Bruce Silver, MD

Numerous studies have shown that poorly designed reading rooms reduce radiologists' productivity, contribute to reporting errors, and increase work-related physical injuries. Even so, poorly designed reading rooms continue to be the norm rather than the exception. The following case study illustrates tools and techniques that were used to overcome many obstacles in converting a poor design concept for PACS reading rooms into an excellent outcome in a two-day time period.

Swedish Covenant Hospital in Chicago had ordered PACS equipment, which was only months away from delivery. While an actual design had not yet been created, the vision was to vacate the film file room and install the PACS reading stations within this space. There were no funds to do anything more than minor renovation within the film file room, and no expensive PACS furniture would be acquired.

Due to the short time frame in which these changes had to be made, the hospital engaged Kenneth Johnson, a radiology space planning and workflow consultant, to facilitate the design process. 

Four simple steps were used to facilitate a successful outcome: 

• Form the right team to develop and present recommendations. A common mistake is having only radiologists and radiology department personnel form the group that recommends how to design space within the radiology department. As a result, the recommendations that are presented often are perceived as self-centered. To avoid this concern and, more important, to have the recommendations accepted by administration, the makeup of the team should include other key stakeholders who can speak for the institution.

With this in mind, we made sure the PACS reading room design team for this project consisted of the chief radiologist, radiology administrator, PACS manager, IT director, facility manager, and the consultant who served as facilitator for the design process.

• Start with the big picture. Another pitfall to avoid when designing space is focusing on that area alone, in this case the film file room. One of the first steps the facilitator took was to become familiar with the radiologists' workflow when reading films. A "functional drawing" was then created on which document this workflow (Figure 1). A functional drawing eliminates the grid lines and notes that are typically on an architectural drawing and instead illustrates all casework, furniture, and equipment.

Observations of the workflow within the current department and the use of this drawing led to two conclusions that were immediately obvious to the design team: The film file room would be entirely too small an area to accommodate the number of required reading stations, and the areas in which hard-copy films were currently being read within the department would work well for PACS reading rooms. All of these reading rooms were in close proximity to one another but still allowed privacy. As a result of this realization, the team agreed to recommend that PACS reading stations should be installed in all areas where hard-copy films were read except for location #7, which had been the alternator dedicated to emergency department films. These studies would be read at any PACS station, and this reading station would be eliminated.

One area of concern, however, did surface in analyzing the impact of installing PACS reading stations within the current reading rooms. The size of three of the areas in which radiologists were currently reading films (4, 5, and 6 in Figure 1) was quite small, and the workspaces would be tight if PACS reading stations were installed in them. This concern was noted and addressed later in the day.

• Create mockups of your design. One of the most important steps the facilitator coordinated was the creation of a full-scale mockup of an ideal PACS reading station. A common misconception is that mockups are expensive and time-consuming to create. As illustrated at Swedish Covenant, however, this need not be the case. The mockup was created within a few hours at no cost, and it proved to be invaluable in helping the team achieve its goals.

To create this full-scale mockup in such a short time, we scavenged the department to find as many components as possible. A table was found that was similar in size to what was considered ideal for the actual work surface of the PACS station. To illustrate the concept of a "cockpit" design that enables the radiologist to work at peak efficiency, we used masking tape to mark the desired contour of the front edge of the workstation. Other components that were collected in the quick scavenger hunt included a monitor, keyboard, and telephone. Cardboard boxes were used to simulate components that could not be located.  

Once the mockup of a PACS reading station was created, a number of radiologists, the PACS manager, and the hospital IT director sat at the console and simulated the actual reading process. This exercise resulted in three significant outcomes: The design was refined. The IT director better understood the complexity of the design of a PACS workstation and the value in being able to adjust the height of the work surface. And the IT director agreed to recommend to senior management that customized PACS furniture would be purchased for all reading rooms. PACS furniture was no longer labeled "expensive," it was now being recommended as a good investment.

In parallel with creating the mockup of the PACS reading station, the facilitator created a template for a PACS reading station from a bed sheet. The chief radiologist, hospital facility manager, and facilitator then walked through each of the locations where a PACS station was to be located. Trying to find a way to position this sheet in reading areas 4, 5, and 6 (Figure 2) made it obvious to all team members that these rooms would be extremely-if not unacceptably-tight spaces in which to work (left). In discussing various options to resolve this situation, the facility manager noted that the walls within this space could be removed at very little cost and three nice-sized reading rooms could be created within this space (right). The facility manager agreed to present this recommendation to senior management later in the day. 

• Gain funding approval. Good ideas are worth nothing unless they are approved. A noon meeting on the second day had been scheduled for the facilitator to present his initial observations to senior management and the design team. Instead of the discussion being dominated by the facilitator, however, all team members actively participated. Many visual aids were used to illustrate the basis for the recommendations. 

A PowerPoint presentation was first used to show photographs of good reading room designs and pitfalls to avoid. Slides of the functional drawing were used to illustrate why it would not be feasible to convert the film library into a PACS reading ballroom and that, instead, reading stations should be installed in areas where films were currently being read.

Radiologists and the director of IT then used the mockup of the PACS reading station to illustrate the needs of a radiologist to work effectively and efficiently for extended time periods at such a station. The result of this demonstration was that senior management approved funding for the acquisition of customized PACS furniture. 

The final issue that was discussed in this meeting was concern regarding the small size of reading areas 4, 5, and 6. The facility manager presented the changes that he recommended could be made at very little cost and would greatly improve the working conditions within these rooms (Figure 2). As a result of his presentation, funding to make these improvements was also approved by senior management.

Keys to developing a better design and having it accepted by senior management include use of a skilled outside facilitator, creation of the right team, and use of mockups to refine and present concepts. As illustrated in this case study, it is possible to make significant changes well into a project-even after many people feel the project is past the point of no return, when plans have been finalized, no more funding is available for any further changes, and so on. The key is to use whatever tools and techniques will best demonstrate the value of optimizing designs and workflow in a way that senior management will understand, encouraging them to approve changes that should be made.


Hedge A. Reading room ergonomics. Orlando: Presentation at 2005 meeting of Society for Computer Applications in Radiology. 
Nagy P, Siegel E, Hanson T, et al. PACS reading room design. Sem Roentgenol 2003;38(3):244-255.
Siddiqui MK, Chia S, Knight N, Siegel E. Design and ergonomic considerations for the filmless environment. JACR 2006:3:456-467.
Siegel E. Effect of ergonomic factors on medical image perception. Chicago: Presentation at 2007 meeting of RSNA.

Dr. Silver is chief radiologist at Swedish Covenant Hospital in Chicago, and Mr. Johnson is president of Kenneth Johnson and Associates in Columbus, OH.

Articles

Numerous studies have shown that poorly designed reading rooms reduce radiologists' productivity, contribute to reporting errors, and increase work-related physical injuries. Even so, poorly designed reading rooms continue to be the norm rather than the exception.

Bruce Silver, MD

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