Unscheduled Radiology Orders

Some radiology orders placed by physicians and other ordering providers have not been scheduled as intended by the clinician. As of May 2021, there were 90,000 unscheduled radiology orders across the MGH, which creates a patient safety risk if the clinical intent is not executed in a timely fashion.  A collaborative effort between MGH Ambulatory Management, MGH Radiology, and ambulatory departments/divisions, this project will outline steps to mitigate the issue and to continue to improve our care delivery processes.

Brigham and Women’s Hospital completed this project in 2018–2019. There were over 50,000 unscheduled radiology orders across the Brigham, identified as a quality and patient safety risk through collaborative case review of a reported safety event in February 2018. It was determined that the clinical intent of a provider was not executed in a timely fashion. During the safety review process, the following root causes were identified:

• Orders themselves may not contain accurate or complete data to schedule from due to onerous order entry workflows.
• Unscheduled orders workqueues were not actively worked due to unclear expectations/accountability, inaccuracy, volume of orders, and/or competing demand.
• All scheduling by ambulatory clinic support staff

• Reduce the number of unscheduled radiology orders 50% by August 31, 2021 and 100% by November 30, 2021.
• Implement a new standardized operating procedure across the system to prevent re-accumulation of unscheduled orders.

The project will be implemented in two phases occurring at the same time: clean-up of backlog and future state design and rollout. The specific objectives of each phase are included below.

Phase I – Clean-Up of Backlog

• Clean-up of existing unscheduled orders in workqueues
• Measure progress against resolution of backlog

Phase II – Development of Future State

• Create workflow models to allow radiology scheduling
• Develop metrics to ensure accountability across organization
• Create future state standard operating procedures (SOPs) guided by clear process and best practices to avoid backlog

Central radiology has taken the first pass on clean-up efforts. All the unscheduled radiology orders have been divided into different modalities, and the reviewers have reviewed the orders and taken appropriate action: cancel, schedule, or escalate for clinical review. Central radiology schedulers have reviewed all orders with schedule status and reached out to practices to complete the scheduling process. All the orders with escalate status were reviewed by a radiologist and similar action was taken: cancel, schedule, and escalate.

All the remaining orders were handed off to ordering practices on July 30. There are helpful tip sheets and training materials for practice review to help during this clean-up process. Practices (physicians and APPs) must complete review of 100% of their orders by November 12 to achieve the MGB November goal.

“Best Practice” Principles

• Review all orders within 7 days of the order being placed.
• Take the appropriate action for the order (i.e. schedule, defer, discontinue, etc.)
• Notify the patient of action taken.
• Notify the provider if the order is discontinued, following SOP.
• Use a dashboard to monitor and to ensure timely execution of provider clinical intent.

More information on the future state is forthcoming.