Prof. Philip Gishen
Dr Nicola Strickland
Department of Radiology
It isn’t just the economic crisis that might bring profitability to the forefront of the imaging manager’s mind. Global mobility, technological advances and the formation of the European Union (EU), in combination with the digital revolution, has completely transformed the way radiology is practiced. In this article, we look at the tools that imaging departments can use to remain ahead of any economic woes.
1) An Ideal Imaging Experience?
Firstly, it is useful to establish an ‘ideal’ vision of where your imaging service should be. Public transport to the hospital, easily available parking and good signs to the department are essential. This does not just happen – make it happen. A warm friendly greeting for the patient by the receptionist, to a comfortable and spotless environment - no detail is too small to elaborate. Radiology departments must make imaging available to the patients when and where they wish.
Our ideal solution to waiting lists is a “have the procedure and go” department. To run this system, flexibility is a byword, as you have little control of numbers of patients arriving at any one time. To work such a scheme you must be allowed to expand or contract your services, bypassing hospital bureaucracy. Extra space for scanners and staff may be needed if the service grows. Once the x-ray or scan is done an ‘instant’ report is required. A large reporting room allows free and easy exchange of ideas and multiple opinions without embarrassment, teaching on current cases and an easily accessible contact point for clinicians to access radiologists for discussion of cases. This reporting room should be the centre of your department. 12 or more workstations with sound-proof divisions, excellent adjustable lighting and chairs, air conditioning, telephones, reference books and internet access should be readily available. Visits by clinicians to the reporting room are not interruptions – they are essential to reinforce the role of on-site radiologists.
2) Implement Multidisciplinary Meetings
Multidisciplinary Team meetings (MDT), where every case is discussed with clinical colleagues and histopathologists, are an essential part of departmental life. The MDT room should include at least dual overhead projectors, PACS connection, microscopy, connection to remote rooms, and excellent furniture, heating and air-conditioning.
Working an hourly timetable allows the creation of a flexible work force and a department which has a capability to work longer days. Appendix 1, on page 18, shows the construction of a working day for individual radiologists. You must assess whether your work output is sufficient. The Ready Reckoner (see appendix 3 on page 23) has been compiled from the detailed work output figures of six departments. This is a realistic expectation based on an average of 40 weeks of work output per year (not including private radiology practice and the ability of radiologists to produce substantially more work in this environment).
Delegate major jobs to the most suitable people; for example Head of Research, Head of Postgraduate Teaching, Head of Undergraduate Teaching, Head of Conference Organisation.
A research committee should be established with a dedicated coordinator. The appointed head of imaging research should develop close communications with clinical colleagues on all imaging projects, making sure there are imaging consultants on the project: they will report the research, be involved in the writing of papers and attract grant applications. A database on research activities outlining grant projects, applications and grant income is essential.
There must be a simple process for starting new projects, research radiation compliance and all research governance matters, to develop a viable academic department. Money is vital, so there must be robust methods to establish all possible funding streams.
A successful postgraduate training scheme depends on committed, enthusiastic consultant trainers. Trainees, when they move into consultant posts in new departments, always cite inspirational trainers as the single most important contribution to their careers.
A robust rota of undergraduate teaching is not reliant on one or two radiologists. The design includes teaching by consultants and specialist registrars and radiographers who provide insight into taking x-rays, scans and safety checks. The medical students have a mixture of didactic teaching, observing reporting and scanning as well as multidisciplinary team meetings. This teaching is best achieved with small groups to personalise learning.
7) Assess Individual Modalities
Meet regularly with the radiographic leaders of each modality to look at output (appendix 2, see below). Modern working practice requires imaging departments to work from early morning to late evening. Not every modality needs to be worked this way. If you can cope with the numbers of patients in the normal working day, do so, but many modalities, e.g., MR, require prolonged use of equipment to reduce costs for the consumer and cope with the yearly 15 - 20% rise in MR scanning requests. Make waiting lists the responsibility of radiographers. You must not give anyone the excuse to “get the investigation elsewhere”. Doctors will use the department providing the quickest service.
During the past two years we have run an ultrasound service for general practice patients requiring no appointments. Patients have been asked to arrive with their request forms. This removed a huge amount of bureaucratic activity around the booking process. The ultrasound requests rose from 850 patients to 3,500 per month within 18 months. We coped by re-organising timetables, getting more people to scan - some for short periods of time, improving the waiting area and patient information and increasing the amount of equipment.
What we found was more patients coming from greater distances, bypassing their local hospitals that had waiting lists. The problem for UK departments is the method of payment. For this system to work you must have a fee-per-item of service and a management which responds to increases in numbers to buy equipment, hire staff and have sufficient space.
8) Manage Equipment Requirements
How should one manage equipment? Personally we favour an ‘everlasting equipment renewal’ contract or ‘managed con tract’. A 15-year contract allows a company to install, replace and service the equipment and introduce new technology.
Final Thoughts: Is “Recession-Proof” Possible?
A government or national hospital practice, working a fixed salary scheme, not dependent on patient throughput, will always have a need for more staff. What incentive, other than professional pride, encourages a radiologist to report 300 instead of 100 cases? The salary is the same, but there is a constant assumed need for ‘more staff’. We should learn from private practice, where the approach is “Let’s get more work, cut the level of staffing, do the same job and work harder to increase profit”.
So, finally, recession proof – yes, very possible. Make the life of the individual radiologist better, turn every situation to an advantage, not a hindrance, make the patient and clinician need you and your practice only. If there are no waiting lists, all imaging studies are reported and patients are treated wonderfully, you are effectively now recession-proof.
The Industry Standpoint on the Recession
Graeme Allan, General Manager Digital Medical Solutions, Europe North, Carestream Health has this to say about the industry standpoint on the recession:
“As with the rest of the world, the European healthcare industry is impacted by the current economic downturn. Access to capital is more limited and institutions are looking carefully at planned investments. In the past most healthcare facilities opted for capital expenditure. Now, as capital becomes increasingly restricted, we are seeing a greater use of our lease and pay-per-procedure plans, especially by small to mid-size hospitals.
Despite the economic slowdown, many European organisations are still pressing ahead with essential modernisation as part of e- Health technology initiatives. The delivery of telemedicine also remains a priority, particularly for those countries where a lack of radiologists exists. Carestream Health is currently implementing a number of Europe’s long-term regional e-Health projects and these are continuing as planned, but perhaps
at a slower speed.
In our industry, certain factors enable success in any economic climate and in periods of uncertainty they take on renewed importance. Healthcare institutions face incredible challenges - declining reimbursements and government funding, shrinking budgets and growing costs. At Carestream Health we remain committed to efficient and effective delivery of our solutions and services, managing both cost and quality and providing value for money. Being a global supplier helps our position as we have greater stability than regional or national suppliers.
R&D remains a priority and we have no plans to decrease our continuing investment in new product development as such a move would hinder our long-term growth strategy. The market for imaging equipment and solutions may well dip in 2009 but most European healthcare providers take a long-term perspective and are looking for systems and solutions that lower cost and improve care through innovative technology. R&D efforts are central to meeting those aspirations. As an example, new products like the CARESTREAM DRX-1 System fit perfectly in constrained economic times. This new detector can be employed in all applications where a 35 x 43 cm X-ray cassette would be used and can be incorporated into all types of radiology environments without modification of existing rooms.
Growth in 2010 will depend on stabilisation of the financial markets not only in Europe but also across the world. During the interim, the aligned efforts of the European Union will play a key role in helping the industry remain optimistic for the future. The current situation is temporary, long-term markets will improve, and in the meantime the key to riding the storm is to remain focused on customers, cost and quality.”