Big data is changing everything having to do with business analytics, but report turnaround times (TATs) remain at or near the top of radiology’s most scrutinized performance metrics. And for good reason. Consistently achieving efficiency on radiology-report TATs—or failing to—can make or break private practices’ relationships with hospital partners, elevate or crush academic radiology departments’ reputations and, today more than ever, affect the patient experience as well as the caliber of care quality.
The challenge, now as always, is to balance the need for speed with the demand for diagnostic accuracy and, with it, report communicativeness. How best to pull that off with every study? RBJ asked several experts and came away with the following tips.
1. Scrutinize every stride.
The efficiency with which each step is managed along the imaging-exam “journey” affects TATs for better or worse. And this goes for everything that happens between order receipt and final signoff. So reminds Charles McRae, MBA, chief executive officer of Columbus Radiology in Ohio and a vice president of regional operations at Radiology Partners. Consequently, “you have to look at a continuum of data to see where the problems really are” if turnaround times are regularly subpar, he explains. “Otherwise, improvement efforts won’t be effective. For example, it does no good to add extra staff to fix turnaround times when the problem is that it takes 45 minutes for patients to be seen because there isn’t sufficient equipment to handle the studies.”
For inpatient and emergency exams performed in an acute-care facility, McRae points out, the timeline needs to include order receipt, patient transport, scan start and finish, transmission to PACS, radiologist interpretation, dictation start and finish, report transcription and correction and—phew, finally—report finalization/signoff.
“You want to quantify the time between each step,” says McRae, who knows a thing or two about analyzing moves and missteps from his previous career as an offensive lineman in the NFL. “Only in this way can you really analyze where the gaps are and come up with a way to improve things.”
2. Decide which metrics matter most—and teach them.
Few would disagree that setting objective, measurable benchmarks is a critical step in decreasing report TATs. And for hospital systems, at least, educating faculty physicians and administrators about why turnaround times are important—in turn obtaining their buy-in when it comes to deciding on metrics and prioritizing studies—is the No. 1 step on the road to decreasing delays in report completion. That’s the view of radiologist Eric England, MD, of the University of Cincinnati and UC Health.
“It’s important for everyone to know the reason turnaround times are important for a hospital system,” England says. “And it’s important to have radiologists take a lead role in guiding which studies should truly be included in the turnaround time metrics—as opposed to having hospital administration blindly dictate which studies should be included and what those time metrics should be.”
Most all stakeholders would agree that head CT for possible stroke, for example, is a higher priority for sped-up TAT targeting than, say, radiography for foot pain. But not all would know enough to make such distinctions top of mind. For this reason, radiologists “need to have a seat at the table,” England says, “and look to [optimizing] turnaround times as a way to improve quality of care.”
England adds that academic radiology departments face a unique education-related challenge when it comes to formulating metrics—one that must be addressed head-on. “The quality of education could be at risk from faster turnaround times,” he explains. “If faculty are feeling increased pressure to read faster through a required turnaround time, they may not involve residents in studies in order to reduce that turnaround time” and meet the metric.
UC Health data indicate that involving a resident or residents in a case can increase report turnaround time by 20 to 40 minutes, inclusive of a teaching interval, England says. Ignoring the critical role of training and educating residents when formulating TAT metrics may discourage these residents from participating in cases, negatively impacting their training and potentially impeding the caliber of patient care.
“If residents are trained in identifying these studies and in quickly drafting reports for review by a staff radiologist,” he says, “they will be well-positioned to efficiently manage turnaround time-dependent studies in clinical practice after graduation.”
3. Right-size your reader resources.
The single best move many radiology operations can make if they’re constantly struggling with unacceptably long turnaround times is optimizing radiologist staffing. Lizzy Young, MD, of the University of New Mexico and UNM Health is among those who believe so. “When staffing is underpowered to meet demand, you risk staff burnout,” Young notes. “If this is a chronic problem, you likely need to hire more people. If it’s a temporary problem, it’s worth digging in and extending hours.” Let overlong TATs become synonymous with your group, and don’t be surprised when referrers send patients elsewhere, she adds.
Young recalls the difference stakeholders saw when UNM’s radiology chair, Gary Mlady, MD, introduced two new after-hours shifts for attending radiologists working along with on-call residents. Fellowship positions were added to the busiest sections, among them body and musculoskeletal imaging. Widening faculty ranks across the board has “really helped to keep sections from falling behind,” Young says. Most non-emergent studies are read within a few hours, and emergent studies are read within one hour, which is the goal stated in a clear policy formulated when the additional hires were made.
Similarly, Columbus Radiology schedules radiologists such that rads are always available to interpret studies. “Turnaround times can go off the rails,” McRae says, “especially for routine reports, if staff isn’t on hand 24/7/365 to handle final reads.”
4. Fly straight into the cloud.
Improving report turnaround times may not be rocket science. Sometimes the only variables open to significant adjustment are exam priorities and staffing levels. However, some of the latest and greatest tech-based solutions, judiciously selected and applied, can lead to meaningful gains.
Cloud computing, for example, can fill this bill. Matthew Morgan, MD, of University of Utah Health in Salt Lake City and colleagues documented its effectiveness at driving down TATs, publishing their work in the December 2017 edition of JACR (“Ditching the Disc: The Effects of Cloud-Based Image Sharing on Department Efficiency and Report Turnaround Times in Mammography”).
The researchers divided 60 screening exams that required prior images into two groups of 30 each. The standard institutional protocol for requesting and receiving these images—fax and snail mail—was used for the control group, while a cloud-based image transfer solution was leveraged to ask for and obtain prior mammograms from those in the experimental group. A comparison of these methods revealed that the mean number of days from examination request to receipt was far lower in the experimental group (3.16 days) than in the control group (6.08 days).
Additionally, the authors observe, utilizing a cloud-based image transfer to obtain prior mammograms reduced the interval between examination request and receipt by an average of 2.92 days. “This improvement in system efficiency is relevant for interpreting radiologists working to improve reporting times and for patients anxious to receive their mammography results,” they write. It’s also relevant in other radiology subspecialties, as when priors must be procured from elsewhere, Morgan and Young tell RBJ.
5. Speak it and reap. (Rewards, that is.)
Speech-recognition software can prove a potent armament in the war on long TATs, as documented in research published in JACR in 2014. Led by Ramin Khorasani, MD, of Brigham and Women’s Hospital, the study team reviewed TATs, as well as radiologist productivity, at a 150-bed community hospital in the five-month periods before and after the implementation of the software.
They found report turnaround times decreased markedly in the “after” period. Specifically, TATs for median-percentile reports plummeted from 24 hours to one hour. And other tracked reports fell just as dramatically. “The implementation of [speech recognition software] was associated with 24-fold improvement in the median radiology report turnaround time in a community hospital with no trainees,” the authors conclude. “Improvements were obtained without affecting normalized radiologist productivity.”
For its part, Columbus Radiology uses a tool that enables the maintenance of a unified worklist. This not only facilitates the reading of studies against the disparate PACS in place at the practice’s partner facilities, McRae says, but also prioritizes STAT exams so the practice can consistently hit its goal of reading 95 percent of emergency scans within 30 minutes.
6. Re-invent the TAT wheel.
Asked to describe the most innovative TAT reduction strategy he’s ever seen, Morgan doesn’t have to deliberate long. Right in his own department at U of Utah Health, he recalls, the decision was made to read breast cancer screening exams immediately, while patients are still onsite. This negates the need for callbacks for additional imaging, cutting not only precious time but also patient anxiety.
In Columbus Radiology’s case, innovative thinking on cutting TATs has resulted in the implementation of a system for batching studies. Studies are divided into categories: outpatient emergency, inpatient emergency, inpatient routine and outpatient routine. All are assigned turnaround expectations, 30 minutes or less for emergency studies of both types and four hours or less for routine studies in both categories. The worklist solution is used to monitor the progress of the various batches, with batches sorted according to time remaining. “Triaging the batches this way is very effective in keeping turnaround times where they should be,” McRae says. “Nothing gets lost in the shuffle, and no one has to order an exam STAT—and interfere with turnaround times—if it’s routine but needed fast.”
Sometimes starting from scratch when strategies fail to decrease turnaround times involves looking at variables that may not traditionally come under scrutiny—but could or should. For example, relative value unit (RVU) flow falls into this category when it comes to emergency radiology, according to the authors of “Radiology Study Flow on Report Turnaround Time,” published in the American Journal of Roentgenology in December 2017.
For the study, researchers analyzed a total of 7,378 imaging exams completed in either 30 minutes (“TAT 30”) or 60 minutes (“TAT 60”). Predicted turnaround time for TAT 30 studies was discovered to have increased by 0.75 minutes per work RVU for TAT 30 studies and by 0.87 minutes per work RVU for TAT 60 studies. “The quantification of a radiologist’s workload in terms of RVU flow may affect radiology report turnaround time in emergency radiology,” write the authors, all of whom are associated with the department of radiology and biomedical engineering at Yale. Based on the research, they note, “other factors, such as specific attending radiologist, presence of a resident, and time from the start of a radiologist’s shift may significantly affect turnaround time.”
7. Tackle noninterpretive tasks.
Interruptions are unavoidable in almost every field of work. Radiology is no exception, and often managing the break in concentration means preparing for it to avoid being discombobulated. Case in point: finding alternative means of handling noninterpretive tasks, like handling telephone calls. In a study of this part of the job, “Quantifying the Impact of Noninterpretive Tasks on Radiology Report Turnaround Times” (JACR, July 2017), McKinley Glover IV, MD, MHS, of Massachusetts General Hospital and colleagues discovered that, in a single hour, an additional 4.25 minutes of turnaround time was added for every one-minute increase in duration of telephone calls.
Meanwhile, across the country in New Mexico, “we eliminated a lot of annoying phone calls just by making the individual section reading rooms more available and visible online, and by having more set, automatic study protocols,” Young says.
And according to a poster presented online by AHRA, Mary Washington Hospital in Fredericksburg, Va., achieved a 16-minute reduction in report TATs for emergency CT exams with contrast and a six-minute reduction in report turnaround time for emergency CT exams with contrast. The TAT-reduction team pulled this off by, among other steps, dedicating one phone line for CT use.
As Glover and colleagues conclude: “Standardizing capture of noninterpretive tasks may aid development of strategies that address productivity, communication and value in radiology. … Systematic quantification of noninterpretive tasks may aid radiologists in demonstrating value beyond report generation.”