f01a.jpg (10283 bytes)“Service with a smile” may be too clich?, but freestanding imaging centers have come to know that successful businesses provide a friendly atmosphere for their customers.

Today, more hospital radiology departments also are learning that lesson. Strategic planning for the future means not just asking how to provide the best images possible, but how to deliver those images faster and cheaper to physicians — and how to help patients feel more comfortable.

As demand for medical imaging studies grows, free-standing imaging centers proliferate across the country and increasingly compete with hospitals. Frequently, these centers can provide quality service in a friendlier, less intimidating environment than the local hospital.

The growing need for images also is creating a shortage of radiology technologists. So, as hospital radiology departments nationwide plan for the future, obtaining the latest technology and retaining imaging techns remain high on their list of priorities.

Providing a cheerful environment for patients has become equally important to compete with free-standing imaging centers and because patients demand it.

Improving patient services
“While we always cared about the patient’s welfare, there is no question that patient priorities are becoming the driving force behind decisions,” says Hedvig Hricak, M.D., chair of radiology at Memorial Sloan-Kettering Cancer Center (New York City). With easy access to medical information on the Internet, patients are more informed than they were five years ago. As patients become more knowledgeable, they demand more from their healthcare providers.

When Memorial Sloan-Kettering opened its 190,000-square-foot Laurance S. Rockefeller Outpatient Pavilion in midtown Manhattan last summer, it touted its technological progressiveness and its patient-oriented physical design. Waterfalls, sculptured gardens, and plenty of space and creature comforts were included to create a tranquil environment focused on the body, mind and spirit. “If there is one thing that goes into the design of the facility, it is putting the patient first,” Hricak says.

Spencer Madell, M.D., vice president at MedSolutions Inc. (Nashville), a medical management company, agrees. Before joining MedSolutions, Madell helped design UMass Memorial HealthAlliance’s new radiology department (Leominster, Mass.). If hospitals want to compete for the local imaging market, he says, they must match the clinics’ level of service or lose out.

“Nobody wants to go to the hospital,” Madell says. He recommends that hospitals make their radiology departments appear as much like a free-standing facility as possible with easy access from the parking lot and pleasant surroundings. Traditionally, radiology departments were located in dark basements and outpatients had to walk through the hospital past sick patients and unpleasant sights and smells. Madell says it is important to keep the radiology department located along an outside wall so outpatients can step inside without walking through the hospital.

Once inside, Madell recommends keeping outpatients separated from hospital inpatients. At UMass Memorial HealthAlliance, designers created separate entrances with inpatients accessing radiology services from an inside door and using clinic rooms along the inside half of the room. Instead of wheeling in patients to wait in hallways, a separate holding room was created. Outpatients, who enter from the outside, wait in a separate waiting room and primarily use rooms located along the outside section of the facility.

“At least for outpatients, you want to make it appear that they are the only ones there,” Madell says. “It separates the sick people from those who come in for testing and screening.”

Madell also suggests placing all radiology modalities in one location, but strategically locating departments that frequently use radiology services adjacent or nearby, such as the emergency department and women’s healthcare services.

Above all, the theme must be happy and cheerful, he adds. Large waiting rooms with comfortable chairs and a children’s play area, an inviting front reception area and a bright atmosphere are vital to attracting customers.

Sharon Robbins, director of radiology and imaging services at UMass Memorial HealthAlliance, says having outgrown the existing facility and trying to compete with other radiology facilities just minutes away made the renovation necessary.

“Right now, [patients] register at one area of the hospital and then go to X-ray,” says Robbins. “When the facility opens up [in August], they’ll just go straight to radiology and leave from there.”

The facility also was built with an eye to the future. The infrastructure for a PACS (picture archiving and communications system) is built into the new center, so digital technology can be phased in slowly.

New vs. renovations
Renovating existing space does not have to cost much more than a traditional radiology department and can provide an inviting environment that mimics an outpatient setting, Madell says. Building a whole new facility, however, does provide the best opportunity for incorporating new design concepts.

f01b.jpg (13923 bytes)The first priority at BryanLGH Medical Center, of Lincoln, Neb., after its merger, is to develop a centralized computer system to track patient information and images between the two hospitals and new outpatient center.

At BryanLGH Medical Center (Lincoln, Neb.), a merger of two local hospitals in November 1997 created an opportunity to rethink the hospitals’ radiology facilities. Although the administration has no immediate plans to redesign the radiology departments at either hospital, BryanLGH is building a new outpatient facility to provide patients a comfortable, convenient location away from the hospital.

“We saw a great opportunity to start from scratch,” says Brock Christensen, director of radiology at BryanLGH. “Outpatient centers are highly attractive to patients. You can park your car in front of the building, register, have your exam and be on your way.”

The separate facility will minimize a parking crunch at the two hospitals and will get patients through faster, because they will not have to compete with inpatients for time.

“You need to expand beyond the walls and take the clinic to the population, too,” Christensen says. But growing from a single hospital to a three-facility system has created another service challenge — communicating between all three systems.

Christensen says his radiology department’s first priority is to develop a centralized computer information system to keep track of patients and films between the two hospitals and the new outpatient center when it is completed next spring. Outside consultants helped BryanLGH decide that going filmless should be part of that technological overhaul.

“The merger accelerated the decision to go filmless,” says Christensen, adding that the facility plans to begin implementing PACS next spring. The benefits are obvious: No hard copies to transport — or get lost — between hospitals, which are about three miles apart; radiologists at any facility can read films, if another facility becomes overwhelmed; and archiving film will not require valuable storage space.

In addition to the benefits to the hospital staff, Christensen says being digital will provide better and faster service to their referring physicians, particularly to Nebraska’s large rural population. BryanLGH staff meets regularly and shares resources with rural hospitals and medical centers across the state, and administrators already have begun talking about ways to enhance teleradiology services after the PACS is in place.

“It’ll be a big change,” Christensen says, “but we’re not here to force this change down the physicians’ throats. We’re going to show them the tools, and if they like it, it’ll be here.” The facility still will be able to provide films for those physicians who prefer them to digital images.

Edward M. Smith, Sc.D., professor of radiology at the University of Rochester (N.Y.) Medical Center, agrees that there always will be a need for film, but hospitals should plan to switch to digital. “If, in the next three to five years, a radiology department is not approaching being nearly filmless, they will not be able to compete in managed care,” he says. “The efficiencies both in productivity and the turnaround to referring physicians will become more and more critical as people’s time and cost constraints put pressure on medicine.”

But Smith says shifting to a filmless environment is not easy. It creates a whole new way of working and a shift in the thinking process as well. Radiologists will go from reading images in batches to a real-time environment in which images and reports are transmitted rapidly to a referring physician in an hour or less, rather than the six to 48 hours in most departments today.

PACS potential
Once the shift is made, Smith says he has seen significant increases in efficiency, even in small hospitals that perform less than 40,000 procedures a year. The cost of introducing a PACS, he adds, may seem prohibitive to many small hospitals, but increasing the number of procedures and reducing film expenses can mitigate the initial investment over time.

For hospitals that cannot afford to buy a PACS of their own, other options are becoming available. Companies will install and manage a PACS, with the hospital paying on a pay-per-use basis. The company owns the equipment, keeps it working and guarantees to update the hardware and software at no additional cost to the hospital.

Jon Lehman, CEO of Inphact, The Radiology Solutions Co. (Nashville), says that with this arrangement, “the fundamental shift goes from a capital or equipment model to a service mindset. Departments will be able to buy these functions as a service, as opposed to having to buy and manage the equipment.”

Lehman says Inphact took the service model one step further by providing the long-term archival storage at a central site and putting images on a Web server for physician access. The cost runs from $8 to $12 a procedure for everything from providing the equipment that captures the image to the long-term archive facilities.

Although some in the industry say they do not feel comfortable yet with the reliability of off-site image networking and archiving provided by Inphact and other vendors, Lehman says interest in such services is spreading and he anticipates his business will double from 30 sites to 60 sites this year.

However you decide to implement a PACS, University of Rochester Medical Center’s Smith says the key for existing departments is to do it gradually. “It’s very important in almost any institution that you don’t introduce a PACS to a whole department at one time,” he says. “Plan for the whole program, but work your way in.” Phasing the implementation also will spread the costs out over several years.

Much planning also must go into how to implement PACS throughout the hospital and how the radiology department will service other departments, such as the ER.

The staff at Cedars-Sinai Medical Center (Los Angeles) has been searching for those answers since they began designing a new 121,000-square-foot imaging wing that will include a PACS.

Lynne Roy, director of imaging at Cedars-Sinai, says a 15 percent increase in imaging procedures each year since 1993 had put the center at full capacity. In addition, the department is scattered around the hospital, requiring duplicate reading rooms and registration desks. The new wing, which is scheduled to open in December 2001, will consolidate the hospital’s radiology services into a state-of-the-art facility with a patient-friendly design.

To implement a PACS throughout the large hospital, Cedars-Sinai had to decide how to distribute the images electronically, either over the Web or through PACS viewing stations. Cedars-Sinai opted to distribute primarily over the Web, but with some viewing stations distributed in key areas, such as the ICU. Roy said the hospital has not decided how to service the OR yet, but specialties that rely heavily on film, such as orthopedics and neurosurgery, probably will stay with film for now.

In addition to the hardware decisions, Smith says implementing a PACS requires careful planning to work with and train staff.

“A lot of times people don’t want to adopt new technologies,” Smith adds. “You need a strong leader to make this work. But, if you do it in a well-organized manner, people are kept informed and they buy into the PACS concept, there doesn’t have to be a lot of trauma.”

Improving staff retention
Providing the best service to patients and physicians requires not only a well-designed facility and the latest technology, but also an adequate number of qualified personnel. The increasing demand for radiology images has been a boon for imaging technologists, but has led to staff shortages in hospitals nationwide.

At BryanLGH, Christensen says staff shortages, particularly in nuclear medicine, remain a big concern, although he hopes the merger will allow him to share staff between the two hospitals soon. To help ease the crunch, the department is sending two employees to the University of Nebraska Medical Center to become certified nuclear medicine technologists. In return, they have agreed to work at the hospital for a certain number of years to pay back the contract.

“We’re investing in the future,” Christensen says. “We want to show our employees that we care and that we want them to come work here.”

That’s the right approach, says Bruce Crawford, vice president of MED Travelers (Irving, Texas), a healthcare staffing firm. The demand for imaging techs will only get stronger, Crawford predicts, giving technologists an increasing advantage in the workforce. Hospitals must implement creative ideas to attract and retain employees.

“Never stop recruiting,” Crawford advocates. When imaging techs knock on your door, “instead of turning a deaf ear and saying ‘We’re full right now.’ It needs to change to ‘We’re always interested in talking to good candidates.’”

Crawford also recommends cross-training techs. Hospitals would gain workers who can provide cross coverage, and techs would feel challenged in their jobs. One frustration Crawford says he hears frequently is that once workers are trained, they become more marketable and leave for bigger hospitals that pay more money. Although workers must agree to stay for a certain number of years, bigger hospitals can buy out the contract along with the employee.

To overcome that problem, Crawford says employees must be happy where they are. Besides the obvious need for competitive salaries, Crawford says simply fostering a collegial environment, where technologists feel respected and have the opportunity to move up the ladder, provides incentives to stay.

“One of the things I hear is difficulty between physicians and imaging techs,” Crawford says. “It’s not like you can put out a memo that says ‘All physicians will have new respect for the techs starting today.’” But, he adds, when hospitals implement policies that eventually build a more collegial environment, imaging techs are more apt to enjoy where they are.

Sloan-Kettering’s Hricak says understanding the staff and balancing their wishes with the needs of the department and the budget are important aspects of managing a radiology department. “The key component is communication,” she adds.

At Sloan-Kettering, Hricak says technologists are not cross-trained, because the institution provides tailored specialty care and cross-training would not fit its mission. “This works for us. It may not work for a center across the street,” Hricak says, adding that the most valuable aspect of strategic planning is listening to the community you serve and staying focused on providing the best service appropriate to them.

“You cannot do strategic planning for radiology in a vacuum,” she says. “You cannot just copy what other people do. How you operate has to fit your environment.” end.gif (810 bytes)