Applied Radiology

The world of radiology has become a complex service and business. Radiologists provide diagnostic information by analyzing the results of studies obtained from sophisticated imaging equipment, and are increasing their participation in the therapy of disease by offering and performing a myriad of new treatment options. A growing number of professionals and skilled experts support the radiologist in this endeavor.

In today's large hospital-based radiology departments, a "team" mentality exists the team members include physicians, technologists, nurses, admin istrators, secretaries, and file room and billing office staff. Engineers, informatics staff, physicists, and maintenance personnel also may be part of the inhouse team. In other situations, some of these tasks are outsourced to contracting firms. The advent of conversion to PACS-based departments is affecting how each of these individuals are called on to provide expertise to assure a successful radiology service.

Fundamental to the service of radiology is the diagnostic image. Whether the image is used for diagnosis of a patient's medical problem or as a guide for therapy, it is the essence of all radiological procedures. The conversion from film-based to digital media for storage, display, and archiving will have a variable effect on the tasks performed by the different team members involved in the production and management of the images. For some of the players involved, these changes will be so profound that a methodology is needed for their management. By simply introducing PACS into the equation with-out enacting a plan for managing these changes, great opportunities to improve the productivity, efficiency, and quality of the service will be lost.

In this article we will discuss the value of strategic thinking and provide a more in-depth discussion of how to use one of the most valuable strategic thinking tools what we have called the "sheet of music"-to assist in the management of change. We will then explore how PACS will change the tasks of individual members of the radiology team.

Strategic thinking

Thinking and planning are activities that we perform every day, and the sequence in which we complete these steps is an important factor in achieving maximum effectiveness. Ideally, we should devote an adequate amount of time to thinking about all sides of a particular problem before progressing with planning or implementing a solution. Many of us learn this lesson the hard way. Often, we forge ahead with elaborately developed plans prior to focusing enough attention on what we ultimately hope to achieve with our plans. We then find our-selves going back to the beginning to rethink our options and correct our initial misadventures before resuming our planning and implementation processes.

Strategic thinking tools (or frame-works) can be used to aid in the process of strategic thinking. One of the most attractive attributes of such tools is that they are easy enough to be understood and applied by radiologists who have had no formal business training. Essentially, the tools communicate at a fundamental level between people. For example, in a regional healthcare community, where people possess diverse backgrounds, these tools enable the players to cross boundaries and effectively relate at a common, fundamental level.

A specific tool known as the "sheet of music" will be described herein to present a view of the impact of PACS on the radiology team. The sheet of music is a tool or framework for thinking about the activities of all the members of an organization or department; it is analogous to the conductor's musical score, providing a clear understanding of the roles to be played by each of the musicians. In any well run organization or department, a leader requires the same type of understanding of tasks of each of the members. Perhaps even more important is a clear understanding by all participants of their respective roles and the ways in which these roles complement those of other team members. In this way, duplication of roles is avoided and synergy between the players can be optimized.

The framework for a sheet of music tool is simply a series of columns. Each column has a heading which represents a specific segment of a department or organization. Below each heading are approximately five areas of activity that are determined to be the major focal areas for the section in question.

A well managed team will review the sheet of music several times a year. The head of each "section" should be represented at a team meeting, all seated around a table. When the dialogue becomes focused on prioritization within each column and interaction of items within and between columns, the result is a set of activities that fit together (in type and time) and are the most important areas of activity necessary for the organization or department to meet the needs of the customers.

Benefits from using tools

There are a number of benefits to using strategic thinking tools, including the following:

Development of a common framework for solving problems -The sheet of music provides a framework in the form of a series of columns of activity, arranged by section of the organization or department.

Identification of a common "language" for addressing problems -The language consists of sheet of music, "sections", and "areas of focus." This tool is best used to address a specific problem. Whenever the problem needs additional attention, the team can revert back to the sheet of music tool for implementing a solution.

Simultaneous focus and flexibility of thought -Focus is derived by having a solid framework to identify the most key areas of a problem. However, in establishing the specific content (i.e., elements of the tool) there is flexibility for individual input as team consensus is developed.

Stimulation of creativity in problem resolution -Team brainstorming of content within the framework is conducive to creative synergy.

More effective communication by asking the right questions to find the right answers -The questions raised by the sheet of music tool are: what sections (groups) are involved in the decision making process and what are the areas of focus within each section.

The promotion of teamwork in problem solving -Teamwork is established as the process moves from individual input to consensus on the final result.

Establishment of team confidence in the problem solving approach -Confidence is achieved as the consensus process is carried out. The utilization of a framework helps ensure that all groups and their individual members are given adequate opportunity to incorporate their thoughts and concerns into a problem solving consensus.

Building of a foundation for solving problems in the future -As situations change, the sheet of music may be updated to address current concerns. The foundation established in creating the initial sheet of music tool makes updating the framework an efficient and effective process.

Provision of outlines for planning -Strategic thinking with the use of tools promotes "doing the right things." Planning-the process of "doing things right"-follows. The areas of focus become "the right things to do."

A focus on customer satisfaction -A meaningful team activity should always focus on the customer. Here, not only is the patient a customer, but every radiologist, as a potential user of the system, is a customer as well. The collaborative development of focus areas ensures that customer satisfaction is brought to fruition.

In a given application, some of the above benefits will be more significant than others. However, it is important to review all benefits to make sure that the users are getting the most utilization that they can for any given application. This can be done as a conclusion to the planning session.

Sheet of music applied to the introduction of PACS

Now that we have identified key benefits to using strategic thinking tools, let us look at several of the specific components needed for implementation of PACS into a relatively large radiology service and see what will happen to the work environment with the conversion to a digital PACS. Tables 1 through 6 summarize the major changes to individual components which we have identified. It is clear that some will be more affected than others. For example, the film librarian's duties will disappear, as will the transcriptionist. It behooves the organization to be cognizant of this fact and to begin to develop strategies for handling the personnel in these categories. Human resource counseling and training will be necessary for most of these individuals. Some will move on to positions outside the department, and others will be trained to fill some of the positions created by a PACS-run system.

The technologist will be little affected, though there will be a change in the method for introducing data regarding the patient and the method of accepting an image. The technologist will no longer be required to print studies on film for every case but may be called on to do this occasionally for unique needs. However, in most cases where PACS is nearly complete, the technologist is relieved of this task and it is moved into a common central location.

The radiologist will review his/her patient's request and data before reading the images from monitors located near the image reading station. Comparison images will be more easily sorted and will be electronically available much more rapidly. The medical report will be dictated using a voice recognition system, which the radiologist will have to become familiar with. Verification will be electronic, and there will be opportunities to consult with colleagues and other clinicians at a distance. All of these activities will require a certain familiarity with the system and its operations, to be gained with time and experience. It is important for the radiologist to realize that they will not be as accurate initially when reading softcopy images compared to the more familiar film. Efforts should be taken by management to minimize conversion and adjustment.

An interesting and all important role in conversion to a digital department is taken on by the quality control person(s), as illustrated in table 4. Much of what their day-to-day tasks entail is going to change. Specifically, they may be called on to maintain a much less frequently used processor in lieu of maintaining the networks, archives, and display stations.

Maintenance of the networks sometimes falls to the overall healthcare information systems (HIS) team. Nevertheless, somebody in radiology should be cognizant and understanding of the unique needs for networking large image data sets and the problems associated with this in order to represent radiology needs at the HIS level. Such a person will have to check the computer displays on a regular basis. They will be responsible for making sure that software associated with new or upgraded equipment is completely validated before being inserted into the PACS environment. This task may be handled by the industry representatives, but due to the multi-vendor environment, there must be some in-house way of providing oversight.

Finally, it is the quality control staff who usually are responsible for the training aspects of various personnel. We are well aware that, in the PC environment, software changes take place constantly. The need for somebody to be familiar with and able to explain these changes to users is paramount.

The people who perform the ancillary functions will have to understand the computer format and the new functions and information that it will provide in an online manner. Transportation is one example of a seldom thought of activity which will benefit from electronic assistance.

The above are generic comments that likely will be true in most situations. The real value of using the sheet of music is a greater understanding of how these changes will affect your personnel and how your organization should plan for these changes. Do not underestimate the value of this approach as a communication tool as well. The process of using the tool is every bit as important (if not more so) than the actual action items identified. Again, maximum benefits from the film-to-PACS conversion will only be gained if management decision-makers consider the effects on individual jobs and tasks and work at providing better service through a continuous reevaluation of the processes involved.     AR