The run charts for the urologic MRI studies showed a median time duration reduction in the scanning times and the interval between the scanning and writing of the radiologic report, but not the duration of the prepping time, which was increased non-significantly. The total study duration was reduced but not significantly. The increased prepping time could partially be explained because 30% of the prospective cohort was scanned with intravenous contrast in comparison to 3% in the control group. 

At the beginning of the implementation period, our radiologist made many errors in protocoling the new protocols, and the radiographers scanning with the wrong protocols (mismatch bias). After feedback from the radiographers in March 2023 that they needed help understanding the new protocols, they recommended education on the different protocols and changing the names of the protocols. The same information was also shared with the radiologist. After this, we saw smoother run charts where the times were more consistent and stable (Figures 4, 5, 6, 7). 

When performing a sub-analysis of the prospective four tailored protocols, we noticed a substantial difference in the median scanning times (Table 2), especially for the MRI renal lesion and MRI kidney treatment control. Before introducing the new protocols the patient was programmed for 1 hour in the schedule. We could now see that MR hydrography was the scan with the longest median time of 41 minutes and MR kidney control with the shortest at a median of 32 minutes. 

In light of this new information, we created a new-state VSM (figure 8). The VSM shows the workflow with the median for each process in the prospective cohort. In the new-state VSM We also identified three new opportunities for applying the Kaizen-process. 

• Opportunity 3: Scheduling

With the reduced times, we have been able to change and tailor how the scheduling is performed and have a more efficient day-to-day program where we scan more patients daily. 

• Opportunity 4: Prepping time

We saw an increase in the median prepping time of around 3,5 minutes. One reason for this  could be the increased use of intravenous contrast and the time it takes to prepare the patient for this, but this increase is also noticeable in protocols that do not use intravenous contrast. This could be an opportunity to continue implementing the Lean (Kaizen-like) Process Improvement we have learned in the past year. 

• Opportunity 5: Time duration for the writing of radiological report

The significantly reduced time duration from the scanned study to the writing of the radiological report indicates that the radiologists start writing the report sooner but that the writing process is taking longer. On the one hand, it has become easier for the radiologist to write already tailored scannings, but on the other, something is interfering with that process. It could be because the radiologists start on the report but have different tasks or functions interfering with the writing process (e.g. conferring with colleagues, calls, etc), meaning that the writing process has to be paused. Another reason could be that the radiologist needed clarification or had a complex scan and needed to ask a colleague for advice. A lack of experience in evaluating MRUs or a lack of load of MRU, because it is challenging to master an examination that does not occur that often. Specifically, the protocol “MR kidney treatment control” has a long writing report time with a median of 13 hours, which raises the question of whether this scan is more complex. 

In summary, what have we learned?

• At the beginning of implementing the new protocols, we had a lot of mismatch bias and error for protocoling and the radiographers scanning with the wrong protocols. The feedback from their team that they could not understand the new protocols led to changing the name of the protocols so they could understand the focus – this highlights the importance of communication-feedback-loop in a workplace. 
• Small changes were done frequently, and non-value-added activities were caught quickly due to good feedback from all stakeholders. It has helped to find  opportunities to work on and make meaningful changes. 
• The application of the technique is limited by a need for more engagement from some of the stakeholders in the process. Team leaders are working to motivate and empower stakeholders to sustain the changes made so far and work on new opportunities for further improvement.
• We were inspired by Lean Principles and the “Kaizen philosophy” and adapted it to our hospital and cultural setting. That is why we call it Kaizen-like process improvement. And although implementing changes takes time because of the system structure and many stakeholders involved, we have been able to sustain the changes after eight months.