same day CT scans. Ad hoc evening lists were being scheduled to scan patients between 9am and 5pm for a period of one week. ED patients requiring ultrasound
that could not be accommodated during the normal working day. were scanned in the scan room or, if clinically indicated, at the bedside. A senior
member of the surgical team reviewed the patient and treatment commenced
A two-day 2P event was arranged. This required data collection and the with or without admission. Any patient who attended after 5pm was admitted, if
development of a current state value stream map (VSM) prior to the event. The required, and scanned the following morning. To identify potential benefits, the
team involved in the event consisted of a range of professionals associated with medical team documented the expected and actual benefits for each patient who
the CT scanning service and each team member had ideas as to the root cause accessed this service.
of the problems. These ideas were captured on a ‘fishbone’ (cause and effect)
diagram. It was found that, on average, there was a decrease in presentation to scan of
approximately 10 hours per patient, with an increase in the ED waiting time
From the VSM, it was identified that there were up to 22 steps in the process of of only 15 minutes. It was estimated that an average of three bed nights per
appointing and scanning a patient. Only two of these steps added value for the patient scanned had been saved as, once a patient was admitted, the process for
patient, and the process took as long as 32 days. One of the problems creating requesting and conducting the scan could take up to 48 hours. The patient could
this delay was that of carve-out for the one-stop clinics and ward patients. These then be an inpatient for a further 24 - 48 hours whilst a clinician reviewed the
patients seldom arrived at the correct time for their slots, leading to delays in results, prescribed treatment and discharged the patient.
scanning the outpatients and wastage of slots.
An increase in sonography posts was approved as a result of the experiment, and
It was decided to conduct a rapid experiment of fully booking one of the two the service has now been established. It is anticipated that it will be extended
scanners with outpatients only, and partially booking the morning session on to include trauma examinations, vascular examinations and obstetric and
the second scanner with outpatients. The rest of the appointment slots were gynaecology examinations.
then available for ward patients, one-stop clinics and emergencies. This proved
successful, with improved capacity for outpatient appointments and a better flow Conclusion
through the fully booked scanner, whilst allowing the second scanner to deal with This article has attempted to provide some ideas for service improvement which
urgent cases only. Standards were written for referral management, appointment others may wish to consider for their own departments. In particular, it is hoped
and scanning processes. Staggered radiographer lunch breaks are taken, allowing that the benefits of the adoption of Lean thinking have been illustrated and, in
inpatient scanning to continue uninterrupted. The waiting time for an outpatient particular, how Lean can be used to bring staff together in the pursuit of service
appointment reduced by two weeks and the majority of in-patient requests are excellence.
now accommodated on the day of referral.
Further reading
Acute abdominal ultrasound Fillingham D. Can lean save lives? Leadership in Health Services 2007:20:231.
In March 2007 a rapid improvement event was held to implement changes to Fillingham DF. Lean Healthcare: Improving The Patient’s Experience. Chichester:
the abdominal pain pathway identified as necessary during a previous scoping Kingsham Press; 2008.
event. Whilst introducing these changes, it was recognised that difficulties in Institute for Healthcare Improvement. Going Lean in Healthcare. IHI Innovation
accessing diagnostics, in particular ultrasound scanning, was causing blockages Series White Paper, Cambridge MA. 2005.
in the pathway, resulting in delays in diagnosis, unnecessary admissions, and Womack JP, Jones DT. Lean Thinking: Banish Waste and Create Wealth in Your
extended length of stay for a significant number of patients. A 2P event allowed Corporation. London: Simon and Schuster; 2003.
the feasibility of offering a dedicated abdominal pain ultrasound service to the ED Womack JP, Jones DT, Roos D. The Machine That Changed The World. London: Simon
to be assessed and a rapid experiment was organised to allow abdominal pain and Schuster; 1990.
patients quick access to ultrasound with prompt review by senior staff.
Siemens Medical Systems loaned a midrange piece of ultrasound equipment and Amanda Martin is clinical manager and Anthony Maxwell is a
a suitable room for scanning was identified within the ED. The examinations were
consultant radiologist in the radiology department at Royal Bolton
performed by an advanced practitioner in ultrasound. The service was offered
Hospital.
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IMAGING & ONCOLOGY
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