Uncharted/Missed Documents Project

Lead by Drs. Cunningham and Dippenaar, this committee has had several meetings with Richard Harding and representatives from the Diagnostic Imaging Department. Phase one of this project focused on
reducing the number of reports from Imaging that were being sent to the wrong physician creating confusion and inefficiencies.

Steps were taken to identify causes:
1. Meeting with physician group identifying the issue from their perspective.
2. One on one meeting with Richard Harding to go through the detailed steps and created a ‘Current State Value Stream Map’.
3. Physicians supplied examples of erroneously sent reports.
4. The Imaging Department head reviewed all examples and identified groupings of sources of errors.
5. A meeting with the affected Imaging clerical group was arranged, and the process was discussed.
6. The Imaging clerical group identified the source of errors as being a part of their patient check in process.
7. It was instructed to the Imaging clerical group to change their process and only add the doctors stated in the ‘copies to’ section on the requisition.

Outcome of the Activity:
1. Process and engagement provided an open forum to explain the issue encountered by physicians.
2. Time was given to identify within the department what was the source of the errors.
3. Implementation of a new process was followed up by feedback of the physicians.
4. A positive outcome was achieved through the Physician Engagement process.

As a result of the excellent work by the Diagnostic Imaging group, lead by Travis Thompson, almost a complete reduction of errors has been achieved.
Phase two will be to consult with the Laboratory Department to determine whether the same positive results can be achieved.