photoAccording to Webster’s Dictionary, the word “manage” has its origins in the French “manege”: training and/or putting horses through their paces.

For department managers everywhere, their continual maneuvering to corral people, costs, operations and outcomes is not unlike trying to keep a stable full of horses on track while each neighs and whinnies for constant attention.

How then does one manage a radiology department — and go about it most effectively? Are there any sure bets? What “places” high on the list? What “shows” potential? Are there specific strategies that lead to the winner’s circle? Absolutely.

“I think everything is meshed together. At certain times, in certain projects, some things may rise to the top and become a little bit more important than the others, but I don’t think you can manage your department today without looking at everything,” says Victor Sarro, administrator of radiology at Thomas Jefferson University Hospital (Philadelphia). “You are always trying to do planning as well as day-to-day management. You are always looking ahead, but you can’t forget what is going on now.”

“Looking at everything,” weighing all relevant factors, can end up meaning different things to different managers, depending upon the size and the setup of their departments. At the same time, all radiographic facilities — from the smallest private offices with three or four rooms of basic X-ray equipment to the largest university-affiliated hospitals offering a full range of diagnostic imaging services — share many of the same concerns, on a scale appropriate to their particular operation. Says Sarro: “Radiology departments tend to use a lot of two things: labor and capital, which are, in most hospitals today, difficult to get more of.”

Resurrection Medical Center rises out of the northwest side of Chicago, not far from bustling O’Hare International Airport. A not-for-profit, 380-bed community hospital, Resurrection Medical belongs to the Resurrection Healthcare Corp. system, which owns four hospitals and numerous nursing homes and long-term care facilities.

Gregory D. Moss, M.D., radiology department chairman and interim administrative director, says his department — overhauled in 1995 — performs about 140,000 examinations a year and carries an annual budget expense of $6.6 million, $2.5 million of which is allocated for operating expenses. The department employs approximately 150 equivalent full-time persons, including 11 full-time and three part-time radiologists.

“Staffing is an issue,” says Moss. “There is a shortage of technologists, particularly. My goal is to eliminate a lot of the non-technical procedures from our techs, trying to get aides and clerical staff to handle a lot of that so our technologists can concentrate on doing technologists’ jobs. Paperwork and other things — collating, transporting, telephones and everything else — much of that can be handled by non-technologist people, and that is what we’re trying to evolve.”

“When we talk about costs, especially in the area of labor, I like the principle of capacity management,” remarks Elizabeth Harris, director of imaging services at Mercy Medical Center in Baltimore. “Capacity management has a lot to do with looking at your week’s schedule or looking at tomorrow’s schedule, but always preplanning to know the total amount of resources you will need. It is to ensure that you are not overstaffed one day and not well-staffed another, and, consequently, you end up paying overtime.”

A technologist by profession, Harris shares responsibility for Mercy’s radiology department with her medical director, a radiologist.

A nonprofit, community hospital celebrating its 125th anniversary this year, Mercy offers a full complement of diagnostic imaging services to the 75,000 patients who pass through its doors annually. Annual expenses, based on the number of exams, total slightly more than $3.8 million. Staff fluctuates between 60 and 75 full-time and part-time persons, but Harris relies on what she calls a “flex pool or prn staff” to work on an as-needed basis. While prn workers command a higher hourly rate, they provide Harris with a flexibility that allows her to keep personnel costs in check.

“If you have an opening on Friday’s schedule and you have a couple of prn folks staffed but then patients start canceling out, you can always flex your prn staff down,” she states. “I started having an as-needed pool many years ago; I think that is a big cost savings in any department, not just diagnostic imaging.”

Joel Gray, Ph.D., maintains that staffing a radiology department effectively requires a balancing act. Gray, newly appointed vice president of business and clinical development at Trex Medical (Danbury, Conn.), had been a medical physicist in the radiology technology department at the Mayo Clinic (Rochester, Minn.) for 20 years, responsible for technology management.

A technologist can cost a hospital $100,000 a year, including salary, benefits and overhead, he points out, so he suggests that hospitals can save money by contracting for technologists on a part-time basis. In fact, he intimates, technologists would prefer that arrangement. “In some cases, it is due to the inflexibility of the organizations of not wanting to do that. I think some administrators look at it as twice as many people they have to worry about.”

Gray indicates that reimbursement issues in the last 10 years have pushed radiology departments to staff 24 hours a day, seven days a week, thus increasing overall personnel costs.

“What used to happen in the emergency room (ER), you would come in at 10 o’clock at night with a twisted ankle, and because whether it was sprained or broken was in question, they would take an X-ray, the ER physician would look at it and decide what to do. The next morning the radiologist would come in, read it and bill for it. The insurance companies, Medicare, in particular, now say that you cannot do that. The person who makes the clinical decision based on that X-ray, whether it is a radiologist or an ER physician is the one who is going to get reimbursed for it. Consequently, radiology departments are staffing up at night.”

Reimbursement formulae also figure prominently in managers’ equipment-purchasing decisions. When a new MR room costs several million dollars and a top-of-the-line CT scanner has a price tag of $1 million, radiology managers quickly learn the fine art of partnership and negotiation — with vendors, referring physicians, their own administrators, even other departments within the hospital.

photoResurrection Medical Center’s Gregory D. Moss, M.D., says his goal is for existing support staff to handle non-technical procedures, thus allowing technologists to focus on imaging responsibilities.

At Thomas Jefferson, which is affiliated with nearby Thomas Jefferson University, Sarro approaches capital expenditures by first evaluating the needs of his department’s individual sections within the context of the department’s overall priorities.

“We try to match things with programs; for instance, MRI still is an up-and-coming technology. I think there are more and more uses every day where this is becoming an important diagnostic tool. That is one of the types of things we want to look at, see where the equipment and software have progressed, and where it is useful in the practice here,” he offers.

“You have to look at what your referring physicians are looking for as well; they are always an important piece,” he continues. “It doesn’t do any good to put in something and then everybody says, ‘Gee, what did they do that for? I would never use an MRI for that purpose.’ Take bone densitometry, for example. Everybody is using DEXA-type scanning primarily. You would not put in a nuclear camera to do it because nobody does it that way anymore.”

Mercy Medical’s goal of not only maintaining, but also enhancing, its reputation as one of the 10 best hospitals in the United States for women’s care (Self magazine, May 1997) prompted administrators to spend a million dollars for brand-new, fully digital ultrasound equipment and accompanying facility renovations. This year, the hospital has turned its attention to CT scanning.

“You have to determine where the hospital product lines are going; diagnostic imaging does not work in a vacuum,” Harris explains. “Our strategic goals are the hospital’s strategic goals. In CT scanning right now, we know we want to expand women’s care. We’re going to bring in the Cadillac of the systems out there because we need to maintain our competitive edge.”

Harris is confident she will get her “Cadillac” CT system. However, if budget realities were to dictate that the dollars are not available for a high-end upgrade, how would she respond?

“If, indeed, the hospital has only $1 million, and we’re asking for $1.4 million, there are so many different contractual agreements you can get into with your vendor that you can still work with that $1 million and get what you want — if you know how to conduct your business,” she advises. “Maybe we have to postpone that and live with what we have for another four to six months until there is improved cash flow, if it is going to be an outright purchase. You can lease your equipment; you can buy now and pay later. Certainly, there are consequences to every decision you make, but there is always an answer,” she concludes.

At Resurrection, Moss recently postponed a MR purchase for a year, based solely on budget considerations, he says. If he can justify the cost-benefit relationship, he may be authorized “to go outside the budget. We have done that for some equipment,” he recalls.

“We are flexible and reasonable,” he allows. “In this age of cost-containment and decreased reimbursement, we have to be flexible, and we have to justify everything based on what the value is going to be. Patient volume plays into that.”

Resurrection also manages radiology department expenses with its arrangement to serve as a pilot site for Fuji Medical Systems U.S.A. Inc. (Stamford, Conn.) PACS, an agreement that was in force when Moss became director. According to Moss, Fuji selected Resurrection as its first prime clinical site for a couple of reasons: the hospital already was using a Fuji computed radiography system, and its location, near O’Hare, made it an attractive testing ground.

Resurrection does not have to buy all PACS-related equipment from Fuji, however. “If we can find a PC or something that’s cheaper, more economical for us to buy off the shelf, we can do that. That’s part of our agreement,” he says.

PACS purchasing is the specialty of Tom Johnson, M.D., of U.S. Radiology Partners (Dallas, Texas). Former chief radiologist for the U.S. Air Force, Johnson was project manager for the Air Force flagship hospital, the 1,000-bed Wilford Hall Medical Center, during a PACS conversion that cost $19 million and spanned five years, 1992 to 1997. In his new position with Radiology Partners, Johnson is responsible for the credentialing, quality assurance, quality control, licensing and overall clinical strategic direction issues that result when the company partners with small, often rural, radiology practices.

s02c.jpg (8685 bytes)Thomas Jefferson University Hospital evaluates potential radiology capital expenditures from several angles, matching priorities with programs and considering the needs of referring physicians.

Even though PACS prices have decreased since his Air Force days, Johnson admits installation and service costs still can prove daunting to a hospital administrator with a nervous eye on the bottom line. He recommends the following strategy for making inroads with a request for PACS funding, because, as he puts it, “You can’t just say, ‘We want a PACS.’”

• Get a buy-in from the hospital by citing better patient care, more efficient use of resources and a return on investment. “You have to have hard dollar savings, i.e., we’re going to save on film costs, but there are also soft savings in better communication between the referring clinicians and the radiologists, faster turnaround — things that are not quite as easy to quantify.”

• Know exactly what your requirements are and put them on paper. “You have to say what you want this PACS to do, how you want it to fit into your current operation, how it will change your current operation when you do put it in. You have to have a business plan.”

• Nurture vendor relationships. “It is really a partnership with a vendor. It cannot be that they just come in and say, ‘we have this hardware,’ and they drop it on you and walk away. It becomes a hand-holding partnership. You will find one vendor or another who fits the unique requirements for your particular location, whether it be service or a certain technology, or maybe they are going faster toward the Internet than others or maybe one is less proprietary than the others.”

• Create a team approach. “Bring in the information management/information technology folks, the people who are not necessarily radiologists or rad techs. These are the people who are laying the fiber and running the wires and running telecommunications. You cannot think of it as a radiology department program. It is a systematic, hospital-wide program.”

• If necessary, go in stages. “If they cannot buy in to a large PACS, do a miniPACS. Link all the things you can link relatively easy, like your CTs, your MRs, your ultrasounds, at a much lower cost and demonstrate to the hospital how much better that was for the patients and for the referring clinicians. Find out who the major naysayers are and take them to a RSNA (Radiological Society of North America) or a HIMSS (Healthcare Information Management Systems Society) conference to show them where the world is going.”

“No one is anti-PACS,” he insists. “I mean, that is like saying someone is anti-television. Most people object to it because of the high cost, and they are not convinced it is ready for prime time. It is an education issue more than anything else.”

Service contracts, whether they be for an elaborate PACS or a single MRI, present additional opportunities for cost savings — especially if a radiology department can supplement those contracts with the hospital’s own service crew.

“First-call service reduces the cost of your service contract because it eliminates a lot of unnecessary calls for the company. First-call service is not the one that is profitable for them,” opines Gray. “The ways [service contracts] usually work, they get a flat fee for all the maintenance, so, in effect, the fewer times they can show up at your door at all the better off they are.”

Gray recommends negotiating multiyear service contracts at the time of equipment purchase. “That’s the only time you have any negotiating power,” he warns.

Sarro, who can depend on Thomas Jefferson’s in-house service to handle repairs to general X-ray equipment, considers service contracts for higher-tech equipment because the dollar risk of not having a functional CR or MRI is high. At the same time, he negotiates staff training packages as part of service contract agreements: “What kind of training will the company provide you in order to utilize the equipment?”

Long-term service contracts and software agreements have tamed training costs for Michael Harris, assistant administrator of radiology, physics and engineering services at Johns Hopkins Hospital (Baltimore). Harris, who came to Johns Hopkins 15 years ago from GE Medical Systems (Waukesha, Wis.), has overall responsibility for nearly 300 pieces of radiology equipment assessed at $70 million. He credits his being able to manage each piece effectively, from acquisition to disposal, to his in-house database management system.

A strategy he prodded into development when he first arrived at Johns Hopkins, the database management system tracks incidents that occur with different systems, all work actions performed by the department’s technicians and engineers, and verifications and confirmations mandated by regulatory agencies.

“In order to make this system effective, there are a few things that we have to track well beyond standard repairs,” he begins. “We track performance issues — someone was unhappy with the appearance in imaging, for example. They may or may not occur again, but if there is a repetitive occurrence of those things, it helps us explain to the vendor or to justify taking action on those items. We track warranties, to prove to vendors we have a repeated occurrence during the warranty period that should be corrected without cost. We track installations, so that when equipment is delivered we start to look at what occurs during the installation period, such as, who worked on installing parts of the system from our staff. We track upgrades, PMs, breakdowns, standard repairs. We also track, and this is a biggie, accidents,” he says, recalling the time a technician turned on a MRI scanner one Monday morning — and the computer smoked. The technician quickly discovered that a toilet leaking from the floor above had dripped into the computer cabinet, resulting in a large portion of the system having to be replaced. “We made it easy for the insurance company to track what happened and we recovered our loss, which was a substantial amount,” he says.

Harris says most vendors support the tracking system because it assures them of prompt payment. And that vendor backing allows Johns Hopkins to compile a more complete history for its equipment, one that includes work detail performed by both in-house staff and vendors’ technicians.

“The goal is 100 percent,” he says. “I don’t think we have reached that goal, but we reach 100 percent of all the issues that require us to pay for vendor services.”

The advantages a database management system brings to an operation the size of Johns Hopkins radiology department are obvious, but Harris believes that such a system would prove effective in a smaller hospital environment if it were expanded beyond radiology to include all technology, in every department. “Of primary importance is the safety to staff and patients,” he says. “You ensure that by being pro-active in your equipment-care efforts. This system is part of being pro-active.”

Effective managers negotiate, they balance, they devise long-term plans, they scrutinize short-term issues. All that comes more easily when they remember what several managers consider paramount: collaboration and communication.

“When you work with other departments, you learn more about what’s going on,” says Sarro, who meets regularly with administrators of other departments. “When you collaborate together, it generates new ideas.”

“We are a service department, so we have to interact with every other department and provide service in a kindly and accurate fashion,” says Moss, citing his department’s monthly meetings with ER physicians and radiologists. “With costs and reimbursements declining, you want to keep your customer satisfied and coming back.”

“My biggest key to success, as I call it, is communication,” asserts Elizabeth Harris. “Every single Thursday of every single week, we have a staff meeting. Every project that happens in our department everybody knows about right up front — from the hiring of staff to new facility renovations to capital equipment acquisitions. My philosophy is, if you do not communicate, you are going to spend a lot of time cleaning up in the back end what you need to be doing on the front end.”end.gif (810 bytes)