1. 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

2. Introduction and Background

3. 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:

4. 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:

5. 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

6. Goals and Objectives

7. 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

8. Appointment Scheduling Data Collection and Analysis

9. 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?

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

11. Appointment Scheduling Findings and Conclusions

12. 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.

13. 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.

14. 30-Minute Appointment Findings
Spine appointments contributed to extra minutes per week

15. 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

16. Head/Neck Appointments
Average: 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%

17. Prostate Appointments
Average: 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.

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

19. 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)

20. 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%

21. 90-Minute Appointment Findings
Liver appointments contributed to 1.10 extra hours per week
Abdomen appointments contributed to 58 extra minutes per week

22. 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%

23. 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)

24. Appointment Scheduling Guidelines Recommendations

25. Short-Term Recommendations
Pilot: Reduce the scheduled time from 60 minutes  45 minutes
Head/Neck Average Length: minutes
Prostate Average Length: minutes
Lung (No SDX) Average Length: minutes
Spine Average Length: minutes
Pelvis Average Length: minutes
Pilot: Reduce the scheduled time from 90 minutes  75 minutes
Liver Average Length: minutes
Abdomen Average Length: minutes

26. 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

27. Patient Flow Data Collection and Analysis

28. 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

29. 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

30. 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

31. Patient Flow Findings and Conclusions

32. 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.)

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

34. Design Requirements, Constraints, and Standards

35. 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

36. 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)

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

38. Criteria Importance Weighting

39. Patient Flow Recommendations

40. 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

41. 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

42. 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:

43. Patient Flow Pugh Matrix
Recommended Patient Flow

44. Expected Impact

45. 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

46. 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%

47. Thank you!
Questions?

48. 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

49. 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

50. 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

51. 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 minutes long
IV contrast should not be scheduled in a 30-minute time slot