Introduction RADIOLOGY ORIGINAL ARTICLE

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1 bs_bs_banner Journal of Medical Imaging and Radiation Oncology 57 (2013) RADIOLOGY ORIGINAL ARTICLE Measuring and managing radiologist workload: Application of lean and constraint theories and production planning principles to planning radiology services in a major tertiary hospital Sharyn LS MacDonald, 1 Ian A Cowan, 1 Richard Floyd, 2 Stuart Mackintosh, 2 Rob Graham, 2 Emma Jenkins 2 and Richard Hamilton 2 1 Radiology Department, and 2 Business Development Unit, Christchurch Hospital, Christchurch, New Zealand SLS MacDonald MBChB, FRANZCR; IA Cowan MBChB, FRANZCR; R Floyd B App Sci, BSc (Hons), PhD; S Mackintosh BSc; R Graham BSc (Hons); E Jenkins BSc (Hons); R Hamilton BSc. Correspondence Dr Sharyn LS MacDonald, Radiology Department, Christchurch Hospital, Riccarton Avenue, Private Bag 4710, Christchurch, New Zealand. sharyn.macdonald@cdhb.govt.nz Submitted 25 April 2012; accepted 16 May doi: / Abstract Introduction: We describe how techniques traditionally used in the manufacturing industry (lean management, the theory of constraints and production planning) can be applied to planning radiology services to reduce the impact of constraints such as limited radiologist hours, and to subsequently reduce delays in accessing imaging and in report turnaround. Methods: Targets for imaging and reporting were set aligned with clinical needs. Capacity was quantified for each modality and for radiologists and recorded in activity lists. Demand was quantified and forecasting commenced based on historical referral rates. To try and mitigate the impact of radiologists as a constraint, lean management processes were applied to radiologist workflows. A production planning process was implemented. Results: Outpatient waiting times to access imaging steadily decreased. Report turnaround times improved with the percentage of overnight/on-call reports completed by a 1030 target time increased from approximately 30% to 80 to 90%. The percentage of emergency and inpatient reports completed within one hour increased from approximately 15% to approximately 50% with 80 to 90% available within 4 hours. The number of unreported cases on the radiologist work-list at the end of the working day reduced. The average weekly accuracy for demand forecasts for emergency and inpatient CT, MRI and plain film imaging was 91%, 83% and 92% respectively. For outpatient CT, MRI and plain film imaging the accuracy was 60%, 55% and 77% respectively. Reliable routine weekly and medium to longer term service planning is now possible. Conclusions: Tools from industry can be successfully applied to diagnostic imaging services to improve performance. They allow an accurate understanding of the demands on a service, capacity, and can reliably predict the impact of changes in demand or capacity on service delivery. Key words: planning; productivity; radiology; time; workload. Introduction For several years leading up to 2007, our tertiary Radiology service had accumulated large waiting lists for outpatient imaging (with waiting times in excess of 1 year for ultrasound, CT and MRI), and large volumes (up to 1500 cases) of unreported imaging. Delays were contributing to excess bed utilisation, delaying diagnosis and treatment (with associated clinical risk), and were disrupting patient flow through areas such as outpatient clinics. Within Radiology, enquiries relating to the backlog of unreported imaging were resulting in constant interruptions to office staff and radiologists, and negatively impacting on activities such as multidisciplinary team meetings. Servicing a local population base of approximately , as well as taking referrals from a much wider region for specialist services, the service has multiple imaging modalities distributed over three main sites including Christchurch Hospital (approx 650 beds) and 544

2 Planning radiology services the adjacent Christchurch Women s Hospital (approx 130 beds). The Radiology Service has funding for 23 FTE radiologists and 12 registrars, and produces approximately reports per year. Case mix includes non-deferrable acute demand from community, emergency and inpatient services, and community and hospital outpatient work which can be deferred for variable periods of time. In addition to diagnostic reporting, a significant proportion of available radiologist hours are consumed by other non-reporting clinical activities such as interventional and procedural work, multidisciplinary meetings, and teaching. As demand for imaging services increased both in volume and complexity, service planning had failed to reliably predict the staff and machine capacity required to meet demand. Service delivery was poorly coordinated across modalities. In March 2007 the Radiology service began a joint project with the Canterbury District Health Board s (CDHB) Business Development Unit (BDU) targeted at reducing delays to accessing diagnostic imaging services and reducing delays for diagnostic reporting. After establishing machine capacity including agreeing reasonable rates of work (patients or scans per hour) it was quickly identified that limited radiologist hours were the single largest contributor to delays across the service, i.e. radiologist hours were acting as a constraint. The manufacturing industry has considerable experience in on time delivery of services or products, and in dealing with constraints. To optimise their outputs they traditionally leverage the principles of lean thinking (maximising value while minimising waste), the theory of constraints (in summary, the theory is that the rate of achievement of a goal-orientated system is typically limited by at least one constraint, e.g. lack of skilled personnel, that you need to identify and work out how to get the maximum out of the constraint, and need to restructure the rest of a system around it), and production planning processes (these organise the use of resources so that workplace efficiency is maximised). These techniques provide a framework for the systematic review and where required, redesign of work processes. The aim of this study was to investigate if these principles and planning processes could be applied to our radiology service to allow us to minimise the impact of the radiologists as a constraint and make maximum use of available equipment and staff resources to reduce waiting lists and report turnaround times. We required tools to support daily and weekly workload planning, and medium to long-term service planning. Methods Background The BDU team included a project manager, data analysts and production planning engineers who advised and assisted Radiology clinical and administrative staff throughout the project. There were five phases of the project: (i) Understanding radiologist capacity; (ii) setting goals; (iii) setting up production planning tools; (iv) reducing waste and variation for the radiologists; and (v) implementation of production planning. Understanding existing processes To quantify radiologist capacity a relatively complex activity list was created incorporating all of the tasks that are performed in clinical radiology sessions (Table 1). The measures in the radiologist activity list include mean report times for each modality (calculated from radiology information system (RIS) data), and time estimations for non-reporting clinical tasks established through a combination of observation by BDU staff, and radiologist consensus. The non-reporting clinical tasks are grouped as follows; procedure (by type, e.g. interventional, fluoroscopy), advanced diagnostic studies (which allows for activities such as radiologist scanning of foetal hearts, and reviewing imaging on a workstation such as CT colonograms), referral related administration (justification, appropriateness, protocol and triage and scheduling), informal case discussions, multidisciplinary or clinical case review conferences, registrar supervision and teaching or tutorials. For each of the tasks in the radiologist activity list, a corresponding volume (equal to total demand) was entered along with a frequency to describe how often that volume of work is done (e.g. daily or weekly). The activity list was used to calculate the total number of hours of radiologist time required to complete all clinical tasks including reporting, and to calculate how many hours were available for reporting once fixed demand non-reporting type activities such as meetings and procedure work were allowed for. Setting goals Turnaround targets for completing imaging and completing reporting were set after considering how to ensure radiology could positively impact on timely patient care. Referring clinical services were consulted to ensure there was consensus that waiting times were reasonable. The turnaround targets for accessing outpatient imaging, and for report turnaround across all groups were the primary key performance indicators monitored to assess the success of changing our processes. For completing imaging, target times from receiving referral to scheduling were set as follows: emergency and inpatient imaging, immediate or within four or 24 hours (depending on triage category), and outpatient imaging within two days, two weeks or four weeks. For report turnaround, target times from exam completion to report distribution were set as follows: 545

3 SLS MacDonald et al. Table 1. Radiologist activity list with activities undertaken in clinical radiology sessions grouped by type and including associated volume, frequency, time per activity and total time requirements Activity Mean volume Per Number per month Time per activity, minutes Mean hours per day Mean hours per month % of total hours Reporting X-ray 249 Day Reporting CT 54 Day Reporting US 80 Day Reporting MRI 17 Day Reporting mammography 30 Week Reporting fluoroscopy 40 Week Reporting interventional 10 Day Procedure diagnostic 39 Day Advanced diagnostic studies 10.4 Day Procedure Interventional 5.1 Day Procedure fluoroscopy 27 Week Procedure mammography 26 Week Referral related admin 191 Day Informal case discussions 120 Week Conference preparation 49 Week Conference run time 49 Week Registrar, fellow supervision 12 Day Tutorial preparation 9 Week Tutorial run time 9 Week Procedure diagnostic group: time required to review imaging in progress, e.g.: checking of plain radiographs on request by a medical radiation technologist (MRT), checks of ultrasound, CT and MRI while the patient is still on the table. A radiologist interruption occurs in 25% of all ultrasound scans, 10% of all CT and MRI scans, and 5% of all plain radiographs. 15 minutes per interruption (from start to return to previous work state at time of interruption) was allowed based on observation. Advanced diagnostic studies: any procedure or examination which requires active radiologist participation separate from the reporting, but is not interventional, biopsy, problem mammography or fluoroscopy. Examples include ultrasound performed by a radiologist such as foetal heart scanning or intra-operative scanning, or examinations involving a radiologist in workstation time such as CT of coronary arteries, or CT colonography. emergency and inpatient imaging completed during normal working hours one hour, overnight emergency and inpatient imaging, reports distributed by 1030 hours the following working day, and for outpatient imaging, reports distributed within 24 hours. Setting up production planning tools To complete the set up of production planning, work was undertaken to quantify demand, and to set up a master scheduling process (to be used to direct scheduling across the whole department). Quantifying and forecasting demand Historical referral volumes formed the basis of weekly demand forecasts that were implemented for each modality. Using the referral received time stamps in the radiology information system, daily received referral volumes from equivalent periods in previous years were used to populate simple demand forecasts for the current year. Where comparison to actual volumes for a modality for the current year consistently demonstrated growth this was allowed for in the forecast. Care was also taken to allow for special events affecting the rates of referral, e.g. public holidays, again based on historical data. Inpatient and emergency demand was forecast separately from outpatient demand. With radiologists acting as a constraint this enabled the non-deferrable need to image and report now demand to be quantified and allowed for in subsequent planning steps. Master schedule A master schedule was developed (Table 2), which takes the demand forecast for each modality and for the department and translates it into the machine time required for imaging or scanning, and the radiologist hours required for the reporting component. The master schedule derived data were required to support the decision-making processes around setting capacity for each modality. From the perspective of radiologist hours acting as a constraint, it would allow us to quantify the radiologist hours required to enable all the imaging and reporting requirements of the department to be met in any given week, or alternatively, if there were insufficient hours available, it would allow us to establish a workload able to be met with the hours available. Unless additional reporting hours could be recruited either by overtime or outsourcing, maintaining a reasonable workload for the radiologists would require reducing outpatient throughput. Assuming there were at least enough 546

4 Planning radiology services Table 2. Master schedule excerpt for CT Mon Tue Wed Thu Fri Sat Sun Week total Base Total resourced hours Alt hours In Px F/C Resourced capacity Daily forecast profile 16.92% 16.31% 15.74% 16.74% 15.43% 10.56% 8.29% 100% OP F/C In patients forecast Out patients forecast Scan rate Out patients planned Total patients Rpt rate Operating hours Operating hours % of Resourced 95% 95% 95% 95% 95% 145% 138% 100% Waitlist Rptg hours Rptg hours % of total hours 42% 42% 42% 44% 42% 50% 44% 43% Base refers to routine outpatient capacity for the modality. Inpatient (In Px) and outpatient (OP) demand forecasts (F/C) are included along with the rate (in minutes) at which scans can reasonably be completed (scan rate) and reported (Rpt rate). Waitlist indicates the impact on the waiting list of the weeks plan. Demand as a percentage across the week appears as the daily forecast profile. Forecast inpatient demand is combined with planned outpatient demand and multiplied by the scan rate to give the total operating hours required to complete the work. This can then be compared to the resourced hours to determine the percentage of total capacity that will be used. A similar calculation has been done for reporting (rptg) hours. hours to meet emergency and inpatient demand, the impact of reducing outpatient throughput on modality outpatient waiting lists, and required operating hours of a modality, could also be evaluated. Reducing waste and variation To help try and minimise the impact of radiologists acting as a constraint, lean methods were applied to the radiologist work place to ensure they had maximum opportunity to report and were not wasting time on activities that could either be removed or delegated to others. Initiatives included: Creating an optimum work environment that minimised unnecessary disruption to reporting sessions including: Standardising layout of reporting workstations (incorporating occupational safety and health advice on selecting a desk height appropriate for shared use), resolving seating, noise and lighting issues, and maintaining tidy work areas (with the assistance of radiographic assistants). Providing and restocking basic supplies e.g. pens, notepaper, replacement batteries for pagers. Providing up to date versions of commonly used reference materials including telephone lists and radiologist specific resources such as liver segment diagrams and follow-up guidelines. These were initially paper based but have subsequently been transferred onto an in-house developed intranet. Developing an intranet-based Radiologist locator (which utilises RIS login and activity data to locate radiologists), making it easy for Radiologists, radiographers, administrative staff and clinicians to locate their target Radiologists, without interrupting others. 1 Simplifying and standardising protocols and processes around imaging and meetings. Protecting Radiologists from unnecessary interruptions through: Introducing a report hotline to manage report enquiries, including prioritisation of cases for reporting. Nominating an office staff member to work as a radiologist assistant, acting as a single point of contact in the office for radiologists. Ring-fencing protected reporting time from hours daily to clear the overnight/on-call cases. Clinical services were engaged in helping to restrict interruptions in reporting areas to those that were genuinely urgent during this time. Supporting signage was posted outside of reporting areas. Offering morning post-acute conferences for surgery and medicine to act as a single point of interruption for review of acute imaging. Working as a team to achieve continuous flow and meet departmental report distribution targets: To minimise variation in report turnaround times for patients of equal clinical urgency and to try and improve the flow of emergency and inpatients through the imaging and reporting processes, reporting triage was aligned with report distribution targets. Radiologists and Registrars continued to be rostered to their sub-specialty reporting areas however, they were asked to work as a combined diagnostic reporting team, looking at the entire work-list for cases they could report, oldest to newest, in the following order: outstanding overnight/on-call imaging, emergency patients, inpatients, outpatients. 547

5 SLS MacDonald et al. Implementation of production planning The information obtained from the activity lists (used to record machine and radiologist capacity), radiologist roster, demand forecasting and master schedule were then used in combination to plan workload across all modalities in a coordinated manner. Weekly planning meetings and brief daily operational meetings were commenced to support the process. The weekly planning meeting was used to set a work plan a week typically three to four weeks in advance. The meeting group included BDU staff (manipulating data in the master schedule), radiologists, appointments, senior medical radiation technologists (MRT) and nursing staff. During planning, machine capacity in each modality was confirmed or adjusted to allow for any staffing limitations or scheduled servicing. Radiologist roster data (extracted from the Physician Scheduler (Clairvia Inc., Durham, NC, USA) roster program database) was combined with information derived from the radiologist activity list to calculate the actual available reporting hours (total hours less fixed demands such as meetings and procedural work). The master schedule was used to convert the emergency and inpatient demand forecast into the number of machine operating hours required to complete the imaging, and radiologist hours required to report the emergency and inpatient imaging. This time was deducted from the total machine and radiologist hours available. Remaining capacity was available for imaging and reporting outpatients. Where radiologist hours were insufficient to meet total demand and additional hours could not be obtained via planned overtime or outsourcing, and where events that reduce capacity such as service days could not be moved in to a short of hours week, outpatient volumes were adjusted down until a reasonable reporting workload had been set. Decisions to reduce to capacity took in to account relative waiting times across the modalities and were radiologist lead. Results Production planning processes were implemented in Outpatient waiting times steadily decreased with the four-week category ultrasound referrals now waiting four weeks (compliant) and the four-week category CT and MRI referrals currently waiting an average eight weeks. Report distribution/turnaround times improved significantly. In the six months following implementation the percentage of overnight/on-call reports completed by the 1030 hours target time has increased from approximately 30% to between 80 to 90%. The percentage of emergency and inpatient reports completed within one hour increased from approximately 15% to approximately 50% with approximately 80 to 90% available within 4 hours. The number of unreported cases on the radiologist work-list at the end of the working day reduced (Fig. 1) and has consistently been less than 100 cases. For the calendar year 2010, the average weekly accuracy for demand forecasts for emergency and inpatient CT, MRI and plain film imaging was 91%, 83% and 92%, respectively. For outpatient CT, MRI and plain film Diagnos c Worklist Diagnos c Hours 72:00 60: :00 Reports :00 24:00 Hours :00 0 0:00 Fig. 1. Radiologist work-list, total unreported case count and reporting hours at 1700 hours week days prior to and following the implementation of production planning. The case count requiring reports is on the left (blue line), total number of hours of reporting on the right (red line). Both steadily declined (as anticipated) when workload was matched to radiologist hours. 548

6 Planning radiology services imaging the accuracy was 60%, 55% and 77%, respectively. At a total annual level the accuracy of outpatient forecasts for these modalities was 72%, 76% and 82%, respectively. For inpatient demand, the correlations between radiology demand and hospital occupancy or admissions were investigated, but the degree of correlation was found to be less accurate than a forecast based purely on historical referral volumes. Discussion Prior to undertaking this project CDHB Radiology had little or no understanding of capacity available in comparison to capacity required to meet demand for its services, it had poor systems in place for coordinating its complex multimodality department, and had no real performance metrics in place. Service planning was typically based on gut feel rather than on robust data. More often than not, resources required were underestimated, resulting in growth in outpatient waiting lists or reporting work-lists or both. That the radiologists, and in particular their capacity to complete reporting, was quickly identified as the major constraint that was preventing patients from completing their radiology journey was not a major surprise. When radiologists are attending to the multiple tasks required of them in a clinical session, the relatively passive worklist of unreported studies typically takes a back seat to the demands of procedural work, consultation, registrar supervision, multidisciplinary meetings and the like. On reflection the failure to account for all of the tasks that make up a radiologist s workload has been a major contributor to underestimating the radiologist resource requirement in our service planning over many years. As understanding and attempting to mitigate the impact of the radiologists as a constraint became a major focus of the project, the degree to which some of their tasks could be delegated to others or simply cancelled was vigorously explored. Multidisciplinary meetings were controversially targeted in an attempt to boost reporting time; fortunately clinical colleagues and external references such as those published by the Royal College of Radiologists 2 supported that these activities were core to the work of clinical radiologists and eventually allowed the focus to be shifted elsewhere. Lessons were learned about the need to build understanding and acceptance of what makes up the role of specialists in services such as radiology which provide patient care and referring clinician support in ways that differ from most medical and surgical specialties. Alternative ways of delivering a reporting service were considered (protected reporting sessions, duty radiologists) but they did not fit with the subspecialty team based model on which our service is based. Ultimately we believe that the cumulative impact of the work done on reducing waste and variation, including re-engineering reporting processes to better achieve report turnaround targets, has achieved more sustainable improvements in service provision and realised the additional benefit of improving radiologists workexperience. A major benefit of the project was having an accurate and visible picture of demand for Radiology services. Rather than growing our waiting lists as might have been anticipated, the routine use of production planning processes has enabled us to reduce them. Understanding the gap between demand and capacity allowed us to aggressively recruit for the additional hours required on any given week through fee for service reporting and outsourcing (when funding allowed), and if not successful, to juggle what capacity we had to address the areas of greatest need. If we did reduce capacity in a modality then staff in the affected areas were encouraged to run down accrued leave balances, or to plan quality assurance or training activities in any down time (in a busy tertiary setting reducing outpatient capacity rarely results in nothing to image). In recent times our site has been exposed to a series of major earthquakes that have either directly or indirectly affected our emergency, inpatient and outpatient demand. Aggressive monitoring and adjustment for the resulting temporary drop in demand from all sources, coupled with a clear understanding of our capacity, allowed us to systematically plan our way through clearing our remaining outpatient waiting lists. With regard to demand forecasting, our emergency and inpatient demand has proven reasonably stable and therefore predictable. Quantifying this demand and planning work in a coordinated manner ensured capacity was allocated to minimise access delays for these patients. Outpatient demand is less predictable, likely due in part to fluctuations in processes that lead to referrals such as outpatient clinic schedules (which vary for example around school holidays). Given the relative lower acuity of the outpatient demand allows some of it to be deferred, it is less critical that the outpatient forecast is accurate at a weekly level. It is however important that the outpatient forecast is reasonably accurate longer term for service provision and waiting list management. The planning tools have been used to inform medium term (18 24 months ahead) service planning, in particular to look at what our resource requirements will be if demand continues to grow at historical rates. The tools can also be used to evaluate the impact of taking on new work. In conclusion, we have found that the principles of lean management and the theory of constraints along with production planning tools can be successfully applied to diagnostic imaging services to improve performance. Our department now has an accurate understanding of the demands on its service, its capacity, and can reliably predict the impact of changes in demand or capacity on service delivery. 549

7 SLS MacDonald et al. References 1. Rumball-Smith A, MacDonald S. Development and utilisation of a real-time display of logged in radiology information system users. J Digit Imaging 2010; 24: The Royal College of Radiologists. How Many Radiologists Do We Need? A Guide to Planning Hospital Radiology Services. The Royal College of Radiologists, London,