"CSMC: One Footprint,Two Services", © Danielle Cohen, Imaging Economics, 12/05

When Cedars-Sinai Medical Center, Los Angeles, was built in the 1970s, it was conceptualized as a series of horizontal hospitals, with each floor having, among other services, its own radiography capabilities. That concept, however, was envisioned prior to the creation and use of modern-day cross-sectional imaging modalities, such as CT or MRI—expensive purchases that take up a large amount of space.

By the early 1980s, the layout concept was proving inefficient to handle the hospital's inpatient and outpatient imaging needs. Cedars-Sinai had a limited outpatient imaging capability, with freestanding MRI scanners housed in vans in a parking lot on the campus. The hospital's outpatient imaging department received growing competition from a number of small, boutique-style imaging centers in the surrounding area.

"We could not provide the service and we couldn't handle the volume that was required for outpatient work," says Barry D. Pressman, MD, FACR, chair of the S. Mark Taper Foundation Department of Imaging at Cedars. "This was the time when outpatient procedures were increasing almost exponentially, and there was more and more pressure, as well as appropriateness, to move procedures of all kinds of imaging to the outpatient world. Since we couldn't do that, and because we really needed a facility for our MR scanners, we thought about the best way to adjust to this new paradigm.

"We also found that the level of service that we could give to clinicians and our patients was being harmed by the artificial separation of our outpatient imaging doctor and our inpatient imaging doctor," he says.

Pressman says the hospital faced a major decision: whether to build a somewhat larger imaging center for outpatients, or whether to consolidate what was up to that time a very dispersed imaging department for inpatients with the outpatients "in order to bring some economies of scale to the clerical, technical, and physician portion of the process, as well as to increase the utilization of capital equipment."

Building a larger outpatient imaging facility would have meant that those scanners would sit idle much of the weekend and at night. It also would have required an increased number of physicians to read outpatient studies and inpatient studies, and would not allow for the best utilization of the technologists, who, instead of doing whatever was needed, would be forced to wait for the next outpatient or inpatient to arrive.

"MR really made consolidation more important because of the capital cost incurred," Pressman says.

In order to gain efficiencies, the decision was made in 1992 to consolidate physicians, technologists, and capital equipment into one facility. Initially, a small outpatient facility was built to accommodate patients while a larger facility was in the planning, fund-raising, and construction stages.

Construction on the S. Mark Taper Foundation Imaging Center began in 1998, and the center officially opened in March 2003. The four-floor, 121,000-square-foot facility—which cost about $100 million, including construction and equipment—includes 65,000 square feet of new building, as well as refurbished contiguous existing hospital space, all of which now constitutes a uniform-appearing "new building."

The Taper has five CT rooms, four fluoroscopy rooms, five radiography rooms, seven ultrasound rooms, five vascular ultrasound rooms, 13 nuclear medicine rooms—two PETs and one PET/CT—and six MRIs, one of which is located down the street.

The Taper, which has one of the largest nuclear medicine departments in the country, also has its own radiopharmacy. An interventional radiology suite is located elsewhere within the hospital. Digital screening mammograms are offered at the Taper, while diagnostic mammography is performed at the imaging department's breast center across the street.

The Taper houses main scheduling, waiting, and registration areas, three sub-waiting areas, conference rooms, and 25 reading rooms. Picture archiving and communications system (PACS) and radiology information system servers are kept in a secured room.

Through the Taper, the imaging department was able to consolidate the outpatient and inpatient inventories, reportedly saving the facility more than $1 million per year on supplies.

There are 397 full-time employees staffing the center, with 30 radiologists, as well as 10 residents and two fellows, one in nuclear medicine and one in neuroradiology.

On average, the Taper sees about 300 outpatients and approximately 350 inpatients per day. In 2000, the hospital's radiology department performed 280,000 procedures; the Taper was budgeted for 428,000 procedures in 2005. "We're starting to reach capacity," says Lynne Roy, MS, CNMT, MBA, MHA, director of the Taper imaging center. "It's going to be harder and harder to do those last-minute studies that we get. Outpatients don't want to come in at 2 in the morning, neither do inpatients, although sometimes they [inpatients] do."

GOING WITH THE FLOW

Carefully designed patient flow patterns are at the heart of the center's success. Much of what was previously decentralized has now been centralized, including scheduling, transportation, and nursing.

The administrators worked with the facility's architects on creating flow patterns that kept outpatients and inpatients separated. The layout includes different corridors through which outpatients and inpatients flow, as well as different doors through which they enter the same examination area. "We have outpatient and inpatient halls, so that the outpatients and inpatients do not see each other," Roy says. "They don't allow the two sets of patient populations to really mix. The reason we did that was to attempt to stay competitive."

If, for some reason, an inpatient needs to be brought into an outpatient hallway, there is the potential for patients crossing each other's path, but only for a moment. Outpatients never have to be in the inpatient corridor.

Outpatients enter the Taper from the street side; although possible, it is unnecessary for them to walk through the hospital to the imaging department. Upon arriving inside the center, outpatients check in at a main desk, and receive a pager, which is used to contact a patient when it is their turn to be seen. The pager system also provides privacy as it is no longer necessary to call out a patient's name.

If an outpatient has not preregistered for their examination, they are sent to the registration department. A centralized scheduling department is located next to registration for easier flow in preregistration situations.

Depending on the modality required, outpatients are sent to a corresponding sub-waiting area. "We've done it so that they don't feel like they're in a cavern. We've taken them from a big waiting room to a small waiting room so that they feel like they're in a small, private office," Pressman says.

Each sub-waiting area has its own check-in area so that patients are not lost in the shuffle. Dressing rooms are located in the sub-waiting areas, where staff members are charged with informing the technologist aides when a patient is ready to be seen. The technologist aides then bring patients into the examination room and prepare them for the examination, which is conducted by the appropriate technologist. The Taper has brought the wait time from the moment an outpatient arrives at a sub-waiting area to the moment a technologist aide brings them to a room down to an average of 11 minutes.

SHIPS PASSING

Inpatients, on the other hand, are brought to the imaging department by transporters via two sets of elevators that are available for their use—one set was already part of the hospital, while the second set was installed when the center was constructed. The elevators egress into the appropriate hallway.

Inpatients are then brought to designated holding areas before being brought into the examination room.

All modalities are located in cores or pods, including CT, ultrasound, MRI, radiography, and nuclear medicine. Within each modality pod are preferential outpatient and inpatient rooms. While those rooms are preferential, they are not exclusive to one patient population or the other, but can be used for either when needed.

"We developed a process and flow pattern to keep the inpatients and outpatients separate, so that we have maximized capital utilization and, most important, maximized flexibility," Pressman says. "The patients don't know it, but the outpatients are in a hospital, and the inpatients are in an outpatient facility," Pressman says. "The process has worked as we hoped it would."

A third set of patients—those referred from the hospital's emergency department—were also considered when the imaging center was in the planning stages. There are two plain film rooms located within the emergency department, and the CT core is located next to it so that patients requiring that study, especially trauma patients, can have easy access.

The center design is optimized to make the workflow easier for the staff. Housing all procedures within the same facility has been a time-saver. The Taper hired 42 technologist aides to assist the technologists, and the inpatient transporters carry phones to improve communication with dispatch and the imaging department's staff. Technologists now handle patients as they come in, regardless of whether they are inpatients or outpatients.

Radiologists and technologists both benefit from the absence of film made possible by a PACS. "It was important that PACS was coming online at the time [the Taper was being developed] because that helped us. We planned the whole thing around PACS because we knew we'd be able to move images and handle the large volumes," Pressman says. "It's very tough to handle outpatient films and inpatient films in the same location, whereas, with PACS, that's not an issue. Without PACS, you really couldn't do this in a big center. It would just be chaos with the films," he says.

REFERRALS AND REVENUES

Approximately 95% of the Taper's monthly outpatient referrals come from the hospital's 2,000 privileged physicians—most of those are physicians in practices in the hospital's vicinity or nearby, although about 15% come from a distance.

At least half of the referrals come from specialists. Oncologists make up the largest group of referrers, accounting for 18% of the Taper's outpatient referrals during 2005, followed by cardiologists (11%); internal medicine physicians (9%); general surgeons (6%); nephrologists, neurosurgeons, and neurologists (5% each); gastroenterologists, pulmonary/critical care, and endocrinologists (4% each); and obstetricians/gynecologists, urologists, orthopedic surgeons, rheumatologists, otolaryngologists, and others (less than 4% each).

Outpatient procedures comprise about 53% of the Taper's revenues, while inpatients comprise about 55% of its volume. Inpatients tend to undergo a great deal more of the low-revenue plain films, while outpatients undergo a relatively higher volume of the high-revenue procedures.

For instance, radiography accounts for 30% of the inpatient volume, and 9% of the outpatient volume; and 60% of all CT patients are outpatients. MRI accounts for 5% of the inpatient volume, and 12% of outpatient; nuclear medicine contributes 12% of inpatient imaging and almost 30% of outpatient; and ultrasound 9% of inpatient imaging and 6% of outpatient imaging. Mammography is 99.9% outpatient, and makes up about 9% of the outpatient volume.

The use of all modalities has been growing at the Taper, although PET/CT and MRI are the fastest growing. There is also a big demand for CT angiography.

Medicare patients are the most predominant (about 35%), followed by PPO, HMO, and Medi-Cal patients, respectively.

When the Taper opened, the challenge was, and continues to be, to retain outpatient imaging and to not lose it to a freestanding facility. The competition it faced has only increased over the years: There are approximately 10 freestanding centers nearby; a number of large physician groups in the area have obtained or are obtaining scanners, such as CT, PET/CT, and MRI; and two physician-owned specialty hospitals have also opened in the area.

"You need to have unquestioned quality, and you need to try to be equal or better in service—smaller facilities have an upper hand in that [service] regard, but a lot of people are loyal to us because our quality is unquestioned," Pressman says.

The quality comes in the ability to provide subspecialists to read all outpatient images, something Pressman says helps tremendously in maintaining loyalty among referrers.

Being a combination inpatient/outpatient imaging center tied in with a major metropolitan hospital has both benefits and drawbacks.

Among the competitive advantages for the Taper are the association with the world-renowned Cedars-Sinai Medical Center, the ability to provide all modalities available, subspecialty interpretations, scheduling flexibility, and a filmless environment.

"A hospital's advantage is that it can provide the entire continuum of care for a patient," Roy says.

The Taper's layout provides tremendous flexibility in scheduling, with no need to shift modalities, technologists, or patients around. Because the Taper has so much equipment, if something fails, the staff can simply use another piece of equipment to complete a patient's examination.

The Taper offers weekend appointments, has extended its overall hours, and is able to accept walk-in and emergency cases. The Taper began offering walk-in service about 2 years ago. Referring physicians who occupy nearby medical office towers and require immediate examinations can send their patients to the Taper without an appointment.

Another competitive advantage for the Taper is the ability to have all inpatient and outpatient images in the same PACS. "If a patient has been an inpatient and comes back as an outpatient, or vice versa, we've got their old studies. It's not an issue to compare them," Pressman says.

While the advantages of the Taper are many, its size provides its own issues. "[Those issues] require constant vigilance and effort to maintain the kind of service that the patients and the doctors deserve and what they expect based on what the smaller outpatient facilities can provide," Pressman says.

"It's difficult to maintain some of those service levels that referring physicians like, but I think that all of the other advantages to their patients, and to them, outweigh some of the disappointments that they occasionally have service-wise. We try to keep that to a minimum, and I think we've been successful, but we're constantly being challenged with service issues because of the size," he says.

Among the competitive disadvantages for the Taper are its size, the regulations it must follow as the imaging department for a hospital, and wait times for physicians and patients.

The main disadvantage for any hospital competing with a smaller imaging facility is that it is large, and some outpatients simply do not like going to a hospital, no matter how the layout is arranged. The administrators and architects did try to decrease the size concept for patients, including making the Taper aesthetically pleasing and creating the sub-waiting areas.

The need to comply with hospital processes for the acquisition of capital equipment also puts the Taper at a disadvantage. Currently, the center has only 16-slice CT scanners, although it expects to receive a 64-slice scanner in the first half of 2006 as the hospital goes through the proper protocol to obtain one. Smaller, freestanding facilities can obtain whatever modalities they want, as long as they have the space and can afford them.

It is also difficult for an imaging center that also serves a very busy 959-bed hospital to compete on the basis of wait times associated with scheduling appointments and obtaining readings.

The facility has a goal of 24 seconds from the time someone calls to schedule an appointment to the time they speak with a staff member. To keep to that time frame, the Taper has hired more schedulers, changed the hours of the staff, and tried to reduce the number of calls that must be handled by a human. About 60% of the phone calls that come into the Taper are from patients.

Mammography calls have been redirected to a separate phone line because the volume is so great, causing longer wait times.

Plain radiography is not scheduled at all, unless it is one part of a series of studies. That decision was made in order to decrease the time a staff member spends on scheduling an appointment. Removing plain films from the schedule eliminated 25% of the calls that staff members had to handle.

Inpatient scans are not scheduled for any modality, but rather are handled by the tech supervisor in each area, who maintains a priority list based on chronological receipt of the request. That is offset by any emergency requests.

Each week, the center's administrators review wait times for scheduling appointments in order to decide how to decrease them. Wait times for appointments vary by modality; CT has about a 1-day wait, MR about 3 days, mammography screenings about 3 to 4 months, and same-day ultrasound. A few years ago, those waits were much longer.

Patients are not the only ones who must wait sometimes. The Taper's radiologists read about 700 to 800 studies a day, which means that it takes more time to get results, as opposed to smaller facilities that read much fewer studies a day. "It's a little bit harder for us to give the same perfect service that you get in a place that does 20,000 exams a year, but we're trying. That's our goal—to be equivalent to any facility," Pressman says. "One of the biggest problems in any large facility is communication—reaching the doctor. Since we have so many doctors, we're constantly battling that.

"Anything we can do to improve our communication is high on our list," he says. "It's a very difficult problem."

When the hospital first began to plan for the imaging center, it took about 3 days from the time an inpatient study was ordered to the report being completed; now, that figure is down to about 18 hours on average.

While all reports are automatically faxed to referring physicians' offices and uploaded to the center's electronic medical records system, "I think our referring physicians miss the personal touch. That's the danger you have when you go filmless, especially in a large hospital," Roy says.

A BALANCING ACT

Roy and Pressman agree the Taper's advantages outweigh the disadvantages.

"We have a lot of disadvantages; that we do so well is a testimony to the quality [of the services available at the Taper]," Roy says. "Our product is information, and at the end of the day, you have to make a good product. Our subspecialty radiologists help make it one of the best products there is in the Greater Los Angeles area."

Pressman says running any business is not easy, and the Taper is no exception. "It's tough when you're trying to be a McDonald's and a Spago [an upscale Beverly Hills restaurant] simultaneously; a McDonald's when you're trying to move a patient through at that speed, and a Spago in the quality of the service," Pressman says. "That's the effort we're constantly making: Can we get the patients in so quickly that they don't even know they've been here, and how do we at the same time make sure that the techs have treated them well, and the quality of the reports are excellent, and the doctors get called?