Describe the logistic of Pediatric MRI with a devised diagram that depicts the workflow in a pediatric hybrid interventional and cardiac MRI lab. Demonstrate the benefits of such a model in demonstrating and guiding improvement of care.

The Interventional and Cardiac Magnetic Resonance Imaging lab, ICMR, is a NIH planted 1.5T scanner at Children's National Medical Center, CNMC, that provides clinical and research imaging primarily to pediatric and congenital heart disease patients. Existing workflow was derived primarily on example from existing NIH labs and previously existing CNMC MRI services. The ICMR began scanning pediatric patients in May 2013. The core group consisted of 2 Imaging Cardiologist, 1 Interventional cardiologist, 1 NIH scientist, 1 MRI technologist, 1 research nurse. The ICMR draws on additional human resources from the traditional Radiology MRI staff(nurses, technologist, administration staff, child life specialist), the existing Cardiac Catheterization lab staff and faculty, NIH scientist and engineers and is guided by a steering committee comprised of 7 CNMc and NIH faculty. This is not an exhaustive list. In the past three years the ICMR has completed over one thousand cardiac clinical MRI scans, enrolled patients in seven active IRB approved research studies, completed nearly 100 combined X-ray and MRI procedures and over 100 fetal MRI. The productivity has warranted growth included or will include the addition of a Nurse practitioner, a third Imaging Cardiologist, and second Interventional Cardiologist, a second NIH scientist, a research coordinator, a second MRI technologist, and Imaging Post-Doctoral trainee.

Reference concludes that a performance measurement system is paramount in field of health care.

References demonstrate the benefits of having a defined process, which is measurable and transparent.

References show process improvement projects using small incremental standardized changes yields positive results.

Reference concludes visible transparent scorecard helps focus on specific quality improvement projects and drives performance. They conclude it has contributed to develop a quality improvement culture and is a powerful tool in calling attention to and improving performance in a given area.

Drawing from existing experience and published literature we established a diagram model (figure1) of existing workflow. This model is reviewed to determine if it fits real world practices. Areas of success and failure are determined in day to day planning, implementation and coordination of providing pediatric imaging. We are beginning to assign transparent measures to the model in order to promote a culture of continual quality improvement and drive performance.

Logistic is defined as the planning, implementation, and coordination of the details of a business or other operation. Successful MRI of a pediatric patient is then the business or operation of planning, implementing and coordinating a team of health care participants and provider. For each MRI a patient's success will be affected by all of the following.

Flexibility

Communication

With the amount of overlap in requirements for a scan and the people completing these requirements workflow can and often becomes cluttered. Defining the logistics can become equally cluttered making workflow cluttered. Nonetheless, having tasks and roles defined is necessary in order to keep patient moving from point of scheduling to end of scan as in figure 1. Due to the often complexity of pediatric MRI, this figure may be better suited to visualizing the MRI process than a typical flow diagram. This example is more like a refrigerator where the tasks and the person(s) completing them are magnets that can be placed dynamically.

If we look at the example we can see some key factors;

-each required task must have at least one person to complete.

-tasks occur either prior to scanning(green) or while scanning(yellow). Note something like sedation is color coded yellow because generally sedation is generally started once the magnet is ready or the magnet is held open waiting for a sedated patient.

- gaps between persons completing a task could be considered communication gaps

- persons able to complete more than one task would be demonstration of flexibility

Generic view of typical pediatric MRI displayed with model.Consider how poor planning, implementation and coordination is displayed in our model

CCHMC/IRC determining factors for successful sleeping child in research study(Vannest reference)CNMC “feed and bundle” compare and contrast to CCHMC depicted in Example 3CNMC hybrid EP ablation (Grant reference)Hearing and sight impaired CMR (technical Farranesh reference)

MRI in itself can be a challenge. In our pediatric setting we have additional challenege that need to be met. Further complication of research, combined with x-ray procedures, highly technical system, and MR guided diagnostic cardiac catheterization aspects of our procedures call for a defined detail oriented logistic plan. Additionally, with the integration of many departments needed to perform these procedures having a transparent measures to maintain and improve quality of care is needed.

Defining existing measures and the sources.

Developing new measures.