The shared radiology workflow consists of physician’s referral, study approval, scheduling, patient arrival, imaging, reporting, validating, and results distribution. The performance of this process can be measured on different levels: resources utilization, current operations, and outcomes. The end-result of the process is defined by the goal, which can also vary. The major goals are effectiveness (e.g. high-quality, high-safety, high-volume, high-accessibility services, patients’ and physicians’ satisfaction), efficiency (cost-effectiveness, cost-control, revenue generation), and health improvement (better treatment because of accurate diagnostics, less morbidity and mortality because of early diagnostics). The problem with the radiology services is that we often incorrectly measure incorrect metrics. Wherever we see systematic measurement of results in health care—no matter what the country—we see those results improve (R.S. Kaplan, M.E. Porter). Hence, we should move from current radiology operational metrics (report turn-around-time, back-log time, discrepancies, equipment utilization rate, revenue) to clinical operational metrics (diagnosis-related delays of treatment, time to begin treatment) and outcome measurements (patients’ and clinicians’ satisfaction, gross margin of services, involvement in disease-specific clinical teams, better treatment because of accurate diagnostics). The best method for tackling ‘bottlenecks’ is time-driven activity-based costing (TDABC) through better resource utilization, standardized processes, proper staffing, and logistics optimization. Building an enabling IT platform is the key for embedding the changes in the system. Ideal physician measurements are aligned to electronic data collection, attributable to individuals, cascade from organizational goals, supported by evidence and physicians, comparative, and transparent.

1. Prof. Sergey Morozov
MD, MPH, PhD
EuSoMII President
How to identify
radiology productivity
bottlenecks?
PIER @ ECR’17 – March 3 – Vienna

2. 1. To review the metrics of shared radiology workflow in
the domains of efficiency, quality and safety – what?
2. To demonstrate various methods and techniques for
total productivity improvement – how?
3. To delineate team roles in productivity improvement
cycle – who?
Agenda

3. Radiology department =
= System thinking
3

4. The activities chain of radiology
4
Improving a process does not mean to obtain better outcomes.
A chain of activities that an industry performs to deliver a
valuable product or service is called a "value chain"
from Boland GW, GSRQS 2015
Referrer Scheduling Protocol
ProcedureReportingDistribution
§ Customized service
§ Patient safety
§ Throughput
§ Imaging
Technology
§ Anatomic
§ Functional
§ Data mining
§ Oncology-standard
templates
§ Decision support
§ Second opinion
§ Route
§ Urgent
§ Feedback
§ Appropriateness
§ Utilization
§ Decision Support
§ Exam time and location
§ Pre-procedure process
Actionable
report

5. Strategic goals of Radiology
1. Selection criteria
2. Equipment
3. Patient routing
Access1. Number of sites
2. Number of specialists
3. Satisfaction
Quality &
Safety
1. Standards
2. Peer-review
3. Training
Costs
1. Reimbursement rates
2. Additional budget
AccessCosts
Details Standards
Methods
1. Imaging protocol
2. Reporting template
3. Terminology
1. Scheduling interval
2. Report turnaround time
3. Required number of specialists
”AS IS”
1. Access – X
2. Quality - Y
3. Early Dx – Z
4. Costs - M
”TO BE”
1. Access – 2X
2. Quality - 3Y
3. Early Dx – 2Z
4. Costs - M
Strategy
Tactics
Operations
5
ACTION PLAN
Early Dx
Early Dx
Quality&Safety

6. Recipe for failure
6
Engage
multiple
interconnected
parts
Start with
a complex
system
Pay
irrespective
of level
of quality
Adopt
a culture of
individualism
Resist
standardization
Operate
24/7

7. “Bottleneck theory”
§ Equipment
§ Process
§ People
§ Materials
§ Environment
§ Management
§ Strategy
§ Resources
§ Motivation
§ Data collection
and analysis
(esp. manual)
7

8. How to tackle the bottlenecks?
§ Standardizing the processes
§ Increasing qualification of employees
§ Minimizing downtime, setup and changeover
time
§ Eliminating non-value activities = calculate
costs at the point of care
§ Provide a constant buffer stock upstream =
supplies and consumables
8

9. 9

10. Administrative functions
Lost time:
- Oversized time
slots
- Waiting for
emergent
patients
Patient
preparation
Side
activities
Waste
‘Muda’
Preparations Scan
Total
observation
time
Admin. fx Patient
wait
Effective
time
Patient
prep.
Contrast
injection
Patient
departure
Scan
“Motion Study” of CT technician
10

11. The best method for tackling ‘bottlenecks’
§ Time-driven activity-based costing
(TDABC) through
§ better resource utilization
§ matching of personnel skills to tasks
§ locating care in the most cost-
effective type of facility
§ Results in 25% savings
of costs
11

12. The biggest problem with health care
isn’t with insurance or politics.
It’s that we’re measuring the wrong
things the wrong way.
by Robert S. Kaplan and Michael E. Porter

13. Outcome
27%
Most common:
Peer-review metrics
Quality metrics
Narayan, A., Cinelli, C., Carrillo, J. A., Nagy, P., Coresh, J., Riese, V. G., & Durand, D. J. (2015). Quality
Measurements in Radiology: A Systematic Review of the Literature and Survey of Radiology Benefit
Management Groups. Journal of the American College of Radiology, 12(11), 1173-1181.
1861 papers reviewed
75 unique quality metrics categorized
Structure
46%
Most common:
Facility accreditation
Process
27%
Most common:
Appropriateness
13

14. Ideal Physician Measures
14
§ Cascade from organizational goals
§ Selected and supported by physicians
§ Be attributable to individual physicians
§ Comparative and transparent
§ Align to electronic data collection

15. Balanced Scorecard-Outpatient
15

16. Watson Clinic in Lakeland, USA, 2006
The measurement phase of the
project:
§ Patient backlog for CT was at four
days.
§ Room schedule varied by up to 40
percent a day.
§ Patient throughput was at two
per hour per CT.
§ Half of the exams were starting
15 minutes late or later.
CT Project Results
§ CT backlog reduced to one day
§ 90 percent of exams start on time
§ 40 percent increase in CT capacity
§ Dashboard implemented
§ Increased outpatient volumes
to 3.3 patients/hour
§ Financial potential ~ $674,000
over one year
Lean techniques (value stream mapping) and Six
Sigma DMAIC (Define, Measure, Analyze, Improve,
Control) for analyzing and adjusting processes.
A comprehensive dashboard to monitor eight
operational and financial metrics on a monthly basis.
16

17. § Assessment Unit Urgent CT Scans performed
and reported within 4 hours
§ Assessment Unit Routine CT Scans performed
and reported within 24 hours
§ Assessment Unit Routine Ultrasound Scans
performed and reported within 24 hours
§ Assessment Unit Requests received same day
§ CT Scans performed within 24 hours of receipt
of request
§ MRI Scans performed within 24 hours of
receipt of request
§ ED Urgent CT Scans performed and reported
within 1 hour
§ ED CT Scans performed and reported within 3
hours
§ X-Rays Scans performed within 24 hours of the
receipt of request
§ Nuclear Medicine Scans performed within 2
days of receipt of request
§ CT Reports issued on same day as scan
§ MRI Reports issued on same day as scan
17

18. Patients’ satisfaction measurements
HOW TO GET A 5 STAR
RATING AS AN UBER DRIVER
18

19. Reports and ratings
Healthcare
facility
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
For
CMO
Head of radiology department
Healthcare
Department
One of results:
Avg. report turnaround time
decrease by 80% (from 53 to 8
hours)
TAT CT QIV’15
TAT CT
QI’16
CHANGE
19

20. Ratings’ role in management
20
Heads of departments
and CMOs have
sporting/competing
interest
Achieving
excellent results

21. While health care organizations have never
been against improving outcomes, their central
focus has been on growing volumes and
maintaining margins
21
M.Porter, HBS

22. 22
https://hbr.org/2016/11/4-steps-to-sustaining-improvement-in-health-care
A radiology service might be a good initial candidate for the pilot unit
for engaging and standardizing the work of frontline managers =
technicians and nurses.
HBR. 4 Steps to Sustaining Improvement
in Health Care
Kedar S. Mate, Jeffrey Rakover, November 09, 2016

23. “Doing more
with less”
= efficiency
Elton Mayo (1880-1949):
- Human relations movement
- The Hawthorne Effect
- Importance of human interaction and
morale for productivity
William Worrall Mayo
(1819–1911)
23

24. Strategic radiology challenge
§ Clinical operational metrics
§ diagnosis-related delays of treatment
§ time to begin treatment
§ Outcome measurements
§ patients’ and clinicians’ satisfaction
§ gross margin of services
§ involvement in disease-specific clinical teams
§ better treatment because of accurate diagnostics
24

25. Doctors-executives
§ Operations management and execution
§ Many clinicians fail to appropriately distinguish
between urgent tasks and important, non-urgent
tasks - prioritize
§ People leadership
§ Learn how to give negative feedback
§ Setting and defining strategy
§ CIO: “Chief - it's not our business – officer”
© Shahar Waiser, Gett
25
https://hbr.org/2015/04/the-skills-doctors-need-to-be-effective-executives

26. Take-home points
§ Define the purpose of process or improvement
§ Measure significant quality metrics
§ Make metrics actionable
§ Apply IT platform after establishing the
processes
§ Select and develop people - “quality pioneers”
and change managers
26

27. WWW.EUSOMII.PRO