There is no slowing down in the rising demand for diagnostics, but there are ways to stop this delaying the whole hospital, writes Paul Johnson
Diagnostic services are vital for the correct understanding and management of patient care, and as tests improve their use has been steadily growing.
In particular, imaging and laboratory medicine tests have increased every year over the past five years, with the common imaging modalities showing average annual increases of up to 15 per cent every year.
‘Increased automation means laboratories can handle large volume changes without a major impact on fixed costs’
Without more resources, this produces increasing backlogs, more pressure on diagnostic clinicians, and the knock-on effects of increased internal delay and missed waiting time targets. For patients this implies a poorer experience and an extended length of stay in hospital.
Finnamore has been working with four trusts that are leading the way in tackling these challenges. Increased automation means laboratories can handle large volume changes without a major impact on fixed costs. However, imaging exams are performed and reported individually, so the service is more sensitive to imaging demand fluctuation. Our work therefore normally starts with the imaging service.
Erica Denton, national clinical director for imaging at the Department of Health, showed this is a national trend in a presentation last year on seven day working. And in the US, the Choosing Wisely initiative includes major work to reduce inappropriate requesting of imaging.
The increasing use of diagnostics has been prompted, perversely, by faster turnaround, along with the growing fear among clinicians of litigation, the easier access provided by electronic ordering systems and the increased use of junior doctors in requesting diagnostics.
In addition, as GP direct access services are renegotiated this year under the any qualified provider scheme, there is a risk that the provider will lose income if they cannot guarantee suitable turnaround times.
While it seems that the steady increase in demand will continue, our work has identified that there are ways to maintain a high quality and economic imaging service.
University Hospitals of Leicester has used the principles below to successfully reduce imaging’s contribution to emergency department breaches from 25 per cent to 4 per cent in just 12 months. Many of these principles can also be applied to other diagnostic areas.
Ways to meet your targets
Review your internal targets. Resources can be wasted if they are focused on meeting turnaround times that are not necessary. Identify and fast track exams that are required quickly, leaving the less urgent images to non-peak times.
Manage demand. Potential over-ordering is already caught by the imaging department’s statutory “justification”, so successful reduction requires a change in requesting behaviour.
University Hospitals of Leicester has started to find some traction with mechanisms such as internal trading, but only as an evidence base for discussions with requesting specialties, focusing on best use of the limited imaging resources. Demand management methods include:
- using the referral systems to identify and prevent repeated testing;
- providing wider access to test results to prevent this duplication;
- stopping procedures that are non-viable or of limited clinical value;
- discussing variation of peer group’s referral patterns with the specialty consultants; and
- auditing which imaging reports truly have an impact on patient management.
Improve exam coding. Commissioners do not have spare funds, but registering exams correctly will help determine which are financially viable.
Another coding gain is to streamline the number of exam codes you use. Unless you have done this recently, it is likely that only 5 per cent of your codes relate to 80 per cent of your activity. Removing these reduces administration, the number of protocols and allows the clinical risk of low frequency procedures to be evaluated.
Reduce work content of exams. Scanning costs can be reduced by reconfiguring equipment for combined control rooms, improving protocols to minimise supervised sessions and changing booking rules to efficient use of consultants.
Increasing the amount of auto-reporting and increased use of non-consultants can reduce reporting costs.
Increase equipment use. Portsmouth Hospitals Trust identified that staffing numbers and rostering meant that its CT scanners were fully available for only 26 per cent of real time. This enabled it to significantly increase scanner availability through changing substantive working practices, without capital expenditure.
Increase productivity. We have built up a library of clinically accepted reporting rates across several trusts, taking into account exam complexity, specialty expertise, interruptions and other confounding factors. These factors enable realistic capacity planning (see capacity planning box, below) and provide a robust means of evaluating perceived productivity improvements.
University Hospital of South Manchester has successfully implemented several major changes to support increased productivity, including the introduction of a regular duty radiologist and building a “cold” reporting room where the consultant is protected from interruptions.
Use resources effectively. Planning your capacity (reporting staff) to match the volume, timing and urgency of the work coming in, means that service levels can be met in the most efficient way. Monthly reviews of this capacity then allow staff and outsourcing to be flexed to address demand and capacity variation, ensuring targets are met.
Transfer work. This operational planning can be extended to routinely share work and spare capacity with other reporting centres.
Improve quality. This is quality in the “Lean” sense, which is having the right level to ensure the correct result. Doing a longer report or more checking than is needed is considered lower quality and means another patient is losing out.
Exploit the increase. In certain situations, additional and timely testing can prevent admissions; speed diagnosis, treatment and discharge; reduce the number of outpatient follow-ups; and reduce the overall cost of an episode.
By categorising and modelling the forecast demand and available capacity, we have helped trusts map the detailed imbalance between the resources they need and what they have.
The modelling is clinically led, and recognises the variations in complexity and time requirement of the different exams. This helps the service forecast future demand and evaluate how to handle it.
Different scenarios can be created, such as specific performance changes, and the resulting resource imbalance is shown by grade, specialty and modality. This output is then used to inform job planning, performance management and, where necessary, recruitment.
It is now vital for acute trusts to establish the appropriate level of testing and adapt themselves to provide it. To gain the benefit, the rest of the hospital must match the improved responsiveness.
But not everyone will welcome such changes. A significant part of the successes seen so far has depended on extensive clinical involvement to ensure the changes are built around a patient centred service, using operational management techniques and a trust-wide viewpoint to achieve the best overall situation.
Paul Johnson is a managing consultant at Finnamore