Clinical operations management in radiology

Clinical Operations Management in Radiology Silvia Ondategui-Parra, MD, MPH, MSca,b,c, Ileana E. Gill, MDa, Jui G. Bhagwat, MBBS, DPH, MPHa, Lisa A. Intrieri, MD, MBAa, Adheet Gogate, MBBS, MPHa, Kelly H. Zou, PhDa, Eric Nathanson, MBAa, Steven E. Seltzer, MDa, Pablo R. Ros, MD, MPHa

Providing radiology services is a complex and technically demanding enterprise in which the application of operations management (OM) tools can play a substantial role in process management and improvement. This paper considers the benefits of an OM process in a radiology setting. Available techniques and concepts of OM are addressed, along with gains and benefits that can be derived from these processes. A reference framework for the radiology processes is described, distinguishing two phases in the initial assessment of a unit: the diagnostic phase and the redesign phase. Key Words: Operations management, radiology, redesign process J Am Coll Radiol 2004;1:632-640. Copyright © 2004 American College of Radiology

INTRODUCTION Operations management (OM) is “a scientific approach to problem solving for executive management” that encompasses the effective (doing the right thing) and efficient (doing things right) control of organizational processes [1]. Operations management can be used in virtually any organization that is striving to achieve its objectives and improve performance. Although OM today follows differing philosophies, tools, and methods, all forms of OM have the common goal of facilitating the managerial decision-making process. It enables an organization to solve problems and find optimal solutions. Operations management tools are used in almost all industries and businesses today to minimize costs while optimizing performance and improving quality [2]. Today, with increasing demand, rising costs, and decreasing reimbursements, it is crucial to use OM to better manage services. To survive the competitive pressures, Department of Radiology, Brigham and Women’s Hospital, Boston, Massacusetts. a Radiology Management Group, Department of Radiology, Brigham & Women’s Hospital, Harvard Medical School b Department of Health Policy and Management, Harvard School of Public Health c Hospital Administration, Brigham and Women’s Hospital, Harvard Medical School Corresponding author and reprints: Silvia Ondategui-Parra, MD, MPH, MSc, Department of Radiology, Brigham and Women’s Hospital, One Brigham Circle, 1620 Trenton Street, Boston, MA 02120-1613; e-mail: [email protected].

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health care organizations need to provide high-quality services at lower costs, which in turn depends on the abilities and skills of managers to design processes, deploy resources, and control performances [3]. To apply the principles of OM to the field of radiology, it is necessary to gain a better understanding of the concepts and methodologies used. The objective of this paper is to provide an overview of the key concepts of OM and the application of these techniques to improving performance in radiology. CONCEPTS AND BENEFITS OF OM The field of OM gained importance during World War II, when it was used by the American military for the deployment of weapons, fuel allocation decisions, and the planning of attack strategies and troop movements [1]. After the 1950s, OM underwent fundamental changes, from a product-focused scientific technique to a service-oriented methodology [4, pp. 20-131]. Industries observed that OM could be a substantial source of competitive advantage to provide better services, use fewer resources, and reach markets faster. However, the health care sector did not see the need to improve its efficiency until the 1980s, when managed care competition and federal and local reimbursements reforms presented a serious financial challenge to medical institutions and service departments [5]. The need to apply modern logistics or operations concepts in radiology was not initially in high demand, with abundant resources, high cash flow, and nonexistent competitive pressures [6]. Today, with the extraor© 2004 American College of Radiology 0091-2182/04/$30.00 ● DOI 10.1016/j.jacr.2004.04.015

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dinary growth in the field of radiology, the steady rise in imaging costs, and imaging’s central role in clinical practice, an efficient and competitive radiology service needs to improve its operational and business performance, understand the shifting market reality, and learn to refocus. Adopting the managerial skills of OM to bridge the gaps between traditional and modern radiology helps achieve this goal [7-11] by focusing on the analysis of processes, quality of standards, and operating strategy to facilitate executive decision making. Operational decisions are made in support of business strategies [11]. Radiology administrators who are inexperienced in process management and redesign systems may resolve operational problems within their departments by several ineffective strategies: (1) identifying and cutting costs without deeply understanding the problems within the system, (2) adding information systems and additional medical equipment to the existing systems, or (3) imposing higher performance standards and holding employees responsible for meeting those standards (e.g., by tying bonuses to performance, without a system redesign). The current environment requires a step-by-step change in the way departments operate. Simply building on an existing system of suboptimal work practices will not lead to an improvement in performance. It is only through a systemic change, with the participation of all stakeholders and informed by the demands of patients and referring physicians, that higher levels of performance can be attained [12,13]. The redesign process should be a systemic study of departmental activities to find an optimal way to eliminate problems. It involves the integration of the overall strategy of a radiology department with the day-to-day operations and the department’s current operation design. It captures operations process improvement, with the idea of reinventing the process to dramatically improve performance [14]. Finally, because operational improvement is itself a continuous process, it leads to improved systems and processes. Significant improvements such as (1) more efficient resource use, (2) a greater capability to manage and reduce variability in operations, and (3) an enhanced ability to adapt to changing circumstances can be gained from a redesign. These improvements in decision making, system coordination, and process control have a direct impact on patient safety. A more coordinated system that has various operations under a high level of statistical control is less likely to cause mistakes, thus resulting in a higher quality of care. PHASES OF SYSTEMIC REDESIGN IN A RADIOLOGY DEPARTMENT Systemic redesign requires the involvement of all key stakeholders in a department, including radiologists,

technicians, nurses, schedule coordinators, managers, and patients. The process can be carried out in two phases: (1) the diagnostic phase, which focuses on creating a baseline by assessing the current state of operations and conducting a gap analysis by comparing the current state to the best practice in the industry, and (2) the redesign phase, which focuses on setting best practices within the context of the specific department and testing by the implementation and continuous evaluation of the new operations design (Fig. 1). The Diagnostic Phase The diagnostic phase develops the case for action. The outcomes of this phase are (1) a shared vision statement and analytic results that provide direction for change; (2) the identification of the areas for improvement and intervention; (3) maps of current process flows and bottlenecks, as well as critical activities in the flow; (4) agreement on a set of critical performance metrics and performance standards; and (5) hypotheses for improvement. Overall, the diagnostic phase involves understanding what the process does, how and why it does it, how effectively it works, and how it might be improved. It specifies the current performance in the context of the mission of the department and the services it provides to customers and establishes the gap between expectations and outcomes. The diagnostic phase thus provides the platform for the redesign [16,17, pp. 138-150]. Baseline: Establish the Current State of Operations. It is important to establish a baseline because most members of a department have only a partial sense of the system they are involved in, determined by their positions, roles, and locations. Infrequently, they are unaware of or take for granted bottlenecks and delays that from their local perspectives are minor nuisances (e.g., a patient is not sufficiently prepared at the inpatient unit for an examination) but from a system perspective have a significant impact on overall delivery and performance (e.g., the schedule gets thrown off). Baseline measurements are indispensable to assess the future effects of changes. Moreover, to analyze a department’s operating process, its workflow diagram or process map needs to be explored (Fig. 2). The department’s tasks, flows, queues, and decision points are diagramed, mapping the process from the beginning to the end. Information to construct the workflow diagram should be derived from interviews of “customers”: the patients, referring physicians, and payers, as well as from process workshops composed of workers of various functions of the radiology department [15]. Process maps are needed for the different imaging

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Process redesign

Redesign phase

Diagnostic phase

Gap analysis

Establishment of baseline

• Assess gap (fail points) between current and expected performance

• Understand the department’s operations and current performance

• Identify opportunities for improvement and intervention

• Define and map the work flow process

Setting best practice

Implementation and evaluation

• Within the specific context of the radiology department

• Implement change and continuously monitor outcome of action

• Account for variability

• Redefine model

Tools

Tools

Tools

Tools

• Workflow diagram • Interviews with nurses, techs, physicians • Capacity/use analysis • Performance analysis

• Performance standards • External benchmarking

• Redesign teams and leadership team • Queuing theory, linear programming, network project, inventory • Simulation models • Statistical methods

• Implementation plans/timelines • Dashboard/balanced scorecard

Fig. 1. Operations management scheme for process redesign.

Patient entry

• • • • •

Image acquisition

Order entry/scheduling Patient preparation

•

Examination protocols

• •

Prior study retrieval (hard copy or electronic [PACS]) for comparison

•

Patient access/transport

Patient identification confirmed. Images acquired Images distributed to physician workstation for interpretation

Results

• • • •

Image interpretation Transcription Edit and verification Results distribution

Procedure room cleanup

Start Imaging request

End Patient arrives in the radiology department

Images distributed to physician workstation

Results in the hands of the referring physician

Fig. 2. Radiology department diagram. PACS ⫽ picture archiving and communication system.

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WORK CENTER 2

Services seen by patients

Technologist performs the study

Patient leaves unit table

Patient arrives with medical history on hand

Determination of protocol examination

Radiologists review results

WORK CENTER 1 WORK CENTER 3

Unit secretary requests appointments from radiology scheduling central department (24 hours in advance)

Radiologists perform dictation

Services unseen by patients

Image results

Fig. 3. Radiology department unit work centers.

modalities, as well as inpatients, outpatients, and emergency department patients. If the diagram is being constructed to analyze and improve a particular aspect of the workflow, each step within that aspect can be broken down into further detail. For example, a blueprint model can be used to provide a detailed outline of an inpatient unit’s workflow process (Fig. 3). A blueprint model identifies parts of the service, such as the transcription of images, that patients, payers, and physicians do not see (invisible tasks). It uses a line that separates the visible from the invisible tasks [18]. Once the process flow diagram is constructed, the focus of analysis, or “operating unit,” can be identified. Depending on the level at which the analysis is being done, the operating unit can vary. For example, if the workflow of a hospital is being analyzed, the radiology department can represent the operating unit. In this case, appointments and patients represent the operating unit inputs and the imaging films and written reports the outputs. Similarly, if a radiology department is being analyzed in the diagnostic phase, then any one of the modalities, such as magnetic resonance imaging (MRI), can be the operating unit. Within an operating unit, the various processes are carried out by people or equipment

(called work centers) in a particular order (known as routing). For example, in an MRI unit, an inpatient examination is conducted in the following order (routing): (1) scheduling by the secretary (work center 1), (2) image taking by technologists (work center 2), and (3) the reading of images by radiologists (work center 3) [19]. During any given diagnostic imaging procedure, different processes routed through particular work centers will use some of the department’s capacity. A work center “run time” represents the time period consumed by each work center capacity, the “setup time” corresponds to the time period needed to prepare patients or the facility for the job (in an MRI unit, technicians require an average of 5 minutes for a patient to change out of street clothes and 5 minutes to prepare the patient to have the image taken), and the “machine constrained time” is the time used by the equipment for a given examination. The capacity of the operating unit can then be described as the available operating hours per period of time on the basis of equipment constrains and labor run time. Therefore, the time requirements of a working center must be analyzed for run time, setup time, and machine (scanner) constrained time. Once the operating unit’s processes are identified and

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its capacity evaluated, the performance of the unit can be assessed in multiple dimensions. Measures of costs, use, delivery, the variability of imaging modalities and protocols, quality, and customer satisfaction depend on the department’s overall strategy. For a particular radiology subunit, the department’s strategy will define the metrics used for performance assessment. A radiology operating unit performance can be assessed in terms of (1) technical staff members’ productivity: assessing the percentages of technologists’ workdays that are spent on “productive work”; (2) capacity use: evaluating the percentage of available capacity that is actually used; (3) the staffing-to-demand ratio: providing the ratio of full-time equivalent inputs to specific demands to determine whether or not resources are effectively allocated; and (4) skill mix analysis: looking into staff members’ activities and determining if they match their skill levels. A focus on the “customers” also helps develop an endto-end view of the process, from the moment a referring physician orders a study to the moment he or she receives a report. The time between these points is a key indicator of overall performance. This type of analysis can thus serve as the baseline to drive the process of operational redesign at the system level. Gap Analysis. Having diagrammed the processes in a radiology service, along with a previous set of performance metrics and indicators, a manager can now easily identify where the system might not flow. By assessing the gap between current and expected performance, fail points can identified to improve the delivery of service. External benchmarking and comparison of the current operation’s performance to the agreed best practice or standard for a department can also identify specific opportunities for improvement. However, because no two radiology departments are completely alike, unique characteristics of a department under analysis should be integrated into the department’s new vision. The best standard for any radiology department is the comparison of its past and present performance to the new performance to be achieved. These overall performance indicators and the metrics used to measure them will later become the basis for a “dashboard.” A dashboard, much as in a car, is a set of indicators that provide a comprehensive snapshot of all ongoing departmental activities [15,20]. Thus, at the end of the diagnostic phase, the key groups in a department will have a grounded sense of the operations of the department that makes redesign feasible and implementation possible. The Redesign Phase The redesign phase is the process of restructuring departmental operations to overcome the problems identified

in the diagnostic phase. The outcomes of this phase are (1) the establishment of performance standards for the department and (2) the implementation of the redesigned processes along with continuous performance evaluation. Once a department’s operational processes are known and fail points are identified, the process of rethinking and restructuring the department begins. Reengineering (or redesigning) means to start from the beginning with a clean sheet in terms of how to design the department to better serve customers. A key element in this redesign phase is to focus on processes rather than individuals. The inputs of all ground-level employees, including radiologists, technologists, nurses, administrators, auxiliary staff members such as transcriptionists and patient transporters, and front-line staff members such as receptionists, are critical; they have the most knowledge that will help in the redesign [21,22, chap. 9;23]. Setting Best Practice. Setting the best practice should be done within the specific context of a particular radiology department, with its inpatient and outpatient base and its referring physicians. For instance, a department’s technologists may have taken medical education courses, resulting in capacity reduction, or the department may service a patient base that is disproportionately dependent on particular payers, such as government-subsidized payers. These specific circumstances must be taken into account [24]. Typically, the redesign is conducted by several redesign teams whose work is coordinated by a leadership team [25]. Members of the redesign teams must obtain and deliver continuous reorganization information to the remaining departmental staff members. Radiologists have realized that merely adding more work practices, processes, and technologies to the existing operations does not fundamentally redesign them. In fact, existing inefficiencies may be prolonged, amplified, and reinforced. Thus, in a redesign process, particular attention must be given to how the inpatient and outpatient flow interact, its time, volume, and type of diagnostic imaging variability [26]. Variability can become an obstacle for a successful redesign process. Imaging patients have a wide array of diseases as well as differences in severity and diagnostic alternatives for the same disease (clinical variability). In addition, there is a random scheduling of appointments in radiology departments (flow variability), and among health professionals and health providers, there is variability on the techniques requested (professional variability). Thus, the proper identification of variability is crucial in the efficient operation of a radiology department. For example, depending on the clinical variability of patients and the number of machines, it may make sense

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to allocate inpatients and outpatients to separate procedure rooms. To account for systemic fluctuations in a radiology department and to establish successful operation processes, various descriptive statistical methods and simulation models can be used. Linear programming, network theory, queuing theory, and inventory management are relatively simple and very powerful techniques in radiology OM. Linear programming addresses the optimal number of units (e.g., patients) respective to a specific program. It is used whenever a linear function is characteristic of the process. Network programming can be used to choose the best pathway to follow a process among multiple path options. Finally, queuing theory encompasses the nature of a queuing (waiting line) system by examining its performance and type, aspects of the system that can be altered by managers, and tools available to predict the system behavior. The queue behavior can be measured depending on the particular managerial system faced: waiting time, length of the queue (numbers of patients waiting), service times (rate of service), total time in the system, facility use, and others. Different type of queues, such as single-stage systems (parallel, multichannel, and multiline) and multiple-stage systems, have different levels of complexity and consequently simple and complex formulas that can be used. Modeling techniques can be used to accurately predict the success of complex redesign processes [27]. Implementation and Evaluation of Design. With a new and detailed redesign process, it becomes possible to actually implement changes, because members have now visualized new ways of working together. Implementation plans have to be drafted with specific activities to be undertaken, with milestones and a timeline. Roles have to be redesigned and a redesign project leader in the department has to monitor the progress and intervene when progress stalls. The project leader helps create conditions in which redesign is not a one-time event but becomes a way of life necessitated by the changing environment of health care and the introduction of new technologies. Key assessment metrics used to monitor the redesign process are to be expressly chosen or even developed to obtain the required feedback for continuous performance improvement. The goal of continuous improvement presents radiology senior leadership with the task of constantly checking a department’s design and providing the organization with a circular model of design-redesign-implementation-design processes. REENGINEERING AN MRI SECTION: A CASE EXAMPLE USING THE OM METHOD Suppose that the radiology department of a large teaching hospital is planning to review its MRI unit process

with the objective of increasing access. The OM method (redesign processes) can be applied to the MRI section as follows. The Diagnostic Phase A steering committee composed of file clerks, technologists, managers, radiologists, and referring physicians of the MRI unit will initiate and plan the redesign process. Patients’ input will be obtained from a previous survey of patients’ satisfaction with the department’s MRI unit. The current state of the MRI unit process will be addressed through an end-to-end mapping of the process, with a validation of accuracy by all departmental stakeholders (Fig. 4). The MRI unit’s capacity and performance analysis will be conducted through data collection using several variables: (1) examination volume, (2) days to fifth available appointment, (3) time from request to completion of an examination, and (4) cost per relative value unit. Descriptive analyses and comparisons of means and proportions by Student t tests may be performed to identify fail points. The Redesign Phase After identifying key bottlenecks, the steering committee will be able to determine opportunities for process enhancement. Suppose that two bottlenecks are identified in the diagnostic phase (Fig. 5). Thus, two individual teams will be responsible for resolving each of these bottlenecks: team 1 will improve protocol issues, and team 2 will improve the late arrival of scheduled inpatients. Benchmarking for this department will be another key activity at this point in the project. The committee will need to identify academic radiology departments in the area with similar volumes, equipment, and quality of services to set performance standards. The implementation of the redesign will be scheduled to achieve different goals through a predetermined timeline. Each team will need to prepare and implement solutions for the identified bottlenecks within the established timeline. For example, team 1 can identify the process of incorrect or delayed protocols and offer the following solutions: (1) establish an electronic entry of protocol, and (2) mandate the immediate entry of protocol on receipt of a request into appropriate categories. Similarly, team 2 can analyze the reasons for the late arrival of scheduled inpatients and recommend increasing the number of transporters in the hospital. The periodic and ongoing assessment of key performance indicators helps reveal the continued gains in the process. Follow-up surveys of referring physicians, radiologists, technologists, and clerks can develop ideas and suggestions that will contribute to the continuous refinement of the process. Three months after the implemen-

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Patient transportation

Fig. 4. Magnetic resonance imaging (MRI) unit flow chart.

Verify fact sheet

Patient arrival in MRI unit

Patient preparation Image acquisition

Prior study retrieval and examination protocols

MRI unit cleanup

Order entry/scheduling

Image interpretation

Radiology department central transcription site

Results distribution

Request for MRI Protocol entered by radiologist

Bottleneck #2: patient transportation

Patient screening

Patient preparation/transportation

Scanning

Patient leaves gantry Fig. 5. Magnetic resonance imaging (MRI) operating unit bottlenecks.

Bottleneck #1: protocol issues

Ondategui-Parra et al./Clinical Operations Management in Radiology 639

tation of the process modifications is completed, changes in the baseline variables can be evaluated. Thus, improvements in the process can be assessed.

crucial in the current economically challenging environment faced by radiology departments. GLOSSARY

CONCLUSION Operations management focuses on the analysis of processes, the quality of standards, and operating strategy to facilitate the managerial decision-making process. Through operational processes analysis, an organization becomes able to solve problems and find optimal solutions. The benefits of an operational redesign process are multiple. It includes an increased operational efficiency, with increased staff productivity, improved capacity use, and the superior delivery of services. Moreover, OM decreases operating costs, with an additional increase in revenue and volume. Overall, OM offers high satisfaction among staff members, who thus experience a greater sense of personal engagement and fulfillment, which is essential for the change to flow quickly and successfully. However, within OM, there are obvious challenges to overcome. Nowadays, any organizational change triggers the fear of job loss. Involving people to be aware of the inadequacy of the current operations often goes a long way for changes. It is crucial that all employees be involved in the diagnostic phase for data collection and in the redesign phase for data analysis and the implementation of changes. For OM to succeed, it is most important for the employees on the ground level to be actively involved. A second challenge is the limited time availability of department members. Again, by involving the members, they will begin to acknowledge that the current system is inadequate and that some investment on their part will lead to improvement in performance. Finally, an overall lack of buy-in may occur, and the senior management has to take the lead by engaging members in the actual work. Here, it is worthwhile to mention that the senior leaders need to rely on data analysis to propose changes in the operations. If the executives make the decisions without analytical backing, then true change usually does not occur, because of the introduction of individual biases. This may eventually lead to the failure of the OM plan. For the plan to succeed, the leaders must assume the role of monitors of the developed plan to ensure that it is followed, continuously reevaluated, and supported by all employees [28,29]. Overall, the process advocated here helps a department’s senior leadership break the vicious cycle of imposing performance standards without redesign, leading to increasing frustration and demoralization among employees and increased attrition. The operational and financial gains achieved by a successful redesign process are

Machine constrained time. The time required by the machine or scanner in a particular routing of jobs. Operating unit. Corresponds to the focus of the analysis. The focus might be at different levels: a computed tomography unit in a radiology department, an entire radiology department, or even an entire health facility. Run time. The sum of the times required to complete the work for each task. Setup time. The time necessary to prepare for a job and to clean up after the job is completed. The setup time is independent of the number of items in the batch. Work centers. Within an operating unit, particular kinds of transformation operations are performed by people or pieces of equipment called work centers, in a particular order called routing. All steps in a routing can be associated with an identifiable work center. Workflow diagram. A workflow diagram illustrates the components of a process analysis. A department’s tasks, flows, queues, inventories, and decisions points are diagrammed, mapping the process from the beginning to the end. It provides managers with a way to visualize a process and to define and manipulate it at arm’s length. REFERENCES 1. Wagner H. Principles of management science with application to executive decisions. Englewood Cliffs (NJ): Prentice Hall; 1970. 2. Krajewski L. Operations management strategy and analysis. 4th ed. Reading (MA): Addison-Wesley; 1996. 3. Henderson M. Operations management in health care. J Health Care Fin 1995;21(3):44-8. 4. Davis M, Aquilano N, Chase R. Fundamentals of operations management. 3rd ed. New York: Irwin McGraw-Hill; 1999. 5. Forman H. Cost, value, and price: what is the difference and why care? Radiology 2001;218:25-6. 6. Mango P, Shapiro L. Hospitals get serious about operations. McKinsey Q 2001;2. 7. Johnston R. Service operations management: return to roots. Int J Operations Production Manage 1999;19(2):104-16. 8. Poudevigne G. Planning the radiology department of the future. Available at: http://www.ahra.com. 9. OECD data show health expenditures at an all-time high. Available at: http://www.oecd.org. 10. Chan S. The importance of strategy for the evolving field of radiology. Radiology 2002;224:639-48. 11. Development stage company website with overview United States Diagnostic Imaging expenditure data. Available at: http://www.imageanalysisinc.com. Accessed: January 30, 2003. 12. Ling X. The impact of strategic operations management decisions on community hospital performance. J Operations Manage 2002;20:389408.

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