Are Your Physicians Happy?

Turbo charging turnaround time

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This article, submitted by Jeffrey L. Fultz, NMTCB, won third place in the Professional category of the 2004 RT Image Writing Competition.

Anyone who has worked in radiology for any length of time knows that next to patient care, turnaround time (TAT) is one of the most critical issues facing the department. Oftentimes, a department's reputation within the physician community will be based solely on this aspect of operation. Only a few other things will change your reputation more - for better or worse - than a drastic change in turnaround time.

You may initially have an acceptable TAT. But then a film librarian or transcriptionist calls off or quits. All of a sudden your four-hour turnaround time jumps up to 12 or even 24 hours. Now you have half of the physicians or radiologists you deal with calling you, wanting to know what is going on and why they don't have their reports. Usually, the radiologists are going to come to you and say, "Just fix it." Will you be prepared?

Starting the Process

There are several aspects that affect your final report turnaround time. This includes everything from the order entered in a timely manner to the radiologist signing the final report.

The first step in evaluating your TAT is to identify your weakest link. To find the bottleneck, daily monitoring is very effective. It will not only give you a day-by-day snapshot of what areas need improvement, but if employees know procedures are being monitored, they are also more attentive to what they do.

Set up a useful report that shows the weak areas. In this report, I monitored the following areas:

• exam time from start to completion
• time from order entry to exam completion
• time from exam completion to dictation
• time from dictation to transcription
• time from order entry to transcription
• time from transcription to radiologist sign-off
  

All of the following information comes from the statistics in our radiology information system (RIS). I established a standard of 97 percent of all reports to be completed within a 24-hour time frame. Every day, I check this report to see if any procedures fall out of that standard. If one area consistently falls out, I address those who have control over that area. For example, if the "time from dictation to transcription" begins to fall, I will speak with the transcription department to see if there have been any changes that caused this. I then work with the transcription supervisor to resolve the issue.

I hold certain groups of individuals responsible for the different areas measured:

• Start to completion - This is solely the responsibility of the technologists involved in performing the exam.
• Entry to completion - This involves not only the technologists performing the exam, but also the people originally entering the order, such as a unit secretary or registrar.
• Completion to dictation - This involves only the radiologists.
• Dictation to transcription - This involves only the transcriptionists.
• Entry to transcription - This involves everyone mentioned up to this point.
• Transcription to sign-off - This involves only the radiologists.
  

Education First

You will find that areas outside radiology are affecting your TAT. It will take patience and a willingness to educate others to accomplish your goals but, in the end, it is worth the effort.

Meet with nursing supervisors to inform them of the importance of entering an order in a timely manner. If a physician orders a chest X-ray at 9 a.m., it shouldn't be entered at 4 p.m., delaying radiology's TAT and leaving the ordering physician wondering why it is taking radiology so long for a simple exam ordered hours earlier.

Another opportunity for process improvement in this area is to have the person entering the order call the radiology department to announce that there is an order in the system.

There is software available that can assist in this area if you are having problems with physician orders outside of your hospital. These products can be installed, allowing exams to be ordered online sent electronically to your department.

Another way to improve TAT is by offering your most frequently referring physicians secure access to your RIS. They can then order exams the same way as a unit secretary can with in-house patients.

The Final Steps

Time from transcription to radiologist sign-off is another area of concern. There are several ways to approach this issue. I have tried everything from printing a list of orders in the queue every two to three hours to meeting with them collectively, as well as individually, to show them exactly where the breakdown is in the process. If you have a system with electronic signature, this will automatically improve the area.

If you have a group of radiologists that are comfortable with over-reading and signing another radiologist's dictation, this can save a lot of time when they are off or in a rotation at another hospital. Once the radiologists are aware of how they can improve their portion of the process, you can usually get their input and they will work with you to streamline the process.

The last portion of your TAT, and probably the most important, is length of time for the ordering physician to get the report. It's pointless to have a report generated and signed in six hours, then take three days to get it to the physician.

I have found that "auto faxing" is probably the most efficient way to generate a report for the ordering physician. Most RISs have this option and can be sent to any fax number. Therefore, not only will the report go to the units for in-house patients, it can also be set up to go to the referring physicians. Most systems will also allow you to set up the time that reports will print out in the offices. That way you don't have to worry about the receiving fax machine being busy and the report never getting through. If it is set up to print after hours, the office only needs to ensure there is adequate paper in the machine.

Generally, the report will be automatically generated and faxed (or even sent to a specified printer in-house) once the radiologist signs the report. Some facilities and radiologists are comfortable with a draft version released to the units in-house with the understanding that it is a draft and the signed version may differ. Some facilities don't want to send out the draft version for that same exact reason.

A digital dictation system can be set up for physician access to the dictation before its transcription. This is accomplished using a physician-specific access code through the telephone system. It allows the physician to hear the dictation before having the hard copy report in hand, but can assist in a time-sensitive decision necessary for appropriate patient care.

I think we would all agree this is an important issue facing everyone in radiology. But if TAT is properly monitored and tracked, areas of weaknesses identified, protocols altered or established to address and improve areas of weakness and a standard of acceptability set and enforced, it can dramatically improve your overall reputation in the physician community.

Author's note: The processes I just described are performed in a non-PACS environment. Once your department goes completely to PACS, the process changes completely, making the current one, for the most part, obsolete.

— Jeffrey L. Fultz, NMTCB, is director of radiology services at Memorial Hospital Jacksonville in Florida. Questions and comments can be directed to editorial@rt-image.com.