peter nuttman, melbourne health: journey towards a 7 day imaging service: challenge accepted!

Journey Towards a 7 Day

Imaging Service –

Challenge Accepted!

Peter Nuttman

Imaging Operations Manager

Presentation Outline

• Imaging Service overview

• Two ED Initiatives

– Improve access to ED Radiology services after-hours

(Jan 2013)

– Reduce after-hours ED CT report turn-around times

(Oct 2013)

• Improving access to MRI services

– Expanding weekend MRI service for Outpatients

(underway)

– Weekend MRI service for inpatients (business case)

Overview • Over 185,000 examinations per annum

• RMH – City Campus

– Main Radiology

– ED Radiology

– Private Imaging

– Department of Nuclear Medicine

• Royal Melbourne Hospital Royal Park Campus

• Over 210 EFT: Radiographers, Nuclear Medicine Technologists, Administrative staff, Radiologists, Registrars, Nurses

• Comprehensive consultative, diagnostic and therapeutic imaging

service for in-patients, outpatients, private and emergency referrals

• 24 hour 7 day a week

• General Radiography, Ultrasound, CT, MRI, Nuclear Medicine,

Mammography, Fluoroscopy, Angiography, Interventional

Radiology, Bone densitometry

Imaging Service

Increasing demand

2007/2008 2008/2009 2009/2010 2010/2011 2011/2012 2012/2013

Total 137,436 155,721 167,503 174,502 181,418 185,239

120,000

130,000

140,000

150,000

160,000

170,000

180,000

190,000

Acti

vit

y

Financial Year

Total Imaging Activity

Total

Activity across the week

for 1 month

Service Demand 24/7

ED Service Demand 24/7

Radiographer After-hours roster

Outline

• Imaging Service overview

• Two ED Initiatives

– Improve access to ED Radiology

services after-hours (Jan 2013)

– Reduce after-hours ED CT report turn-

around times (Oct 2013) • Improving access to MRI services

– Expanding weekend MRI service for Outpatients (underway)


ED Radiology Challenge

• A hospital review was undertaken to determine what improvements needed

to be made across the organisation to support the achievement of the 4

hour National Emergency Access Target (NEAT) of 90% of patients being

discharged from ED in under 4 hours.

• It was identified that Radiology could assist with this goal by reducing

delays outside of normal business hours to access services and for CT

reports to be available.

Adjust Radiographer EFT after-hours to better

match demand to reduce patient delays

accessing services.


Number 1

Analysis of ED CT Procedures Performed per Radiographer per hour

Saturday & Sunday data highlighted (Monday 3rd Sept - Sunday 16th September)

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

0 4 8 12 16 20

Time interval (4 hours)

Pro

ce

du

res

pe

r R

ad

iog

rap

he

r

pe

r h

ou

r

Mon Tue Wed Thu Fri Sat Sun

ED Radiology Challenge - Radiographer resources for CT

Analysis of ED CR Procedures Performed per Radiographer per hour

Saturday & Sunday data highlighted(Monday 3rd Sept - Sunday 16th Sept)

0.0

1.0

2.0

3.0

4.0

5.0

6.0

0 4 8 12 16 20

Mon Tue Wed Thu Fri Sat Sun

ED Radiology Challenge - Radiographer resources for General X-ray

Opportunity • Increase Radiographer EFT after-hours for identified time periods to bring the ratio

(procedures performed per EFT per hour) closer to during business hours to

reduce delays.

Barriers • Funding.

• Business cases for the incremental expansion of ED and Ward services requires

careful consideration of additional resource requirements for support services like

Imaging and Allied Health. Typically this is not something that has been

considered in the past.

Culture • As a general rule additional weekend and night shifts are not popular.

• The solution was to recruit someone who would work the majority of the additional

Friday and Saturday night shift. With the Saturday and Sunday day shifts being

added to the shared roster.

ED Radiology Challenge - Radiographer resources

Costs – Workload analytics invaluable as a way to justify additional EFT.

– Funded as part of the business case for the Short stay Unit expansion from

12 beds to 15 beds.

Outcome – Improved access to Imaging services after-hours

– More sustainable work environment for Radiographers.

ED Radiology Challenge - Radiographer resources for General X-ray


Number 2

Improve CT report turn-around times (TATs) after-

hours to support the achievement of the 4 hour

NEAT target of 90% of patients being discharged

from ED in under 4 hours.

• A Radiology Registrar

is rostered to ED

Radiology 24 hours 7

days a week.

• A Consultant

Radiologist is

rostered to ED

Radiology Monday to

Friday from 0800 –

1700 and Saturday &

Sunday for 9 hours.

• Historical rostering

arrangements no

longer considered

sustainable.

ED Radiology Challenge – Radiologist / Registrar reporting resources

3rd Quartile 2 hour 9 minutes 3rd Quartile 2 hour 55 minutes

Difference

46 minutes


Opportunity • Future Consultant Radiologist EFT requests be used to introduce a 1300 to

2300 shift 7 days a week to match demand.

Barriers • Significant additional funding would be required (2 EFT Consultant Radiologists

with late shift penalties & on-costs).

Culture • Radiologists were not keen at all to work such a late shift.

• Radiology Registrars did not want an additional night shift.

Funding • No new funding was available to increase reporting resources after-hours.


Alternative Proposal / Model • Use the existing external reporting service to report ED CT cases after-

hours rather than introduce a late Radiologist shift.

• No additional funding required.

• Radiology has very successfully partnered with an external reporting

service (Imaging Partners Online) since 2008 to report a mix of non-

urgent and urgent cases (in particular ED CT C-spine clearances).

• Expanding the existing IPO relationship to leverage their established

infrastructure, experience and expertise with supporting hospitals after-

hours made sense to try and sustainably achieve the goal of reducing

report TATs and support the achievement of NEAT within the existing

budget.



After-hours C-Spine Clearance Initiative

Patients requiring a C-Spine clearance when a 1st or 2nd Year Radiology

Registrar is rostered on overnight had to wait until the next day for a

Radiologist to provide a report.

This was because only a 3rd Year and above Radiology Registrar being

authorised to report such cases.

This situation created significant delays before it can be determined

whether or not the patient can be discharged or admitted to the ward. It

also meant that patients unnecessarily often spent an anxious night on a

trolley in ED with a cervical collar on.

After-hours C-Spine Clearance Initiative (continued)

To improve patient care, approval was given in December 2009 to

trial sending after-hours C-Spine clearances to the external

reporting service if a 1st or 2nd Year Registrar was rostered on after-

hours and obtaining a report within the next 2 hours would have a

positive impact on the clinical management of the patient.

The estimated reduction in length of stay as a result of this targeted

initiative was approximately 9 hours per patient.

Although the number of patients that benefit from this initiative are

relatively low (average 20 per month) the improvement in patient

care for those patients impacted by the initiative has been

significant in terms of speed of management decisions, improving

patient comfort, safety and experience.


Other strategic advantages RMH has gained partnering with a

high quality reporting service provider

• Expand services with reporting a variable cost in the early phase.

• Smooth variations in demand, cover unexpected staff shortages or

unfilled vacancies to improve report TATs.


New ED CT after-hours work flow effective from

Tuesday 1st October 2013

• The default position is for all ED referred CT scans completed during the

following periods to be sent to IPO for reporting:

– Sunday to Thursday 1800 – 2400;

– Friday & Saturday 1800 – 0300.

• The proposal will also have a flow on positive impact on report TATs for after-

hours ED CR and Ultrasound reports and non-ED referred urgent CTs, that the

Radiology registrar will now be focusing on after-hours during the defined time

periods that IPO will be used.

• The impact of this initiative on agreed KPIs and workflow will be closely

monitored, with an initial trial period of 2 months.



• Proposal treated as a major change initiative. With wide consultation with

stakeholders (Radiographers, Radiologists, Radiology Registrars, ED Team,

Executive).

• Support from RIS/PACS Manager and team to leverage IT capabilities to:

– Automate a whole series of steps that used to be required for the

Radiographer to send images to IPO to just one field setting in Karisma.

– Developed an IPO ED CT web page that communicates at a glance when

studies have been sent to IPO and reported, including a report TAT.

• Agree on the protocol of what data to send.

• Agree on Quality Assurance and feedback program.

• Success of the trial will be measured by the following KPIs:

– Impact this initiative has on ED reporting TATs.

– Impact this initiative has on non-ED Reporting KPIs.

– Impact this initiative has had on the 4 hour ED discharge target.

– Financial viability of the model.

– ED satisfaction with the new after-hours CT service model.

– Radiologist satisfaction with the new after-hours CT service model.

– Radiology Registrar satisfaction with the new after-hours CT service

model.

– Workflow impact for Radiographers.


• The 3rd Quartile TAT has been reduced by

79 minutes

• 2 hours 56 minutes down to 1 hour 37 minutes

• 3rd Quartile time with Consultant is 2 hours 9

minutes


Summary of outcomes so after 204 cases from the 1st -16th Oct (from time images are available on the IPO Gateway).

Benefits achieved so far • Significantly improved ED CT report TATs after hours that are better than during

hours.

– Delivering better outcome for patients.

• Cost effective.

• Maintain quality

– Australian Doctors reporting in UK, Sydney and Melbourne depending on time

of day.

– Credentialed by MH.

• High staff satisfaction

– Our Radiologists are happy they do not have to work regular night shifts

– Registrars were not interested in working additional night shifts

– Junior Registrars much happier with the arrangement as it reduces stress.

– Radiographers very happy with the new workflow as a result of automating a

whole series of steps to send to IPO.

– ED are very happy with the service provided.


An example of the benefits that might be

achieved by thinking outside the square and

giving serious consideration to totally new

service models after-hours


Outline

• Imaging Service overview • Two ED Initiatives

– Improve access to ED Radiology services after-hours (Jan 2013)

– Reduce after-hours ED CT report turn-around times (Oct 2013)

• Improving access to MRI services

– Expanding weekend MRI service for Outpatients

(underway)


MRI Inpatient & Outpatient

Challenge

• The first step is to make certain there is a very compelling need to

expand inpatient and outpatient services into the weekend.

harder to attract staff to work on a weekend.

penalty rates apply.

• The only Imaging modality with significant access issues at RMH is MRI.

• An incremental targeted approach adopted.

MRI Service Background information

• RMH currently has three MRI scanners.

– 1.5T MRI in RMH Private Imaging

– 3T MRI in Main Radiology

– 1.5T MRI in Main Radiology


Challenge


Challenge

• Demand for MRI services is expected to continue to increase into the

foreseeable future. – No ionising radiation.

– Standard of care for more indications.

– Staged expansion of Medicare rebates, especially to GPs.

• There is also an interest to start offering Cardiac MRI.


Challenge

Plans to improve patient access to MRI services

in the near future

• Installation of a 4th MRI in RMH Private Imaging around November 2014.

• Replacement of the 1.5T RMH inpatient scanner around February 2015, which

will increase access through the productivity and throughput gains that can be

leveraged from technological gains made over the last 20 years.

• Installation of a 1.5T intra-operative MRI in mid 2015


Challenge

Opportunity • It is proposed that MRI services are permanently expanded on weekends to

increase the number of available appointment slots and reduce MRI waiting

lists for both outpatients and inpatients.

• The current long waiting lists for MRI outpatient requests and delays for

inpatients to access services provides the burning platform for change.

Culture • Over the last 2 years extra weekend overtime sessions have been offered for

outpatient cases from time to time (subject to availability of staff) to try and

reduce growing waiting lists.

• This incremental approach is invaluable as logistical challenges for providing a

weekend service have already been addressed and the benefits for patients

well established.


Challenge

Barriers • Need to find a sustainable and acceptable staffing solution for Radiographers,

Nurses, Reception and Radiologists.

Funding • The solution must be at least cost neutral given the current financial climate.

• Private patients that are not bulk billed will help to cover additional weekend

costs.

• Reporting done on Monday to keep costs down.

• Can a service model be developed that is financially viable given the extra

salary & wages costs incurred on a weekend?


Challenge

Key finding:

Additional weekend penalty rates for an expanded MRI service are more than

offset by the following sunk costs.

• Capital investment

– Performing more MRI scans after-hours provides the option for more MRI

scans to be performed with the existing equipment and investment made.

– Delaying investment in an additional MRI ( e.g. $1.7 – $2.5 million depending

on system specifications and options).

• Depreciation of equipment.

– There is no notable additional depreciation incurred as a result of performing

after-hours MRI scans on existing systems.

– Delaying additional depreciation (e.g. $170K per annum)


Challenge

• Depreciation of equipment (continued).

– The 10 year life cycle is determined by the Capital Sensitivity rule, unless a major

upgrade is undertaken that can extend the life by a maximum of another 5 years.

– In addition there is the cost and depreciation of the MRI building / suite itself, with

typical building works costing around $1.5 million.

• Service & maintenance costs

– Additional MRI scans can be performed after-hours without increasing service &

maintenance costs. Saving approximately $170K per annum if instead an

investment was made in another MRI.

• Space costs.

– The Radiology Department and RMH in general is landlocked and has limited

opportunities for further expansion within the current footprint.


Challenge


Challenge


Challenge

Outpatient Proposal

The advantages this MRI weekend Outpatient strategy offers as a result of 3

additional shifts per week include:

• Increased patient satisfaction as a result of:

– Reduced waiting lists, especially for contrast cases.

– Convenience. The option of weekend services is valued by many as

they can fit the appointment around work and other commitments.

– Parking is more readily available and less expensive.

• Increase the number of trained MRI Radiographers and other staff in

readiness for the additional 3T MRI in RMH Private Imaging, iMRI and

cardiac MRI.

• Increased referrer satisfaction, which will assist with retaining market

share and discourage potential competitors from entering the precinct.


Challenge

Advantages of proposal (continued):

• Relatively quick implementation lead time.

• No capital investment required.

• Low risk.

– If for some reason MRI demand decreased, the additional staff that are

employed can be rostered instead on the additional 3T and intra-

operative MRI when operational.

– Some rostered overtime is still being used that can allow future staffing

adjustments to be made to cover any demand fluctuation trends.

• Win – win solution for staff

– Mix of rostered overtime (good for staff who want to earn extra money)

and increasing ordinary hours (good for creating employment

opportunities and building a sustainable MRI service / not burning staff

out).


Challenge


Challenge

Inpatient Proposal


Challenge

Average MRI call out on a Saturday and Sunday for time period highlighted

= 2.1 patients

The advantages this MRI weekend inpatient strategy offers includes:

• Allows MRI service to be extended to the weekend, improving inpatient access

and flow.

• Will reduce the number of weekend on-call requests in the evening to only

those requests that are time critical knowing that a service is offered the next

day.

• Provides a good MRI training environment by having support available for a

less experienced MRI Radiographer.

• If and when there is no inpatient work scheduled the Radiographer can assist

on the 3T MRI or help in ED Radiology.


Challenge


Challenge

• Future consideration will be given to rostering a Monday to Friday shift on the

inpatient scanner from 1.30 pm to 10.00 pm.


Challenge

Next steps for expanding weekend service

Average MRI overtime / call out midweek for time period shown

= 0.8 patients

Next steps for expanding weekend services

• Offering Outpatient CT services at RMH Private Imaging

• Supporting Medicare Locals to reduce ED Admissions

Conclusion

• The case for moving more towards a sustainable 7 day a week imaging service

is very compelling and seems inevitable if the patient is kept at the centre of

decision making. Especially for hospital sites.

• Increasing asset utilisation across 7 days can actually make providing a service

on the weekend financially attractive despite penalty rates and provide a

strategic advantage.

– But ensure productivity is maximised during the week first.

– Explore private patient models to help offset some of the additional salary

& wages costs on the weekend.

Conclusion (continued)

• Establishing the need and burning platform for change is key to gaining

momentum towards a 7 day a week service because it is not necessarily

something the majority of staff will embrace.

• Wide consultation with staff and other key stakeholders is essential to reach a

solution that will work and be sustainable, trying to always find a win-win

flexible solution if at all possible.

• Think outside of the square – as different innovative staffing models may be

required for a 7 days a week service or expanding after-hours. Including

consideration to partner with external providers.

Conclusion (continued)

• An incremental change approach seems to work best in healthcare to:

– Gain momentum for change and as a way of overcoming objections and

barriers;

– Provide time for staff to be involved with the journey, observing early

benefits and providing suggestions for new work processes;

– Greater capacity to deal with unexpected ramifications in an orderly

manner that might otherwise have had the potential to derailed the

initiative.

• Data analysis is key to understanding and building a robust staffing model

and supporting business cases.

peter nuttman, melbourne health: journey towards a 7 day imaging service: challenge accepted!

Health & Medicine