Royal Brisbane & Women’s Hospital – Medical Imaging Reviewmedia01.couriermail.com.au/.../rbhreview/radiology.pdf · Royal Brisbane & Women’s Hospital – Radiology Review

Royal Brisbane & Women’s Hospital – Medical Imaging Review Metro North Health District

February 2011

Liability limited by a scheme approved under Professional Standards Legislation

Martin Heads Dr. David Alcorn CFO, Metro North Health District Executive Director RBWH Level 3 GPO Box 48 15 Butterfield Street Brisbane QLD 4001 Herston Queensland 4006

February 2011

Private and confidential

Dear Martin & David,

Royal Brisbane & Women’s Hospital – Radiology Review

We are pleased to attach our analysis and findings in relation to the review of the Radiology Department at the Royal Brisbane & Women’s Hospital (RBWH). This review was performed under the terms of our Statement of Work (signed by Martin).

Our report sets out:

► An overview of the role, function and demand for Radiology services at the RBWH

► The key improvement opportunities identified as a result of the consultation process

► A discussion by modality highlighting key referral points, demand and utilisation (key issues and recommendations specific to various modalities are highlighted as appropriate)

► Conclusions based on stakeholder interviews, data analysis and comparisons and leading practice experience

► Key recommendations that will impact on the financial viability of the Department, patient care and improved services for RBWH clinicians

We would like to acknowledge and thank the RBWH staff for their time and co-operation during this review.

Please contact Dion Newell (08 8417 1780), Robin Michael (0418 818 228)or myself (07 3011 3516) if you have any questions on this report.

Yours sincerely

Ian Fisher Partner Attachment Copy to: Keith Mc Neill

Metro North Health District Royal Brisbane and Women’s Hospital Medical Imaging Review Ernst & Young i

Contents

1. Executive summary ............................................................................................. 2

1.1 Background......................................................................................................................................... 2 1.2 Approach ............................................................................................................................................ 2 1.3 Key issues and findings........................................................................................................................ 4

2. Radiology overview ............................................................................................. 8

2.1 RBWH role and requirement for Radiology ........................................................................................... 8 2.2 Demand for services ............................................................................................................................ 9 2.3 High level cost structure .................................................................................................................... 12

3. Stakeholder consultation ................................................................................... 14

3.1 Radiology Department culture ........................................................................................................... 14 3.2 Access to services ............................................................................................................................. 14 3.3 Resourcing ........................................................................................................................................ 17 3.4 Reporting .......................................................................................................................................... 17 3.5 Participation in clinical meetings ........................................................................................................ 20 3.6 Data quality ...................................................................................................................................... 21 3.7 Revenue ........................................................................................................................................... 21 3.8 Rostering .......................................................................................................................................... 22 3.9 Technology ....................................................................................................................................... 22 3.10 Research................................................................................................................................. 23 3.11 Service Planning ..................................................................................................................... 23 3.12 Administration Function .......................................................................................................... 24

4. Modality ........................................................................................................... 25

4.1 Overview .......................................................................................................................................... 25 4.2 Department Structure ....................................................................................................................... 25 4.3 Workflows and systems ..................................................................................................................... 26 4.4 Data Issues ....................................................................................................................................... 27 4.5 Benchmark data ................................................................................................................................ 30 4.6 General radiology .............................................................................................................................. 30 4.7 CT .................................................................................................................................................... 39 4.8 MRI ................................................................................................................................................... 48 4.9 Ultrasound ........................................................................................................................................ 58 4.10 Angiography ........................................................................................................................... 64

5. Data Quality ..................................................................................................... 70

6. Conclusions ...................................................................................................... 71

6.1 Radiology Department culture ........................................................................................................... 71 6.2 Access to Services............................................................................................................................. 71 6.3 Reporting .......................................................................................................................................... 72 6.4 Data.................................................................................................................................................. 74 6.5 Finance ............................................................................................................................................. 74 6.6 Technology ....................................................................................................................................... 75 6.7 Service Planning ............................................................................................................................... 77

Appendix A Stakeholders consulted ...................................................................... 78

© 2011 Ernst & Young Australia.

Liability limited by a scheme approved under Professional Standards Legislation.

Metro North Health District Royal Brisbane and Women’s Hospital Medical Imaging Review Ernst & Young 2

1. Executive summary

1.1 Background

The objective of the Medical Imaging Department review at RBWH was to rigorously test the improvement opportunities identified in the Phase 0 Core Business Review Report and to identify the specific action plans required to realise those benefits.

The resultant action plan will support RBWH to focus on critical areas where specific elements of Radiology are impacting on the ability to maximise service quality and efficiency, or lost revenue opportunities.

The scope of this engagement was to assist RBWH to:

► Develop a clear understanding of the key drivers of RBWH Medical Imaging services (all modalities), a clear profile of key demand and referral points, performance and particularly, the key drivers of revenue and costs

► Identify opportunities for maximising revenue and efficiency in the Department, based on available benchmarks from other radiology practices, and by analysing Department workflow and inter-relationships between modalities operated by the Department

► Identify any governance and organisational structure issues that will assist to provide clear accountability and responsibilities

► Determine strategies and current utilisation of ICT for Diagnostics and Imaging services

► Develop an implementation plan to capture benefits

The review was given an added impetus due to issues arising from the recent review of the Administration function in the Department that are negatively impacting service delivery.

1.2 Approach Ernst & Young has reviewed the operations of the Radiology Department with a view to:

► Maximising the Department’s operational efficiency

► Optimising private patient revenue

► Minimising costs

► Determining whether the Department’s asset base is appropriately utilised, maintained and refreshed

► Identifying opportunities to improve the quality of the service delivered to patients and referring clinicians

Our approach to this review has involved interviews with stakeholders from within the Radiology Department, and key referring clinicians from across the hospital.

To validate the issues raised during the stakeholder consultation we have sought to obtain data and information to validate key discussion points and areas of concern that are within the scope of this review.

We also conducted Departmental walkthroughs to observe current workflow and processes. The purpose of our walkthroughs was to identify or validate issues raised through consultation, rather than to conduct a specific process mapping or time and motion study.


The approach is displayed diagrammatically below.

Figure 1 – Review approach

Nursing Other (e.g. clerical and

orderly)

Clinical Services

IT, Finance & Billing

Business Management

/IT

Radiographers&

Sonographers

Radiologists

Emergency admission

Walk ins

Outpatients

Inpatients

Level 1 – Bottom up work flow,

walkthroughs & data collection

‘Bottom up’ process understanding and data collection to develop baseline, identify current

issues and potential impacts/benefits from a process or

‘shop floor’ perspective

Level 2 – Top down interviews

‘Top down’ interviews to identify issues and impacts/benefits from a strategic or departmental perspective

This activity has taken place over an eleven week timeframe – see below for key activities.

Figure 2 - Timeline of key activities

► Opening meeting

► Data collection

► Stakeholder interviews

► Walk through

► Data analysis & validation

► Report writing

► Report complete

090807060504030201

OctoberSeptemberAugust

Week 10 11

November

12

The deliverables from the engagement contained in this report include:

► A summary of key areas of concern raised during stakeholder interviews

► A services directory identifying key referral points and processes across Radiology

► An assessment of the activities and workflow of the RBWH Radiology Department

► An assessment of the efficiency of assets utilised

► Review of the billing and referral practices of the Department

► A review of the Department’s use of private practice


► Proposed recommendations to improve processes and to improve the financial position of the Department more generally

► Proposed action plan for implementation

1.3 Key issues and findings Context RBWH is Queensland’s largest tertiary hospital, providing quaternary/tertiary services to the state’s population, Northern New South Wales and the Northern Territory, and secondary services to residents of it’s local catchment. The RBWH has undertaken over 183,000 medical imaging examinations over the past 12 months, with 34.8% of these driven by inpatient activity, 33.3% by outpatient activity, and 31.8% by the Emergency Department.

Activity has increased steadily over the last three years (July 2007 – August 2010) and it is clear that staff working in the Department find it difficult to keep up with demand. However, analysis of RBWH activity shows that staff numbers (particularly in the Nursing and Radiography grades) have increased at a greater rate than activity.

A number of issues have been raised throughout the course of our review that may impact on the ability of Radiology services to meet the future needs of referring clinicians and patients in a timely and efficient way. These key issues are summarised below, together with our recommendations.

Key issues Access to services

The current booking processes are inefficient and time consuming for referring clinicians and do not appear to be under control. The current processes are a source of frustration for many both within and external to the Department and they impact on the quality of service the Department provides.

This issue will be difficult to address for as long as the Department continues to rely on a manual, paper based order process. It is also apparent that senior leadership of the Department do not seem interested in embracing more technology enabled processes.

Reporting

Whilst the clinical quality of reports provided to referring clinicians is high, the turnaround time for reports is poor and clinically appropriate. The time from examination to interim and final report does not meet the Department’s own targets and does not compare favourably with other hospitals of this size and complexity. This cannot be fully explained by the current ratio of reporting radiologists to activity and requires further investigation.

In addition there are further issues with reporting that require resolution:

1. The policy for follow up of reports with unexpected results, or reports that change following review by Consultant Radiologists

2. The quality of ‘scout’ images used in theatre by Orthopaedic surgeons

3. Access to dedicated PACS viewers in operating theatres

4. The automatic generation of paper reports for review by ED doctors


5. The reluctance of external doctors to refer patients to RBWH medical imaging due to the perception that they do not receive reports in a timely fashion

These issues are explained in more detail in this report.

Data quality

The quality of data available in Medical Imaging is poor. This negatively impacts the Department’s ability to understand how efficiently resources within the Department are being used, where there are bottlenecks in Departmental processes, and how effectively capacity and demand are being managed. It also impacts the ease with which the Department can claim the revenue for billable patients and measure their own performance for management purposes.

Urgent action is required to address these issues to ensure that quality data is captured and analysed. Without improvements to data that enable processes and workflow to be measured and monitored, and KPIs to be established and managed, the Department will continue to struggle to improve service delivery, and will continue to lose revenue.

Finance

The Department is currently failing to bill all activity that can legitimately be billed. A number of factors account for the fact that the Department is not currently recovering as much revenue as it should. The major reason is the variation in billing classifications across systems, poor identification of chargeable patients and identification of private insurance or Medicare details. These issues are detailed by modality in section 4.

We estimate that, as a minimum, there is approximately $3.3m in “lost” revenue due to these practices. As a maximum, we estimate $12.2m could be recovered. The following table shows:

• all actuals billed through Practix for all patient types in the 2009/10 year

• an estimate of achievable revenue if all examinations assigned a ‘chargeable’ billing classification in the RIS were billable

• an assumed average conversion rate of outpatients as chargeable and inpatients electing private cover

• a stretch target or best case estimate through significantly increased billing of outpatients

Potential Billing Opportunities

General Radiology

CT MRI US Angio Other Total

Billed through Practix in 2009/10

303,183

1,003,373

1,345,397

449,220

82,080

147,150

3,330,403

Chargeable assignment in

RIS

333,730

2,280,444

2,204,721

602,961

894,924 -

6,316,780

Average Hospital conversion rates

892,860

2,787,906

2,505,469

654,564

1,838,580 -

8,679,379

Increased outpatient billing

1,334,754

4,526,830

2,751,562

1,078,920

2,545,192 -

12,237,258


It should be noted that these estimates are based on hospital wide estimates and consideration should be given to how these may vary across modalities. In the 2009/10 financial year, RBWH billed approximately $3.3m in private practice fees.

If billing classifications within RIS are accurate, there is potential for an additional $3m in revenue or as high as an extra $9m under the stretch target scenario with increased outpatient billing. By comparison a similar sized tertiary hospital in Australia with less equipment than the RBWH (E.g. only 2 CT, 1 MRI – licensed) was forecasting to achieve $5m in revenue for 2009/10.

These outcomes are dependent upon the supporting processes and infrastructure such as front line staff asking appropriate questions, receiving appropriate training, sufficient data entry standards, accurate billing classification within the system and subsequent data flow and billing processes.

Recommendations The key recommendations from this review are as follows:

► A clear set of goals should be developed for the Department.The KPIs should be supported through a structured performance management framework.

► An experienced Administration Manager with strong leadership skills should be appointed to the Department as soon as possible. The Administration Manager should be provided with support from the management team to resolve the outstanding issues from the administration review as rapidly as possible and start to rebuild positive relationships within the administration team and across the Department more broadly.

► A detailed analysis of the current booking process in collaboration with referring clinicians, to determine priority improvements for implementation, is needed. Those improvements should then be trialled and if successful implemented.

► A business case for implementing electronic ordering is required to support the capture of data to enable measurement and reporting of key metrics, such as(order to examination time and order to report time. In the interim, ordering times should be included on request forms and entered into the RIS system to allow appropriate performance metrics to be assessed.

► A business case is required to focus on utilising a 24 x 7 CT roster to:

1) scan inpatients in the evening and weekends

2) increase the scanning of billable outpatients during weekends

3) provide support to ED during the night

► There is a need to investigate the utility of voice recognition software and possibly arrange a trial of a licence with a mainstream vendor. If the trial has a positive result, a business case should be developed to compare the cost and efficiency of report generation between traditional methods and utilising voice recognition, either with transcriptionist edits, or done by Radiologists themselves.

► There is a need to work with the Orthopaedic Surgeons to understand their concerns regarding the quality of ‘scout’ images, and access to PACS in theatre and put in place an action plan to address the issues.

► There is an urgent need to initiate a data review. This should involve:


1) specifying the information that Medical Imaging requires to support process improvement and drive greater efficiency

2) specifying data and field descriptions

3) identifying the implications for ICT and workflow to collect the required data

4) determining the documentation and continuous training required to ensure data entry consistency from front line staff, technical staff and reporting radiologists

► There is a need to develop “guidance rules” on the data entry standards expected by all staff entering information into the RIS and any other systems containing data fields of potential utility to the Department’s management. Compliance with these standards should be monitored through data quality audits, with the results distributed to the management team and acted upon.

► The RBWH Radiology Department should develop, in collaboration with key stakeholders, Departmental KPIs that are routinely collected and reported in the public domain.

► RBWH needs to review billing classifications to ensure that they are aligned to both OSIM and PractiX classifications. Ensure consistency in naming conventions, assignment and ease of comparison across all relevant systems.

► RBWH needs to review data input processes to identify where/how variability in classification is occurring and determine process improvement strategies to ensure all possible chargeable patients are being billed. This should include determining how/why all patients flagged as chargeable in the RIS are not being billed through PractiX.

► There is a need to conduct further analysis of potential billing opportunities to increase private practice billings and consider appointing ownership of Privately Referred Non Inpatient initiatives to a dedicated member of staff as has been implemented in other Departments.

Disclaimer

Our report may be relied upon by Metro North Health District and Queensland Health pursuant to the terms of our engagement letter. We disclaim all responsibility to any other party for any loss or liability that the other party may suffer or incur arising from, relating to, or in any way connected with the contents of our report, the provision of our report to the other party or the reliance upon our report by the other party. You have agreed that you will not amend the report without Ernst & Young’s prior written approval. The information contained in this report is, in part, based on information and explanations provided to us by RBWH staff and other stakeholders. Ernst & Young has not attempted to verify any of the information provided to us. Our enquiries to date may fail to have identified one or more material matters which a more extensive examination might disclose.


2. Radiology overview

2.1 RBWH role and requirement for Radiology The RBWH is a 987 bed general tertiary referral teaching hospital. It is the largest tertiary hospital in Queensland, providing services to patients from across the State, Northern New South Wales and the Northern Territory.

Medical Imaging is a critical and integral part of the clinical service provided at the RBWH. Patient flow and clinical outcomes are directly affected by the efficiency and quality of the service Radiology provides to patients and referring clinicians.

There is an appropriate expectation amongst the treating clinicians at the RBWH that the services of the RBWH Radiology Department are responsive, efficient and provide a quality reporting and interventional service that adds value to the excellence of the diagnostic and treatment regimes that the hospital clinical staff deliver.

There is a further expectation that the Radiology Department is equipped with contemporary imaging equipment that provides high quality diagnostic images to the reporting radiologists and referring clinicians, and that there is sufficient equipment to enable timely access.

As medical imaging technologies evolve through developments in hardware, scan detectors and refined algorithms built into scanner and workstation software, the dependence on medical imaging to assist in determining the diagnosis of patients, the treatment and monitoring of patients, and the post-treatment monitoring of patients is increasing considerably.

It is essential that the Radiology Department at the RBWH is appropriately equipped, appropriately staffed and appropriately funded to fulfil its role as a critical service in the treatment processes of the hospital.

It is clear from the stakeholder interviews that the Department is considered by most staff and referring clinicians to be well equipped, and to produce reports that are of a very high clinical quality. Patients who require imaging urgently usually receive it within an appropriate timeframe, and referrers state that they have a good relationship with the Department as a result. In addition to this, the input of Radiologists to multi-disciplinary team meetings is a service that is valued by the referring clinicians.

However, the Department is struggling to deliver a timely service for routine patients, and to operate within its current budget, and it is widely recognised that the systems and processes within the Medical Imaging Department do not support timely and quality delivery of care. A number of referring clinicians report considerable frustration with the booking systems used by the Department to manage its patient flows.


2.2 Demand for services 2.2.1 High level demand The total number of Radiology examinations conducted at the Royal Brisbane Hospital during the 2009/10 financial year was 183,365 examinations. Examinations are recorded in the Radiology Information System (RIS) by accession number and may represent multiple examinations for a single patient.

The ability of the Radiology Department to respond to demand from referring units for efficient access to imaging services, efficient turnaround and a quality reporting process is a critical element in delivering quality healthcare to patients.

The following table details the breakdown of Radiology services provided at RBWH between July 2009 and June 2010 by modality and patient type, as sourced from the RBWH Radiology Information System (RIS).

Type

Ang

io

CT

Dig

ital

Fl

uros

copy

Gas

troi

ntes

tina

l

Imag

e In

tens

ifier

Mam

mog

raph

y

Mat

erno

foet

al

MRI

Gen

eral

Ra

diol

ogy

Ultr

asou

nd

TOTA

L Re

ques

ts

% o

f Tot

al

Inpatient 3,696

10,474

604

378

3,848

59

4,010

32,786

7,966

63,821 34.81

Outpatient 2,206

12,580

917

24

22

1,347

1

8,811

20,607

14,608

61,123 33.33

Emergency 159

16,900

20

5

34

6

581

35,206

5,510

58,421 31.86

Total 6,061

39,954

1,541

407

3,904

1,412

1

13,402

88,599

28,084

183,365

Radiology services are relatively evenly distributed in terms of the amount of examinations carried out for inpatients, outpatients and emergency patients, though it is clear from the data detailed later in this report that outpatients have longer waiting times.

As is typical in a comprehensive Radiology practice, general radiology services place the greatest demand by volume on Radiology, followed by CT, Ultrasound and MRI. As detailed in the modality specific sections, RBWH has a higher than national average percentage of CT and MRI investigations. This may be due to the quarternary nature of the services at RBWH and the level of equipment and resources dedicated to high end specialties at the RBWH. The following chart shows the modality profile of RBWH in comparison to other teaching hospitals within Australia.


0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

MRI CT US General Interventional

Comparison of Modality Profiles

RBWH Hospital 1 Hospital 2

As a broad indicator the profile and demand on Radiology modalities at the RBWH is consistent with the general industry profile and the peer hospitals with a high demand for General Radiology, CT and MRI services.

Figures provided by the RBWH demonstrate that demand for the service is increasing steadily, as is demand for Radiology services nationally. However, the RBWH has seen an increase in staff numbers in recent years to accommodate this demand. Please see table below for details.

Actual %Increase in total activity (Jul 07 - Aug 10) 1588 11%Increase in total staff numbers 45.54 28%Increase in Managerial & Clerical 2.52 7.60%Increase in Medical & VMOs 4.75 12.80%Increase in Nursing 11.7 53%Increase in Operational 5.69 131%Increase in Professional & Technical 21.02 33%

The following graphs provide a breakdown of Radiology services provided by the Medical Imaging Department between 2007 and 2010 by modality, and in total. It is important to note that the tables show activity in the Radiology Department only – they do not include additional demand that may have been referred outside of the RBWH to external private providers, nor do they show activity that is not recorded such as advice, guidance and ‘second opinions’ provided to other hospitals across the state.

Please note: these graphs are based on management reports provided by RBWH rather than examination level data. Only raw data for the financial year 2009-10 has been analysed by Ernst & Young. Detailed analysis of the examination level data by modality can be found in section 4 of this report.

Graph 1 – RBWH Medical Imaging activity by modality


Graph 2 – RBWH total Medical Imaging activity

Further analysis has shown that out of the total 183,365 examinations conducted in 2009/10, a number are multiple examinations on the same day1. The number of patients receiving medical imaging services is 116,189.

1 i.e. the data is showing the same MRN number with multiple accession numbers on the same date at the same time. Running further queries to determine the number of patients with examinations at exactly the same time reduces the number of records to approximately 142,000. However, a number of these examinations may still occur on the same day, within minutes or seconds of each other in some cases. Further querying the data to


2.2.2 Demand from referring units As expected the greatest demand on the Medical Imaging Department is generated through Emergency and Critical Care Services reflective of the governance structure and reporting lines of the Medical Imaging Department.

Whist demand for Radiology services is spread rather evenly across outpatients, emergency and inpatients a key driver of service needs comes from internal referring units. Focusing on internal referrals (inpatients and emergency) the greatest demand for Radiology comes from a number of key services within the hospital: the Intensive Care Unit, Emergency Department, Oncology, Colorectal, Orthopaedics, Neurosurgery and Surgery. Demand for imaging services has grown over time, as outlined in section 2.2.1, and is expected to continue to increase, particularly in the ‘high-end’ modalities, as referring clinicians capitalise on the utility of new imaging technologies.

The data provided to Ernst & Young did not include details of patients referred outside of the RBWH by their treating clinician. Hence, internal demand may actually be higher than indicated in the table below which outlines the high referring specialties within the RBWH.

Referring Unit Angiography CT MRI General Radiology Ultrasound Other Total % TotalOutpatients 2,091 11,957 8,253 19,813 10,775 1,969 54,858 29.9%Emergency 210 16,988 632 35,371 5,581 97 58,879 32.1%Intensive care Unit 558 1,656 380 7,058 681 135 10,468 5.7%Oncology 505 1,416 271 3,790 618 99 6,699 3.7%NHD 73 377 915 448 3,693 327 5,833 3.2%Orthopedics 162 562 150 3,848 342 535 5,599 3.1%Maternity 9 59 116 2,679 2,246 35 5,144 2.8%Colorectal 338 1,226 207 2,516 509 282 5,078 2.8%Neurosurgery 295 1,072 769 822 167 50 3,175 1.7%Surgery 243 43 24 654 30 2,102 3,096 1.7%Rheumatology/Endocrinology 114 509 265 1,010 411 47 2,356 1.3%Respiratory/Dermatology 70 496 108 1,056 278 51 2,059 1.1%Urology 135 471 48 708 313 226 1,901 1.0%Medical 69 377 163 810 276 41 1,736 0.9%General Surgery 88 257 84 949 173 103 1,654 0.9%MAPU 68 339 176 711 318 18 1,630 0.9%Infectious Disease 111 247 66 802 167 20 1,413 0.8%Vascular 336 269 54 574 79 37 1,349 0.7%Gynaecology 79 295 78 432 264 61 1,209 0.7%Neurology 57 249 315 345 117 41 1,124 0.6%Burns/Pain 34 82 37 434 64 453 1,104 0.6%Coronary Care Unit 29 147 46 667 199 4 1,092 0.6%Cardiology 18 208 64 543 147 6 986 0.5%Other 369 652 181 2,559 636 526 4,923 2.7%Totals 6,061 39,954 13,402 88,599 28,084 7,265 183,365

2.3 High level cost structure Critical Care Services have provided financial information to demonstrate the cost to operate the Radiology Department over a three year period. We have prepared a consolidated view of the cost to operate the Radiology Department at the RBWH based on data provided. The following demonstrates the P&L against budget for a three year period.

Expense Categories 2008 Actual

2008 Budget

2009 Actual

2009 Budget

2010 Actual

2010 Budget

Revenue

User Charges (721,825) (685,800) (738,450) (774,899) (1,221,612) (987,492)

Expenses

analyse total patients receiving Radiology services with examinations on the same day (i.e. count accession numbers for MRN on same day) results in 116,189.


Labour expenses 18,599,301 16,267,962 21,774,452 20,524,849 25,052,227 23,574,219

Domestic Supplies 257,698 206,270 (2,202) 257,421 94,514 98,136

Clinical Supplies 2,060,640 2,086,592 2,361,571 2,546,997 2,393,030 2,446,266

Prosthetics 59,370 0 77,700 64,767 202,329 0

Other Supplies & Services 38,515 69,000 82,125 39,634 110,932 71,112

Purchases 2,416,223 2,361,862 2,519,193 2,908,819 2,800,804 2,615,514

Repairs And Maintenance 2,529,265 2,326,500 3,068,501 2,645,237 1,969,265 1,932,200

Loss On Disposal Of Assets 178,873 0 159,497 179,045 55,968 0

Repairs & Maintenance 2,708,138 2,326,500 3,227,998 2,824,282 2,025,233 1,932,200

Communications Expense 15,029 25,300 18,030 13,704 23,807 16,896

Computers Expense 121,779 107,100 61,108 129,141 98,861 54,504

Electricity And Other Energy Expense 0 0 0 0 224 0

Utilities 136,808 132,400 79,138 142,845 122,892 71,400

Depreciation 3,329,132 3,329,132 3,037,318 2,962,190 2,970,964 2,970,310

Other 770,543 532,900 976,857 766,921 964,746 1,108,084

Total Expenses 27,960,145 24,950,756 31,614,957 30,129,906 33,936,866 32,271,727

We note that user charges have increased by 47% between 2008/09 and 2009/10. Data received from the DORI project indicates only 15% of total examinations (based on 2007/08 data) conducted were claimed from Medicare supporting the findings regarding billing opportunities within Medical Imaging at the RBWH.

Labour costs have increased by 15% from the 2008/09 to the 2009/10 financial year as expected with the increased staffing profile within Medical Imaging to meet service demands. Labour expenditure comprises 73% of total Medical Imaging’s total expenditure. Discussions with Medical Imaging Department management suggested the mix of staff (particularly in relation to Radiologists) was considered appropriate currently.

The average cost structure for a medical imaging Department (based on an IBIS World industry report) is outlined below. It is recognised that this includes private providers but does provide an indication of cost profile in relation to the market Medical Imaging operates in:

Expense Category Average Cost Structure RBWH

Wages 51.4% 73.0%

Purchases 15.0% 8.3%

Depreciation 7.5% 8.8%

Repairs & Maintenance N/A 5.8%

Rent 5.0% N/A

Utilities 2.0% 0.36%

Other 19.1% 12.4%

Source: IBISWorld Industry Report, 26th February 2009

Based on annual patient activity the average cost to deliver imagining services per patient is approximately $185/examination. Interestingly, this is very similar to the cost per patient displayed within another tertiary hospital review conducted by Ernst & Young where the average cost based on total examinations was $182/examination.


3. Stakeholder consultation In the course of this engagement Ernst & Young interviewed a range of stakeholders within the Medical Imaging Department, and from across the hospital – including key referrers. Clear and consistent themes emerged from these interviews which have a direct impact on the operations of the Radiology Department and the contribution it makes to efficient patient care within the RBWH. A list of all stakeholders interviewed can be found in Appendix A.

The following positive themes arose in the interviews with stakeholders:

► The Radiologists in the Department are considered to be highly skilled, producing reports of a very high standard

► The majority of referring clinicians believe that patients requiring urgent imaging are dealt with appropriately

► Personal relationships with the Department at the clinical level are viewed positively in the main, and participation of Radiologists in multi-disciplinary team meetings is highly valued

► The Department is considered to be well equipped

These are all important elements of the service provided, and it is essential that the Department maintains and builds on these aspects of the service, whilst attempting to address some of the improvement opportunities within the Department.

The following issues were raised during the stakeholder consultation period:

3.1 Radiology Department culture The Medical Imaging Department does not have a positive culture. Based on the stakeholder interviews, it is clear that the culture is characterised by:

► Low morale and frustration, mainly arising from the recent Administration Review – specifically the recommendations, the way in which it was managed, the impact on operations and the time taken to resolve issues

► An absence of teamwork, and reported instances of ‘gaming’ ‘sabotage’ and ‘politics.’ Stakeholders reported multiple issues with the functioning of the Department that are exacerbated by what one stakeholder described as the ‘protectionist mentality rather than service mentality’ of the Department. In particular it was apparent that some staff members believe that ‘creating a crisis’ is a legitimate way to escalate issues within the hospital, as they do not have confidence in the formal channels for raising issues.

The current culture makes speedy resolution of operational issues difficult, and has prevented the Department from implementing improvements to the quality and efficiency of the service delivered to customers (patients and referring clinicians).

3.2 Access to services It is widely acknowledged by referring clinicians that patients requiring imaging urgently will receive a timely service. However, there is a belief that access to services is not supported by robust processes, and that personal relationships are the grounds for ensuring that investigations take place when they should. A number of issues are outlined below which were raised by multiple stakeholders.


Referring clinicians in Departments across the hospital have difficulty booking non-urgent patients – both in terms of the actual process of making a booking, and in ensuring the patient receives the imaging at the correct time (if for example imaging is required with a certain amount of lead time prior to a future outpatient appointment). Cancer Care, in particular, reported that a large amount of time is spent chasing imaging prior to routine outpatient appointments. They also reported that the priority given to inpatients disadvantages Cancer Care patients who are predominantly treated in an ambulatory setting.

In addition, urgent bookings often require the referrer to physically locate a Radiologist to approve the appropriateness of their request, which is time consuming and inefficient from the referrers perspective. The current paper based ordering process adds to the inefficiency, and is also viewed as unreliable.

There are concerns that patients are waiting too long as a result of the backlog created by problems arising from the administration review, and it is clear from management reports provided to the EY team that waiting times for CT and MRI are increasing. As a result, referrers are ‘gaming’ the system to ensure that they get the investigations done when they want them, and this is impacting patient flow in other areas of the hospital. The following examples were reported:

► Wards refusing to take patients from ED until imaging has been done (as the perception is that patients will get imaging done quicker in ED than if it is organised from the wards)

► Doctors delaying discharge on patients who are otherwise fit to return home, to get imaging done quicker (as they will be seen quicker as an inpatient than as an outpatient)

The graph below shows how waiting times in the Department have increased during 2009/10, particularly for outpatient CTs and MRIs.


Graph 3 – waiting times for all modalities 2009/10

0

20

40

60

80

100

120

Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

Waiting time (days) to next available appointment 2009/10

Urgent CT, MR, US, Angio

CT Inpatients

CT Outpatients

US Inpatients

US Outpatients

US MSK

Fluoroscopy Inpatients

Fluoroscopy Outpatients

Angio Inpatients

Angio Outpatients

Vascular Access

PICC

MRI Inpatients

MRI Outpatients

MRI (GA)

IVP

Womens Obst

Womens Gynae

Womens Inpatients

Mammogram

In addition to the issue with access to services, there is a lack of reliable data/ information regarding capacity and demand that would allow analysis of the root cause of long waits. There is an assumption by some in the Department that capacity is fully utilised and additional staff are required, but there is no data to support or refute this, and all resource planning is based on historical activity and budgets. Patient flow in the Department is a ‘grey area’ to the patient flow team, who have tried unsuccessfully to make progress in this area.

This is frustrating for referrers who want to see action taken to reduce long waits. One example of the priority given to access data by referring Departments is the fact that the Emergency Department released one of their doctors from clinical activities for a week to carry out a data analysis exercise to determine how long patients in ED are waiting for imaging, and the impact this has on their total time in ED. Unfortunately the data was of such poor quality that they were unable to draw any reliable conclusions about waiting times for imaging in ED.


3.3 Resourcing It is clear that the Medical Imaging Department has grown in size over the last three years, with an increase in staff numbers across all groups – see table below.

Increase from July 2007 - August 2010 Actual %

Total staff numbers 45.54 28%

Managerial & Clerical 2.52 7.60%

Medical & VMOs 4.75 12.80%

Nursing 11.7 53%

Operational 5.69 131%

Professional & Technical 21.02 33%

At the same time, activity increased by 11% (i.e. less than the increase across all staff groups other than Managerial and Clerical. However, the majority of staff we spoke to within the Department believe that additional staff are required to support the increasing activity in the Department.

In terms of medical staff it is clear that the current activity falls in line with international guidelines on the number of cases per Consultant Radiologist as being between 10,000 and 12,000 cases. The following table outlines the average number of examinations conducted by FTE type across a number of large tertiary hospitals within Australia. This has been based upon staff profiles and total examinations across all modalities.

Number of Examinations per FTE

Hospital Y Hospital X RBWH

Radiographers/Sonographers 1,930 1,559 2,211

Medical Staff (Incl VMOs) 5,350 3,855 4,556

Nursing N/A 3,029 5,238

Clerical/Administration/Management 5,936 3,029 4,064

3.4 Reporting The clinical quality of reporting services is reported to be high by referring clinicians in most Departments across the hospital. However, there were a number of issues related to reporting that were raised by stakeholders. These are outlined below.

3.4.1 Timeliness of reports The timeliness of reports is an issue. Images are not routinely reported in a timely fashion, or they may be reported by a Registrar but not reviewed and signed off by a Radiologist in an appropriate timescale. For example, it was reported that the majority of breast imaging is only reported on Wednesdays, as that is when the VMO is rostered on, and hence if patients are scanned on a Thursday the referring clinician (and hence the patient) can wait almost a week for reports on breast imaging. The Department’s own figures show they are not meeting targets in this respect, and this is analysed further in section 4.


3.4.2 Report follow-up The process and discipline around follow up with a referring clinician in the event of an unexpected finding, or changes to a report following review by a Consultant Radiologist, are not clear to referring clinicians, and there is some concern amongst clinicians in the hospital that this is an ‘accident waiting to happen.’ In addition, in the Emergency Department there is a concern that verbal reports provided out of hours may later be transcribed and then changed by a Consultant, and there is no record of the original (verbal) report, used by the ED Doctor when making a decision on how to treat the patient.

The RANZCR Standards of Practice for Diagnostic and Interventional Radiology Version 9.1 provide clear guidelines in this respect:

5-5-1 Interpretation and Reporting the Results

Indicator 6 – If preliminary reports are prepared, the practice has a process for reconciling any differences between preliminary and final reports, and for ensuring that this is communicated to the referrer.

5-5-3 Communication of Imaging Findings and Reports

Indicator 3 – If there are urgent and significant unexpected findings, there is a protocol which ensures that :

- The reporting Radiologist uses reasonable endeavours to communicate directly with the referrer or an appropriate representative who will be providing clinical follow up

- A record of actual or attempted direct communication is maintained by the practice

Ernst & Young were advised by the Medical Imaging Department that in both cases the clinician is notified by telephone. However, if the Radiologist does not get a response to their phone call (which is common), they will email the report noting the change. The Department did have an electronic record of all such follow up activity, but unfortunately it was recently deleted by mistake. The contact should also be recorded on the report but this does not always happen.

The Medical Imaging Department has so far been unable to locate a copy of the Department policy/ procedure that states this is the process.

3.4.3 Image Quality As noted earlier, overall the quality of images is good. However, the quality of ‘scout’ images from CT and MRI for spinal orthopaedic and neuro-surgery is considered to be poor, and it was reported by the Director of Orthopaedics that this has been a contributing factor in surgical incidents and adverse events. The ‘scout’ image is effectively the ‘roadmap’ for the operating surgeon, enabling the surgeon to ensure that they are operating on the correct site, and to the correct level. If the image is of insufficient quality it impacts the surgeon’s ability to operate successfully. This is a key concern for the Department of Orthopaedics.


3.4.4 Automatic generation of reports The Emergency Department raised an issue with regard to the considerable frustration resulting from the automatic generation of reports for the purposes of review.

The Emergency Department doctors read plain film images for ED patients, and make clinical decisions based on these assessments, rather than waiting for the report from the Radiologist. For quality assurance purposes, when the report is available they are required to review any abnormal reports against EDIS (the ED Information System) to determine if the abnormality was identified at the time the patient was in the Department, and to follow up with the patient if required. The Department’s requirement is therefore to review all plain films with an abnormal result. However, they currently receive a print out of all reports generated in ED – regardless of modality or result. This large pile of paper sits on a desk in ED, and is manually sorted and reviewed by an ED doctor. It is not clear why reports could not be reviewed in the system, nor why all reports are printed. The process of sorting by an ED doctor is an inefficient use of a skilled resource, and causes considerable frustration for ED.

Upon further investigation of this matter it appears that all reports for all modalities are printed out in the typists office in Medical Imaging on level 3, and taken away for sorting. However, the reason for this process appears to be unknown. Given the volume of reports being generated and the time and resources taken to print, sort and review them, this will have associated costs that are being incurred regardless of the value of this process.

3.4.5 Distribution of reports external to the hospital An issue related to reporting that impacts the Department’s ability to generate additional private practice revenue, is the perception of external referrers that they do not receive written reports from the RBWH. A number of Radiologists reported that they have been told anecdotally by GPs and external specialists that they do not refer patients to the RBWH for imaging, as they ‘never get reports’. This is in stark contrast to the efficient report e-distribution methods used by the vast majority of private radiology practices to support their referring clinicians.

The current process of faxing reports to referring clinicians outside the hospital is considered unreliable, and in addition there have been instances where reports have been faxed to the wrong clinician. These issues may result from errors on the part of the Medical Imaging Department, or by staff at the referring doctor’s practice, but regardless of the source of the error, it impacts negatively on referring doctors’ confidence in RBWH systems and processes, and their likelihood of referring patients to the Department.


3.4.6 Images not reported The following table outlines the number of reports that have not been reported on based on the RIS data provided for the 2009/10 year by modality. These reports do not have a transcription time assigned and as such are considered as ‘unreported’.

Not Reported

Total Exams

% Not Reported

General 903 88,599 1.0%

CT 889 39,954 2.2%

MRI 377 13,402 2.8%

US 539 28,084 1.9%

Angiography 752 6,061 12.4%

Digital Fluoroscopy 198 1,541 12.8%

Gastroentestinal 30 407 7.4%

Image Intensifier 1,098 3,904 28.1%

Mammorgraphy 41 1,412 2.9%

Materno-Fotel 1 1 100.0%

Totals 4,828 183,365 2.6%

Unreported examinations carry a number of serious clinical risks including the possibility that findings necessitating urgent intervention may be unnoticed, as well as the risk of patient harm from an inaccurate preliminary interpretation by a non-expert reader.

3.5 Participation in clinical meetings Radiologists in the Department attend clinical meetings based on their areas of interest and expertise. This contribution to multi-disciplinary team meetings is valued by clinicians across the hospital, and is an essential element of the integrated service provided by the Radiology Department. The key issue for the Department in this respect is the capacity of the Radiologists to balance their workload so that they are able to attend the meetings and keep on top of the reporting workload. This was reported to be difficult as it can take up to 1.5 days a week of the four day standard working week for Radiologists to prepare and attend these meetings. The impact of this is threefold:

► Radiologists report out of hours to catch up on reporting

► Reports are delayed

► Multi-disciplinary team meetings are cancelled or rescheduled due to unavailability of the Radiologists – this creates difficulties for other clinicians in the meeting who must then reschedule their own workload


3.6 Data quality Data quality is a significant issue for the Department particularly in relation to tracking patient flow through the Department, understanding where they have issues that need addressing, and billing.

As an example, waiting time data is unreliable and this is demonstrated by the fact that some referrals are logged as arriving in the Department after the investigation has taken place. As the date and time of referral is marked on the form when it arrives in the Department, and this is a manual process, there are a multitude of reasons why it may be flawed. In addition, multiple entry points for requests complicate the process and make it difficult to control and maintain consistency. The diagram below shows the different points of entry for referrals into the Department.

The lack of robust workflow data make it difficult for the Medical Imaging Department to determine the cause of long waits – in particular whether they are the result of processes that could be improved within the current resourcing arrangements. As a result, the Medical Imaging Department is one of the few areas in the hospital where the patient flow team have been unable to adequately understand the current flow through the Department.

The absence of data is also problematic for referring clinicians as it means there is no clarity regarding how long their patients will have to wait for imaging. This makes it difficult for them to plan the care of their patient, and to provide reliable information to the patient regarding their future care.

3.7 Revenue Discussions with stakeholders demonstrated that revenue is a secondary concern for most staff in the Radiology Department (with the exception of some Medical Staff), and not seen as part of their responsibilities. As a result, a culture of seeking opportunities to maximise revenue or increase efficiency has not developed. A common comment in this respect was


that there is no incentive to increase revenue or increase activity as the Department is busy enough already and there is not benefit to them from a budget perspective.

3.8 Rostering The Radiologist rosters are currently prepared six weeks in advance, and reviewed one week out. There are often changes to the roster one week out, and this was reported to cause some issues in the event that patients have been booked and Radiographers rostered on to align to the specialist skills of some Radiologists.

Although it is recognised that staff commitments do necessitate some changes to rosters, this may be an area where guidelines are required to establish the circumstances in which changes can and cannot be made to rosters within a certain amount of time. As an example, there are hospitals that have put in place rules that rosters are fixed six weeks in advance, and all leave and professional development commitments must be booked prior to the roster being agreed. The only changes allowed after that day are those arising from unforeseen circumstances.

Radiographers are currently on call out of hours for CT, but are regularly called in (unlike Radiology Registrars who are rostered on out of hours shifts). It was reported by a number of stakeholders that there has been reluctance by the Radiographers to move to a 24 x 7 shift, but many stakeholders believe this would be less expensive and would support quicker turnarounds in ED.

3.9 Technology Broadly speaking, stakeholders are happy with the technology currently available in Medical Imaging at RBWH. However, there were some issues raised that could be addressed with relative ease. These are detailed below.

3.9.1 Using the full capability of technology available It is clear that the Department is well equipped with modern technology, however there was some dissatisfaction expressed by stakeholders within and external to the Department that the full capability of the equipment is not being used. It was reported that attempts have been made by some of the more junior Consultant Radiologists to suggest changes to work practices that would allow better use of the equipment’s capability, but they have been frustrated by a lack of response or discussion of alternatives. In addition, some of the referring clinicians would like to see the full capability of the equipment being used, to deliver the best imaging possible.

3.9.2 PACS Web Viewers The dedicated PACS screens work well, however when viewing images through the web viewers referring clinicians do experience some frustration with the speed of the viewer, i.e. it is considered to be too slow. As the current web viewer is a thick client the image build time is dependent on the network bandwidth and there are obvious limitations affecting high volume applications such as web viewers. There may be opportunities to implement improvements to the PACS web viewer or to switch separate networks for high end modalities to improve quality of images.


3.9.3 Access to screens in theatres The lack of dedicated viewing screens for images in theatre is a problem, particularly in Orthopaedics. Orthopaedic surgeons require the images from PACS throughout surgery and use them for measurement and to guide their procedures. Due to a lack of dedicated viewing screens they are not always able to access the images (as the PCs are being used by other staff for input of data throughout the procedure). This is a quality and safety issue as the image should always be available to the surgeon prior to and during the procedure. Although technically it is available, as PACS is available in each room, in reality it is not accessible. This impacts the surgeon’s ability to operate safely, and has the potential to slow down throughput in theatre.

3.9.4 Electronic ordering The Department does not have electronic ordering software, which in part explains a number of issues related to data quality, workflow efficiency and quality and safety. Electronic ordering could save considerable time for referring clinicians, would ensure that all requests were processed and tracked and would enable a better understanding of capacity and demand within the Department.

3.9.5 Voice recognition software A number of Medical Imaging Departments are migrating to voice recognition to improve productivity and effect cost savings. A number of hospitals have implemented this application and reporting radiologists have agreed to self edit their reports positively improving report accuracy and timeliness. While there are reported to be integration issues with the current version of the RIS, this is certainly an opportunity that should be monitored and pursued as and when appropriate.

3.10 Research There is a perception amongst referring clinicians that there is a lack of research in the Medical Imaging Department, and there are difficulties accessing equipment for research purposes. However, although there are competing demands on clinician time, the Department does contribute to and participate in a number of research projects. Specific time is allocated to allow for research time for clinicians within the Department.

The Director of Research and Education, Professor Alan Coulthard, heads a core team encompassing two Senior House Officers, a part-time Research Nurse and full-time Research Coordinator, with many other members of the Department actively participating in research. The RBWH Research Report shows a considerable number of staff to be involved in research, staff attaining awards and a substantial volume of publications.

3.11 Service Planning A number of Radiology Department staff reflected a frustration with their lack of involvement in service planning at the wider hospital level – particularly in those areas that impact the Medical Imaging Department. This has real impacts on the medical imaging Department’s ability to deliver services within budget and hinders their engagement in hospital wide initiatives and programs. The most recent example of is the hybrid theatre that was established without securing the additional funding to staff it with Imaging staff. It is unclear whether recurrent funding will be secured to staff the hybrid theatre beyond the end of 2010.


3.12 Administration Function A review of the administrative function in the Medical Imaging Department was carried out in June 2010, and a number of recommendations put forward as a result. Although the majority of the recommendations were accepted there were a number that proved contentious, and that are still being negotiated. It is clear that the administrative review was established with good intent, however as a result of the review there have been a number of problems within the Department, including:

► A high profile backlog of appointments

► Scheduling errors

► Low morale

The Administration Manager appointed to take over the newly restructured team, and to implement the report has recently resigned.

This report will not revisit the reasons for the administration review, however it is clear that the issues created by the review need to be addressed rapidly as they are having a detrimental impact on the effective working of the Department. There also appear to be some lessons available to the hospital in how such reviews are implemented, and the communications strategies and staff engagement that needs to pervade such reviews.


4. Modality

4.1 Overview The RBWH provides a comprehensive range of imaging services to referring clinicians and their patients. Whilst there are some common opportunities for improvement across the Department, there are differences in the way each modality is staffed, managed and provided, and it is therefore useful to separate them out when analysing demand and service provision.

This section provides an overview of each major modality.

4.2 Department Structure As of August 2010 the Medical Imaging Department employed 205.5 FTE staff, as detailed in the table below.

Staff group FTEs

Managerial & Clerical 35.78

Medical incl VMO 41.65

Nursing 33.71

Operational 10.02

Professional and Technical 84.37

Total 205.53

The Department is structured into four broad teams: Radiologists, Radiographers, Nursing and Administration, all reporting to Associate Professor Peter Scally. Associate Professor Scally reports to a Divisional Head (Associate Professor Marianne Vonau) who takes a close interest in the operations of the Department. The Department structure is represented below.

Dr Peter ScallyDirector

Dr Ray Gwynne, Deputy Director

Assoc Professor Alan Coulthard

Deputy Director Research & Education

Paul EsdaleDirector, Medical

Imaging Operations

Helen McMahon Nurse Unit Manager

Administration Manager (Vacant)


4.3 Workflows and systems In the absence of any record of the time of order/ request, and the paper based nature of referrals, it has not been possible to carry out a systematic analysis of workflow and systems using RBWH data.

Without data on the time an order for Medical Imaging services was provided it is not possible to determine the responsiveness of Medical Imaging to urgent requests, and how the demands being placed on Medical Imaging may impact on patient flow between RBWH Departments, access block and length of stay. These are all critical factors that have financial consequences for RBWH (e.g. increasing costs per DRG) and can also impact on patient care, safety and the quality of service delivered.

The manual nature of the ordering process results in a number of issues that have been highlighted throughout our stakeholder discussions. These include:

1. Potential for request orders to be misplaced, lost or delayed in being entered into RIS and scheduling systems. During walkthroughs a number of order forms were sighted sitting on the back of doors waiting for errors to be dealt with or to be collected.

2. Request forms may have missing information which results in follow up and additional effort for administration staff to obtain relevant information from requesting clinicians, or potentially incomplete data sets. The most relevant example observed throughout this engagement was the lack of an order request time. Electronic ordering systems can be developed with in built algorithms to ensure specific information is entered as mandatory.

3. The recent incidents of backlog in Radiology were reported in the Sunday Mail on 15 August 2010. Through discussion it was reported that much of this backlog was created by administrative staff in retaliation to the recent Administration Review. An electronic ordering system would not result in examination requests not being attended to as a result of not being input into systems.

4. In some circumstances the manual process of having to walk an order form around to Radiology, find the right location for that particular request form, ensure someone is available to receive the form and then return to clinical activities is time consuming and inefficient. This was reported as a specific issue with ordering in the Emergency Department.

5. The manual nature of request forms does not provide any mechanism for Radiology to manage demand. Electronic ordering systems allow specific ‘ordering protocols’ to be incorporated to assist in managing demand and over ordering. In the United States these protocols are mandated with serious actions for breach of protocol (i.e. ‘gaming’ the system).

6. EDIS data standards (contained within the ED Terminology reference document issued by the state wide ED Network) state that ‘Consultation Request Time’ should be recorded in the EDIS system. This is defined as:

The time at which the ‘ED Treating Clinician’ or ‘Senior ED Dr’ initialises a request to an Inpatient Team and/or health service within (or occasionally outside of) the hospital for advice, a review and opinion, or notification of admission. Also known as “time of referral”, “consult referral time” or “consultation request time”


As a result it would be expected that the time a referral to Medical Imaging is made should be recorded in the EDIS system. Although some ED doctors do make a note of this in a free text field on EDIS (for the purpose of monitoring the patient), it is not a mandatory field and it does not appear to be a field that can by used to measure the time from order request to examination (based on discussions with EDIS Data Managers).

4.4 Data Issues Throughout the course of discussion with key stakeholders within the Medical imaging Department the quality of data contained within the RIS system was continually described as poor quality and it was identified that management are unable to rely on that data.

These issues extended to frustration of referrers and other areas within the hospital attempting to utilise data captured within Medical Imaging and impacting on their ability to effectively identify where processes may be breaking down throughout a patient’s hospital journey.

Whilst it was noted that the data was of poor quality making it difficult to assess performance in certain areas it was not common for stakeholders to comment or provide suggestions on how data quality may be improved or how this was currently being addressed.

A range of key data issues identified in the analysis conducted by Ernst & Young are highlighted below.

High outliers

For the purposes of ensuring that all high outliers are removed we have run all metrics within modalities for exam to interim, exam to final and interim to final report excluding those examinations that take over a week to report on. The following table highlights that 17,490 examinations have taken over a week to report on by modality with over 75% of these reflected in General Radiology. These are discussed further within each modality.

The significance of these outliers is relevant and will skew averages in measuring performance metrics and data. In some cases this may be genuine but without further investigation and data cleansing it is not possible to determine the root cause of outlying data.

Total Examinations Taking Over 1 Week to Report

Modality Monday Tuesday Wednesday Thursday Friday Saturday Sunday Total

General 2,300 2,281 2,420 2,776 2,043 938 748 13,506

Ultrasound 348 380 494 427 330 103 83 2,165

Angiography 163 109 62 124 72 13 7 550

MRI 93 117 123 178 60 9 15 595

CT 22 46 41 82 55 9 12 267

Image Intensifier 5 8 17 51 30 6 4 121

Mammorgaphy 22 26 42 25 17 132

Digital Flouroscopy 16 25 49 27 13 1 131

Gastroentestinal 2 1 1 8 11 23

Total 2,971 2,993 3,249 3,698 2,631 1,078 870 17,490


Data Errors

In addition we have excluded a number of examinations that have exhibited negative values in determining the time taken from examination to report. I.e. the report time in the system is recorded as occurring prior to the examination time. A sample of the 1,567 records excluded is provided below. As can be seen from the table the accession numbers between the two data sets match as shown by the yellow highlighted cells. In addition the blue highlighted cells demonstrate that the examination time in the RIS system is after the transcribe and final report date and time. The green highlighted cells show an example where the transcribe date and time is before the examination time but the final report time occurs after the examination time/date.

MRN Acce ssion Orderable Type Modality Date Time Room Loca tion BillingRequesti

ng_dr Acce ssionTra nscribe

DT/TMFinal

DT/TM

B331254 RA090105661RA Abdomen

Plain Film INPATIENT RA 1/30/2010 19:26 19:26:09 RB DEM 2 9B SouthPublic

Medicare

WAINWRIGHT,

DANA - RBH -

INTMED RA09010566112/07/09 09:03:53

12/07/09 13:27:44

B735512 DF100000004

DF Arthrogram Shoulder

Right OUTPATIENT DF 4/23/2010 21:45 21:45:10 RB DFl 17 Hand Clinic Medicare

KTET -TETSWORTH, KEVIN DF100000004

01/15/10 07:37:52

01/15/10 16:06:08

B197422 CT090030631 CT Head OUTPATIENT CT 9/16/2009 9:36 9:36:50 RB CT 1OPD

NSurg Medicare

WINTER, CRAIG RBH

N/SURG OPD CT090030631

09/09/09 14:56:47

09/16/09 11:32:13

B571871 US090027152 US Chest OUTPATIENT US 9/9/2009 15:00 15:00:26RB US DEM DEM Acute

Unsighted Medicare

Card

LAI, KIM EMERGE

NCY DEPT RBWH US090027152

09/08/09 16:13:30

09/09/09 15:18:44

B322553 MR090014883 MR Head OUTPATIENT MR 8/27/2009 12:39 12:39:00 RB MRI 2OPD

Neuro

Unsighted Medicare

Card

WINTER, CRAIG RBH

N/SURG OPD MR090014883

08/21/09 08:00:54

08/27/09 17:51:07

Exa mina tion and Referral Data Provided Re porting Time Da ta Provide d

Duplicate Data

In addition to the above data elements Ernst & Young identified that the time of examination field is not being adequately utilised. In many instances a patient’s examination time is recorded as only one examination time for many examinations on the same patient. E.g. a scan on the right arm and a scan on the left arm are recorded as occurring at the same time.

As a result this may also skew data averages and attempts to measure performance metrics. For example, it is not possible to assess the efficiency of radiographers from the time an examination was started to the time it was finished. It is unclear from the data provided as to whether standard practice is to enter the examination time as a start time, time completed or individual times for each examination.

As a result we have removed these duplicate entries in assessing metric data. The following example demonstrates how the inclusion of these ‘duplicates’ may skew metric data.

Patient Examination Exam Time Interim Report Time

Time from Exam to Report

Patient A Exam 1 9.00am 11.00am 2 hours



Patient B Exam 1 9.00am 5.00pm 8 hours

Average Exam to Report Time

3.5 hours


In comparison if we were to exclude the multiple examinations recorded at the same time for Patient A our results are quite different.

Patient Examination Exam Time Interim Report Time

Time from Exam to Report


Patient B Exam 1 9.00am 5.00pm 8 hours

Average Exam to Report Time

5 hours

In addition Ernst & Young noted through data analysis that bulk approval of final reports was occurring in some instances. Further investigation is required to understand from Radiologists whether this is a product of the actual review process and RIS functionality or whether underlying issues exist. Possibilities include:

• Administrative/clerical staff are approving reports after notification from Radiologists that those reports are authorised and processing approvals in batches through the RIS

• Radiologists are reviewing reports and then batch approving as a result of RIS functionality

• Data being ‘cleaned up’ and unreported examinations being subsequently authorised in the system without review

Examples of this data are provided in the following table:

MRN Modality Patient

Type Exam Date Transcribe Date Final Date

1002457 RA Inpatient 11/19/2009 10:29 11/29/2009 12:16 11/30/2009 17:22

1002457 RA Inpatient 11/19/2009 13:33 11/29/2009 12:17 11/30/2009 17:22

1002457 RA Inpatient 11/24/2009 13:52 11/29/2009 12:18 11/30/2009 17:22

Practix Data

Practix data to analyse the level of billing occurring in each modality has been provided by RBWH’s own source revenue team. It is not possible to split out examinations billed by patient data within Practix.

Additionally, it is not immediately possible to link data at the examination level between each data set. The common fields utilised are the patient medical record number (MRN) and the date of service. With some additional work it may be possible to link this data within the databases created by Ernst & Young, however, this has not been conducted for the purposes of this review.

As such, in determining potential revenue opportunities the data provided within the RIS system has been relied upon as accurate and compared to levels of billing within Practix. To the extent that the assignment of billing classifications is not correct within the RIS further investigation is required to understand the root causes of incorrect data entry.


4.5 Benchmark data The following table provides an outline of the performance of the RBWH benchmarked against another large tertiary hospital within Australia. The turn around times are significantly larger for all modalities and indicate some very serious issues which require immediate attention. The metrics for RBWH are discussed throughout each modality section following.

Minutes Exam to Interim Exam to Final Interim to Final

Hospital X RBWH Hospital X RBWH Hospital X RBWH

MRI 24 1,320 127 3,540 103 2,220

CT 25 240 134 2,160 109 1,920

US 5 1,380 33 2,880 28 1,500

General 20 3,060 84 4,440 64 1,380

Interventional 84 2,040 281 4,740 197 2,700

4.6 General radiology 4.6.1 Demand Data from Medicare Australia shows that between 2005/06 and 2009/10 the average annualised growth rate for diagnostic radiology was 2.3%, and that in 2008/09 diagnostic radiology accounted for 48.4% of all imaging test orders.

The profile from RBWH is showing a lower growth rate in this modality than the national average, with a 1.75% increase from 2007/08 to 2008/09, and a decrease of 3.2% between 2008/09 and 2009/10. However, as a percentage of all imaging requests at RBWH plain film is in line with the national average, as it represents 48.3% of all requests.

From June 2009 to July 2010 there were 67,992 plain film examinations referred from internal referrers at the RBWH, with over 50% of requests coming from patients in Emergency with Intensive Care (10%), Oncology (5%) and Orthopaedics (5%) also being high requesters of general radiology examinations.

The total volumes by key referrer can be seen in the table below.

Referring Unit General Radiology

Emergency 35,371

Outpatients 19,813

Intensive care Unit 7,058

Orthopaedics 3,848

Oncology 3,790

Maternity 2,679

Colorectal 2,516

Respiratory/Dermatology 1,056

Rheumatology/Endocrinology 1,010

General Surgery 949

Neurosurgery 822

Medical 810


Infectious Disease 802

MAPU 711

Urology 708

Coronary Care Unit 667

Surgery 654

Vascular 574

Cardiology 543

NHD 448

Burns/Pain 434

Gynaecology 432

Neurology 345

Other 2,559

Totals 88,599

We have analysed the activity in the Department by hour of day and day of week for the financial year 2009/10, as demonstrated in the graphs below.

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Average examinations by hour of day - Plain Film

It is clear from this graph that key periods of activity are between 8am and 6pm, which reflects the number of staff rostered on during this period. There is some concern from the Emergency Department that insufficient plain film examinations are done overnight, resulting in a backlog at the start of the working day. Unfortunately, as order times are not captured in the system, it is not possible to investigate this in more detail, though the peak from 9am until 12pm with a drop off in activity after hours appears consistent with this comment.

It is interesting that there is a drop in the average number of examinations between 12 and 1pm, despite no changeover of staff occurring at this time. This is similar to a number of other modalities, and the assumption is that this is due to lunch breaks. This may present an opportunity to review the rostering of staff to maintain greater scanning continuity across the working day.

The following graph shows the average number of examinations by day of the week.


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Average examinations by day of week - Plain Film

This shows considerable variation in the numbers of examinations taking place on different days of the week, with approximately 18% less on a Friday than on a Monday, and 40% less on weekends than on the average weekday.

The total volumes by hour of day and day of week are representative of similar sized tertiary hospitals within Australia.

4.6.2 Analysis of report completion/efficiency Based on the RIS data provided we have conducted an analysis of the time taken from examination to interim report and examination to final report. Interim reports are those that have been dictated by a Registrar or a Consultant Radiologist, and transcribed, but not signed off as a complete and accurate record by the reporting Radiologist. As all reporting by Registrars must be reviewed and signed off by a Consultant Radiologist, this represents a significant workload, and can be the cause of considerable delay.

The data for examination to interim report for plain film is presented in the graph below. It is clear from this graph that on the whole the interim reports for emergency patients are completed quicker than for inpatients or outpatients (with the exception of examinations that take place on a Sunday).

In terms of the range of average times taken to produce an interim report, there is a considerable difference between the lowest average (40 hours for emergency patients scanned on weekdays) and the highest (approximately 58 hours for inpatients scanned on a Weekend).

It is recognised that in the Emergency Department the referring clinicians will read the images themselves in order to expedite patients through ED where possible, and this may account for the lack of urgency with which these images are reported.


The following table provides an outline of the averages by weekday and weekend for examination to interim report times by patient type.

Hours Emergency Inpatient Outpatient Total Average

Average weekday 40 57 57 51

Average Weekend 45 58 51 54

The above table demonstrates that on average most general radiology examinations are not reported on within 48 hours. Based on the Department of Medical Imaging’s own performance indicators and targets they expect 85% of general examinations to be reported within 72 hours. However, as at February the reports provided indicate only 45% of examinations are reported within 72 hours.

In addition, the graph below demonstrates the average time from interim to final report by the day that the interim report was generated. This demonstrates that there is a considerable gap between the interim report being generated and the final report being signed off by the Consultant Radiologist. This step takes on average 34 hours on a weekday, with significantly longer delays for those reports where the interim report was generated on a weekend (62 hours), particularly on Sundays as demonstrated in the graph below. It is unclear why this would be the case.

It is also significant to note in the graph below, that the delay between interim and final report is often longer for emergency patients.


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Average time from interim to final report, by day of interim report - Plain Film

RA INPATIENT

RA OUTPATIENT

RA EMERGENCY

The following table provides an outline of the averages by weekday and weekend for interim to final report times by patient type.




The final graph below demonstrates the average time in total from examination to final report, by day of week the examination took place on. This shows that in total, average times range from approximately 2 days to approximately 4 days. These are significant findings as even at the lower end of the scale this is considerably longer than the Department’s own targets, and should be an area of concern for the Department’s management team.

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Average time from examination to final report, by day of examination - Plain Film

RA INPATIENT

RA OUTPATIENT

RA EMERGENCY


4.6.3 Billing and financials The following table outlines the examinations that have been assigned particular billing classifications within the RIS system. The billing classifications have been assigned as either chargeable or non-chargeable in consultation with RBWH’s revenue Department. Practix data was obtained and compared by number of examinations billed (by CMBS code) to the number of exams classified as chargeable in the RIS system.

Number Examinations Chargeable Non-

Chargeable Total % Chargeable in

RIS

Outpatient

3,562

17,045

20,607 17.29%

Emergency

717

34,489

35,206 2.04%

Inpatient

2,715

30,071

32,786 8.28%

Total 6,994

81,605

88,599 7.89%

Examinations Billed through Practix

5,649

% Identified as chargeable Billed 80.77%

As highlighted above 80.77% of examinations that are identified as chargeable in the RIS system are being billed through Practix. However, only approximately 8% of total examinations are being assigned a chargeable classification in the RIS. The split by patient type appears much lower than the expected conversion rates across the hospital (e.g. take up rate of private insurance for inpatients across the hospital is approximately 30%).

The revenue that has not been billed (based on an average fee from Practix data $53.67) has been derived to provide an indication of potential lost billing opportunities. Further opportunities may also exist where examinations classified as non-chargeable in the RIS are actually able to be charged provided all relevant criteria are met. The following table outlines the number of examinations assigned to chargeable and non-chargeable billing classifications within the RIS.


Billing Classification (RIS) Outpatients Emergency Inpatients Total

Eligible Other 3,435

7 146

3,588

Other Chargeable 127

710 2,569

3,406

Total Chargeable 3,562

717 2,715

6,994

Medicare - Public 14,002

20,833 22,891

57,726

Not Eligible 49

211 -

260

Unsighted Medicare 2,798

12,688 5,369

20,855

No Billing Classification Assigned 120 4 5 129

Other Non-Chargeable 76

753 1,806

2,635

Total Non-Chargeable 17,045

34,489 30,071

81,605

Total 20,607

35,206 32,786

88,599

Current conversion rate 17.3% 2.0% 8.3% 7.9%

Applying an average rate of conversion to estimate billing opportunities we have derived a conservative and aggressive estimate based on the total examinations by patient type.

These estimates are outlined in the table below and indicate that between $330k and $1.3m of revenue could be generated depending on the supporting infrastructure and accuracy of data capture and data flows. During the 2009/10 year only $303k was billed for general radiology procedures.

Average General Radiology Exam Fee: $53.67 Billed

2009/10: $303,189

Outpatients Inpatients Total ($)

Current RIS Classifications 17% 8%

Potential Revenue ($)

188,016

145,714 333,730

Hospital wide average conversion rates 33% 30%


364,973

527,887 892,860

Increased outpatient billing 65% 35%


718,885

615,869

1,334,754


The graph below represents diagrammatically the level of examinations that are being assigned a billing classification across each patient type.

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Outpatient Emergency Inpatient

% Examinations assigned chargeable billing classification in RIS

Chargeable Non-Chargeable

Key observations from the data analysed include:

► On average approximately 17% of outpatients, 8% of inpatients and 2% of emergency patient examinations are being flagged as chargeable in the RIS system. This is much lower than the average conversion rates for each patient type experienced hospital wide. Hence, there appears to be opportunity to improve the identification and billing of chargeable patients in the RIS system

► 24% of examinations within the RIS data do not have medicare details sighted/recorded indicating further billing opportunities may be lost.

► 65% of outpatient referrals are represented by patients flagged as public without a private referral. In other jurisdictions many of these patients may be classified as privately referred non-inpatients providing relevant criteria are met. It is understood Queensland Health have sought legal advice regarding the possibility of billing this patient cohort.

► 129 examinations have not had a billing classification assigned at all supporting the issues noted in relation to data quality. Further analysis is required to understand the root cause of why chargeable billing classifications are not being assigned within the RIS system.

► We note that the level of billing compared to what is being identified under a chargeable classification has remained reasonably constant throughout the course of the year. This indicates that actions to rectify the cause of issues have not been taken to improve identification of chargeable patients.

4.6.4 Issues and findings Based on our data analysis for General Radiology we note the following issues and findings in relation to the service delivery and billing arrangements:

► The time taken to report images in general radiology is a cause for concern. Although we understand that in a number of areas the referring clinicians will read the images themselves, nonetheless the average reporting times (both from examination to interim report, and from interim to final report) are of concern from the perspective of quality of care, and indicate considerable opportunity for improvement.


► Our analysis of activity by hour of day and day of week demonstrates that the equipment is not being fully utilised outside the hours of 8am and 6pm, or at weekends. Whilst there are challenges in accessing the required staff to treat patients and patients presenting during these hours, it does provide an indication that there is additional capacity that could be utilised with the correct level of resources.

► Difficulties were experienced in gaining access to relevant metrics to analyse the performance of the Radiology Department. We noted that the manual ordering process for examinations, and the absence of any attempts to record ordering times makes it very difficult to analyse flow through the Department. The ability to link data between systems was also hampered by inconsistent data and poor data quality.

► Approximately 8% of examinations are being identified under a chargeable billing classification in the RIS. Significant opportunity to increase identification of billable patients and charge either the patient or Medicare appropriately appears to exist but requires further investigation.

4.6.5 Recommendations ► RBWH should undertake a detailed process mapping exercise to map out the source of

data, data input, flow of data between systems, audits or reviews conducted post data input, feedback from audits/reviews to staff responsible for data input to determine the level of training and/or learning that is being provided as a result of audits/reviews. The purpose of this review would be to determine the root causes of errors in data input, determine mitigation strategies, and identify inefficiencies and process improvement opportunities.

► The possibility of electronic ordering and associated benefits specifically in relation to demand management, performance management and improving data quality should be investigated.

► The own source revenue team should conduct a detailed review of Medical Imaging to identify issues resulting in non-identification of chargeable patients and assess the appropriateness of assignment of billing classifications with a view to maximising revenue opportunities for both the Medical Imaging Department and the RBWH.


4.7 CT 4.7.1 Demand Data from Medicare Australia shows that between 2005/06 and 2009/10 the average annualised growth rate for CT was 5.3%, and that in 2008/09 CT accounted for 13% of all imaging test orders.

The profile from RBWH is showing a considerably higher increase in this modality than the national average, with a 12.5% increase from 2007/08 to 2008/09, and a 9.4% increase between 2008/09 and 2009/10. As a percentage of all imaging requests at RBWH CT is also higher than the national average, as it represents 21.8% of all requests. This may be a reflection of the tertiary nature of the services being offered at RBWH.

From June 2009 to July 2010 there were 39,954 CT examinations at the RBWH. The most significant observation regarding total activity is that approximately 50% of this activity takes place on the CT scanner in ED, with the other 50% being carried out on two CT scanners in the Medical Imaging Department. This suggests that there is considerable capacity in terms of CT scanners within the Medical Imaging Department.

The table below provides a breakdown of the source of referrals to CT. Overall, 26% of demand for CT comes from inpatients, 32% from outpatients and 42% from ED.

Referring Unit CT

Emergency 16,988

Outpatients 11,957

Intensive care Unit 1,656

Oncology 1,416

Colorectal 1,226

Neurosurgery 1,072

Orthopedics 562

Rheumatology/Endocrinology 509

Respiratory/Dermatology 496

Urology 471

NHD 377

Medical 377

MAPU 339

Gynaecology 295

Vascular 269

General Surgery 257

Neurology 249


Cardiology 208

Coronary Care Unit 147

Other 836

Totals 39,954


In addition to understanding the total activity of CT, the following graph displays the average number of examinations by time of day. This shows that although the peak hours for activity are between 7am and 6pm, CT examinations do take place throughout the night, albeit at lower levels. Despite this, the Medical Imaging Department do not currently roster a Radiographer on to cover CT from 12pm to 7am, but rather have an ‘on call’ system to cover this time. Given the amount of activity taking place out of hours, a strong case could be made for moving to a roster system for this activity, to reduce cost (a roster system being less expensive than an on-call system in the event that on-call staff are regularly called in), and increase examination turnaround time.

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Average examinations by hour of day - CT

The graph below shows the average number of examinations by day of the week. Approximately 46% less examinations take place on the weekend than on the average weekday at RBWH.

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Average examinations by day of week - CT


4.7.2 Analysis of report completion/efficiency The analysis of the time taken from examination to interim report for CT demonstrates some of the quickest turnaround times for interim reports, for example an average of only 82 minutes on Wednesdays in ED (see graph below). However, there is still considerable variation, with ED patients waiting an average of 2 hours for an interim report, inpatients an average of 4 hours and outpatients an average of 6 hours.

In calculating these averages we have excluded 267 examinations that have taken longer than a week to report on. The table below demonstrates the proportion of examinations that have been reported within certain timeframes.

% of Exams reported

within x days for CT

Under 1 day 1 - 2 days 2 - 3 days 3 - 5 days 5 - 7 days

Over 1 week

CT 96.7% 1.0% 0.4% 0.4% 0.3% 1.2%

This data is consistent with that reported in management reports with the target of 80% of examinations being reported within 24 hours being exceeded but a target of 50% under an hour not being met with an average of only 15% of CT examinations each month being reported under an hour.

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Average time from examination to interim report, by day of examination - CT

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OUTPATIENT

EMERGENCY

The following table provides an outline of the averages by weekday and weekend for examination to interim report times by patient type.




The following graph demonstrates that the time from interim to final report adds significant delay into the examination to final report cycle. The data supports the suggestion by the Emergency Department that delays in obtaining reports may be experienced increasing the time patients spend in the Emergency Department. Given the criticality of CT images for making a diagnosis and the time pressures on ED, this represents a significant delay.


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Average time from interim to final report, by day of interim report - CT

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The following table provides an outline of the averages by weekday and weekend for the transcription of an interim report time to the authorisation of a final report by patient type.




In addition, the following graph demonstrates the average times in total from examination to final report for CT. This shows considerable variation in terms of the average time taken by day of the week. This suggests that there is considerable room to improve the service by scheduling capacity to match the demand profile, particularly for inpatients who experience the largest variation in wait times, and the highest average waiting time overall. Through reducing variation and matching capacity to demand, a number of hospitals internationally have demonstrated the ability to reduce delays without additional resources. Fridays appear to provide a peak indicating that examinations taken on Fridays are taking longer to report on.

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Average time from examination to final report, by day of examination - CT

CT INPATIENT

CT OUTPATIENT

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The following table provides an outline of the average time taken from examination through to the authorisation of a final report by patient type.




On average across all patient types it is taking approximately a day and a half to authorise final reports from the time a CT examination occurs. This represents an excessive turnaround time for report authorisation in comparison to other jurisdictions. This is of concern considering that 42% of CT examinations are referred through the emergency Department and require quick turnaround times. The table below demonstrates the significance of this turnaround time in comparison to another large teaching hospital in Australia. This warrants further investigation to determine where and why delays in the process are occurring.

Total Average Hours (Weekday)

Hospital X RBWH

Exam to Interim (Minutes) 25 240

Exam to Final (Interim) 134 1,971

4.7.3 Billing and financials The following table outlines the outpatient examinations that have been assigned particular billing classifications within the RIS system. The billing classifications have been assigned as either chargeable or non-chargeable in consultation with RBWH’s revenue Department. Practix data was obtained and compared by number of examinations billed (by CMBS code) to the number of exams classified as chargeable in the RIS system. The revenue that has not been billed (based on an average fee from Practix data) has been derived to provide an indication of potential lost billing opportunities. Further opportunities may also exist where examinations classified as non-chargeable in the RIS are actually able to be charged provided all relevant criteria are met.

Chargeable Non-Chargeable Total % Chargeable

in RIS

Outpatient

5,186

7,394

12,580 41.22%

Emergency

502

16,398

16,900 2.97%

Inpatient

780

9,694

10,474 7.45%

Total 6,468

33,486

39,954 16.19%

Examinations Billed through Practix 2,625



As highlighted in the above table only 40.58% of examinations that are identified as chargeable in the RIS system are being billed through Practix. This indicates either an issue in billing all examinations (i.e. interface between RIS and Practix data) or a significant data entry error.

Approximately 16% of total examinations are being assigned a chargeable classification in the RIS. However, as a percentage of total examinations only 6.5% of CT examinations are being billed through Practix.

The split by patient type is higher than the hospital average for chargeable outpatients (40% in RIS vs 33% average) but much lower than the expected conversion rate for private inpatients (7% vs 30%).

The following table highlights the number of chargeable examinations by billing classification assigned within the RIS. This highlights that for over a quarter of examinations no medicare details are sighted and/or recorded with half of these being referred from Emergency. 3,521 of these examinations are for outpatients where it would be expected significant opportunity to generate billing opportunities exists.

Of note also is that 122 outpatient examinations have not had any billing classification assigned. This highlights further the focus required to improve data quality within the Medical Imaging Department.

On a monthly basis approximately 600 CT outpatient examinations are being flagged under patient billing categories that are considered not chargeable. Half of these not being flagged as chargeable are a result of medicare cards unsighted whilst the remainder are public patients that do not meet the medicare requirements.


Eligible Other

5,134

1 33 5,168

Other Chargeable

52

501 747 1,300

Total Chargeable

5,186

502 780 6,468

Medicare - Public

3,371

9,806 7,349 20,526

Not Eligible

369

105 - 474

Unsighted Medicare

3,521

6,174 1,888 11,583

No Billing Classification Assigned

122

4 2 128

Other Non-Chargeable

11

309 455 775

Total Non-Chargeable

7,394

16,398 9,694 33,486

Total

12,580

16,900 10,474 39,954

41.2% 3.0% 7.4% 16.2%


Based on Practix data provided the average fees for CT scans at the RBWH is $382.24 for the 2009/10 year. For the 2009/10 year approximately $1m in fees were billed. In the table below potential exists to obtain a further $1.2m if all billing classifications in the RIS are converted to billable opportunities. It should be noted that the accuracy of classification, provision of training, correct questioning of patients and follow up to ensure appropriateness of classification is critical to achieving these goals.

Applying average conversion rates across the hospital may result in a potential additional $1.7m in fees and a stretch target if increased outpatient billing opportunities existed would result in an additional $3.5m on top of current billing levels for CT.

Average CT Exam Fee: $382.24 Billed 2009/10: $1,003,373


Current RIS Classifications

41% 7%


1,982,297

298,147

2,280,444

Hospital wide average conversion rates

33% 30%


1,586,831

1,201,075

2,787,906


65% 35%


3,125,576

1,401,254

4,526,830

These revenue targets should not be considered unrealistic. Applying conservative estimates to those outpatients and inpatients where medicare details have not been sighted or no billing classification assigned only would result in the following assuming these patients were able to be billed:

Conservative Estimate Total Billable 33% Conversion

Rate Expected

Chargeable Total ($) @

$382.24/exam

Inpatient – Unsighted Medicare Details 1,888 30% 566 216,501

Outpatient – Unsighted Medicare Details 3,521 33% 1,162 444,136

Outpatient – No Billing Classification 122 33% 40 15,389

Totals 5,531 1,769 676,026

The graph below represents diagrammatically the level of examinations that are being assigned a billing classification across each patient type.


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The utilisation and 24/7 staffing of the Emergency CT highlights the effect that extending service hours can have with the number of examinations almost double that of CT 1 and CT 2. As can be seen from the graph below inpatient activity utilising the DEM CT continues through to 12pm.

Further investigation to assess the impact of introducing additional staff to operate either CT1 or CT2 is required which may assist in freeing up capacity on the emergency scanner and allowing additional inpatient scanning to occur out of hours. This may also provide capacity to examine more outpatient appointments during the day.

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CT1 Emergency CT1 Inpatient CT1 Outpatient

CT2 Emergency CT2 Inpatient CT2 Outpatient

CT DEM Emergency CT DEM Inpatient CT DEM Outpatient


4.7.4 Issues and findings Based on our consultation and analysis the following are the key issues and findings in relation to the provision of CT services:

► There is capacity to increase the amount of activity taking place in the Department, if additional staff could be made available. The CT scanners in Medical Imaging are currently utilised 50% less than the scanner in ED.

► There would be value in developing a business case for moving to a 24/7 roster for CT Radiographers in the Department, rather than utilising an on-call system out of hours.

► The absence of order request times within the RIS or other hospital systems does not allow ordering patterns to be determined and utilised to assist in demand planning and providing input into decisions such as rostering.

► The average time taken to report CT scans (from examination to final report) does not meet the Department’s own targets and should be a cause for concern and focus of improvement initiatives.

► Examinations flagged as chargeable in the system could potentially result in an additional $1.2m to $3.5m in revenue on an annual basis based on current volumes and an average revenue of $382 per CT examination. This would be dependent upon many supporting processes and factors but a portion of this potential revenue opportunity is not considered unreasonable to achieve.

4.7.5 Recommendations ► Delays occurring from interim to final reporting should be investigated and the impact

delays may be having on referring clinicians understood. This should involve undertaking a study to confirm accurate waiting times from order to exam and exam to report and developing protocols and targets with key referrers and users of CT services such as Emergency to assess the performance of medical imaging.

► Billing classifications should be reviewed to ensure they are aligned to both OSIM and Practix classifications to ensure consistency in naming conventions, assignment and ease of comparison across various systems.

► Review of the data input process should occur to assess where/how variability in billing classification is occuring and determining process improvement strategies to ensure all possible chargeable patients are being billed. This would include determining how/why not all patients flagged as chargeable in the RIS are being billed through Practix.

► A business case to assess the benefits/costs of introducing a 24/7 CT roster to address staffing cost pressures (e.g. increased on call) and free up capacity for the DEM CT scanner should be considered.


4.8 MRI 4.8.1 Demand Data from Medicare Australia shows that between 2005/06 and 2009/10 the average annualised growth rate for MRI was 8.1%, and that in 2008/09 MRI accounted for 0.8% of all imaging test orders.

The profile from RBWH is showing a variable growth rate, with 31.3% growth from 2007/08 to 2008/09, and 8% growth from 2008/09 to 2009/10. In addition, MRI accounted for 7.3% of all imaging test orders at RBWH. This may be the result of it being a tertiary centre and therefore having more complex patients.

From June 2009 to July 2010 there were 13,402 MRI examinations at the RBWH. 30% of demand was from inpatients, 66% from outpatients and 4% from ED. The source of all referrals is identified in the table below:

Referring Unit MRI

Outpatients 8,253

NHD 915

Neurosurgery 769

Emergency 632

Intensive care Unit 380

Neurology 315

Oncology 271


Colorectal 207

MAPU 176

Medical 163

Orthopedics 150

Maternity 116

Respiratory/Dermatology 108

Other 682

Totals 13,402

Outpatients have been grouped as a single referrer to demonstrate the demand that is being generated from internal providers. The following graph displays the average number of examinations by hour of day, and demonstrates that the peak hours for MRI activity are between 7am and 6pm, but with a spike also between the hours of 1am and 2am. From this it can be seen that although MRI examinations are conducted out of hours (with the exception of between 5am and 6am), activity does decrease out of hours, and hence there is some capacity from an equipment perspective to take on additional activity.


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Average examinations by hour of day - MRI

In addition to the analysis of MRI by hour of day, we have also analysed activity by day of the week. The graph below displays the average number of examinations by day of the week, and shows that there are 65% less MRI examinations on weekends than on the average weekday. Minimal MRI scans are occurring outside the hours of 8am and 9pm. The potential extension of MRI operating hours may also provide further capacity to distribute inpatient scanning across the day although consideration of resourcing and potential additional costs would be required.

Given the current escalating waiting times for outpatient MRIs serious consideration should be given to opportunities to develop alternative staffing arrangements in order to schedule additional MRI clinics on weekends. This would enable the backlog to be reduced and would generate additional revenue (if the scans are carried out on the rebatable scanner).

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Average examinations by day of week - MRI

It is also interesting to note that there are fewer examinations on average on Thursdays and Fridays, despite the sample rosters provided indicating that more staff are rostered on Thursday and Friday than on Monday and Tuesdays (though we cannot verify if this is always the case).


4.8.2 Analysis of report completion/efficiency In calculating average turnaround times we have excluded 595 examinations that have taken longer than a week to report on representing over 6% of total MRI examinations for 2009/10. The table below demonstrates the proportion of examinations that have been reported (either interim or final) within certain timeframes.

% of Exams reported

within x days for MRI


Over 1 week

MRI 62.9% 13.0% 7.1% 6.7% 4.1% 6.2%

The information represented in the graph below shows that the average time from examination to interim report varies considerably depending on the day of the examination and the patient type. For example, the time from examination to interim report for patients in ED on a Friday, Saturday and Sunday is nearly double that of Monday, Tuesday and Wednesdays.

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Average time from examination to interim report, by day of examination - MRI

MR INPATIENT

MR OUTPATIENT

MR EMERGENCY

The table below outlines the average time taken from examination to interim report by patient type. Generally, Emergency MRI examinations are reported within 24 hours of the examination time. Inpatient reporting times are extending to nearly a day with outpatient reports taking up to 32 hours on average during weekdays. Averages on weekends are extended for all patient types resulting in an additional 9 hours on average.




The next graph demonstrates that considerably more delay is introduced into the process between interim and final report.


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Average time from interim to final report , by day of interim report - MRI

MR INPATIENT

MR OUTPATIENT

MR EMERGENCY

In total, final reports for those patients who have had an MRI will take on average between 43 hours (ED) and 49 hours (outpatients).




The following graph demonstrates the time taken for the end to end process of examination time through to final report time. Significant peaks are observed on Thursday, Fridays and Saturdays.

-10 20 30 40 50 60 70 80 90

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Average time from examination to final report, by day of examination - MRI

MR INPATIENT

MR OUTPATIENT

MR EMERGENCY

The table below outlines the averages from examination to final report by patient type.





In total, final reports for those patients who have had an MRI will take on average between 55 hours (ED) and 63 hours (outpatients) on weekdays. This is considerably longer than the Department’s own targets of reporting 50% of all examinations under an hour (either interim or final report). The 2009/10 performance indicators provided by RBWH indicate that the average per month achieving this target was 3%, with 59% reported within 24 hours (target of 80%) and only 80% within 72 hours (target of 85%).

4.8.3 Billing and financials The Practix Data provided demonstrates that more patients have been billed than flagged as chargeable (see table below). This may be the result of subsequent audits and identification of patients flagged under non-chargeable categories that have been billed.

Once again the data inputs appear to be of poor quality, however, analysis on a monthly basis shows that this trend is continuous and as such it may be assumed that the causes of data errors in the RIS are not being addressed through feedback of audit results and appropriate training.

We note that CMBS codes are not currently recorded in the RIS system which may result in errors/difficulties in linking data through between the RIS and billing system. In other reviews conducted by Ernst & Young tertiary hospitals are recording CMBS item codes and other additional data fields within the RIS making for much easier data analysis.

The following table provides data on the volume of examinations assigned a chargeable billing classification within the RIS and subsequently billed through Practix.


in RIS

Outpatient

2,060

6,751 8,811 23.38%

Emergency

21

560 581 3.61%

Inpatient

301

3,709 4,010 7.51%

Total 2,382

11,020 13,402 17.77%


4,779


Of concern is the fact that only 17% of patients are being flagged under a chargeable classification within the RIS. Nearly half of all unbilled examinations are a result of Medicare cards being unsighted (e.g. 3,622 exams). Further analysis is required to determine the root causes of these issues.


The following table outlines the outpatient examinations that have been assigned particular billing classifications within the RIS system.


Eligible Other

2,038 - 18 2,056

Other Chargeable

22

21 283 326

Total Chargeable

2,060

21 301 2,382

Medicare - Public

3,013

375 2,609 5,997

Not Eligible

98 - - 98

Unsighted Medicare

3,622

149 993 4,764


11 - - 11


7

36 107 150


6,751

560 3,709 11,020

Total

8,811

581 4,010 13,402

% Flagged as Chargeable in RIS 23% 4% 8% 18%

Approximately 18% of total examinations are being assigned a chargeable classification in the RIS. The split by patient type is lower than the hospital average for chargeable outpatients (23% in RIS vs 33% average) but much lower than the expected conversion rate for private inpatients (8% vs 30%).

Considering the rules relating to the rebatable MRI scanner the number of outpatients currently being billed raises some concern. It would be expected that the majority of outpatient examinations on the rebatable scanner would be billed to Medicare.


The Radiology informatics team have advised Ernst & Young that the licensed MRI scanner is currently the MRI 2. Assessing the utilisation of rooms by hour of day it is evident that over 80% of total MRI scans are completed on the licensed scanner.

Number Exams % Total MRI

Exams

MRI 1

Emergency 22 0.2%

Inpatient 757 5.6%

Outpatient 1,663 12.4%

Total 2,442 18.2%

MRI 2

Emergency 559 4.2%

Inpatient 3,253 24.3%

Outpatient 7,148 53.3%

Total 10,960 81.8%

Total MRI Exams 13,402

Of the 10,960 examinations on the licensed MRI scanner (MRI 2) during the 2009/10 year 65% are outpatient scans, 30% inpatient and 5% emergency patients. On the unlicensed scanner (MRI 1) 68% of the total 2,442 scans are outpatient scans, 31% inpatients and 1% emergency patients.

Further revenue opportunities exist if it is possible to reassign the patient mix on each scanner. However, consideration would need to be given to patient care needs, capability of the equipment required and capital acquisition plans which may include replacement of a potentially older scanner.

The table below highlights the billing classifications assigned to examinations on the licensed scanner. As is evident only a very small proportion of these outpatients are being assigned a chargeable classification currently. Many of these may be subsequently billed as a result of audits conducted. Of particular concern are those examinations where no medicare details are being sighted.

Billing Classification (RIS) Outpatients

Eligible Other 1,640

Other Chargeable 15

Total Chargeable 1,655

Medicare – Public 2,469

Not Eligible 66

Unsighted Medicare 2,943

No Billing Classification Assigned 9

Other Non-Chargeable 6

Total Non-Chargeable 5,493

Total 7,148


% assigned chargeable billing classification 23%

Based on Practix data provided the average fee for MRI scans at the RBWH is $281.52 for the 2009/10 year. For the 2009/10 year approximately $1.3m in MRI fees were billed.

Applying an current conversion rates as assigned in the RIS would result in $2.2m in MRI fees, at average hospital rates of conversion estimated potential billing opportunities would resultin $2.5m in fees, whilst billing all outpatients on the licensed scanner and potentially increasing the mix between the MRI scanners would result in up to $2.7m in revenue. These should be considered targets to achieve and are reliant upon the accuracy and appropriateness of billing classifications within the RIS data.

Average MRI Exam Fee: $281.52 Billed 2009/10: $1,345,397


Current RIS Classifications

85% 8%


2,119,984

84,738

2,204,721

Hospital wide average conversion rates

87% 30%


2,166,800

338,669

2,505,469


95% 35%


2,356,449

395,113

2,751,562

These revenue targets should not be considered unrealistic as billing all current outpatient examinations on the licensed scanner (i.e. 7,148 exams) would result in approximately $2m in revenue.

The graph below represents diagrammatically the level of examinations that are being assigned a billing classification across each patient type currently within the RIS.


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%




4.8.4 Issues and findings Based on the data analysis for MRI, and interviews with stakeholders the following issues and findings are relevant: ► MRI equipment is not currently utilised to full capacity out of hours and on weekends,

given the current MRI waiting times. This represents an opportunity both from a waiting times perspective, and a revenue generation perspective.

► There is some variation in the day to day averages of activity that does not appear to be explained by rostering patters. This variation should be examined in more detail to determine the cause and possible solutions.

► Current reporting times are not within the Department’s targets, and represent a considerable delay in the patient pathway. For outpatients, an eight day wait for results on top of the wait for the scan represents a considerable length of time for the patient. Similarly, for inpatients a 6 day wait for results could considerably impact length of stay.

► Potential for an additional $900k to $1.2m of revenue if all outpatients on the licensed scanner are able to be billed and conversion of private patients is in line with hospital averages. Even if some of this patient cohort remains unbillable an increase in sighting and recording of medicare status and details (i.e. 3,622 exams annually) would provide significant opportunities.

4.8.5 Recommendations ► RBWH should consider conducting a study to ascertain the types of patients being

examined on each scanner to determine the clinical need and requirements with a view to increasing the utilisastion of MRI 1 and improving the mix of patients on the licensed scanner for billing purposes where appropriate, bearing in mind patient care responsibilities and the technical capabilities of each scanner.

► Billing classifications should be reviewed within the RIS to ensure they are aligned to both OSIM and Practix classifications, ensure consistency in naming conventions, and assignment and provide ease of comparison across various systems.


► A review of the data input process to identify where/how variability in classification is occurring should be carried out, to determine process improvement strategies to ensure that all possible chargeable patients are being billed. This would include determining how/why not all patients flagged as chargeable in the RIS are being billed through PractiX.

► Investigate potential options to extend and/or alter the hours for MRI services and determine how this may assist in determining an optimal patient mix, without impacting clinical or patient outcomes.


4.9 Ultrasound 4.9.1 Demand Data from Medicare Australia shows that between 2005/06 and 2009/10 the average annualised growth rate for Ultrasound was 5.8% and that in 2008/09 Ultrasound accounted for 36.6% of all imaging test orders. The profile from RBWH is not strongly aligned to the national average, with an increase of 6.96% from 2007/08 to 2008/09, but only 0.3% from 2008/09 to 2009/2010. In addition, ultrasound at the RBWH represents only 15.3% of all imaging test orders. This may be due to the variable counting of obstetric ultrasound across facilities.

From June 2009 to July 2010 there were 28,080 ultrasound examinations at the RBWH, with 28% of demand from inpatients, 52% from outpatients and 20% from ED. The table below details the referring Departments for ultrasound.

The following graph displays the average number of ultrasound examinations by time of day.

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2

4

6

8

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12

H1

H2

H3

H4

H5

H6

H7

H8

H9

H10

H11

H12

H13

H14

H15

H16

H17

H18

H19

H20

H21

H22

H23

H24

Average examinations by hour of day - Ultrasound

From the graph above it can be seen that the majority of ultrasound examinations take place between 7am and 5pm, mirroring the roster pattern for this modality and the fact that 52% of services are delivered to outpatients. It appears from the rosters that the dip in activity at 1pm and 2pm may be due to the end of one part time shift at approximately 2pm, and the start of a shift at 2pm and another at 2:30pm.

The following graph shows the average number of examinations by day of the week. There are 68% less examinations on weekends than on the average weekday. This is significant when it is considered that waiting times for ultrasound in 2009/10 were between 20 and 30 days.

In addition a key point to note is that on the rosters made available to Ernst & Young, Thursday had the most staff rostered on, but Wednesday has more examinations on average.


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20

40

60

80

100

120

Average examinations by day of week - Ultrasound

4.9.2 Analysis of report completion/efficiency In calculating average turnaround times we have excluded 2,165 examinations that have taken longer than a week to report on representing over 8% of total ultrasound examinations for 2009/10. The table below demonstrates the proportion of examinations that have been reported (either interim or final) within certain timeframes.

% of Exams reported

within x days for US


Over 1 week

Ultrasound 63.4% 8.5% 5.6% 7.7% 6.4% 8.4%

These statistics are reflective of management reports for Medical Imaging indicating that whilst 86% of Royal Brisbane Ultrasounds are reported within 24 hours, those of the Royal Women’s (which are reported separately) are only reporting 30% within 24 hours on average.

It is clear from the table below, that there is considerable variation in the average time taken from examination to interim report across patient types. ED scans take on average 3 hours whilst outpatients take up to 40 hours on average to report on during weekends. The largest variation in scans for outpatients, which should be the most predictable and manageable source of activity as it is largely planned.

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30

40

50

60

70

80

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Average time from examination to interim report, by day of examination - Ultrasound

US INPATIENT

US OUTPATIENT

US EMERGENCY


The table below outlines the average waiting times as demonstrated in the graph above by patient type. Significant variance is noted for outpatients, inpatients and ED which may in some respect reflect the urgency of the conditions and patients being treated.




The graph below shows that additional delay is added to the process between the interim report and the final report, with particularly long waits again for outpatients. This is consistent across modalities and further investigation should be undertaken to identify the root cause of this process delay and whether it is appropriate or requires attention.

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20

40

60

80

100

120

140

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Average time from interim to final report, by day of interim report - Ultrasound

US INPATIENT

US OUTPATIENT

US EMERGENCY

The table below highlights the average time in hours taken to authorise interim reports by consultant radiologists.




The following graph shows the average total time from examination to report for ultrasound, again demonstrating large variations, from 34 hours in ED, to over 2 and 1/2 days for outpatients.


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40

60

80

100

120

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Average time from examination to final report, by day of examination - Ultrasound

US INPATIENT

US OUTPATIENT

US EMERGENCY

The table below demonstrates the average hours taken from examination to final report for each patient type and separated by a weekday and weekend average.




4.9.3 Billing and financials Practix data provided shows that the volume of billable patients being captured appears to have improved from January 2010, although opportunities to convert examinations flagged as non-chargeable to chargeable do remain.

The following table provides data on the volume of examinations assigned a chargeable billing classification within the RIS and subsequently billed through Practix.


in RIS

Outpatient

5,910

8,698

14,608 40.46%

Emergency

102

5,408

5,510 1.85%

Inpatient

732

7,234

7,966 9.19%

Total 6,744

21,340

28,084 24.01%


4,817


Unlike many other modalities a significant portion of examinations assigned a chargeable billing classification within the RIS are being billed through Practix (71%). However, only 24% of examinations are being assigned chargeable billing categories within the RIS.




Eligible Other

5,885

2 69 5,956

Other Chargeable

25

100 663 788

Total Chargeable

5,910

102 732 6,744

Medicare - Public

3,468

3,468 5,945 12,881

Not Eligible

275

87 1 363

Unsighted Medicare

4,898

1,773 1,108 7,779


40 - 1 41


17

80 179 276


8,698

5,408 7,234 21,340

Total

14,608

5,510 7,966 28,084

% Flagged as Chargeable in RIS 40.5% 1.9% 9.2% 24.0%

Approximately 24% of total examinations are being assigned a chargeable classification in the RIS. The split by patient type is considerably higher than the hospital average for chargeable outpatients (40% in RIS vs 33% average) but much lower than the expected conversion rate for private inpatients (9% vs 30%).

Based on Practix data provided the average fee for ultrasound scans at the RBWH is $90.72 for the 2009/10 year. For the 2009/10 year approximately $450k in ultrasound fees were billed. Applying expected rates of conversion from the RIS would result in an additional $150k in fees, at average hospital rates of conversion the estimate may be as high as an additional $200k, whilst applying aggressive targets for billing of outpatients would result in up to $665k in additional fees to the 2009/10 year.

Average US Exam Fee: $90.72 Billed 2009/10: $449,220




536,510

66,451

602,961



437,618

216,946

654,564




861,974

253,104

1,115,078

Of the 5,910 examinations for the 2009/10 year that have been flagged under chargeable billing classifications within the RIS system approximately 71% have been invoiced.

To place the opportunities in context, 4,898 outpatient examinations have a classification of Medicare card not sighted and 3,468 are classed as Medicare but not chargeable as patients have elected to be public patients. If an additional 33% of each of these classifications was chargeable an additional $250k in addition to what was billed in 2009/10 would be possible.

4.9.4 Issues and findings ► Very few ultrasound examinations are being conducted out of hours. However, it is

reported that significant waiting times for ultrasound exist and in 2009/10 were between 20 and 30 days.

► Over 8% of ultrasound scans have taken over a week to report on.

► Emergency ultrasound scans are being reported on within 3 hours, however, inpatients on average take up to 24 hours and outpatients 40 hours to provide an interim report. Further delays are experienced in finalising reports. Protocols of releasing interim reports to referring clinicians have not been clarified but may provide a reason as to why there does not appear to be urgency in finalising reports.

► The conversion of patients assigned a chargeable billing classification within the RIS and being billed through Practix is 71%. As with other modalities it is essential to understand the flow of data through each system and identify where/why patient details may not be captured.

► Learnings from ultrasound in terms of billing all patients captured through the RIS and flowing through to PractiX may assist in determining improvement strategies to be applied to other modalities.

4.9.5 Recommendations ► The potential to alter rosters and/or hours of service for ultrasound services should be

investigated in light of the current waiting times (20 – 30 days).

► Investigation should be conducted to understand the delays in turnaround times for ultrasound reporting. The main issue based on management reports appears to be the Royal Women’s ultrasound imaging and investigation should include consideration of the most appropriate turnaround times for each referrer and patient type in consultation with referrers.

► A review of the data input process to identify where/how variability in classification is

occurring should be carried out, to determine process improvement strategies to ensure that all possible chargeable patients are being identified and billed.


4.10 Angiography 4.10.1 Demand From June 2009 to July 2010 there were 6,061 Angiography examinations at the RBWH. 61% of these were inpatients, 36% outpatients and 3% from ED. The table below shows the source of referrals for angiography. The quality of the interventional services at the RBWH was commented on by a number of referrers throughout the stakeholder consultation.

Referring Unit Angiography

Outpatients 2,091

Intensive care Unit 558

Oncology 505

Colorectal 338

Vascular 336

Neurosurgery 295

Surgery 243

Emergency 210

Orthopaedics 162

Urology 135



Other 963

Totals 6,061

The following graph displays the average number of Angiography examinations by time of day. It shows less variation between the volumes during the day and at night than other modalities, though this may be explained to some extent by the large proportion of patients who are inpatients.

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1

2

3

4

5

H1

H2

H3

H4

H5

H6

H7

H8

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H10

H11

H12

H13

H14

H15

H16

H17

H18

H19

H20

H21

H22

H23

H24

Average examinations by hour of day - Angio

The following graph displays the average number of examinations by day of the week.


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5

10

15

20

25

30

35

Average examinations by day of week - Angio

4.10.2 Analysis of report completion/efficiency In analysing the metrics for report completion and efficiency we have removed high outliers taking over a week to report. This represents a significant portion of Angiography examinations (19%). The table below outlines the % of examinations reported within certain timeframes.

% of Exams reported

within x days for

Angiography Under 1

day 1 - 2 days 2 - 3 days 3 - 5 days 5 - 7 days Over 1 week

Angiography 43.3% 16.8% 7.8% 8.2% 4.8% 19.2%

The graph below demonstrates considerable variation in terms of the average time taken from examination to interim report, with reports for inpatients taking anywhere from 32 hours to 49 hours depending of the day of examination. Reports for patients in ED average from 32 hours. Clearly decisions have been made about the care of these patients in the interim, but this is still a considerable delay, and suggests difficulties with managing reporting in this area (or data quality issues).


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50

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Average time from examination to interim report , by day of examination - Angiography

INPATIENT

OUTPATIENT

EMERGENCY

The table below highlights the average time taken from examination time to interim report time by patient type.




The graph below demonstrates further delay between the interim report and final report.


On average as highlighted in the table below Angiography interim reports are taking over 2 and ½ days on average to be authorised by consultant radiologists.




The total time from examination to final report for angiography averages 81 hours (over 3 days) for inpatients, 77 hours for outpatients and 80 hours for patients referred by ED. This is considerably longer than the Department’s own targets and suggests considerable room for improvement.

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Average time from examination to final report, by day of examination - Angiography

AN INPATIENT

AN OUTPATIENT

AN EMERGENCY

The table below highlights the average time from examination to final report by patient type.




4.10.3 Billing and financials Interventional radiology involves a high proportion of consumables and expensive prosthetics such as neuro-coils. It is important that private patients in particular are identified, the cost of consumables tracked and patients billed appropriately.

In the 2009/10 financial year 89 Neurointerventional procedures were conducted at the RBWH. Information received from Neuroradiology suggests approximately $685k in implantables was expended during the 2009/10 financial year with $200k already expended in the 2010/11 year.

The clinical nurse in Neuroradiology maintains a manual spreadsheet and records neurointerventional procedures through a review of the HBCIS system at the time of intervention to ensure all acute admissions are captured or at least the POLO is notified. The elective intervention patients are asked about private health status at the time of


booking and interview. These cases are then referred to POLO to contact the patient and check cover with the relevant health fund.

The private cases are forwarded in a separate document, directly to Revenue Control for their processing. However, it is understood that no billing has been completed since September and it is noted that this process is reliant on individuals intervening. Comment was received that previously this information was sent to business managers but often was not followed up.

The table below highlights the number of patients assigned a chargeable billing classification within the RIS and those subsequently billed through Practix.


in RIS

Outpatient

635

1,571

2,206 28.79%

Emergency

4

155

159 2.52%

Inpatient

257

3,439

3,696 6.95%

Total 896

5,165

6,061 14.78%


82


The table above highlights that less than 10% of examinations identified as chargeable within the RIS are actually being billed through Practix. Again this highlights either a significant data issue within the RIS or a significant level of under billing.



Eligible Other 625 - - 625

Other Chargeable 10 4 257 271

Total Chargeable 635 4 257 896

Medicare – Public 577 109 2,718 3,404

Not Eligible 2 - - 2

Unsighted Medicare 989 36 654 1,679

Other Non-Chargeable 3 10 67 80

Total Non-Chargeable 1,571 155 3,439 5,165

Total 2,206 159 3,696 6,061

% Flagged as Chargeable in RIS

28.8% 2.5% 7.0% 14.8%


Approximately 15% of total examinations are being assigned a chargeable classification in the RIS. However, only 1% of total examinations are being billed through Practix. Nearly 28% of examinations have been assigned ‘Medicare details unsighted’ indicating some significant issues with staff identifying patient status appropriately.

Based on Practix data provided the average fee for Angiography services at the RBWH is approximately $1,000 for the 2009/10 year. For the 2009/10 year only $82k in Angiography fees were billed.

Applying current billing classifications assigned within the RIS it would be expected approximately $900k may be billed, utilising average rates of conversion an estimate of potential billing opportunities is $1.8m, whilst an aggressive strategy may achieve up to $2.5m depending on factors relating to supporting infrastructure and processes.

Average Angiography Exam Fee: $1,000.98 Billed

2009/10: $449,220




635,622

257,252

892,874



728,693

1,109,887

1,838,580



1,435,305

1,109,887

2,545,192

4.10.4 Issues and findings ► The follow up and billing of coils and implantables utilised is reliant on key individuals

and the updating of a spreadsheet through manual processes. Whilst $685k was expended on coils and other implantables during 2009/10 it has not been confirmed the portion of these costs recovered or whether they are included in the $82k in billing through Practix.

► No communication has occurred between relevant parties to follow up billing of coils and implantables for 2010/11 since September.

4.10.5 Recommendations ► RBWH investigate opportunities to automate inventory tracking and integrate data with

the billing system to provide a seamless transfer of information that is not reliant on manual intervention.


5. Data Quality Throughout this review there have been considerable issues with data quality and this has impacted the review team’s ability to fully analyse patient flow through the Department, and the management of capacity and demand.

The lack of quality data impacts not just this review, but also the ability of the Medical Imaging Department management team to determine if resources are being used efficiently, and if capacity is being appropriately scheduled to meet demand.

There are three main causes of poor data quality, these are:

► Lack of consistency in data definitions

► A reliance on manual processes for inputting data with little process control

► No clear accountability or responsibility for data quality

For example, we have had difficulties with analysing the source of referrals to the Medical Imaging Department, as there was no mapping of referring doctor to requesting Department in the RIS. The lack of recording of ordering requests in other feeder systems (E.g. EDIS, OSIM) also contributes to this. Although the referring doctor field was provided there is inconsistency in the naming conventions used which prevents efficient manipulation of the data. The profile we generated in this report was based on a time consuming process to match data.

There is clearly a need for improved use of systems and training for data input so that data can be used to monitor, understand and plan for demand. However, despite the fact this has been recognised as a problem for some time it seems there is little ownership of a solution, and hence little progress has been made.

It is clear that the Department needs to initiate a major data review to specify the information it requires to support process improvement and drive greater efficiency. This data review should cover the specification of data and field descriptions, the implications on ICT and workflow to collect the required data, and the documentation and continuous training required to ensure data entry consistency from front line staff through technical staff to reporting radiologists.


6. Conclusions

6.1 Radiology Department culture Staff morale is low, and the culture of the Department has been negatively impacted. The absence of goals to unite the Department and drive performance is impacting the Department’s ability to respond to issues and improve service delivery

It is our opinion that the Department needs to develop clear goals and a set of measurable indicators that are used to manage Departmental performance..

In addition, in the short term the specific issues arising from the Administration Review require rapid resolution to enable the Department to return to ‘business as usual’ and to clear the current backlog of requests.

Recommendation: A clear set of goals should be developed for the Department, supported by KPIs for the leadership team. The KPIs should incentivise behaviours that are aligned to the culture and goals of the Department, and leaders should be held to account for those KPIs through a structured performance management framework.

Recommendation: An experienced Administration Manager with strong leadership skills should be appointed to the Department as soon as possible. The Administration Manager should be provided with support from the management team to resolve the outstanding administration issues as rapidly as possible, and to start to rebuild positive relationships within the administration team.

6.2 Access to Services The current processes and systems for booking appointments are not conducive to the provision of an efficient, streamlined service. The processes are inefficient and time consuming for referring clinicians, and are difficult for the Department to control. The review team suspect that this may lead to a considerable number of appointment cancellations, and rework in terms of bookings, but due to the poor quality of data it is not possible to determine if this is the case. However, it is clear that the current process is a source of frustration to many – particularly referring clinicians.

A number of the current issues with the process could be addressed if the Department moved from a paper based system to an electronic ordering system. This would enable referring clinicians to request examinations electronically, thereby increasing confidence that referrals will be received in the Department, and reducing the need for referring clinicians to physically locate a Radiologist to obtain a signature on a piece of paper.

Electronic ordering would also enable the time of request to be captured, which would contribute significantly to understanding the current processes within the Department, and total waiting time from order to examination, and from order to report.

From the perspective of access to specific modalities, the key conclusion we have drawn is that there would be considerable value in developing a business case for a 24 X 7 roster for Radiographers to cover CT in the Emergency Department, and to increase the scanning of billable outpatients on weekends. This would align Radiographer rosters more closely to demand in the Department, and could reduce costs in this area (by changing from an on-call to a roster system).


In terms of access to other modalities or the service more broadly, the major conclusion from this review is that the current quality of data does not enable a clear understanding of workflow and bottlenecks in the Department. This is detrimental to establishing a culture of continuous improvement, as there are no reliable metrics to support measurement of improvement. Our recommendation in this respect is to prioritise data quality improvements, as outlined in the data quality section of this report.

Recommendation: RBWH should carry out a detailed analysis of the current booking process in collaboration with referring clinicians, to determine priority improvements for implementation. Those improvements should then be trialled, and if successful implemented.

Recommendation: in the short term the Department should put in place processes to capture the order request time on the request form, and this should be recorded in RIS for data analysis purposes.

Recommendation: RBWH should develop a business case for implementing electronic ordering, to support routine processes that allow measurement and reporting of key metrics, such as order to examination time, and order to report time.

Recommendation: RBWH should develop a business case focussed on utilising a 24 x 7 CT roster to scan inpatients in the evening and weekends, and increase the scanning of billable outpatients during weekends, plus to provide support to ED during the night.

Recommendation: RBWH should actively engage in continuous benchmarking exercises with peer hospitals, place the results in the public domain, and formally employ the results of these studies to improve their process efficiency and effectiveness.

Recommendation: Following the collection of more robust data further analysis of workflow and bottlenecks within the Department should be undertaken, to identify opportunities for improvement. In addition, waiting times should be made routinely available to referring clinicians

6.3 Reporting The clinical quality of reporting is high and this is a key factor of the current service that must be maintained. However, the turnaround time for reports is a cause for concern and requires improved management. As an example, the Department should investigate the possibility of providing visibility of images currently awaiting reporting to all reporting Radiologists, so that workload can be managed more proactively across modalities. Furthermore, subject to improvements in data quality, the Department should analyse the reporting processes to determine the cause of long waits, and opportunities to reduce those waits.

The follow up process in the event of an unexpected finding or changes to a report is an area where improvement is required to ensure quality of care. In particular it is necessary as a matter of priority for the Department to locate the current process re follow up, or if it cannot be located, a new policy should be developed. The contents of the policy should be communicated to all reporting Radiologists and referring clinicians to ensure that expectations are set regarding this process. In addition, a record of actual or attempted communication should be re-established and regularly backed up to ensure this data is not lost.


Following clarification of the policy, compliance with the policy should be audited on a regular basis, and non compliance addressed. The outcomes of the audit should be reported to Department Management and the Hospital Executive on a regular basis.

In terms of the quality of images, the Orthopaedic Department’s concerns re the quality of ‘scout’ images, and access to PACS in theatre should be a priority for the hospital as they impact on the ability to deliver high quality, safe clinical care. We noted that this is a key concern for the Orthopaedics Department, but does not seem to be on the radar of the Radiology Department. We therefore recommend that as a first step, representatives from the Medical Imaging Department meet with the Director of Orthopaedics to discuss these concerns and agree potential solutions. If additional investment is required, the Departments should work together to develop a business case for the additional investment.

We have also noted that access to reports may be a constraint on increasing activity within the Department, as there is reported to be a lack of confidence amongst external referring doctors that they will receive reports. If the Department wants to increase activity in the Department (and therefore private practice revenue), there will need to be further analysis of the cause of this issue, and measures put in place to address the concerns and increase confidence in the service provided by the Radiology Department.

A final conclusion relates to the current practice of printing all reports generated by Radiology. This practice should be investigated further to determine why it takes place, what value it delivers and the resource implications of continuing it. This information can then be used to determine whether it should continue. In addition, the Department needs to work with ED to determine a more efficient way of providing them with access to the reports of abnormal plain films.

Recommendation: RBWH Radiology Department should investigate the possibility of making visible to all Radiologists current examinations awaiting reporting (across all modalities) to enable more proactive management of workload. Radiologists should be encouraged to report across modalities (where appropriate) to reduce backlogs in the system.

Recommendation: The RBWH Radiology Department should investigate the utility of voice recognition software and possibly arrange a trial of a licence with a mainstream vendor. If the trial has a positive result, a Business Case could be developed to compare the cost and efficiency of report generation between traditional methods and utilising voice recognition, either with transcriptionist edits or done by Radiologists themselves.

Recommendation: The Radiology Department should work with the Orthopaedic Surgeons to understand their concerns re the quality of ‘scout’ images, and access to PACS in theatre, and put in place an action plan to address the issues.

Recommendation: The Radiology Department should locate the Department Policy regarding report follow up in the event that a report is changed between interim and final report, or there are significant and unexpected findings, and ensure it complies with current RANZCR Standards of Practice. If the policy cannot be located a new policy should be written. Furthermore, a method for regularly auditing compliance with the policy, and follow up of non-compliance should be established, and the results reported to the Departmental and Hospital Executive on a routine basis

Recommendation: Further to the above, a record of actual or attempted communication should be re-established, and regularly backed up to ensure it is not lost.


Recommendation: RBWH should revisit the current mechanism for distributing reports to referring clinicians outside the hospital, to determine if a more reliable process is required, and if so if it is feasible. If such a process can be put in place the new approach should be widely communicated to referring clinicians, with a view to increasing referrals from external referrers.

Recommendation: RBWH Radiology Department should assess whether there is value in continuing to print out all reports generated by the Department. In addition they should work with ED to identify and implement a more effective method of providing ED with access to abnormal plain film results.

6.4 Data The review team have experienced first hand the difficulty of obtaining quality data from the Radiology Department. This has impacted the review team’s ability to fully analyse patient flow through the Department and capacity and demand across the modailities. The lack of quality data is a considerable concern for RBWH as it hinders the ability of the Radiology Department management team to understand and control processes within the Department. Without quality data it is not possible to draw reliable conclusions about how effectively resources are being managed, and where opportunities exist for improvement. We recommend that improvements to data quality are prioritised as they underpin the ability to measure and manage many of the outcomes of the other recommendations in this report. In particular it is clear that the Department needs to initiate a major data review and ensure that the required training and support is provided to staff in the Department to improve data entry and consistency. Recommendation: Initiate a data review. This should involve: specifying the information Medical Imaging requires to support process improvement and drive greater efficiency; specification of data and field descriptions; identifying the implications for ICT and workflow to collect the required data; and determining the documentation and continuous training required to ensure data entry consistency from front line staff through technical staff to reporting radiologists.

Recommendation: The RBWH should develop guidance on the data entry standards expected by all staff entering information into the RIS and any other systems containing data fields of potential utility to the Department’s management. Compliance with these standards should be monitored through data quality audits, with the results distributed to the management team

Recommendation: The RBWH should run refresher courses for staff around data standards and data entry consistency expectations. Induction processes for new staff should include training on data standards.

Recommendation: The RBWH Radiology Department should develop, in collaboration with key stakeholders, Departmental KPIs that are routinely collected and reported in the public domain.

6.5 Finance It is clear from the data provided that there is considerable scope to increase revenue through addressing issues with billing classifications across modalities, as significant numbers of examinations that could potentially be billed are not currently being billed.


It was noted that the Medical Imaging Department do not generally achieve their private practice threshold and as such significant opportunity for Radiologists to share in the success of converting chargeable patients exists. The reasons for this include:

► The variation in billing classifications between RIS and other systems such as OSIM ► A high proportion of patients that are not having medicare details captured ► Not all patients assigned a chargeable billing classification in the RIS are being

billed through Practix ► Not all outpatients are currently being billed. The majority of outpatients on the

licensed MRI scanner for example should be billable. It is understood that Queensland Health/RBWH has sought legal advice to clarify their position in relation to certain patient cohorts

The total estimated opportunity in respect of the above points amount up to $9m per annum.

In addition, there is the potential to increase hours in some modalities and improve the mix of patients/throughput to increase revenue, but this requires further investigations/business cases to determine the appropriateness of these recommendations.

Recommendation: Review billing classifications to ensure that they are aligned to both OSIM and PractiX classifications. Ensure consistency in naming conventions, assignment and ease of comparison across all relevant systems.

Recommendation: Review the data input process to assess where/how variability in classification is occurring and determine process improvement strategies to ensure all possible chargeable patients are being billed. This should include determining how/why all patients flagged as chargeable in the RIS are not being billed through PractiX.

Recommendation: RBWH should conduct further analysis of PRNI opportunities to increase private practice billings and consider appointing ownership of PRNI initiatives to a dedicated member of staff as has been implemented in other Departments.

Recommendation: RBWH Radiology Department should clarify who has responsibility for identifying private patients when they arrive in the Department, or during their examination, and run refresher sessions with staff to set the expectations around this area. Identifying private patients should become part of ‘business as usual’ rather than a discretionary activity.

Recommendation: RBWH should implement automated inventory tracking or, at the very least in the short term, manual processes and procedures to allow consumable use and costs to be effectively captured, linked to patients and cost recovered where possible.

Recommendation: The Medical Imaging Department should build closer relationships with the revenue team to develop a suite of initiatives to improve patient billing opportunities

6.6 Technology Radiology is a “process oriented” discipline and attempting to optimise processes in the absence of effective technology is problematic. At RBWH there are considerable opportunities to improve service delivery and management through better use of technology.


Electronic ordering software is now widely available and used successfully in a number of Radiology Departments internationally. Despite this RBWH continues to operate a paper based system that is inefficient and time consuming for referring clinicians, and provides little opportunity to monitor processes.

We recommend that RBWH develop a business case for implementing electronic ordering of examinations, to facilitate improved data quality and measurement of the process, to facilitate improvements to referral information, and to reduce the amount of time referring clinicians spend walking forms to the Department, and the interruptions to Radiologists.

Given the considerable delays in finalising reports we believe that voice recognition software is another potential technology that the RBWH should consider, as it has been routinely used in radiology reporting for many years. The USA was an early adopter of this technology and there are now many hospitals that employ voice recognition with radiologist correction as their sole report generation technology, as it introduces process efficiency and reduces the cost of report generation. Many of the voice recognition applications are now integrated directly or via integration brokers into RIS and PACS systems.

There is also an opportunity to increase the speed of PACS web viewers for referring clinicians across the hospital. This was a widely reported cause of frustration, and by resolving this issue the Department could achieve a ‘quick win’ in response to this report, by demonstrating to referring clinicians that they are able to respond to the concerns of their clients. Queensland Health are implementing a statewide Radiology information system referred to as QRIS. The objective of the implementation is to deliver an integrated QRIS and PACS solution to provide clinicians with timely access to the right radiology information, at the right time, regardless of location, in order to deliver quality patient care. The RBWH was initially considered outside of the scope of the QRIS implementation although it is understood that they may now be included in the roll out. Given the issues existing in RBWH the QRIS system may provide opportunity to improve management of radiology reporting, improved workflow, improved patient scheduling and tracking, allow images produced at one hospital to be reported at another, improve overall productivity. The inclusion of RBWH in this statewide solution and timing should be considered. A final conclusion relates to use of the full capability of the current imaging equipment. Imaging equipment is increasingly sophisticated in terms of the images that can be provided, and the Department is well equipped with such machines. However, there does appear to be some frustration at a perceived unwillingness to alter work practices to make best use of the equipment available. Given the critical role that imaging plays in diagnosis and treatment, it would be advisable for the Department to consider the potential improvements to clinical practice offered by the equipment available. In addition, when staff have suggestions for improving clinical practice it is important that those staff are engaged, and the ideas discussed to ensure that opportunities for improvement are not missed, and staff enthusiasm is harnessed for the benefit of improved service delivery. Recommendation: RBWH should develop a business case for implementing electronic ordering of examinations, to improve data quality and therefore understanding of the process (by capturing order time); to facilitate improvements to the referral information provided; to reduce the time spent by referring clinicians on walking forms to the Department; and to increase the level of confidence in the booking process; and to reduce the amount of interruptions Radiologists experience throughout the day.

Recommendation: RBWH initiate discussions with Clinical and Statewide Services to ensure they fully investigate the potential benefits and proposed roll out of QRIS for RBWH.


Recommendation: RBWH should investigate the feasibility of increasing the speed of the PACS web viewers.

Recommendation: The RBWH should investigate the utility of voice recognition software – see recommendations in reporting section.

Recommendation: the Radiology Department should develop a culture of continual improvement in service delivery. This can be progressed through a number of mechanisms, but as a starting point it is recommend that the Department establish a regular forum at which opportunities to improve service delivery can be raised, discussed, and action plans developed and monitored. This forum must be seen as part of core business, and given the appropriate authority to make and implement decisions.

6.7 Service Planning Service planning in an organisation the size of RBWH is a complex task, with changes to existing services or the development of new services inevitably having impacts across the organisation. It is clear that in this context, Medical Imaging have not always been consulted as early in the process as they should be, and as a result new services have negatively impacted staffing and expenditure. This is not uncommon in large teaching hospitals however it is an issue that can be rectified with relative ease. We recommend that hospital management review the current framework for approving service developments with a view to ensuring that future service changes or developments are not signed off until it is clear that the impacts on other areas of the hospital have been fully understood, costed and planned for, in collaboration with the impacted Department. Recommendation: RBWH should develop a framework for ensuring that the planning and development of new or improved services within the hospital includes representatives from all Departments impacted by that service. In addition, the RBWH should ensure that no additional services are approved without evidence that consultation and impact assessments.

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Appendix A Stakeholders consulted

Name Role / PositionDr. David Alcorn CEO, RBWH

Assoc. Professor Peter Scal ly Director Medical ImagingAssoc. Professor Marianne Vonau Executive Director Critical Care and Cl inical Support ServicesDr Ray Gwynne Deputy Director, Medical ImagingAssociate Professor Alan Coulthard Director Research and Education, Medical Imaging Paul Esdaile Director Medical Imaging TechnologySusan Green Assistant Director Medical Imaging TechnologyDavid Merritt Assistant Director Medical Imaging Technology Dr Vincent Andri jich Radiologist Dr Mari lyn Tracey Radiologist Dr Andrew Groundwater RadiologistDr Thulasi Rajah RadiologistDr Jennie Roberts RadiologistDr John Clouston Radiologist Jacqui Roche Radiographer Ray Buckley Radiographer Jim Watt Radiographer Helen McMahon Nurse Unit Manager Medical Imaging Liam Caffery Radiology Information SystemsAdrian Chambers Data Entry for PratiX system Jamie Watts Cl inical Assistant Medical Imaging Dr Bronwyn Wil l iams Acting Director Multidiscipl inary Pain CentreProf. Ian Jones Executive Director Women's and Newborns servicesDr. Scott Campbell Director Neurosurgery

Noelle Cridland Acting Executive Director NursingDr Roger Al l ison Executive Director Cancer Care ServicesAlanna Geary Nursing Director Cancer Care Services

Dr Liz Kenny Radiation Oncologist, Cancer Network & Queensland Health Imaging Program

Dr Robert Henderson Director, NeurologyAssociate Professor Alan O'Connor Director Emergency MedicineDr Sharon Smith Consultant, Emergency MedicineDr Judy Graves Executive Director Medical ServicesKerri Mcleod Nursing Director, RBWH Dr. Steven Yang Director Orthopaedics Dr Barry O'Loughlin Executive Director General SurgeryDr David Cartwright Director NeonatologyDr John Younger Cardiologist - supports cardiac imaging in MI departmentAnthony Nesbit Patient Flow UnitLynda Delaforce Finance DirectorLyn Mason Director ICT ServicesMark Mikula Technical Services Manager Katherine Phil l ips Manager, Private Practice Special ist SuitesKaryn Hicks Project Officer Critical Care ServicesSally Lockyer Private Practice Bi ll ingTravis Hodgson Senior Manager Revenue & Private Patients Greg Cl ibborn Manager Revenue Operations


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Documents

Royal Brisbane & Women’s Hospital – Medical Imaging Reviewmedia01.couriermail.com.au/.../rbhreview/radiology.pdf · Royal Brisbane & Women’s Hospital – Radiology Review