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30420140502001

  1. 1. International Journal of Industrial Engineering Research and Development (IJIERD), ISSN 0976 – 6979(Print), ISSN 0976 – 6987(Online), Volume 5, Issue 2, March - April (2014), pp. 01-17 © IAEME 1 WORKLOAD AND PRODUCTIVITY MEASUREMENT FOR NUCLEAR MEDICINE DEPARTMENTS IN THE GULF COUNTRIES’ HOSPITALS Salman A. Salman* , Saad M.A. Suliman**, Mansour E. AbouGamila*** * University of Bahrain, Department of Mechanical Engineering, Manama, Bahrain **University of Bahrain, Department of Mechanical Engineering, Manama, Bahrain ***Arabian Gulf University, Manama, 26671, Kingdom of Bahrain ABSTRACT One of the most important corner stones for efficient performance management is performance measurement. This paper focuses on productivity measurement of Nuclear Medicine (NM) Sections at four different hospitals in Gulf countries. The main purpose of this study is to create a measuring unit that fairly represents each nuclear medicine procedure weight. The scope of this study was not limited to the physicians but it has involved specialists and nurses at Nuclear Medicine Sections. Moreover, the study has attempted to link workload metrics with other financial indicators such as periodic expenses, paid hours, and equipment depreciation to monitor the cost efficiency, operational efficiency, equipment utilization, and staffing issues. A model has been developed through multi-steps to establish the relative value unit (RVU) for measurement of nuclear medicine physicians, specialists, and nurses productivities. The model has been applied to measure the productivity level of the mentioned staff categories during January and February, 2013. The results showed that nurses’ productivity can be measured by the number of procedures’ performed and using of RVU model for this staff category does not make any difference. However, RVU model showed significant difference in physicians’ and specialists’ productivity in comparison with the number of performed procedures metric. The sensitivity analysis showed that minimal changes in the time factor will result in a significant change in the weight (RVU) of the procedures but the maximum adjustment factor has less effect. Moreover, the study was unable to measure the weight that is relative to the patient condition, patient age, and special requirements for certain procedures. INTERNATIONAL JOURNAL OF INDUSTRIAL ENGINEERING RESEARCH AND DEVELOPMENT (IJIERD) ISSN 0976 – 6979 (Print) ISSN 0976 – 6987 (Online) Volume 5, Issue 2, March - April (2014), pp. 01-17 © IAEME: www.iaeme.com/ijierd.asp Journal Impact Factor (2014): 5.7971 (Calculated by GISI) www.jifactor.com IJIERD © I A E M E
  2. 2. International Journal of Industrial Engineering Research and Development (IJIERD), ISSN 0976 – 6979(Print), ISSN 0976 – 6987(Online), Volume 5, Issue 2, March - April (2014), pp. 01-17 © IAEME 2 Keywords: Medical Imaging, Relative Value Unit, Nuclear Medicine, Productivity Measures. 1. INTRODUCTION The world of healthcare providing institutes is changing dramatically due to multiple reasons including significant demand increase, knowledge growth, technology advances, and cost inflation (Maitino, 2010). Due to these reasons, healthcare management is a very complicated area of management and subsequently efficient leadership is always required (Chan, 2002). One of the most important corner stones for efficient leadership is performance management which is based on performance measurement. Performance measurement is a wide term that involves productivity measurement. Productivity can be defined as a measurement tool used to represent the production efficiency. Regularly productivity is expressed as an average, articulating the total yield divided by the total input (Bair and Gwin, 1985). In clinical field, the yield or the output could be the number of treated patients, number of patient visits, number of performed diagnostic procedures, customer satisfaction, or generated revenue. In the other hand, the input could be the time, variable expenses, staff salaries, or fixed cost (e.g. facility rent expense).The capability to gauge each clinical staff work performed, productivity, or contributions toward the organizational mission and objectives has become an importance facing all hospital departments— in non-profitable, profitable, and academic settings. In non- profit organization, measurement of individual productivity and work performance is important for staffing issues, staff evaluation, and building futuristic strategic plans such as expansion and budgeting. In profitable hospital, measurement of individual staff productivity is mainly needed to measure the compensation, cost measurement, and pricing the provided services. In academic settings, such as university hospitals or research centers, productivity measurement is more complicated where the variability of the output is very high. The main purpose of measuring the individual academic staff productivity is to have an integrated figure about his/her productivity beside his/her clinical output. Moreover, in research centers, specifically, productivity measurement is important to track each researcher contribution in certain research projects. This paper aims to drive clear and uniform principles of measuring workload at one section of the medical imaging department at four specialist hospitals in Gulf countries. The most challenging part of this issue is that the workload emerges from the interaction between the requirements of the procedures (diagnostic/ therapeutic), the circumstances under which it is performed (e.g. radiation exposure), the skills and perceptions of the operator. Thus, the workload cannot be measured only by counting the number of patients, or number of procedures. Many factors should be incorporated to end with representative and fair workload measures. One of the most useful tools used to measure medical imaging procedures’ weight is known as Relative Value Unit (RVU). Simply, this tool measures the weight of a process relative to another standard procedure. This analytical method helps managers to measure productivity using historical data to derive meaningful benchmarks by removing subjectivity such as differences in work habits among operators (physicians, technologists, and nurses) and differences in the time, skills, and drawbacks required to perform one examination compared to another. This tool is also practical for cost segmentation per RVU in terms of salary cost (paid hours), equipment depreciation cost, operating supply cost, maintenance cost, and administrative cost. The hospitals under the study use a very basic method to calculate the workload and individual productivity by counting the number of patients or
  3. 3. International Journal of Industrial Engineering Research and Development (IJIERD), ISSN 0976 – 6979(Print), ISSN 0976 – 6987(Online), Volume 5, Issue 2, March - April (2014), pp. 01-17 © IAEME 3 number of procedures. This method is not valid due to its inability to represent the workload and productivity where different procedures required different weights and workloads. The dramatic increase in medical imaging procedures utilization, and subsequently, the vivid increased cost raise the requirement for an accurate, to certain limit, measurement tool of the workload (output) and the productivity in all hospital departments. The RVU system established by Medicare (American Medical Association, 1988) is built according to standardized protocols and procedures used in Europe and in the United States. The RVU value for each service is used for physician reimbursement. Thus, RVU values involves not just the work done by the physician, but also the liability expenses and the procedures expenses which are not incurred by the facility. Due to all these differences, Medicare RVU values cannot be directly applied to the hospitals under the study. The need to establish a dedicated RVU/ productivity system or model for medical staff at the hospitals under the study is originated as follows: • Establish a RVU based productivity measurement system for nuclear medicine section. • Compare the currently used method (number of patients/procedures) with the proposed one (RVU model). • Link workload measure (RVU) with other financial indicators such as periodic expenses (i.e. variable and fixed costs), paid working hours, and equipment depreciation to monitor the cost efficiency, operational efficiency, and equipment utilization; respectively. 2. LITERATURE REVIEW Bair and Gwin (1985) stated that productivity data facilitate the ability to increase efficiency by integrating financial and planning information to ensure more fiscally viable products and services without sacrificing the quality of care. In the budgeting process, productivity data provide additional information about direct and indirect expenses. These expenses are correlated to program objectives and projections regarding caseload size. Productivity measurement also provides useful information on average length of treatment, staffing patterns, reimbursement patterns, diagnostic groups, and treatment outcomes. Analyzing these data provides information that can assist in personnel projections, improving staff effectiveness, creating new programs, and containing or reducing costs. The first productivity measurement metric is the number of patient visits per physician. This tool measures the number of patients who are allocated and registered to specific physician. In specific, patient visits per physician expresses critical indicators of whether physicians are using office resources and schedules reasonably, identifying those who require careful inspection. Number of patient visit per physician does not include only new patient and returning patient, but it includes also patient on the panel. The advantage of this tool is that it is quick and easy to be measured. It is usually used to compare workload between specialties. However, this metric is not fair where it is highly dependent on the equal patient access among all physicians. Also, it does not consider the provided procedures per visit, collaboration and complexity of the patient condition or the provided procedures. Therefore, patient visit per physician is not used usually as a primary productivity
  4. 4. International Journal of Industrial Engineering Research and Development (IJIERD), ISSN 0976 – 6979(Print), ISSN 0976 – 6987(Online), Volume 5, Issue 2, March - April (2014), pp. 01-17 © IAEME 4 benchmark, but it is important in understanding operational factors that contribute in business growth. The second metric, Total Volume per Current Procedural Terminology (CPT) Code by Service Category is another clinical productivity measure used to evaluate individual and group productivity. This term represents the number of billed or unbilled patient visits during the economic year. In contrast to the number of patients visit per physician, this metric links patient visit or service with the significant contact between a health care provider such as physician, specialist, or nurses where advice, procedure, service, or treatment occurs. In each patient visit, all billed or unbilled CPT codes will be recorded. Due to this reason, this metric is considered as a readily and quick measure representing the time spent in each patient visit with detailed description of provided procedures, treatment, or services. The main drawback of this metric is that its values are highly dependent on the specialty and are not comparable between different specialties (American Medical Association, 1998). The third metric, Total Net Fee-for-service Revenue measures staff productivity in terms of the real income their services, procedures, or treatment created. It includes the revenue collected from patients and third-party payers for services provided to full fee-for- service (FFS). This metric has an essential role in drawing of new budget plans and pricing strategies. Indirectly, Total Net Fee-for-service Revenue reports can be considered as early warning signals for changes in productivity levels (Albertsen and Atkinson, 2000). The fourth metric, Total Patient-care Gross Charges are the total value of all medical or surgical services provided to all patients by the organization before contractual adjustments required by third party payers or other adjustments during defined reporting period. The most difficult part of this measure is the fact that changes in the charges schedule can skew results from period to another and this needs to be taken into consideration (Albertsen and Atkinson, 2000; American Medical Association, 1998). The fifth metric is the procedure relative value unit (RVU). Simply, this tool measures the weight of a process relative to another standard procedure. This analytical technique aids managers to measure productivity using historical data to develop expressive and meaningful benchmarks by eliminating subjectivity such as differences in work practices among operators (physicians, technologists, and nurses) and differences in the time, skills, and drawbacks required to perform one exam compared to another. Clinical services, which are described by Healthcare Common Procedure Coding System (HCPCS) codes and Current Procedural Terminology (CPT) codes, vary from those that involve considerable amounts of time and effort, clinical staff, and specialized equipment, to those that need little physician time and minimal other resources. Accordingly, RVU calculation mainly depends on weighing the involvement of these factors in each clinical service. Specifically, for each clinical service described by CPT, Medicare determines RVUs for three types of resources which are physician work, practice expense, and professional physician malpractice. The RVU of these three components of clinical services’ weights contribute differently. Physician work, practice expenses, and professional physician malpractice comprise 52, 44, and 4 percent of total Medicare expenditures on physician clinical services, respectively (Hsiao et al, 1988).Work RVU includes the duration of the provided services, technical skill and effort needed, mental effort and judgment required, and stress to provide a service. The work RVU for a diagnostic angiography is more than twice the work RVU for an intermediate office patient visit because the angiography requires more physician time and effort than the visit. Moreover, each clinical service RVU should be reviewed every five years to update the work RVU for the relative service. The value of each code (standard
  5. 5. International Journal of Industrial Engineering Research and Development (IJIERD), ISSN 0976 – 6979(Print), ISSN 0976 – 6987(Online), Volume 5, Issue 2, March - April (2014), pp. 01-17 © IAEME 5 numeric for each procedure in the CPT) can change if the components of service have changed during the former years. A code with a higher work RVU requires more time, more efforts, more skills or some combination of these three (Glass & Anderson, 2002; Moorefield et al, 1993; Hsiao et al, 1988).Practice expense of RVUs refer to the non-physician clinical (i.e. nurses and radiology technician) and nonclinical (i.e. secretary) staff of the practice, as well as it accounts for expenses for equipment, building space, and office supplies (Health Care Financing Administration, 1991). The practice expense RVU related with the diagnostic angiography is higher than the practice expense RVU for the intermediate office patient visit. For the angiography, the practice expense RVU, is primarily indirect expenses, like administrative staff, building, and office supplies; however, it does not include medical supplies, clinical staff, and equipment where they are incurred by the facility. The RVUs for the office patient visit include clinical staff time and the equipment and supplies typically used during a visit, as well as a share of the indirect expenses of a physician practice. All these expenses are not incurred by the facility. Thus, the practice expense RVU for an office patient visit per unit of time is higher than that for angiography for the same unit of time (Moorefield et al, 1993). Malpractice RVU refers to the cost of professional liability expenses. This is commonly the smallest component of the RVU where it represents around 4% of the total RVU. The malpractice RVUs are based on malpractice insurance premium data composed from commercial and physician-owned insurers. Since malpractice insurance rates can radically change over the years, both significant increases and decreases depending on the part of the country and specialty. It is critical to update premium costs in calculating the malpractice RVUs every five years (Health Care Financing Administration, 1991).Relative Value Unit model has been used successfully in measuring academic and research activities (D’Alessandri et. al., 2000). Importantly, several attempts to accurately assess academic production have produced few noteworthy results, in large due to the lack of RVU type metrics to assess nonclinical performance. One of the most useful attempts to measure academic activity weight quantifies all components of an individual’s academic activity; weights them by approximation of effort, influence, and value to the division’s objectives; and then sums the values to deliver a net academic RVU. The concept and methodology are based on the clinical work RVU that has been discussed earlier. Each activity or achievement is allocated with a relative percentage of effort (on the basis of time and degree of complexity in performing that activity) and an academic weight (which can differ along with division objectives) that are multiplied together to arrive at a total academic RVU (Lu and Arenson, 2005). 3. RELATIVE VALUE UNIT DEVELOPMENT METHODOLOGY This paper focuses on the most important key players at any nuclear medicine section who are the physicians (NM radiologists), specialists (NM technologists), and nurses. To find out a representative RVU value for each nuclear medicine procedure, some essential information need to be clarified and agreed upon by the stakeholders of these four nuclear medicine sections. First of all, all nuclear medicine procedures need to be listed. Second, all stakeholders should agree upon the main variables which are involved in each procedure with their involvement extent. After collecting all these information, RVUs can be calculated for each procedure and evaluated by sensitivity analysis. The main steps that have been taken to estimate a uniform and fair RVU value for each nuclear medicine procedures are described below.
  6. 6. International Journal of Industrial Engineering Research and Development (IJIERD), ISSN 0976 – 6979(Print), ISSN 0976 – 6987(Online), Volume 5, Issue 2, March - April (2014), pp. 01-17 © IAEME 6 3.1. Listing nuclear medicine procedures’ names and codes Due to the variability of the services provided by the four Nuclear Medicine Sections which were involved in this investigation, the list of procedures’ names and codes were taken from the section with the biggest number of procedures. They are 78 medical procedures. 3.2. Determining the variables and their involvement extent in each procedure To investigate the variables that should be included in the study to determine the weight of each procedure; fifteen interviews with Nuclear Medicine Sections’ chairpersons and decision makers have been conducted. The aims of these interviews were to 1) assess their impression about the currently used method of calculating the section workload and staff productivity, 2) Obtain their opinion about the Medicare RVU model and its importance in measuring the workload and productivity, 3) determine the variables need to be assessed to calculate fair and representative RVU for each Nuclear Medicine procedure that suit the hospitals’ requirements, and 4) determine the weight of each variable. The main criteria for a variable inclusion were: • The variable should be measurable; • The variable should be well defined or specific; • The variable should be related to the procedure nature and not to the patient condition. The basic unit for each procedure represents the value of the procedure in terms of the main factor. The remaining other factors should be given weights based on their involvement in each procedure. The interviews with the Nuclear Medicine Sections’ chairpersons attempt to establish a weight for each variable. The selection of the variable weight is depending on the majority agreement. The fifteen conducted interviews showed that the “number of performed procedures” metrics is the method used in most specialized hospitals. This reflects that performance measurement at Nuclear Medicine Sections in the region of concern is basic and simple. However, thirteen out of fifteen of the interviewed decision makers don’t believe that the last metrics is fair and wise. Only two of them believe on it and think it gives a general view about the productivity. Moreover, the thirteen decision makers who believe in RVU model suggested that all factors contributing in the weight of each procedure should be incorporated. In other words, the length of the procedure (time) should not be the only factor that would be considered in calculating nuclear medicine procedure weight (RVU). The thirteen decision makers agreed that time, risk, complexity should be scaled and added to the procedure weight in accordance to their involvement extent. Twelve out of thirteen believed that the required skills and knowledge could distinct between the procedures. It is important to mention that the interviewees’ response does not reflect the importance or the weight of the factor itself rather than that the factor should be considered in the RVU calculation formula. Importantly, twelve out of thirteen decision makers believed that time factor should be the basic factor and the other contributing factors should have a maximum adjustment index of 30% of the procedure basic weight or value. One out of thirteen believed that the contributing factors should have a maximum adjustment factor of 50% of the procedure basic weight or value. Based on the main questions asked during the interviews with the thirteen chairpersons, it has been decided to direct the project towards adopting professional RVU for
  7. 7. International Journal of Industrial Engineering Research and Development (IJIERD), ISSN 0976 – 6979(Print), ISSN 0976 – 6987(Online), Volume 5, Issue 2, March - April (2014), pp. 01-17 © IAEME 7 nuclear medicine procedures. Moreover, four factors will be included in the criteria. The chosen factors are: time, radiation exposure (risk), complexity, and required knowledge and skills. Many researchers, such as Merzich and Nagy (2007), advocate using the time factor as a basic factor to calculate the weight (RVU) of any procedure. Accordingly, it has been decided to consider the time factor as the base to calculate the RVU for each procedure. The other three factors will add maximally 30 percent of the basic value of each procedure that will be distributed equally between the three factors. a. Procedure duration (Time Input) The duration (effective time) required to prepare the patient, perform the requested procedure, and report the findings which are relevant to Nurses, Nuclear medicine Technologists, and Nuclear Medicine Physicians; respectively, has been tabulated. This data has been collected from the department procedure protocols’ logs which includes all details about all procedures performed at the department. Many researchers, such as Merzich and Nagy (2007), advocate using the time factor as a basic factor to calculate the weight (RVU) of any procedure. Accordingly, it has been decided to consider the time factor as the base to calculate the RVU for each procedure. With this data, it has been assumed that the procedure will require the same duration with all patients regardless his/her condition. b. Radiation exposure factor (Risk Factor) Due to the difference in the radioactive materials used for each procedure, it is suggested to assign different weight for each procedure in accordance to the energy of the radioactive material; the higher radioactive material energy the higher risk involved in the procedure and vice versa. The range of the energies used in Nuclear Medicine starts from 100 to 600 KeV. In accordance, all radioactive materials with energy between 100-300 KeV will be considered in the “Mild Risk” category (M), while all radioactive materials with energy more than 300 will be considered in the “High Risk” category (H). Procedures that do not expose the staff with radiation will be considered in “No Risk” category (N). c. Complexity factor This factor is highly subjective due to the difference of staff standpoint for each procedure. Accordingly, this factor will be measured by surveying all NM staff available. The staff will be required to categorize each procedure in one of three categories: Not complicated (N), Mildly complicated (M), and Highly complicated (H). The categorization is based on the comparison with the standard procedure which is Chest X-ray. d. Knowledge and skills required Again, this factor is highly subjective due to the difference of staff standpoint for each procedure. Accordingly, this factor will be measured by surveying NM staff available. The staff is required to categorize each procedure in one of the three categories in terms of the requirement for knowledge and skills in comparison to the Chest X-ray procedure: No knowledge and skills (N), Mild knowledge and skills (M), and High knowledge and skills (H). 3.3.Relative value unit formulation Calculation of Nuclear Medicine procedures’ RVUs will depend basically on the effective time for each procedure relative to each staff category (Physician, Specialist, and Nurse). The first step in calculating RVU is to establish the basic values on which each
  8. 8. International Journal of Industrial Engineering Research and Development (IJIERD), ISSN 0976 – 6979(Print), ISSN 0976 – 6987(Online), Volume 5, Issue 2, March - April (2014), pp. 01-17 © IAEME 8 procedure RVU should be built. For this purpose, the duration of the procedure, for each staff category is compared with the duration of a standard procedure in medical imaging, specifically the “Chest X-ray” procedure. In other words, patient preparation by NM nurse, procedure performing by NM specialist/technologist, and case reporting by NM physician are compared with the standard time to prepare a patient in Nuclear Medicine Sections, the standard time for performing a “ chest X-ray” by an X-ray technologist, and the standard time to report a “ chest X-ray” by radiologist. These standard times are according to the practice of the Medical Imaging Department of the concerned hospital. Thus, since chest X-ray requires 10 minutes to be performed and 5 minutes to be reported, then the nuclear medicine procedure performing time and reporting time will be relative to 10 minutes and 5 minutes, respectively. Regarding to the nursing time, since Chest X-ray procedure does not include patient preparation by a nurse and all Nuclear Medicine procedures require 15 minutes of patient preparation according to the protocols of hospitals under the study, then patient preparation part for all procedures will be relative to 15 minutes. After finding the basic values for all Nuclear Medicine procedures, a specific weight will be added in accordance to the agreed weight given to each factor involvement extent as in Table 1: Table 1: Factors involvement extents and the associated weight percentages The Factor Involvement Extent Factor 1 (Risk) No (0%) Mild (5%) High (10%) Factor 2 (Complexity) No (0%) Mild (5%) High (10%) Factor 3 (Skills) No (0%) Mild (5%) High (10%) Basically, the RVU for each procedure will be calculated according to the following formulae: Basic Value = (Procedure Duration/Standard time) …………………………................... (1) RVU = Basic Value + (Basic value X(Factor 1 Involvement extent % + Factor 2 Involvement extent % + Factor 3 Involvement extent)) ..................................................................... (2) 4. RESULT AND DISCUSSION 4.1.Relative value unit calculation To calculate RVU for each procedure, the basic unit and the involvement extent of each factor in each procedure are required. Table 2, Table 3, and Table 4 shows some RVU calculations for NM Specialists, Physicians and Nurses; respectively, according to formulae 1and 2.
  9. 9. International Journal of Industrial Engineering Research and Development (IJIERD), ISSN 0976 – 6979(Print), ISSN 0976 – 6987(Online), Volume 5, Issue 2, March - April (2014), pp. 01-17 © IAEME 9 Table 2: Specialist RVU for some NM procedures Procedure Title and Code Basic Unit Risk Factor Complexity Factor Knowledge and Skills Required Factor RVU 30882 NM CNS-Brain death Scan 6 5.0% 5.0% 10.0% 7.2 30881 NM CNS-Brain perfusion scan 6 5.0% 5.0% 10.0% 7.2 30869 NM CNS-Cisternogram 6 5.0% 10.0% 10.0% 7.5 30905 NM CNS-CSF Leak Study 12 5.0% 10.0% 10.0% 15 30830 NM CVS-Cardiac (MUGA) Scan 6 5.0% 5.0% 5.0% 6.9 30825 NM CVS-Cardiac First Pass Study 3 5.0% 5.0% 5.0% 3.45 30826 NM CVS-Cardiac Infarct Scan 3 5.0% 5.0% 5.0% 3.45 30827 NM CVS-Cardiac Perfusion Imaging (Rest) 4 5.0% 5.0% 10.0% 4.8 30844 NM Therapy-Thyroid cancer Ablation with I-131 10 10.0% 0.0% 5.0% 11.5 30843 NM Therapy- Thyrotoxicosis with I-131 10 10.0% 0.0% 5.0% 11.5 30916 NM Therapy-Sr89 for Symptomatic bone metastases 6 10.0% 0.0% 5.0% 6.9 30901 NM Therapy-Y90 Colloid Knee Left 6 10.0% 0.0% 10.0% 7.2 30865 NM Therapy-Y90 Microsphere for liver tumor 11 10.0% 0.0% 10.0% 13.2 30917 NM Therapy-Y90 Octreotide for Neuroendocrine tumor 9 10.0% 10.0% 10.0% 11.7 30890 NM Therapy-Y90 Zevalin for Lymphoma 9 10.0% 5.0% 10.0% 11.2 5 30902 NM Therapy-Y90 Colloid Knee Right 2 10.0% 5.0% 10.0% 2.5
  10. 10. International Journal of Industrial Engineering Research and Development (IJIERD), ISSN 0976 – 6979(Print), ISSN 0976 – 6987(Online), Volume 5, Issue 2, March - April (2014), pp. 01-17 © IAEME 10 Table 3: Physician RVU for some NM procedures Exam Code Basic Unit Risk Factor Complexity Factor Knowledge and Skills Required Factor RVU 30882 NM CNS-Brain death Scan 6 0.0% 5.0% 10.0% 6.9 30881 NM CNS-Brain perfusion scan 6 0.0% 5.0% 10.0% 6.9 30869 NM CNS-Cisternogram 6 0.0% 10.0% 10.0% 7.2 30905 NM CNS-CSF Leak Study 6 0.0% 10.0% 10.0% 7.2 30830 NM CVS-Cardiac (MUGA) Scan 6 0.0% 5.0% 5.0% 6.6 30825 NM CVS-Cardiac First Pass Study 6 0.0% 5.0% 5.0% 6.6 30826 NM CVS-Cardiac Infarct Scan 6 0.0% 5.0% 5.0% 6.6 30827 NM CVS-Cardiac Perfusion Imaging (Rest) 6 0.0% 10.0% 10.0% 7.2 30844 NM Therapy-Thyroid cancer Ablation with I- 131 6 0.0% 5.0% 10.0% 6.9 30843 NM Therapy- Thyrotoxicosis with I-131 6 0.0% 5.0% 10.0% 6.9 30916 NM Therapy-Sr89 for Symptomatic bone metastases 6 0.0% 0.0% 10.0% 6.6 30901 NM Therapy-Y90 Colloid Knee Left 24 10.0% 0.0% 10.0% 28.8 30865 NM Therapy-Y90 Microsphere for liver tumor 24 10.0% 5.0% 10.0% 30 30917 NM Therapy-Y90 Octreotide for Neuroendocrine tumor 24 10.0% 5.0% 10.0% 30 30890 NM Therapy-Y90 Zevalin for Lymphoma 24 10.0% 5.0% 10.0% 30 30902 NM Therapy-Y90 Colloid Knee Right 24 10.0% 10.0% 10.0% 31.2 Table 4: Nurses RVU for some NM procedures
  11. 11. International Journal of Industrial Engineering Research and Development (IJIERD), ISSN 0976 – 6979(Print), ISSN 0976 – 6987(Online), Volume 5, Issue 2, March - April (2014), pp. 01-17 © IAEME 11 Exam Code Basic Unit Risk Factor Complexity Factor Knowledge and Skills Required Factor RVU 30882 NM CNS-Brain death Scan 1 5.0% 0.0% 0.0% 1.05 30881 NM CNS-Brain perfusion scan 1 5.0% 0.0% 0.0% 1.05 30869 NM CNS- Cisternogram 1 5.0% 0.0% 0.0% 1.05 30905 NM CNS-CSF Leak Study 1 5.0% 0.0% 0.0% 1.05 30830 NM CVS-Cardiac (MUGA) Scan 1 5.0% 0.0% 0.0% 1.05 30825 NM CVS-Cardiac First Pass Study 1 5.0% 0.0% 0.0% 1.05 30826 NM CVS-Cardiac Infarct Scan 1 5.0% 0.0% 0.0% 1.05 30827 NM CVS-Cardiac Perfusion Imaging (Rest) 1 5.0% 0.0% 0.0% 1.05 30844 NM Therapy- Thyroid cancer Ablation with I-131 1 10.0% 0.0% 0.0% 1.1 30843 NM Therapy- Thyrotoxicosis with I-131 1 10.0% 0.0% 0.0% 1.1 30916 NM Therapy-Sr89 for Symptomatic bone metastases 1 10.0% 0.0% 0.0% 1.1 30901 NM Therapy-Y90 Colloid Knee Left 1 10.0% 0.0% 0.0% 1.1 30865 NM Therapy-Y90 Microsphere for liver tumor 1 10.0% 0.0% 0.0% 1.1 30917 NM Therapy-Y90 Octreotide for Neuroendocrine tumor 1 10.0% 0.0% 0.0% 1.1 30890 NM Therapy-Y90 Zevalin for Lymphoma 1 10.0% 0.0% 0.0% 1.1 30902 NM Therapy-Y90 Colloid Knee Right 1 10.0% 0.0% 0.0% 1.1
  12. 12. International Journal of Industrial Engineering Research and Development (IJIERD), ISSN 0976 – 6979(Print), ISSN 0976 – 6987(Online), Volume 5, Issue 2, March - April (2014), pp. 01-17 © IAEME 12 The range of RVU’s for the specialists are from 2.5 to 11.7 and for the physicians are from 6.6 to 31.2 and for the nurses are from 1.05 to 1.1. The variations in their RVU’s are due to the nature of the activities to be done in each procedure by each of them, where the time required, risk factor, complexity factor and the knowledge and skills required factor are different. 4.2.RVU developed approach versus Medicare’s approach As mentioned above the methodology of calculating the weight of each procedure was mainly dependent on the time required to perform the procedure. Moreover, a maximum adjustment factor of 30 percent was added to represent the contribution of other important factors which are risk, complexity, and the required knowledge and skills. Each one of these three factors has different involvement extent in each procedure. Thus, the involvement extent was categorized into three levels: no involvement, mild involvement, and high involvement. Each involvement level was represented with a specific weight: 0 percent for no involvement, 5 percent for mild involvement, and 10 percent for high involvement. On the other hand, Medicare Nuclear Medicine Sub-committee reviewed the RVUs for all Nuclear Medicine Procedures that are defined on Current Procedure Terminology (CPT) book in 2009 (Mathews and McGinty, 2010). The weight of each procedure was calculated based on time, used equipment, liability expenses, and other expenses that are not incurred by the facility where the procedure is performed. Medicare model considers pre- procedure time, dose processing, and radiation protection survey which are done in our case by NM nurses, radiopharmacists, and nuclear medicine physicists; respectively. Considering these components as a part of procedure performance will increase the required time for each procedure and subsequently will increase its weight or it’s RVU. The second difference, Medicare has agreed that RVU will be relative to 5 minutes unit of time. Thus, after determining the total amount of time required for each procedure, the basic value of each procedure was calculated by dividing the total amount by 5 minutes unit of time. The third difference, Medicare adds extra RVU for procedures that need special equipment in a step to consider the equipment factor. Medicare system adds 1 RVU for all procedures’ weights which require either thyroid probe, ventilation imaging equipment, well-counter, or other probes. It also adds 5 RVUs to the procedures which needs basic imaging camera or non- SPECT imaging equipment. Ten RVUs are added to all procedures which need basic SPECT camera. Such a change in the procedure weight is required to increase the RVU of the procedure which should be reflected in its price. In our case, adding extra RVU for the type of the required equipment is not relevant because the model is belt to measure the weight of the procedures regardless its expenses. Fourth difference, Medicare adds liability expenses, which is named as malpractice RVU, to the work RVU and expenses RVU. 4.3. Sensitivity analysis The sensitivity analysis was used to investigate the influence of changing the two uncertainties the study involves (Procedure’s time and maximum adjustment factor) on the final result of the RVU. Because of the huge data and the big number of procedures the project involves, one procedure has been chosen to investigate the `effect of changing one of the uncertainties on the final RVU value. The reporting time of “NM Tumor-sentinel Node Imaging (Colorectal)” procedure (Exam code: 30874) was used for this purpose. The highlighted yellow column and row show the procedure reporting time by a nuclear medicine physician and the agreed maximum adjustment factor; respectively. The highlighted column and row show the effect of changing the value of time or the maximum adjustment factor on
  13. 13. International Journal of Industrial Engineering Research and Development (IJIERD), ISSN 0976 – 6979(Print), ISSN 0976 – 6987(Online), Volume 5, Issue 2, March - April (2014), pp. 01-17 © IAEME 13 the final procedure reporting RVU. Table 5 shows the changes of the adjusted RVU for the mentioned procedure with changes of its reporting time and the maximum adjustment factor. Table 5: The influence of changing procedure time and maximum adjustment factor on the final result of the RVU 4.3. Application of relative value unit To explain the application of Relative Value Unit Model, the performed procedures at specific hospital in Gulf countries during January and February 2013 has been summarized as shown in Table 6. This table is used specifically to investigate the difference in calculating the workload of Nuclear medicine departments by using both metrics: “Number of Procedures per month” and “Relative Value Unit”. All these measurements are based on the suggested procedures’ weights that are created by the proposed RVU model. The table has been used to compare between the staff productivity in terms of number of procedures and RVU. It’s clear from Table 6that the productivity of February in terms of number of procedures was slightly higher than the productivity of January. Interestingly, although the number of performed procedures in February 2013 was slightly higher than January 2013, the RVU model shows the opposite of these results. The RVU model sates that the productivity of specialists and physicians were higher in January 2013 by more than 25% and 15%; respectively. Moreover, the RVU model shows insignificant increase in nurses’ productivity in February 2013 in comparison to that of January. These results suggest that the RVU model is very important to measure the specialists’ and physicians’ productivity. However, Nuclear Medicine nurses’ productivity can be measured simply by the number of patients. This is due to the fact that patient preparation part is almost the same in all nuclear medicine procedures. Reporting Time for Procedure 30874 Percentage of Change -40% -30% -20% -10% 30min 10% 20% 30% 40% Basic Value 3.6 4.2 4.8 5.4 6 6.6 7.2 7.8 8.4 MaximumAdjustmentFactor 0% 3.6 4.2 4.8 5.4 6 6.6 7.2 7.8 8.4 AdjustedRVU 10% 3.96 4.62 5.28 5.94 6.6 7.26 7.92 8.58 9.24 20% 4.32 5.04 5.76 6.48 7.2 7.92 8.64 9.36 10.08 30% 4.68 5.46 6.24 7.02 7.8 8.58 9.36 10.14 10.92 40% 5.04 5.88 6.72 7.56 8.4 9.24 10.08 10.92 11.76 50% 5.4 6.3 7.2 8.1 9 9.9 10.8 11.7 12.6 60% 5.76 6.72 7.68 8.64 9.6 10.56 11.52 12.48 13.44 70% 6.12 7.14 8.16 9.18 10.2 11.22 12.24 13.26 14.28
  14. 14. International Journal of Industrial Engineering Research and Development (IJIERD), ISSN 0976 – 6979(Print), ISSN 0976 – 6987(Online), Volume 5, Issue 2, March - April (2014), pp. 01-17 © IAEME 14 Table 6: Lists of performed procedures in during January and February 2013 at specific hospital in Gulf countries Exam Code Jan-13 Feb-13 Jan-13 Feb-13 No. of Procedures No. of Procedures Nurse RVU Specialist RVU Physician RVU Nurse RVU Specialist RVU Physicia n RVU 30882 3 1 3.15 21.6 20.7 1.05 7.2 6.9 30881 0 2 0 0 0 2.1 14.4 13.8 30830 2 4 2.1 13.8 13.2 4.2 27.6 26.4 30827 10 25 10.5 48 72 26.25 120 180 30828 10 5 10.5 75 72 5.25 37.5 36 30838 15 1 15.75 346.88 108 1.05 23.13 7.2 30840 7 9 7.35 56.35 46.2 9.45 72.45 59.4 30847 2 25 2.1 10.35 13.2 26.25 129.38 165 30858 4 0 4.2 46 26.4 0 0 0 30857 2 1 2.1 25 13.2 1.05 12.5 6.6 30862 1 1 1.05 8.05 6.6 1.05 8.05 6.6 30849 1 0 1.05 12 6.6 0 0 0 30893 2 5 2.1 24 13.2 5.25 60 33 30894 1 7 1.05 8.4 6.6 7.35 58.8 46.2 30922 5 10 5.25 42 33 10.5 84 66 30925 10 19 10.5 84 66 19.95 159.6 125.4 30887 9 0 9.9 216.45 64.8 0 0 0 30912 9 3 9.45 112.5 64.8 3.15 37.5 21.6 30903 8 10 8.8 70 86.4 11 87.5 108 30883 3 5 3.3 26.25 32.4 5.5 43.75 54 30835 4 2 4.4 35 43.2 2.2 17.5 21.6 30918 1 5 1.1 10 10.8 5.5 50 54 30891 99 80 108.9 866.25 1069.2 88 700 864 30844 8 5 8.8 92 55.2 5.5 57.5 34.5 30902 6 0 6.6 15 187.2 0 0 0 TOTA L 222 225 240 2264.88 2130.9 241.6 1808.35 1936.2 Moreover, the productivity of two nuclear medicine physicians has been compared by using the number of procedures and RVU metrics for February 2013. As it is shown in Table 7, Physician A has reported 54 procedures compared to 43 procedures have been reported by Physician B. In accordance, the productivity ratio between A/B is 1.25, thus Physician A is working 25% more than Physician B in terms of number of reported procedures during that month. However, when the same comparison is made by using the proposed RVU system the scenario is different. Physician A has reported 561.3 RVU in comparison to 675 RVU has been reported by Physician B. Thus, the productivity ratio between B/A is 1.2, thus Physician B has produced 20% more than Physician A during the same month in terms of RVU.
  15. 15. International Journal of Industrial Engineering Research and Development (IJIERD), ISSN 0976 – 6979(Print), ISSN 0976 – 6987(Online), Volume 5, Issue 2, March - April (2014), pp. 01-17 © IAEME 15 Table 7: The productivity of two Physicians (A & B) given by Number of procedures and RVU during February 2013 at specific hospital in Gulf countries Physician A Physician B Procedure Code Number of Procedures RVU Total RVU Procedure Code Number of Procedures RVU Total RVU 30882 4 6.9 27.6 30882 1 6.9 6.9 30881 7 6.9 48.3 30881 1 6.9 6.9 30869 2 7.2 14.4 30869 2 7.2 14.4 30903 1 10.8 10.8 30903 4 10.8 43.2 30883 2 10.8 21.6 30883 4 10.8 43.2 30835 2 10.8 21.6 30835 6 10.8 64.8 30918 4 10.8 43.2 30918 4 10.8 43.2 30891 5 10.8 54 30891 2 10.8 21.6 30901 1 28.8 28.8 30901 3 28.8 86.4 30865 1 30 30 30865 2 30 60 30917 1 30 30 30917 3 30 90 30890 1 30 30 30890 1 30 30 30902 2 31.2 62.4 30902 4 31.2 124.8 30862 4 6.6 26.4 30862 1 6.6 6.6 30849 5 6.6 33 30849 2 6.6 13.2 30863 5 6.6 33 30863 1 6.6 6.6 30859 7 6.6 46.2 30859 2 6.6 13.2 Total 54 561.3 43 675 Similar productivity analysis has been made for two nuclear medicine specialists. As it is shown in Table 8, Specialist C has performed 95 procedures compared to 64 procedures have been performed by Specialist D. In accordance, the productivity ratio between C/D is 1.48, thus, Specialist C is working 48% more than Specialist D in terms of number of procedures performed during that month. However, when the same comparison is made by using the proposed RVU system. Specialist C has performed 702.5 RVU in comparison to 843.03 RVU for Specialist D. In accordance, the productivity ratio between D/C is 1.2, thus Specialist D has performed 20% more than Specialist C during the same month in terms of RVU. The previous examples show that the number of procedures performed or reported does not represent the productivity of the nuclear medicine specialists or physicians where the nature of the procedures differs significantly. The RVU model may not be 100 percent accurate in representing the actual productivity; however it is much near to it, than the number of procedures.
  16. 16. International Journal of Industrial Engineering Research and Development (IJIERD), ISSN 0976 – 6979(Print), ISSN 0976 – 6987(Online), Volume 5, Issue 2, March - April (2014), pp. 01-17 © IAEME 16 Table 8: The productivity of two Specialists (C & D) given by Number of procedures and RVU during February 2013at specific hospital in Gulf countries Specialist C Specialist D Procedure Code Number of Procedures RVU Total RVU Procedure Code Number of Procedures RVU Total RVU 30882 5 7.2 36 30882 2 7.2 14.4 30881 2 7.2 14.4 30881 1 7.2 7.2 30869 1 7.5 7.5 30869 2 7.5 15 30905 1 15 15 30905 6 15 90 30830 5 6.9 34.5 30830 1 6.9 6.9 30825 10 3.45 34.5 30825 5 3.45 17.25 30826 15 3.45 51.75 30826 3 3.45 10.35 30827 6 4.8 28.8 30827 2 4.8 9.6 30831 5 12.65 63.25 30831 9 12.65 113.85 30838 1 23.13 23.13 30838 9 23.13 208.13 30837 2 23.13 46.25 30837 8 23.13 185 30840 4 8.05 32.2 30840 1 8.05 8.05 30879 1 48 48 30879 1 48 48 30893 1 12 12 30893 1 12 12 30894 8 8.4 67.2 30894 3 8.4 25.2 30895 7 7.2 50.4 30895 2 7.2 14.4 30832 9 7.2 64.8 30832 1 7.2 7.2 30822 3 8.75 26.25 30822 4 8.75 35 30921 9 5.18 46.58 30921 3 5.175 15.53 Total 95 702.5 64 843.05 5. CONCLUSION AND RECOMMENDATION RVU values can vary from system to another and some would criticize its preciseness but for many it can be quite valuable and crucial for measuring changes in activity or productivity from one period to another; or the comparative productivity of staff performing similar activities in one department or at different hospitals. Having a unified unit to measure the output of Nuclear Medicine departments at different hospitals will support strategic planning at higher level (Ministry of Health), decision making, and budgeting. As it has been discussed, the established RVU model is more reliable in measuring Nuclear Medicine Physician and Specialist productivity than depending on the number of patients or procedures metrics. However, nurses’ productivity can be measured fairly by using number of patient’s metrics due to the standardized tasks they perform in all Nuclear Medicine Procedures. As it has been deliberated, RVU has many applications that support the management at different levels. It is very helpful to determine the needed manpower, compare cost effectiveness from different prospective, and assess the operation efficiency. For future studies, it is highly recommended to validate the main uncertainty of this model which is the time per procedure factor (reporting time, procedure time, and patient
  17. 17. International Journal of Industrial Engineering Research and Development (IJIERD), ISSN 0976 – 6979(Print), ISSN 0976 – 6987(Online), Volume 5, Issue 2, March - April (2014), pp. 01-17 © IAEME 17 preparation time) which is taken from the standard protocol of one hospital without validation. Moreover, more factors can be included to the weight of the procedure; such as patient age, patient condition, quality of the outcomes and other factors which are related to the patient condition. REFERENCES 1. Maitino AJ, Levin D, Parker L, Rao VM, Sunshine J. (2010). Nationwide trends in rates of utilization of noninvasive diagnostic imaging among the medicare population between 1993 and 1999. Radiology; 227: 113. 2. Chan, S. (2002). The Importance of strategy for the evolving field of radiology. Radiology, 224: 639-648. 3. Bair, J. and Gwin C. (1985). A productivity systems guide for occupational therapy. Rockville, MD: The American Occupational Therapy Association, Inc. 4. American Medical Association. physicians' current procedural terminology: CPT 1998. Standard Edition. Chicago, IL: AMA, 1998. 5. Albertsen P, Atkinson B (2000). Measuring contributions to the clinical mission of medical schools and teaching hospitals. Academic Medicine, 75 (12): 1231-1237. 6. Hsiao WC, Braun P, Yntema D, Becker ER (1988). Estimating physicians’ work for a resource-based relative value scale. N Engl J Med; 319:835-41. 7. Glass KP, Anderson JR (2002). Relative value units: from A to Z. J Med Pract Manage; 17:225-8. 8. Moorefield JM, MacEwan DW, Sunshine JH (1993). The radiology relative value scale: its development and implications. Radiology; 187:317-26. 9. Health Care Financing Administration (1991). Medicare program: fee schedule for physician services: proposed rule. Fed Reg; 56:25792-862. 10. D’Alessandri RM, Albertsen P, Atkinson BF (2000). Measuring contributions to the clinical mission of medical schools and teaching hospitals. Acad Med; 75:1231-7. 11. Lu Y and Arenson H (2005). The academic radiologist’s clinical productivity: an update. AcadRadiol; 12:1211-23. 12. Merzich R, & Nagy P.G. (2007). The Academic RVU: A System for Measuring Academic Productivity. J Am Coll Radiology 4:471-478. 13. Mathews A. and McGinty T. (2010). Physician panel prescribes the fees paid by medicare". The Wall Street Journal, 56:25792-862.

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