CLINICAL IMPROVEMENT IN RADIOLOGICAL IMAGING SYSTEMS (CIRIS) FINAL REPORT Jamie Weir Clinical Professor of Radiology Aberdeen Royal Infirmary On behalf of the CIRIS Liaison Board for Scotland Edited by Beatrice Cant, NHS QIS Submission date: 3 February 2006 Project Grant-holder: Mr A J Cowles Royal College of Radiologists This project was funded by NHS Quality Improvement Scotland: Project Reference P02/06
CONTENTS 1 INTRODUCTION 2 2 AIMS. 4 2.1 Stage 1 (Year 1).. 4 2.2 Stage 2 (Years 2 & 3). 4 3 IMPLEMENTATION 5 3.1 Implementing CIRIS in all acute Trusts in Scotland.. 5 3.2 Extraction of relevant data. 5 3.2.1 Investigations... 6 3.2.2 Equipment. 7 3.2.3 Staffing.. 8 3.3 Tailoring CIRIS for Scotland.. 8 3.4 Development and use of Web version of CIRIS. 8 3.5 Exploring linkages between relevant bodies... 9 4. DISCUSSION... 9 5. CONCLUSIONS.. 10 6. ACKNOWLEDGEMENTS.. 11 7. APPENDICES.. Appendix I The Benefits of CIRIS.. 12 Appendix II - Composition of CIRIS Liaison Board for Scotland 13 1
1. INTRODUCTION In 1997, the Royal College of Radiologists (RCR), the Society and College of Radiographers (SCR) and a commercial software company (3E Europe Ltd) began developing the CIRIS (Continuous Improvement of Radiological Imaging Services) programme. An initial grant of 250,000 was obtained from the Department of Health to allow a generic software-based system to be developed. After evaluation of the pilot sites, which included the Western General Hospital in Edinburgh, the system was substantially remodelled with a further grant of 250,000 from the Department of Health. The CIRIS programme is a comprehensive system for delivering clinical governance in radiological imaging services and provides a means of auditing these services. CIRIS supports this audit activity by providing each participating institution with a comprehensive model of a radiology service called MOM (Management, Operations and Measurement). The model enables the service to: conduct service improvement audits against standards set by the CIRIS Governing Board for each of the areas covered by MOM identify improvement needs and put together action plans to meet these needs organise all its documentation on policies, procedures, protocols and processes for easy access by staff schedule much of its routine work (such as review of procedures) to ensure that it is done [Source: CIRIS Healthcare Ltd.] Further information on the benefits of CIRIS is given in Appendix I. The programme content of CIRIS is maintained by the CIRIS Governing Board which comprises nominees of the RCR and SCR. In 1997, the Standing Scottish Committee (SSC) of the RCR initiated a comprehensive data gathering exercise to inform policy decisions regarding the provision of imaging services throughout Scotland. Data on workforce issues, workload and equipment was collated. In 1999, the subsequent report from RCR, Workload, Workforce and Equipment in Departments of Clinical Radiology Scotland, identified serious deficiencies in radiological services throughout Scotland. Following production of this report and at the same time that CIRIS was developing in the UK, a working group was established by the Information Services Division (ISD) of NHS National Services Scotland (NSS) to review the collection of national radiological statistics with the main aim of acquiring sufficiently robust data to allow planning of imaging services to be more appropriately managed on a national basis. The committee comprised two ISD members, two radiologists and two business managers together with a lay person to represent patients interests. The results obtained from a paper exercise, and reported by ISD in 2001, indicated a large variation in the ability of individual Trusts to make satisfactory returns. A CIRIS Strategy 2
Group, reporting to the CIRIS Governing Board, was formed in late 2002/early 2003 to review the benchmarking question-set in CIRIS, including a review of the pilot forms used by ISD. With the development of CIRIS and the lack of robust data from the ISD exercise, the Clinical Resource and Audit Group (CRAG) of the Scottish Executive Health Department 1 agreed to fund a three-year national programme to introduce CIRIS into all Acute Trusts in Scotland from April 2002. Funding was made available in two stages, with stage 2 funding dependent upon receipt by CRAG of a report of satisfactory progress in stage 1. Satisfactory progress was defined as a minimum of two-thirds of acute Trusts in Scotland having a fully functioning CIRIS system in operation by the end of month 9 of the project. The provision of national funding allowed all Acute Trusts in Scotland to participate in CIRIS during the 3 years of the project and enabled the collection of national data from radiology departments. From the outset, the expectation was that the continuation of CIRIS in Scotland after project funding ended would be dependent upon individual Trusts entering into individual agreements with CIRIS Healthcare Ltd to continue to use CIRIS. Individual Trusts would therefore have to weigh up the benefits of using CIRIS against the cost of the software licence, estimated as being 150 per radiologist/radiographer per year. The project was overseen by the specially convened CIRIS Liaison Board for Scotland (CLB) (Appendix II) whose purpose was to provide a controlling forum, act as the reference and contact point for outside agencies, and provide the links to the main CIRIS Governing Board, the RCR/SCOG and the software company, 3E (Europe). The CLB was also responsible for ensuring that the information available on CIRIS was appropriate for Scotland. Although much of the documentation, legal statutes, Health and Safety Regulations, ionising radiation legislation, etc, are common to the whole of the UK, some adaptations were required (for example, the inclusion of links to the Scottish Intercollegiate Guidelines Network (SIGN) guidelines). As well as providing a robust means of data collection CIRIS has the potential to lead to improvements in patient care by allowing: standards to be set, measured and improved provision of peer review the management load to be spread throughout imaging departments by increasing the responsibility, education and job satisfaction of all members of a department Trusts to appropriately manage their imaging services The Scottish Executive to plan satisfactorily on the basis of robust information on all aspects of imaging including workforce, workload, equipment, patient waiting times and numbers of patients waiting. 1 CRAG became part of NHS Quality Improvement Scotland (NHS QIS) on 1 January 2003. 3
2. AIMS The overall aim of the project was to improve patient care by improving the management and planning of imaging services through the provision of robust information on all aspects of imaging at local and national level. The project provided the opportunity for all Acute Trusts in Scotland to participate in this project to determine whether the CIRIS programme was an effective tool for this purpose. 2.1 Stage 1 (Year 1) The purpose of stage 1 was to allow CIRIS Healthcare to: 1. Install the CIRIS system in all acute Trusts in Scotland who agreed to participate in the project 2. Provide a national introductory training day for 2 representatives from each participating Trust 3. Provide on-site training and on-going support, on technical and nontechnical aspects of the CIRIS programme, on an individual Trust basis, including: a. Training of CIRIS Co-ordinator in each participating Trust b. Discussion of CIRIS management structure and possible composition of Improvement Monitoring Team (IMT) c. CIRIS induction course for all proposed members of the IMT d. Workshop on the operation of the IMT e. Review of CIRIS programme. 2.2 Stage 2 (Years 2 & 3) The purpose of Stage 2 was to: 1. Continue to implement CIRIS in all Acute Trusts in Scotland with close liaison of trained personnel via the CLB 2. Extract the relevant data as required by the Scottish Executive Health Department (SEHD) and ISD by specifically developing Scottish based programmes under the auspices of the newly formed CIRIS Strategy Group and the relevant CIRIS bodies 3. Inform the CIRIS Strategy Group of the necessary developments for Scotland via the CLB who will also oversee the continuous participation and linkages necessary to inform all users of such development 4. Use the proposed web version of CIRIS to provide dynamic real time access to information and response to Trusts of benchmarking procedures 4
5. Continue to explore the linkages between RCR, standards set by NHS Quality Improvement Scotland, SIGN and other relevant bodies, leading to improvements in clinical care across all Acute Trusts. 3. IMPLEMENTATION 3.1 Implementing CIRIS in all Acute Trusts 2 in Scotland Stage 1 was completed successfully by March 2003, with the involvement of all but two Acute Trusts (Fife, because of a serious staff shortage, and North Glasgow, because of the implementation of a new Radiological Information System (RIS)), and a CIRIS co-ordinator identified in each Trust. In accordance with the agreed funding conditions, Stage 2 funding was therefore released in March 2003. Following a request from SEHD to NHS QIS a further 6 months funding was awarded in February 2005, taking the project end date to November 2005. By the end of year 2, all Trusts except North Glasgow were actively inputting data to the CIRIS system and by the end of the project CIRIS had been introduced into all Acute Trusts in Scotland. The CIRIS system changed to a web-based format about half-way through the project and was constantly in the process of evolution. Towards the end of the grant, a letter was sent to the Chief Executive of each Health Board indicating that CIRIS was changing from a national resource to an independent Health Board resource and asking them to consider funding the continuation of the system in their Health Board. 3.2 Extraction of relevant data In order to test whether CIRIS was capable of supporting the type of national benchmarking exercise required by SEHD (see phase 2 aims), the CLB agreed that two national data collection exercises should take place in November 2003 and May 2004. All Trusts were asked to supply data on various aspects of their radiology/radiography service including personnel, waiting times and waiting numbers, and equipment base. These exercises included data from all Trusts except North Glasgow, which accounts for approximately 20% of the overall workload in Scotland. However, verification was obtained by the CLB that the pattern of responses for North Glasgow would be similar to the rest of Scotland hence the data are considered to be representative of Scotland as a whole. All data collation and analysis was conducted by CIRIS Healthcare. The purpose of the data collection exercises was to ascertain the number of examinations performed and to take two snapshots on single days in the 2 In 2004, Trusts in Scotland were dissolved and replaced by NHS Boards in response to the NHS Reform Act. Although this happened during the lifetime of this project it had no material impact on the use of CIRIS in Scotland. However, as the project was established on the basis of Trust participation, the term Trust has been retained throughout this report. 5
middle of November and May to indicate the number of outpatients on the waiting list and the waiting times relating to specific radiological investigations. The protocol for the second data collecting exercise in May 2004 was modified slightly following analysis of the November 2003 results. Investigations The types of investigations undertaken fell into three broad groups based on the length of time waiting for an appointment and the number of patients involved. These were: 1. Examinations of Magnetic Resonance Imaging (MRI), Computed Tomography (CT) (body and head), general ultrasound, and lower gastro-intestinal (GI) contrast studies (barium enemas). These were by far the most significant in terms of waiting times and numbers. 2. A wide variety of examinations mainly concerned with specific areas of radiology 3. All remaining examinations, without significant waiting times or numbers of patients on the system. In relation to the second group, examinations related to nuclear medicine were not robust enough to produce any significant data because many departments of nuclear medicine were outwith radiology departments and had not been included in the data census. Paediatric ultrasound returns were also sporadic because many departments did not have the ability to differentiate paediatric from general adult examinations and therefore could not extrapolate the figures from their databases into the specific age groupings. The results from both data collection periods were similar. Tables 1, 2 and 3 show the number of examinations conducted, the number of outpatients waiting and the average waiting time for outpatients, respectively, for the two time periods, November 2003 and May 2004. The data shown in Table 1 includes inpatients, outpatients and emergency procedures; the data in Tables 2 & 3 refer to outpatients only. Table 1 - Number of examinations undertaken by selected examination type All sites, November 2003 and May 2004 Examination Totals Examination Type Nov 2003 May 2004 Change % Change Breast imaging (inc. Interventional) 4,160 2,765-1395 -34% CT head and body 11,282 12,942 1660 15% IVU 863 415-448 -52% Lower GI contrast studies 1,998 1,637-361 -18% MRI 4,756 4,567-189 -4% Non-obstetric ultrasound 18,681 19,576 895 5% Nuclear medicine 2,497 2,590 93 4% Paediatric ultrasound 986 680-306 -31% Plain radiography 113,844 120,171 6327 6% 6
Upper GI contrast studies 1104 995-109 -10% Grand Total 160,171 166,338 6167 4% Source: CIRIS Healthcare Table 2 - Number of outpatients waiting by selected examination type All sites, November 2003 and May 2004 Examination Totals Examination Type Nov 2003 May 2004 Change % Change Breast imaging (inc. Interventional) 227 153-74 -33% CT head and body 2,905 2,219-686 -24% IVU 325 155-170 -52% Lower GI contrast studies 1,233 1,234 1 0% MRI 4,906 5,642 736 15% Non-obstetric ultrasound 5,669 6,750 1081 19% Nuclear medicine 596 695 99 17% Paediatric ultrasound 233 348 115 49% Plain radiography 212 358 146 69% Upper GI contrast studies 321 412 91 28% Grand Total 16,627 17,966 1339 8% Source: CIRIS Healthcare Table 3 Average waiting time for outpatients in days by selected examination type All sites, November 2003 and May 2004 Examination Totals Examination Type Nov 2003 May 2004 Change % Change Breast imaging (inc. Interventional) 14 9-5 -33% CT head and body 53 37-16 -30% IVU 23 15-8 -34% Lower GI contrast studies 54 41-13 -25% MRI 114 100-14 -12% Non-obstetric ultrasound 47 51 4 8% Nuclear medicine 42 29-13 -32% Paediatric ultrasound 27 16-11 -40% Plain radiography 5 4-1 -23% Upper GI contrast studies 32 34 2 7% Source: CIRIS Healthcare The results showed that waiting times and waiting numbers continue to be problem areas in radiology with CT, MRI and ultrasound having the longest waiting lists due a combination of equipment and operator limitations. The MRI figures were the worst with an average waiting time of over 100 days and the longest waiting time in any one Trust being a year. Equipment In November 2003, information was collected on the planned replacement date for various types of radiological imaging equipment for the decade from 2004 to 2014. In total, 1,525 pieces of equipment were identified, 22% of 7
which was due for replacement by the end of 2004. For 253 pieces of equipment (16.6% of the total), there was no planned replacement date. The planned replacement date for MRI and CT Scanners is shown in Table 4. Most radiology equipment is asset depreciated over 10 years therefore, in theory, there should only be 10% replacement per year if the replacement targets are being met. Table 4 Planned replacement date MRI and CT Scanners in use at November 2003 and March 2004 Planned Replacement Date Scanner Type/Date None Pre- 2004 2005 2006 2007 2008 2009 2010 2011 Total 2004 MR Scanners Nov 2003 5 3 1 1 2 1 3 2 4 0 22 May 2004 1 0 2 1 0 1 1 2 6 1 15 Change -4-3 1 0-2 0-2 0 2 1-7 CT Scanners Nov 2003 4 2 3 1 1 4 3 5 6 n/a 29 May 2004 0 1 1 2 5 3 4 7 4 n/a 27 Change -4-1 -2 1 4-1 1 2-2 n/a -2 Source: CIRIS Healthcare Staffing Information on radiology department staffing collected in May 2004 showed that there were 823 whole-time equivalent (WTE) radiographers (including sonographers) and 154 WTE consultant radiologists in Scotland (these figures exclude data from North Glasgow Trust which were not available at the time). If the known number of consultant radiologist posts in the North Glasgow Trust is added to the figure, then of the 264.7 WTE established consultant posts in radiology in Scotland, only 200 were filled, a vacancy rate of approximately 24%. 3.3 Tailoring CIRIS for Scotland During the project, the CIRIS Governing Board was restructured with Scottish input as appropriate. The Chairman of the Standing Scottish Committee of the Royal College of Radiologists (Professor Donald Hadley) as co-holder of the project grant and Chair of the CLB, had the necessary linkage through to the RCR and the CIRIS Governing Board to ensure continuity and appropriate action. 3.4 Development and use of web version of CIRIS A new and updated version of CIRIS was made available on the web in September 2003, allowing access via the Internet and removing the need for the system to be installed on a PC. Scottish users were transferred to the new version in October 2003. CIRIS continued to develop new modules and features for users on an ongoing basis. 8
3.5 Exploring linkages between relevant bodies In order to improve access to relevant information, for example, SIGN guidelines, the Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) and the clinical documentation from the National Institute of Clinical Excellence (NICE), web-based products were developed and incorporated into modules in CIRIS during the lifetime of the project. These included an IR(ME)R Service, available from September 2004, aimed at assisting departments in meeting their statutory obligations, and a SIGN Service, available from January 2005, to help departments manage and report on their compliance with radiology aspects of SIGN guidelines. These and other clinical governance aspects of CIRIS were favourably received and used by departments in Scotland. 4. DISCUSSION During the first half of this decade, a number of Trusts and hospitals in England introduced CIRIS into their management system on a commercial basis. In Scotland, the introduction of CIRIS in a non-mandatory way into all Acute Trusts did cause problems which in some Trusts took a considerable amount of time to resolve. Many Trusts felt that the system was for managerial purposes only and required a lot more work with very little immediate return for the individual Trust or hospital involved. A few hospitals had similar systems and did not wish to enter data twice as it was not time effective. On the other hand, some hospitals had used CIRIS before and were impressed by its capabilities not only for operational purposes but also for management and clinical governance issues. By the end of the project, all Acute Trusts in Scotland were using CIRIS, some more than others, and it was enabling the collection of sufficient data to inform a national profile for radiology. The two data collection exercises in 2003 and 2004 showed the potential capability of CIRIS, albeit on a limited level, and the returns highlighted the necessity for improvement particularly in terms of definitions. The need for an adequate radiology information system with nationwide coverage and agreed definitions and application was recognized in the Kerr Report 3 and although...mandatory use of CIRIS was identified as possibly the best option available to NHS Scotland in the short-term, the report concluded that, in the longer term a single, national, clinical information system for all specialties should be the goal for the service. Clinical governance in radiology is an important clinical issue and following the end of the CIRIS project there is now no such national system in place. 3 Building a Health Service Fit for the Future A National Framework for Service Change in the NHS in Scotland, Vol 2 A Guide for the NHS, pp124-125. Scottish Executive, 2005. 9
5. CONCLUSIONS During the 3½ years of the project, CIRIS produced, for the first time, a national profile of radiology services, particularly in terms of an asset data base, patient waiting times and the number of patients waiting for investigations. It also established a national clinical governance framework for radiology services particularly with the later inclusion of IR(ME)R legislation, SIGN guidelines, and NICE guidelines. The degree to which CIRIS improved the management of radiology departments depended upon the amount of enthusiasm for the system within a particular hospital or Trust and the input required for outcomes to be deliverable. Some hospital departments who have used CIRIS have found it beneficial for the management of their particular departments and also helpful in relating their situation to the national profile. At the moment, there is no other national resource capable of performing to the CIRIS level. It may be that the development of a national radiological information system (RIS) together with national roll out of the Picture Archiving Communication System (PACS) and interrogation of these data bases will be sufficient to provide the Scottish Executive with a national radiological profile, but it is likely that a considerable amount of extra work will need to be undertaken to replace the original ISD statistical questionnaire and the information and data gained and stored by CIRIS. Members of the CLB believe that a national system producing reliable information leading to better patient management is desirable. At the moment, although there are unanswered questions about whether CIRIS is capable of performing at such a level, there is no indication of any natural successor. Many lessons were learnt during the CIRIS project, not least the importance of accurate definitions, close liaison between the product specialists and the users and the elucidation of clear requirements in the changing political climate. A significant amount of information was obtained during the course of the project and the development of a national profile for radiology in Scotland was advanced. The two data collection exercises were also shown to be robust. A third data collection exercise was planned for the autumn of 2005 but was not undertaken because of a lack of direction from the various bodies that required information. 10
6. ACKNOWLEDGEMENTS Professor Donald Hadley, Chairman of the CIRIS Liaison Board for Scotland, and the other members of the Liaison Board for their valuable help over the duration of this project. I would especially like to thank Beatrice Cant (formerly of CRAG now of NHSQIS), for all her support and advice and for her help in the production of this report. 11
APPENDIX I THE BENEFITS OF CIRIS Rather than struggling to develop internal solutions for clinical governance in a constantly changing environment, joining the CIRIS community allows radiology services to share knowledge and best practice, and to gather evidence to replace anecdote. CIRIS has been designed to provide small and large radiology services alike with a suite of resources to administer the service efficiently, to plan and deliver change effectively, using professionally set standards. In particular, radiology services will be able to use CIRIS to: conduct audits of their organisational processes, the performance of various aspects of their service, and the quality of their rooms and equipment, all in an integrated way; demonstrate and record clinical improvement actions in an untamperable record, thereby reducing the risk of litigation; maintain records of improvement as part of the ongoing management of their service so that there are fewer disruptive spurts of ddata collection for CHI or other inspection processes; schedule much of their routine work and to bring together all the documents associated with clinical governance activities so that these are readily accessible to staff for consultation and review; spread the clinical governance workload throughout their service to reduce the burden on a few key individuals while at the same time empowering staff, thereby promoting seamless management; obtain more objective evidence to support cases for additional resources and staff; tap into the expertise of others, thereby saving time and effort; share their successes, good ideas and effective practice with others; focus their service on the issues that most affect the efficiency and effectiveness of service delivery; provide realistic service with the resources available. Source: CIRIS Healtcare Ltd, 7 May 2002 12
APPENDIX II COMPOSITION OF CIRIS LIAISON BOARD FOR SCOTLAND The CLB is under the auspices of the Standing Scottish Committee of the Royal College of Radiologists. Professor D Hadley (Chairman) Murray Crichton Dr M Cornbleet Beatrice Cant Jane Chisholm Scott Heald Jamie Weir Graham McKenzie Elspeth Ewing Steve Evans Elizabeth Wise Joanna Wardlaw Charlie Knox (or deputy) Royal College of Radiologists Society and College of Radiographers Scotland Senior Medical Officer, Scottish Executive Clinical Resource and Audit Group/NHS Quality Improvement Scotland Information Services Division (ISD) ISD Statistical Review Group Representatives CIRIS Link Scottish Intercollegiate Guidelines Network (SIGN) Scottish Executive, Information Technology- 13