Service improvement for radiologists


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Service Improvement for Radiologists
a signposting document summarising service improvement methodology and benefits

Success factors - general
Success factors - computerised tomography

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Service improvement for radiologists

  1. 1. NHS Radiology Service Improvement Team Service Improvement for Radiologists a signposting document summarising service improvement methodology and benefits November 2007Endorsed by: NHS NHS Delivering the 18 Week Cancer Services Collaborative Patient Pathway ‘Improvement Partnership’
  2. 2. READER INFORMATIONPolicy EstatesHR/Workforce PerformanceManagement IM & TPlanning FinanceClinical Partnership WorkingDocument Purpose Best Practice GuidanceROCR Ref: Gateway Ref: 8959Title Radiology Service Improvement: a signposting document summarising service improvement methodology and benefitsAuthor NHS Radiology Service Improvement TeamPublication date 12 November 2007Target Audience NHS Trusts CEs, StHAs CEs, Foundation Trusts CEs, Allied Health Professionals, Consultant Radiologists, Performance Directors.Circulation List Service Improvement Personnel, Allied Health Professionals Medical Directors, Consultant Radiologists.Description This signposting document has been written by Radiologists for Radiologists. The document summarises service improvement methodology and benefits and draws on learning from hospitals across England to help deliver timely and effective imaging services.Cross RefSuperseded Docs N/AAction Required N/ATiming N/AContact Details NHS Radiology Service Improvement Team 3rd Floor, St John’s House, East Street, Leicester, LE1 6NB Tel: 0116 222 5122 Web: www.radiologyimprovement.nhs.ukFor Recipient’s Use
  3. 3. Service Improvement for RadiologistsContentsForeword 4Preface 5Introduction - Service Improvement in Radiology 6Building a culture for improvement 8 Service improvement methodology 8 Capacity and demand 8 Staff implications 9 Working practices 10 Booking and choice 13 IT and new technology 14 Patient experience 15 Demand management 16Lean thinking 18Summary 19Glossary 20References 21Useful websites 23Useful documents 24Acknowledgements 26Success factors (inserts at back of document) NHS RADIOLOGY SERVICE IMPROVEMENT TEAM - 3
  4. 4. Service Improvement for Radiologists Foreword Radiology services in the UK have been transformed in recent years with changes in workforce, increasing skill mix, new technology and relentlessly increasing demand for complex investigations. Against this backdrop comes the challenge of needing to reduce waiting times. In England the 18 week referral-to-treatment target comes into force at the end of 2008 and similar pressures apply in Scotland, Wales and Northern Ireland. What this effectively means for radiology departments is to aim towards a minimal wait imaging service. Whilst increasing investment and outsourcing to other sectors have a role, the main thrust to achieving this will inevitably come from improving the efficiency of our existing services. A great deal of service improvement has already been implemented and demonstrated to be effective in many departments throughout the country. This publication is a signposting document which summarises this experience and knowledge. It has been written by radiologists for radiologists and I would urge you to take the time to read it and to use it. It may provide the answers you have been looking for! Dr Erika Denton National Clinical Lead for Imaging, Department of Health4 NHS RADIOLOGY SERVICE IMPROVEMENT TEAM -
  5. 5. Service Improvement for Radiologists Preface This signposting document aims to summarise current service improvement knowledge and experience for UK radiologists. It draws learning from working with hospitals across England. This document includes descriptions of underlying principles, specific examples and links to further useful information.“ Our experience has shown that service improvement is a continuous process by the whole team, with clinical and managerial leadership, supported by an improvement facilitator. There is always scope for further improvements, and as situations and processes in the NHS are in continual flux, process mapping and redesign has to be revisited regularly. Robust and appropriate data is absolutely essential to monitor performance and allow early detection of drift from accepted criteria, and then informs the actions needed to correct the situation. In our department, service improvement has dramatically changed the quality and safety of the service, not only delivering better patient waiting times, but an enhanced patient experience generally. There have been tangible staff benefits also, as processes become more organised and life is calmer. Empowered staff enjoy making improvements work and take pride in the service they deliver. ” Dr G Hoadley, Clinical Director - Radiology, Blackpool Fylde & Wyre Hospitals NHS Trust National Clinical Lead - Radiology Service Improvement Team“ Senior clinical and managerial enthusiasm is essential but we also try to foster a culture of improvement in every member of staff in our department. As a result we continue to see real progress in the service we offer our patients and also in the working lives of our staff. ” Dr R Seymour, Clinical Director - Radiology, South Devon Healthcare NHS Foundation Trust National Clinical Lead - Radiology Service Improvement Team“ I have seen falls in waiting times as a direct result of an active service improvement philosophy in my own department for a number of years. This philosophy includes an acceptance that no department is perfect, engagement of all staff in the work, and a recognition that the best results are achieved by continually making small changes. If this is underscored by strong clinical leadership and commitment, success is guaranteed. ” Dr R Evans, Consultant Radiologist - Mayday Healthcare NHS Trust National Clinical Lead - Radiology Service Improvement Team We hope that you will find this document a useful tool in your efforts to improve your own departments service. Robin Evans Graham Hoadley Richard Seymour National Clinical Leads, Radiology Service Improvement Team, Cancer Services Collaborative ‘Improvement Partnership’ NHS RADIOLOGY SERVICE IMPROVEMENT TEAM - 5
  6. 6. Service Improvement for Radiologists Introduction - Service Improvement in Radiology Radiology services in the UK are undergoing There is published evidence in favour of rapid transformation. The specialty has moved Radiology Service Improvement (4) based in recent years from being under-resourced upon practical experience from departments and under-staffed, tolerating long waits and all over the country whose staff have adopted inefficiency, to a central focus of government these methods with success. Much of the health reform, and public expectation. The benefit has occurred when examples of good recent publication of diagnostic waiting time practice have been shared and disseminated, data, now in the public domain, has been a and this has been a key role of the National significant development in highlighting the Radiology Service Improvement Team. problems in diagnostics (1). In spite of much recent investment and improvement work, What is Service Improvement? government initiatives aiming to eliminate Service Improvement seeks to support clinical diagnostic waits represent a major challenge excellence with administrative excellence, by for imaging services. continuously adapting and refining processes and pathways, for the benefit of patients, No one doubts that eliminating waits will carers, and staff. require more capacity, but earning resource for this in a competitive financial environment Principles (for example Payment by Results) will require • The patient is at the heart of, and involved a more radical approach. We will need to in, the process. become highly skilled in optimising the use • It is clinically led and managerially driven. of existing capacity, and also be able to • Improvement is made across the whole demonstrate efficient working practices. This pathway. is where the relatively new field of Radiology • No individual group of patients is Service Improvement can play a crucial role. disadvantaged. • Workforce issues are recognised and This document defines Service Improvement addressed. (SI) and outlines its methods. It is a reference • Skill mix is used appropriately. source for all clinical radiologists, and has • The benefits of new technology are fully been compiled by members of the National realised. Radiology Service Improvement Team (2). • Patient safety is paramount. • Robust data informs redesign and business The fundamentals of service improvement in planning. healthcare derive from work undertaken in • Tools and techniques are used to ensure the USA at the Institute of Healthcare sustainable benefits. Improvement (3). Health services can learn a • Change is in line with organisational needs great deal from industrial production methods and objectives. such as “Lean thinking” (Toyota Production • The patients journey starts before and ends System), and “Six Sigma” (Motorola). Service after the visit to radiology. improvement methods are neither radical nor • Proactive patient pathway management is complex; indeed many are simply common supported. sense, and are already part of good • Embedding service improvement in the departmental management. department structure will ensure sustainability.6 NHS RADIOLOGY SERVICE IMPROVEMENT TEAM -
  7. 7. Service Improvement for RadiologistsBenefits • OrganisationsMany of the benefits can accrue at minimal or • Efficient, cost effective cost. Where this cannot be achieved, • Removal of unnecessary steps leading to:robust capacity and demand data will lead to • Lower DNA ratesa stronger business case for additional • Shorter waiting times.resources. Benefits will be demonstrated in • Improved recruitment and retention ofthe following areas: staff. • Improved service quality.• Patients • Reduced risk. • Shorter waiting times for examinations • Fewer complaints. and results. • Potential to release under-utilised capacity, • Better quality information. and so increase activity. • Fewer unnecessary visits to hospital. • Increased opportunities for innovation and • Choice and certainty about appointment service expansion. times. • Smoothing patient flow across the whole • Informed choice and decisions about organisation. their care. • A more user-friendly service with respect for dignity and privacy. • More equitable service provision across the health community. • Increased patient safety.• Staff • Improved morale. • Decreased pressure of work. • More predictable workload. • Ability to plan services more effectively. • Fewer incoming calls and complaints. • Fewer interruptions, more peaceful environment (reduced “turmoil”). • Improved skills and learning. • Heightened opportunities for career development. • Removal of unnecessary steps. • Staff empowerment. NHS RADIOLOGY SERVICE IMPROVEMENT TEAM - 7
  8. 8. Service Improvement for Radiologists Building a culture for improvement Patient centred Service improvement Service improvement places the patient at the methodology heart of all our activities. Making the service truly patient centred requires a change in Radiology departments are used to measuring mindset from fitting the patient into pre- and monitoring activity and waiting times. designed processes, to designing processes This data alone can give little indication of the that will offer choice and certainty to all efficiency or effectiveness of the service, or patients and lead to a superior patient the influence of external pressures. It is a experience. common assumption that long waits are simply due to insufficient capacity or excessive A philosophy of improvement demand. Service improvement involves The most successful organisations embrace measuring that capacity and demand. change and constantly seek ways to make Contrary to expectation, waits are rarely beneficial changes. Such organisations seek to found to be due to excessive demand or develop a culture in which all staff are insufficient capacity. More usually they are encouraged to find ways of improving the explained by the adverse effect of variation in service, both in terms of efficient ways of demand and capacity, or by under-utilisation working and patient satisfaction. of existing capacity. Only when capacity and Managing change demand are measured can a service be truly Institutions require innovators and champions understood (7). to effect progress, as change is a necessary, inevitable and continuous requirement within Principles of capacity and quality organisations. The voice of the cynics demand data collection should be heard, as a balance to excessive speed of change, but not allowed to veto • Capacity, demand, activity and backlog change (5). should be measured in common units of time. Small steps are easier to manage than large • Routine data collection should be part of leaps, particularly in the early stages. The the daily management activity in all Success Factors are a good place to start (6), modalities, and incorporated into job plans. and do not always require huge resource or • Data should be displayed as cumulative run shifts in working practice. charts, allowing visual comparison of capacity and demand, activity and backlog, Sustainability over time. Trends will then be easily Driving change is of limited value unless the appreciated, and adverse changes will be improvements are sustainable. This is best detected early. achieved by ensuring that the clinical teams • This data should be available to all staff. and team leaders are aware of the change • Robust capacity and demand data should drivers, and are empowered and committed inform the business planning process and to the changes and objectives. Success should be used in all bids for new resources. be recognised and praised. Change forced on • Ongoing data collection is a useful an organisation from outside is difficult to management tool to detect unexpected maintain and must be continually driven, but increases in demand that require additional is demoralising to staff, time consuming, and capacity to avoid lengthening waits. ultimately is less effective than change driven from within.8 NHS RADIOLOGY SERVICE IMPROVEMENT TEAM -
  9. 9. Service Improvement for Radiologists• The data enables variation in demand to be Staff leave policy understood. Such variation is a major • Robust policy applies to all staff, including contributing factor to development of backlog. consultants. By understanding variation, steps can be taken to • Leave notice commonly stipulated at six minimise it, or capacity may be flexed to match weeks. the variation in demand. • A policy to determine appropriate planned• Manual data collection (in particular demand staff absence. data) can be time-consuming. Wherever possible, the departmental Radiology Information System Service improvement facilitator (RIS) should be used. Hospital information and IT This may be an individual or a number of departments may have a crucial role to play in this, individuals and the resource may be shared by adapting a RIS system to provide this data. trust wide. The role is probably more sustainable if the experience and expertise is shared across the institution, rather thanMethodology - staff implications being purely radiological. An enlightened trustService improvement is a team effort requiring will consider this money well spent in view ofinput from all grades of staff involved in the gains that can be made, and the role isproviding the service. Knowledge of service cost effective in terms of departmentalimprovement methodology should be efficiency (8). Personnel may be drawn from aincluded in all job descriptions. Among the disestablished post, or from within the staffimportant functions are: complement (9).Clinical service improvement lead Functions of service improvementAn essential role to: facilitator (SIF):• Instigate, drive and champion change. • Support data collection.• Communicate and drive changes with • Facilitate and coordinate process mapping, radiologist colleagues. and implementation of change.• Communicate the nature of changes within • Cross-department liaison. radiology to other departments, and • Project management skills. encourage process changes that will The person(s) in the role requires a range facilitate improvements in radiology. of skills:• Work with the clinical director, through job • Communication - service improvement planning, to achieve changes in working works best when applied across the whole practice. health community, by joining up the wholeManagerial support patient pathway. A SIF must be able to liaiseAt executive and departmental level: with other parts of the organisation to• Facilitate and implement changes to facilitate this. working practices. • Process mapping - a detailed knowledge of• Where necessary provide financial support. process mapping ensuring that the correct• Provide links to other directorates. personnel are present, and that an action plan is drawn up and implemented.Data management • Presentation skills – necessary to deliver the• All relevant clerical staff should be tools and techniques, and communicate responsible for data collection. results to staff.• Waiting list validation and daily waiting list management is part of this function. NHS RADIOLOGY SERVICE IMPROVEMENT TEAM - 9
  10. 10. Service Improvement for Radiologists • Change management facilitation - a good • Selected angiography procedures performed SIF is a powerful change agent. Drive and by non-radiologists. enthusiasm, combined with effective • TRUS and prostate biopsy performed by negotiation and influencing skills, will often sonographers. achieve the desired result. • Radiology investigations performed by • Data interpretation and analysis - necessary medical staff will become commonplace. to inform process design. Links with the Radiology input will be essential for hospital information and IT departments will establishment and maintenance of make this much easier. competency. • Nurses involved in consent procedures. Skill mix • Advanced practitioners in breast imaging – Skill mix may take many forms, but should reporting, ultrasound, biopsy. always be based upon appropriate training, supervision, and audit, to ensure patient A wide range of roles may also be performed safety at all times. Aptitude of individual staff by assistant practitioners (6). members will vary between institutions. One of the underlying principles is that no staff Methodology - working member should undertake tasks that may be practices reasonably delegated to another. In this way all staff are working to their ability, strengths An important part of service improvement is and training (2, 11, 12). to understand processes from the patients’ point of view. The following are examples of advanced practice from around the country (10): Process mapping • Sonographers perform and report non- In order to understand administrative obstetric, musculoskeletal, and vascular processes fully it is necessary to process map. ultrasound. It is surprising how staff at all levels • Radiographers perform barium enemas, and misunderstand the complexity of the patient other fluoroscopic procedures. processes they are involved in every day. No • Radiographer reporting single person knows or understands all the • Plain films processes across the entire patient pathway, • Selected CT end to end. • Selected MR • Fluoroscopic procedures. Process mapping requires designated time for • Protocol driven, radiographer-led exams e.g. representatives of all staff groups to meet and IVUs, DEXA, Nuclear Medicine. scrutinise departmental processes across the • Radiographer and sonographer vetting of entire pathway. A facilitator is required to requests. record in detail every step of these processes. • IV injections for all contrast examinations The aim is to identify bottlenecks and given by non radiologists, including unnecessary steps that cause delays. radiographers, nurses, health care assistants. • Radiographers and/or radiology nurses perform selected interventional procedures (for example central line placement, breast biopsy), or sedation.10 NHS RADIOLOGY SERVICE IMPROVEMENT TEAM -
  11. 11. Service Improvement for RadiologistsA key outcome of process mapping is an • DNA policiesagreed action plan, concentrating on DNAs waste capacity and cause duplicationremoving bottlenecks and unnecessary steps, of effort. They should be managedand taking all possible measures to improve proactively according to a locally agreedthe patient experience. There is an policy, which should apply to all modalitiesopportunity at this point to test ideas, and the in a department. Many departments havechanges are then adopted if successful, or found that sending patients a seconddiscarded (7, 13). appointment results in a further DNA, and they have adopted a “one strike” policy,Waiting list management returning requests to the referrer after a• Waiting list profile single DNA. Booked appointments (see page With long waiting lists it can be helpful to 13) have been shown to be a very effective segment the backlog into different way of reducing DNAs, by engaging the categories of wait (for example, 0 to 4 patient and offering choice of appointment weeks, 4 to 8 weeks etc). There are often time. Appointment reminders, either by many fewer patients waiting a long time, SMS text message or phone call, can also be and the waiting list profile enables these to effective. be identified and booked as a priority. As waiting times shorten it becomes more Pathway redesign useful to segment the backlog into shorter The way that radiology integrates with patient time units (for example, 0 to1 week, 1 to 2 care pathways has followed traditional weeks, etc). methods for many years. This often involves multiple outpatient visits interspersed with• Waiting list validation tests, with patients waiting at each step of A useful starting point in dealing with long the journey. The cumulative effect of all the waiting lists is to validate the waiting list to waits is a very long total pathway. These ensure its accuracy. This involves contacting methods need to change to shorten the all patients waiting to ensure that the patient pathway to an acceptable level. investigation is still needed (for instance the Processes and pathways should be redesigned need has not been removed by another test to reduce the number of patient visits to or surgery in the interim), and that it has hospital, and to link clinical decision making not already been performed. This has a closely to the production of test results. Once number of benefits, including reducing again there are many examples already in use, DNAs, reducing waiting list size, and and there is scope for these to be more verifying patient contact information. Non- widely adopted. responders can be returned to the referrer and removed from the waiting list. Among the effective solutions are: Experience has shown up to 40% • One-stop clinics providing simultaneous reductions in waiting list size (backlog) clinical assessment and diagnostic using validation (6). procedures. • Direct access to diagnostics for appropriate referrers, to eliminate unnecessary outpatient attendances or secondary care referral (14). NHS RADIOLOGY SERVICE IMPROVEMENT TEAM - 11
  12. 12. Service Improvement for Radiologists • Proactive patient management - where the • Reduce the number of queues. There is a next step is triggered as soon as the result is strong tendency for Radiology departments available. This may be further imaging or to form multiple queues for investigations. other tests, outpatient review, or discussion Many factors influence this, including at a clinical meeting. Locally agreed and priority (urgent, soon, routine), the person implemented pathways are a robust who performs the test e.g. radiologist or mechanism for ensuring that the next step sonographer. Multiple queues reduce occurs, facilitated by an appropriate person efficiency and generate delays, as well as who will usually be the radiologist or their taking up staff time. The aim should be to agent, or a specialist nurse. Telephone, fax pool as many requests as possible into a and email are the quickest methods of minimum number of queues. Obviously as communication and can all be made secure waiting lists reduce, it should be easier to enough for the purpose. schedule all work as it comes in. The ideal • Radiologists should be empowered (under situation is a single queue across the whole local agreements) to organise further tests health economy. when these are inevitable. An example is where an ultrasound identifies a liver lesion Improving radiologist efficiency which requires CT or MR for All radiologists are aware of events characterisation, or a chest radiograph throughout the day that impede efficient shows a likely malignancy where a CT scan working, causing frustration and stress. By is the inevitable next step. Evidence examining these instances it is possible to suggests that it is increasingly design strategies to make us more efficient, unacceptable for the radiologist to simply and relieve stress. Again there are many passively suggest the next test (15, 16). examples in practice. • Patient pathway coordinators who contact • Reducing interruptions. While it is important outpatients to organise investigations and that radiologists are available for collate results for clinicians. consultation and advice, access can be Scheduling controlled to ensure protected reporting Changes to the way investigations are time. This will lead to increased efficiency, scheduled can have significant benefits in less stressful work time, and may help to terms of smoothing patient journeys, and reduce the error rate. Surgeons, for reducing delays. example, cannot be easily interrupted in the operating theatre. Among the possible • Reduce batching. Collecting a series of solutions are: similar investigations to be booked in a • A duty radiologist available on a rotating batch has some rewards in departmental basis for consultation and troubleshooting. efficiency but builds in an inherent delay This may be the on call radiologist. resulting in increased waiting times for • Dedicated reporting sessions in a remote some patients. This is particularly noticeable location for fixed periods of time. Off site if batching is applied to performance of the reporting has been shown to reduce scan, and the reporting. It is preferable to interruptions and improve work flow. book smaller numbers of tests more • Restricted times for consultation by junior frequently where possible. doctors (“Radiology clinics”) (6).12 NHS RADIOLOGY SERVICE IMPROVEMENT TEAM -
  13. 13. Service Improvement for Radiologists• PACS processes. PACS offers an excellent • Common protocols. The development of opportunity to change the way that common imaging and reporting protocols radiologists work and to improve efficiency. across clinical networks (e.g. cancer With protocol driven scanning, radiologists networks) has been shown to be effective in can report multiple modalities in remote reducing repeat investigations, allowing locations, with subspecialty work being most effective use of capacity, and allocated appropriately. minimising patient dose.• Where double-reporting is practiced, in the context of full desktop integration, the first Methodology - booking reporting radiologist can direct the case into the second reporter’s worklist. and choiceCreating additional imaging capacity Significant improvements in the utilisation ofIn order to minimise waiting times, practices capacity can be achieved by giving patientsshould change to exploit all available imaging choice of the time and date of ancapacity. Examples of this could include: investigation. Scheduling becomes more efficient, DNA rates are reduced, less effort is• Extended day and weekend working to expended in rearranging appointments. It has smooth out variation in demand, and been shown that patient and staff satisfaction improve productivity when the hospital is rates are improved (17). quieter. It also offers a service at times that better suit many patients, and when travel Definitions: and parking are often easier. Partial booking: At the time of the request• Alternative providers. The Alliance patients are informed that they will be independent sector MRI contract in England contacted a few weeks prior to the has shown that waits can be radically appointment, to agree a time and date for reduced by the use of independent sector the examination. Alternatively the patient providers. The administrative processes to could be asked to telephone the booking support such activity should be refined to clerk after a specified time interval to arrange ensure a seamless service that does not this. Partial booking is useful when waiting place undue pressure on existing NHS staff. times are longer than the rota or scheduling Appropriate clinical governance processes cycle. In practice this usually means waiting need to be in place. Close integration of the times longer than six weeks. independent provider into the local NHS Full booking: Close to the time of decision to environment will avoid duplication of effort, request an investigation (preferably within and assure a high quality integrated one working day), the time and date of this imaging service. investigation is agreed with the patient. The• Sharing capacity between local hospitals patient may attend radiology directly from the and across networks - it makes sense to clinic, the department may telephone the share capacity between adjacent centres patient, or the patient may be asked to ring with appropriate agreements in place in the department. This is the ideal form of order to exploit spare capacity, and share booking but requires waiting times to be waiting list burdens. shorter than the rota or scheduling cycle (i.e. usually less than six weeks). NHS RADIOLOGY SERVICE IMPROVEMENT TEAM - 13
  14. 14. Service Improvement for Radiologists Methods • Deferred demand refers to those studies The following are just some examples of with a planned delay, often cancer booking that have been employed successfully follow-up scans, and are ideally dealt with in radiology departments. There are many by partial booking. variations of these models in use around the • Increasingly the onus is being placed upon country: radiology departments to ensure that patient follow-up is not delayed by failure of • Telephone booking centre (“call centre”) results to reach the appropriate clinician. where patients phone to arrange an This will be another driver for proactive appointment within a few days, and the patient pathway management by request form is faxed or emailed from radiologists. primary care, to allow time for vetting. • Outpatient staff may have access to the RIS Methodology - IT and new to book certain agreed investigations themselves, whilst the patient is still in the technology clinic. New technologies for data management and • Patients can attend radiology straight from image storage offer potential for significant the outpatient department to arrange an improvements in the service when appointment with a trained booking clerk, implemented with appropriate service who is also able to provide patient redesign. The available new technologies information, bowel prep etc. include: As IT systems develop, direct electronic Patient management systems booking at the point of referral, to agreed The electronic patient record (EPR) will allow protocols, will be an effective and efficient radiologists full access to the clinical patient system. Even in departments with older IT record when justifying and vetting requests. infrastructures, using electronic rather than This would most likely be linked to electronic paper diaries enables greater flexibility and requesting of diagnostic tests to speed efficiency. delivery and reduce errors. A community wide Issues to consider: IT solution would also allow electronic • If vetting is done in a timely manner, it can requesting by Primary Care Practitioners, thus be built into a partial booking process facilitating the booked appointments systems before the appointment is made. referred to on page 13. • Vetting may be retrospective if local Radiology transcription systems protocols are robust enough, to allow an Digital dictation systems facilitate a more even speedier appointments system. streamlined workflow, with the added • In an ideal service there would be no delays advantage of allowing clinicians access to the and the appointment would then be agreed vocal record and thus instant availability of a before the request has been vetted and/or report prior to transcription. Improved clarity authorised. Generally only a small of the voice record reduces the likelihood of proportion of requests in any modality are transcription errors. Digital dictation also changed or rejected, so this is not avoids the problems sometimes associated problematic as long as the patient is with voice recognition. informed of this possibility.14 NHS RADIOLOGY SERVICE IMPROVEMENT TEAM -
  15. 15. Service Improvement for RadiologistsVoice recognition (VR) software gives Methodology - patientalmost instant transcription of dictation and experiencesupports true hot reporting. It has beenshown to improve report turnaround time. The main drivers for all aspects of serviceThere is also potential for savings on improvement are the patient experience andsecretarial costs, or redeployment of staff to staff satisfaction (see next section). Much of theother duties (for instance to create a service focus on patient experience rightly concentratesimprovement facilitator, data manager, or on waiting time reduction, but this is only oneMDT coordinator). There is evidence to aspect of service that can be improved.suggest that VR will slow down the reportingspeed of radiologists by up to 15%, but this Whilst radiology staff can empathise withmay be offset by faster report turnaround patients’ experience, it can be difficult to seetime. one’s own service through unbiased eyes. An important component of service improvementPicture archiving and is developing the ability to see the servicecommunication systems from the patients’ perspective. Only when thisPACS offers potential benefits from instant has been achieved can the service claim to beavailability of images, possibility of viewing truly patient centred.images at multiple sites simultaneously,teleradiology for remote reporting or specialist Suggestions to make a service moreopinion. If PACS is implemented without patient centred:service redesign the benefits will not be • Give patients real choice regarding theirmaximised and the department will have poor appointments (see Booking and Choice).electronic processes to replace poor paper • Suggestion boxes, focus groups and openprocesses. days. Questionnaires are generally of limited value unless designed to address a specificPACS creates new roles and releases staff to area.take on new roles. It can make reports and • Invite local patients to be full members ofimages available over networks to GPs, the departmental service improvement team.Independent Sector Treatment Centres and • Involve these patient representatives in alltertiary care centres, especially if connected the team’s work such that all aspects ofvia the Connecting for Health (CfH) national service improvement have a patient focus.spine. This also gives the possibility of sharing • Use patient representatives to examine areasimages across a wider network or SHA. which are specifically patient experienceReport verification and correction is simplified orientated:as images can be viewed easily alongside the • Review all appointment letters,report being checked. Fuller details of PACS information leaflets and the content ofbenefits and how to realise them are available the departmental website.through the CfH website and from the • Review hospital signposting; how easy is itNational Radiology Service Improvement to find the (18). • Examine issues of patient dignity during radiological procedures. • Attend the department as “mystery patients” to observe an aspect of the service or to assess how a new initiative works in practice. NHS RADIOLOGY SERVICE IMPROVEMENT TEAM - 15
  16. 16. Service Improvement for Radiologists • Ensure robust mechanisms for investigation • Many of the issues that cause staff the most of complaints, and all complaints should be stress are also those that lead to inefficiency, reviewed at the department governance such as portering delays, interruptions whilst meeting. reporting, inadequate patient preparation • The flexibility of extended day working and so on. If staff problems are resolved, allows patients the option of attending out the service for the patients will improve. of office hours, which may be more • Involvement in service improvement activity, convenient and when parking is often including the role of service improvement easier. facilitator, has obvious service benefits, in • Make full use of existing forums such as the addition to enhancing staff development. Patient Advice Liaison Service. Methodology - demand Staff experience Many teams have found that improving management patient experience leads to a better working Historically radiology services have been at a environment for staff. disadvantage compared to clinical services in How improved patient experience may obtaining new resources. This has meant that improve working lives: uncontrolled increases in demand have • Reduced waiting times lead to fewer generally been under-funded, placing services complaints, and greater staff satisfaction in under pressure, and contributing to long the knowledge that they are providing a waits. Demand management remains one of quality service. the greatest challenges to Radiology. There • Reduced DNA rates lead to less reworking are various methods to manage demand, and of appointments. several are set out here: • Improved scheduling reduces stress caused Vetting of incoming requests: by unpredictable workload, and allows • This is time consuming for busy clinical greater scope for planning CPD and other radiologists, though the burden may be shared development activities. by radiographers working to agreed robust • When patients are treated with respect and protocols. It can add significant delays to given control over the processes (such as the patient journey. choice of appointment time) they are less Clinical guidelines: stressed and easier for staff to deal with. • There are many examples such as Making the • Reducing interruptions (6) can have a Best Use of a Radiology Department (MBUR), dramatic effect on the working but it is widely acknowledged that these are environment, can contribute to improved time consuming and difficult to apply in the efficiency, and could reduce errors. current funding structure. They are likely to How improving working lives may lead play an increasingly important role as they to improvements in the service: become incorporated into electronic • Offering flexible working hours may enable requesting. extended days and increased capacity. • Flexibility in hours may aid recruitment and retention, and encourage the return to work of some staff.16 NHS RADIOLOGY SERVICE IMPROVEMENT TEAM -
  17. 17. Service Improvement for RadiologistsClinical pathways:• There is much work in progress on It is a fact of life for most developing these as a means of radiologists that demand rises standardising practice, and controlling demand, and agreeing local healthcare inexorably year on year. This is models. The most prominent examples are due to a number of factors, the Map of Medicine, and the RCR/RCGP Primary Care referral criteria. They may be including the development of incorporated into electronic booking new clinical services, systems, and may be used to form the basis of pathways through independent developments in existing services alternative providers. (e.g. oncology), the increasingService Level Agreements:• Where utilised these provide agreed levels reliance clinicians have on of service provision and certainty about imaging, and increasing public anticipated demand (19).Clinical budgeting: and political expectations. The• Should cross-charging of other departments for diagnostic tests become more rationale for demand commonplace (as will occur in England, management may therefore be driven by PbR), diagnostic units will be remunerated for all work undertaken. This shifting, and in the future could encourage referrers to manage their investigations may be considered own demand, and enable departments to respond appropriately to increased demand. appropriate, or at least accepted, On the other hand, this also presents a risk that were previously rejected. to departments if activity is outsourced. Radiologists of the future will have to adapt to such changes and configure services to be able to deal with new demands. In England Payment by results, and service line reporting (22), will help to fund capacity for such growth in demand. NHS RADIOLOGY SERVICE IMPROVEMENT TEAM - 17
  18. 18. Service Improvement for Radiologists Lean thinking Traditional service improvement as described • System redesign. in this publication is a set of tools designed to • Eliminate, simplify and combine steps. allow users to improve processes based on • Improve remaining processes. robust data collection. To be sustainable it • Stabilise processes – Standard working needs to be embedded in departmental (Gold Standard). culture. It concentrates on improving • Smooth demand. processes within the department. • Eliminate batching. • Do work in order (today’s work today). Lean is a more global organisational philosophy in which the workforce are Remove waste empowered and expected to make or suggest • Overproduction. changes. Information and data on progress • Waiting. against objectives is available to staff in a • Motion. highly visual manner. This daily effort is • Transport. combined with rapid improvement events as • Overprocessing. required. Lean considers the entire patient • Inventory. pathway rather than just steps within the • Defects (rework). department, by first identifying those • Unused creativity / intellect. elements of the total process that add true value to the patient experience and then Empower staff and create a culture of mapping these in the context of the whole continuous improvement pathway – the value stream map. The process • Visual management. is similar to conventional process mapping but • Daily improvements encouraged. on a wider scale. • Pursue perfection. Successful implementation of Lean will result Organisation of work in long term cost savings, but the main • Flex capacity to meet demand. benefit is as a driver of quality. By eliminating • Establish the rhythm of work (Takt time). bad processes and waste, and creating • Work by actively pulling work through. standard working practices that eliminate Improve quality and safety variations from best practice, Lean can create • Standard working. a safer working environment for the patient. • Visual management. The need for this is illustrated by the fact that the current error rate across all medical Lean outcomes - demonstrative processes is around 5%, with many of these improvements in: causing serious harm to patients. • Delivery times – end to end journey times. • Cost savings – money and time. Key elements of Lean thinking are: • Quality and safety – fewer errors, incidents, Improve flow across and between complaints. processes • Morale – sickness rates, staff retention. • Value stream mapping. • Focus on high volume work, do not concentrate on the unusual studies.18 NHS RADIOLOGY SERVICE IMPROVEMENT TEAM -
  19. 19. Service Improvement for RadiologistsSummarySuccess factors FeedbackSince the development of service Feedback from the assessment is madeimprovement methodology nearly seven years directly to the users at their email address.ago, experience of clinical teams throughout The summary provided gives the user a scorethe country has shown that all imaging for each section and a total percentage score,modalities share common problems. The tools and provides recommendations for furtherand techniques of service improvement have work in low scoring areas.matured, and a number of ‘success factors’(6) have been identified, which will make the All recommendations provide links via themost significant and measurable radiology service improvement website toimprovements. Originally collated in 2005 and documents, presentations, publications andrevised in November 2007, they take the case studies.continuous learning from sites who have Teams can reassess themselves at any interval,succeeded in reducing waiting times and has especially after the implementation of newimproved the patient and staff experience. changes.Whilst the success factors provide a guidethey will not deliver sustainable change alone.Root cause analysis, supported by data, of theissues affecting service delivery will identifythe correct solutions required. The successfactors are supported by numerous casestudies (10) from sites describing how theimprovements were made.Individual pull-out sheets of success factors(generic and modality specific) can be foundin the back of this document.Radiology Service ImprovementAssessment Tool (RSIAT)A web-based Radiology Service ImprovementAssessment tool (RSIAT) tool is available (20)to allow clinical teams to assess their progressin service improvement. It is drawn from theexperience of those teams who haveundertaken successful work in redesign. It is atool to be utilised by all grades of staff, or bythe team as a whole. Assessment of the levelof improvement made assists individuals andteams to focus further efforts in redesign. NHS RADIOLOGY SERVICE IMPROVEMENT TEAM - 19
  20. 20. Service Improvement for Radiologists Glossary PBC Practice Based Commissioning SI Service Improvement CSCIP Cancer Services Collaborative ‘Improvement Partnership’ DNA Did not attend RIS Radiology Information System IT Information Technology SIF Service Improvement Facilitator VR Voice Recognition CfH Connecting for Health PALS Patient Advice and Liaison Service ISTC Independent Sector Treatment Centres MBUR Making best use of Radiology departments RCGP Royal College of General Practitioners SLA Service Level Agreement SHA Strategic Health Authority SMS Short Message Service RSIAT Radiology Service Improvement Assessment Tool PbR Payment by Results20 NHS RADIOLOGY SERVICE IMPROVEMENT TEAM -
  21. 21. Service Improvement for RadiologistsReferences1 Delivering the 18 Week Patient Pathway www.18weeks.nhs.uk2 NHS Radiology Service Improvement www.radiologyimprovement.nhs.uk3 Institute for Healthcare Improvement www.ihi.org4 Clinical Radiology (2003) 58: 97–1015 NHS Institute for Innovation and Improvement Radiology Success Factors – Modernising Radiology Services Toolkit www.radiologyimprovement.nhs.uk7 Radiology Toolkit Service Improvement Facilitator Job Description The Role of the Service Improvement Facilitator Service Improvement Case Studies Team working within clinical imaging – A contemporary view of skills mix Improving Radiology services together – a Report of the National Urology/Radiology Service improvement www.radiologyimprovement.nhs.uk13 Improvement Leaders’ Guides Right Test, Right Time, Right Place Royal College of Radiologists – Sept 2006 – ISBN: 1-905034-16-4 NHS RADIOLOGY SERVICE IMPROVEMENT TEAM - 21
  22. 22. Service Improvement for Radiologists 15 Lancet (2006) 367: 443–45 04_02p443_445sh%20qxd.pdf 16 National Patients Safety Agency - Early identification of failure to act on radiological imaging report 17 Service Improvement in a Radiology Department - South Devon Healthcare Trust - 18 PACS Benefits Realisation and Service Redesign Opportunities - PACS_Realisation_Final_May_IRB.pdf 19 The Royal College of Radiologists 20 Radiology Service Improvement Assessment Tool NHS RADIOLOGY SERVICE IMPROVEMENT TEAM -
  23. 23. Service Improvement for RadiologistsUseful Radiology Service Royal College of Society and College of Cancer Services Collaborative ‘Improvement Partnership’ Royal College of General Lean Enterprise NHS Institute for Innovation and Healthcare Department of Health NHS RADIOLOGY SERVICE IMPROVEMENT TEAM - 23
  24. 24. Service Improvement for Radiologists Useful documents Radiology Service Improvement Modernising Radiology Services : A Practical Guide to Redesign (Toolkit) August 2003 A National Framework for Service Improvement for Radiology July 2003 Framework_for_Improvement.pdf Radiology Success Factors and Case Studies (Section D Radiology toolkit) May 2005 Challenges and Top Tips May 2004 Service Improvement Facilitator: A Key role in Radiology Services May 2004 National%20Radiology%20SIF.pdf Case Studies and Learning from Phase 2 and 3 Pilot Sites June 2004 RSIAT - Assessment Tool Ultrasound Gaining a Clearer Picture: A collection of Case Studies December 2004 Emergency Care Radiology: Supporting the delivery of Emergency Care November 2004 PACS: Benefits Realisation and Service Redesign Opportunities website version 2005 PACS_Realisation_Final_May_IRB.pdf Urology: A Guide to Service Improvement in Urology: Improving Diagnostic Services Together March 2005 Radiology_urology_report_sept2003.pdf24 NHS RADIOLOGY SERVICE IMPROVEMENT TEAM -
  25. 25. Service Improvement for RadiologistsGeneral ImprovementImprovement Leaders’ 2002 & the service through the patients eyesRoyal College of Radiologists – Clinical Radiology Patient Liason on the Clinical Radiology Patients Liason Groups Pilot of Patient Liason Information: Service Improvement Guide: Cancer Services from patient and carer experiences: Coronary Heart Programmewww.heart.nhs.ukSpread and SustainabilityAccelerating the spread of good Practice: A workbook for Healthcare : Fraser SW Kingham Press,Chichester, West Sussex 2002Spreading and Sustaining new practices: Research into Practice Programme Challenge of Implementing Sustainable Improvement in Cancer Services - Lessons from theDemonstration Sites supported by the Cancer Services Collaborative ‘Improvement Partnership’ NHS RADIOLOGY SERVICE IMPROVEMENT TEAM - 25
  26. 26. Service Improvement for Radiologists Acknowledgements Dr Graham Hoadley National Clinical Lead – Radiology Service Improvement Dr Robin Evans National Clinical Lead – Radiology Service Improvement Dr Richard Seymour National Clinical Lead – Radiology Service Improvement Lesley Wright National Associate Director – Diagnostics Lisa Smith National Manager Radiology Service Improvement Susie Peachey National Manager Radiology / Pathology Service Improvement Carol Keirl Previously National Manager Radiology Service Improvement Ana Bela De Gouveia PA Radiology/Pathology Service Improvement Team Dr Conall Garvey Consultant Radiologist – The Royal Liverpool and BroadgreenUniversity Hospitals NHS Trust Dr Erika Denton Consultant Radiologist – National Clinical Lead for Imaging – Department of Health Dr Janet Williamson National Programme Director – Cancer Services Collaborative ‘Improvement Partnership’26 NHS RADIOLOGY SERVICE IMPROVEMENT TEAM -
  27. 27. NHS Radiology Service Improvement TeamNHS Radiology Service Improvement Team3rd FloorSt Johns HouseEast StreetLeicesterLE1 6NBTelephone: 0116 222