University Hospitals of Morecambe Bay NHS Trust
NHS / Health Body
Action Taken
The Trust has undertaken several actions to address radiology reporting delays, including offering overtime to consultants, supporting undergraduate radiographer training, maximizing advanced practitioner skills, employing locums, introducing advice and guidance for GPs, and workforce planning. Voice recognition technology has been rolled out across all radiology staff. (AI summary)
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Dear Mr 0' Donnell Re: Requletion 28 Report To Prevent Future Deaths Constance Pridmore (deceased) Thank YOU for your repart daled 12 2016, requesting & review of the Trusts procedures with regard to the assessment of X-rays, on (he basis Ihat delays in oblaining radiologists' reporls creales a foreseeable risk of future dealhs: The Trusl's Clinical Direclor for Core Clinical Services and Consultant Radiologist has reviewed our procedures and can advise &5 {ollows Introduction The number ad range of imaging invesligations performed per varies but the reporting workload is broadly predictable and University Hospitals of Morecambe NHS Foundalion Trust (UHMB) does not have sufficient reportng capacity to promply report all Ihe Images that are acquired. As Identified in your report, Ihere Is a shorlage of radiologists and this Is reflective of a nalional problem: The Royal College of Radiologlsts (RCR) has produced several snapshot surveys demonstrating the scale of the Issue_ The most recent RCR survey (February 2016) shawed that In fact; UHMB was In the upper quartile wlh no studies >1 month: In addilion, rdiology services nalionally have experienced contnual growth over the last elght years ad this brend is expected lo continue. In relation to changes in cllnical praclice, as clinical applicalions wilhin imaging technology advance, Ihe Trust will coninue lo Increase demand for the service: There is also a Increased dependence upon radiological investigations by clinicians (o support Ihe clinical decision-making process_ In 2013, Professor Sir Bruce Keogh's report recommended Ihat all inpalient Imaging investigations be compleled and reported within 24 hours However, the shartage of radiologists and Increase In workload means that this Westmorland General Hospilal Burton Road Kendal LA9 7RG CHAIR: PEARSE BUTLER Tel: 01539 732288 CHIEF EXECUTIVE: JACKIE DANIEL May day Bay
standard, inlended for achievement by 2016/17, Is widely accepted to be an ideal rather Ihan & realistic target, The Trust conlinues (o work lowards this bul il is a challenge. The lack of reporting capacity assoclated risk Is appropriately recorded on our corporale risk register, which Is reviewed at least on quarterly basis: In addition (0 priorilisation, Ihe main aclions (o address (his are around recrullment, skill mix and use of technology: Backoround Approximalely 300,000 imaging investigalions per annum are perloned at UHMB, of which 170,000 are X-rays: For (hese to be useful, Ihe images need lo be considered ad a opinian documenled. For Ihose tesls which involve radlalion, Ihls Is also & stalulory duty under the lonising Radialion (Medical Exposure) Regulations. For many sludies Ihe images will be immediately available ad will be reviewed by the clinlcian who has requested them. It is normal praclice in this trust and elsewhere (hal their oplnion Is used as Ihe basis for trealment, al least unlil such time as Ihe sludy is 'reporled' The documenlation of an opinion by someone whose maln role Is evaluating imaging is known &s 'reporling' ad is Usually carried oul by radiologist or a specially (ralned 'reporting radiographer' Reporlng end Relener Evalualion A small number of studies are considered suitable (or 'relerer evalualion' and Ihe opinion documented will be that of (he referrer; wilh an option to ask for the Ilm lo be reviewed and reported by a radiologist In these cases Ihere would be no (ommal report Issued by & radiologisL Examples of X-rays thal are considered suilable for referrer evaluation at UHMB include X-rays of Ihe (eeth revlewed by a dentist ad follow Up X-rays of healing fractures in adulls reviawed by an orthopaedic surgeon: The reason for reporler evalualion is lo make best use of reporting capacily ad also because Ihe relerer is somelimes in a belter posilion lo judge whelher the lindings are acceplable, for inslance when an X-ray relates to previous surgery and the surgeon is the best judge ol whelher ay Implanled hardware Is where Ihey intended il lo be. Referrer evalualion Is slandard practice in NHS hospilals; allhough ils scope varlas. There are many centres, for example, which apply this to all in-palient X-rays but the policy a UHMB Is considerably less extensive. The polentlal (ar Increasing (he scope of relerrer evaluation (o pravide greater reporting capacity for other studies has been considered (hrough Ihe Trusls Governance procedures but our prelered option has been (0 try lo maximise the reporting capacily avallable (0 us. We believe the scope ol relerrer evalualion wilhin the Trust (o be reasonable sale ad (here Is & standard operaling procedure t0 guide reporlers on Ihe Trust"s working practices relaling lo Image reporting: Some Trusls do not report images where a pallent has died between Ihe acquisition ad Ihe reporting of Ihe image but having sought advice on Ihis from the Medical Prolection Society, UHMB conlnues lo do s0. Working arngemenls end Pioriisallon Within UHMB Ihe Picture Archiving and Communication (PACS) system Is shared across live siles and as (ar as possible the departments prioritise an the basis ol urgency rather than geography: Work is divided into emergency cover; 'duty radiologist"' sessions ad mulli-disciplinary leam meetlng (MDT) support, wilh Ihe remaining clinical time es reporting lime. This Is subdivided into different modalilies (plaln * rays, CT, MRI, elc:) wilh the split depending on the reporters' area of expertise and (he volume of work: Inforalion about the number of studies waitng Ihe dale of the oldest studies in each modality are sent to every reporter twice a week. Wlthln each sesslon Ihe defaull position Is lo slart wilh the studies marked clinlcally urgent and then chronologically wilh the oldest study and work lowards the present; but reporters are expecled lo exercise their clinical judgement as (0 exacly which studies to report Nat all reporters can report lhe same rnge ol studies and no one person can report evary klnd of study: and and and
The waiting images are actively managed by a radiographic manager who also send work (0 oulsourcing campanles as required. Withoul addilional reporting capacily priorilsalion remalns Imporlant There are no nalional guldelines on this and allhough consideration has been glven (o constructing a Ilow diagram to assisl wilh Ihis, the complexity of what Is ultimalely a clinical decision based on number of (actors across a range o modalilles does not lend Ilsell lo such simplificalion: Urgency of imaqing Some studles are more urgent Ihan others. Sometimes Ihis is apparent Irom the moment of referral, for instance palient brought Into Ihe Emergency Department In extremis_ At other limes, however; il is not apparent Ihat Ihere are crilically important findings Ihal might immediately change the patient"s treatment unlil afler the image has been repored. When it appears Ihat a study Is urgenl then Il Is prioritised accordingly Ihe professional judgement of those in the X-ray department However, clinical risk occurs If prioritising urgent cases causes delays in reporting of routine requesis, as signilicant findings are also discovered in thls group of patients. Balancing Ihls is a further challenge. Kev Peromance Indicalors Performance Indicators are measured vla dala extraction from the Compulerised Radiology Inlormalion System (CRIS) and a perfomance dashboard is populated. Reporting backlog is monitored daily Walting Iist tracking and activity measures are reported weekly Regular job plan review productivity monltoring Is in place for all radiologists Capacity and demand work Is regularly undertaken Workforce The Dalton Review reported that lhe UK has around 48 trained radiologlsts per million population: Thls (igure has remained stalic for Ihe last five years and represents half the lolal In other EU countries. The paper considers different ways of working In terms of outsourcing; skill mix lhe use ol lechnology Io overcome the challenge and UHMB has already implemented some of these Ideas. In the UK, no appointment was made (o 41% of unfilled consullant posts advertised and the Norlh West showed a higher vacancy rate (han other regions. This rellects the experlence In UHMB where there are currenuy 5 vacancies, based on workload calculatlons from 2011, since which tlme CT and MR have both doubled In volume &nd Increased in complexily: Clearly recruilment Is central lo developing further capacity and Ihe Trust has made progress and appointed Ihree radiologists in lhe past 12 months with ongoing recruitment efforts, Including Internatlonal recruitment: Funther actions relaling (o recnuitmenLend skillmix include: Rolling programme of in-house Iraining for CTMMR radiographers Radiographer (raining plans have been identified lo fulure proof services, with funding opportunilles for training identified Addilional programmed activities and payment are on offer (o substanllve consultants to report additional work beyond their normal employed hours Westmorland General Hospital Burlon Road Kendal LA9 7RG CHAIR' PEARSE BUTLER Tel: 01539 732288 CHIEF EXECUTIVE JACKIE DANIEL will using Key and and
Support for undergraduale radiogrepher (raining from the Universlly of Cumbria and elective placements from other universities (0 allract new recruits Maximisalion ol advanced practilioner skills 8 honorary conlracts wilh external radlologists who provide ad hoc support Trust associate specialist posts avallable Rotas for 7 day and exlended day servlces agreed for radiographers in CTIMR and sonographers In Ullrasound: Locum radiologists employed when suilable and available Advice and guidance inlroduced to enable to have emall conversalions for advice and access to More complex diagnoslics ~ lo avoid unnecessary Imaging requests and slreamline the palient palhway Worklorce planning to review skll mlx and age profile of slaff Aclions relaling to technology Include; Home reporting to be explored with Ihe advent of new PACS (rom Seplember 2016, which should Improve recruitment and retention opportunities Voice recognilion technology has been rolled oul across all radiology staff, streamlining Ihe process and speeding up report lurnaround limes Qther actions and developmenlsinclude: Conlinued involvement in the 'Belter Care Together' stralegy with partner heallh care providers (0 develap clear palient palhways, oplimlsing use of imaging services, reducing unnecessary requests ad improving patient oulcomes Optimisation project to ensure relevant diagnostic tests are performed at Iha right time within specilic patient palhways and unnecessary imaging requesls are avolded hope thal you find Ihis inlonalion helpful bul if you should require ay further infomation, please do not hesllate Io contact me
standard, inlended for achievement by 2016/17, Is widely accepted to be an ideal rather Ihan & realistic target, The Trust conlinues (o work lowards this bul il is a challenge. The lack of reporting capacity assoclated risk Is appropriately recorded on our corporale risk register, which Is reviewed at least on quarterly basis: In addition (0 priorilisation, Ihe main aclions (o address (his are around recrullment, skill mix and use of technology: Backoround Approximalely 300,000 imaging investigalions per annum are perloned at UHMB, of which 170,000 are X-rays: For (hese to be useful, Ihe images need lo be considered ad a opinian documenled. For Ihose tesls which involve radlalion, Ihls Is also & stalulory duty under the lonising Radialion (Medical Exposure) Regulations. For many sludies Ihe images will be immediately available ad will be reviewed by the clinlcian who has requested them. It is normal praclice in this trust and elsewhere (hal their oplnion Is used as Ihe basis for trealment, al least unlil such time as Ihe sludy is 'reporled' The documenlation of an opinion by someone whose maln role Is evaluating imaging is known &s 'reporling' ad is Usually carried oul by radiologist or a specially (ralned 'reporting radiographer' Reporlng end Relener Evalualion A small number of studies are considered suitable (or 'relerer evalualion' and Ihe opinion documented will be that of (he referrer; wilh an option to ask for the Ilm lo be reviewed and reported by a radiologist In these cases Ihere would be no (ommal report Issued by & radiologisL Examples of X-rays thal are considered suilable for referrer evaluation at UHMB include X-rays of Ihe (eeth revlewed by a dentist ad follow Up X-rays of healing fractures in adulls reviawed by an orthopaedic surgeon: The reason for reporler evalualion is lo make best use of reporting capacily ad also because Ihe relerer is somelimes in a belter posilion lo judge whelher the lindings are acceplable, for inslance when an X-ray relates to previous surgery and the surgeon is the best judge ol whelher ay Implanled hardware Is where Ihey intended il lo be. Referrer evalualion Is slandard practice in NHS hospilals; allhough ils scope varlas. There are many centres, for example, which apply this to all in-palient X-rays but the policy a UHMB Is considerably less extensive. The polentlal (ar Increasing (he scope of relerrer evaluation (o pravide greater reporting capacity for other studies has been considered (hrough Ihe Trusls Governance procedures but our prelered option has been (0 try lo maximise the reporting capacily avallable (0 us. We believe the scope ol relerrer evalualion wilhin the Trust (o be reasonable sale ad (here Is & standard operaling procedure t0 guide reporlers on Ihe Trust"s working practices relaling lo Image reporting: Some Trusls do not report images where a pallent has died between Ihe acquisition ad Ihe reporting of Ihe image but having sought advice on Ihis from the Medical Prolection Society, UHMB conlnues lo do s0. Working arngemenls end Pioriisallon Within UHMB Ihe Picture Archiving and Communication (PACS) system Is shared across live siles and as (ar as possible the departments prioritise an the basis ol urgency rather than geography: Work is divided into emergency cover; 'duty radiologist"' sessions ad mulli-disciplinary leam meetlng (MDT) support, wilh Ihe remaining clinical time es reporting lime. This Is subdivided into different modalilies (plaln * rays, CT, MRI, elc:) wilh the split depending on the reporters' area of expertise and (he volume of work: Inforalion about the number of studies waitng Ihe dale of the oldest studies in each modality are sent to every reporter twice a week. Wlthln each sesslon Ihe defaull position Is lo slart wilh the studies marked clinlcally urgent and then chronologically wilh the oldest study and work lowards the present; but reporters are expecled lo exercise their clinical judgement as (0 exacly which studies to report Nat all reporters can report lhe same rnge ol studies and no one person can report evary klnd of study: and and and
The waiting images are actively managed by a radiographic manager who also send work (0 oulsourcing campanles as required. Withoul addilional reporting capacily priorilsalion remalns Imporlant There are no nalional guldelines on this and allhough consideration has been glven (o constructing a Ilow diagram to assisl wilh Ihis, the complexity of what Is ultimalely a clinical decision based on number of (actors across a range o modalilles does not lend Ilsell lo such simplificalion: Urgency of imaqing Some studles are more urgent Ihan others. Sometimes Ihis is apparent Irom the moment of referral, for instance palient brought Into Ihe Emergency Department In extremis_ At other limes, however; il is not apparent Ihat Ihere are crilically important findings Ihal might immediately change the patient"s treatment unlil afler the image has been repored. When it appears Ihat a study Is urgenl then Il Is prioritised accordingly Ihe professional judgement of those in the X-ray department However, clinical risk occurs If prioritising urgent cases causes delays in reporting of routine requesis, as signilicant findings are also discovered in thls group of patients. Balancing Ihls is a further challenge. Kev Peromance Indicalors Performance Indicators are measured vla dala extraction from the Compulerised Radiology Inlormalion System (CRIS) and a perfomance dashboard is populated. Reporting backlog is monitored daily Walting Iist tracking and activity measures are reported weekly Regular job plan review productivity monltoring Is in place for all radiologists Capacity and demand work Is regularly undertaken Workforce The Dalton Review reported that lhe UK has around 48 trained radiologlsts per million population: Thls (igure has remained stalic for Ihe last five years and represents half the lolal In other EU countries. The paper considers different ways of working In terms of outsourcing; skill mix lhe use ol lechnology Io overcome the challenge and UHMB has already implemented some of these Ideas. In the UK, no appointment was made (o 41% of unfilled consullant posts advertised and the Norlh West showed a higher vacancy rate (han other regions. This rellects the experlence In UHMB where there are currenuy 5 vacancies, based on workload calculatlons from 2011, since which tlme CT and MR have both doubled In volume &nd Increased in complexily: Clearly recruilment Is central lo developing further capacity and Ihe Trust has made progress and appointed Ihree radiologists in lhe past 12 months with ongoing recruitment efforts, Including Internatlonal recruitment: Funther actions relaling (o recnuitmenLend skillmix include: Rolling programme of in-house Iraining for CTMMR radiographers Radiographer (raining plans have been identified lo fulure proof services, with funding opportunilles for training identified Addilional programmed activities and payment are on offer (o substanllve consultants to report additional work beyond their normal employed hours Westmorland General Hospital Burlon Road Kendal LA9 7RG CHAIR' PEARSE BUTLER Tel: 01539 732288 CHIEF EXECUTIVE JACKIE DANIEL will using Key and and
Support for undergraduale radiogrepher (raining from the Universlly of Cumbria and elective placements from other universities (0 allract new recruits Maximisalion ol advanced practilioner skills 8 honorary conlracts wilh external radlologists who provide ad hoc support Trust associate specialist posts avallable Rotas for 7 day and exlended day servlces agreed for radiographers in CTIMR and sonographers In Ullrasound: Locum radiologists employed when suilable and available Advice and guidance inlroduced to enable to have emall conversalions for advice and access to More complex diagnoslics ~ lo avoid unnecessary Imaging requests and slreamline the palient palhway Worklorce planning to review skll mlx and age profile of slaff Aclions relaling to technology Include; Home reporting to be explored with Ihe advent of new PACS (rom Seplember 2016, which should Improve recruitment and retention opportunities Voice recognilion technology has been rolled oul across all radiology staff, streamlining Ihe process and speeding up report lurnaround limes Qther actions and developmenlsinclude: Conlinued involvement in the 'Belter Care Together' stralegy with partner heallh care providers (0 develap clear palient palhways, oplimlsing use of imaging services, reducing unnecessary requests ad improving patient oulcomes Optimisation project to ensure relevant diagnostic tests are performed at Iha right time within specilic patient palhways and unnecessary imaging requesls are avolded hope thal you find Ihis inlonalion helpful bul if you should require ay further infomation, please do not hesllate Io contact me