How to design and display processes in the radiology department

How to design and display processes in the radiology department Poster No.: C-1757 Congress: ECR 2014 Type: Educational Exhibit Authors: P. Val...
Author: Henry Bradley
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How to design and display processes in the radiology department Poster No.:

C-1757

Congress:

ECR 2014

Type:

Educational Exhibit

Authors:

P. Valdes Solis; Marbella/ES

Keywords:

MR, Professional issues, Management, Computer applications, Computer Applications-General, Outcomes analysis, Quality assurance

DOI:

10.1594/ecr2014/C-1757

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Learning objectives • • •

To learn the basic concepts about processes and process-oriented management. To learn how to design processes in the radiology department. To kKnow the different tools available to display processes.

Background Process- oriented management is one organization strategy that enhances the competetitiveness or radiology department, and it is a central tool to run a quality management program. In spite of its importance, many radiologists don't know how to define and display processes. There are many tools available, but some of them are expensive and complex solutions.

Findings and procedure details 1.What is a process There are multiple definitions of process: • • • •

A process is a defined sequence of tasks that require the cooperation of several roles from one or several organizations. A series of steps or actions that lead to a desired result or output. A set of common tasks that creates a product, service, process, or plan that will satisfy a customer or group of customers. A sequential series of steps leading to a desired outcome

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Fig. 1: Schematic representation of process concept. References: Radiology, Hospital Costa del Sol - Marbella/ES Processes are characterized by: • • • •

They are a set of tasks They have a defined start and end event They have a defined objectives and result They are characterised by an input-output relationship

Processes are largely affected by one or more of the following factors: a) personnel who operate the processes; b) materials which are used as inputs (including information); c) machines or equipment being used in the process (in process execution or monitoring/ measurement; d) methods (including criteria and various documentations used along the process);

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e) work environment Understanding how these factors interact and affect processes is a key consideration in process studes. 2. Why are processes so important? The new management culture involves a process orientation, which increases the efficiency of our department. The mission statement of our organization should include references to a process-oriented management. But this approach should be reflexive, and all the documentation, methodologies and activities and resources control, should be oriented to a process centered management. We should always keep in mind that the main purpose is the expected results. Whenever managing processes, it is important to: • • • •

Identify the main processes in our department Describe them Follow them and measure them Improve them

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Fig. 2: In order to understand processes we have to know what we want, the results we need, and all the tasks, resources and people involved. References: Radiology, Hospital Costa del Sol - Marbella/ES 3. Quality improvement and process centered management A quality management system based upon processes can be represented this way:

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Fig. 3: This approach is customer (or patient) centered , and takes into account the importance of the patient satisfaction and the follow up and measurement of the results of the process. References: Radiology, Hospital Costa del Sol - Marbella/ES 4. Process management The process management includes: • •

Macro-process management Micro - process management

4.1. Macro- process management •



Process list. The first step when beginning a process centered management is to decide thelist of processesincluded. Sometimes it is difficult to decide which processes should be included. The list should be the result of the analysis of the activities that are already done in the department. Process map. (see further)

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Network of processes. A network of processes consists of several processes and their relationships. A process can have relationships with both preceding and following processes, and with processes that are performed concurrently. Several consecutive processes form achain of processes: it comprises a number of processes that have a chronological relationship with each other. Process managers list. One process manager is to be defined for each process. The process manager is the role responsible for the micro-process management for a specific process. Process portfolio reports.They are used for process portfoio controlling. They are based on the department's processes on a specific controlling date.

There are different examples of processes in the radiology department: • • • •

Request of imaging studies Patient appointment • Inpatients • Outpatients Radiology reporting

4.2. Micro-process management This micro- process management includes the process description, the process schedules, the process task plan, the process responsability chart and the process performance indicators. The main steps to be considered in this management are the process description and the process measurement. Process description The process description includes: • •

Activities: Process diagram or proces map Characteristics: Process card

4.2.1. Constructing a Process Flowchart (after Iowa State University) Step 1: Determine the Boundaries 1. 2.

Where does a process begin?. In our radiology department: the imaging request. Where does a process end?. In our department: the report distribution.

Step 2: List the Steps

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1. 2.

Use a verb to start the task description. The flowchart can either show the sufficient information to understand the general process flow or detail every finite action and decision point.

Step 3: Sequence the Steps Step 4: Draw Appropriate Symbols 1.

Start with the basic symbols: 1. Ovals show input to start the process or output at the end of the process. 2. Boxes or rectangles show task or activity performed in the process. 3. Arrows show process direction flow. 4. Diamonds show points in the process where a yes/no questions are asked or a decision is required. 5. Usually there is only one arrow out of an activity box. If there is more than one arrow, you may need a decision diamond. 6. If there are feedback arrows, make sure feedback loop is closed; i.e. it should take you back to the input box.

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Fig. 4 References: Radiology, Hospital Costa del Sol - Marbella/ES Page 9 of 50

Step 5: System Model 1. 2. 3. 4. 5. 6.

Draw charts using system model approach. Input - use information based upon people, machines, material, method, and environment. Process - use subsets of processes in series or parallel. Output - use outcomes or desired results. Control - use best in class business rules. Feedback - use information from surveys or feedback.

Step 6: Check for Completeness 1.

Include pertinent chart information, using title and date for easy reference.

Step 7: Finalize the Flowchart 1. 2. 3. 4.

Ask if this process is being run the way it should be. Are people following the process as charted? Do we have a consensus? What is redundant; add what is missing.

The purpose of process mapping is to use diagramming to understand the process we currently use and ask what is expected of us; what should we be doing to provide better customer focus and satisfaction. It will identify what best practices we need to incorporate and find appropriate benchmarks for measuring how we can arrive at better ways of communicating our services.

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Fig. 7: Example of a process diagram (in fact, a subprocess). References: Radiology, Hospital Costa del Sol - Marbella/ES

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Fig. 8: Subprocess diagram explained References: Radiology, Hospital Costa del Sol - Marbella/ES 4.2.2. Process card A process card is the information support which includes all the characteristics needed to control the process and all the activities defined in the process map. The information included may be different in every department and should be defined by the organization. It should include: • • • • • • •

Process mission Proscess owner Process boundaries Process indicators Inspections Documentation and registries Resources

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Fig. 5: An example of process card. References: Radiology, Hospital Costa del Sol - Marbella/ES 5. Process follow-up and measurement In a process based management organization it is very important to follow up and measure the processes, in order to know if the results are the expected ones. A process management system is useless if, after describing and drawing the processes, they are not measured. When the process is being evaluated, it is important to check: • •

Theprocess capability: measures how close a process is running to its specifications limits, relative to the natural variability of the process. Theprocess performancetries to verify if the sample that the process has generated is capable to meet the customer requirements.

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Example: we have defined that the wating time to perform an abdominal ultrasound in the emergency setting should be less than 60 minutes in 95% of cases. We measure our results in one month and we check that 90% of the ultrasounds were performed in less than 60 minutes. This means that our process "emergency abdominal ultrasound" has a capability of 90%, and that the performance or efficiency is under expected, as only 90% of ultrasounds were compliant with the standard, instead of the planned 95%. In order to measure the process, we have to begin defining some indicators (see below) Once the different indicators are defined, the process should be followed up. Control charts and performance dashboards are tools that can help. These two commonly used displays can help visualize data on various metrics and facilitate monitoring and analysis of those data. 5.1. Control charts Process output and its variation can be depicted in one or two basic formats: static or dynamic. •



Commonly used static representation of process output include tabular values such as mean, median, variance, and standard deviation, which are displayed using histograms, bar charts or tables. Dynamic displays of process output include run charts and control charts, in which data are plotted over time.

5.2. Scorecards and Dashboards Scorecards and dashboards are used to track results within an organization. • •

Scorecards are strategic and used to monitor progress toward identified objectives Dashboards are operational and used to monitor clinical and nonclinical processes

Both often include gauges, color, graphs, and charts in their display of business performance data. Both scorecards and dashboards may provide linkage capability, which allow users to go to the next lower level of data, which are often displayed using control charts.

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Fig. 6: Scorecard in Hospital Costa del Sol. Process: Breast imaging (not real data) References: Radiology, Hospital Costa del Sol - Marbella/ES 6. Indicators The terms quality indicators or metrics are used to describe data that can be used by hospitals or organizations to measure quality and safety, monitor trends, or make a comparison to another institution or agency. There are 3 types of measures used in quality work: • • •

Structure: Physical equipment and facilities Process: How the system works Outcome: The final product, results

Structure and process are easier to measure; outcome is more important. In order to develop indicators, some steps should be considered: 1.

Which is the process mission

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2. 3. 4. 5.

What kind of results are expected and how to measure them Define how to calculate the indicator (formula): indicator specifications Define the expected value. Perform preliminary tests. Describe and represent the indicator (card or other format)

Some examples: • •

• •

• •

Process indicators: • Appropriatness of exam ordering • Time from order to completion of computed tomography (CT) examination • Patient waiting time • Critical test reporting rates • Error rates of imaging labelling Outcome indicators: • Contrast extravasation rates • Contras-induced nephropathy rates • Diagnostic accuracy of imaging intepretation Performance indicators that can be considered as high value in radiology: • Critical- test result communication timeliness • Time to diagnostic mammography • Contrast extravasation rate • Structured reporting frequency • Radiation dose exposure documentation rate • Interventional radiology complication rate.

7. Tools used to represent processes Display tools Standard Microsoft Office solutions, such as Microsoft Visio or Microsoft Excel can be used to display flow charts. Free software, as Dia and LibreOffice can achieve the same results.

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Fig. 11: Display tools and an example of process map. References: Radiology, Hospital Costa del Sol - Marbella/ES Modelling and simulations tools These are more advanced tools that establish relationships between processes and relationships to other objects such as the organizational hierarchy. Special project management software, such as Adonis or ARIS can be used for these purposes.

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Fig. 10: An example of modelling software. References: Radiology, Hospital Costa del Sol - Marbella/ES Workflow management and CASE tools A workflow management system is an application - independent software, which supports the modelling, implementation and monitoring of workflows and, if necessary, it performs other functions such as workflow simulation and analysis. CASE (Computer Aided Software Engeneering) is used for the partially- automated, development of software. A CASE tool supports partially automated certain activities in software development. Tools which support enterprise modelling (and process modelling) are called ECASE tools. ARIS and Adonis also provide CASE functions. Modelling, simulation, workflow management and CASE tools are advanced tools that are not usually implemented in radiology departments. Some departments have a strong support by engineers and IT specialist, but this is not the usual thing.

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7.2. Standard software tools Examples: Microsoft Visio, Microsoft Excell, LibreOffice, Dia…

If you want to

You can use

Collect data

Microsoft Excel, LibreOffice Calc

Create charts

Microsoft Excel, LibreOffice Calc

Create flow chart

Microsoft Visio, LibreOffice, Dia

Create process card

Microsoft Word, LibreOffice Writer

Computer based software tools are used in a traditional way: • • •

Files are created in a local computer Results are printed (paper) or electronically printed (PDF format). Files are stored in books (paper) or in files repositories (PDF files).

This approach has some advantages and many disadvantages: • • • •

Advantages • Powerful tools • Easy to use Disadvantages • Data can be lost • Accesibility of data is not always assured • Difficult to access to the final documents • Very difficult to mantain files (whenever you have to modify one file, you have to access the original file in your computer, modify it and upload the new file). • No collaborative options

If you use a paper based file, the documents can be very difficult to access. Usually, radiology managers have to use these tools, and basic software is most frequently used.

8. Working in the cloud There are different cloud services available, and most of them are free of charge.

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They include practically all the basic tools we need to show and control our processes: • • • •

Text processing tools Data sheet Drawing Forms

Some of them are: • • • •

Google Drive Zoho docs Microsoft SkyDrive Apple iCloud.com

Advantages: • • • • • • • • •

Free (limited storage; usually enough) Easy to use No need of software installation Available from anywhere, using different plattforms (tablets, computers…). Collaborative tools Only one version of the document (the last edited). You can download security copies, but the one in the cloud is the last one. You can download the document in different formats. Easy to integrate with different web services. Allow links in documents. This is useful when you want users to get access to different documents (for example: access to a procedure - text - from a process - drawing -)

Disadvantages • • •

Services not available if no internet conection available Dependence (Google, Microsoft, Apple…) Security? Confidentiallity?

These tools change the way of working: when using cloud services, the file being edited is the same that is being displayed. This ensures that it is the last version of the file the one displayed. If you have to edit the file, you don't need to download it; you just edit it. These apps are strong enough and allow you to include all the information needed.

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Fig. 12: The main window in Google Drive.It looks like a desktop directory file, but your files are in the web. References: Radiology, Hospital Costa del Sol - Marbella/ES

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Fig. 13: You can add different kind of files. Web services are growing up, and there are more and more web programs which allow you to do many functions without leaving the web navigator. Most of these services are free. Storage in Google Drive is free (limited storage, but enough for what needed in this task). References: Radiology, Hospital Costa del Sol - Marbella/ES

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Fig. 14: The drawing application in Google Drive allows you to make charts with all the needed elements. You can export the files in different formats. References: Radiology, Hospital Costa del Sol - Marbella/ES

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Fig. 15: One very useful tool is the posibility of adding links. You can link external web pages or different documents in your Google Drive directory. This adds value to your documents. You can describe a process in a drawing document and include links to text files (with procedures, description of techniques, etc). References: Radiology, Hospital Costa del Sol - Marbella/ES

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Fig. 16: Probably, the most useful tool in Google Drive are the colaborative options. You can add users to your document. They can see the document, add comments or edit it. If you are the document's owner it is you who decide what your collaborators can do and what they cannot do. References: Radiology, Hospital Costa del Sol - Marbella/ES

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Fig. 17: The text tool has improved and, now, it includes all the needed options to create quite complex documents, such as procedures. References: Radiology, Hospital Costa del Sol - Marbella/ES

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Fig. 18: This web services create a new way of working. You create a document which is stored in the server. You can access the document from any computer connected to the web. You can edit the document (if you have the privileges), but you don't have to download the document in order to change it. This is quite useful. References: Radiology, Hospital Costa del Sol - Marbella/ES

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Fig. 19: Another interesting tool in Google Drive is the forms. You can design a form, and the data are automatically stored in a data sheet in your account. References: Radiology, Hospital Costa del Sol - Marbella/ES

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Fig. 20: Google Drive is not the only option. You can use Zoho docs, Skydrive or iCloud. All have their advantages and disadvantages. But, as all of them are free, you can try them all and choose the one better for you. References: Radiology, Hospital Costa del Sol - Marbella/ES

Images for this section:

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Fig. 1: Schematic representation of process concept.

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Fig. 2: In order to understand processes we have to know what we want, the results we need, and all the tasks, resources and people involved.

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Fig. 3: This approach is customer (or patient) centered , and takes into account the importance of the patient satisfaction and the follow up and measurement of the results of the process.

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Fig. 4

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Fig. 5: An example of process card.

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Fig. 6: Scorecard in Hospital Costa del Sol. Process: Breast imaging (not real data)

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Fig. 7: Example of a process diagram (in fact, a subprocess).

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Fig. 8: Subprocess diagram explained

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Fig. 9

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Fig. 10: An example of modelling software.

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Fig. 11: Display tools and an example of process map.

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Fig. 12: The main window in Google Drive.It looks like a desktop directory file, but your files are in the web.

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Fig. 13: You can add different kind of files. Web services are growing up, and there are more and more web programs which allow you to do many functions without leaving the web navigator. Most of these services are free. Storage in Google Drive is free (limited storage, but enough for what needed in this task).

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Fig. 14: The drawing application in Google Drive allows you to make charts with all the needed elements. You can export the files in different formats.

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Fig. 15: One very useful tool is the posibility of adding links. You can link external web pages or different documents in your Google Drive directory. This adds value to your documents. You can describe a process in a drawing document and include links to text files (with procedures, description of techniques, etc).

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Fig. 16: Probably, the most useful tool in Google Drive are the colaborative options. You can add users to your document. They can see the document, add comments or edit it. If you are the document's owner it is you who decide what your collaborators can do and what they cannot do.

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Fig. 17: The text tool has improved and, now, it includes all the needed options to create quite complex documents, such as procedures.

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Fig. 18: This web services create a new way of working. You create a document which is stored in the server. You can access the document from any computer connected to the web. You can edit the document (if you have the privileges), but you don't have to download the document in order to change it. This is quite useful.

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Fig. 19: Another interesting tool in Google Drive is the forms. You can design a form, and the data are automatically stored in a data sheet in your account.

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Fig. 20: Google Drive is not the only option. You can use Zoho docs, Skydrive or iCloud. All have their advantages and disadvantages. But, as all of them are free, you can try them all and choose the one better for you.

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Conclusion 1. 2. 3. 4. 5. 6. 7.

Process management is a key tool in a radiology department management. You should know your processes; not every department has the same processes or have the same needs. There are no universal rules to define, descibe or display processes It is important to define the document support and, all personal in the department should have easy access to the documentation. These documents are a way to improve quality, not an end point There are different tools and formats to design and display processes Web tools are very useful as they allow collaborative work, and make process design easier. Though they may have some disadvantages, they probably are the future in the design and display of our processes.

Personal information References •



• •

• •





Beltrán Sanz J, Carmona Calvo MA, Cararasco Pérez R, Rivas Zapata MS, Tejedor Panchón F. Guía para una gestión basada en procesos. Instituto Andaluz de Tecnología. ISBN 84-923464-7-7. Junta de Andalucía 2003. Erturk SM, Ondategui-Parra S, Ros PR. Quality Management in Radiology: Historical Aspects and Basic Definitions. Journal of the American College of Radiology. 2005 Diciembre;2(12):985-91. Gareis R, Stummer M. Processes & Projects. Wien: Manz; 2008. Kaewlai R, Abujudeh HH. Key Performance Indicators in Radiology. In: Abujudeh HH and Bruno MA editors. Quality and Safety in Radiology.Oxford: Oxford University Press, 2012. p 147-160 Mainz J. Defining and classifying clinical indicators for quality improvement. Int J Qual Health Care. 2003 Dec 1;15(6):523-30. Mendelson RM, Bairstow PJ. Imaging Pathways: Will They Be Well Trodden or Less Traveled? Journal of the American College of Radiology. 2009 Mar;6(3):160-6. Ondategui-Parra S, Bhagwat JG, Gill IE, Nathanson E, Seltzer S, Ros PR. Essential practice performance measurement. Journal of the American College of Radiology. 2004 Agosto;1(8):559-66. Steels JR, Terrel JA, Hovsepian DM, Jordan VS. Control Charts and Dashboards. In: Abujudeh HH and Bruno MA editors. Quality and Safety in Radiology.Oxford: Oxford University Press, 2012. p 196-209.

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