It’s not “lean” to wait 150 days for an MRI

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This news story, “Ottawa Hospital seeks fourth MRI machine,” from Ottawa describes an unfortunate situation where 90% of patients had been waiting 360 days for an MRI. So the hospital added capacity – by adding a third MRI machine (an expensive proposition). They also improved some administrative processes. Waiting times fell to about 150 days, still a long time to wait. What does the hospital want now?The hospital wants another expensive MRI machine, which will probably cost a couple of million dollars.

“…the Ottawa Hospital needs a fourth MRI machine to bring them down any further, says the head of diagnostic imaging at the Ottawa Hospital.”

It could be that they need another machine, but the news story doesn't report the utilization rate of the machine. Is it running anywhere near 75 or 80% capacity (the practical maximum before queuing theory says patient flow will suffer)? Have they improved their scheduling processes and looked at the whole value stream to reduce delays in patient flow caused by problems like missing orders, incorrect orders, and bottlenecks at the registration desk?

There are often cheaper ways to get more capacity. Have they reduced the turnover time between patients, using lean “quick changeover” methods?

We don't know. But considering the deficits at the hospital ($25M) and the deficits for Ontario ($25B), I hope they are considering every alternative short of buying a new machine.

I worked with a children's hospital U.S., where the team I was coaching from radiology was able to reduce outpatient MRI waiting times from 14 weeks to just 2 weeks. Sure, they worked a little overtime to help get the backlog down, but the main backlog and waiting time reductions came from process improvements and breaking a bottleneck with a very selective staffing increase (this is different than blindly throwing people at the problem). They got waiting times down without buying a new MRI. In fact, when they first started looking at the data, the MRI utilization had only been about 40% during the 12-hour working day (which really means the ultimate utilization was just 20%!). With improved value stream flow and better staffing patterns, they quickly got utilization up over 60% of the working hours. That was far cheaper than buying another MRI (one for which no space was available, anyway).

From my headline, the comment that bothered me from the story was this:

“We are as lean as we almost can be, but I really need that fourth MRI to get any better,” said Dr. Mark Schweitzer.

There's the problem with the word “lean.” In common, everyday usage, people use it and it has nothing to do with the Toyota Production System. Everyday usages of “lean” means “we don't have enough people” or “we don't have enough equipment.” Even if they have high utilization and they are truly as efficient as they can be with existing resources, making patients wait five months can't really be anybody's definition of Toyota “lean,” which would mean meeting customer needs (demand) at the highest quality, at the lowest cost.

One reason waiting times are down is an artificial constraint of demand for MRI:

Many doctors have been “self-censoring” by ordering CT scans and ultrasounds instead of joining the Ottawa Hospital MRI queue, said Schweitzer.

I wonder if the physicians were pressured by those controlling the budgets to not order MRI? Is that necessarily the best thing for the patients? It depends – is the MRI medically necessary? Is it value to the patient?

It's one of the complexities in healthcare… it's often argued that supply creates demand (or lack of supply constrains demand). It's like adding more lanes to a congested freeway… traffic delays don't get any worse because more people choose that road (as explained here).

Will adding a fourth MRI machine reduce waiting times? It might, but that's one expensive “Do” for the Plan-Do-Check-Act cycle! If I were advising them, I'd make sure every possible process improvement had been investigated first.

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Mark Graban is an internationally-recognized consultant, author, and professional speaker who has worked in healthcare, manufacturing, and startups. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. His most recent book is the anthology Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also a Senior Advisor to the technology company KaiNexus. His latest book has been released as an "in-progress" book, titled Measures of Success.

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12 Comments
  1. Dragan Bosnjak says

    Well I would say that the situation is not much better here in Italy regarding waiting times. But here there is also an other problem: private and public hospitals – the MRI technicians often tend to schedule very long times in the public hospitals and then tell you to go to their friend’s private practice where the customer needs to pay much more and have the service made instantly. And they take the percentage of profit for sending this patient…
    It is a typical example of lame thinking where the only thing in mind of these people is the profit and the patient (customer) is the last on the list…
    .-= Dragan Bosnjak ´s last blog ..What Can We Learn About Lean Psychology and Mastery from Rafa Nadal =-.

  2. Natalie says

    I don’t know where you live but I live in Ottawa. I injured my shoulder 9 months ago. Physio didn’t help so x-rays and an ultrasound were ordered. They showed nothing. I was told to try a different physiotherapist. Now, 9 months later, the shoulder is still not any better. Now I have a year to wait for an MRI. The news says that the wait times are down to 150 days here in Ottawa but the reality is that the wait times are close to a year. So, if it’s something that needs surgery (probably another 6 month to a year wait), we’re looking at over 2 years and maybe even close to 3 years since the initial injury before it’s fixed. I’m not a happy camper at the moment!

    1. Cartier says

      Prime example of why we need to adopt continuous improvement in Canadian healthcare – MRI wait times are currently 1 year in Alberta also. I have a friend in Colorado who requested an MRI, received it next day, had surgery and was in post op physio within 4 weeks.

      As of 2 weeks ago there is a 3 day wait time for private MRI’s in Alberta, 1 year for public.
      We don’t have a capacity issue, nor do we have lean healthcare. Yet.

      1. Henna says

        Unfortunately this isn’t a lean issue. The wait times at least in Ontario are actually due to government funding. Hospitals will run MRIs 24/7 if they have the funding. When the Ottawa hospitals received extra funding for running MRIs I have gone at 2am, 12am and on a Sunday. The wait times get lengthy when the hospital can only afford to run it a certain amount of time and then have to prioritize urgent over “elective” like mine and Natalie’s shoulder. This is why if you go to a private MRI clinic in Gatineau Quebec just across from Ottawa your wait time is very quick, if you can pay out of your pocket there is no wait.

        1. Mark Graban says

          The government and the citizens have to decide “what problem are we trying to solve?”

          Which goals take priority? Short wait times for “elective” procedures? Fairness? Keeping spending down and within budgets?

  3. Mark Graban says

    Natalie – Thanks for posting your story. I’m sorry to hear about the delays. I am in the U.S.

    Our system is by no means perfect. But what frustrates me is when the dogmatic healthcare reform advocates in the U.S. paint a picture of Canada’s system being perfect. If you even mention government data (say, for Ontario) about patient access problems and waiting delays, they just scream at you.

    http://www.health.gov.on.ca/transformation/wait_times/index.html

  4. Henna says

    I agree that the MRI system is not 100% “lean” in the business sense however it should be noted that in Ottawa machines are typically run at as close to capacity as possible (see this article -> http://www.canada.com/ottawacitizen/story.html?id=f0aab085-21aa-4868-82a0-bc500d4071b4). I went for an MRI this morning at the Ottawa Hospital (Civic campus) at 2AM and there were three other patients waiting. The clinic breaks and patients continue again at 3AM. My second MRI is on a Sunday afternoon at 4pm at another Ottawa hospital (Montfort). So from my experience they are doing the best possible job given their resources. The issue is that there is no centralized system. I have spent a lot of time calling the different local hospitals and neighbouring cities (try Kingston) to find the shortest wait times, put myself on every cancellation list and made clear I am available 24 hrs. If there were a centralized system I would not have to bother my doctor to send in multiple requisitions to each hospital. A centralized system would eliminate shorter wait times at other local hospitals and ridiculous wait times at the Ottawa Hospital (both campuses). Most people don’t even know that CHEO (Children’s Hospitals of Eastern Ontario) does adult MRIs. A centralized system would spread around requests and could reduce the average wait times. I have also heard that budget cuts have made it difficult for Ontario to pay for 24 hour MRIs, which is why not all hospitals can do it. However I have no proof for this.

  5. Henna says

    Sorry Mark just wanted add one other comment, I completely agree our system is not perfect. However I feel the difficulty lies in access to the system but not necessarily the system itself.

    1. Cartier says

      I wonder to what degree the system itself is causing the difficulty accessing it.

      1. Mark Graban says

        I worked with a hospital in northern Ontario.

        They kept saying “we don’t have enough inpatient beds” so patients were waiting for admission in the emergency department hallway for days.

        We toured the hospital (newly built) and they pointed to a wing with 24 available beds.

        “Wait, I thought you didn’t have beds?”

        The more accurate thing to say was “we have beds, but not enough staff.” Why didn’t they have staff for those beds? Government budget constraints.

        So, politicians can complain about long waiting times and can promise to get to the bottom of the issue… but some of the problem is of their own making.

  6. […] It’s not “lean” to wait 150 days for an MRI dal Lean Blog di Mark Graban: Prima di comprare una nuova macchina per MRI dobbiamo risolvere tutti gli sprechi nel processo che non ci permettono di avere le visite programmate in pochi giorni anziché in 6-12 mesi… (traduzione automatica) […]

  7. […] physicians, instead of telling people what to do or how to change. One such initiative helped a children’s hospital reduce the waiting times for outpatient sedation MRIs from 12 to 14 weeks down to just 2 to 3… and they’ve sustained those results for […]

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