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Journal of the Academy of Hospital Administration

Process Reengineering in the Radiology Department in a Corporate Hospital

Author(s): Rachel Varghese*

Vol. 13, No. 1 (2001-01 - 2001-06)

Keywords : Business Process Reenginerring, Process, Radiology Department

Introduction

In a country like India most of the expenses involved in health care are out of the pocket expenditure, and patients pay for each service or procedure. As a result there is ongoing pressure from health care consumers for lower cost, quality health care. This intensifies the competition in health sector where providers try to market their services at the lowest possible cost without compromising the quality of the service. So more and more organizations are employing techniques such as process reengineering where by substantial cost reduction is achieved together with improvement in the quality of the service.

Business Process Reengineering

Business Process Reengineering is "the analysis and design of workflows and processes within and between organizations" (Davenport and Short 1990). It is the critical analysis and radical redesign of existing business processes to achieve breakthrough improvements in performance measures.

Davenport and Short define business process as "a set of logically related tasks performed to achieve a defined business outcome." A process is " a structured, measured set of activities designed to produce a specified output for a particular customer or market. It implies a strong emphasis on how work is done within an organization" (Davenport)1. In health care 'Processes' are defined as "a group of functions that result in a whole output to the patient, not necessarily a whole service".

One of the key success factors for reengineering in health care will be to redefine the organizations in terms of process and the organization of people will need to enable these processes.

Present Study

Major advances have occurred in the field of diagnostic imaging over the past few years. New technologies are rapidly bringing new capabilities to businesses, thereby raising the competitive par and the need to improve business processes dramatically. As the sophistication of the imaging technology continues to grow, substantial investments have to be made in the area. In order to break even the investments at the earliest and to make the most of the resources, systems have to be defined and devised. Inappropriate use of the resources and unorganized processes results in substantial loss to the organization.

Taking the above aspects into consideration a study was conducted in the radiology department of a 300 bedded corporate hospital to analyze the performance of the exiting system with regards to various radiological investigations so that re-engineering of processes can be done to improve efficiency of the system.

Objectives of the Study

  • To study the existing processes in the radiology department
  • To re-engineer the processes in order to improve the efficiency of the processes and to facilitate better utilization of the resources.

The Radiology Department

The department deals with the diagnosis and treatment of disease through the use of radiography, fluoroscopy and radioisotopes. The department has facilities such as X-ray, Fluroscopy, Ultrasound (US), CT scan, MRI and Nuclear Medicine. But large numbers of patients are seen in queue mostly in front of X-ray and US rooms. Inpatients are given priority over outpatients for investigation. There is no common counter for the radiology department. The patients report at the respective investigation room where as in case of US there is a separate counter right in front of US room. There is a common typing pool in the radiology departments where all radiology investigation reports are typed. A portion of the reports is typed at the US counter also.

Methodology

The radiological investigation processes are mapped by grouping the patients into two distinct categories.

  1. In patients- These are the patient admitted in the hospital for diagnostic and therapeutic purpose
  2. Out patients - These are patients availing treatment from the outpatient department of the hospital.

Under each category process flow is dealt as follows:

  • Process flow till the patient reaches the investigation counter
  • Process Flow in the Radiology Department
  • Process of report dispatch

1. Radiologic Investigation of In Patients

The doctor instructs the patient to undergo radiological investigation on the same day or the following day. Based on doctor's instruction the staff nurse makes arrangements for sending the patient for investigation. The sister keys in the requisition before sending the patient for investigation. In case of investigation like US, CT scan and MRI the sister rings up the concerned investigation room and informs them before sending the patient for the test. When the patient is ready to go for investigation the sister informs the transport desk by phone. The transport boy comes to the ward and shifts the patient to the investigation room. The sister sends the requisition slip and case file along with the patient. The transport boy reports with the patient at the investigation room. In case of any delay the transport boy leaves the patient in the waiting area with the relatives and goes. Once the investigation is over the technician informs the transport desk. The transport boy comes to the investigation room and shifts the patient back to respective in-patient area.

Problems Identified

* Instead of posting the patient for investigation the previous day, if the doctor instructs him/her to undergo investigation on the same day, it results in the patients being sent to the investigation room during the peak hours, when the OPD and Health Checkup patients are waiting for investigation.

*The requisition which the staff nurse keys in is available on line at the typing pool of the radiology department. This information is presently not used for any type of scheduling activity. It is used for the purpose of report generation. But this usage is also limited since all the systems used for report generation are not in LAN connection.

* For sending each and every patient for investigation the sister has to ring up the transport desk. There can be a delay at the transport desk to initiate the process if the transport boy is not available at the particular point of time.

* The sister has to make a requisition manually for the second time for sending along with the patient, since the online requisition is not used for initiating investigation, which is a duplication of the work.

* The sister has to ring up the investigation rooms (especially US, CT scan, MRI) before sending the patient for investigation since the cases are not scheduled based on the online requisitions sent.

* Even through preference is given to inpatients for the investigation, these patients sometimes have to wait if there are other inpatients already waiting in the queue.

* The sister/technician in the investigation room has to ring up the transport desk for transporting the patient back to the in patient area if the transport boy has already left, leaving the patient in the queue in front of the investigation room.

Proposed Activity

A common counter for the all radiological investigations with a receptionist to schedule the cases can be recommended. As soon as the sister keys in the requisition from the ward, the receptionist sees it online and schedules the cases. The sisters complete keying in the requisition of all patients who have to undergo investigation, the following day by 7pm the previous day so that scheduling can be done well in advance. This schedule is seen online at the transportation desk and at all nurse's stations. Based on this schedule the transport boy goes and collects the patient from the inpatient area and reports at the radiology counter. So the sister need not ring up the transport desk for shifting each and every patient.

In case there is any problem due to which, a particular patient cannot be sent at the scheduled time, the staff nurse rings up and informs the radiology counter at least half an hour before the scheduled time so that re-scheduling of the case can be done. In all other cases the sister keeps the patient ready for investigation so that there would not be any delay once the transport boy comes to pick up patient from the ward.

Since lots of investment is involved in installing systems in all the investigation rooms, in the initial stage the radiology receptionist can take the print out of the schedule and can give to the investigation rooms on hourly basis. Scheduling of cases for any hour is done at least an hour in advance so that there will not be any uncertainty regarding the same. The receptionist is in turn furnished with the status of the patients who underwent investigation in the past hour from each investigation room.

A protocol has to be made for sending the requisition of all inpatients who have to undergo routine investigation; well in advance (the previous day of the investigation) so that these cases can be scheduled in the early morning hours before the inflow of out patients and health check patients start. Thus overcrowding at the investigation room within patients during peak hours can be avoided.

Slot can be provided towards noon for all other non- routine inpatient cases who have been asked by the doctor to undergo investigation on the same day.

The transport boy can wait to take the patient back to the inpatient area since the waiting time will be considerably reduced with the introduction of the new system. So the technician does not have to ring up the transport desk for shifting the patient back to ward.

Proposed Changes in the Existing System:

The present counter in front of the ultrasound room can be converted into a common counter for all radiological investigations. The typist in the ultrasound counter can be made the receptionist for the proposed radiology counter. This receptionist deals only with the scheduling of all radiological investigations. She also prepares the patients for radiological investigations by explaining them the pre procedural preparations and clarifying their doubts. She furnishes each investigation room with the schedule of the patients who will be undergoing investigation, on an hourly basis.

The proposed radiology counter can be provided with an online system so that the details of all inpatients, out patients and health check ups patients who have to undergo investigation is made available to the receptionists. Similarly the transport desk is provided with an online system so that the transport of the patients to and from the investigation room is taken care of by the transport desk without the staff nurse in the ward or the technician in the investigation room initiating the process by ringing up the transport desk. Later the same facility can be extended for the transportation of patients posted for surgery also.

Additional Requirements:

  1. system in the transport desk with LAN connection
  2. Process flow in the radiology department

Once the investigation is over the technician takes the film to the dark room. The dark room technician develops the film and keeps it ready for dispatch. The technician from the investigation room collects the developed film and takes it to the radiologist for reporting. The radiologist writes the report. The technician collects the report and gives to the typist. The typist generates a computerized copy, which is later collected back by the technician. The technician takes the printed report to the radiologist for verification and signature. In case of any correction the technician takes the report back to the typist and the entire cycle is repeated.

Problems Identified

*The technician is involved in each and every activity till the time; the final report is ready for dispatch. This includes jobs like taking the film to the dark room, collecting back the developed film, taking the film to the radiologist for reporting, collecting the report, giving the report for typing, collecting back the computer generated report, taking the report to the radiologist for verification and signature. These are activities, which do not require the professional expertise of the technician, and thus results in usage of high cos labor for less skilled jobs.

*Since a stand by system is also currently used for report generation the profile of the patient and the type of investigation the patient underwent need to be typed again.

*The verification of the report is done only after the hard copy is generated. This results in duplication of the work and wastage of resources in case any correction needs to be made in the report.

Proposed Activity

In place of the technician, a helper boy collects the developed films and takes it to the radiologist for reporting. The doctor instead of writing the report manually can facilitate the process by

  1. Speaking into a Dictaphone. The cassette is later collected by the helper boy and is given to the typist for typing, or
  2. Doctor speaks into central codal typing pool, or
  3. Doctor dictate the report and the typist keys in

The typist prepares the report in the system, which is verified online by the radiologist, and the radiologist puts screen signature. Once the radiologist puts the screen signature the patient's treating doctor can use it for online reference and the typist can take the print out of the same. The helper boy takes the hard copy of the report to the doctor of signature.

Proposed changes in the existing system

LAN connection has to be given to all existing systems used for report generation.
Additional Requirements A helper boy has to be recruited Provision for Dictaphone or codal typing pool

C. Process of report dispatch

Nursing Aide boy or staff nurse from the inpatient area comes and collects the reports of the in patients. In case the doctor needs the report immediately for further management, the staff nurse collects the report and informs the doctor by phone. In case of routine investigations (e.g. X-ray chest of post CABG patients) the report is kept in the case file and the doctor sees the report during his next visit to the patient.

Problems Identified

If the nursing aide boy is not available, the staff nurse from the inpatient area has to go and collect the report from the radiology counter. This is a misuse of the nurse's skills and also results in distraction from their duties. This might reduce the efficiency of their work and also result in delayed report collection.

In case of emergency the doctor has to either ring up the radiology department or has to wait for the report to reach the ward.

Proposed Activity

The helper boy in the radiology department dispatches the signed reports to various inpatient areas on a periodical basis. Doctors see the report of the patient online even before the hard copy of the report reaches the ward.

image 1

image 2

Note

Process flow till the time the patient reports at the investigation counter and the Process of report dispatch are same for US as in the case of other investigations. The process flow in the radiology department differs slightly and is therefore mapped separately in the flow chart shown above.

2. Radiological investigation of out patients Existing Activity Flow

The patient consults the doctor in the OPD. The consultant orders for investigation if needed. The patient pays the investigation fee at OP billing and reports at the respective investigation room.

The patients who undergo investigation in the morning hours are asked to collect the report from the respective investigation room two hours after completion of the investigation. Reports are dispatched from the investigation room till 4.30 pm after which the remaining reports will be sent to report collection. But the patients keep on coming to radiology department to collect the report even after it is dispatched to report collection.

Problems Identified

* Long waiting time of OPD patients for investigation

* The patients are prepared for investigation only after reaching the investigation room. For example, patients have to undergo US lower abdomen with full bladder. But they are asked to drink water only after reaching the US counter. This results inlong waiting time.

* The treating physician has to wait for the hard copy of the report even if the treatment has to be initiated immediately.

* The reports generated in the morning hours are dispatched to report collection around 4.30 pm in the evening. If the patient comes for report collection after this time he has to be sent to report collection. This results in inconvenience and confusion to patients. The technician also will be disturbed and distracted on job.

Proposed Activity

As soon as the out patients pay the investigation fee at the OP billing their requisition should come online at the radiology counter. This helps to schedule these cases.

The preparation of the patient for investigation should start immediately after the doctor instructs for investigation. The wing secretaries in the OPD should be made responsible for preparing the patients for investigation. Drinking water should be made available in all wings so that this will be helpful for the patients who need to be with full bladder for US. Thus the patient will be ready for investigation by the time he reaches the investigation room.

Systems used by doctors in OPD should be given LAN connection and should be used by the doctors for seeing the reports online.

The reports of out patients should be given only from a single counter that is the report collection counter. This reduces ambiguity regarding report collection. The reports should be sent to report collection counter through the helper boy.

image 3

image 4

Conclusion

Reengineering does away with unnecessary processes and thus helps in reduction of steps involved. Once implemented it results in increased efficiency of processes with over all cost reduction. It also helps in improving the quality of care and increased patient satisfaction. But reengineering takes time and costs money in lost revenues, at least in the short run since it calls for restructuring of certain aspects of the existing system. Steps should be taken to ensure that the fear of failure does not lower the targets for reengineering. It is difficult to find a single approach exactly matched to a particular company's needs, and the challenge is to know what method to use when, and how to pull it off successfully such that bottom-line business results are achieved.

References

  1. Davenport, T.H. (1993). Process Innovation. Harvard Business School Press: Boston, MA.
  2. Malhotra, Yogesh. (1998). "Business Process redesign: An Overview." IEEE Engineering Management Review. 26 (3).
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