Achieving sustained quantifiable results in an interdepartmental quality improvement project

In the mid-1980s Beth Israel Hospital Boston began a participatory management approach that encourages all members of the organization to improve productivity, efficiency, and quality through interdepartmental and intradepartmental project teams. The CT [computerized tomography]-Nursing-Transport Team, the hospital's first quality improvement project Team, grew out of an organizational challenge to solve an interdepartmental problem. The goal of the project was to have inpatients arrive on time for their scheduled CT-Scan appointment. Prior to the project's inception, over 50% of all inpatients scheduled for CT-Scans arrived more than 20 minutes late.

The team learned the Juran quality improvement methodology, using just-in-time training. The methodology consists of four major steps: problem definition and organization, the diagnostic journey, the remedial journey, and holding the gains. The team used many quality improvement tools including flow-charting, checksheets, histograms, Pareto charts, run charts, and brainstorming to find the root causes of the problem and achieve results.

The team members collected data and flowcharted the complexity of the CT appointment and patient pick-up process to pinpoint the root causes of delays. They found that three floors accounted for a majority of the delays and that four reasons for delays explained two-thirds of the problem. Additionally, as nurses and CT technologists flowcharted the process, they found that they used a different definition of "on-call" and that misconceptions existed about the scan and the preparation for it. When transporters were included on the team, the team discovered that delays occurred in a pattern and that communication with central transport was poor and inconsistent. After the team made changes in break times, equipment, communication, planning, and timing, the late patient arrivals dropped dramatically--more than 80% of patients arrived within five minutes of a scheduled appointment. One year after the project team stopped meeting, close to 70% of patients continue to arrive within five minutes of their scheduled appointment time, despite increased volume and no additional scanners.

The success of the project reinforced many well-known quality improvement conditions for success. These include (1) choosing a project that is "high pain, high drain," (2) having a committed project leader who can keep the team effort going, (3) using data to lead the team to the root cause of a problem by pointing out where, when, and why the problems occur, (4) utilizing flow-charting and shadowing to understand the process from a fresh perspective, and (5) holding well-facilitated meetings with a defined purpose, ground rules, and meaningful agenda.