Prof. Werner Jaschke
Department of Radiology
The radiology department at Innsbruck University Medical Centre has two divisions located in two different buildings, staffed by 66 physicians, approximately 200 technicians and 88 scientists. Our centre is a wellknown leader in fields such as interventional radiology, particularly in the treatment of aortic aneurysms and intracranial aneurysms. Our team have also developed research in areas such as ultrasound-guided biopsies of the prostate, stereotactic treatment of liver tumours, stereotaxy (http://sip.uki.at), CT-guided biopsies of lung nodules and ultrasound imaging and guided therapies of the musculoskeletal and peripheral nervous system
PACS has been one of the main catalysts for change in the profession of medical imaging, and Austria is no different in this. We first established a government-sponsored teleradiology service in Austria as a pilot project called “Telemedicine Tirol”, following what constituted the first hospital-wide PACS at a university hospital in Austria, and one of the largest PACS installations in Europe. Remote consultations are now provided to five local hospitals. On a daily basis, this adds between 2 – 5 % to our overall workload. However, the advent of teleradiology has also given rise to certain operational challenges.
Due to local laws, services are preferentially provided on a local basis and we provide only emergency services and second opinions. Our decision to cut back on our teleradiology operations with outside partners was based on poor reimbursement levels. The remaining services are run more as a courtesy to the smaller institutions whose specialists might not cover the sorts of cases they receive than as a profit-making project.
Productivity Monitoring Key to Good Management
Productivity is becoming increasingly important for good management. We have a fixed annual budget and therefore although there are no penalties in place, if resources are not allocated properly, we may have to cut necessary costs. In parallel, if we perform well, the next year’s budget will increase. Therefore, our department operates continuous productivity monitoring and training of staff members. We calculate the output of the department and the numbers of exams performed on an ongoing basis, and relate this to the cost of exams and the income generated by them.
The hospital administration keeps track of the costs per procedure or exam performed. Therefore, if you request new equipment they can calculate not only the cost of the investment but also the running costs such as the staff, materials and accessories that will be required to run it. These running costs are an important factor in estimating whether an investment is realistic or not.
Patient Access a Priority
There are no waiting lists for medical imaging in Austria, and patient access to treatment is very good. Productivity is higher due to greater incentives for doctors. They earn a fixed income, plus extra income from patients with additional private healthcare coverage. Therefore, by doing more, doctors earn more.
Also in Austria, public hospitals operate on a traditional hierarchical structure which, in my opinion, adds to productivity. For example, Chairpersons here are in a position to delegate more responsibility to up-andcoming colleagues, fostering their careers with an and eventually developing their roles to positions of leadership. The general trend is that these individuals, after tens years experience in a bigger hospital can go into private practice or can take a top position in a large radiology department.
Skepticism About Accreditation in Austria
In Austria, there are laws as in other European countries, obliging medical institutions to comply with industrial ISO 9001 standards. Each two years we have to undergo re-accreditation processes to ensure we are upto- date. However, these are not specifically designed for healthcare institutions, and therefore their true impact on quality management is limited. As a result, accredi tation is not viewed in a positive light; as well as being labour and time-intensive, the question remains of who will foot the bill. Also, as the reimbursement levels remain the same whether you undergo accreditation or not, there is a low incentive to get involved.
The results of these procedures are not made public like in the US, which is directed towards patients as consumers with a right to survey the results of institutions, but only used internally. Another negative aspect of accreditation is that it does not measure or regulate the quality of the output of the department. Even if the results of the ISO process are that the reporting process is satisfactory, it makes no comment on the effectiveness of the report for the patient, or whether the referring physician was correct to order that specific exam. Therefore it has limited impact on improving medical quality.
Restructuring the Radiology Department
In early 2007 the hospital administration, the university and myself, initiated a restructuring project for the department of radiology, to cut superfluous processes and related costs and to increase efficiency and medical quality. By eliminating parallel structures, we will offer a more streamlined service, but quality need not suffer. It will take an estimated two years to achieve these goals, and we may have to lose technical and administrative staff along the way. We have a two-man coaching team that are experts in organisational change management to oversee the project and to deal with staff concerns.
Paring down our team may be problematic. We are a public institution, and in Austria, if a public sector worker is on a permanent contract then they have a job for life and it is not possible to make them redundant. Therefore we won’t replace staff that leave. In the University, they get around this by only hiring on a contract basis since 2002. But the hospital administration have a different system – they hire doctors for an initial six years, then allow them two following years to be monitored. If they are hired again after this then it is a given that they also have a job for life. It allows those responsible to be sure they are making the right employment decision.
Management training is more of a concern in Austria for those interested in developing long-term career goals. If you are going to become a permanent member of staff then taking courses on leadership, people skills and administration is a necessary addition to one’s education. Otherwise all hospital staff receive a weeklong crash course in the basics of healthcare management including an overview of the administrative and organisational structure of the hospital. If people want to go further than this they have the option of following part-time courses in management with private trainers for up to one year.