RAISING THE BAR

Choosing the right radiology partner for your hospital begins with crafting an effective RFP process.

In the course of a typical year, a large number of hospitals are going to switch radiology groups. In fact, according to the national radiology group Radisphere, anywhere from 5% to 15% of American hospitals will change groups annually.

Which begs the question—why?

The major issue driving change is dissatisfaction, said Hank Schlissberg, chief strategy officer for Radisphere, particularly when it comes to attitudes a hospital’s medical staff have developed concerning incumbent radiology groups.

For example, Schlissberg said that in a survey of 75 community hospitals conducted by Radisphere, those hospitals reported that they paid an average of $300,000 to $500,000 annually in administrative costs related to services such as nighthawk fees, transcription costs, and excess software licenses. “This is obviously significant,” he said.

There are also concerns related to basic quality of care issues like excessive turnaround times and lack of subspecialty access. And hospitals are often dissatisfied with how willing and able radiology groups are to drive growth by improving the quality and service of the radiology department.

At the same time, said Ingrid Lund, PhD, senior consultant for the Advisory Board (a global health care research, technology, and consulting firm), radiology groups and departments are—for a variety of reasons—under “enormous pressure” to evolve their practices in areas like clinical expertise and service.

Radiologists should be focusing on a number of areas, she said, such as:

• Clinical effectiveness, where radiologists should improve their performance in the area where their bread is buttered—reading and reporting studies.
• Strategic alignment, through which radiologists should be able to “prove to their partners that they are integral members of the imaging team and are ready to provide effective growth strategies that work in today’s fee-for-service world as well as tomorrow’s more risk-based models.”
• A progressive practice structure that “rewards physician excellence in both clinical and non-clinical measures and builds an ethic of service . . . among physicians.”

So, it’s apparent that while many hospitals are thinking about changing their radiology groups, radiologists also are looking to evolve their practices in a way that makes them more attractive partners. Consequently, said Schlissberg, hospitals should be able to “raise the bar” concerning what it should expect and demand from a prospective radiology partner. And, Schlissberg said, the request for proposal (RFP) should reflect that.

After having been through the RFP process “hundreds of times,” Radisphere has developed a template that, he said, “is a best-of-the-best” approach to the RFP. This RFP focuses on three categories, Schlissberg said—medical staff support, quality, and financial and operational issues.

Medical Staff Support

According to Schlissberg, hospitals should hold a “very high bar” for radiology groups when it comes to the subspecialty access they provide. “A lot of errors and discrepancies in radiology are driven by the simple difference between the generalist and the subspecialist reading, for example, an MRI of a lumbar spine,” said Schlissberg. “The discrepancy rate is actually quite extraordinary, and we would encourage you to hold a high bar.”

According to Lund, subspecialization, in addition to offering quality benefits, opens up the possibility of offering expanded services, “and is valued by referring physicians and hospitals.”

Schlissberg also suggests that hospitals “push hard” on the issue of preliminary and final reads. “With the technology available today, there is little reason for costly preliminary reads that delay turnaround times, incur significantly dramatic out-of-pocket costs, slow down throughput in the emergency department, and increase the patient length of stay,” Schlissberg said.

Quality

Lund conducted a series of interviews with radiology directors, group practice leaders, and industry experts, “and one of the things that surprised us is the sheer lack of data around performance,” she said. “What are the standards?”

While many hospitals don’t even try to address issues surrounding peer review and quality in their RFPs because the question of quality is so difficult to define, Schlissberg said, those issues should still make their way into RFPs.

“Peer review is a great example,” he said, adding that it should be random, frequent (as frequent as 2% of all cases), and proactive instead of reactive, and should be done at the time studies are ordered instead of through something like an end of the year review, well after many errors already have been made.

Peer reviews also should be double blind, he said, pointing out that two radiologists in a local practice simply exchanging reports and asking each other to read them may not be very effective. Better to send the cases to a second radiologist—who they don’t know—and have them read all over again, he suggested.

“There should be a level of expectation around the issue of quality and peer review that the industry has the right to demand,” Schlissberg said. “Therefore, put it on paper.”

Hospitals also should ask prospective groups how they go about tracking metrics related to quality assurance and critical findings. “Health care is such a big data environment and groups of any scale will aggregate data and really provide benchmarking and analysis at a [high] level,” he said.

Finally, hospitals should expect to see some kind of evidence of the clinical effectiveness of the groups they are considering. “Are they practicing what they preach?” he asked. “Are they talking about patient safety initiatives, outcomes, and clinical variations? And what have they published? You expect the ones who are publishing to be on the cutting edge of these issues.”

Financial and Operational Issues

Hospitals also should expect groups to help drive growth, whether it is by guaranteeing subspecialty access and certain service levels, or through marketing or “identifying opportunities for referrals from key physicians,” said Schlissberg.

Whatever the RFP process looks like in the end, Schlissberg strongly urges that the process be totally transparent. “We encourage an open RFP process that includes the incumbent group and other candidates,” he said. “And be very inclusive in the way you run the process. It’s politically savvy and, for us, has led to much smoother transitions.”

One Hospital’s Experience

Wooster Community Hospital in Wooster, Ohio, is a 150-bed acute care hospital that also serves as a stroke center. The hospital performs more than 60,000 radiological procedures a year, and, because of its stroke commitment, has radiology needs around the clock, said Dave Harrison, MBA, RT, the hospital’s imaging services director.

According to Harrison, about 5 years ago it became clear that the hospital’s medical staff was becoming increasingly dissatisfied with its incumbent radiology group’s performance.

The staff was specifically concerned about slow turnaround times, said Harrison, “leaving us with a situation where a lot of physicians simply ordered everything as stat.”

In addition, the interventional capabilities of the group were limited, which meant that the hospital often had to ship patients outside the hospital for service, “which wasn’t a good thing for our organization,” Harrison said.

Harrison said that the hospital also had concerns about quality issues. “The quality processes were manual and labor intensive, and there was a lot of room for improvement,” he said.

For example, emergency department physicians would read reports after hours, with a follow-up read performed by radiologists the following morning. “When there was an error in those reads, there was a delay in tracing that error and getting the patient taken care of appropriately,” said Harrison. “And that delay could be significant.”

Quality assurance was problematic as well, “and really lacked substance,” Harrison said. “It was one of those, ‘Hey, I’ll look at 10 of your cases, and you look at 10 of mine.’ It basically allowed us to get numbers, but wasn’t the best way to do it.”

So, with a radiology contract renewal date of April 2009 on the horizon, the hospital began exploring alternatives in the fall of 2008, “giving ourselves a considerable amount of time,” Harrison said.

The first thing the hospital did was set up a committee, which included key hospital figures such as Harrison and the hospital’s CFO, CIO, and vice president of outpatient services.

The committee also included surgeons and emergency department physicians “who will let you know when something goes wrong,” Harrison said. “So we wanted their input on how to make things better.”

The committee came up with “must haves”—which meant, Harrison said, that the hospital wanted its RFP to reflect the goals it expected to achieve by changing providers.

These goals included a desire to improve services, have its interventional needs met, straighten out workflow issues, reduce administrative fees, and ensure that the new radiology group could handle the hospital’s 60,000 procedures each year.

“We wanted to identify what was important to us,” said Harrison. “And we wanted to incorporate things that were measurable.”

For example, the hospital wanted the RFP to reflect its concern with the issue of turnaround times. Under its previous radiology contract, said Harrison, more than 38% of reports took more than 24 hours to come back, “which was totally unacceptable.”

So the hospital included a provision in the RFP that required that no more than 10% of reports would take longer than 24 hours to process. Today, under the new radiology group, that rate is less than 8%.

In an effort to reduce administrative costs, the hospital’s RFP also reflected Wooster’s desire to find a group that could cut nighthawk costs and had voice recognition technology in place that would help cut transcription expenses. The result? The hospital has, according to Harrison, eliminated more than $300,000 in administrative costs.

Harrison has these suggestions for hospitals going through the RFP process:

• Make sure the change represents a long-term solution to those concerns that led to the change in the first place. “Nobody really wants to change a radiology group,” Harrison said. “Make a good decision and hope that it holds, because changing [a group] every few years is definitely time intensive.”
• Get organizational buy-in from hospital staff.
• Make sure the process is transparent—”I went on one site visit to see how the [radiology group] worked, and that was immeasurably helpful,” Harrison said.
• Expect evolutionary change. “You want your group to stay in motion and constantly move forward,” Harrison said. “I’ve been in radiology for over 20 years and you are never asked to do less. You’re asked to do more, and you have to do it faster.”

Harrison also has a warning about timing, suggesting that hospitals look closely at their contracts to see whether they contain 30-, 60-, or 90-day outs. Harrison has a colleague who was going through the RFP process with three different groups, but had the incumbent group threaten to pull out in 30 days if the hospital didn’t sign with it.

“The group played hardball,” Harrison said. “And [the hospital] chose not to make a change.”

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Michael Bassett is a contributing writer for Axis Imaging News.