1. 1 Improving Efficiency in the Angiography Suite Kamran Ahrar, M.D. Elizabeth Ninan, PA-C Jasmine NovoGradac, MBA,BSN,RN Terrell Evans, RT (R)(CT)(MR) Division of Diagnostic Imaging Section of Interventional Radiology

2. 2 Background Limited Capacity – Total of 3 Angiography Suites at Alkek (Main Hospital) – 2 have up-to-date equipment, used routinely – 1 out-dated unit, used as an overflow room Increasing Demand for Angiography or Fluoroscopy Guided Procedures – Increasing number of patients with liver tumors receiving liver-directed therapies – Alkek expansion project: Additional hospital beds – Anticipated 17% increase in overall volume for 2011

3. 3 AIM To Reduce the Inter-Procedure Time Interval in the Angiography Suite by 20% by August 6, 2010

4. 4 Vacant Angio SuiteInter-procedure Time Interval

5. Baseline Data Snapshot of Angiography Suite Utilization May 24 to May 28, 2010 Each box represents 10 minutes Time intervals were rounded to the nearest 10-minute mark Call cases are not included Procedure in Progress Vacant Angio Suite A-10 and A-11: High Quality Angio Suites A-9 Old Equipment, used as overflow procedure room

6. Baseline Data Metric: Inter-procedure Time Interval

7. Baseline Data Metric: Vacant Angio Suite (between procedures)

8. 8 Main Causes of Inefficiency

9. 9

10. 10 Strategy to Improve Efficiency Make sure patients are properly worked-up and ready to be transferred to the angiography suite Make sure the angiography suite is clean and properly set- up to receive the patient Make sure there is a nurse available to transfer the patient into the angiography suite as soon as the suite becomes available

11. 11 Vacant Angio SuiteInter-procedure Time Interval

12. 12 Other Interventions Patient Preparation/Readiness – Confirmations of appointments – MLP worked up of patients (blood products, pre-medications, consents) – Anticipate Cancellations – Improve Coordination with the OR for combined interventions – Dedicated Two Transport staff to IR Room Readiness – The Charge technologist will assist to complete tasks – Medical Assistant will help clean up the room and set up new procedure tray

13. 13 Each box represents 10 minutes Time intervals were rounded to the nearest 10-minute mark Call cases are not included Procedure in Progress Vacant Angio Suite A-10 and A-11: High Quality Angio Suites A-9 Old Equipment, used as overflow procedure room Final Data Snapshot of Angiography Suite Utilization August 2 to August 6, 2010

14. Results Metric: Inter-procedure Time Interval

15. Testing for Statistical Significance Inter-procedure Time Interval Two-Sample T-Test and CI: Inter-procedure Interval Two-sample T for Inter-procedure Interval Period N Mean StDev SE Mean Post 47 47.7 20.4 3.0 Pre 39 62.5 26.1 4.2 Difference = mu (Post) - mu (Pre) Estimate for difference: -14.85 95% CI for difference: (-24.82, -4.89) T-Test of difference = 0 (vs not =): T-Value = -2.96 P-Value = 0.004 DF = 84 Both use Pooled StDev = 23.1389 P-value <.05, so Pre and Post Means are statistically significantly different at the 95% level

16. Results Metric: Vacant Angio Suite (between procedures)

17. Testing for Statistical Significance Vacant Angio Suite(between procedures) Two-Sample T-Test and CI: Vacant Room Time (between procedures) Two-sample T for Vacant Room(between procedures) Period N Mean StDev SE Mean Post 47 26.6 18.2 2.7 Pre 39 39.8 23.6 3.8 Difference = mu (Post) - mu (Pre) Estimate for difference: -13.22 95% CI for difference: (-22.21, -4.24) T-Test of difference = 0 (vs not =): T-Value = -2.93 P-Value = 0.004 DF = 84 Both use Pooled StDev = 20.8484 P-value <.05, so Pre and Post Means are statistically significantly different at the 95% level

18. Return on Investment Pilot Period: 5 days, tracked over 70 patients, reviewed 47 Intervals – 9.4 Intervals per day – Reduced Suite Vacancy by 13.22 minutes per interval Total Gain: 124.27 minutes per day – Anticipated Gains: Ability to accommodate additional patients and procedures – Increased patient satisfaction – Shorter length of stay – Additional revenues Ability to finish scheduled cases in a timely fashion – Less overtime – Higher job satisfaction, improved morale, better staff retention Unexpected secondary gain of charges from PA work up of patients the day prior to procedure 18

19. 19 Return on Investment: Most Optimistic

20. 20 Return on Investment: Most Conservative Min (conservative) Max 1 additional patient per day 2 additional patients per day Contribution to Margin per Patient$200.00 Avg. Procedure per Patient2.40 Avg. Work Days per Year250 Potential Revenue per Year$120,000.00$240,000.00 Additional Charges generated from MLP role expansion and billable/year$200,000.00 Total Potential Margin per Year$320,000.00$440,000.00 Costs Cost of an additional RN$75,000.00 Cost of an 0.5 MA$18,000.00 Cost of an additional PA$85,000.00 Total costs$178,000.00 Net Potential Revenue Gain per Year$142,000.00$262,000.00

21. 21 Return on Investment: Most Likely

22. 22 Moving Forward Future Actions: – The float nurse was a temporary solution we had pulled from our outpatient facility – As of now, we are not able to provide the float nurse function to keep the vacant angiography suite time to a minimum – We have requested additional nurses for 2011 – If approved, a nurse will be assigned to the function tested in this pilot Maintained Actions: – Work-up of patients the day before (generating $ 200K E & M charges) – Confirming appointments – Charge tech helping with room turn over Quarterly Audits

23. 23 Conclusion Reduction in the Inter-Procedure Time Interval for the Angiography Suite by 24 % Reduction in the Vacant Angiography suite by 33% Outcomes: – Accommodate additional patients – Provide a better work environment – Generate additional revenues Allocation of resources is justified

24. 24 Thank you. Acknowledgements: M. D. Anderson CS&E Faculty and Staff Tatiana Hmar-Lagroun, Project Facilitator James A. Terrell, Applied Statistics Michael J. Wallace, MD; Sponsor