President Scott Branton Senior Associate RAD-Planning, USA.
In architecture there is a well known phrase “less is more” which was part of a movement away from overly complex architecture to a more simplified form. This same adage applies equally well to the design and operation of efficient medical imaging centres. In the midst of declining resources and a world-wide recession, imaging providers are struggling to maintain profitability. On the flip side of the coin, driven by population growth and the need to expand services to an ever widening patient base, radiology departments are seeing an increase in patient referrals for MR and CT, which means a higher percentage of patients with higher acuity levels, requiring increased staff interaction and longer scan times.
So how can an imaging facility manage these seemingly divergent restraints? In a word: efficiency, and this efficiency needs to be applied across the board, from operations to imaging centre planning and design. For example having just five extra minutes in a centre’s average scan time for MR or CT patients, in a department that does 20 scans per day six days per week, means an additional 520 hours of facility operation annually. Five hundred and twenty hours of additional staff time, utilities and equipment usage without any additional revenue. Or put another way, working one 10-hour day per week for free! All imaging providers will tell you that working for free is not a good plan for success.
Since efficiency needs to be applied across the board in order to be effective the first place to start is to look at the overall layout of the imaging facility. Nothing will kill efficiency faster then a poor facility layout. A poorly planned radiology department can create multiple bottlenecks that slow patient throughput. Admittedly, many radiology administrators in existing centres find this frightening, assuming that the facility layout is something that is a given and not subject to change. Many imaging centre operators are convinced that unless they are planning a move or major expansion they cannot afford to revise the department’s layout. While this may be true for the large gantry scan rooms, it does not necessarily apply to the many less technical support spaces that many times have a more significant impact on patient throughput than the scan room itself. These days it is very common for a facility to make changes in lighting or mechanical equipment to improve energy efficiency, realizing that the energy savings will pay for the improvements. The same is true for layout improvements. Remember those 520-hours of additional staff and equipment time from just five extra minutes of average scan time? Shaving 520-hours off of a staffing plan can easily pay for layout modifications.
The typical response when you ask an Imaging Facility Manger about what areas of the facility layout have the greatest impact on MR and CT patient throughput, the most common answer is the scanner room. The scanner room is a critical component of the patient imaging and throughput process, it is not the bottleneck at most facilities. The bottleneck usually occurs with the interaction with patients before and after the scan and this most often occurs at the dressing room, a mundane and often overlooked support space that has a huge impact, not only on patient throughput, but also patient satisfaction. So how is it that a non-technical space that is less then 60 square feet in area can bring a 20,000 square foot imaging department to a halt? The answer is as simple as it is frightening: if the patient is not ready to be scanned the scanner sits empty. Far too often imaging centres mistakenly assume that they can “get by” with only one changing room, which usually servers multiple scanners. The thinking is that they can just quickly process patients through the one changing room and then have them wait somewhere else. The most common mistake seen in imaging centres is too few dressing rooms, dressing rooms in the wrong areas and/or dressing areas that are too small. As a general rule of thumb for every large gantry scanner or modality there should be at least two dressing rooms. These dressing rooms also need to be large enough at allow accessibility for patients with mobility restrictions and ideally large enough to accommodate a second person to assist the patient in the gowning process. Having a dressing room large enough for two-persons is most beneficial at imaging centres that serve paediatric or geriatric populations. The goal is to always have one patient gowning-in, one patient in the bore of the scanner and one patient gowning-out to maximise throughput. In order to do this, each scanner needs to have two changing rooms dedicated to it. Too often, in an attempt to save a few dollars in construction or lease costs, imaging centres will set up two or three dressing rooms to be shared by multiple scanners and typically only one of those is ADA accessible. With the Baby Boomer generation reaching retirement age, the number of people over age 65 will nearly double between 2000 and 2030. This means that more patients will have some type of mobility restriction. Having larger dressing rooms that allow for a second person to assist the patient in the gowning process will speed patient preparation. This combined with upgraded finishes and lighting inside patient dressing rooms has proven to greatly improve a centres overall patient satisfaction rating.
Another component of the patient dressing room is where patients store their personal belongings while they are being scanned. It is strongly recommended that imaging centres use personal storage lockers that are located out-side of the dressing room. This gives the patient personal control over their belongings, which helps reduce the liability of the imaging centre from lost item claims. Many times an imaging centre will tell us that they do not use lockers and prefer to allow the patients to lock their belongings in the dressing room. This is less of an issue if each scanner has at least two dedicated changing rooms, but if changing rooms are being shared with other scanners, this can quickly cause a bottle-neck as new patients are held up waiting for the previous patient to finish their scan, change and collect their belongings before the next patient can even start to gown-in.
Another problem is imaging centres that have the proper number of dressing rooms for their fixed scanners, but fail to take into account the effect of mobile scanners. The common example that we see is a centre that brings in a mobile to help relieve a patient back-log, only to find that the back-log does not improve, due to the fact that they cannot efficiently process patients through the existing number of dressing rooms. This problem is further compounded when the mobile scanner is a PET or PET / CT. Now the centre has the issue of having to dedicate spaces for radioactive or ‘hot’ patients only and can no longer share changing rooms or toilets with the non-nuclear scanners. What starts out as a way to increase services and revenue backfires without proper planning and upgrades to support the new services, ultimately negatively affecting patient satisfaction due to increased wait times.
Lastly, facilities need to understand their patient demographics and adjust the layout to align with the patient population. The best way to handle this is to provide segregated access paths and support spaces for inpatients and outpatients. This allows the support spaces to be tailored to the unique needs of each patient population. For example, dedicated holding, induction / recovery and screening for inpatients allows patients with higher acuity levels to be separated from outpatient traffic. The attached plan is a great example of how to share fixed base scanners with both inpatient and outpatient populations and still maximise patient throughput for each patient group. The added benefit of preventing cross traffic between inpatients and outpatients is avoiding the negative connotations and associated health concerns when healthy outpatients share space with less healthy individuals. Studies have shown that outpatients feel less comfortable in settings when they are aware of sharing space with patients that require a higher level of medical care.
So what can a facility due to safeguard against these issues? First, review the existing layout to make sure that the proper patient support spaces exist to support both the fixed and mobile modalities; remember, two changing rooms per scanner. Secondly, the support spaces should be sized to accommodate mobility-restricted patients and located in close proximity to the scanners. Provide patient lockers outside of the changing rooms to allow for the greatest flexibility. Lastly, review the quality level of finishes and lighting within these spaces that patients come in close contact with. A little extra attention to detail in these spaces where patients spend time can reap huge benefits.
If upgrades need to be made, usually a medical centre's in-house staff can provide design and construction for minor projects, just keep in mind that as a general rule state health departments require that a licensed architect or engineer be involved in any medical projects that change wall or door locations. If needed, bring in outside professional design assistance, but be sure to use professionals that understand the unique issues related to medical imaging and patient throughput.
Remember that layout modifications to improve patient throughput will be a one-time expense compared to the possible perpetual staffing costs and patient dissatisfaction of an inefficient operation.
Robert Junk is President of RADIOLOGY-Planning, a recognised leader in radiology and imaging suite design. He has been involved in healthcare design and medical imaging for over 25 years. He is an expert contributor to the US Department of Veteran Affairs’ imaging series Design Guides and has served as an expert witness in cases involving imaging suite failures.
Scott Branton is a Senior Project Manager for RADIOLOGY-Planning (RAD-Planning) with nearly 20 years of professional experience. He has provided designs and project supervision for healthcare and imaging projects for a breadth of clients from top-tier research institutions to municipal health services.