The Process Improvement team began working closely with Endoscopy staff. They found that the team could improve FCOTS through several changes, many of which were identified by the nurses doing the work, including (from left) Graciela Di Lullo, RN, Jean Silk, RN, Conrad Worrell, RN, and Renee White, RN.

Beginning the first case of the day on time can have a ripple effect. Starting on time increases the chances of ending on time and improves the experience of patients and staff alike. But when the first case of the day starts late, it can create a cascade of delays.

In Radiology and Endoscopy, poor metrics on first-case on-time starts (FCOTS) had caught the attention not only of senior leaders but also those on the front line, including Endoscopy nursing director Sandra Cialfi, MBA, BSN, RN, CGRN.

“We recognized that we had deficiencies, but we didn’t have an organized way to address them,” said Cialfi.

Working with the BWH Performance Improvement team, staff from Radiology and Endoscopy could dramatically improve their FCOTS rates and, from Cialfi’s perspective, reach a turning point that now makes other improvement opportunities feel achievable. Here’s how.

CSIR Sees Improvements

In spring 2017, when team members from Cross-Sectional Interventional Radiology (CSIR) were asked to identify potential causes of delayed first-case start times, different theories abounded. But everyone agreed on one thing: the FCOTS rate was disappointingly low. Eighty percent of cases weren’t beginning on time.

“We knew that starting the day on time could have a big impact, but addressing this in a meaningful way was challenging to do,” said Paul Shyn, MD, director of Cross-Sectional Interventional Radiology. “We were trying off and on to take steps to address this, but were finding that there were dozens of reasons why a case might not start on time. We addressed many, but found that there would always be another reason. We would fix a problem, the rate would improve, but then it would slide back.”

Shyn and his colleagues wanted sustainable improvement. They reached out to Jonathan Baum, BWH’s lead consultant for Analytics, Planning and Process Improvement (APPI), and his team for assistance.

When APPI begins working with a group, they talk to frontline staff, observe the work and collect the data.

“In the case of CSIR, leaders had already been doing a lot of work to improve FCOTS,” said Baum. “While we were understanding the causes, the rate of FCOTS was actually improving. There was a focus on it, but that can be short-lived.”

To help CSIR sustain and continue these improvements, Baum recommended they develop a system to identify what’s important to improve; measure performance each day, make that data visible in the work area and, finally, hold a daily huddle to review why cases didn’t start on time. The huddle would also allow the team to problem-solve and brainstorm additional improvements.

“What’s great about the huddles is that we saw real-time action, rather than meeting after a month when people would have been sharing anecdotes rather than data,” said Rose Wach, technical director for both CSIR and Angiography.

Once the huddle concept started in July, FCOTS shot up to 93 percent. The team developed best practices, which became standard practices. Staff started seeing the results and looking for more opportunities for process improvement.

Since then, the FCOTS metric has occasionally fluctuated, particularly if bad weather or other circumstances delay patient or staff arrival times. Overall, however, the team sees its improvements as a major win –one that has helped pave a path for additional positive change.

Angiography and Beyond

In September 2017, Wach became technical director of the Division of Angiography and Interventional Radiology, and Matthew Schenker, MD, became the division’s chief. It was a time of change and opportunity. They began implementing daily huddles and focusing on ways to improve – beginning, once again, with FCOTS.

“We quickly saw that the issues in Angiography were different,” said Wach. “We were able to bring some of the lessons we had learned from CSIR with us, but also recognized that the struggles were unique.”

In CSIR, cases and schedules are predictable, but in Angiography, emergency cases can change plans at any time. The team realized they needed to focus on the variables they could control rather than getting stuck on the unpredictable.

“Often, groups get fixated on other areas of the hospital that affect their operation – the wait for lab test results, how long transport takes – or on the need for more resources,” Baum said. “What we’re trying to do is not minimize those issues, but instead focus on what is within your control and what you can do to change things.”

Baum also emphasizes the important role of leadership. The tone that departmental leaders set – and whether they attend huddles and commit to change –influences the success and sustainability of improvement efforts, he said.

“This has been a key ingredient for the success we’ve seen in Radiology,” Baum said. “People are seeing that this is important to their leaders, and that Rose, Paul, Matt and others are reinforcing this message through their actions.”

Endoscopy Capitalizes on a ‘Turning Point’

In Endoscopy, “scope in” is an important moment. It’s when the flexible tube of the endoscope enters the patient and the endoscopic procedure officially begins. In spring 2017, the FCOTS rate, as measured by “scope in,” was between 10 and 15 percent.

Each morning at a daily safety huddle, Endoscopy would discuss FCOTS. Leaders at the safety huddle saw room for improvement and approached Baum to ask if he and his team could help Endoscopy in the way they helped Radiology.

As with Radiology, the team decided to address FCOTS first.

“FCOTS is a great place to start not only because there’s usually room for improvement, but also because as we begin observing and objectively presenting data, teams identify other opportunities and ways to improve the quality of procedures,” said Keith Murphy, director of Process Improvement in APPI. “They become engaged in the process and motivated when they begin to see real changes and improvement.”

Murphy, Baum and Mark Galluzzo, a senior consultant in APPI, began working closely with Endoscopy staff. Through trial and error, they ultimately found that the team could improve FCOTS through several changes, many of which were identified by the nurses doing the work. One example: nurse who prepared the patient stay with them through the procedure rather than handing the patient off. Steadily, the team began finding ways to improve workflow with buy in from those on the front line.

“One of the cornerstones of doing improvement work is the iterative nature of it.” said Baum. “It’s an experiment: we’ll run an experiment for a week, and then take what we learn and run another experiment.”

“A big key in Endo was that the experiment didn’t stop, the team kept learning and tweaking the steps each day,” said Galluzzo.

Galluzzo acknowledged that change is hard for individuals and for teams, but sees the value in going through the steps of improvement work.

“When local leadership and Performance Improvement partnered daily to watch, listen and learn of problems associated with FCOTS, it was a bit overwhelming at first.  Every day, we seemed to learn of a new problem,” said Galluzzo. “But then we asked, ‘Well, if we didn’t do this today, when do we think we would we have learned about this issue?’ One of the responses was, ‘We might never have found this out.’”

The numbers for Endoscopy have radically improved: Preprocedural work is consistently completed on time in 90 percent of cases and on-time start has jumped to 60 percent. Cialfi said that seeing those numbers was a turning a point for many members of the team.

“The data speak for themselves,” she said. “People are feeling like they are being heard – nurses, physicians, technicians – and they are invested in this. If we can continue to make improvements, it’ll be very positive for everyone, but especially for our patients.”