A team of professionals at Baptist Health—a five-facility institution—has developed a collaborative, methodical process for imaging investments. Here’s your chance to “TAP” into their expertise.
Of the more than 1,000 hospitals recently surveyed by the American Hospital Association, 80% have cut administrative expenses, 48% have reduced staff, and 22% have cut services in response to the current economic crisis; however, 70% are still reporting a decline in overall financial health. Hospitals also face limited access to capital and higher cost of capital compared to previous years, both of which restrict a hospital’s ability to fund improvements.1,2 One area particularly hard-hit by the economic crisis is clinical technology, with 70% of surveyed hospitals stopping, postponing, or scaling back clinical technology projects planned or already in progress.1
Despite the precarious financial climate and the heightened importance of making sound resource allocation decisions, most health systems do not have a structured, continuous process to assess clinical technology and inform decisions about equipment maintenance, replacement plans, and new acquisitions.3 As a result, decisions about equipment are unduly impacted by internal politics, vocal physicians, and the ability of individuals to pitch their requests convincingly. In the absence of a rigorous technology assessment process, organizations experience unnecessary, overpriced acquisitions. This suboptimal allocation of resources drains capital that then cannot be directed toward effective patient care.4
In 2004, Baptist Health implemented the Technology Assessment Process—a collaborative, methodical approach to managing imaging technology across the system. The Technology Assessment Process has allowed Baptist Health to evaluate its imaging technology relative to industry best practices, base decisions about equipment on concrete data, allocate capital in support of clinical technology that is aligned with growth and strategic plans, and enhance the organization’s ability to meet provider requirements and improve patient care.
As a direct result of this process, Baptist Health has advanced its imaging technology portfolio by streamlining inventory, decreasing the average age of equipment, improving the overall condition of equipment, and elevating its level of imaging technology. The purpose of this article is to explain the Technology Assessment Process, convey how it is managed, discuss how and why it has been successful, and demonstrate how the process can be replicated at other organizations to produce similar outcomes.
Leading the System Approach
In 2003, the COO of Baptist Health called for a streamlined process that would rigorously assess technology across the organization’s five facilities, beginning with imaging due to the large dollar amounts consistently allocated to the field. The COO identified a high-level champion (VP, Operations), and selected a System Lead Director of Imaging to manage the initiative. The System Lead Director of Imaging position was staffed by an Imaging Director who, in addition to overseeing imaging at the flagship facility, is tasked with providing coordination and consultative support for imaging services across the system.
The Technology Assessment Process
The Champion and System Lead Director developed and, in 2004, implemented the organization’s Technology Assessment Process. Its core purpose is to operationalize a system-wide plan to maximize the return on (net present value) and prioritization of the system’s capital investments while balancing service area dynamics. The five phases of the Technology Assessment Process are repeated annually and cover a 5-year horizon.
Phase 1: Catalogue inventory
During the first year of implementation, the organization focused on building a database of detailed information about each piece of imaging equipment in the system. A review of imaging inventory revealed documentation was complete but not necessarily useful or user-friendly. As a result, Imaging Directors worked with their team of managers, technologists, and vendors to research each piece of imaging equipment at each facility (Table 1. Inventory Data) and input the detailed information into a centralized database. The inventory database has since been updated annually.
The System Lead Director controls quality by assessing completeness of data for each piece of equipment. A second layer of quality control is the database gatekeeper. This person is skilled in data entry and has knowledge of imaging technology, which allows him to identify errors and inconsistencies in data. The gatekeeper works directly with Imaging Directors to ensure a comprehensive inventory can be viewed at the facility and system levels.
Phase 2: Assess each piece of equipment
Imaging Directors next audit each piece of equipment. They assess the equipment’s condition, age/lifespan, and level of technology relative to industry best practices. They recommend a replacement strategy and develop a financial analysis to justify the recommendation (Table 2. Audit Criteria and Definitions). The gatekeeper inputs this information into the centralized database. The result is an informative snapshot of each piece of imaging equipment.
Audit Criteria and Definitions
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| Table 2. Each year recommendations are made on what to do with each piece of imaging equipment based on its condition, level of technology, and financial analysis. |
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Prioritization Scale
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| Table 3. Using a three-tiered scale with detailed guidelines, imaging equipment requests are prioritized at the facility and system levels. |
Phase 3: Prioritize equipment requests by facility
Perhaps the most challenging of all phases in the Technology Assessment Process is the prioritization of equipment requests. Imaging Directors at each facility must prioritize requests by assigning a priority number (“1” is a high priority, “2” a moderate priority, “3” a low priority) to each piece of equipment (Table 3. Prioritization Scale).
The categorization is based not only on audit data but also on input from referring physicians, the Radiology Medical Director (RMD), and the facility’s administrator. Imaging Directors gain a sense of physician interests throughout the year and discuss them with the RMD to answer questions such as “How clinically important is this technology?” “What are its applications?” and “What will it replace or augment?”
The RMD and Imaging Director collaborate to prioritize imaging requests. If a piece of equipment is rated a Priority 1 and is valued at more than $250,000 or is a new technology, the Imaging Director is required to create a pro forma with the Finance Department. The Imaging Director then meets with the facility’s administrator to present the list of priorities and discuss the facility’s growth and strategic plans. Together, they address questions such as “How do these priorities fit with our growth strategy?” “How do they meet provider demand?” “Can we support this technology?” “What is the ROI?” and “When will we break-even?”
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| Figure 1. Imaging Technology Adoption Curve, 2009-2010.5 Baptist Health has migrated its imaging technology status from “late majority” to “early adopter” over a 5-year period due to the Technology Assessment Process. |
Phase 4: Prioritize as a system
The next phase focuses on prioritizing equipment requests across the system and developing a 5-year, system-wide imaging investment strategy. The System Lead Director convenes a meeting with all Imaging Directors to discuss only Priority 1 technologies. Imaging Directors must force-rank their facility’s Priority 1 requests and then collaborate to prioritize top requests as a system. Their collective focus is on emergent/end-of-life equipment, new technology, and rigorous ROI analysis to justify rankings. The Imaging Directors discuss issues such as relocation of equipment within the system to improve utilization and the probability of new technologies successfully meeting provider demand and patient needs.
Phase 5: Vet priorities with key stakeholders
The final phase of the process is designed to create transparency and build consensus around system priorities. The System Lead Director and VP, Operations (the initiative’s Champion) are in constant communication about imaging technology throughout the year, but prior to the annual Capital Allocation Process, they meet specifically so the System Lead Director can present imaging priorities to the VP, Operations. This more formal meeting serves as preparation for the upcoming site visits during which they will jointly present priorities to facility administrators.
The primary purpose of the site visit is to gain administrator buy-in to system-wide priorities. The System Lead Director and VP, Operations present administrators with the system-wide list of prioritized imaging requests and the rationale behind it. Because of the open communication between Imaging Directors and their respective administrators during the previous phases of the process, administrators are not blindsided by the information presented during the site visit. Instead, the meeting provides administrators the opportunity to inquire about recommendations and provide additional input. The VP, Operations and System Lead Director are authorized to adjust the list based on information gathered during the site visits.
Finally, the System Lead Director presents the vetted list of imaging requests at the Administrators Council, a meeting attended by all administrators and chaired by the COO. This presentation allows administrators to confirm their consensus on imaging’s system-wide priorities. The COO uses the time to challenge assumptions upon which prioritizations are made and facilitate consensus.
Outcomes
Baptist Health was traditionally a “late majority” adopter of imaging technology. Over the past 5 years, Baptist Health has used the Technology Assessment Process to migrate its status to “early adopter” of imaging technology relative to industry best practices (Figure 1. Imaging Technology Adoption Curve).
Baptist Health has decreased inventory by 6% and lowered the average age of equipment from 7.8 years to 5.0, with standard deviation in average age of equipment decreasing from 8.8 years to 1.8 years. In addition, the Technology Assessment Process has led to an overall improvement in the condition of equipment and level of technology. In 2004, 90 pieces of imaging equipment (46% of all imaging equipment) needed to be replaced. In 2009, that number has dropped to 49 (28% of all imaging equipment).
Furthermore, the Technology Assessment Process has made decisions about capital allocation for imaging equipment transparent and more efficient. Imaging Directors are able to access current data about inventory and present compelling arguments for equipment requests. Administrators are able to make informed technology decisions and directly connect them to strategic goals.
Keys to Success
The Technology Assessment Process must be driven from the top. The COO mandate makes clear that the initiative is a priority while the Champion’s leadership helps drive the initiative. Their combined involvement lends credibility to the process and fosters leadership buy-in, a critical element when implementing the process and building consensus with referring physicians.
Another integral factor is commitment to the upfront investment required to successfully implement the process. The first time a system completes a full-scale inventory requires a significant number of hours over a period of months, particularly if no FTE is assigned to the initiative. Once the baseline is established, however, maintenance of the data requires only a minimal time commitment.
The Technology Assessment Process also must be led by someone who is knowledgeable about imaging technology, dedicated to implementing best practices, and respected throughout the organization. These qualities make it possible for the System Lead Director to manage the process, provide insight that balances cases presented by a facility’s management, and sustain momentum.
Although the Technology Assessment Process is led from the top of the organization, its collaborative nature is integral to injecting integrity into the force-ranking of priorities and corresponding resource allocation. The collaborative approach also breaks silos because it introduces a system of checks and balances that encourages leaders to discuss technology assessments and question each other’s requests.
Finally, the Technology Assessment Process must coincide with the organization’s annual capital allocation process. Doing so promotes intentional planning that ties technology decisions to a long-term budget and strategic plan. Otherwise, the Technology Assessment Process loses its ability to impact capital allocation decisions.
Replicating Success
The Technology Assessment Process is rigorous, consistent, replicable, and therefore relevant to multiple disciplines. Baptist Health has implemented this process in cardiology, surgical, endoscopy, lab, and pulmonary. The organization is beginning to generate similar outcomes in these areas. By objectively assessing inventory and new technologies, and prioritizing requests for multiple service lines across the system, Baptist Health is positioning itself to further maximize its capital allocation decisions.
Robert Perez is System Lead Director and Imaging Director, Pulmonary Services, at Baptist Health, Jacksonville, Fla. He was integral to developing the Technology Assessment Process at Baptist Health and has managed the process since its implementation in 2004.
Mark Slyter is president of Baptist Medical Center and executive vice president and COO for Baptist Health Systems; he served as Champion for the Technology Assessment Process from 2003 to 2005, working directly with Mr Perez to develop and implement the process.
Edward H. Sim has been administrator of Baptist Medical Center Beaches since January 2009. He served as Champion for this initiative from October 2005 to January 2009.
References
- American Hospital Association. The Economic Crisis: The Toll on Patients and Communities Hospitals Serve. Available at: www.aha.org/aha/content/2009/pdf/090427econcrisisreport.pdf. Accessed August 5, 2009.
- Levy A, Lawrence J, Shiple D. A fresh look at capital investments. Healthcare Financial Management. March 2009:45-51.
- Playbook for the Economic Downturn: Protecting Margins and Positioning for Growth. Washington, DC: Health Care Advisory Board; 2009:52.
- Abenstein JP. Technology assessment for the anesthesiologist. Anesthesiol Clin. 2006;24:677-96.
- Adapted from Clinical Technology Investment Guide: 2008 Reference Guide to Emerging Clinical Innovations. Washington, DC: Health Care Advisory Board; 2008:16-17.
