- Email: [email protected]
Benchmarking of radiological processes
International Congress Series 1268 (2004) 361 – 365
www.ics-elsevier.com
Benchmarking of radiological processes D. Weseloh a,*, K. Reiff a, S. Braitinger b b
a Siemens AG, Medical Solutions, Erlangen, Germany Radiologische Gemeinschaftspraxis, Schießstattweg 60, 94032 Passau, Germany
Abstract. A consortium benchmarking project was conducted with the participation of 15 radiology departments in Germany. The process parameters including cycle time, process time, and process cost for staff, were measured along the process chain, for pre-defined reference workflows. Furthermore, profiles of the radiology departments were acquired, including their technological and organizational specifics. The measured parameters were then correlated with the institutes’ profiles. As a result, economical benefits of technological solutions like electronic scheduling or speech recognition software could be assessed. D 2004 CARS and Elsevier B.V. All rights reserved. Keywords: Best practice; Radiological process model; Process cost; Cycle time; Benchmarking; Patient throughput; Radiology; Workflow model; Patient satisfaction; Radiological processes
1. Introduction RIS/PACS solutions with different integration levels have been implemented in thousands of radiological departments around the globe with the main goal to create a more efficient environment, to speed up processes, to save costs, to experience higher satisfaction levels of patients and staff and for many other reasons. Interestingly the focus from industry as well as from the end user has been mainly on the technical features of the RIS/PACS solution rather than on measurable process outcomes of the solution [1]. The quality of the radiological workstation, the newest hardware for storage, the ability to retrieve and distribute images, results and system stability over time are practically seen as the main factors for the desired outcome. Standard communication protocols like DICOM or HL 7 are an enormous step forward for a defined and controlled data flow, but were is a benchmark of what one wants to achieve as a desired outcome, what is best practice, when looking at the processes or sub-processes? Every radiological department is a unique environment. Comparing different already digitized solutions at various radiology departments to define a best practice workflow should offer useful information for the designer and the user of a RIS/PACS solution. * Corresponding author. E-mail address: [email protected] (D. Weseloh). 0531-5131/ D 2004 CARS and Elsevier B.V. All rights reserved. doi:10.1016/j.ics.2004.03.343
362
D. Weseloh et al. / International Congress Series 1268 (2004) 361–365
If one could define an ideal process for e.g. scheduling of exams or reporting, this could contribute to more examination over time and higher satisfaction, by fast distribution of images, and thereby earlier diagnosis and therapy. 2. Methodology To generate the necessary data for the identification of the best practice elements, 15 radiological departments in Germany and Siemens have founded a project group. The method of choice being identified was a process benchmark between the parties involved, all being equipped with a RIS/PACS solution (in one case, the RIS system was not in use). The parties involved were four university hospitals, six county hospitals, three private practices, and two small hospitals in conjunction with a private radiologist. See also Table 1. The project team conducted a consulting group that normally performs process benchmarks for industries and is well respected. The project team also wanted to have somebody involved with an independent view on the processes. During the project it proved to be valuable having a combination of experts on product and workflow on one hand and people that understand the methodology of process benchmarking on the other hand. The measurements were done on six predefined examination types, which are performed regularly in the participating radiological departments. They served as reference workflows for later comparison: 1. Standard X-ray of a mobile patient: wrist or ankle in two levels 2. Standard X-ray of a immobile patient: abdomen in two levels Table 1 Technological profiles of project participants Type
No. PACS
University Hospitals
Big County Hospitals
Integrated Practices
Practices
a
RIS
HIS
E.I.D.a Org. specifics
SAP/ISH
yes
1
Siemens GAP
2 3 4
Siemens Medos SAP/ISH yes Siemens Innomed SAP/ISH no AGFA on-site dev. SAP/HR3 yes
5 6 7 8 9 10 11
Siemens Siemens Siemens Siemens Siemens Siemens Siemens
12 13 14 15
Clinicom GWI Medico SAP/ISH GWI GWI Micom
no yes yes yes yes yes yes
Siemens MacDoc
Medico
yes
Siemens GAP Siemens GAP AGFA GAP
– – –
yes no no
Electronic image distribution.
WRAD – Medos ITB Medos GAP GAP
Techn. specifics
decentral, one electronic dictation, unit assessed teleradiology teleradiology decentral teleradiology decentral, one unit assessed
teleradiology teleradiology speech recognition, electronic request, teleradiology decentral, one teleradiology unit assessed teleradiology speech recognition
D. Weseloh et al. / International Congress Series 1268 (2004) 361–365
3. 4. 5. 6.
363
Chest exam on the ward in bed CT examination of a mobile patient: head or chest with pathology MR examination of a mobile patient: head (oncology) Fluoroscopy of a mobile patient: esophagus or phlebography
The measurements were performed on the process chain from the examination request to the delivery of report. They comprised the length of all process steps with involvement of the patient or the patient’s image and text data, as well as significant time spans like from request to examination, or from examination to report delivery. The lengths of the individual process steps were then used for retrospective calculation of staff related process cost, by multiplication the time values with the cost per time unit derived from the individual salary. The time values were assessed in interviews with the personnel usually involved in the corresponding process step, i.e. radiologists, technicians, typist, and secretaries. Three to five people were asked to estimate the length of each process step, based on their daily experience. Above this, satisfaction values from patients, staff, and referring physicians were obtained in interviews. 3. Results 3.1. Time span and process cost for examination request Fig. 1 shows the time span and the associated costs for the process step from request to completion of the scheduling procedure. Stationary and ambulant cases were considered in respect to their relative weight; the same applies for the various examination types. Hospitals obviously have higher time and cost values than private practices. This is explainable due to the higher complexity level of stationary cases.
Fig. 1. Time span and process cost for examination request.
364
D. Weseloh et al. / International Congress Series 1268 (2004) 361–365
Differences in the time/cost relation are mainly not caused by differences in the individual salaries. The dominant factor here is the involvement degree of registration staff, technicians, radiologists, and staff from the wards in clarification activities and information exchange. The best practice representative is the integrated practice No. 11 with 1.5 min average processing time, and 0.30 o associated costs, whereas other hospital radiology generate costs of up to 5.50 o, for this process step. The main reason found for these significant differences were the communication requirements between the requesting party and radiology. By using an electronic examination request (as part of the RIS) the time needed for institute No. 11 was considerably lower. The result mentioned above was achieved with a combination of an electronic request with mandatory fields to be filled out, so that no or minimum time was needed for the clarification process between the parties. The other institutes suffered of illegible referral slips and missing information, leading to avoidable communication steps and information exchange iterations. 3.2. Process time for reporting We investigated the process time for reporting an oncology MR head examination. This process time reaches from invoking the patient’s text and image data at the reporting workplace, to the delivery of the report. Radiologists and typist are involved in these process steps. See Fig. 2. University hospitals No. 1 and No. 2 had considerably longer process times for the radiologists, due to their educational position leading to intense involvement of assistant physicians in the reporting process. Thereby these values do not indicate shortcomings in the process. Again the integrated practice No. 11 represented best practice process implementation. An obvious explanation for this is the use of speech recognition software, in combination
Fig. 2. Process time for reporting a standardizes MR examination.
D. Weseloh et al. / International Congress Series 1268 (2004) 361–365
365
with self-correction. No. 11 was the only department in the consortium with such an implementation. The self-correction made time-consuming correction cycles with the typist obsolete. In addition to this time (and cost) reduction, reports were completed earlier and generally sent to the wards on the same day. The other radiology departments used traditional tape dictation, digital dictation, or speech recognition without self-correction. In all cases, we observed time-consuming correction cycles and turnaround times of usually one or more days. 4. Conclusion When comparing good and poor IT process implementations in radiology and their impact on staff cost, one comes to relatively small amounts of money, usually in the area of a few Euro. However, considering 100,000 procedures per year, this amount is equivalent to the salaries of several employees. Normally, this potential cannot be converted into a real plus in the budget, however it clearly shows the workload that can be taken away from the shoulders of the personnel, leading to increased quality of work and higher satisfaction of staff. When one wants to improve radiological work processes, benchmarking can help to reveal potential for enhancing efficiency, either by specific organizational measures, or by developing IT based solutions. Indeed, integrated RIS/PACS solutions can have a significant impact on the workflow. This process benchmark in this document has demonstrated specific points of improvement. The methodology is a valuable help for both the industry in designing workflow solutions as well as for the radiology institutes in optimizing their individual workflows. Reference [1] Y.-Y. Shieh, G.-H. Roberson, Integrated radiology information system, picture archiving and communications system, and teleradiology—workflow-driven and future-proof, Journal of Digital Imaging 12 (2 Suppl. 1) (1999 May) 199 – 200.
www.ics-elsevier.com
Benchmarking of radiological processes D. Weseloh a,*, K. Reiff a, S. Braitinger b b
a Siemens AG, Medical Solutions, Erlangen, Germany Radiologische Gemeinschaftspraxis, Schießstattweg 60, 94032 Passau, Germany
Abstract. A consortium benchmarking project was conducted with the participation of 15 radiology departments in Germany. The process parameters including cycle time, process time, and process cost for staff, were measured along the process chain, for pre-defined reference workflows. Furthermore, profiles of the radiology departments were acquired, including their technological and organizational specifics. The measured parameters were then correlated with the institutes’ profiles. As a result, economical benefits of technological solutions like electronic scheduling or speech recognition software could be assessed. D 2004 CARS and Elsevier B.V. All rights reserved. Keywords: Best practice; Radiological process model; Process cost; Cycle time; Benchmarking; Patient throughput; Radiology; Workflow model; Patient satisfaction; Radiological processes
1. Introduction RIS/PACS solutions with different integration levels have been implemented in thousands of radiological departments around the globe with the main goal to create a more efficient environment, to speed up processes, to save costs, to experience higher satisfaction levels of patients and staff and for many other reasons. Interestingly the focus from industry as well as from the end user has been mainly on the technical features of the RIS/PACS solution rather than on measurable process outcomes of the solution [1]. The quality of the radiological workstation, the newest hardware for storage, the ability to retrieve and distribute images, results and system stability over time are practically seen as the main factors for the desired outcome. Standard communication protocols like DICOM or HL 7 are an enormous step forward for a defined and controlled data flow, but were is a benchmark of what one wants to achieve as a desired outcome, what is best practice, when looking at the processes or sub-processes? Every radiological department is a unique environment. Comparing different already digitized solutions at various radiology departments to define a best practice workflow should offer useful information for the designer and the user of a RIS/PACS solution. * Corresponding author. E-mail address: [email protected] (D. Weseloh). 0531-5131/ D 2004 CARS and Elsevier B.V. All rights reserved. doi:10.1016/j.ics.2004.03.343
362
D. Weseloh et al. / International Congress Series 1268 (2004) 361–365
If one could define an ideal process for e.g. scheduling of exams or reporting, this could contribute to more examination over time and higher satisfaction, by fast distribution of images, and thereby earlier diagnosis and therapy. 2. Methodology To generate the necessary data for the identification of the best practice elements, 15 radiological departments in Germany and Siemens have founded a project group. The method of choice being identified was a process benchmark between the parties involved, all being equipped with a RIS/PACS solution (in one case, the RIS system was not in use). The parties involved were four university hospitals, six county hospitals, three private practices, and two small hospitals in conjunction with a private radiologist. See also Table 1. The project team conducted a consulting group that normally performs process benchmarks for industries and is well respected. The project team also wanted to have somebody involved with an independent view on the processes. During the project it proved to be valuable having a combination of experts on product and workflow on one hand and people that understand the methodology of process benchmarking on the other hand. The measurements were done on six predefined examination types, which are performed regularly in the participating radiological departments. They served as reference workflows for later comparison: 1. Standard X-ray of a mobile patient: wrist or ankle in two levels 2. Standard X-ray of a immobile patient: abdomen in two levels Table 1 Technological profiles of project participants Type
No. PACS
University Hospitals
Big County Hospitals
Integrated Practices
Practices
a
RIS
HIS
E.I.D.a Org. specifics
SAP/ISH
yes
1
Siemens GAP
2 3 4
Siemens Medos SAP/ISH yes Siemens Innomed SAP/ISH no AGFA on-site dev. SAP/HR3 yes
5 6 7 8 9 10 11
Siemens Siemens Siemens Siemens Siemens Siemens Siemens
12 13 14 15
Clinicom GWI Medico SAP/ISH GWI GWI Micom
no yes yes yes yes yes yes
Siemens MacDoc
Medico
yes
Siemens GAP Siemens GAP AGFA GAP
– – –
yes no no
Electronic image distribution.
WRAD – Medos ITB Medos GAP GAP
Techn. specifics
decentral, one electronic dictation, unit assessed teleradiology teleradiology decentral teleradiology decentral, one unit assessed
teleradiology teleradiology speech recognition, electronic request, teleradiology decentral, one teleradiology unit assessed teleradiology speech recognition
D. Weseloh et al. / International Congress Series 1268 (2004) 361–365
3. 4. 5. 6.
363
Chest exam on the ward in bed CT examination of a mobile patient: head or chest with pathology MR examination of a mobile patient: head (oncology) Fluoroscopy of a mobile patient: esophagus or phlebography
The measurements were performed on the process chain from the examination request to the delivery of report. They comprised the length of all process steps with involvement of the patient or the patient’s image and text data, as well as significant time spans like from request to examination, or from examination to report delivery. The lengths of the individual process steps were then used for retrospective calculation of staff related process cost, by multiplication the time values with the cost per time unit derived from the individual salary. The time values were assessed in interviews with the personnel usually involved in the corresponding process step, i.e. radiologists, technicians, typist, and secretaries. Three to five people were asked to estimate the length of each process step, based on their daily experience. Above this, satisfaction values from patients, staff, and referring physicians were obtained in interviews. 3. Results 3.1. Time span and process cost for examination request Fig. 1 shows the time span and the associated costs for the process step from request to completion of the scheduling procedure. Stationary and ambulant cases were considered in respect to their relative weight; the same applies for the various examination types. Hospitals obviously have higher time and cost values than private practices. This is explainable due to the higher complexity level of stationary cases.
Fig. 1. Time span and process cost for examination request.
364
D. Weseloh et al. / International Congress Series 1268 (2004) 361–365
Differences in the time/cost relation are mainly not caused by differences in the individual salaries. The dominant factor here is the involvement degree of registration staff, technicians, radiologists, and staff from the wards in clarification activities and information exchange. The best practice representative is the integrated practice No. 11 with 1.5 min average processing time, and 0.30 o associated costs, whereas other hospital radiology generate costs of up to 5.50 o, for this process step. The main reason found for these significant differences were the communication requirements between the requesting party and radiology. By using an electronic examination request (as part of the RIS) the time needed for institute No. 11 was considerably lower. The result mentioned above was achieved with a combination of an electronic request with mandatory fields to be filled out, so that no or minimum time was needed for the clarification process between the parties. The other institutes suffered of illegible referral slips and missing information, leading to avoidable communication steps and information exchange iterations. 3.2. Process time for reporting We investigated the process time for reporting an oncology MR head examination. This process time reaches from invoking the patient’s text and image data at the reporting workplace, to the delivery of the report. Radiologists and typist are involved in these process steps. See Fig. 2. University hospitals No. 1 and No. 2 had considerably longer process times for the radiologists, due to their educational position leading to intense involvement of assistant physicians in the reporting process. Thereby these values do not indicate shortcomings in the process. Again the integrated practice No. 11 represented best practice process implementation. An obvious explanation for this is the use of speech recognition software, in combination
Fig. 2. Process time for reporting a standardizes MR examination.
D. Weseloh et al. / International Congress Series 1268 (2004) 361–365
365
with self-correction. No. 11 was the only department in the consortium with such an implementation. The self-correction made time-consuming correction cycles with the typist obsolete. In addition to this time (and cost) reduction, reports were completed earlier and generally sent to the wards on the same day. The other radiology departments used traditional tape dictation, digital dictation, or speech recognition without self-correction. In all cases, we observed time-consuming correction cycles and turnaround times of usually one or more days. 4. Conclusion When comparing good and poor IT process implementations in radiology and their impact on staff cost, one comes to relatively small amounts of money, usually in the area of a few Euro. However, considering 100,000 procedures per year, this amount is equivalent to the salaries of several employees. Normally, this potential cannot be converted into a real plus in the budget, however it clearly shows the workload that can be taken away from the shoulders of the personnel, leading to increased quality of work and higher satisfaction of staff. When one wants to improve radiological work processes, benchmarking can help to reveal potential for enhancing efficiency, either by specific organizational measures, or by developing IT based solutions. Indeed, integrated RIS/PACS solutions can have a significant impact on the workflow. This process benchmark in this document has demonstrated specific points of improvement. The methodology is a valuable help for both the industry in designing workflow solutions as well as for the radiology institutes in optimizing their individual workflows. Reference [1] Y.-Y. Shieh, G.-H. Roberson, Integrated radiology information system, picture archiving and communications system, and teleradiology—workflow-driven and future-proof, Journal of Digital Imaging 12 (2 Suppl. 1) (1999 May) 199 – 200.