Now, last column I promised you a quick synopsis of the new Imaging Series Design Guides, which take the rough area calculations of the VA's space planning criteria and begin to provide generalized suite layout recommendations as well as technical, operational and safety considerations for planning your new facility.

As I mentioned previously, the four new Design Guides in the Imaging Series are: Radiology, Nuclear Medicine, Radiation Therapy and MRI.

Generally speaking, each of these design guides includes a narrative which walks you through the purpose and function of each modality, and lays out the specific siting considerations and special construction that may be required. Operational considerations are described, as are the safety considerations for each piece of equipment.

Following the narrative descriptions, the Design Guides each provide a functional suite or departmental diagram, showing a proposed arrangement for patient care, staff and support spaces needed in support of the relevant areas. The functional diagrams are directly related to the narrative descriptions of the operational considerations for the area.

The final section in each Design Guide includes the guide plates which are illustrations of typical room layouts, complete with lighting, air conditioning, medical gasses and plumbing locations. Each room is then further broken down to the specific pieces of equipment needed to support the VA's functional plan for each space, down to the level of trash cans and coat hooks!

While these guide plates shouldn't be seen as a replacement for either professional design services or as somehow superseding the technical requirements as provided by your equipment vendor, they can be extraordinarily useful in helping to make sure that those factors that are most important to you don't get overlooked in the blinding tornado of details that surround each and every radiology equipment installation.

The new Imaging Series Design Guides are a must for every radiology manager, architect, equipment planner or anyone drawn into a capital project for radiology. These amazing resources are available for free download here from the VA's Web site.

I recently converted an extra bedroom in my house to a home office where I can tinker on evenings, weekends, or on those days when I'm hard pressed to get out of my Homer Simpson slippers. My dogs, I've discovered, have a particular disdain for the delivery drivers as they bark like crazy when the UPS or FedEx truck parks pull up outside. This is usually a loud indication that I've got a package. Just the other day my package "bark-alarm" went off and I was thrilled to find glossy copies of the new, yet-to-be-released Veterans Administration (VA) Imaging Design Guides.

It shouldn't be surprising to anyone that has worked with or for the VA that they have standards for just about everything and that these include published design guides for planning, design and construction of their hospital facilities. It should also come as no surprise to anyone who has worked with the VA that the four volumes from their imaging series are more than 10 years out of date...but not for long.

I was asked to collaborate on not just incremental revisions, but wholesale rewrites, of the four volumes in the Design Guide Imaging Series. These include MRI, Nuclear Medicine, Radiation Therapy and Radiology. I'm thrilled to share that with you soon, hopefully very soon, these resources will be available for free via the VA's Web site.

The MRI Design Guide title is pretty self explanatory as to the contents. The Nuclear Medicine Design Guide includes information on site design in support of single-photo nuclear cameras, PET and PET/CT hybrids, bone densitometry rooms and radiopharmacy/hot labs. The Radiation Therapy Design Guide includes details on planning for linear accelerators, simulator setups, treatment planning rooms and dosimetry workstations. The Radiology Service Design Guide, the "big daddy" includes most of what we think of as a part of radiology, from all manner of straight rad rooms (general X-ray, R&F and mammography) to ultrasound, interventional suites to CT siting.

In my next installment, I'll provide information on the scope of information in each of the four Imaging Series Design Guides, as well as a Web link to point you to the page where you can download these documents for your own use. In the meantime, however, my dogs are letting me know that I've got another package...

I suspect that I approach pariah status with some of my former professional colleagues. Until a few weeks ago, I was working in an architectural firm and I was not too subtle about the fact that I felt that design professionals (architects and engineers) weren't living up to their professional responsibility when it came to radiology design. This isn't a universal truth, but there are innumerable examples of hospitals and imaging centers that were code-compliant, yes, but concrete testaments to designers' ignorance of the technical, operational and financial realities of medical imaging. Architects have shed massive quantities of responsibility without similar levels of independence.

Well, perhaps they haven't shed responsibility, but they certainly haven't kept up with changes in the technology and clinical care that continue to ramp-up. Just look at the differences in throughput with conventional film versus digital radiography (DR). Architects see an X-ray machine. Compare the patients examined in a single-slice CT a dozen years ago against who we're scanning in a contemporary 64-slice.

It used to be that your design professional would tailor unique design responses to a client's specific needs. Often they would insinuate themselves into your organizational structure during planning to learn as many of the unspoken needs and desires as they could. They would work hand-in-glove with the manufacturers and contractors to determine the best way to sculpt a facility in response to these goals while working to make the facility attractive and durable.

Today, much of radiology design is copy-and-paste from design templates or vendor "typical" installation guides. By and large, architects don't get how PACS reshapes workflow or how the increasing use of radiology as an interventional platform should change decade-old stock designs. Fifty-year buildings are built making equipment that will need to be replaced on a 7 to 10 year increment inaccessible, as if that new MRI is supposed to last until 2055.

There are a number of reasons why many in the design professions have slipped back to where my 8-year-old is. Many who buy professional design services see them as commodities and there has been a "race to the bottom" to cut fees as far as possible. Some professional design fees are half--as a percentage of construction costs--of what they were 20 years ago. Architects have had to pare services accordingly and now rely on product and equipment manufacturers to spoon-feed them canned design solutions. For many designers, even if they wanted to provide the service that only comes from an intimate level of technical and operational knowledge, their own throughput pressures make it difficult to dedicate that quantity of attention to a single client or project.

To no small degree, we've allowed genuine knowledge and expertise to give way to market positioning and PR. Face it, health care is a profoundly complex enterprise yet we rarely balk when we see firms market themselves as "health care design experts." Larger firms may be able to put together "all-star" teams of design experts who really do represent the best and brightest for ERs, patient rooms, ICUs, ob/gyn, ORs and radiology, but the notion that any one person could effectively be an expert in the design of more than a couple areas within the hospital is laughable.

Radiology facilities planning capital projects need to map out their expectations of their design team before they even begin shopping for a designer. Those expectations must be clearly spelled out and communicated to prospective design consultants. Radiology services are simply too valuable, both in terms of clinical care and financial investment, to fail to define one's expectations and effectively vet the professionals you hire.

To be sure, by expecting more you are likely setting yourself up to pay more for the services. But when you compare the cost of professional design services to the value of the radiology services they can facilitate (or handicap), differentials in professional fees are inconsequential.

The larger battle, however, may not be in justifying a fractional increase in fees, but rather in getting a design team to step up and assume the increased level of responsibility for their clients' outcomes. Radiology providers, however, need to set the expectations. Failure to do so when in hiring skilled designers--as it is in raising my daughter--will result in aggravations that will last for many, many years.

Anyone who has lived in the middle part of the country probably has a healthy disdain for the word “forecast” since the local news weathercasts in this part of the world are often flummoxed by what’ll happen later today, to say nothing of three days from now. Similarly, “prediction” conjures up recollections of mid-season prognostications--seemingly universally wrong--about which teams will ascend to the World Series or Superbowl. Personally, I prefer the enigmatic sounding “futurist,” but whichever description works for you, they all somewhat describe what I was recently asked to do...

I often get asked to give presentations or audio conferences on the intersection between imaging and architecture. Most often these are a combination of one-part conventional wisdom, two-parts current events, a dash of crucial technical information and a generous pinch of “learn from someone else’s mistake” examples. Earlier this month I was challenged to look forward to the next 10 plus years of MRI technology and the ramifications for imaging providers. The experience was, in a word, enlightening.

Imaging is expensive. Not simply the out-of-pocket costs for a contrast CT for John Q. Uninsured, but the equipment, facilities, support and staff requisite to all of radiology. When a purchase is expensive, it’s natural to try and diminish the concerns about failure by building a rationale, clinical or financial, based on established need. We do this for equipment purchases. We do this when planning new facilities. We do this when calculating how many FTE’s are needed. In short, many (most?) of our radiology capital-intensive decisions are made looking back on where we’ve been, instead of looking forward to where we’re going.

Imagine navigating all the way from home to work by looking only in your rearview mirrors for the entire drive. This is what we do in radiology, and this is precisely why an exercise dedicated solely to looking forward offers a wealth of new decision inputs.

Looking back over the recent past of MRI we are all struck by the declines in reimbursement, particularly for IDTF facilities. Knee-jerk reactions are to slash costs or count on increased volume from shuttered competitors to preserve profitability. But what are the future factors that will influence the financial aspect of MRI?

If we look at the original single-slice CT and recognize that exam times used to approach an hour, it’s patently obvious that we have made enormous strides in CT throughput. While we may never get an MRI study down to 10-12 minutes, you can bet that stronger magnets, faster gradients, improved software, multi-channel coils and innumerable other advancements are all pushing diagnostic exam times downward for MRI. There are currently providers who have 20 minute standard exam schedules for MRI, and these efficiencies will continue to expand.

Just a year or so ago it seemed that popular wisdom held that 3T systems weren’t ready to emerge from the research setting for widespread clinical use. By late last year, sales of 3T systems were the fastest growing MR type while sales of new low-field systems had nearly evaporated. Based on the last 20 years of precedent, today’s research MR systems will be tomorrow’s clinical MR systems. MRI manufacturers are struggling to keep up with the orders for special ultra-high field systems (5T and greater). FDA safety clearance for MRI already extends up to 8T, and the University of Illinois just received safety clearance for their 9.4 Tesla human MRI.

Apart from the financial and technical components, the entire issue of who will be receiving MRI scans is also undergoing a substantial shift. The per-capita use of all imaging studies, including MRI, increases dramatically with age. As the initial bolus of baby boomers is silently slipping over the AARP threshold, rates of imaging utilization in the U.S. can be expected to continue the double-digit growth that we’ve seen in the newer technologies.

When taken together (and with other factors such as clinical applications, which I haven’t touched on here), the future path of MRI may not be perfectly detailed, but the direction seems quite clear. We will be imaging more patients, faster than ever before, on successive generations of stronger and stronger magnets. Reimbursement will continue to decline, spurring greater efficiency gains in patient throughput from operations and technical advancements.

The radiology “winners” in this tumultuous period will be those who can cast at least one eye toward the future when making today’s plans. Doing so, however, will likely require a departure from conventional practices, as well as a willingness to trust in the inevitability of tomorrow.

Health care architects have a problem that is shared with radiology administrators and others directly involved in building new space for radiology. Design and construction projects are often marked with busted-budget angst, the bricks-and-mortar version of having eyes larger than your stomach. All of the focus on the cost-per-square foot (and squeezing $10,000 out of the project here and $50,000 from over there) reinforces the fallacy that the millions of dollars spent on radiology facilities makes the buildings valuable. Watch out, because I’m about to say something that will alarm nearly every health care architect and radiology administrator…

Your buildings, your posh waiting rooms, your high-tech imaging suites are worthless!

OK, maybe ‘worthless’ is a bit strong. There is undoubtedly some real property value for the commodity represented by the dirt the buildings sit upon. But the building itself is not where the value lies for radiology providers.

The value of a health care practice lies in the quality of care you provide your patients and the numbers of them you can care for. Can technology improve quality and quantity of imaging services? You bet it can! But patients won’t flock to an outdoor 256-slice CT. Imaging providers must have facilities in order to support the technology and operations.

I just did something sneaky… did you notice? I told you your building isn’t valuable and then took you on a logical walkabout to come back to recognizing the necessity of the building you have. So, are we back in the same place we started? Not if you followed my argument. Too often we focus on the size, the cost, the color, the “prettiness” (for lack of a better word) of our buildings and we fail to recognize them for what the value they ultimately provide.

The building for a radiology department or imaging center fails if it doesn’t recognize and support best-practice operations that occur inside. If we figure out how we should work to care for patients, then break down each step of “work” to know where we need the patients, caregivers, support staff, imaging equipment, waiting rooms, writing surfaces, storage areas, bathrooms, etc.…then we begin the process of building an environment of care.

This is not intended to be a license to spend money on building projects like you were printing Ben Franklins in your basement. It’s not an issue of ignoring the budget, or the available space, or existing staffing limitations, but rather settling on an ultimate objective and figuring out how your facility can, in some small measure, get you closer to where you really want to be.

When it comes right down to it, hospitals and imaging centers don’t get reimbursed based on the comfort of their waiting room chairs or how impressive their front door is. They get reimbursed for patient care. Maybe comfy chairs and impressive entrances are important parts of the experience for your patients and warrant an added degree of attention. But designs for new facilities, additions, or even just a single equipment replacement, should focus first on the objectives of patient care.

For facility managers, architects, engineers, equipment planners and even radiology managers facing capital improvement projects, there will be ample pressure to conform to budgets, space and timelines. To achieve an end result that you are truly proud of, you may need to coax your entire collaborative team to throw off these mundane considerations—for at least a little while—and address the bigger picture issues of who you are serving and how.

I swear, I don't have a crystal ball. Last week, when I wrote about two events that will change MRI standard of care, I didn't expect the Sentinel Event Alert to come out the very same day that the blog was posted.

But it did...

In the few days since then, there has been an interesting sequence of responses from those confronted with this new alert.

Denial: The Joint Commission has never made MRI safety an issue before, plus there are no explicit legal or accreditation requirements, therefore this must be some sort of aberration, right? Wrong... Take, as an indication the nearly 18 month "dry spell" in Joint Commission Sentinel Event Alerts before the MRI alert. There was no shortage of patient safety incidents that haven't (at least, not yet) been raised to the level of Sentinel Event Alert. The injuries and deaths quantified in the alert are real, as are a multitude of other events from non-accredited facilities. This will not be a "flash in the pan."

Confusion: The Joint Commission releases a Sentinel Event Alert, so it only seems natural to turn to the Joint Commission's own standards for advice on how best to address the challenges identified. But those whose minds follow such a rational path will find themselves frustrated because the Joint Commission has no standards on MRI patient safety! The alert references the ACR Guidance Document for Safe MR Practices: 2007, but falls short of citing it as the new Joint Commission standard. However this oversight may be moot as there is a necessity for patient safety standards and, in the absence of any competing document, the ACR's is it.

Frustration: For those charged with compliance with Joint Commission (or any other) standards, there was a crying need for a checklist; some means of identifying the specific tasks that need to be done to achieve the JC's goals. But the provided responses don't lend themselves to checkbox compliance and are largely in the ‘check everything' vein or more qualitative statements about performing existing functions better. The frustration borne of this lack of specificity arises from both a desire to comply with best-practice regulation and the sure knowledge that this Alert will be at the forefront of Joint Commission surveyors' thoughts on their next visit. This juxtaposition of a poorly-defined standard and guaranteed accountability leads to the next emotion...

Panic: Some of us are simply wired such that priority equals panic. If something is important, it must be at the center of a whirling mass of activity. Others will have reached panic having worked their way through the other stages of response. However you reached this stage, it is vital to "talk yourself down." Capitalize on the strength of the emotion, but don't make rash decisions in a highly-agitated state.

Analysis: Once you've overcome your initial response, it's crucial to take steps to review your facility safeguards against the Joint Commission's Alert and the ACR Guidance Document. You very well may discover procedures, equipment or facilities that throw you back into a momentary panic state, but don't let that prevent you from completing a comprehensive review. Build your own checklist from the Alert and go through the ACR Guidance Document methodically, including the appendix on safe facility design, and evaluate your performance. You might find the MRI Suite Safety Calculator from MRI-Planning to be a good resource to help you in this effort.

Brainstorm: Develop a grocery list of responses to improve the safety of your MRI services. Carefully consider your staff, your MRI equipment, the types of exams you perform, your physical facilities, your standard procedures, and come up with ways to improve each and every one. These may include implementing protocols for gowning all MRI patients, purchasing more bore padding or the deployment of the recommended ferromagnetic detection screening devices. Don't be afraid to think big, either. If a major obstacle to safety is the location of walls, doors and windows, think about what might be done now, and what could be a part of the next equipment upgrade / replacement project.

Prioritize: If you've been successful at analyzing your situation and brainstorming responses, you will probably find yourself sitting in front of a list of potential changes that will take months, perhaps years, to implement. Don't get overwhelmed! Begin to identify those changes that can be implemented today and work your way down to those that may take a longer period of time to complete. Then, go through your list again, identifying those changes that could have the greatest positive impact on safety and operations. If you flagged tasks that were in a ‘to be done later' category, you may want to rethink the prioritization.

Plan: Lay out a real timeline for how you will implement your prioritized list with specific objectives and milestones by which you can measure your progress. Invariably, these sorts of changes will involve others (techs, administration, referring physicians, support staff, vendors and contractors) so a significant part of your plan will have to center around building a cooperative spirit around process and safety improvements.

Act: The world's greatest unfulfilled plan is little more than scrap paper. For many of us, the real resistance to making changes won't come in the planning stages, but when new processes require alterations to "the way we've always done things." Be prepared to push through this resistance while continuing to try to build consensus for your new (and improved) direction. Have strategies in your back-pocket for overcoming the roadblocks that may be thrown up, such as "that will drag on patient throughput," or "we don't have the funds for that right now," or "let's wait and see how the last change affects things before we go overboard with more changes."

Evaluate: While it shouldn't be used as a tool to derail a comprehensive safety strategy, it is crucial that you evaluate your interventions. Get feedback and collect ideas from everyone involved in the process of change, and use that information to fine-tune your processes. The reality is that we need to incorporate safety as an integral part of patient care and throughput. Strategies that are going to be successful over the long-term will respect this balance and will need to be tweaked as the clinical and operational demands shift over time.

With these steps, MRI providers will be able to work through any initial frustration and respond to the Joint Commission's MRI Sentinel Event Alert in a way that will improve their operations and the safety of patients and staff.

Tick-tock. Tick-tock. The moments are slipping away between our pleasant state of ignorance and a cold-water awakening that's about to hit. Actually, it'll be two cold-water awakenings.

First, the Joint Commission announced last summer that its next Sentinel Event Alert, their highest patient safety alert, will focus on MRI safety issues. Recent rumblings suggest that this alert may soon emerge.

When you combine the near-complete absence of existing safety regulation for MRI with the institutional apoplexy that seems to come in the wake of Sentinel Event Alerts, there will be many radiology administrators, risk managers and technologists who will soon be fielding questions about their facility's level of safety. Sadly, this will be the first substantive look at the clinical, operational and physical MRI safety issues at many facilities.

Second, the slow wheels of justice are creeping toward a trial date for the civil suits against the hospital, director of radiology, MRI management company, technologists and MRI equipment manufacturer involved in the infamous 2001 fatality at Westchester Medical Center.

Attorneys for the family of the young boy who died aren't tipping their hand other than to say that they don't see this as a ‘settling' case and intend to take it to trial, which could start in April. Despite legal efforts to shield the various institutions and individuals from prosecution, at the moment the plaintiffs appear to be looking to attach a degree of culpability to both the individuals and institutions involved. Should this case proceed to verdict it will establish the civil benchmark for standard of care as it applies to safety provisions and training.

Just a few months from now, the landscape of providers' and staffers' responsibility for the safety of patients in the MRI environment may be undergoing a dramatic shift. This shift, it appears, will increase the minimum levels of protection that will be expected of providers.