Not many radiology departments have a full-time economist on staff, but Dr. Hans-Peter Busch's does. The director of radiology with Krankenhaus der Barmherzigen Brüder, a 600-bed hospital in Trier, Germany, Busch originally trained to be a physicist. "So I like numbers, figures and facts," he says.

A frequent speaker and author of "Management Handbuch für Radiologe," Busch is one of a number of radiologists hoping to bring productivity-boosting methods to the profession.

Busch's main aim is what he calls "process optimization" -- finding ways to streamline workflow, improve utilization and keep patients happy.

By some accounts, these kinds of strategies work. Earlier this month, Mayo Clinic researchers reported in the Journal of the American College of Radiology they were able to boost productivity among radiologic technologists by 50 percent through a measurement-feedback program, potentially saving the department $174,000 a year in personnel costs.

And Busch says optimization will soon be increasingly necessary, especially as payer models move from paying per exam (the "so more, so better" model, as Busch puts it) to tying payments to a course of treatment or even population, as in the accountable care organization (ACO) model, in which radiology departments will have to be even leaner.

Even now, there are benefits, he says. Since hiring the economist and running process optimization strategies, his team found unexpected ways to run a tighter and, yes, better-smelling, ship.

"Only to do good radiology," Busch says, "you cannot survive."

Here are some of his tips.



Measure, measure, measure

If Busch has a mantra, it's measure everything. Before optimization can truly start, you have to know what you're working with through reliable measurements of utilization, downtime and other factors, such as average wait times for patients, or how long it takes to get contrast medium injections or sequences.

And measurements are required both before optimization processes are in place and then again afterward, to make sure interventions are working, Busch says.

"Even if you succeed," he says, "you must have for all these succeeded processes continuous monitoring, otherwise one year later, you're in the old status."



Defining parameters

For Busch, a critical aspect of measurement is developing and defining parameters, which can be helpful in benchmarking: comparing your department's performance with similar departments across the region to see how you stack up, such as Busch described in an article in RöFo: Fortschritte auf dem Gebiete der Röntgenstrahlen und der Nuklearmedizir earlier this year (http://www.ncbi.nlm.nih.gov/pubmed/20143285).

For his department, Busch and his economist developed a system in which every exam is assigned a number of working points. The more complicated the exam, the more points it gets. The team then measures effectiveness by determining cost per point, in terms of staff time and material. With this, they can get a handle on their productivity and costs and be better able to see where they rank among other departments in Europe.

Busch says one of the most important results of this process was a reorganization of his team, shifting from grouping staff by modality to grouping by location.

"In former times, we had a team for CT, a team for MRI, a team for X-rays," he says. "Now we have a group of people that are responsible for one floor. We are structured more by location and not imaging method. Why? They can use better their workload if they're flexible."



Go for an advanced RIS

As with any endeavor, you can only do as much as the tools you have let you do. A basic radiology information system can help you view PACS and reports, but in order to measure productivity you have to have equipment for analysis, Busch says.

"A good RIS system gives you analytic tools to manage the department," he says. The information should be easy to understand with charts and diagrams, "not just rows of numbers for 10 pages."

At his department, they use an RIS made by the British health IT company iSoft (http://www.isofthealth.com/en-GB/Solutions/UK%20Department/Radiology.aspx), and have an automatic system to record usage of equipment by gathering data sent from MRI and CT scanners. But he says any good RIS system that lets you evaluate data would work.



Rely on professional management

In the old days, Busch says, administration handled financing, human resources and other mainly clerical duties, and the radiologist was free to just perform radiology.

"But now it's mixed, and a radiologist has to be a radiologist and a manager."

But the problem is "nobody has time and education for management," Busch observes. "And often it's an add-on job to daily work to a radiologist, and if the radiologist is working hard in his interventional room until 7 or 8 p.m., there's no time for management, and it can't be done in a professional way."

Rather than putting off quality control, staffing issues and other factors to end-of-day working groups, Busch recommends bringing in a consultant, or, if the department is big enough, a full-time employee -- like Busch's economist.

"Management, especially if you are not too small a size, needs a person who specializes in this," he says.



Make quality visible to patients

When patients enter an exam room in Busch's department, the first thing they might notice is the smell -- fragrances waft through the air, courtesy of an air-sweetening device made by Aromatao. Also, soothing light shines throughout the room.

While these touchy-feely gimmicks are sometimes off-putting to doctors, Busch says his team found through patient feedback that patients like it. His hospital even ran double-blind studies on the effect of the lights and found recommendation rates were higher for patients who experienced what Busch calls "ambiance."

"It's important not only to have good visible parameters but also to create a good atmosphere in the room," he says. "You must make quality visible for patients."

Busch acknowledges that there is some resistance to these ideas, but he says radiologists can't ignore marketing aspects of their profession.

"This is a new feeling for radiologists," he says. "In the past, they focused only on radiology, but they must sell their radiology to somebody, otherwise even with the best radiology they cannot succeed."