Radiation Oncology: CT Simulator Efficiency and Utilization Final Report Presentation April 17, 2018 Team 2: Julia Clark, Alex Mize, Maddie Price, Karan Shah Clients/Professor/Coordinators: Dawn Johnson, Director of Operations, Radiation Oncology Chris Alcala, Chief Radiation Therapist, Radiation Oncology Dr. Mark Van Oyen, IOE 481 Professor, Industrial and Operations Engineering Zac Costello, Performance Improvement Engineer, Performance Improvement Kate Sell, Performance Improvement Fellow, Performance Improvement 18W2-final-report-presentation

Introduction and Background

Patient Position Tracking CT Simulator Patient immobilized using devices to simulate treatment positioning CT scan used to precisely plan radiation treatment in order to minimize radiation to the surrounding healthy organs Department serves both in-patients and out-patients Patient Positioning Patient Position Tracking Control Room Scanning Source: https://medicine.umich.edu/dept/radonc/patient-care

Current Appointment Scheduling Guidelines 30, 60, or 90-minute time blocks available for appointments Appointment lengths determined based on anatomical location of treatment area Lung Tumor Source: http://spokanecyberknife.com/treatment-options/lung-tumors

CT Simulator Patient Flow Initial Diagnosis Radiation Oncology Consultation CT Simulation Treatment Planning Daily Treatment Patient arrives one hour early for appointment Patient checks in at front desk Patient brought to holding room to complete pre-simulation tasks Patient brought to CT Simulator room for scan Patient taken on department tour

Goals and Objectives

Goals and Objectives Primary goal Create advanced appointment scheduling guidelines and design a more efficient CT Simulator patient flow process Objectives Decrease patient wait time during CT Simulator appointment Decrease CT Simulator room idle time Decrease the difference between scheduled appointment time length and actual appointment time length Increase patient throughput

Appointment Scheduling Data Collection and Analysis

Appointment Time Length Data Collection Sample size: 255 patients Data collection period: February 26, 2018 – March 28, 2018 CT Simulator employees record data for general linear model regression Patient Sticker Time sim room set up begins Time sim room clean up ends IV contrast on directive? 4D sim on directive? SDX on directive?  

Patient Attribute Data Collection Coordinator pulled following data based on patient CSNs: Height Weight BMI

Appointment Scheduling Findings and Conclusions

General Linear Model Regression Statistically significant variables at 5% significance level: IV Contrast (yes or no) SDX training (yes/assess or no) Number of treatment areas (isos) Vacuum Bag (yes or no) Qfix (yes or no) Adjusted R-Squared value: 34.41% (very low) Use of linear regression equation to guide appointment time length scheduling is infeasible, but the above factors should be considered in scheduling decisions.

Actual Appointment Time Length Analysis All means lower than scheduled time length Wide standard deviations due to high variation in patient needs Scheduled Time Length (minutes) Mean of Actual Time Length* (minutes) Standard Deviation of Actual Time Length* (minutes) 30 29.11 11.21 60 35.05 18.35 90 62.10 20.33 *Time between when patient enters the CT Simulator room and when employees finish cleaning the room Deep-dive analysis on specific appointment types is necessary for appointment time length recommendations.

30-Minute Appointment Findings Spine appointments contributed to 10.75 extra minutes per week

60-Minute Appointment Findings Head and Neck appointments contributed to 2.38 extra hours per week Prostate appointments contributed to 2.10 extra hours per week Lung (No SDX) appointments contributed to 1.46 extra hours per week Spine appointments contributed to 1.12 extra hours per week Pelvis appointments contributed to 1.01 extra hours per week

Head/Neck Appointments Average: 36.17 mins Scheduled Time % of Appointments Shorter Than Scheduled Time % of Appointments Longer Than Scheduled Time 60 Minutes (Current) 96% 4% 45 Minutes (New) 75% 25%

Prostate Appointments Average: 30.35 mins Scheduled Time % of Appointments Shorter Than Scheduled Time % of Appointments Longer Than Scheduled Time 60 Minutes (Current) 88% 12% 45 Minutes* (New) 71% 29% *Since prostate patients require a full bladder for scan, the department would need to closely communicate with MAPSA and the patients prior to the appointment to ensure the patient drinks at the correct time to avoid delays. Thus, this change may be difficult.

Lung (No SDX) Appointments Average: 28.09 mins Scheduled Time % of Appointments Shorter Than Scheduled Time % of Appointments Longer Than Scheduled Time 60 Minutes (Current) 100% 0% 45 Minutes (New)

Spine Appointments Average: 26.50 mins Scheduled Time % of Appointments Shorter Than Scheduled Time % of Appointments Longer Than Scheduled Time 60 Minutes (Current) 100% 0% 45 Minutes (New)

Pelvis Appointments Average: 31.67 mins Scheduled Time % of Appointments Shorter Than Scheduled Time % of Appointments Longer Than Scheduled Time 60 Minutes (Current) 100% 0% 45 Minutes (New) 78% 22%

90-Minute Appointment Findings Liver appointments contributed to 1.10 extra hours per week Abdomen appointments contributed to 58 extra minutes per week

Liver Appointments Average: 63.50 mins Scheduled Time % of Appointments Shorter Than Scheduled Time % of Appointments Longer Than Scheduled Time 90 Minutes (Current) 83% 17% 75 Minutes (New) 58% 42%

Abdomen Appointments Average: 43.40 mins Scheduled Time % of Appointments Shorter Than Scheduled Time % of Appointments Longer Than Scheduled Time 90 Minutes (Current) 100% 0% 75 Minutes (New)

Appointment Scheduling Guidelines Recommendations

Short-Term Recommendations Pilot: Reduce the scheduled time from 60 minutes  45 minutes Head/Neck Average Length: 36.17 minutes Prostate Average Length: 30.35 minutes Lung (No SDX) Average Length: 28.09 minutes Spine Average Length: 26.50 minutes Pelvis Average Length: 31.67 minutes Pilot: Reduce the scheduled time from 90 minutes  75 minutes Liver Average Length: 66.09 minutes Abdomen Average Length: 43.40 minutes

Long-Term Recommendations Continue appointment time length study Estimated 3-4 additional months of data needed to assess time lengths for all appointment types Estimated 1-2 additional months of data needed to assess ways to reduce variation in appointment time lengths Reduce appointment time increments from 30 minutes to 15 minutes for all appointment types

Patient Flow Data Collection and Analysis

Observations Sample size: 32 patients Data collection period: January 22, 2018 – February 9, 2018 Team members took observational notes to identify common sources of delays Pre-simulation checklist tasks (face photo, educational videos, etc.) Inaccurate or incomplete patient directives Patient eating, drinking, and/or bowel movement requirements Patient tardiness

Preliminary Time Study Data Collection Sample size: 34 patients Data collection period: February 12, 2018 – February 23, 2018 Team members noted common types of delays that occur and parts of the process that can and cannot be included in the time study Patient # Check In Brought to Holding Room Finished with Pre-Sim Tasks Brought to Simulation Room Prep Complete Positioning Start Positioning End Scout Start Scout End Scan Start Scan End Exit Sim Room

Time Study Data Collection Sample size: 90 patients (102 hours) Data collection period: March 7, 2018 – March 30, 2018 Team members recorded patient time study data to calculate patient flow metrics Process Start Time End Time Reasons for delays Pre-scan set up/patient positioning _ _ : _ _ IV Contrast Start: _ _ : _ _ End: _ _ : _ _  SDX Training Start: _ _ : _ _ End: _ _ : _ _  Physician needed Paged: _ _ : _ _ Arrival: _ _ : _ _  Physics needed Paged: _ _ : _ _ Arrival: _ _ : _ _  Dosimetry needed Paged: _ _ : _ _ Arrival: _ _ : _ _  Patient needed to go to bathroom  Complicated bolus  Could not complete SDX training  > 1 iso?  Inaccurate or incomplete simulation directive Note: Small subsection of data collection sheet displayed above

Patient Flow Findings and Conclusions

Value Stream Map (Part 1 of 2) P/T: Process Time W/T: Wait Time FTQ: First Time Quality High Low FTQ for Room 10 defined as percent of patients without any possible source of delay present (consent, face photo, etc.)

Value Stream Map (Part 2 of 2) P/T: Process Time W/T: Wait Time FTQ: First Time Quality High

Design Requirements, Constraints, and Standards

Soft Design Constraints (Requirements) Minimal cost Simple implementation Minimal employee training Employee and patient acceptability Minimal interaction with outside departments Decreased patient wait time Decreased CT Simulator room idle time Increased patient throughput

Hard Design Constraints Physician CT Simulator scan approval Patient health and safety Limited physical space and budget Other processes in Radiation Oncology Department 7:00 AM – 6:00 PM CT Simulator room operation time University of Michigan semester time frame Department software (Microsoft Visio)

Design Standards HIPAA PHI Radiation Oncology Department Standards Performance Improvement Department Standards Microsoft Visio IEEE MLearning

Criteria Importance Weighting

Patient Flow Recommendations

Future State Map (Part 1 of 2) (1) Second room designated as an “overflow” Room 10 P/T: Process Time W/T: Wait Time FTQ: First Time Quality (2) Patients watch pre-sim educational videos prior to CT Simulation appointment, preferably at their initial consultation or on a tablet in waiting room (3) MAPSA employee assigned to prepare a “next day patient missing questionnaire” list

Future State Map (Part 2 of 2) P/T: Process Time W/T: Wait Time FTQ: First Time Quality (4) Ohio State University study with separate room for immobilization

Ohio State University Research Study James Department of Radiation Oncology conducted a CT Simulator improvement project in August 2014 Department worked with Academy for Excellence in Healthcare (AEH) Result of project was a two-step immobilization process for CT Simulator appointments 1.) Induction Room: Patient is immobilized 2.) CT Simulator Room: Patient is scanned Hybrid schedule allows 14 appointments in 8-hour day Source: https://fisher.osu.edu/sites/default/files/iap_c-02_james_radiation_oncology_full_report_0.pdf

Patient Flow Pugh Matrix Recommended Patient Flow

Expected Impact

New Appointment Scheduling Guidelines Patient throughput could increase by approximately 288 patients annually 96 Head/Neck 60 Prostate 36 Lung (No SDX) 24 Spine 36 Pelvis 24 Liver 12 Abdomen CT Simulator room idle time and difference between scheduled appointment length and actual appointment length could decrease by 234 hours annually

Improved Patient Flow Total process time could decrease by 24% from 62 minutes to 47 minutes Patient wait time could decrease by 35% from 48 minutes to 31 minutes Lead time could decrease by 29% from 110 minutes to 78 minutes First time quality could increase from 42% to 57%

Thank you! Questions?

Appendix A: Head/Neck Appointment Calculations Patient Throughput (24 appointments * 60 minutes/appointment) – (24 appointments * 45 minutes/appointment) = 360 minutes / 45 minutes/appointment = 8 appointments/month * 12 months/year = 96 appointments/year Room Idle Time Sum of (60 minutes/appointment – actual appointment time length) = 572 Sum of (45 minutes/appointment – actual appointment time length) = 212 minutes/month 572 minutes/month – 212 minutes/month = 360 minutes/month

Appendix B: Prostate Appointment Calculations Patient Throughput (17 appointments * 60 minutes/appointment) – (17 appointments * 45 minutes/appointment) = 255 minutes / 45 minutes/appointment = ~ 5 appointments/month * 12 months/year = 60 appointments/year Room Idle Time Sum of (60 minutes/appointment – actual appointment time length) = 504 Sum of (45 minutes/appointment – actual appointment time length) = 249 minutes/month 504 minutes/month – 249 minutes/month = 255 minutes/month

Appendix C: SDX Appointments Scheduled Time Length (minutes) % of All SDX Appointments Mean of Actual Time Length* (minutes) Standard Deviation of Actual Time Length* (minutes) 60 43.90% 54.61 17.67 90 56.10% 62.43 20.83 *Time between when patient enters the CT Simulator room and when employees finish cleaning the room 60-minute appointments often lasting longer than scheduled time SDX training could be done in separate room (Room 10) or at separate appointment prior to CT Simulator appointment

Appendix D: IV Contrast Appointments Scheduled Time Length (minutes) % of All IV Contrast Appointments Mean of Actual Time Length* (minutes) Standard Deviation of Actual Time Length* (minutes) 30 5.00% 40.33 21.50 60 63.33% 45.50 17.94 90 31.67% 63.53 20.16 *Time between when patient enters the CT Simulator room and when employees finish cleaning the room 30-minute appointments expected to be 40.33 minutes long IV contrast should not be scheduled in a 30-minute time slot