Management tools assist in reducing queues in U.K.

November 5, 2004

Radiologists in the U.K. are successfully deploying management tools to shorten waiting lists and improve efficiency in their departments, as part of a government-funded modernization program. Strategies for maximizing efficiency, including tools tested in government service redesign pilot projects, were presented at a British Institute of Radiology meeting in September.

"If you want to change a department, how do you get people to change the way they have been operating for the last 20 years?" asked Dr. Robin Evans, national clinical lead for radiology service improvement at the government's Modernisation Agency.

But change appears to be long overdue. The government has identified radiology as a vital component in patient care but also as a major bottleneck that causes lengthy waiting times, poor communication, and lack of certainty and choice. Its new booklet, Modernising radiology services: a practical guide to redesign, offers spreadsheets and tips for helping departments run more smoothly, based in part on experience with pilot sites.

Overall, 32 radiology sites-equivalent to 8% of all U.K. departments-have participated in service improvement schemes, and the program may be expanded in the future. Twenty-two sites took part in the most recent phase, for which results were reported this summer. Of these, 15 sites achieved a 50% reduction in waiting times in one or more modality, and two pilot sites achieved a 90% reduction in waiting times for one or more modality.

"We have been able to achieve improvements in waiting times in most modalities and now have data to support bids for new resources," said Evans, clinical director of radiology at Mayday University Hospital in Thornton Heath.

As part of the 18-month program, the hospital was assigned a project manager to oversee service improvement. Measurements of capacity, including staff and room time, versus demand for imaging services have proven particularly useful in identifying inefficiencies that cause study backlogs. Although the waiting list for fluoroscopy was equivalent to 11,000 minutes, a capacity and demand analysis indicated that the facility had more capacity than it needed.

"We thought that if we had a long waiting list, it must be because there was too much work. It wasn't true, and that is often the case," Evans said. "Generally speaking, though, if demand is greater than capacity, you can say to management, we cannot win this situation; we need more resources."

By making processes more efficient, staff were able to reduce the fluoroscopy waiting list dramatically. The picture was different in ultrasound, where the waiting list was much higher, at 40,000 minutes. In that case, a capacity/demand analysis showed that capacity was lower than demand. The data helped justify the purchase of a new ultrasound system and an extra part-time radiologist.

The hospital benefited from reviewing its imaging study waiting lists. The lists included many patients who had recovered and no longer needed a study and others who had opted to use a private facility rather than wait. The backlog has decreased gradually, partly due to validation of the waiting list. Process mapping, in which staff take time out from their work to fully analyze all steps involved in provision of radiology services, has also proved useful at Mayday.

"When you look at every step of the process, from the referral to getting the report out, it is amazing what you discover in inefficiencies. It takes a while to pick things up that you can change and improve," Evans said.

Before the service improvement program was introduced, getting a radiology report typed took from two days to a week. After this inefficiency was highlighted, the department purchased a digital dictation system that reduced turnaround time to the targeted 24 hours, with no additional transcription staff.

In its report, A Guide to Good Medical Practice for Clinical Radiologists, published in May, the Royal College of Radiologists stressed the importance of timely and accurate reports.

"I believe that films should be reported within 24 hours. That is crucial to the practice of radiology," said Prof. Philip Gishen, clinical director of imaging at Hammersmith Hospitals Trust in London. "There is no magic person coming down from the heavens to do reporting. It is an essential part of our job."

The current trend in some hospitals almost appears to be to delegate reporting duties to whoever will accept them, which is often radiographers and nurses. Gishen, however, has implemented a system that requires radiologists, including senior team members, to report at set times. Doctors are required to fill hourly slots for reporting as part of the system, which has helped hospitals meet the 24-hour turnaround target in most cases. With the timetabling system, if a radiologist is unexpectedly called away on a particular day, a colleague has to cover only one hour of work.

"Everybody has to be on board if you are making a timetable. It will not succeed if it is top down. Timetabling needs to be fair," Gishen said.