Imaging project highlights timeliness issues

Fast report turnaround depends on leadership

Several key behaviors promote quick turnaround on imaging reports, but the overriding factor appears to be strong leadership, an imaging benchmark project has found.

"The more successful departments have strong medical leadership," says Emmet Goldberg, director of operations improvement for University Health System Consortium (UHC) in Oak Brook, IL. "The technology is there to reduce turnaround time, but it’s how people will adapt to timeliness and quality issues that determines success."

The imaging benchmarking project sponsored by UHC included 49 of its members, major university hospitals around the nation, and some private and community hospitals for comparison. Because reported performance levels vary widely among members, and imaging expenses account for 3.7% of operating expenses, the project’s goals were to provide members with information on how to compare to each other and to be "best in class" performers. A steering committee met in mid-1995 to set the course for the project, establishing the project scope and determining that the findings would come from two mechanisms: a benchmarking survey and site visits.

The survey included questions on demographics, staffing, process measures (such as scheduling practices), and outcomes measures (result reporting turnaround time and staff utilization, for example). The Medicare RBRVS relative value unit (RVU) methodology was also used to facilitate comparison of performance levels by major imaging modality (general diagnostic, ultrasound, CT, MRI, special procedures and nuclear medicine).

Use radiologists to benchmark radiology

Bruce Hillman, MD, chairman of the department of radiology at the University of Virginia Health Sciences Center, in Charlottesville, VA, praises the straightforward, yet in-depth, surveying process used in this study. "Other benchmarking forms I’ve seen are unwieldy, asking for unrealistic accounting procedures and that sort of thing," he notes. "This one was produced by people who understand radiology. In the end, it offered reasonable, real-world comparisons that could lead to practical solutions."

Based on the results of the benchmarking survey, five "better performers" (three UHC members and two other hospitals: Central DuPage, in Winfield, IL, and Western Pennsylvania, in Pittsburgh) were selected for site visits.

The benchmarking teams usually consisted of directors of radiology departments, some staff radiologists, and UHC facilitating staff members. The site-visit teams generally were looking for who is responsible for what; the role of the radiologist; how the work flowed through the department; how residents were involved; and how work was prioritized. The teams brought back valuable data on balancing patient care with the teaching function, how residents can influence turnaround times, and how some hospitals use electronic systems to prompt physicians to do reports or readings. Here are some specific findings:

• Market forces are causing hospitals to reduce inpatient utilization and radiology departments to reduce costs and improve service. Some major ways to reduce operating expenses include supply standardization, increased use of ionic contrast media, and re-evaluation of equipment maintenance arrangements.

• To support improved turnaround times on reports, it is necessary to expand attending physician coverage hours and accessibility, including expansion of service hours to provide greater patient convenience. Residents can be better utilized, as well, by adapting their supervision by physicians.

• The survey and site visits revealed a number of consistent practices among better performers:

— Where possible, films are read before the patient is released from the department.

— Radiologists are required to read all assigned cases before leaving each day.

— Transcriptionist staffing is scheduled to coincide with radiologist dictation patterns.

— Radiologists are provided remote access to edit and sign off on transcribed reports; they are expected to sign off on reports from nonhospital locations, even at night.

As mentioned before, the head of radiology is ultimately responsible for reviewing timeliness information and enforce change. "Some hospitals have prompting mechanisms for timeliness," adds Goldberg. "For instance, if a report is ready to be signed and hasn’t been signed in four to five hours, the physician’s name flashes on a screen."

• A technological advantage isn’t necessary to be a better performer, but hospitals should take better advantage of existing technology. Most of the UHC participants have up-to-date equipment, but the better performers, for example, excelled in equipment maintenance, even infrequently used equipment.

But that works only if the equipment is actually used. Goldberg points out that some hospitals have the philosophy, If it’s paid for, keep it around,’ even though equipment may be costly to maintain or results in inefficient usage because it is old. A better solution, he says, may be to tap into the growing market for used equipment and sell it.

• Flexibility in staffing is ecessary to control labor expenses. Some institutions coordinate technical and radiology staff activities to eliminate duplication or reduce call-back requirements. Supervisors should make careful evaluations of such staff needs as clinical support staff, use of multiskilled workers, on-call requirements, and overtime.

Larry Ranahan, MD, director of radiology for the University of Chicago Hospitals and Health System, has already implemented some of the findings, hooking up the right people in Chicago with other hospitals to improve on his department’s MRI procedures. "This study provided a relative value framework for better comparability," Ranahan says. Before comparing apples to apples, for example, "you need to find the apples in the bunch," he points out. This particular benchmarking study enabled him to also compare his institution’s results with community-based hospitals, not just university establishments similar to his.

10-hour standard for final reports

By adopting "better performer" practices on report timeliness, for example, final image reports can be produced in less than 10 hours, the study found. As for cost savings, the average participant would save $772,575 annually if it reached the 50th percentile level for controllable expense per RVU. The average savings would jump to $1,489,603 if the 75th percentile was achieved.

"There wasn’t necessarily a single solution for hospitals, but there were some commonalities," Goldberg comments. "We found that the ones that achieved success made it a priority, asking the question, Isn’t there a different way this could be done?’"

[Editor’s note: For more information, contact Emmet Goldberg, (630) 954-1032. E-mail: goldberg@msgate.uhc.edu.]