Progress in medical technologies such as MRI continues to improve healthcare delivery and to increase life expectancy and quality of life, but it is also one of the main reasons for rising health expenditure across OECD countries (Organisation for Economic Co-operation and Development) (OECD, 2012). Ireland’s healthcare expenditure places it among the highest of the OECD nations as a portion of its national income (Reilly, 2011). In 2011, the Irish government’s ‘Health at a Glance’ report indicated that Ireland spent 11.4% of its gross national income on its healthcare, ranking it 6th out of the 27 OECD countries. The report also showed that Ireland spent €3,781 per capita on health provision (DOH, 2011). While it is widely acknowledged that richer countries spend more on healthcare, this does not always translate into better healthcare outcomes. For example, despite the fact that the US has the highest health spending per capita among peer countries, it rates low on life expectancy, infant mortality, and premature mortality (Bloom et al., 2012). This would suggest that prudent management of healthcare spending is crucial to optimise healthcare delivery.
Table 2.1 Healthcare Spending and Health Outcomes 2008. http://www.conferenceboard.ca/hcp/hot-topics/healthspending.aspx
Yet despite the healthcare expenditure and rapid growth in the availability of diagnostic technologies such as MRI, Ireland still lags behind the OECD averages in relation to MRI units. In 2007 it had eight and a half MRI units per million population, which is below the OECD averages of eleven over the thirty four OECD countries (Mulholland, 2009). However, in a study conducted by Emery and Feasby for the University of Calgary in Alberta Canada, it was suggested that increasing the number of MRI scanners is not the only solution to long wait times, but that looking at the management of MRI requests might be more helpful (Emery et al., 2009).
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2.3. Prioritisation & Appropriateness of MRI Requests
In the aforementioned study by Emery in 2009: “Management of MRI Wait Lists in Canada,” the authors conducted a survey of public MRI facilities in Canada, and found that nearly sixty per cent of institutions did not have documented guidelines for prioritisation of MRI requests, and that quality assurance methods were not employed to ensure that guidelines were followed. They also discovered that there was no attempt by any of the centres to reduce wait times by decreasing inappropriate requests. They concluded that “there appears to be a need to standardise MRI wait list management given the variation in management practices and wait times observed” (Emery et al., 2009).
A study from the Institute of Clinical Evaluative Sciences in Ontario, suggests that wait times for MRI could be improved by reducing unnecessary scans. Lead author Dr John You indicates that one way of reducing wait times is to “not to order scans in patients who are unlikely to benefit from them” (You et al., 2009). This could mean employing a method of prioritisation of MRI requests such as the one developed by the Western Canada Waiting List Project (WCWL). The WCWL is a collaboration of nineteen partner organisations in Canada, committed to addressing the issue of excessive wait lists and influencing the way waiting lists are structured and managed (Noseworthy et al., 2003b). The principal tools developed by WCWL are point-count measures, that assess the severity of patients’ conditions and the extent of benefit expected from wait-listed services (Hadorn, 2003). Points are assigned according to the severity of patients’ symptoms and clinical findings, and the requests are assessed accordingly. (Appendix A)
Although the WCWL project has not completely solved the problem of waiting lists and times, having a standardised, reliable means of assigning priority for services is an important step towards improved management in Canada and elsewhere (Noseworthy et al., 2003a). (Hadorn, 2002) had found that “developing clinically acceptable priority criteria for MRI is substantially more complicated than developing analogous criteria for surgical procedures or children’s mental health, with the primary obstacle lying in the nature of diagnostic procedures.”
In 2009 in Ontario Canada, a Best Practice Guidelines document was developed to assist radiologists and other staff to establish and manage effective, efficient and safe MRI programmes. Amongst the guidelines set out in the section ‘Assessing the Appropriateness of the Scan Request’ there is the recommendation that “Hospitals will develop clear operating policies outlining when an MRI or CT scan can be performed without the requisition being first reviewed by the radiologist” (Panel, 2009)
The Royal College of Radiologists in the UK, have developed referral guidelines that are evidence based, iRefer, which can help in the choice of the right radiological investigation. These imaging referral guidelines are available for use by all National Health Service (NHS) employees, and help to ensure that patients receive timely and accurate diagnoses, reduce unnecessary radiation exposure, and promote efficient and fair use of available diagnostic resources (RCR, 2012). To date, Ireland does not hold the license for this tool or any such similar referral guidelines.
The case study by Taunton & Somerset NHS Trust, “Improving waiting lists for MRI scans” has shown a reduction in their waiting list by introducing a number of changes, one of these changes being the implementation of new referral guidelines (NHS, 2009f). This Trust has succeeded in reducing their MRI waiting times from forty weeks to just eleven weeks.
Until recently in New Zealand only a specialist could order an MRI which meant it could take some time before an appointment was obtained. However, with the introduction of a new computerised tool which can help GPs to determine what medical imaging is needed, and to request that imaging, patient access to MRI scanning has improved. GPs are now gaining the ability to directly order complex medical imaging, such as MRI, for their patients (MOH, 2011).
Some research in America looking at appropriateness of requests, and evaluating the effects and applicability of the American College of Radiologists’ (ACR) Appropriateness Criteria by non-radiologist physicians in an MRI preauthorisation centre, found an increase in the rate of appropriate MRI exams and a decrease in the rate of inappropriate MRI exams. The ACR Appropriateness Criteria are “evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for a specific clinical condition” (ACR, 2012). In this study, ACR Appropriateness Criteria were applicable to about fifty per cent of MRI requests (Levy and al, 2006).
A second study of the use of CT and MRI after implementing a preauthorisation program based on the ACR Appropriateness Criteria and the guidelines of the Royal College of Radiologists (United Kingdom) found that the number of MRI requests decreased substantially, which resulted in reduced imaging costs and waiting times (Blacher and al, 2006).
2.4. List Management
NHS Improvements was set up over a decade ago in the UK to improve patient experience and outcomes. NHS Improvement Diagnostics was subsequently established to support the delivery of high quality and effective diagnostic services (NHS, 2012d). A number of case studies in NHS hospitals have been recorded and documented by NHS Improvement Diagnostics with a view to improving various areas of the service, and one such case in Liverpool & Broad Green Hospitals NHS Trust looked at eliminating “carve out” in order to reduce waiting times in MRI. ‘Carve out’, also known as ring fencing, simply means to divide the available capacity into smaller fixed amounts of capacity. This results in a significant variation in the length of time that routine patients wait, patients can be kept waiting at all stages in the process by interrupting flow, non-urgent cases are kept waiting much longer to be seen than urgent patients, and queues are prioritised irrespective of individual needs (NHS, 2005a). In this case study, the hospital in question made a number of changes, which included: standardising the scanning slots for similar body parts, an MR radiographer carrying out limited vetting, and all patients are scanned in order of time i.e. first in, first out. While this involved extra staff training in vetting, the result was a reduction in the waiting times. Such was the success of the endeavour, that more radiographer vetting is planned in order to sustain the initiative (NHS, 2009a).
In South Devon Healthcare NHS Foundation Trust (Torbay), another case study was conducted looking at reducing vetting by consultants, as it was felt that this time spent was a waste of resources, and led to booking delays. Instead, the vast majority of MRI requests were then vetted by the MRI radiographers, with very specialised studies still being referred to consultant radiologists. This has resulted in seventy nine per cent of all referrals being vetted and accepted within twenty four hours, and eighty four per cent being vetted and accepted within forty eight hours. The average vetting time for consultants is three days, as opposed to one day for radiographer vetting (NHS, 2009h).
By re-designing their request cards, reviewing the vetting process and introducing a booking centre, Portsmouth Hospitals NHS Trust have reduced their average turnaround times from referral to scan from up to six weeks down to ten days (NHS, 2009i). This involved cross referencing referral criteria and protocols with radiologist involvement, and offering training and education to referrers, radiologists, radiographers and booking teams (NHS, 2009i).
In October 2008, the MRI department at University Hospital of North Staffordshire NHS Trust was experiencing extreme pressure on services, and management was considering outsourcing some of the service, as waiting times had previously been as long as three years.
However, with a few changes implemented which included radiographer protocolling and their booking guidelines reviewed and improved, they have managed to increase their MRI scanner utilisation by twenty five per cent (NHS, 2009e).
South Devon Healthcare NHS Foundation Trust (Torbay) participated in another case study in the NHS Diagnostics Improvement called ‘Eliminating Consultant Specific Scanning Lists’, in which all consultant radiologists agreed to relinquish their personally owned MRI lists. The MRI protocols were standardised, the lists ran more efficiently, and as a result the waiting times were reduced (NHS, 2009b).
This Trust also provided additional evidence that standardising MRI protocols help to reduce waiting times. To achieve this, the two main musculoskeletal consultant radiologists agreed to follow the same MRI musculoskeletal protocols, and were happy to pool specialist referrals and correspondence. This has greatly improved flexibility and ease of booking, and in particular has greatly improved access for specialist procedures such as MR arthrography (NHS, 2009j).
Since 2005, in Rotherham General Hospital, all MRI referral cards have been protocolled daily by radiographers, and this has resulted in their waiting times being reduced from over four weeks down to two to three weeks. Instead of routine requests being vetted once a week by a radiologist and ‘batches’ occurring, administrative staff have a steady flow of vetted and protocolled requests available. This allows free slots or cancellations being filled much sooner (NHS, 2005b).
In a further case study documented in NHS Diagnostics Improvement, Central Manchester Foundation NHS Trust have revised and changed their care pathway for stroke / TIA patients in line with NICE guidelines. Their scanning protocols have been streamlined and standardised, and their service has become radiographer led. This entails radiographers carrying out vetting and referral acceptance. These changes have resulted in scan times being reduced and a significant increase in patient access and throughput (NHS, 2009c).
2.5. Increasing MRI Service Hours
In July 2011, The Guardian newspaper reported that the number of patients waiting more than six weeks for a test such as an MRI scan in the UK had quadrupled, according to analysis of NHS data (Campbell and Ball, 2011). In the same article the Royal College of Radiologists responded: “Waiting times for diagnostic imaging tests are showing a worrying trend upward. Radiologists and radiographers are trying their best to address the rise in waiting times for diagnostic imaging by working extended hours and weekends, but it is difficult to keep pace with increasing demand.”
One such hospital in the UK that made the decision to support the extra skills needed to work extended hours in MRI was Blackpool Victoria Hospital. This Trust devised a clear training plan for radiographers new to, or currently training in MRI, which would help to continue and expand extended day working and on call in MRI (NHS, 2009g).
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The current situation in Ireland’s public hospitals regarding an extended working day is in the process of reform, with the Public Service or “Croke Park” Agreement in place until 2014. This agreement is between public servants and their managers, and is “a commitment to work together to change the way in which the public service does its job, so that both its cost and the number of people working in the public service can fall significantly, and therefore save government finances” (Reform, 2012). In return for a move towards flexibility and reform, the government gave certain commitments to serving public servants, including no further reductions in their pay rates; and no compulsory redundancies until 2014, when the agreement will be reviewed. The extended working day for radiography was provided for, subject to negotiation, in the Croke Park Agreement (Hunter, 2011), and an extended working day in MRI departments is one option that could be examined when funding and resources allow.
2.6. Wait Time Benchmarks
An important feature of performance improvement efforts in the NHS in England has been the establishment of measurable, time-limited targets that are incentivised by appropriate work place rewards and sanctions (Mays, 2006). A study conducted by (Saulnier et al., 2004) for the Canadian Medical Association, found that “developing a common understanding of appropriate versus excessive waiting times is critical in a publicly funded system with constrained capacity and many competing demands on resources.”
In June 2004, the National Health Service in the UK announced a wait time reduction effort, the “eighteen week patient pathway”, which guaranteed that no citizen would wait more than eighteen weeks from GP referral to treatment by 2008 (NHS, 2008). In many cases, the wait could be much shorter, but the ‘Eighteen Weeks’ programme was designed to ensure that there is a clear maximum wait time, applied consistently across the country (NHS, 2012a). As a result of this initiative, waiting times fell steadily from 2000 onwards and, by the middle of 2006, median waiting times for inpatient treatment were at their lowest ever (Kings and Fund, 2007)
However six years later in 2012, The Guardian newspaper reported that “The number of patients waiting more than eighteen weeks for NHS treatment has continued to increase year-on-year, with more than 22,600 patients facing long waits in December 2011” (Ball, 2012).
In March 2009, the Scottish Government set a national waiting time standard ensuring that patients will wait no more than six weeks for any of the eight key diagnostic tests, which include MRI, and are currently working to local targets ensuring that patients will wait no more than four weeks (NHS, 2012c).
An interim report by The Wait Time Alliance in Canada on “Timely Access to Health Care” was conducted in 2005, investigating the need for benchmarks for medically acceptable wait times. They recommended a ten year plan, which committed Canadian provinces and territories to developing these benchmarks, as it was discovered that at that time internationally, only Italy had documented benchmarks. In Italy, the maximum wait time for an MRI scan is sixty days (CMA, 2005).
Table 2.2 shows provisional benchmarks by priority level (unless specified, time refers to calendar days) as recommended by the Wait Time Alliance, Canada in 2005:
Table 2.2. (CMA, 2005)
Claudia A. Sanmartin and the Steering Committee of the Western Canada Waiting List Project also recognised the need to establish standard definitions of waiting times in MRI, and identified in their study the different stages involved waiting for an MRI scan. (Fig.2.1)
Fig.2.1. (Sanmartin, 2003)
Sanmartin concludes in her article that establishing standard definitions for waiting times is one of several strategies that could be used to address the issue of waiting lists and waiting times. The development of benchmarks for waiting times could then provide valid and accurate information on waiting times to better inform patients, healthcare providers and policy makers (Sanmartin, 2003).
2.7. ‘Lean’
“Many hospital radiology departments are adopting “lean” methods to improve operational efficiency, eliminate waste, and optimise the value of their services” (Kruskal et al., 2012). ‘Lean’ was a term coined by researchers when studying the philosophy of the management system in place at Toyota car manufacturers, and the culture they had created amongst their workers to improve processes which led to the final product, and in short, is the continuous and systematic elimination of waste (NHS, 2012b). This approach has been very successful, and is being used extensively in many pathology labs and clinical settings, so much so that the NHS is now applying Lean thinking in radiology (NHS, 2012d). The Lean approach, which emphasises process analysis and mapping, has particular relevance to MRI departments, which “depend on a smooth flow of patients and uninterrupted equipment function for efficient operation” (Kruskal et al., 2012).
Some examples of success using Lean to help reduce waiting times for MRI include Windsor Regional Hospital and St. Joseph’s Health Care, London.
Windsor Regional Hospital, London applied Lean methods to MRI scans by conducting value stream maps, identifying each step in the process, and recording waits between steps and error rates at each step. As a result of this, they uncovered wasted time in planning and performing scans. To improve these issues, they implemented a number of changes, which included standardising protocols, and reviewing and restructuring their daily work list according to body part etc. These changes have resulted in a reduction in their wait times by fifty per cent (OHQC, 2011).
St. Joseph’s Health Care, London also applied Lean techniques which uncovered idle scanner time and wasted staff time due to unnecessary interruptions or looking for supplies. By streamlining the booking and protocol-setting process, their booking time was decreased from thirteen days to one and a half days, with an overall reduction in their wait times by two thirds (OHQC, 2011).
A case study conducted in Worcestershire Acute Hospitals NHS Trust by NHS Diagnostics Improvement showed how applying Lean booking helped to reduce waiting times from over one year to less than ten weeks in all their modalities including MRI. This simply involved booking straight forward non-complex examinations in the first portion of a work session, thus maximising throughput, with shorter appointment times and interruption free working (NHS, 2009d).
Great Ormond Street Hospital for Children NHS Trust conducted a process mapping of a patient’s journey through the radiology department using Lean techniques to discover why their waiting list in radiology was ten to twelve weeks. This posed a problem, as it often resulted in patients breaching government set targets, such as the eighteen week benchmark wait from referral to treatment. A number of issues were highlighted as a result of employing Lean methods, amongst which was under-utilisation of their MRI scanner. This was due to a number of reasons beyond the scope of this thesis. After addressing these issues they achieved a reduction in their waiting times to just five weeks (NHS, 2009k).
2.8. Outsourcing
The provision of privately managed, radiology facilities for the NHS is nothing new. Even over twenty five years ago, privately operated magnetic resonance imaging facilities were being developed as an extension of NHS facilities, thereby allowing the general public to access up-to-date MRI technologies that would otherwise only have been available on a fee-for service basis (Banerjee, 2004). Although outsourcing in the NHS is here to stay and the market seems set to grow (PublicService.co.uk, 2012), one public service union reports that outsourcing clinical services “shows negative effects on patient care, poor value for money as well as evidence of inadequate monitoring and evaluation of the services” (Unison, 2012).
A paper written by (Carley, 2012) ‘Strategic Outsourcing in the NHS – Beyond Ideology and Money?’ highlights various contentious issues raised by outsourcing, amongst which are transparency, accountability, and patient safety. He points out the legitimate concerns over the appropriate use of public money, and the importance of raising standards, being accountable for those standards, and the continuous improvement in patient and staff safety.
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