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Optimization of Aga Khan University Hospitals MRI and CT Scan Procedures using Operations, Finance and Marketing Concepts

IBA Student TeamAyaz Saleh, Haris Usama, M. Ahmed Anjum, Mohsin Ali Sadiq

AKUH TeamMr. Syed Sohail, Ms. Nida Husain, Mr. Rehanullah Baig, Muhammad Yusuf

IBA Project CoordinatorsDr. Nasir Afghan and Mr. Asad Ilyas

Project AdvisorsDr. Shahid Qureshi, Mr. Asad Ilyas and Professor David Robb (SEM Tsinghua)

Table of ContentsList of Figures7List of Tables9List of Exhibits11Acknowledgments12Abstract13Foreword14Executive Summary17Chapter 1 Project Introduction201.1 Aga Khan University Hospital211.2 Patient Types231.2.1 Emergency Patients231.2.2 In-Patients231.2.3 Out-Patients231.2.4 Outside Referrals (OSRs)241.3 Department of Radiology251.4 Magnetic Resonance Imaging271.5 Computerized Tomography281.6 Project Premise29Chapter 2 Literature Review302.1 Case Study Quinte MRI312.1.1 Summary312.1.2 Issues312.1.3 Setting312.1.4 Solution312.2 Course Manual for Operations Management322.2.1 Summary322.3 Other Literary Material32Chapter 3 Research Objectives, Methods, Tools and Limitations333.1 Objectives343.1.1 Operations343.1.2 Marketing343.1.3 Finance343.2 Methods353.2.1 Team Interviews353.2.2 Data Mining353.2.3 Observation of Work Practice353.2.3.1 Scheduling and Queuing353.2.3.2 Time and Motion Study363.2.4 Patient Survey363.2.5 Sensing373.3 Research Tool Design383.3.1 Patient Survey383.3.2 Time-Motion Study383.4 Limitations403.4.1 Marketing403.4.2 Operations403.4.3 Finance40Chapter 4 Data Collection and Analysis414.1 Observations424.1.1 Patient Survey424.1.1.1 Ease of Getting Care424.1.1.2 Waiting Time474.1.1.3 Staff (Receptionists, Technologists, Radiologists)504.1.1.3 Facility564.1.1.5 Pricing Structure604.1.1.6 Post Test634.1.1.7 Referral674.1.2 Time-Motion Study684.1.2.1 MRI684.1.2.2 CT Scan694.1.3 Scheduling and Queuing704.1.3.1 MRI704.1.3.2 CT Scan714.3 Revenue Model724.3.1 MRI Model734.3.2 CT Scan Model74Chapter 5 Conclusions755.1 Operations765.1.1 Interdependencies & Lack of Coordination765.1.2 Lack of Monitoring of Idle time765.1.3 Scheduling of Appointments765.2 Finance785.2.1 Lack of Data Analysis785.2.2 Complexity of the procedures785.3 Marketing795.3.1 Lack of innovative communications795.3.2 Inappropriate pricing795.3.3 Lack of patient understanding of the quality of service795.3.4 Lack of Doctors recommendations795.3.5 Unethical Issues80Chapter 6 Recommendations826.1 Marketing836.1.1 Strategic Partnerships836.1.1.1 Price-Discount Partnerships836.1.1.2 Communication Partnerships836.1.2 Online Reporting846.2Operations856.2.1 Recommendations to enhance throughput856.2.1.1 Scheduling of procedures856.2.1.1 Recruitment for independence and improved coordination876.2.2 Staffing & work flow efficiency recommendations876.2.2.1 Staff Training on Hard Skills876.2.2.2 Performance-based Incentives886.2.2.3 Mentoring886.2.3 Patient Engagement Tactics886.2.3.1 Increase seating capacity886.2.3.2 Wi-Fi886.2.3.3 Information Booth896.2.3.4 Tuck Shop896.2.3.5 Play Area and Mothers Nursing Center896.3 Finance906.3.1 Pricing Strategy906.3.1.1 Loyalty Cards906.3.1.2 Discounts based on Frequency of Procedures906.3.1.3 Discounts based on the time of the appointment916.3 Need for Further Study926.3.1 Cost Drivers Mapping926.3.2 Employee Climate Survey926.3.3 AKUH Brand Assessment926.4 Road Map93Bibliography95Exhibits96

List of Figures[footnoteRef:1] [1: Figures follow the nomenclature of Chapter Number]

Figure 1.1 Patient Types.23

Figure 4.1 - Ease of scheduling your exam..42

Figure 4.2 - Courtesy of receptionist answering telephone calls43

Figure 4.3 Hours imaging center is open..44

Figure 4.4 Convenience of imaging center's location..45

Figure 4.5 - Parking space & distance to the clinic.46

Figure 4.6 - Time in waiting room..47

Figure 4.7 - Waiting Time for test to be performed.48

Figure 4.8 - Overall waiting time in imaging center.49

Figure 4.9 - Courtesy of office staff50

Figure 4.10 - Due attention given to you..51

Figure 4.11 Staff satisfied queries..52

Figure 4.12 - Good advice and treatment.53

Figure 4.13 Staff being friendly and helpful..54

Figure 4.14 Staff answered your questions..55

Figure 4.15 - Neat and clean waiting room..56

Figure 4.16 - Comfort and safety while waiting57

Figure 4.17 Cleanliness of the Washrooms58

Figure 4.18 Privacy...59

Figure 4.19 - MRI and CT Scan Prices are market competitive60

Figure 4.20 - Prices are justified61

Figure 4.21 - Preference for an alternative with lower price62

Figure 4.22 - Timely Delivery of the results.63

Figure 4.23 - Ease in collecting results64

Figure 4.24 - Staffs guidance for setting an appointment65

Figure 4.25 Post-Test Privacy66

Figure 4.26 Recommending Radiology Services to Others.67

Figure 4.27 - Average IDLE Time during the day (MRI) ..70

Figure 4.28 - Average IDLE Time during the day (CT) .71

Figure 4.29 - Revenue Distribution among Procedures.72

Figure 5.1 - Cause & Effect - Low Yield80

Figure 6.1 - Cycle of Continual Improvement94

List of Tables[footnoteRef:2] [2: Tables follow the nomenclature of Chapter Number]

Table 4.1 - Ease of scheduling your exam42

Table 4.2 - Courtesy of receptionist answering telephone calls43

Table 4.3 Hours imaging center is open44

Table 4.4 Convenience of imaging center's location45

Table 4.5 - Parking space & distance to the clinic46

Table 4.6 - Time in waiting room47

Table 4.7 - Waiting Time for test to be performed48

Table 4.8 - Overall waiting time in imaging center.49

Table 4.9 - Courtesy of office staff.50

Table 4.10 - Due attention given to you51

Table 4.11 Staff satisfied queries52

Table 4.12 - Good advice and treatment53

Table 4.13 Staff being friendly and helpful54

Table 4.14 Staff answered your questions55

Table 4.15 - Neat and clean waiting room56

Table 4.16 - Comfort and safety while waiting57

Table 4.17 Cleanliness of the Washrooms58

Table 4.18 Privacy59

Table 4.19 - MRI and CT Scan Prices are market competitive..60

Table 4.20 - Prices are justified61

Table 4.21 - Preference for an alternative with lower price62

Table 4.22 - Timely Delivery of the results63

Table 4.23 - Ease in collecting results64

Table 4.24 -Staffs guidance for setting an appointment65

Table 4.25 Post-Test Privacy66

Table 4.26 Recommending Radiology Services to Others67

Table 4.27 MRI Time-Motion Study Summary (in minutes) 68

Table 4.28 CT Scan Time-Motion Study Summary (in minutes) 69

Table 4.29 MRI Average IDLE time during the day70

Table 4.30 CT Scan Average IDLE time during the day71

Table 4.31 Revenue Distribution.72

Table 5.1 - Conclusion Summary..81

Table 6.1 Scheduling according to Patient Type86

Table 6.2 Pricing Strategy and Formula91

List of ExhibitsExhibit 1- Survey Form for Patients Perception..97

Exhibit 2- Process Map for MRI Procedure.98

Exhibit 3- Time-Motion Study Observations for MRI Procedure (in minutes)99

Exhibit 4- Process Map for CT Scan Procedure100

Exhibit 5- Time-Motion Study Observations for CT Scan Procedure (in minutes)101

Exhibit 6- Procedure Description, Volumes and Charges MRI.102

Exhibit 7- Procedure Description, Volumes and Charges - CT Scan.105

Exhibit 8 - Procedure Description, Volumes and Charges NM.108

Exhibit 9 - Procedure Description, Volumes and Charges SPEC110

Exhibit 10 - Procedure Description, Volumes and Charges STD.112

Exhibit 11 - Procedure Description, Volumes and Charges US116

Exhibit 12 - Procedure Description, Volumes and Charges VIR..118

AcknowledgmentsBefore beginning the final year project report, we would like to express our gratitude and appreciation to all those people who helped us during the course of our research.We start by thanking the team of AKUH - Mr. Syed Sohail, Ms. Nida Husain, Syed Rehanullah Baig, and Mr. M. Yusuf. Their team was always at our beck and call. They specially made time for us from their busy schedules, provided the information we needed and gave us the necessary administrative support to ensure our team had no problems. We also want to thank Dr. Shahid Qureshi, our project advisor at the beginning of the project. A special note of thanks goes to Professor David Robb of SEM Tsinghua who supported us with material and technical assistance during the project.Last, but not the least, we would like to acknowledge Mr. Asad Ilyas and Dr. Nasir Afghan, Project Coordinators at IBA. Mr. Asad Ilyas, who also became our primary advisor after the interim presentation, was literally just a phonecall away. He was always available for advice, support and words of encouragement. And Dr. Nasir went out of his way to help the team in improving its reporting and presentation. Their critique was most pivotal in setting the teams direction. We sum up our token of appreciation by acknowledging all the secondary resources used for our research and literature review.

AbstractAga Khan University Hospital (AKUH) is one of the leading healthcare providers in Pakistan. Equipped with state-of-the-art technology, the hospital invests heavily in research and focuses on high quality service. Given its infrastructure, AKUH incurs heavy costs that result in premium pricing. The hospital offers unique value in terms of safety and health. It has an in-patient turnover of about 60,000 and services about 700,000 outpatients annually.The hospital is currently expanding its facilities with significant investments in increasing capacities of Emergency Room, Internal Clinics and Private Wings and Wards. The Department of Radiology also has plans to add another Magnetic Resonance Imaging (MRI) and Computerized Tomography (CT scan) machines by the end of 2012. This initiative has been taken to distribute the patient load during peak hours, improve lead times and compensate for unexpected problems. The department has experienced a healthy increase of revenue over the years yet the number of procedures per year has been fairly consistent. This is because there is only one machine for MRI and CT Scan each. Other factors contributing to such performance are the premium price-tag of radiology procedures, extraordinary waiting time, low referrals from physicians and priority status of emergency patients over those with appointments.

ForewordBefore starting the report formally, the team would like to outline the series of events during the course of the project. Work on the MBA Project started off early in Fall Semester of 2011 with a debriefing from the coordinators. They explained the significance of the project, the purpose it served both academically and in job placements as well as the problems the students of previous batches had encountered. The students were then required to form their groups. At the same time, our coordinators and faculty members were approaching various companies for getting projects. The team selection was based on a number of factors with the most obvious being the instant chemistry the members shared from the beginning of our MBA program. The team had experience studying in groups together and also shared warm social ties. Another key reason why the group formation made sense was what each member brought to the team; each had a unique work experience and academic interest. Therefore, the cumulative skill set of the group was highly diversified. After the team finalization, the next step was to select a project. Projects brought by the coordinators were from both blue-chip and local companies and also ranged in disciplines. Project selection followed the free market mechanism. Both the client and the student group had to mutually agree to work with each other. Hence appointments were setup with clients whose projects interested the group.The student teams first meeting was with Aga Khan University Hospitals Radiology Team. The synergy between the two groups was instant. The AKUH team had great enthusiasm for the project and the student team was equally intrigued by the possibility of working with one of the most prominent organizations in the country. Both the student team and AKUH would later court several other prospects but none would compare to the interaction the two had had with each other. What fascinated the student group about the AKUH Radiology project was that it was multifaceted in nature. It had a combination of operations management, finance and marketing and it allowed the student group the opportunity to observe a small but integral part of the Radiology Departments operations in its totality. During this time, the team had also finalized its advisor Dr. Shahid Qureshi.The project started off with the development of Terms of Reference a set of guidelines for the project and a roadmap for the student team. This document outlined the project deliverables, the responsibilities of both the client and the student team and a brief description of the business concepts to be used. This document was finalized and approved by December 2011. The New Year started with grunt work on the project. The team was introduced to the staff and the managers of different areas. Special security badges were made so that the team members had 24-hour access to the facilities. A few weeks were spent observing the information flow and business process. Data-mining was being done simultaneously with AKUH team openly sharing the procedures operational data. Off-the-premises, the team devised research tools for patients survey and time motion study. Haris contacted his Professor of Operations from SEM Tsinghua, Mr. David Robb, who recommended the Quinte Case for the student teams reference. Development of Feedback survey requires focus groups with representatives of the target population. However, it was not possible to get AKUH doctors in the same room at the same time due to the massive daily workload. The team had to resort to secondary sources to devise the feedback form. The team frequently sought Mr. Asad Ilyas help for the financial aspects of the project. He was adamant that the team should capture the cost drivers of the procedures. He thought it would help the team to suggest better pricing strategies. However, upon discussing the proposition with Mr. Syed Sohail, Senior Manager Radiology Department, the team realized that capturing costs of healthcare provider is a complete project within itself. Syed Sohail is an alumnus of Institute of Business Administration. The team then sought the coordinators permission to pursue a revenue model. Field work started from February and went well into April. This included the time-motion study and patient feedback of the patients. The team had an interim presentation during the 2nd week of February with the coordinators on project progress. The coordinators guided the team regarding the report format and future direction. It was at this juncture that Mr. Asad Ilyas decided to become the teams advisor. Compilation of data, analysis and reporting started in May. The feedback from physicians could not be collected because the survey form design was not reviewed and approved by AKUH team. There was frequent interaction with the coordinators during this phase with changes being made in the report according to their guidance. The final report submission and presentation took place on 21st July, 2012.

Executive SummaryAga Khan University Hospital has been expanding its facilities since 2008 to cater to the increase healthcare services demand. This has resulted in an increase in patient load on all allied departments such as radiology, laboratory etc. The Emergency Room capacity has been increased by 100% with plans to increase in-patient capacity by 20% by the year end. The department of Radiology has plans to install additional units of MRI and CT Scan Machines by the end of 2012. The student project is multifaceted in nature touching on operations, finance and marketing disciplines. Following are the research objectives: Recommend ways to maximize capacity utilization of existing set-up and highlight areas of improvement in operational practices Recommend ways to increase the number of referrals from AKUH-based physicians and outside referrals from physicians Develop differential pricing strategy to increase patient footprint using revenue modelsThe project methods include Team Interviews, Data Mining, Observation of Work Practice, Scheduling and Queuing, Time and Motion Study, Patient Survey and Sensing. Following are the conclusions of the study: Many interdependencies and a general lack of coordination were observed in MRI and CT Scan operations. Machine Idle time was not being monitored especially in MRI procedures. Operational Staff was reluctant to schedule appointments after 7 pm. Data generated from the operations was not used for sophisticated reporting. Complexity of the procedures prevents the modeling of an individual procedures cost. Unlike the rest of the healthcare industry, AKUH does not market directly to the end patient using mass media. MRI and CT Scan procedures are among the most expensive procedures in the country. Patients generally do not fully understand and appreciate the quality of the hospitals services. Doctors generally do not tend recommend AKUH Radiologys services. Unethical practices in the healthcare industry has some impact AKUHs revenue stream. Following are the recommendations of the study:1. Forge Strategic Partnerships with other businesses such as banks and social clubs. This will improve the laboratorys visibility in the eyes of the end patient, update them on the departments activities and provide them payment solutions. 2. Introduce Online Reporting for Customer Convenience. This is a value added service where the patients will not have to come back to receive their test reports. 3. Hire independent anesthetist to eliminate interdependencies and recruit separate staff for co-ordination. This will streamline the departments processes through improved exchange of information and reduced dependencies.4. Train staff on soft skills and corporate identity through Capacity Building and Mentoring. This is a key recommendation which will result in visible difference in other initiatives. It will inculcate a sense of ownership and improve the departments culture. 5. Schedule procedures based on the queuing model. The queuing model takes into account the patient type. Through patient consent, appointments can be given in a manner that ensures utilization in the off-peak hours as well as reduces the waiting time of the customers. 6. Introduce performance-based incentives. This is meant to motivate the staff even further through extrinsic rewards. 7. Increase seating capacity in the waiting area and provide free Wi-Fi service or establish information booth. These initiatives are meant to improve the customers waiting experience.8. Introduce differential pricing model and offer discounts through Loyalty Cards and discounts based on the frequency of procedures. This will improve the departments image in terms of the prices it charges for its procedures and also develop a sense of loyalty among the customers.

Chapter 1 Project Introduction

1.1 Aga Khan University HospitalAga Khan University Hospital (AKUH) started its operations in 1985. It is a philanthropic, non-profit, private teaching institution committed to providing the best possible option for diagnosis of disease and team management of patient care. AKUHs multidisciplinary approach to diagnosis and care ensures a continuum of safe and high-quality care for patients all services under one roof. The University Hospital provides high quality patient care in a broad range of secondary and tertiary services to over 50,000 hospitalized patients and to approximately 600,000 outpatients annually. AKUH remains a differentiated provider in the field of healthcare. It has continued to excel because it provides quality services and is keen to innovate. (Aga Khan University)Following are some of the key highlights of the University Hospitals accomplishments: AKUH is the first hospital in Pakistan to be awarded US Joint Commission International accreditation (JCIA) for achieving and maintaining the highest international quality standards in health care. AKUH is the first hospital in Pakistan to receive ISO 9001:2008 certification for patient care and support services and ISO 22000:2005 certification for specialized food safety standards. It is the only hospital that has a network of over 190 Laboratory Specimens Collection Units across Pakistan and Afghanistan. The hospital performs over 7 million clinical laboratory tests performed. It is the only hospital in Sindh where over 120 patients diagnosed with hearing impairment have received their Cochlear Implant. It has performed over 140 Bone Marrow Transplant (BMT) which were carried out by highly skilled oncologists and haematologists with excellent outcomes to date. AKUH is only hospital in the Province to offer Corrective Heart Surgery for Children and Newborns with Congenital Heart Defects. Doctors appointment can be booked 24 hours a day, 7 days a week for clinics at the main hospital and Clifton Medical Services. It has a 24-hour Drug and Poison Information Centre providing the most updated information regarding medicines and their use and poison management.

1.2 Patient TypesThe patients can be categorized into three main categories:1.2.1 Emergency PatientsThese patients have priority status. They can arrive at any time and are accommodated immediately for any procedure. These patients may or may not be In-patients and maybe asked to spend time in the hospital depending on the post-procedure state of their condition.1.2.2 In-PatientsThese are the patients that have already been admitted to the hospital. Their state may allow scheduling flexibility. 1.2.3 Out-PatientsThese are patients that come in for procedures specified by AKUHs doctors. These patients can be divided into two further categories: Patients with prior appointments Patients without any appointment (walk-ins)

Figure 1.1 Patient Types

1.2.4 Outside Referrals (OSRs)These are patients that come in for procedures specified by doctors outside AKUH. These patients can be divided into two further categories: Patients with prior appointments Patients without any appointment (walk-ins)

1.3 Department of RadiologyThe Department of Radiology offers 24/7 services that cater to the needs of inpatients, outpatients and outside referrals by providing the best possible and modern diagnostic facilities in main Radiology (AKUH) and in off-campus facility of Clifton Medical Services (CMS). It also provides services to French Medical Institute for Children (FMIC), Kabul, Afghanistan through Tele-radiology. The Department is certified by the Pakistan Nuclear Regulatory Authority (PNRA) working under the regulatory requirements of International Atomic Energy Agency (IAEA). On an international level, the Departments practices are certified by JCIA and ISO 9001: 2008. For quality assurance and radiation safety, regular audits and inspections are conducted by PNRA. The Department caters to approximately 18,000 patients a month. It is fortified with a team of Radiologists, Research faculty, Medical Physicists, trained/ licensed Radiographers, Management Teams, Support Staff including receptionists, filing clerks, transcriptionists, porters and secretaries. (Aga Khan University)The departments service portfolio includes: General / Special Radiography Fluoroscopy Ortho-pantomography and Cephalometry Ultrasound Color Doppler CT Scan (64 Slice[footnoteRef:3]) [3: Explained Under Computerized Tomography]

MRI (1.5 Tesla, 18 Channel, with Cardiac imaging applications, Cardiac MRI and CTA[footnoteRef:4]) [4: Computerized Tomographic Angiography]

Cerebral Coiling Whole Body Scanning Vascular Angiography Hepatobiliary Urologic, Neuro Intervention Digital Subtraction Angiography Nuclear Medicine Bone Densitometry Interventional Radiology Paediatric Radiology Women Imaging (Mammography/ Mammotome) Dexa Scan The department has transitioned into fully digitalized radiology and is now equipped with Picture Archiving and Communicating System (PACS). The General radiography procedures inclusive of IVP[footnoteRef:5] and Flouro are carried out on Computed Radiography System (CR) and Digital Retrofit (DR) which has minimized the patient waiting time, radiation dose, report turnaround time, film rejection rate, film loss and increased throughput. (Aga Khan University) [5: Intravenous Pyelogram]

1.4 Magnetic Resonance ImagingMagnetic resonance imaging (MRI), nuclear magnetic resonance imaging (NMRI), or magnetic resonance tomography (MRT) is a medical imaging technique used in radiology to visualize detailed internal structures. MRI makes use of the property of nuclear magnetic resonance (NMR) to image nuclei of atoms inside the body.An MRI machine uses a powerful magnetic field to align the magnetization of some atomic nuclei in the body, and radio frequency fields to systematically alter the alignment of this magnetization. This causes the nuclei to produce a rotating magnetic field detectable by the scannerand this information is recorded to construct an image of the scanned area of the body. 36 Magnetic field gradients cause nuclei at different locations to rotate at different speeds. By using gradients in different directions 2D images or 3D volumes can be obtained in any arbitrary orientation.MRI provides good contrast between the different soft tissues of the body, which makes it especially useful in imaging the brain, muscles, the heart, and cancers compared with other medical imaging techniques such as computed tomography (CT) or X-rays. Unlike CT scans or traditional X-rays, MRI does not use ionizing radiation. (William C. Shiel Jr.)

1.5 Computerized TomographyComputerized (or computed) tomography (CT Scan), formerly referred to as computerized axial tomography (CAT) scan, is an X-ray procedure that combines many X-ray images with the aid of a computer to generate cross-sectional views and, if needed, three-dimensional images of the internal organs and structures of the body. Computerized tomography is more commonly known by its abbreviated names, CT scan or CAT scan. A CT scan is used to define normal and abnormal structures in the body and/or assist in procedures by helping to accurately guide the placement of instruments or treatments.A large donut-shaped X-ray machine or scanner takes X-ray images at many different angles around the body. These images are processed by a computer to produce cross-sectional pictures of the body. In each of these pictures the body is seen as an X-ray "slice" of the body, which is recorded on a film. This recorded image is called a tomogram. "Computerized axial tomography" refers to the recorded tomogram "sections" at different levels of the body.The body, as seen on CT scan slices from the skin to the central part of the body being examined, can be further "added" together to get a three-dimensional picture of an organ or abnormal body structure. Following are some facts about the procedure: CT scanning adds X-ray images with the aid of a computer to generate cross-sectional views of anatomy. CT scanning can identify normal and abnormal structures and be used to guide procedures. CT scanning is painless. Iodine-containing contrast material is sometimes used in CT scanning (Melissa Conrad Stppler).

1.6 Project PremiseAKUH has been expanding its facilities for the past 3 years. The Emergency Room capacity has been doubled. Current plans in the work also include increasing the volumes of internal clinics. The volume of In-patients is also rising. The department of radiology also has expansion plans in the works with additional machines for MRI and CT Scan (1 each) arriving by the end of 2012. The Department of Radiology has also been recording increasing revenues on an annual basis. Yet the number of MRI and CT Scan procedures per year have been fairly consistent in the last 3 years. A number of factors contributing to this stagnancy have been identified by the AKUH Radiology Team. Following are some key reasons: There is only one machine for MRI and CT Scan each. The price tag of AKUHs services makes it difficult to attract patients on its own. Out-patients from the clinics and walk-in patients are not fully catered. Emergencies require pushing the scheduled procedures back and patients with appointments end up waiting longer. Recommendations of physicians to other facilities on account of prices and some unclassified unethical practices. AKUH Radiology Department has state-of-the-art facilities and high qualified field staff[footnoteRef:6]. Yet the patients do not seem to value the departments proposition. The waiting time seems to compound the dissatisfaction from the high prices. [6: Radiologists and Technologists]

Chapter 2 Literature Review

2.1 Case Study Quinte MRI2.1.1 SummaryQuinte MRI is a small service provider of medical diagnostic technologies. After just six weeks in operation at a medical centre, the company developed an extensive waiting list, and physicians began referring patients to competing facilities. Quinte MRI's business development coordinators must provide recommendations and an action plan to deal with this process and productivity problem in a setting with extreme variability. (Carol Prahinski, 11/30/2009)2.1.2 IssuesBottlenecks; Scheduling; Process Analysis; Capacity Analysis2.1.3 SettingUnited States, Small-Medium Enterprise, 20022.1.4 SolutionThe solution to these issues lies in regaining control of the scheduling process as this is an integral part of the operations. Streamlining the scheduling process to reduce variability and improve reliability is required here. The company needs to introduce the use of technology to remove manual processes, improve process efficiencies, minimize errors and improve communication across the business lines of operation. Hiring a new employee is also recommended to support the scanning operations as there is no backup or adequately trained support for the only technologist running the operations.

2.2 Course Manual for Operations Management2.2.1 SummaryIt is a course manual taught in university of Auckland and also at the SEM Tsinghua. Their MBA programs provide hands on learning on basic principles of scheduling such as demand forecasting, queuing theories, sampling data and other operation concepts such as bottlenecks and demand vs. capacity management. (Robb, 2011)2.3 Other Literary MaterialFollowing is the list of literature reviewed during the course of this project: Marketing Research: An Applied Orientation (2009), 6th edition, by Naresh K. Malhotra & Satyabhusan Dash Chapter 8 - Work Measurement from Operations Management (2006), 5th edition, by Russell & Bernard W. Taylor, III The Costs of CT Procedures in an Academic Radiology Department Determined by an Activity-Based Costing (ABC) Method (2000) by Nisenbaum, Harvey L.; Birnbaum, Bernard A.; Myers, Melissa M.; Grossman, Robert I.; Gefter, Warren B.; Langlotz, Curtis P.

Chapter 3 Research Objectives, Methods, Tools and Limitations

3.1 ObjectivesThe project is multi-tiered in nature. It primarily deals with the optimization of MRI and CT Scan Procedures at AKUH Radiology Department; however, achieving it requires deeper probing into the departments finances, operations and marketing. Following are the key objectives of the project:3.1.1 Operations Recommend measures to maximize capacity utilization of existing set-up through queuing model and time-motion study Highlight key areas for improvement in operational practices.3.1.2 Marketing Recommend measures to increase the number of referrals from AKUH-based physicians and outside referrals from physicians through feedback and suggestions.3.1.3 Finance Recommend differential pricing strategy to increase patient footprint using revenue models

3.2 Methods3.2.1 Team InterviewsThe student team spent ample time with the AKUH team before and after project finalization. During these meetings, candid discussion took place and the AKUH team readily shared information about their departments financial and operational performance, the underlying problems, organizational structure, costing methods, competitors actions and their codes of ethic. The information shared during these sessions helped the team build context of the project and identify the areas of focus for studying. 3.2.2 Data MiningThe AKUH team was kind enough to share operational and finance data related to the MRI and CT Scan procedures. These included: Budget Variance Report of each modality for the last 5 years. Price Lists for MRI and CT Procedures with their subcategories[footnoteRef:7] along with the proposed price list for 2012. [7: Price of each procedure varies with the body part being studied and procedural requirements such as anesthesia and contrast. ]

Operational Logs Monthly Volumes of Procedures performed along with the referring source Yearly Volume Breakdown of Patients into In-patients and Outpatients for 2011.3.2.3 Observation of Work Practice3.2.3.1 Scheduling and QueuingScheduling was assessed by taking multiple observations of patients arrivals, during different times of the day. This data was compared with the operational logs of the department to check for variance. Average waiting time and queue size were determined and effective changes in scheduling appointments have been devised. 3.2.3.2 Time and Motion StudyTo assess the average time of the processes specific to MRI and CT procedures, the student team conducted time and motion study for selected procedures based on their frequency. Time and Motion study involves breaking down of processes into simpler sub-tasks and assessing their efficiency through timing. This allowed the student team to highlight specific hindrances such as interdepartmental dependencies, employee productivity and various other issues. The method used to calculate the Standard Minute Value comprises of following steps:i) Establish Standard Job Stepsii) Break down that certain procedure into small elementsiii) Time the elements and take several observationsiv) Rate the Operator[footnoteRef:8] [8: Not applicable to MRI and CT Scan Machines. ]

v) Calculate the average timevi) Calculate standard time i.e. the product of average time & rate at which operator is performingvii) Compute the Standard Minute Value or Standard time i.e. Normal time * (1+Total Allowance time)[footnoteRef:9] [9: Formula applicable to Operator based machines only. Therefore, it is not applicable to MRI and CT machine. ]

3.2.4 Patient SurveyTo determine the perception of patients regarding their experience of MRI and CT procedures, the student team formulated a comprehensive survey questionnaire. 3.2.5 SensingThe team spent a significant amount of time in the waiting area during the time-motion study. This gave them the opportunity to informally interact with patients who were waiting in the lounge. Patients were not told about the nature of the project and they were casually asked about their overall experience of AKUH services. While collecting patient survey, the team members were frequently moving across the MRI and CT scan departments. This allowed the team to observe incognito the procedures being performed from an operational perspective. On occasions when the feedback was being gathered in the procedure areas, one team member would record observations of idle time and average lead time.

3.3 Research Tool Design3.3.1 Patient SurveyThe questionnaire comprised of following sections: Ease of getting care Waiting time Behaviour of staff Overall outlook of facility Price structure Post test experience Future referrals. Each section has four to five questions to assess the respondents perceptions. All questions are closed ended and based on five-point Likert scale[footnoteRef:10] which allows to record reliable responses and reduces the variability in the results. Another benefit is the minimization of errors in analyzing and interpreting data. [10: Based on a scale of 1 to 5; 5 being strong agreement or excellent and 1 being strong disagreement or very poor.]

We have employed traditional approach i.e. sampling without replace. In addition to that cross sectional technique has been applied. Sample size is 200 respondents.See Exhibit 1- Survey Form for Patients Perception3.3.2 Time-Motion StudyA specific format was developed for Time-Motion Study of MRI and CT Procedures which breaks down the entire process into the following elements: Approach to counter Registration Payment Waiting Time History Declaration form (In case of MRI) Changing room Waiting Time ProcedureObservations are recorded in minutes. Convenience sampling technique has been used.Total 28 MRI and 28 CT Scan procedures have been studied to get accurate approximation of Standard Minute Value.

3.4 LimitationsFollowing are the limitations of the student project:3.4.1 Marketingi) The student team could not conduct a focus group with patients and doctors before research tool development.[footnoteRef:11] [11: Getting patients for a focus group would have required going through AKUHs Ethics Committee and AKUH Doctors could not be spared due to the workload.]

ii) In many instances, responses were collected from the attendees of the patients undergoing the procedures.iii) Doctors Survey could not be conducted as the feedback form was not approved in time. iv) The patient survey of the patients does not take into account following their demographics or patient type (In-patient, out-patient, emergency)v) Sample Size was reduced to 150 from the initial estimate of 200 due to time shortage. 3.4.2 Operationsi) Time-Motion Study does not take into account the multiple entrances to the radiology floor and multiple service desks. ii) Convenience sampling was adopted and highest occurrence procedures were studied for Time-motion study. This is because there are many subcategories of MRI and CT scan procedures depending on the body part being studied. Each procedure has different time durations and level of medical staff/patients preparation. 3.4.3 Financei) The differential pricing strategy does not take into account the cost drivers[footnoteRef:12]. [12: Identifying cost drivers is a massive undertaking as it required going beyond the scope of procedures to include the departments and eventually the entire hospitals costing. ]

Chapter 4 Data Collection and Analysis

4.1 Observations4.1.1 Patient SurveyEach table represents responses to a question on the survey form.[footnoteRef:13] [13: See Exhibit 1 - Survey Form for Patients Perception]

4.1.1.1 Ease of Getting CareTable 4.1 - Ease of scheduling your exam

ResponseFrequency%

Poor1812

Fair1711.3

Good2214.7

Very Good6543.3

Excellent2818.7

Total150100

Figure 4.1 Ease of scheduling your exam[footnoteRef:14] [14: LEGEND: 1 Excellent; 2 Very Good; 3 Good; 4 Fair; 5 Poor]

Most of the respondents found it easy to schedule their examination for CT scan and MRI. But about 38% did not find the process to be easy.Table 4.2 - Courtesy of receptionist answering telephone calls

ResponseFrequency%

Fair21.3

Good1711.3

Very Good5939.3

Excellent7248

Total150100

Figure 4.2 Courtesy of receptionist[footnoteRef:15] [15: LEGEND: 1 Excellent; 2 Very Good; 3 Good; 4 Fair; 5 Poor]

There was not a single respondent who complained about the receptionist being impolite or rude. It has been rated excellent in general.

Table 4.3 - Hours imaging center is open

ResponseFrequency%

Fair74.7

Good3624

Very Good2516.7

Excellent8254.7

Total150100

Figure 4.3 Imaging Center Hours[footnoteRef:16] [16: LEGEND: 1 Excellent; 2 Very Good; 3 Good; 4 Fair; 5 Poor]

About 95% of the respondents generally found the imaging hours to be excellent, very good or good. There was not a single patient who considered it to be poor.

Table 4.4 - Convenience of imaging center's location

ResponseFrequency%

Poor21.3

Fair2416

Good3120.7

Very Good2516.7

Excellent6845.3

Total150100

Figure 4.4 Imaging Centers Location[footnoteRef:17] [17: LEGEND: 1 Excellent; 2 Very Good; 3 Good; 4 Fair; 5 Poor]

About 72% of the respondents found it very convenient to locate the imaging center where as only 1.2% of the respondents found it difficult to locate the imaging center.

Table 4.5 - Parking space & distance to the clinic

ResponseFrequency%

Poor7550

Fair2416

Good2114

Very Good138.7

Excellent1711.3

Total150100

Figure 4.5 - Parking space & distance[footnoteRef:18] [18: LEGEND: 1 Excellent; 2 Very Good; 3 Good; 4 Fair; 5 Poor]

Only 34% of the respondents considered parking space and distance to the clinic to be convenient while the rest 66% did not.

4.1.1.2 Waiting TimeTable 4.6 - Time in waiting room

ResponseFrequency%

Poor5838.7

Fair3724.7

Good2416

Very Good2516.7

Excellent64

Total150100

Figure 4.6 Time in the Waiting Room[footnoteRef:19] [19: LEGEND: 1 Excellent; 2 Very Good; 3 Good; 4 Fair; 5 Poor]

Most respondents (38.7%) considered the time in waiting room to be high. However, only 5% considered it to be excellent.

Table 4.7 - Waiting Time for test to be performed

ResponseFrequency%

Poor4026.7

Fair4328.7

Good1812

Very Good3221.3

Excellent1711.3

Total150100

Figure 4.7 Waiting Time[footnoteRef:20] [20: LEGEND: 1 Excellent; 2 Very Good; 3 Good; 4 Fair; 5 Poor]

Most of the respondents considered the waiting time for the test to be high as 55% of them considered it to be either fair or poor. Only 11.3% considered it to be excellent.

Table 4.8 - Overall waiting time in imaging center

ResponseFrequency%

Poor6845.3

Fair2416

Good2214.7

Very Good2818.7

Excellent85.3

Total150100

Figure 4.8 Waiting Time in the Imaging Center[footnoteRef:21] [21: LEGEND: 1 Excellent; 2 Very Good; 3 Good; 4 Fair; 5 Poor]

The respondents considered the overall time in the imaging center to be very high as more than 60% of them considered it either fair or poor while only 5.3% rated it to be excellent.4.1.1.3 Staff (Receptionists, Technologists, Radiologists)Table 4.9 - Courtesy of office staff

ResponseFrequency%

Poor10.7

Fair53.3

Good1912.7

Very Good4932.7

Excellent7650.7

Total150100

Figure 4.9 Courtesy of Staff[footnoteRef:22] [22: LEGEND: 1 Excellent; 2 Very Good; 3 Good; 4 Fair; 5 Poor]

The courtesy of the office staff was generally rated as very high. About 83.4% of the respondents considered it to be either excellent or very good while only 0.7% considered it to be poor.

Table 4.10 - Due attention given

ResponseFrequency%

Poor21.3

Fair64

Good3120.7

Very Good7348.7

Excellent3825.3

Total150100

Figure 4.10 - Parking space & distance[footnoteRef:23] [23: LEGEND: 1 Excellent; 2 Very Good; 3 Good; 4 Fair; 5 Poor]

Respondents generally felt that the level of attention given to them was very encouraging as 64% rated it to be either very good or excellent while only 1.3% rated it as poor.Table 4.11 Staff satisfied queries

ResponseFrequency%

Poor21.3

Fair64

Good3523.3

Very Good5335.3

Excellent5436

Total150100

Figure 4.11 Staff satisfied queries[footnoteRef:24] [24: LEGEND: 1 Excellent; 2 Very Good; 3 Good; 4 Fair; 5 Poor]

Majority of the respondents felt that proper instructions were given to them during the course of the procedure. 36% rated the staff as excellent whereas 35.3% rated them as very good on this attribute.

Table 4.12 - Good advice and treatment

ResponseFrequency%

Poor10.7

Fair42.7

Good3422.7

Very Good6342

Excellent4832

Total150100

Figure 4.12 - Good advice and treatment [footnoteRef:25] [25: LEGEND: 1 Excellent; 2 Very Good; 3 Good; 4 Fair; 5 Poor]

74% of the respondents rated the advice given by the staff as excellent or very good.

Table 4.13 Staff being friendly and helpful

ResponseFrequency%

Poor10.7

Fair74.7

Good2718

Very Good4026.7

Excellent7550

Total150100

Figure 4.13 Staff being friendly and helpful[footnoteRef:26] [26: LEGEND: 1 Excellent; 2 Very Good; 3 Good; 4 Fair; 5 Poor]

Respondents are generally happy with the attitude of the staff with 76.7% rating it as either excellent or very good.

Table 4.14 Staff answered your questions

ResponseFrequency%

Poor21.3

Fair64

Good3120.7

Very Good3926

Excellent7248

Total150100

Figure 4.14 Staff answered your questions[footnoteRef:27] [27: LEGEND: 1 Excellent; 2 Very Good; 3 Good; 4 Fair; 5 Poor]

Respondents were satisfied with the staff in terms of having their queries addressed. 48% of the respondents rated the staff as excellent for this question.

4.1.1.3 FacilityTable 4.15 - Neat and clean waiting room

ResponseFrequency%

Fair106.7

Good3020

Very Good5436

Excellent5637.3

Total150100

Figure 4.15 - Neat and clean waiting room[footnoteRef:28] [28: LEGEND: 1 Excellent; 2 Very Good; 3 Good; 4 Fair; 5 Poor]

Generally, the respondents considered the waiting area to be very neat and clean as almost about 75% of the respondents rated it to be either very good or excellent.Table 4.16 - Comfort and safety while waiting

ResponseFrequency%

Poor1.7

Fair53.3

Good2718.0

Very Good4832.0

Excellent6946.0

Total150100.0

Figure 4.16 - Comfort and safety while waiting [footnoteRef:29] [29: LEGEND: 1 Excellent; 2 Very Good; 3 Good; 4 Fair; 5 Poor]

A vast majority of respondents felt that the level of comfort and safety in the waiting area is highly commendable

Table 4.17 Cleanliness of the Washrooms

ResponseFrequency%

Poor106.7

Fair2516.7

Good5033.3

Very Good3825.3

Excellent2718

Total150100

Figure 4.17 Cleanliness of the Washrooms [footnoteRef:30] [30: LEGEND: 1 Excellent; 2 Very Good; 3 Good; 4 Fair; 5 Poor]

The majority of the respondents had a positive opinion to the above question. 33.3% responded that the condition of the bathrooms was good. 43.3% rated it as either excellent or very good and the rest rated it as poor or below standard.Table 4.18 Privacy

ResponseFrequency%

Poor74.7

Fair2214.7

Good3422.7

Very Good3523.3

Excellent5234.7

Total150100

Figure 4.18 Privacy [footnoteRef:31] [31: LEGEND: 1 Excellent; 2 Very Good; 3 Good; 4 Fair; 5 Poor]

Majority of Respondents think that they have privacy while the tests are being performed, while a very few have the opposite view.4.1.1.5 Pricing StructureTable 4.19 - MRI and CT Scan Prices are market competitive

ResponseFrequency%

Strongly Disagree5536.7

Disagree5334.7

Neutral2416

Agree85.3

Strongly Agree106.7

Total150100

Figure 4.19 - MRI and CT Scan Prices are market competitive [footnoteRef:32] [32: LEGEND: 1 Strongly Disagree; 2 Disagree; 3 Neutral; 4 Agree; 5 Strongly Agree]

More than 70% of the respondents think that the prices charged are not market competitive. There were very few who felt it was otherwise.

Table 4.20 - Prices are justified

ResponseFrequency%

Strongly Disagree7952.7

Disagree4228

Neutral2315.3

Agree42.7

Strongly Agree21.3

Total150100

Figure 4.20 - Prices are justified [footnoteRef:33] [33: LEGEND: 1 Strongly Disagree; 2 Disagree; 3 Neutral; 4 Agree; 5 Strongly Agree]

There was a strong consensus among the vast majority that the prices charged are not just.

Table 4.21 - Preference for an alternative with lower price

ResponseFrequency%

Strongly Disagree5637.3

Disagree1812

Neutral2617.3

Agree2214.7

Strongly Agree2818.7

Total150100

Figure 4.21 - Preference for an alternative with lower price [footnoteRef:34] [34: LEGEND: 1 Strongly Disagree; 2 Disagree; 3 Neutral; 4 Agree; 5 Strongly Agree]

When asked if the respondent would prefer an alternative with lower price, almost 50% declined. 34% said that they would prefer an alternative with lower prices.

4.1.1.6 Post TestTable 4.22 - Timely Delivery of the results

ResponseFrequency%

Strongly Disagree96

Disagree32

Neutral1610.7

Agree5234.7

Strongly Agree7046.7

Total150100

Figure 4.22 - Timely Delivery of the results [footnoteRef:35] [35: LEGEND: 1 Strongly Disagree; 2 Disagree; 3 Neutral; 4 Agree; 5 Strongly Agree]

In response to above statement, almost 47% strongly agreed, 35% agreed, 11% were neutral, and only 8% replied in denial.

Table 4.23 - Ease in collecting results

ResponseFrequency%

Strongly Disagree10.7

Disagree21.3

Neutral149.3

Agree6543.3

Strongly Agree6845.3

Total150100

Figure 4.23 - Ease in collecting results[footnoteRef:36] [36: LEGEND: 1 Strongly Disagree; 2 Disagree; 3 Neutral; 4 Agree; 5 Strongly Agree]

When asked about the ease of collecting results, the responses of majority of respondents were highly satisfactory and a very few were of the opposite view.

Table 4.24 -Staffs guidance for setting an appointment

ResponseFrequency%

Disagree42.7

Neutral2013.3

Agree5637.3

Strongly Agree7046.7

Total150100

Figure 4.24 -Staffs guidance for setting an appointment 1[footnoteRef:37] [37: LEGEND: 1 Strongly Disagree; 2 Disagree; 3 Neutral; 4 Agree; 5 Strongly Agree]

In response to above question, almost 47% respondents strongly agreed, 38% agreed, 14% replied in neutral and only 3% disagreed

Table 4.25 Post-Test Privacy

ResponseFrequency%

Disagree96

Neutral3422.7

Agree4328.7

Strongly Agree6442.7

Total150100

Figure 4.25 - Post Test Privacy[footnoteRef:38] [38: LEGEND: 1 Strongly Disagree; 2 Disagree; 3 Neutral; 4 Agree; 5 Strongly Agree]

When respondents were asked whether they have post test privacy while discussing their case with the concerned person, almost 43% respondents strongly agreed and 29% respondents agreed, 23% were indifferent and only 6% respondents disagreed.

4.1.1.7 Referral Table 4.26 Recommending Radiology Services to Others

ResponseFrequencyPercent

Strongly Disagree2013.3

Disagree42.7

Neutral1510

Agree3926

Strongly Agree7248

Total150100

Figure 4.26 - Recommending to others[footnoteRef:39] [39: LEGEND: 1 Strongly Disagree; 2 Disagree; 3 Neutral; 4 Agree; 5 Strongly Agree]

As many as 48% respondents strongly agreed & 26% agreed with the idea of recommending these diagnostic services to others; 10% were indifferent and only 13.3% respondents strongly disagreed with this statement.4.1.2 Time-Motion Study4.1.2.1 MRISee Exhibit 2- Process Map for MRI Procedure.See Exhibit 3- Time-Motion Study Observations for MRI Procedure (in minutes)

Following is a summary of the Time-Motion Study Observations for MRI. Table 4.27 MRI Time-Motion Study Summary (in minutes)[footnoteRef:40] [40: Avg OT = Average Operation Time; Total NT = Total Net Time, Rating = for assigning handicap to operator (Kept constant at 100%); Allowance = Tolerance]

Approach to counterRegistrationPaymentWaitHistoryDeclaration formChanging roomWaitProcedure

Avg OT3.433.212.6191.143.752.299.8911.2538.18

Rating1.001.001.001.001.001.001.001.001.00

Total NT3.433.212.61913.752.299.8911.2538.18

No. Observations282828282828282828

% Allowance1.051.101.051.101.101.101.101.101.10

Standard Time3.603.542.741004.132.5110.8812.3842.00

Total Standard Time (Sum of standard time for all elements) = 182.02 minutesTotal Time in Hours = 3.03

4.1.2.2 CT ScanSee Exhibit 4- Process Map for CT Scan Procedure.See Exhibit 5 - Time-Motion Study Observations for CT Scan Procedure (in minutes)Following is a summary of the Time-Motion Study Observations for CT Scan.

Table 4.28 CT Scan Time-Motion Study Summary (in minutes)[footnoteRef:41] [41: Avg OT = Average Operation Time; Total NT = Total Net Time, Rating = for assigning handicap to operator (Kept constant at 100%); Allowance = Tolerance]

Approach to counterRegistrationPaymentWaiting timeHistoryWaitProcedure

Avg OT3.075.182.1447.5010.434.716.71

Rating1.001.001.001.001.001.001.00

Total NT3.075.182.144810.434.716.71

No. Observations28282828282828

% Allowance1.051.051.051.051.051.051.05

Standard Time3.235.442.255010.954.957.05

Total Standard Time (sum standard time for all elements) = 83.74 minutesTotal Time in Hours = 1.40

4.1.3 Scheduling and Queuing4.1.3.1 MRIFollowing observations are in minutes. Table 4.29 MRI Average IDLE time during the day[footnoteRef:42] [42: It should be noted that Machine utilization is maximum during 9:00 am to 6:00 pm. The Machine Idle time increases for one odd procedure in case anesthesia needs to be administered.]

Time of DayAvgsStdevQuad AvgQuad Avg StdevVariance

9AM-10AM9.51.909.231.873.61

10AM11AM10.11.522.32

11AM12PM8.12.184.77

12PM-1PM7.81.328.071.601.73

1PM-2PM8.11.662.77

2PM-3PM8.31.833.34

3PM-4PM102.878.873.308.22

4PM-5PM9.74.9024.01

5PM-6PM6.92.134.54

6PM-7PM12.83.4913.272.6712.18

7PM-8PM132.114.44

8PM-9PM142.405.78

9PM-10PM40.69.3058.7313.1786.49

10PM-11PM548.6574.89

11PM-12AM81.621.56464.93

Figure 4.27 - Average IDLE Time during the day (MRI)

4.1.3.2 CT ScanFollowing observations are in minutes.Table 4.30 CT Scan Average IDLE time during the day

Time of DayAvgsStedvQuad AvgQuad Avg StedveVariance

9AM-10AM5.21.755.831.803.07

10AM11AM6.51.722.94

11AM12PM5.81.933.73

12PM-1PM5.71.166.571.341.34

1PM-2PM6.81.482.18

2PM-3PM7.21.401.96

3PM-4PM7.11.796.802.013.21

4PM-5PM61.492.22

5PM-6PM7.32.757.57

6PM-7PM12.62.0111.272.724.04

7PM-8PM12.63.3110.93

8PM-9PM8.62.848.04

9PM-10PM103.4018.075.7211.56

10PM-11PM15.45.0625.60

11PM-12AM28.88.6975.51

Figure 4.28 - Average IDLE Time during the day (CT)4.3 Revenue ModelThe revenue model has been devised using prices charged per procedure and the number of procedures performed during the year 2011. It was further augmented by the average procedural time calculated during the operations study.This model takes into account factors such as total time the MRI and CT Machines were used, total time available since the major influx of patients occurs between 9AM to 7PM (Day time) and the sparse population of patients come between 6PM till 9AM (Night Time).Table 4.31 Revenue Distribution[footnoteRef:43] [43: Developed from Exhibits 6 through 12]

ProcedureRevenue in Rs.

CT194,552,330

MRI151,036,510

NM27,726,320

SPEC27,124,800

STD144,920,390

US143,750,090

VIR60,204,620

TOTAL Radiology Revenue749,315,060

Figure 4.29 - Revenue Distribution among Procedures4.3.1 MRI ModelMRI proportion20%

Total # of Procedures8351

Procedures performed during day (85%)7,098

Procedures performed during night (15%)1,253

Total RevenueRs. 151,036,510

Average time / procedure22.41

Total Time in Mins187138

Time spent in doing procedures during day159067.3

Time spent in doing procedures during night28070.7

Avg revenue / procedureRs. 18,086

Avg revenue / MinRs. 807.09

Total Minutes Available475200

Total Minutes Available Day198000

Total Minutes Available Night277200

Total Utilization (Time) Day80%

Total Utilization (Time) Night10%

Downtime (In minutes)

Downtime / Week (System restart etc)420

Patient related issue (metal etc) / week420

Misc Unavoidable lags420

Total Downtime / week1260

Total Downtime (Jan - Nov)55440

Estimated Capacity (Less Downtimes, Lags etc)

Estimated Capacity419760

Estimated Capacity (Day)174900

Estimated Capacity (Night)244860

Utilization (Estimated Capacity Day)91%

Utilization (Estimated Capacity Night)11%

1 % increase in capacity - increase in revenuesRs. 3,387,825

# Mins operational / month17012.54545

1 % increase in capacity / Month (In minutes)170

1% Increase in Capacity / Month (Procedures)7.59

1% Increase in Capacity / Month (Revenue)Rs. 137,306

4.3.2 CT Scan ModelCT Proportion26%

Total # of Procedures15555

Procedures performed during day (79%)12,288

Procedures performed during night (21%)3,267

Total RevenueRs. 151,036,510

Average time / procedure5.64

Total Time in Mins87653

Time spent in doing procedures during day69246

Time spent in doing procedures during night18407

Avg revenue / procedureRs. 9,710

Avg revenue / MinRs. 1,723.12

Total Minutes Available475200

Total Minutes Available Day198000

Total Minutes Available Night277200

Total Utilization (Time) Day35%

Total Utilization (Time) Night7%

Downtime (In minutes)

Downtime / Week (System restart etc)420

Patient related issue (metal etc) / week420

Misc Unavoidable lags420

Total Downtime / week1260

Total Downtime (Jan - Nov)55440

Estimated Capacity (Less Downtimes, Lags etc)

Estimated Capacity419760

Estimated Capacity (Day)174900

Estimated Capacity (Night)244860

Utilization (Estimated Capacity Day)40%

Utilization (Estimated Capacity Night)8%

1 % increase in capacity - increase in revenuesRs. 7,232,962

# Mins operational / month7968.454545

1 % increase in capacity / Month (In minutes)80

% Increase in Capacity / Month (Procedures)14.14

1% Increase in Capacity / Month (Revenue)Rs. 137,306

Chapter 5 Conclusions

Following are the conclusions of the research study. These conclusions have been drawn using the methods mentioned in Chapter 3. These gaps directly contribute to under-par yield of MRI and CT Procedures.5.1 Operations5.1.1 Interdependencies & Lack of CoordinationCertain MRI and CT procedures demand resources from other departments. For example, an infants MRI requires the patient to be sedated. This requires the presence of an Anesthetist. Moreover, if the patient is admitted in one of the wards (i.e. in patient), the patient will move to the radiology department only when the ward mobilizes him/her. Such interdependencies cause the most extensive delays disrupting the entire pre-assigned schedule like a domino effect. The patient may or may not be available on the scheduled time. The Anesthetist may not be available on time as well. 5.1.2 Lack of Monitoring of Idle timeIt has been observed that at times the machine is left idle i.e. it is not in operation. This is usually due to lack of coordination especially with the MRI in cases where anesthesia is required. While the staff waits on the anesthetist or the anesthetist administers the anesthesia to the patient and approves the procedure, the machine is idly waiting for the incoming patient. This results in both disrupting of the schedule and a loss in revenue as well.5.1.3 Scheduling of AppointmentsThe radiology department, like most other departments in the hospital, functions round the clock. The MRI and CT machines are operational 24-hours a day. Even though the machine is active throughout the day, it has been observed that the staff is conditioned to operate it during day time from 8AM to 7PM and they hesitate in issuing appointments beyond that time. This results in an influx of patients during the morning. Given the variability of the entire process, even minor delays in procedures cause a lot of scheduling issues; it eventually results in the patient being dissatisfied due to long waiting hours.

5.2 Finance5.2.1 Lack of Data AnalysisAKUH captures a significant quantity of data through their efficient Patient Management System. This data could easily be used for sophisticated analysis in order to identify areas of improvement. However, currently the data is being used for conventional reporting only such as total number of procedures, frequency etc. However it is not being used to track the number of conversions and other metrics that could help identify gaps. 5.2.2 Complexity of the proceduresEach one of the units i.e. MRI and CT has approximately 90 to 100 different procedures and there is very little uniformity among them[footnoteRef:44]. It is very difficult to develop a uniform costing model since each procedure might consume a different level of resources. One may take 20 minutes while the other may take over an hour; some require contrast dye to be administered, some require more time of the reporting radiologist, some require anesthesia. [44: Variation may be due to the body part being studied or the auxiliaries being used (contrasts, anesthesia). ]

Then there are the problems allocating fixed expenses such as electricity, depreciation, building costs etc. Without proper systems in place to determine accurate estimates of cost per procedure, the department cannot be certain about the procedure charge and how much discount can be offered.

5.3 Marketing5.3.1 Lack of innovative communicationsAKUH follows a strict code of conduct when it comes to its communication strategy. The hospital does not engage patients directly but markets its services through industry publications. The only conventional advertising can be seen around the hospital premises or the main road across its entrance. Given the variety of mediums available and the changing business dynamics, the hospital has been lagging in terms of engaging the patients directly. 5.3.2 Inappropriate pricingMRI and CT scan procedures at AKUH are among the most expensive in the country. This is the single biggest factor contributing to the loss of prospective patients. Infact, in some cases, the procedures at AKUH Radiology are 3 times as expensive as those at other laboratories[footnoteRef:45]. [45: Zia uddin Hospital]

5.3.3 Lack of patient understanding of the quality of serviceMajority of the patients tend to rate the quality of healthcare services based on the price and not in terms of the organizations performance. They fail to fully appreciate the competent team of radiologists and technologists, the resources and the environment at the departments disposal.5.3.4 Lack of Doctors recommendationsAKUH Radiology ranks quite low on doctors list of preferred services. It may be on account of the social class of patients they cater.

5.3.5 Unethical IssuesIssues of unethical practice in healthcare industry are widely known. Many physicians (outside of AKUH) tend to recommend specific medicine and laboratories and hospitals because of their prior arrangements with these businesses. AKUH does not indulge in such unethical practices. Still, the hospital on the whole does tend to lose revenue to such activities. Following is a cause-and-effect diagram of the problems and their reasons for Low Yield of MRI and CT Scan Procedures. This diagram has been determined through the respective methodologies employed for each function.

Figure 5.1 - Cause & Effect - Low YieldTable 5.1 - Conclusion Summary

AreaMethodGaps

OperationsTeam InterviewsData MiningScheduling and QueuingTime and Motion StudyTeam Members ExperienceSensingInterdependencies & Lack of Coordination

Lack of Monitoring of Idle time

Scheduling of Appointments

FinanceTeam InterviewsData MiningLack of Data Analysis

Complexity of the procedures

MarketingPatient SurveyTeam InterviewsSensingLack of innovative communications

Inappropriate pricing

Lack of patient understanding of the quality of service

Lack of Doctors recommendations

Unethical Issues

Chapter 6 Recommendations

Based on the above study, the student team has devised the following recommendations:6.1 Marketing6.1.1 Strategic PartnershipsThe department can explore the possibility of strategic partnerships options in the following areas:6.1.1.1 Price-Discount PartnershipsIt is common for service businesses to partner with banks and provide price discounts to the customers who use their credit cards. These banks are usually long-term or short-term creditors for the businesses. Transaction charge from credit cards contributes to the interest payments to the banks on behalf of the organization hence improving the debt repayment schedule. This trend has been observed in restaurants.AKUH Radiology department should look for such a strategic alliance with banks the hospital does business with. This would allow the department to provide the much needed price concession to the patient and help the organization in loan repayment. 6.1.1.2 Communication Partnerships Hospitals have been partnering with various social clubs of Karachi to leverage their periodic publication and advertise about their services. One example of such a strategic partnership is OMI Hospital and Dreamworld with the formers advertisement appearing in the latters monthly newsletters. Such communication tends to be under the radar and helps in targeting particular segments of the population.AKUH follows strict ethics when it comes to marketing to the patients. But the changing nature of healthcare business dictates that hospitals assure prospective patients about the quality of their services. Granted that being a healthcare provider, AKUH caters to patients regardless of their economic background, but this strategy specifically targets the segment of the population who are willing to pay any price and not compromise on the quality of healthcare. Such communication will serve the following purposes: Reiterate the quality of service of AKUH Radiology Department Update patients about the latest developments Choice of the social club will depend on the demographics[footnoteRef:46] of the clubs clientele. [46: Particular emphasis will be on residential area.]

6.1.2 Online ReportingThe department has a sophisticated information system in place which allows access to digital reports anywhere in the hospital. Building on this system, the department should give the patients access to their reports online. This would require the development of a portal or user interface on the hospital website. Patients can sign into that portal using their names as IDs and their patient numbers as passwords.Although the departments reporting is currently satisfactory, such an innovation will serve as value addition for patients and eliminate their need to wait after the procedure or to come back later for the reports.

6.2 Operations6.2.1 Recommendations to enhance throughput6.2.1.1 Scheduling of proceduresScheduling exercise should take into account the patient category to prevent bottlenecks and prevent the need of patients waiting in queue. Following is the method proposed to schedule different patients: Inpatients: These patients are admitted in AKUH and require radiology services. Most of them can be made to wait as they have other ongoing procedures. However, currently their procedures are scheduled during the day with other patients. If emergency and walk-in patients start reporting, scheduling issues arise. This problem should be catered by assigning different time slots to inpatients. For instance they may be scheduled between 6PM and 10PM daily. OSRs: Patients walking in the radiology department and requesting procedures vary during the day. Peaks in their volumes have been noted between 12PM to 3PM. These patients can either be accommodated right then or might want to come back at a later time after taking an appointment. In case they wish to have their procedures right then, they should be told an accurate estimate of waiting time. For this, the staff needs to be trained. If the patients have to wait for over 3 or 4 hours, a lunch or snacks coupon should be issued to them along with the receipt as some of the patients travel long distances to be there. Out-patients: Out patients are referred to radiology from within AKUH by its consulting physicians at in-clinics. One of the key aspects the radiology department needs to work on is increasing in-house referrals. These patients need to be given a priority. Better profiling of these patients, discounts if necessary, feedbacks and availability of appointments from within the clinicians office are some of the key areas that need to be focused on.

Table 6.1 Scheduling according to Patient Type

Patient TypeSuggestionRationale

InpatientsA separate list should be issued for Inpatients and their scheduling should start at 6PM till 10PM. (refer to fig: 4.27 & 4.28)An inpatient is usually available around the clock as they are admitted in one of the wards at AKU. These patients names are included in the daily list and areaccommodatedduring the peak time somewhere between the procedures In patients will always have a 100% conversion rate and should be accommodated at times when the demand is low.

EmergencyThe waiting patients should be informed immediately that they have received an emergency case and their procedures would be delayed.No scheduling policy applies to emergency patients - they need to be rolled in immediately.

Outpatients with appointments:Appointments should be given out with an interval of 30minutes each for MRI and 15minutes each for CT.The registration desk should also give out appointments in the later hours of the day after getting a patients consent.Priority should be given to patients who require their procedure to be done early as they would need to consult with their doctor on a specific date.If appointments are given sooner than 30 or 15 minutes in case of MRI & CT respectively This results in overlaps that eventually cause delays.During the day time, the capacity utilization is approximately 80-90% for both the machines; it is during night that the utilization falls to remarkable lower levels.Our end goal is to increase referrals and retain existing patients. The staff should try their level best to facilitate patients.

Outpatients - Walk-insIdentify to them the queue length and estimated waiting time. If they want an immediate appointment, give it to them and give them an estimate time before procedure so that they can get other things done. In case they do book themselves on waiting, offer them cafeteria coupons; some may be asked to come back after an hour or two. If they do not want to wait & can go back and come at another time, give them the first available spot during the night shift.It is always better to keep the patient informed informed waiting is always more acceptable and reduces anxiety.Waiting experience can be enhanced using customer engagement techniques. Installing information kiosks, handing out meal coupons etc.If a patient insists he needs an appointment early, and does not like to wait 4-5hours, he can be asked to come at late night. It would considerably reduce his waiting time and also enhance machine utilization.

Patients with Financial NeedsTrain the staff to identify if a patient might walk away due to financial constraints.Engage patients instead of letting them go, try offering discounts and call them at later hours.Refer them to administration for better pitching.If a patient pays 70% or 80% of the charge during a time where the machine remains Idle most of the time, it would result in higher conversion rates and enhance machine utilization.

6.2.1.1 Recruitment for independence and improved coordinationCoordination lapses and dependency on other departments combine to serve as bottlenecks for MRI and CT Procedures. The department needs reinforcement in these areas for efficient operations. There is an anesthesia department which caters to the entire hospital. This is because the department deals with highly sensitive chemicals. An anesthetist is assigned to the radiology department two days in a week but his availability is also subject to the workload in other areas such as ER. Hence, administration of anesthesia to the patients is eventually delayed. The radiology department should hire an anesthetist to eliminate this interdependency. The radiology department should also recruit separate staff for co-ordination with other functions. These personnel will be stationed in other departments on behalf of radiology services and will be responsible for the booking procedures slots after confirming with the front desk. 6.2.2 Staffing & work flow efficiency recommendations6.2.2.1 Staff Training on Hard SkillsThe staff is conditioned to give out appointments during the day time only. Usually they do not offer the patient the option to get an appointment for a time after 8pm. This results in an influx of patients during the peak hours and the machine remains at minimal utilization (approx 10%) during the night time. Not utilizing this time also results in patients being scheduled for later dates some are given a time 2 days after the date originally sought. This results in reneging of the patient which eventually translates into a lower turnover ratio. Training of the staff should be done where they are made to realize the importance of a lost customer how every lost patient translates into lost revenue. Another very effective method may be to keep a feedback machine with three buttons (good, fair, bad) at the reception; once the procedure has been performed, the patient can rate the staff.6.2.2.2 Performance-based IncentivesThe department needs to develop a culture of rewarding and promoting exceptional employee performance. Extrinsic rewards such as recognition through Star Performers and monetary incentives based on volumes of procedures performed during duty (without compromising on service quality) should be introduced. This would automatically develop a culture of high performance. 6.2.2.3 MentoringAKUH Radiology should introduce the culture of mentoring junior staff. Star performers, who can be considered ambassadors of the department, should mentor other staff and make them realize the importance of their work. They must encourage other team members to take genuine ownership of their work. 6.2.3 Patient Engagement Tactics6.2.3.1 Increase seating capacityDuring the peak hours, it was often observed that people had to stand around the waiting area due to the lack of empty seats. The department must increase its seating capacity to improve the patient experience. 6.2.3.2 Wi-FiGiven the increasing trend of accessing internet on mobile phones, the department should give free Wi-Fi service to people in the waiting area. If the department feels such a service would be abused, the service can be protected by password which can then be printed on the patient receipt.

6.2.3.3 Information BoothThe department should develop an information booth around the waiting area. This interactive space will give patients insights on radiology procedures, answers to frequently asked questions, explain instructions of the procedures with graphical representation and have general information about health and well being. It would also serve as an indoor advertisement prop. 6.2.3.4 Tuck ShopThe department should look to set up a separate tuck shop that stocks snack items and refreshments. Patients who have to wait for long periods can redeem their coupons here as well. 6.2.3.5 Play Area and Mothers Nursing CenterA separate play area can be established in the open area adjacent to the radiology department. This would help engage young children who may have accompanied their parents. The department should also look into establishing a nursing center for mothers with infants.

6.3 Finance6.3.1 Pricing StrategyAKUH Radiology currently has the most expensive procedures in the city. Based on the recurrent opinion that the price tags are high, following are the different discount policies the department can adopt:6.3.1.1 Loyalty CardsThere are a large number of patients who are loyal customers of AKUH. These patients entrust the hospitals services with their well-being. This is especially true for many oncology patients who get their chemotherapy and subsequent procedures from AKUH. The hospitals MIS has data on these patients. The radiology department should develop loyalty cards for such patients to reward them for their trust in the AKUH brand. The amount of discounts provided would depend can be associated with the frequency of procedure and the length of patient relationship with the hospital e.g. 5% discount on every Xth MRI or CT Scan for a patient who has been coming to AKUH (any service) for the past year, 10% discount on every Xth MRI or CT Scan for a patient who has been coming to AKUH (any service) for the past two years and so on. Such a scheme will increase patients loyalty and preference for all hospital services.6.3.1.2 Discounts based on Frequency of ProceduresMany patients have to frequent the MRI and CT scan procedures periodically e.g. In-patients who have to get tested before and after a surgery. The department should devise a formula for providing such frequent patients discounts e.g. 2% discount for a second MRI or CT procedure within a months duration. This would increase Patient Footprint of those who frequent MRI and CT Procedures

6.3.1.3 Discounts based on the time of the appointment When a patient is given the option to come at a later time for the procedure, especially after 10:00 pm, he/she should be given an incentive. The incentive has to be a price discount and it should be attractive enough to make patients want to come at a later time. It can once again be a percentage of the procedure charge or a bracket system for rupee amount incentive based either on the time of the night or procedure charge can be developed according to the procedure charge. Besides increasing the likelihood of patient footprint, it will also increase utilization of machines during the late shifts.Table 6.2 Pricing Strategy and Formula

Incentive SchemeSuggested Discounting FormulaMaximum

Loyalty Cards5% discounts on every other (alternating) MRI and CT Procedures for patients availing AKUH services for a year.

10% discounts on every other (alternating) MRI and CT Procedures for patients availing AKUH services for 2 years.20% for Loyalty of 4 years & over.

Procedure-frequency based incentive2% discount for 2nd procedure within a month3% discount for 3rd procedure within a month

1.5% discount for 2nd procedure within 2 months3.5% discount for 3rd procedure within 2 months5%

Time-Based Incentive10:00 pm to 12:00 pm Rs. 500 discount12:00 pm to 02:00 am Rs. 1000 discountOR10:00 pm to 12:00 pm 2.5% of procedure charge12:00 pm to 02:00 am 5% of procedure charge7.5%

Use of specific credit cards5% - 15% for using specific credit cards.15%

6.3 Need for Further StudyAKUH should engage in the following studies both at the departmental as well as hospital level for effective management:6.3.1 Cost Drivers MappingThe hospital needs to determine its cost drivers in order to capture the true costs of each procedure. Given the expanding facilities, this would give the hospital the opportunity to reevaluate its price list, set target return-on-investments for each department and refine project evaluation criteria. This project cannot be conducted in isolation at departmental level because of the hospitals Cost-Center/Profit Center treatment of departments. Therefore, it would have to be an organization-wide exercise.6.3.2 Employee Climate SurveyAt present, the employees exhibit signs of lethargy and lack of motivation. The organization should engage in an employee climate survey which would help determine staffs perception about the organization, their team members and superiors. It would also help determine the problems they face on a daily basis and identify areas of improvement in coordination and internal communication.Such a study will not be a finger-pointing exercise but rather an internal health check of the employees attitudes. 6.3.3 AKUH Brand AssessmentIn order to gauge the patient perception about AKUH brand and what it actually represents, the hospital should undertake several brand studies such as brand audits. The results of such exercises will help determine the resonance of AKUH brand, its points-of-parity, and points-of-differentiation as compared to the rest of the industry and serve as a platform for future brand initiatives.

6.4 Road MapThe student project has identified several areas of improvement within the operations of AKUH Radiology Department. But this report is just a starting point. AKUH needs to undertake several functional and behavioral projects before it is able to enjoy unprecedented return-on-investments. These projects would focus on optimizing both the workforce through culture augmentation and capital resources through effective utilization. More importantly, it would help set a map for future strategy. A good place to start would be engaging the studies under section 5.3. These studies focus on key areas of finance, organizational behavior and company brand. Next step would be to develop concrete action plans based on quantifiable objectives or undertake special projects with sophisticated metrics depicting before-and-after scenarios. Then comes the hard work of actually putting things into motion and implementing the developed change plans. This will be the biggest challenge for the organization as a whole as there will be significance internal resistance. One way to deal bolster motivation is to introduce intrinsic awards[footnoteRef:47]. (Thomas, 2009) The final step is to review the progress and suggest further improvements. [47: The four intrinsic awards that drive employee engagement are Sense of meaningfulness, Sense of choice, Sense of competence and Sense of progress.]

If AKUH decides to seriously pursue the studies under 5.3, the hospital will be well on its way to becoming the genuine first-choice hospital for the masses.

Figure 6.1 - Cycle of Continual Improvement

BibliographyAga Khan University. (n.d.). Aga Khan University Hospital Overview. Retrieved 2012, from http://hospitals.aku.edu/karachi/aboutus/HospitalOverview/Pages/Home.aspxAga Khan University. (n.d.). Department of Radiology. Retrieved 2012, from http://hospitals.aku.edu/karachi/hospitaldepartments/Radiology/Pages/home.aspxAga Khan University. (n.d.). Radiology Services. Retrieved 2012, from http://hospitals.aku.edu/karachi/hospitaldepartments/Radiology/Pages/radservices.aspxCarol Prahinski, J. S.-F. (11/30/2009). Quinte MRI. Ivey Publishing.Melissa Conrad Stppler, M. (n.d.). Article on CAT Scan. Retrieved 2012, from Medicinenet.com.Robb, P. D. (2011). Course Manual for Operations Management.Thomas, K. (2009, November-December). THE FOUR INTRINSIC REWARDS THAT DRIVE EMPLOYEE ENGAGEMENT. Retrieved 2012, from IveyBusinessJournal.com: http://www.iveybusinessjournal.com/topics/the-workplace/the-four-intrinsic-rewards-that-drive-employee-engagementWilliam C. Shiel Jr., M. F. (n.d.). MRI Scan. Retrieved 2012, from Medicinenet.com: http://www.medicinenet.com/mri_scan/article.htm

Exhibits

Exhibit 1- Survey Form for Patients Perception

Exhibit 2- Process Map for MRI Procedure

Exhibit 3- Time-Motion Study Observations for MRI Procedure (in minutes)CycleApproach to counterRegistrationPaymentWaitHistoryDeclaration formChanging roomWaitProcedure

1341423251059

2434373191240

3441934291740

4532464391336

5443645281127

653273546937

7524814251249

833110951141436

944410453111540

105311133121033

113421043114852

12224962214730

1332279319829

143341432381039

153416542141142

164341084391030

174431352312831

18341665391333

19223955210832

20322945412928

214431034281328

22234795151448

233441252311948

2433115833131338

25323743251440

2624310952111036

2743216943151235

283449031101553

Exhibit 4- Process Map for CT Scan Procedure

Exhibit 5- Time-Motion Study Observations for CT Scan Procedure (in minutes)CycleApproach to counterRegistrationPaymentWaiting timeHistoryWaitProcedure

1231541055

224252977

3452191346

4341501159

5574741168

654238846

7573361339

823418975

9273461369

1053147959

1125270755

12462401166

1327250749

14532581059

1523144977

16332591035

17371531037

18464571336

1927359846

20272501135

2137148936

22432361148

23262291368

24262571335

25231681175

26474411335

2727228958

28352491165

Exhibit 6- Procedure Description, Volumes and Charges - MRISr. NoProcedure DescriptionVolume (Jan-Nov 2011)Charges 2011

1ABDOMEN90 16,020

2ANKLE JOINT29 16,020

3ANKLE/FOOT (SINGLE)0 16,020

4ANKLE JOINTS (BOTH)0 32,020

7BREAST (BOTH)10 25,880

8BRAIN & BOLD IMAGING1 37,380

9BRAIN2217 15,290

10BRAIN & PERFUSION0 36,010

11BRAIN FOR BOLD IMAGING4 30,020

12BREAST7 16,540

13BRAIN FOR EPILEPSY0 16,020

14BRAIN FOR I.A.C26 16,020

15BRAIN FOR (M.S. & ENCEPHALITIS)0 28,800

16BRAIN FOR ORBITS59 23,990

17BRAIN FOR PERFUSION1 21,600

18BRAIN (SCREENING)423 5,500

19BRAIN FOR SEIZURES1 20,020

20BRAIN FOR SELLA98 23,990

21BRAIN FOR SPECTROSCOPY49 18,770

22BRAIN FOR TRAUMA0 16,020

24CERVICAL SPINE446 14,750

25CARDIAC MORPHOLOGY27 21,620

27CERVICAL SPINE (SCREENING)223 6,650

28ELBOW JOINT (SINGLE)11 16,020

29EXTREMITY (LONG BONE)22 16,020

30FEET1 32,020

31FEMUR37 16,020

32FEMURS (BOTH)1 32,020

33FOOT29 16,020

34FOREARM8 16,020

35HAND11 16,020

36HANDS (BOTH)0 32,020

37HEAD with MR ANGIOGRAPHY1041 20,180

38HEAD MRA ONLY29 11,270

39HEAD and NECK24 25,150

40HIP JOINT (SINGLE)57 16,020

41HUMERUS15 16,020

42HUMERUS (BOTH)0 32,020

43KNEES (BOTH)19 32,880

44KNEE (SINGLE)279 16,450

45LUMBAR SPINE (SCREENING)487 6,830

46LUMBAR SPINE1264 14,750

47METASTASIS EVALUATION2 30,750

49MR ANGIOGRAPHY9 16,020

50Abdomen with MRA & contrast0 30,170

51MRA ABDOMEN WITH CONTRAST ONLY9 23,990

52Abdomen,MRA&MRCP with contrast0 32,120

53MRA HEAD & NECK3 28,300

54MRA NECK ONLY20 23,990

55MRA PEREPHRAL6 23,990

56MRA SPINE WITH CONTRAST0 23,990

57MRA THORACIC AORTA3 23,990

58MRA WHOLE BODY (SCREENING) MRA PEREPHRAL0 27,290

59MR CHOLANGIOGRAPHY119 16,450

60MR CHOLANGIOGRAPHY & ABDOMEN4 18,800

61MRCP Limited.3 11,540

62MR FOLLOW UP /ADDL.ACQUISITION95 10,480

63MRI & MRA NECK WITH CONTRAST2 28,010

64MRI & MRA SPINE (ONE REGION ONLY) WITH CONTRAST0 39,970

65MRI & MRA THORAX3 31,980

66MRI & MRV BRAIN WITH CONTRAST75 28,010

67MR HEAD AND MRA HEAD & NECK32 23,560

68MR UROGRAPHY1 14,410

69MR UROGRAPHY with ABDOMEN0 18,800

70MRV BRAIN AND CONTRAST17 23,990

71MRV BRAIN WITHOUT CONTRAST8 16,020

72SINGLE SEQUENCE MRI154 6,000

73MUSCULOSKELETAL SURVEYS0 34,140

74NECK25 15,900

75PELVIS276 16,910

76PELVIS FOR CERVIX1 16,450

77PELVIS FOR BOTH HIP JOINTS0 16,020

78PELVIS FOR PAEDS (HIP SPICA)0 16,020

79PELVIS FOR PROSTATE0 16,020

81SINGLE JOINT0 16,020

82SHOULDERS (BOTH)5 32,010

83SHOULDER JOINT (SINGLE)73