, the most expensive and constraining IR resource, are idle for extended periods of time between cases. Goals and Objectives To determine the root cause of the IR scheduling inefficiencies, the team has: 2

Observed IR procedures and interviewed IR staff. Recorded durations of staff activities during IR procedures (room preparation time, procedure time, surgeon time, clean-up, and prep times). Verified ORMIS data accuracy using the observations. Analyzed observed data and historical ORMIS data. Toured and interviewed staff at the Cardiovascular Center (CVC) Cath Lab, which conducts similar procedures to IR. With this information, the team developed recommendations to: Improve IR outpatient scheduling to reduce outpatient delay times. Increase room and physician utilization. Project Scope The study focused on the scheduling of outpatient procedures. The team observed and measured procedure times from room preparation through room cleanup. The subjects of the team interviews were not limited to employees of IR but also other departments related to the process and with similar procedures. The study excluded inpatient and emergency procedures. The team did not observe parts of the IR patient procedure process happening outside the procedure rooms (patient arrival and preprocedure patient preparations, post-procedure and discharge). Because the time between patient arrival and procedure start was important to this study, the team used the ORMIS recordings for analysis related to procedure delay. The team did not observe post-procedure dictations or other physician activities not performed in the procedure area. METHODS When developing the methods for this project, the primary goals consisted of adjusting outpatient scheduling to reduce patient waiting times, and increase room and physician utilization. For secondary goals, the team recommends improved communication between IR staff and related departments. The team believes that these goals have a highly correlated relationship to the overall success of the IR system. Conducting Interviews The team interviewed physicians, nurses, and technicians working in the IR department from February 6 to February 24. The interviews were conducted to get the staff s opinion about the current system. On average, two interviews were conducted per day. The staff varied on a daily basis, allowing the team to interview 20 different employees. Furthermore, the team toured and interviewed staff of the CVC Cath Lab. The procedures conducted in the CVC are similar in nature to those of the IR, both being minimally invasive and using body imaging technology. 3

Receiving ORMIS data ORMIS is a Microsoft Excel based system used by UMHS to record and track surgical procedure data, including the IR department. For each procedure, the nursing staff is responsible for recording the times for different activities performed. Each case is organized by case number. The historical ORMIS data the team received came from the months between July 2011 and January 2012; this data consisted of 4882 cases. Verifying ORMIS data The team needed to verify the accuracy of the ORMIS data before conducting statistical analysis on the historical data. The observations recorded in ORMIS the team analyzed were: Procedure type Scheduled start/stop times Patient arrival/exit time Physician start/finish time Clean-up/Prep time To validate the ORMIS data, the team performed time studies where observations were recorded and compared to the ORMIS data for 34 cases. This allowed the team to calculate the accuracy of the ORMIS data and if it could be used to make recommendations for the client to improve the scheduling of IR cases. The data collection sheet used by the team to record data is shown in Appendix II. From February 6 to February 28, the team observed IR cases four days a week, from 7 AM to noon, for IR rooms 1, 2, 3, 5, and 6. A minimum of 30 observed outpatient cases was deemed necessary by the team to attain statistically significant data. The sample size of 30 was chosen because populations have an approximate normal distribution for the sample mean at this size. At the end of each week, the client sent the team updated ORMIS data and the team compared their data to the ORMIS data recorded by the nursing staff. Analyzing ORMIS data Analyzing ORMIS data helped the team understand how the current scheduling system affects the day to day idle and delay time. The analysis compared the actual time it took to complete each procedure to the scheduled time allotted for each procedure. General statistical analyses were done in order to see any errors in the system, consistent procedural start delays, and procedural scheduling trends, if any. Creating Excel Scheduling Tool The team created an Excel scheduling tool that uses historical ORMIS data and outputs the optimal length a procedure should be scheduled. The team aimed to find the optimal case time percentile that minimizes both the expected idle time and expected delay time for the physicians for each procedure type. The idle time is defined as the time between a case that finishes early 4

and the scheduled end time. The delay time is defined as the time between a case that finishes late and the scheduled end time. The percentiles tested ranged from the 10th through the 90th percentile in increments of 10%. Each percentile has its own expected delay time and idle time if procedures are scheduled at that percentile. Thus, there exists an optimal percentile, where the total expected delay plus idle time is minimized. FINDINGS The team s findings are broken down from two categories: 1) the interview and observation period and 2) the ORMIS data and the Excel scheduling tool. Findings from Interviews and Observations The observations were conducted to verify the ORMIS data; however, interviews were also conducted simultaneously. The team s findings were as follows: Schedulers and boardrunners lack standardized methods. - Currently, no uniform standards exist for the boardrunner to follow in order to revise schedules throughout the day. Also, the communication between the two areas of appointment scheduling is minimal. For example, the scheduling area in Radiology adds 45 minutes to the procedure length if it needs anesthesia while the schedulers in IR add 30 minutes. The CVC Cath Lab has a recently improved system for scheduling cases with methods the IR department could adopt. - Many of the problems experienced in IR are the same ones previously experienced in the Cath Lab. Recently, the Cath Lab conducted an overhaul of the system, switching from whiteboards for scheduling to exclusively electronically updated boards with the focus of improving overall patient scheduling. Starting the first procedure of the day on-time 90% of the time is also one of the key goals in Cath Lab system. Much like IR, the Cath Lab has more rooms available than physicians. However, when cases are scheduled back-to-back, the physician rotates to a different room where the staff has already retrieved and prepped the next patient rather than using the same room and staff again. The small change of rotating physicians between rooms and overlapping procedures allows the Cath Lab to complete over 20 procedures a day with just two physicians while minimizing physician idle time. The IR whiteboard schedule currently in use is unorganized and hard to update. - The whiteboard allows the staff to see the schedule of patients for the day; however, cases are not necessarily organized chronologically. This information is later edited during different parts of the day by the boardrunner and can be very confusing to follow. The edited information, for the most part, is not communicated well within the IR department. The board is also located in a narrow hallway that usually has a lot of traffic. Anyone walking too close to the board can accidentally erase information from the board. The IR electronic boards are being used minimally, if at all. - There are currently two electronic boards in the IR department. The locations of both boards are in corners and few, if any, employees use them as expressed in the interviews. Even though the whiteboard takes longer to 5

update, the daily boardrunner tends to make changes to the whiteboard before the electronic boards. Findings from ORMIS Data and Excel Scheduling Tool After analyzing the ORMIS data, the team observed patterns of the current system. The specific areas of focus for the data were the scheduling length for outpatient cases, how late or early the procedures start on average, and the overall accuracy of the data. The findings are as follows: 80% of the outpatient procedure types are scheduled for longer than necessary. - With 80% of the cases taking less time than scheduled, idle time exists between those cases. Figure 1 below shows that for the six months of historical ORMIS data, 80% of the cases were scheduled for more time than needed and 60% were scheduled for 30 minutes or longer than needed. Figure 1. Outpatient Schedule Length Overestimation The majority of cases start late, specifically 85% start later than the scheduled time. - When comparing the start time of a procedure to the scheduled start time in the ORMIS data, each procedure can either start early, start on time, or start late. Figure 2 shows the number of cases by 10 minute bins from July 2011 to January 2012, positive numbers signify the procedure started later than scheduled and negative numbers mean the case started earlier than scheduled. Only 15% of the cases started on-time or early, and conversely, 85% of cases started late. 6

Figure 2. Outpatient Start Time The ORMIS data from July 2011 to January 2012 is accurate with 6.5% degree of error. - The historical data was found to be accurate with a 6.5% degree of error when compared to the 30 observed cases. However, the team actually observed 34 total cases but 4 cases were not used because data was not collected in ORMIS for unknown reasons. CONCLUSIONS The team s conclusions are broken down into two categories based on the findings from: 1) the interview and observation period and 2) the ORMIS data and the Excel scheduling tool. Conclusions from Interviews and Observations The team s conclusions from the interviews and observations are as follows: The physicians and rooms are being underutilized. - During the interviews, the physicians expressed frustration about being idle between procedures. From the interviews, the team found the schedulers try to place a physician in the same room all day rather than rotating between rooms. The two electronic scheduling boards are being underutilized. - Through the observations and interviews, the team concluded the electronic boards in the IR department are used minimally, and sometimes are turned off. The minimal use results from the location of the boards, and some staff is hesitant to switch from the whiteboards. 7

The whiteboards currently being used to show the daily schedule of patients are inefficient and unorganized. They lack the ability to quickly update patient information such as check-in and arrival to room. - The nurses, physicians, and technicians use the whiteboard area as way to keep up with the status of cases completed throughout the day. However, often times the whiteboard is not fully up to date and can cause confusion about a case that may already be underway or even complete. Conclusions from ORMIS Data and Excel Scheduling Tool The team made the following conclusions from the findings in the ORMIS data and the Excel scheduling tool: The current estimate times used to schedule outpatient cases are overestimated. - Based on the data from July 2011 to January 2012, 80% of the cases in IR are scheduled for more minutes than required. When a case is scheduled for more time than needed, it creates idle time for all staff before starting the next procedure. Also, the room equipment sits idle, all of which are unnecessary costs to the hospital. RECOMMENDATIONS The following recommendations are suggested based on the team s findings and conclusions from two parts of the project: 1) the interview and observation period and 2) the ORMIS data and the Excel scheduling tool. Recommendations from Interviews and Observations The recommendations of the team based on the findings and conclusions of the observation and interview processes are as follows: Improve communication within IR and to outside departments. - Through the team s observations and interviews, lack of communication between the staff in IR contributes to scheduling problems. The IR must communicate better with the outpatient receiving area to know when patients arrive. The electronic board system can by multiple areas in the hospital to notify IR when patients arrive, but this knowledge is delayed when the boardrunner is updating the whiteboard. In addition, the team observed cases where procedures were delayed because the IR was waiting for the anesthesia department to bring equipment. The team recommends the current IR staff to tour the Cath Lab and get feedback from the CVC staff to see what improvements and changes were made to the Cath Lab system. Use only electronic boards. - As observed in the CVC, electronic boards are extremely useful for creating an efficient, flowing patient scheduling system. By having the whiteboard, cases are not updated automatically, nor in a timely manner. The electronic boards also allow for better communication of patient arrival between the check-in area and IR. The team suggests that using only electronic boards can fix this problem. Since the electronic boards are already in place, no additional investment is needed. However, the team recommends replacing the 8

centrally located whiteboards with the poorly placed electronic boards. Only once the whiteboards are removed will the staff be forced to adopt the new electronic scheduling boards. Recommendations from ORMIS Data and Excel Scheduling Tool The recommendations of the team based on the findings and conclusions of the ORMIS data and excel scheduling tool are as follows: Change the current scheduling times of procedures. - The team s analysis of ORMIS data shows that IR schedules procedures for more than the necessary amount of time needed to complete the procedure. The team created an Excel scheduling tool that minimizes the amount of idle time and delay time for patient procedures. The tool can quickly and easily update the optimal procedure lengths as new data is obtained in ORMIS. The new scheduling printouts for the schedulers and boardrunner are shown in Appendix III and IV. The times used by the schedulers are 20 minutes less than those given to the boardrunners, signifying the physician work time; this in turn overlaps back-to-back procedures by 15 minutes without needing to re-train the scheduling procedures of the staff. The boardrunner then assigns arriving patients to rooms based on availability and the minutes on their sheets. The team also recommends the schedulers use a standard amount of time (either 30 or 45 minutes) to add to procedures where anesthesia is needed. Overlap back-to-back procedures. - The team recommends that IR overlaps scheduled procedures between two rooms, rather than putting them back-to-back in one room. With the current scheduling system, physicians have about 30 minutes of idle time in-between cases, where they are waiting for the room to be cleaned and for the next patient to be prepped for procedure. Since there are only two to three physicians working per day, not all five rooms are being used simultaneously. IR can reduce idle time of the physicians by overlapping cases. Appendix V shows an example of reducing scheduled procedure time and overlapping back to back cases. In the example, three cases that currently take 3 hours to complete if scheduled overlapped will only take 1.5 hours for one physician. EXPECTED IMPACT AND OUTCOME The team expects this project to have two direct impacts: 1) improved outpatient scheduling and 2) increased utilization and overall satisfaction of the IR staff and department. Impact on Patients The team expects the project to have the following direct impact on IR outpatients: Reduce delay times for outpatient procedures by improving scheduling procedures. - By reducing procedure length and overlapping procedures the amount of idle time will be reduced. With less idle time, the boardrunners should no longer have to squeeze procedures between others and the amount of delay experienced by future patients will be reduced. The team determined that most outpatient delays are not a product of emergency patients, but rather the current scheduling methods. 9

Impact on IR Staff and Department The team expects the project to have the following direct impact on the IR staff and department: Increase patient throughput by increasing physician and room utilization. - The reduction in schedule length for procedures and the overlapping of cases will reduce the idle time of physicians and will increase operating room utilization. By reducing the idle times of the physicians and the amount of time the rooms are unused, the department can potentially treat more patients on a daily basis. Additionally, if procedures take less time and delay time is reduced, the staff is more likely to finish work by 5 PM. FUTURE WORK The team observed areas of the IR that could be improved that were beyond the scope of this project. The team recommends these areas future groups to study: Communication between Nurses and Physicians The team observed times when the nurses had finished the prep of the patient and would be waiting for the physician to come to the room to start the procedure for periods of time greater than 10 minutes. This waiting time impacts the scheduling system by delaying all future cases. Communication between the Boardrunner and Technicians The team observed situations where the room was marked not ready when in fact it was already cleaned. This miscommunication is an issue because it delays the boardrunner from calling down to the pre-op area to have a patient brought to the prepared procedure room. Due to the communication breakdown, the procedures are delayed by the amount of time it takes for the boardrunner to realize the room is ready. Communication between Boardrunner and Pre-op Area The team observed times where the boardrunner was waiting for a patient who was actually ready for the procedure. Due to this communication breakdown, the procedure is delayed as is the overall schedule. Communication between Boardrunner and Anesthesia Department The team observed times when the boardrunner thought the anesthesia department was going to bring down a patient but ended up waiting in excess of 2 hours for the patient to arrive. The communication breakdown between the two departments adds excessive delay to the system. 10

Use of Electronic Boards and Software The team suggests studying using electronic boards for the boardrunner to post the schedule. The study suggested would be finding the most optimal and easy way to use software that would fit the needs of the boardrunner. Standardizing the Cleaning of Rooms Post-procedure The team suggests performing time studies of the clean-up of the rooms post-procedure. Although the team observed that it generally takes an average of 10 minutes to clean a room, there were times when it took upwards of 20 minutes. The team thinks it would be possible to standardize the work to make clean-up and prep time consistent. 11

APPENDIX I: Current Scheduling Cheat Sheets Schedule Procedure Type Minutes IR ABD AORTA WITH RUNOFF 185 IR ABDOMEN BILIARY STRCITURE DILATION 90 IR ABDOMEN BILIARY TUBE PULL 60 IR ABDOMEN FILTER CHECK 250 IR ABDOMEN G TUBE CHECK AND CHANGE 70 IR ABDOMEN GASTROINTESTINAL TUBE PLACEMENT 90 IR ABDOMEN GENITO-URINARY STRICTURE DILATION 100 IR ABDOMEN HEPATIC ARTERY CATHETER PLACEMENT 60 IR ABDOMEN HEPATIC ARTERY CATHETER PLACEMENT 135 IR ABDOMEN HEPATIC ARTERY CATHETER REMOVAL 60 IR ABDOMEN PERCUTANEOUS NEPHROSTOMY TUBE CHECK AND CHANGE 75 IR ABDOMEN PERCUTANEOUS NEPHROSTOMY TUBE PLACEMENT 130 IR ABDOMEN PERCUTANEOUS NEPHROSTOMY TUBE PULL 65 IR ABDOMEN PERCUTANEOUS TUBE CHECK AND CHANGE 85 IR ABDOMEN STONE REMOVAL CHOLEDOCHAL 215 IR ABDOMINAL AORTA ANGIOGRAM 175 IR ABLATION 120 IR ABLATION CRYO 120 IR ABLATION RF 90 IR ABSCESS TUBE 60 IR AORTIC TRANSLUMBER 90 IR ARTERIOGRAM GI BLEED 190 IR ARTERIOGRAM THROMBOLYTICS 220 IR ASCENDING VENOGRAM 145 IR BIOPSY 90 IR BIOPSY BILIARY 60 IR BIOPSY LUNG 90 IR BROCHIAL ARTERY EMBOLIZATION 205 IR CAROTID STENT 165 IR CHEMO EMBOLIZATION 150 IR CHOLANGIOPLASTY 90 IR CHOLECYSTOSTOMY 105 IR CHOLECYSTOSTOMY TUBE CHECK AND CHANGE 60 IR CHOLECYSTOSTOMY TUBE PLACEMENT 95 12

IR CHOLEDOCHOSCOPY 70 IR DESCENDING VENOGRAM 105 IR DIALYSIS CATHETER PLACEMENT 95 IR DVT LYSIS STENTING 300 IR ENDOGRAFT AORTIC 180 IR ESOPHOGEAL DILITATION 90 IR EVLT SAPHENOUS VEIN 90 IR EXTREMITY LOWER ANGIOGRAM 185 IR EXTREMITY LOWER VENOGRAM 225 IR EXTREMITY UPPER ANGIOGRAM 180 IR EXTREMITY UPPER VENOGRAPHY 60 IR FALLOPIAN TUBE RECANNULATION 90 IR FILTER RETRIEVAL 105 IR FOREIGN BODY REMOVAL 120 IR G-J TUBE CHECK CHANGE REV 75 IR INFERIOR VENA CAVA FILTER PLACEMENT 90 IR INFERIOR VENA CAVA VENOGRAM 240 IR INS CAN ECMO 240 IR IVC RECANALIZATION 180 IR LIVER BIOPSY 110 IR NEOSTAR CATHETER 70 IR OPERATING ROOM PROCEDURE PORTABLE 105 IR PANHEPATIC VENOUS STUDY 205 IR PELVIS ANGIOGRAM 170 IR PERCUTANEOUS FENESTRATION FOR AAA REPAIR 370 IR PERCUTANEOUS NEPHROSTOMY GENITO URINARY STONE REMOVAL 190 IR PERCUTANEOUS TRANSHEPATIC CHOLIANGIOGRAM 130 IR PERCUTANEOUS TRANSHEPATIC CHOLIANGIOGRAM AND DRAINAGE 80 IR PERCUTANEOUS TRANSHEPATIC CHOLIANGIOGRAM WITH TUBE PLACEMENT 150 IR PICC LINE PLACEMENT 70 IR PORT PLACEMENT 80 IR PULMONARY ANGIOGRAM 105 IR PULMONARY EMBOLECTOMY 250 IR RENAL ANGIOGRAM 105 IR RENAL ARTERIOGRAM PTA 185 IR RENAL VENOGRAM 120 IR SUPERIOR VENA CAVA VENOGRAM 130 13

IR SUTURE REMOVAL 35 IR TACE 145 IR THORACIC AORTA ANGIOGRAM 205 IR TIPS 250 IR TIPS CHECK REVISION 185 IR TRACT DILATION 125 IR TRANSHEPATIC V CATHETER 120 IR TRANSJUGLAR LIVER BIOPSY 125 IR TRANSLUMBAR V CATHETER 110 IR TUNNELED CATHETER HICKMAN PLACEMENT 80 IR URETERAL STENT PLACEMENT 90 IR UTERINE FIBROID EMBOLIZATION 210 IR VASCULAR ACCESS REMOVAL REVISION 50 IR VASCULAR ANGIOPLASTY 200 IR VASCULAR EMBOLIZATION 190 IR VASCULAR LYTIC THERAPY 220 IR VASCULAR STENT 175 IR VASCULAR VENOUS SAMPLING 160 IR VENOUS SAMPLING ADRENAL 155 IR VENOUS SAMPLING PARATHYROIID 150 IR VENOUS SAMPLING RENAL 95 IR VENOUS SCLEROTHERAPY 160 IR VISCERAL ANGIOGRAM 170 IR VISCERAL TISSUE ABLATION 105 IR WHITAKER TEST 60 IR WOUND CARE 50 14

APPENDIX II: Data Collection Sheet 15

APPENDIX III: Boardrunner Scheduling Sheet Procedure Type Board Runner Case Minutes ANEURYSM COILING 270 CS ASP FINE NEEDLE GUIDE W IMAGE 60 CS BX LIVER NEEDLE PERC 180 CS CHEST 60 CS GUIDE DRN CATH PLACE S I 120 ENDOFEMORAL THORACIC STENT PLACEMENT 295 IR ABD AORTA WITH RUNOFF 185 IR ABDOMEN G J TUBE PLACEMENT 60 IR ABDOMEN G TUBE CHECK AND CHANGE 50 IR ABDOMEN GASTROINTESTINAL TUBE PLACEMENT 50 IR ABDOMEN HEPATIC ARTERY CATHETER PLACEMENT 135 IR ABDOMEN PERCUTANEOUS NEPHROSTOMY TUBE CHECK AND CHANGE 50 IR ABDOMEN PERCUTANEOUS NEPHROSTOMY TUBE PLACEMENT 120 IR ABDOMEN PERCUTANEOUS NEPHROSTOMY TUBE PULL 65 IR ABDOMEN PERCUTANEOUS TUBE CHECK AND CHANGE 70 IR ABDOMEN STONE REMOVAL CHOLEDOCHAL 215 IR ABDOMINAL AORTA ANGIOGRAM 100 IR ABLATION 120 IR ABLATION CRYO 120 IR ABLATION RF 90 IR ARTERIOGRAM GI BLEED 190 IR ARTERIOGRAM THROMBOLYTICS 220 IR ASCENDING VENOGRAM 145 IR BIOPSY 60 IR BROCHIAL ARTERY EMBOLIZATION 205 IR CHEMO EMBOLIZATION 150 IR CHOLECYSTOSTOMY 105 IR CHOLECYSTOSTOMY TUBE CHECK AND CHANGE 50 IR CHOLECYSTOSTOMY TUBE PLACEMENT 60 IR DESCENDING VENOGRAM 105 IR DIALYSIS CATHETER PLACEMENT 30 IR EXTREMITY LOWER ANGIOGRAM 80 IR EXTREMITY LOWER VENOGRAM 260 IR EXTREMITY UPPER ANGIOGRAM 110 IR EXTREMITY UPPER VENOGRAPHY 70 IR FILTER RETRIEVAL 110 IR FOREIGN BODY REMOVAL 120 IR FORGEIGN BODY REMOVAL 120 IR G-J TUBE CHECK CHANGE REV 70 IR INFERIOR VENA CAVA FILTER PLACEMENT 50 IR INFERIOR VENA CAVA VENOGRAM 380 IR IVC RECANALIZATION 180 IR KYPHOPLASTY LUMBAR 150 IR KYPHOPLASTY THORACIC 100 IR NEOSTAR CATHETER 70 16

IR NEPHRO URETERAL STENT CHECK AND CHANGE 50 IR NEURO 1 VESSEL CEREBRAL ANGIO 150 IR NEURO 2 VESSEL CEREBRAL ANGIO 445 IR NEURO 3 VESSEL CEREBRAL ANGIO 190 IR NEURO ANEURYSM ARTERIOGRAPHY DIAGNOSTIC 90 IR NEURO AVM EMBOLIZATION 175 IR NEURO CAROTID STENT 215 IR NEURO INTRATHECAL CHEMOTHERAPY ADMN 50 IR NEURO VENOUS SAMPLING PETROSAL SINUS 160 IR NEURO WADA ARTERIOGRAPHY 80 IR NEUROLOGICAL EMBOLIZATION 370 IR NEUROLOGICAL LYTIC THERAPY 150 IR NEUROLOGY MISCELLANEOUS 110 IR PANHEPATIC VENOUS STUDY 205 IR PELVIS ANGIOGRAM 170 IR PELVIS VENOGRAM 170 IR PERCUTANEOUS FENESTRATION FOR AAA REPAIR 370 IR PERCUTANEOUS NEPHROSTOMY GENITO URINARY STONE REMOVAL 190 IR PERCUTANEOUS TRANSHEPATIC CHOLIANGIOGRAM 130 IR PERCUTANEOUS TRANSHEPATIC CHOLIANGIOGRAM AND DRAINAGE 80 IR PERCUTANEOUS TRANSHEPATIC CHOLIANGIOGRAM WITH TUBE 210 PLACEMENT IR PICC LINE PLACEMENT 30 IR PORT CHECK 40 IR PORT PLACEMENT 40 IR PULMONARY ANGIOGRAM 160 IR RENAL ANGIOGRAM 130 IR RENAL ARTERIOGRAM PTA 100 IR RENAL VENOGRAM 120 IR SPINAL ANGIOGRAPHY 160 IR SPINAL TAP LUMBAR PUNCTURE 60 IR SPINE CERVICAL MYELOGRAM 80 IR SPINE ENTIRE CANAL MYELOGRAM 75 IR SPINE LUMBAR MYELOGRAM 60 IR SPINE THORACIC MYELOGRAM 40 IR SUPERIOR VENA CAVA FILTER PLACEMENT 130 IR SUPERIOR VENA CAVA VENOGRAM 270 IR TACE 200 IR THORACIC AORTA ANGIOGRAM 205 IR TIPS 260 IR TIPS CHECK REVISION 280 IR TRANSHEPATIC V CATHETER 120 IR TRANSJUGLAR LIVER BIOPSY 180 IR TUNNELED CATHETER HICKMAN PLACEMENT 70 IR ULTRASOUND 90 IR UTERINE FIBROID EMBOLIZATION 210 IR VASCULAR ACCESS REMOVAL REVISION 60 IR VASCULAR ANGIOPLASTY 200 IR VASCULAR EMBOLIZATION 260 IR VASCULAR LYTIC THERAPY 230 IR VASCULAR MISCELLANEOUS 90 17

IR VASCULAR VENOUS SAMPLING 160 IR VENOUS SAMPLING ADRENAL 155 IR VENOUS SAMPLING PARATHYROIID 150 IR VENOUS SAMPLING RENAL 95 IR VENOUS SCLEROTHERAPY 130 IR VISCERAL ANGIOGRAM 230 IR WHITAKER TEST 60 OFFSITE - OTHER 60 OFFSITE - PIC LINE PLACEMENT 60 OFFSITE - RADIOLOGY PROCEDURE 105 18

APPENDIX IV: Scheduler Scheduling Sheet Procedure Type Scheduler Case Minutes ANEURYSM COILING 250 CS ASP FINE NEEDLE GUIDE W IMAGE 40 CS BX LIVER NEEDLE PERC 160 CS CHEST 40 CS GUIDE DRN CATH PLACE S I 100 ENDOFEMORAL THORACIC STENT PLACEMENT 275 IR ABD AORTA WITH RUNOFF 165 IR ABDOMEN G J TUBE PLACEMENT 40 IR ABDOMEN G TUBE CHECK AND CHANGE 30 IR ABDOMEN GASTROINTESTINAL TUBE PLACEMENT 30 IR ABDOMEN HEPATIC ARTERY CATHETER PLACEMENT 115 IR ABDOMEN PERCUTANEOUS NEPHROSTOMY TUBE CHECK AND CHANGE 30 IR ABDOMEN PERCUTANEOUS NEPHROSTOMY TUBE PLACEMENT 100 IR ABDOMEN PERCUTANEOUS NEPHROSTOMY TUBE PULL 45 IR ABDOMEN PERCUTANEOUS TUBE CHECK AND CHANGE 50 IR ABDOMEN STONE REMOVAL CHOLEDOCHAL 195 IR ABDOMINAL AORTA ANGIOGRAM 80 IR ABLATION 100 IR ABLATION CRYO 100 IR ABLATION RF 70 IR ARTERIOGRAM GI BLEED 170 IR ARTERIOGRAM THROMBOLYTICS 200 IR ASCENDING VENOGRAM 125 IR BIOPSY 40 IR BROCHIAL ARTERY EMBOLIZATION 185 IR CHEMO EMBOLIZATION 130 IR CHOLECYSTOSTOMY 85 IR CHOLECYSTOSTOMY TUBE CHECK AND CHANGE 30 IR CHOLECYSTOSTOMY TUBE PLACEMENT 40 IR DESCENDING VENOGRAM 85 IR DIALYSIS CATHETER PLACEMENT 10 IR EXTREMITY LOWER ANGIOGRAM 60 IR EXTREMITY LOWER VENOGRAM 240 IR EXTREMITY UPPER ANGIOGRAM 90 IR EXTREMITY UPPER VENOGRAPHY 50 IR FILTER RETRIEVAL 90 IR FOREIGN BODY REMOVAL 100 IR FORGEIGN BODY REMOVAL 100 IR G-J TUBE CHECK CHANGE REV 50 IR INFERIOR VENA CAVA FILTER PLACEMENT 30 IR INFERIOR VENA CAVA VENOGRAM 360 IR IVC RECANALIZATION 160 IR KYPHOPLASTY LUMBAR 130 IR KYPHOPLASTY THORACIC 80 IR NEOSTAR CATHETER 50 19

IR NEPHRO URETERAL STENT CHECK AND CHANGE 30 IR NEURO 1 VESSEL CEREBRAL ANGIO 130 IR NEURO 2 VESSEL CEREBRAL ANGIO 425 IR NEURO 3 VESSEL CEREBRAL ANGIO 170 IR NEURO ANEURYSM ARTERIOGRAPHY DIAGNOSTIC 70 IR NEURO AVM EMBOLIZATION 155 IR NEURO CAROTID STENT 195 IR NEURO INTRATHECAL CHEMOTHERAPY ADMN 30 IR NEURO VENOUS SAMPLING PETROSAL SINUS 140 IR NEURO WADA ARTERIOGRAPHY 60 IR NEUROLOGICAL EMBOLIZATION 350 IR NEUROLOGICAL LYTIC THERAPY 130 IR NEUROLOGY MISCELLANEOUS 90 IR PANHEPATIC VENOUS STUDY 185 IR PELVIS ANGIOGRAM 150 IR PELVIS VENOGRAM 150 IR PERCUTANEOUS FENESTRATION FOR AAA REPAIR 350 IR PERCUTANEOUS NEPHROSTOMY GENITO URINARY STONE REMOVAL 170 IR PERCUTANEOUS TRANSHEPATIC CHOLIANGIOGRAM 110 IR PERCUTANEOUS TRANSHEPATIC CHOLIANGIOGRAM AND DRAINAGE 60 IR PERCUTANEOUS TRANSHEPATIC CHOLIANGIOGRAM WITH TUBE 190 PLACEMENT IR PICC LINE PLACEMENT 10 IR PORT CHECK 20 IR PORT PLACEMENT 20 IR PULMONARY ANGIOGRAM 140 IR RENAL ANGIOGRAM 110 IR RENAL ARTERIOGRAM PTA 80 IR RENAL VENOGRAM 100 IR SPINAL ANGIOGRAPHY 140 IR SPINAL TAP LUMBAR PUNCTURE 40 IR SPINE CERVICAL MYELOGRAM 60 IR SPINE ENTIRE CANAL MYELOGRAM 55 IR SPINE LUMBAR MYELOGRAM 40 IR SPINE THORACIC MYELOGRAM 20 IR SUPERIOR VENA CAVA FILTER PLACEMENT 110 IR SUPERIOR VENA CAVA VENOGRAM 250 IR TACE 180 IR THORACIC AORTA ANGIOGRAM 185 IR TIPS 240 IR TIPS CHECK REVISION 260 IR TRANSHEPATIC V CATHETER 100 IR TRANSJUGLAR LIVER BIOPSY 160 IR TUNNELED CATHETER HICKMAN PLACEMENT 50 IR ULTRASOUND 70 IR UTERINE FIBROID EMBOLIZATION 190 IR VASCULAR ACCESS REMOVAL REVISION 40 IR VASCULAR ANGIOPLASTY 180 IR VASCULAR EMBOLIZATION 240 IR VASCULAR LYTIC THERAPY 210 IR VASCULAR MISCELLANEOUS 70 20

IR VASCULAR VENOUS SAMPLING 140 IR VENOUS SAMPLING ADRENAL 135 IR VENOUS SAMPLING PARATHYROIID 130 IR VENOUS SAMPLING RENAL 75 IR VENOUS SCLEROTHERAPY 110 IR VISCERAL ANGIOGRAM 210 IR WHITAKER TEST 40 OFFSITE - OTHER 40 OFFSITE - PIC LINE PLACEMENT 40 OFFSITE - RADIOLOGY PROCEDURE 85 21

APPENDIX V: Sample Future Scheduling The proposed schedule shown above has cases overlapped by 15 minutes so physicians can rotate from room to room with little to no down time. In addition, the cases schedule length is reduced from 1.5 hours to 1 hour based on data analysis conducted using the ORMIS data. Comparing the current with the proposed clearly shows how room utilization and physician utilization will be increased. The new method will also allow for future increase in patient throughput if the department so chooses. More importantly, the IR department can conclude the current amount of staff is sufficient and the problems are a matter of improving scheduling, not needing to increase staff. 22