Technologists may hold the express pass to optimized CT workflow. With dwindling reimbursement and CT bundling impacting departments of all sizes, the impetus to milk maximum productivity from CT investments is clear. "CT scanners are very expensive.  It makes no sense to run CT equipment inefficiently. However, not every department does so. Now is the time for departments to make sure they are running these assets as efficiently, productively and as low cost as possible," says Giles L. Boland, MD, of the department of radiology at Massachusetts General Hospital (MGH of Boston). The formula for optimized workflow boils down to three inputs: staffing, technology and management.

Multitasking matters

In the February 2008 issue of the Journal of the American College of Radiology, Boland and colleagues published a study demonstrating that radiology departments could maximize outpatient CT productivity by using multiple techs in a single scanning room.

Using two techs to multitask can dramatically improve CT throughout at a relatively low cost, says Boland. The MGH researchers reported that it took a single technologist 27 minutes to complete all assigned tasks, while a pair could finish the work in approximately half the time, and three techs further accelerated the process.

Ultimately, the single-tech model translated into 2.2 patients scanned per hour, with the figure rising to 5.2 and 7.5 patients per hour, respectively, in the two- and three-tech models.

Boland and colleagues identified 34 unique tasks in CT technologist workflow. By using multiple techs, tasks such as patient identification verification, IV access and power injection prep could be completed simultaneously rather than sequentially, helping the department shave precious minutes from CT throughput.

However, there is another angle to tech staffing. Boland noted that many departments don't understand how productive they are (or aren't). "They need to benchmark themselves against best practices to monitor performance. Once they know what the benchmark is, they can determine why they are above or below the benchmark."

Boland ballparked that efficient, dedicated outpatient scanners can complete 15,000 to 20,000 studies annually.

Facilities that fall below the line may find various factors contribute to their less than stellar performance. For example, mixing inpatients and outpatients on the same scanner is very inefficient as inpatients trump outpatients and factors such as transport delays create a molasses factor. In other departments, protocols may be too long, manual data entry may decelerate techs or hours may be too short.

Tapping into technology

The University of Chicago Hospitals employed a slightly different tactic as it sought to identify and amend bottlenecks in CT workflow. The academic medical center devised an ambitious Continuous Quality Improvement (CQI) project aimed at reining in the impact of reimbursement cuts in CT imaging.

Launched in 2009, the two-year project revised the definition of turn-around time, applied basic principles of electronic workflow orchestration to the scanning suite and yielded astounding results, shares Paul J. Chang, MD, professor and vice chairman, radiology informatics and medical director, enterprise imaging at University of Chicago Hospitals.

"We found we are pretty efficient in the reading room, but incredibly inefficient in the scanning area."  

So Chang and club threw out the conventional definition of turn-around time as they set out to identify the low-hanging fruit and streamline the process. The new turnaround clock begins when a referring physician decides an imaging study may be contributory to the patient's diagnosis and ends when the physician receives a report from the radiologist. The goal, he explains, is improved information throughput—not just faster patient throughput or expedited report turn-around.

Armed with that definition, Chang and team combed through the department to detect inefficiencies. They honed in on paper. "When you see a piece of paper, that's a clue that you have a problem," offers Chang. That's because paper indicates that a human is being used as an integrating agent, or to facilitate workflow in some way.

The team found the reading room fairly devoid of paper. But the scanning suite was littered with paper, and consequently, riddled with inefficiency.

Technologists' workload included a lot of busy work—such as calling transport, completing studies in the RIS and reconstructing datasets. "This is a problem," Chang notes.

To apply the tried-and-true methods of electronic workflow orchestration, the team treated the modality and the injector as IT devices and focused on software to offload, integrate and automate the busy work.

The researchers developed software to automate the protocol process, so that radiologists can automatically protocol the scan via a web client and map the protocol to the scanner via DICOM Modality Worklist Proxy. It means techs no longer have to set up the scanner.

"This accomplishes two objectives," Chang says. The new model cut set-up time from five to 20 minutes to less than one second—and it improves quality as it eliminates the occasional tech error. The team further boosted time savings by pre-programming the injector.

The closed loop initiative applies the same principles to other workflow steps including pushing CTA reconstructions and paging 3D techs. An Intelligent DICOM Router automatically routes studies to the appropriate destination such as PACS or the 3D server.

The end results are compelling. For a standard CT exam such as an abdominal pelvic CT, the closed loop model produced a 66 percent reduction in tech time, from 30 minutes to 10 minutes. The results are similar for complex exams such as CT angiographies. Tech turn-around time fell from 45 minutes to 16 minutes—a 65 percent reduction, shares Chang.

Weekly & Annual Potential CT Patient Throughput

CT scanning volume increases as departments increase the number of technologists assigned to a single room. Graph shows throughput at 100 percent and 85 percent capacity with an 11-hour workday for the 1-, 2- and 3-technologist staffing models. Source: Journal of the American College of Radiology, February 2008.

The personal touch

The drive for maximum efficiency is essential. However, does it de-personalize the department, commoditizing patients and neglecting staff?

"How do we retain customer service in a highly sophisticated environment," asks Boland. "It behooves all of use to remember that we are here to serve the needs of the patients." That means taking the time to explain CT scanning to patients, and meeting and greeting them at the front desk, which may trim productivity, admits Boland.

Similarly, the quest for optimum efficiency may create a working environment that inadvertently compromises workflow by de-valuing techs, offers Jesse Pennington, clinical coordinator for Medvance, a healthcare training provider in Cookeville, Tenn.

"Technological change and increasingly rapid workflow have contributed to increased levels of stress and burnout among techs. The National Institute of Safety and Health identified healthcare occupations as some of the most stressful in the U.S. Stress and job burnout can lead to job turnovers, which will always reduce a radiology department's efficiency," notes Pennington, who recalls pleading with a former employer to cross-train additional CT techs for one year when he was the sole tech on call for an entire hospital.

Pennington recommends that administrators not overlook internal workflow potential. Recruiting and retaining experienced and effective technologists can play a large role in maintaining an efficient department, he says.

Optimizing CT workflow is essential and relatively straightforward. It begins with productivity data or benchmarks that allow the department to gauge efficiency and pinpoint processes that gum up the gears. Next comes the fix—which can be staffing or technology or a combination of methods. The end product—increased productivity—can not only boost revenue but also enhance referring physician satisfaction and patient care.