Current Projects

Staff Engagement: Personnel Radiation Monitoring
Timothy Clark, Kevin Reynolds
1/1/17 – Current
UMass Memorial Medical Center Department of Radiology

Improve Physician/Employee engagement by improving compliance in the radiation monitoring program. The Radiology Department (University/Memorial campuses) provides 375 employees approximately 473 radiation monitoring devices (badge/ring) per month. Increasing compliance with this program will improve staff (Physician and Employee) engagement. Our goal is to reduce the number of unreturned radiation monitoring devices each month with an annual reduction of 40%.

 

Incidental Findings on ED Radiology Studies Communication and Optimization Safety Initiative
Baccei SJ, Coughlin D, Baker B, Brush E, Reznek M, Kennedy T
10/2016-Current
UMass Memorial Medical Center Departments of Radiology and Emergency Medicine

Incidental but actionable findings identified on radiology studies performed in the ED were not consistently communicated to responsible clinical providers in the ED.  This created the potential for actionable findings on the images studies to “slip through the cracks” and not be appropriately followed up on once the patient was discharged from the ED.  A collaborative effort between the Radiology Department and ED resulted in leveraging the PeerVue software program to deliver incidental findings on radiology studies/reports directly to ED email boxes that are routinely monitored by ED nursing staff.  This initiative greatly improved patient safety by ensuring appropriate follow up care for incidental findings on radiology studies from the ED.

 

Improvement of Patient Satisfaction
Timothy Clark, Kevin Reynolds
10/1/16 - Current
UMass Memorial Medical Center Department of Radiology

Similar to fiscal year 2016, the Radiology department will be conducting Patient Satisfaction surveys to evaluate the department current state and to test improvements made based on the feedback from the last surveys conducted.  One major focus this year will be based on feedback specifically related to the communication to patients about their respective wait times for their outpatient appointments. Improvement efforts will be put in place to not only improve communication about wait times but to ultimately reduce the wait times.

 

Employee Idea System Regeneration
Timothy Clark, Kevin Reynolds
10/1/16 - Current
UMass Memorial Medical Center Department of Radiology

As is the entire Umass system, Radiology intends to implement one idea per employee (250) by the end of FY17. One of the strategies that we will undertake is to improve the overall Idea System in the department. Considering that Radiology is split into several different entities (i.e. CT, Ultrasound, Mammography, etc) there are several idea systems, different huddles, and a multitude of opportunities that exist within the department. By improving the overall system, Radiology hopes to exceed the 250 target of ideas and also become a 4 or 5 star idea system.

 

Emergency Department C.T. Scan Turnaround Time Improvement Project.
Timothy Clark, Kevin Reynolds
10/1/16 - Current
UMass Memorial Medical Center Department of Radiology

The focal point for Radiology in 2017 will be focused on the system goal of Reducing ED Boarders.  E.D. Boarders are defined as any E.D. patient who exceeds 120 Minutes in the E.D. after their disposition has been changed to “In-Patient” – Every minute that exceeds 120 minutes is considered “boarding time”. It has been identified that a direct root cause of E.D. Boarders is the extensive Turnaround Time for E.D. patients requiring C.T. Scans. This years’ focus will be on improving the turnaround time associated with these patients in hopes of decreasing boarding hours. Goal: improve by 5% over FY16 the number of patients seen within 120 minutes.

 

Ultrasound Department Throughput: Increase Volume & Revenue Generation
Timothy Clark, Kevin Reynolds
10/1/16 - Current
UMass Memorial Medical Center Department of Radiology

The Quality Project Managers will employ strategies in hopes of improving the throughput of the University and Memorial campus Ultrasound departments. Radiology will focus on many high level performance metrics such as average patient wait time, percent of exams delayed, empty room time, next appointment availability, and employee productivity.

 

Radiology Scheduling – Process Improvement Project
Timothy Clark, Kevin Reynolds, Ansley, Heather
10/1/16 - Current
UMass Memorial Medical Center Department of Radiology

Reports (Complaints) from Referring Offices indicate delays in obtaining correct protocol prior to pre-authorization for insurance. This results in patients being delayed in receiving care. Scheduling of Outpatient CT exams has lead to an increase in the number of rescheduled/cancelled appointments. Following full evaluation, it was determined that the root cause was discordance between Exam Ordered (Prior Authorized) by Referring Office and the Exam Protocol (Protocol by Radiologist). Therefore, Radiology Department will seek to reduce the number of rescheduled appointments due to discordant protocol/order.  Countermeasures will be developed, implemented, and tested to determine improvement within the scheduling process.

 

Portable Chest – Image Quality Improvement Project
Timothy Clark, Kevin Reynolds; Baccei, Stephen; Dill, Karin
10/1/16 - Current
UMass Memorial Medical Center Department of Radiology

Substandard radiographic quality can negatively impact diagnostic accuracy, patient safety, and workflow efficiency.  Variation in radiographic image quality requires a standardized approach to quantify, record, and track image quality criteria over time.  This project establishes a quality improvement program for portable chest radiographs. Utilizing standardized image quality criteria from, sources that negatively impact image quality were identified while a non-punitive review process to prioritize educational and improvement opportunities was created.

 

Interventional Radiology Integration
Timothy Clark, Kevin Reynolds
10/1/16 - Current
UMass Memorial Medical Center Department of Radiology

Staffing changes have provided the opportunity to merge the various interventional programs (body, vascular and non-vascular) into a single program. Rather than programs operating independently, processes will be standardized and streamlined to improve access and operations for referring clinicians and patients.

 

Establishing System Wide Radiology Quality Metrics for Standardized Recording and Presentation across a Multi-Hospital Health Care Institution
DiRoberto, C. Lehto, C., Baccei SJ, Green, K, Clark, T
1/2016 – Current
UMass Memorial Medical Center Department of Radiology

There are no system wide quality metrics for the Department of Radiology.  We will establish quality metrics for all radiology sections in the hospitals throughout our system.  We will then record and report these specific quality metrics by creating a system-wide program that provides a standardized way to present and interpret the data.