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Medical iMaging district services (Mids)

Implementation Toolkit

MIDS Implementation Toolkit2

Agency for Clinical InnovationPO Box 699 Chatswood NSW 2057T +61 2 9464 4666 | F +61 2 9464 4728E [email protected] |

Further copies of this publication can be obtained from: Agency for Clinical Innovation website at: www.aci.health.nsw.gov.au Disclaimer: Content within this publication was accurate at the time of publication. This work is copyright. It may be reproduced in whole or part for study or training purposes subject to the inclusion of an acknowledgment of the source or to implement the Medical Imaging District Services (MIDS) business model.

It may not be reproduced for commercial usage or sale. Reproduction for purposes other than those indicated above, requires written permission from the Agency for Clinical Innovation.

The Agency for Clinical Innovation would like to acknowledge the work of O’Connell Advisory Pty Ltd in the development of this resource in 2013.

© Agency for Clinical Innovation 2014


table of contents

foreword

1. the Mids iMpleMentation toolkit

2. the iMpleMentation process: an overview

3. key iMpleMentation activities

Phase 1: Project initiation and management

Phase 2: audit and assess

Phase 3: Plan for the oPeration of the mids model

Phase 4: imPlement and monitor

UsefUl links

abbreviations

appendices

4

6

7

8

8

19

33

41

43

44

46


why do we need a Medical iMaging district services (Mids) Model?

Public hospital Medical Imaging (MI) departments are under increasing pressure due to a number of issues:

• Increasingdemand: - Increase in the number and complexity of procedures requested – no longer only diagnostic procedures but also interventional and therapeutic – in an already high volume area - Acuity of patients – in-patients, paediatric, elderly and very sick patients in an acute setting where medical emergencies are becoming more frequent 1 - Increased demand for clinical consultation with referrers – multidisciplinary team meetings, consultation, etc.• Timelyreporting–MIDepartmentsinallhospitalswillfinditmoredifficulttomeetdemand,

particularly as National Emergency Access Targets (NEAT) are rolled out• Workforcerequirements• Training,EducationandResearch• Equipmentreplacement• LossofRevenue

With increasing demands from patients, referrers, hospitals and LHDs it is necessary to review MI models of service delivery to achieve the necessary balance and sustainability.

Please see the Agency for Clinical Innovation’s document - Medical Imaging: The need for change for further details - www.aci.health.nsw.gov.au/resources/clinician-resources then click Radiology or Nuclear Medicine.

the goal

Timely access to quality care; building an appropriate workforce that can manage appropriate referrals with appropriate equipment across multiple aspects of patient care; sustainability of public imaging servicesintothefutureandbalancebetweenfinancialandclinicalimperatives.

what is the approach?

In July 2003, the NSW Department of Health mandated the introduction of MI business units. One LHD established a business unit in the late 1990s which incorporates many of the principles intended in their establishment and the MIDS model is based therefore on the Hunter New England business model.

Please see the Agency for Clinical Innovation’s document - Medical Imaging Solutions for further details on the MIDS model.

Medical Imaging encompasses Radiology and Nuclear Medicine and it will be the decision of each LHD to determine how or whether MIDS will be established.

foreword

1 Stapes, John A & Redelmeier, Donald A. (2012) Medical emergencies in medical imaging. BMJ Qual Saf 2012;21:6 446-447


why do we need a toolkit?

This toolkit has been created to help you set up the MIDS model in your LHD. It does not dictate day-to-daytasks,butratherdefinestypicalphasesandactivitiesthatyouwillundertake.Italsoidentifiesmandatoryachievements-checklists-todemonstratethatimplementationisontrackandprogressing with requirements to develop mitigation strategies to manage project risks.

Localsitesknowtheirservice,thestaffavailable,andthespecificaimstheywishtoachieve.Localsites and teams can shape a detailed plan of tasks and responsibilities. We have created tools and documents to help you communicate and display common information, create a business case for the change and to assist you in implementing the model that works for you. The appendices outline the various tools and resources developed to support this project. Some templates can be copied directly from the appendices however some contain snapshots of Excel tools with indicative data and those tools can be downloaded from ACI website at www.aci.health.nsw.gov.au/resources then click on Clinicians and Managers, then Radiology or Nuclear Medicine.

who shoUld Use this docUMent?

This document is intended as a guide and reference for Project Managers / Executive Directors leading the implementation of the MIDS model in NSW MI Departments. We encourage you to share the templates with your Implementation Team, and encourage others to read this guide so they clearly understand the objectives of the model and their role in its implementation.

Your Local Health District (LHD) is positioned to assist with and support the implementation of the model in your department so all queries and requests for support should be directed to them. The Agency for Clinical Innovation (ACI) is available to assist with any queries about the model and its implementation.


1.1 what is the pUrpose of the toolkit?

This toolkit has been developed to assist Project Managers / Executive Directors and other relevant staff to facilitate the adoption of a systemic approach for the implementation of the MIDS service delivery and business model in their MI Department(s).

1.2 how to Use this toolkit

The toolkit is divided into two sections:

1. An overview of the implementation process

2. Key implementation activities – This section provides a detailed examination of activities recommended for inclusion as part of implementation. Please note there are also ‘Gateway’ activities included at the end of each phase to assist you in completing all required activities before moving to the next phase.

1 the Mids iMpleMentation toolkit


2.1 what are the Main steps for iMpleMentation?

This toolkit recommends an implementation process that is divided into four phases:

Phase 1: Project initiation – establish the foundations and governance structures for implementation

Phase 2: Auditing and assessment – understand where you are and what you are trying to achieve

Phase 3: Development – how the MIDS model will operate in your MI department(s)Phase 4: Implementation and monitoring – test and implement the MIDS model; monitor and

manage change through data analysis and reporting

2.2 how long shoUld it take?

Realistically, implementing the MIDS model will take some time to embed into practice. This will depend on available resources to support the model and the need to engage multiple stakeholders (mainlyreferringdepartments)andreconfigureaccountingpracticesthroughoutthehospital.

An implementation schedule for the introduction of the MIDS model is set out below. This is an indicativetimeframeonly,astheavailabilityofresourceswillinfluencethetimeframesinvolved.Remember, you will then need to adjust your overall timeframe as a part of your detailed Implementation Plan.

2.3 what key strUctUres and roles shoUld be in place?

The Project Manager, most likely the Executive Director, needs to establish the appropriate support to drive decisions and implement changes, while also having access to resources to lead activities, deliver the required actions and oversee the ongoing business management of the MIDS working in collaboration with the Clinical Lead(s), the Business Manager and other members of the Implementation Team.

The toolkit provides checklists and questions to assist reporting and decision-making, and provides advice on how to engage and communicate with relevant groups and individuals.

As a starting point, the LHD and senior clinicians need to clarify objectives and readiness for change detailed in the following section. Agreement should be achieved at the earliest opportunity to ensure a successful implementation.

2 the iMpleMentation process: an overview


phase 1: project initiation and ManageMent

The purpose of this phase is to establish the arrangements for directing, managing and progress the implementationoftheMIDSmodelinawaythatmaintainsafocusondeliveringtheintendedbenefitsof the model.

Activities

There are seven key activities to consider in relation to project initiation and management. These are:

step 1: Determine LHD objectives and readiness for changestep 2: Set up MIDS implementation team and obtain executive sponsorshipstep 3: Develop a project implementation budget for the MIDS modelstep 4: Map and engage key stakeholdersstep 5: Develop an implementation planstep 6: Develop a communications planstep 7: Develop a risk register

steP 1: Determine LHD objectives AnD reADiness for cHAnge

Why is this important?

The LHD in consultation with senior Medical Imaging clinicians needs to be clear about its objectives and expected outcomes around the MIDS redesign. Identify what will assist in ensuring success and what are the potential pitfalls. Things to consider:

• Serviceimprovements• Utilisation• Clinicalpractice• Governance• Accreditation

• Resourcing - Equipment - Workforce• Revenuestreamsincludingprivateand compensable patients • Financialsustainability

It is important to consider the collection of baseline data for these objectives and outcomes so that they can be monitored, reported and evaluated throughout the implementation process (see Phase 3). The LHD is then able to determine its readiness for change utilising the template in Appendix 2. By self-rating readiness on Leadership, Culture and Commitment as a percentage, enablers, barriers and necessary actions can be determined. The level of commitment will determine whether the MIDS project produces a good result.

recommended tools and templates:

Appendix 1: LHD Objectives for change

Appendix 2: LHD Readiness for change

3 key iMpleMentation activities


steP 2: set uP miDs imPLementAtion teAm AnD obtAin executive sPonsorsHiP

Why do we need an implementation team and executive sponsor support?

Effective leadership and team support is crucial for the success of any project involving the accomplishment of multiple activities. This project requires a strong implementation team to guide and execute the implementation of the MIDS model of care. It is therefore crucial that the Project Manager / Executive Director obtains support at the executive level and establishes a group of key stakeholders to champion the redesign project and lead its implementation.

Who should be on the implementation team?

For successful implementation, it is essential to select an appropriate team. This team must be:

• MIfocused• Representativeofclinical(medical,radiographic,nursing),clericalandmanagement• Willingtoembracechange• Motivated

The team should include:

• Executive-levelsponsor• ExecutiveDirector*• BusinessManager/Accountant*• Seniorimagingclinicians-medical,nursingandmedicalradiationscientists• Referrerrepresentation• Hospitaloperationsrepresentation

*TheimplementationofthefullMIDSmodelwillrequiretheemploymentofanExecutiveDirectorandBusiness Manager / Accountant at the beginning of the project as they will be responsible for much of the work in the setting up and ongoing management of the MIDS across the Local Health District. It is critical that they understand the original impetus for the change and can measure progress in the years to follow. (Sample Position Descriptions in Appendices 3 and 4)

What are the roles and responsibilities of the project team?

Executive Sponsor: This team member will provide executive leadership and sponsorship. They must demonstrate commitment and have a high level of interest in the outcomes of the implementation project. Their role will be to legitimise the MIDS goals and objectives and to be a visible and vocal champion for the model in the LHD. The Executive Project Sponsor will have responsibility for securing and allocating resources for implementation and will report implementation progress back to the LHD Executive.

Project Manager: The Project Manager will understand the principles of the MIDS model and have experience in implementing and managing business models. Experience might include managing a service or undertaking change projects. They will have experience in managing multidisciplinary groups, and be dedicated to this project for the period of implementation.

They will schedule regular time with the Executive Project Sponsor for support and coaching as the project progresses.


Implementation Team: The Implementation Team will consist of individuals assigned with delivering the implementation of the MIDS model. The team will be given the responsibility for guiding the strategicdirectionoftheprojectandmakingfinaldecisions.

Members of this group will be champions for the implementation project and should include:

• AnExecutiveDirector,MIDStoimplementandmanagetheMIDSinanongoingrole• SeniorclinicalrepresentativesfromMI(RadiologyandNuclearMedicine)-ClinicalDirector(s), ChiefRadiographer(s),ChiefNuclearMedicineTechnologistsandNurse(Unit)Manager(s)• AdedicatedBusinessManager,MIDStoprovidetheall-importantaccountingandinformation reports for the MIDS model in an ongoing role• Referrerrepresentative

Team members will have the capacity and expertise to undertake discrete activities within the project produce documents and make initial decisions on the day-to-day workings of the MIDS model. Some members of the Implementation Team will need to be available for the duration of the implementation period and it may be useful to include alternates for each member. The Executive Director and Business Manager will be required in permanent positions through implementation and afterwards.

Stakeholders: The stakeholder group will consist of multiple groups of people with different roles to play in the implementation. This group may include people who:

• Shouldbekeptinformed• Willbeparticipantsintheprocess• WillbeaffectedbythenewMIDSmodel

Changes from implementation of the MIDS model may require input and sign-off from some stakeholders even though they are not accountable for delivering any of the implementation activities.

How do we develop a good team?

It is important to remember that effective teamwork doesn’t just happen by putting people together in ameetingroom.Thetruebenefitofusingateamisthatitallowsforacollectiveoutputthatisgreaterthan the sum of individual efforts.

Some key hints for developing a good team include:

• Agreeontheteamgroundrulesatthefirstmeeting• Setagendas,confirmdeliverablesandagreeontimeframe• Outlineteamobjectivesandhowtheteamwilloperate• Clearlydefineeachperson’srolesandresponsibilitiesandwhatisexpectedoftheminthe project, e.g. what is the expected workload and duration of their role• Communicateregularlytokeeptheteamalignedongoalsandidentifyandtroubleshootany issues that arise• CreateanenvironmentthatrecognisesthisworkasanintegralpartofimprovingtheMI department(s), understanding that team members are busy and have little capacity to take on additional ‘project work’.• Sharetheleadershipandmatchtaskswiththeskillsofyourteam


Once the implementation team has been appointed, a number of questions need to be asked to help the team understand how they will work, for example:

• Whowillbeyourdecision-makingbody–thatis,thegrouptowhichyouescalateissues,and seek approval to move the project forward? • Whataretheprojectgovernancestructures?• HowwilltheProjectManagerallocateparticulartasks,towhom?• Howwilltheteammaintainexecutiveandclinicalsupportforthisproject?• Howwillthewiderstakeholdersbeinvolvedintheformaldecision-makingprocess?• Howwillweknowthemodelhasbeenimplemented?

We have included the following templates in the Appendices to facilitate the set-up of your project structure: Implementation Team Structures (Appendix 5) and Sample Governance Structures (Appendix 6).

Implementation team and stakeholder meetings: The implementation timeframe is intended to be thorough, intense and focused on starting the delivery of the MIDS model within a year. The implementationwillrequiredecisionstobemadeefficientlyandeffectively.Therefore,regularmeetingswith the implementation team and stakeholder groups are essential.

We recommend fortnightly implementation team meetings and weekly or fortnightly communication between the Project Manager and Executive Project Sponsor. Each meeting should result in action items for team members with allocated timelines for completion.

The Project Manager will need to work with the Executive Project Sponsor to schedule meetings with the LHD to provide project status updates, secure resources and prioritise issues that need to be addressed.

Completed checklists and plans (such as project plan, communication plan etc.) should be provided to the LHD upon completion of each phase for review and endorsement to move to the next phase.

Things to consider:

• AgreehowtheExecutiveProjectSponsorandLHDwillreceiveprogressupdates• AgreeupfrontwhattheExecutiveProjectSponsorexpectsasoutputsateachphase,and where they want to be included in the decision-making and approval process• AppointanExecutiveDirector,MIDStofunctionastheProjectManageronaday-to-daybasis• Shareworkplans,practicesandscheduleswiththeImplementationTeamandhavea dedicated physical space in which key project documents are available for the team to access• HaveaBusinessManager/AccountantintheImplementationTeamtomanagealldata information and reporting• Reviewtheimplementationteam’srolesandresponsibilitiesasyouworkthroughstakeholder mapping and communication planning – there may be a need to change areas of focus or responsibility for key activities based on an analysis of stakeholders and their communication needs• Reviewandtrackimplementation• Develop,reviewandtrackmitigationstrategiesforrisk

See Appendix 7 for a Status Report Template.


steP 3: DeveLoP A Project imPLementAtion buDget for tHe miDs moDeL

Why do we need a budget?

The purpose of the project budget is to better understand the resources available for implementation andtoidentifyanyfinancialgapssothatabusinesscasecanbedevelopedtoaddressthem.Ideally,existing resources can be used to deliver the project.

As part of developing the implementation budget, it is important to clarify all approval processes and overallaccountability.TheLHDExecutiveProjectSponsorcanhelptodefinethefundingrequiredforimplementationcosts,itssource,andfinancialreportingrequirements.

Other costs for implementation such as additional resources, capital expenditure and any IT developmentneedtobeconsidered.Costsrelatingtostockandsupplies,equipment,andstaffingshould be considered as part of the overarching MIDS budget and not the project’s budget. See Appendix 8 for costs to be considered.


Appendix 3: Position description – Executive Director, MIDS

Appendix 4: Position description – Business Manager, MIDS

Appendix 5: Project team structure

Appendix 6: Example project governance structure

Appendix 7: Project Status report template

tip:

à If required, revise your budget again in Phase 3, once infrastructure requirements have been determined.


steP 4: mAP AnD engAge key stAkeHoLDers

Why do we need to map and engage stakeholders?

One of the most important tasks for the Project Manager is to decide who the key stakeholders are and then engage with them to support the implementation of the new model. Mapping stakeholders with the implementation team is an essential activity for the project. The information gained will directly feed into the creation of the Implementation and Communications Plans.

Mapping your stakeholders – The stakeholders for this project will include individuals and groups, those with direct interest in and accountability for its implementation; people who will be affected, and those who may only be involved intermittently. It is necessary for the Project Manager to facilitate appropriate representation from all the disciplines and services that will affect and be affected by the implementation of the MIDS model.

Considerations for a comprehensive list of stakeholders:

• ScopeofMIDSservices- Consider the scope of services proposed for the MIDS model and list everyone who is involved in the delivery of these services — from doctors, nurses, allied health, internal referrers to Medical Imaging, hospital IT and accounting personnel and LHD Executive. If staff members understand the aim of the MIDS model and what is involved in its delivery, they will have a greater sense of ownership and involvement in making the model a success.

• Typesofchanges- Consider the nature of the changes that will occur in the Medical Imaging andreferringdepartmentsandhowtheywillneedtobeintroduced(e.g.newfinancialmodelwhereinfrastructure fees from private patient revenue are retained by the MIDS, referrers are charged a transfer price for each examination based on a percentage of MBS rebate, new equipment purchase / lease, etc.), and think about the different people who will make this happen.

• Typeofconsultation- Consider the level of consultation that will be completed to support the data and build the case for implementing the MIDS model of care. List everyone – medical, nursing, allied health, management and support staff - who will need to be involved in these consultations and the format in which it will be undertaken. As it is a whole of hospital / LHD change, you may need to consider consultation workshops or focus groups.

• Typesofcommunication- Think about the typical types of communication in any change project – progress updates, instructions or requests, reminders, and information to explain or persuade change. Remember, the communication might add another layer of stakeholders to the stakeholder list.

We have suggested a key list of people that may need to be involved; however, this will need to be confirmedwiththeImplementationTeam:

• MedicalImaging(MI)staff–allthedoctors,nurses,alliedhealth,businessandadministrative staff who will be required to drive and support this project• SeniorstaffinhospitaldepartmentswhorefertoMI• Hospitalexecutives• LHDexecutives• MinistryofHealth• OtherMIorhospitalstaff–e.g.orderlies,patientservicesassistants,PACS/RISadministrators• ICTservices


We have provided a Stakeholder Mapping template and a sample list of core stakeholders as a starting point in Appendix 9.

steP 5: DeveLoP An imPLementAtion PLAn

Why do we need an implementation plan?

An implementation plan provides details of all the tasks that need to be undertaken by the implementation team matched to an agreed timeframe. It also outlines the high-level milestones that act as key checkpoints for the project. The plan clearly demonstrates to the team and executive project sponsor how the MIDS model will be delivered and what is required to launch the model by the agreed date, and how risk will be mitigated.

What should be included in the implementation plan?

It is essential that the implementation plan clearly outlines the project milestones and major activities required to implement the project. This document needs to include the date by which each milestone or major activity is to be completed, and who is responsible. Establish timeframes that are suitable and realistic for MIDS.

The implementation schedule will become the primary tool for the Project Manager to assess the progress of the project. The implementation plan should include:

• Projectphases,activitiesandtasksagainstatimeline• Projectmilestones(descriptionsanddates)• Aprojectscheduledepictingwhenthetaskswillbeundertaken,assomeactivitieswillbe dependent on completion of other activities • Alistofidentifiedinterdependencies,assumptionsandrisks.• Howresourceswillbeallocated

An implementation plan template has been provided in Appendix 10.

tip:

à If people are involved and understand what is happening they will have a greater sense of ownership and be more likely to get involved in making the MIDS model a success.

à Engage ICT services early – as they have to plan and prioritise work and should be contacted early and kept up to date with the progress of implementation to facilitate the smooth transition of ICT services

à Consultations should include stakeholders who may be resistant to the model. They will help to raise issues with the project which should allow for development of mitigation strategies


steP 6: DeveLoP A communicAtions PLAn

What is a communications plan?

A communications plan is a schedule of communication activities that set out information and accountabilities to target audiences. The communication plan for redesign projects is crucial to communicate changes and progress to all relevant stakeholders.

Why do we need a communications plan?

The purpose of the communication plan, together with the stakeholder map, is to help maintain and build engagement with all involved or affected by the MIDS model, in order to effect the change to be created in the LHD. Communicate the reasons for the model and how it will operate and affect people in and outside Medical Imaging to avoid any unwanted surprises.

Developing a communication plan

The team needs to consider which communication strategies will be most useful to meet the needs of various stakeholders at different levels of the facility. It is important that stakeholders receive regular updates from the implementation team regarding the progress of the project work plan, especially during the early phases of the project. Stakeholder needs will be different depending on their level of influenceandsupportfortheproject.Ideally,allstakeholdersshouldbeaskedtheirpreferredmeansof communication (stakeholder mapping template). More in-depth communication will be needed to keepstakeholderswithhighinfluencefullyinformedofprojectprogress.

Things to consider:

• Begincommunicationearly• Whatarethekeychangesinimagingandthehospitalthatneedtobearticulatedtostakeholders?• Whoarethedifferentaudiencesandwhatarethekeymessagestheyneedtohear?*• Howwouldyourstakeholdersliketoreceiveinformation–byemail,documents,discussionor other means?• Howregularlydoestheimplementationteamneedtomeetorshareinformation?• Astheclinicalenvironmentiscomplex,withstakeholdersoftenjugglingmanycompeting demands, multiple methods of communication will be most effective to increase the chance that those who need to receive information about the project will get it• TheCommunicationsPlanisalivedocument,notaone-offactivity.Keepitsimplesoitcanbe easily updated• TheCommunicationsPlanshouldberegularlyupdatedinconsultationwiththeImplementation Team - at a minimum this should occur at the end of each phase

*Therewillbedifferenttargetgroupswhowillrequiredifferentmessages,whichcouldinclude,butarenot limited to the following:

1. Medical imaging staffHow will this change affect me? Will this impact on my current position? Who will I report to? What other changes will occur? What can I do to help?


2. Referring clinical departmentsHow will this change affect my department? Will there be any changes to patient care? Will we be notifiedonaregularbasisofhowwearetrackingwithourreferringpatternsagainstallocatedbudget?

3. Facility managersHow will this change affect my facility? How can I ensure that my facility will receive services to the expected standard? How can I ensure ongoing collaboration and cooperation between Medical Imaging and other hospital departments?

4. Supportservices(i.e.finance,ICT,hotelservices)How will this change affect the service I currently provide?

A Communication Plan template has been provided in Appendix 11. This can be used as a prompt to guide communication activities. Remember, the Communication Plan is to assist in delivering therightmessagetotherightpersonattherighttime–souseitoftenandupdateitoften.UsetheCommunication Plan to manage the timing and frequency of communications and prevent repeated and unnecessary circulation of information.

steP 7: DeveLoP A risk register

What is a risk register?

Ariskregisterrecordsidentifiableriskduringthelifeoftheproject.Risksaregradedintermsoflikelihood of occurring and seriousness of impact on the project. Initial plans for mitigating each high-level risk, the costs and responsibilities of the prescribed mitigation strategies and subsequent results should be included in the risk register.

tip:

à Regular face-to-face meetings are recommended as the primary communication strategy in building and maintaining engagement withstakeholders,howeverimagingclinical(particularlymedical)staffingnumbersandrosteringwilloftenmakeregularfacetofacemeetings with the same team members impossible. Flexibility in schedulingandcommunicationmode(e.g.teleconference,etc.)aswell as appointed alternates will be required.

à A range of mediums should be used for communication (face-to-face meetings, workshops, emails, one page factsheets, regular newsletters).

à It is essential to engage executives and departmental heads early in the project to gain support.

à The creation of an implementation plan and communication plan is not a one off activity; it is something that the Project Manager will update throughout the project.

à Communication of the changes and progress to all imaging staff is vital. This may include many staff members so use existing communication mechanisms regularly, e.g. staff meetings, education sessions, email, web-based.


Why do we need a risk register?

The risk register is a key project management tool that should be discussed at each team meeting. The tool provides the implementation team and LHD with a documented risk mitigation strategy that identifiesrisksandminimisesthechanceofjeopardisingtheprogressoftheproject.Italsoassistsinidentifying any interdependencies that the team need to be aware of and monitor closely, i.e. if critical steps have not been completed it will affect the progress of the project.

How do we develop a risk register?

As the details of the MIDS model are planned and the case for change established, a number of risks willbeidentified.Similarly,withprogressionthroughtheimplementationitself,newriskswillariseandothers may be mitigated or resolved. Carry out a thorough analysis of all potential risks and develop strategies to mitigate these risks with the Implementation Team. Work through identifying risks until the Team has exhausted all possible scenarios. The more that is known about potential risks the more prepared the Team will be to manage them.

The risk register should be kept as an ‘audit trail’ of the risks as they come and go and report on these totheExecutiveProjectSponsorateachmeeting(seealsotheProjectStatusUpdatetemplate).TheExecutive Project Sponsor can also use the register when reporting project progress to the LHD.

Typically, a risk register contains:

• Adescriptionoftherisk• Theimpactoftheriskshouldthe event occur• Theprobabilityofitsoccurrence• Asummaryoftheplannedresponse

• Asummaryofthemitigation(theactions taken in advance to reduce the probability and/or impact of the event)• Actionsbynominatedpersonandduedate

A risk register template is provided in Appendix 12.

tip:

à Highlight potential risks as early as possible in the project. This will minimise the potential for unexpected issues to arise later in the project and threaten implementation.


Appendix 8: Budget template

Appendix 9: Stakeholder mapping template

Appendix 10: Implementation plan template

Appendix 11: Communications plan template

Appendix 12: Risk register template


cHeckList

Phase 1 of the MIDS model Implementation Project is now completed! Before the Team moves on to Phase 2, please complete this checklist and review with your Executive Project Sponsor.

Have you:

Established the LHD’s objectives and readiness for change Established Executive sponsorship Nominated or recruited a dedicated Project Manager (Executive Director) to lead the implementation project Established a MIDS Implementation Team and outlined each member’s roles and responsibilities Established and scheduled meeting dates for the implementation team Developed the Implementation project budget Completed Stakeholder mapping exercise Prepared Implementation plan Prepared Communications plan Developed a Risk register Collected baseline data for monitoring and evaluation of objectives and performance

Signature: ___________________________________ Date: __________(MIDS ED / Project Mgr)

Signature: ___________________________________ Date: __________(Executive Sponsor)


phase 2: aUdit and assess

The purpose of this phase is to understand the current position of the MI departments, the facilities and the LHD. In this phase data will be collected and analysed, stakeholders’ expectations will be analysed, MIDS scope will be agreed and objectives will be set for implementing the new model.

Activities

There are seven key steps that will need to be completed in this phase. These are:

step 1: DefinescopeofMIDSservicesstep 2: Definewhatwillbeincludedincostsstep 3: Develop an understanding of current MI operating environmentstep 4: Key stakeholder consultationsstep 5: Determine any current or potential gaps in service provision and how MIDS could address thesestep 6: Communicate results of consultationsstep 7: Determine readiness for MIDS Model

steP 1: Define scoPe of miDs services

Understanding what medical imaging services would be provided within the MIDS model

The purpose of this step is to identify the range of medical imaging services provided throughout the LHD and what should be considered for inclusion as part of the MIDS. This step will inform what cost data should be collected as part of step 3, and will also inform key stakeholder consultations, as outlined in step 4. Information about the number of rooms (capacity), hours of operation and after hours arrangements should be collected prior to undertaking stakeholder consultations as these arrangements may be a discussion point with key stakeholders.

There may be instances where medical imaging services are provided under the jurisdiction of another department(i.e.Cardiologyforangiograms),andthedecisionmaybetoexcludethosespecificservices. This process should identify those services, the scope of the MIDS model, plus the rationale for any services considered out of scope, that should be clearly documented for future reference. This will support any subsequent discussions about the scope of the MIDS model.

Whilst costs of medical imaging services which are directly related to billable services should be easily identifiedandquantified,itisalsoimportanttorecogniseservicesprovidedbymedicalimagingwhichare not linked to medical imaging billable services. This could include such services as specialist radiographer support provided to operating theatres, MI specialist participation in MDT meetings or participation in training and research.

It is suggested that this template is completed for each facility within the Local Health District, and then consolidated to provide a comprehensive view of the MI services provided within the LHD.


Appendix 13: MIDS service checklist template


steP 2: Define wHAt wiLL be incLuDeD in costs

Understanding what direct and what overhead costs will need to be considered within transfer pricing

In order to calculate an effective transfer price, there needs to be agreement with the LHD on what costs will be included, and what costs excluded, in the operating budget.

The decision as whether depreciation will be included or excluded will be dependent upon whether the LHD will commit to a model which will cover the full cost of capital. Modelling may need to be undertaken which provides the LHD with some scenarios – full capital coverage, coverage of minor capital equipment or the LHD excluding capital. If the LHD commits to MIDS including full cost of capital, then decisions need to be made about how funds will be managed to ensure MI is able to access the capital provisions generated through the MIDS model when determined necessary. This will need to be clearly articulated to ensure longevity and provide background in the event there is a change in leadership within the LHD.

It should be noted that the more overhead costs included, the higher the transfer price and the rationale for inclusion should be clearly articulated, as this will need to be communicated to key stakeholders when a transfer price has been calculated and agreed upon.

Appendix 14 - Overhead Costs section is based upon the schedule of all indirect standard cost centres as informed by draft NSW Ministry of Health Cost Accounting Standards volume 2: Costing Standards.Thisshouldbereviewedwhenthefinalversionofthisdocumentismadeavailable.

One of the key stakeholders that should be consulted as part of this process should be the person responsible for overseeing cost allocations within the LHD for the purpose of Activity Based Funding. This person will have a good understanding of what will be included and excluded as part of the medical imaging component of Activity Based Funding, and will be well placed to suggest mechanisms to determine cost allocations of any overhead costs included within medical imaging.

tip:

à Consult with all MI department heads to understand what specialist support they provide to other departments

à Some specialist services may provide and fund medical imaging services within their clinical service. If the decision is to continue this arrangement, then ensure this is well understood by all relevant stakeholders and documented accordingly.


à Appendix 14: MIDS cost considerations checklist template


steP 3: DeveLoP An unDerstAnDing of current mi oPerAting environment

CollatingandprofilingMedicalImagingstaff,equipment,activityandexpenses

There are several aspects which need to be considered:• Staffprofiles• Activitydataincludingprivatepatientactivity

• Equipmentschedules• Costandexternalrevenuedata

Staffingprofiles

AspartofthepreparationforMIDStheserviceshouldhaveaprofile-numberandskillmix-ofallmedicalimagingstaff.Thisprofileshouldbepreparedbyfacility,andthenconsolidated.Afullunderstanding of the total staff resources currently available is necessary for part of the data analysis requiredforStep5,particularlywhenconsideringiftherearepotentialefficiencygainsfrommoreeffective use of available resources.

Activity data

Activity trending will indicate likely future service demands, and it is recommended at least two years of activity data be considered in the analysis although the actual tool has capacity for three years. The medical imaging service should undertake some work to determine current capacity to meet indicated future service and this is discussed further as part of Step 5. This data could also be used to validate the private revenue component, as outlined in the Cost and external revenue data section below.

Equipment schedules

Medicalimagingisacapitalintensiveservice.UndercapitalsensitivitythereareincentivestoreplaceMI equipment on a timely basis (see www.health.gov.au/internet/main/publishing.nsf/Content/capsensdi). Replacement may be via outright purchase or operating lease. There should be forward planning of at least 10 years for the replacement of MI equipment to ensure a strategic approach to capital. Acquisition could be through outright purchase or leasing.

Cost and external revenue data

UndertheMedicalImagingDistrictServiceitisproposedthattheMIDSwillprimarilybefundedusingan activity based price or transfer pricing. Whilst the service would still retain an indicative operating budget it would be expected that remaining net costs would be met through a cross charge through toreferringdepartmentsviaanagreedtransferprice.Underthismodel,itisimpliedthatallreferringdepartments will be allocated a budget associated with activity to cover the costs of transfer pricing, effectively starting the MIDS at a zero based budget. The result should be that anticipated costs should be equal to all revenue, including that generated as a result of transfer pricing.

tip:

à EnsuretheRadiologyInformationSystem(RIS)Managerisengagedas part of the Activity Data analysis as they will be responsible for obtaining the relevant data.


All costs and external revenues will need to be captured to assist in the calculation of the transfer price. This will include any infrastructure component of the private patient revenue to be retained by MIDS to assist funding the cost of equipment replacement, keep the transfer price as low as possible and to incentivise clinicians to maximise private revenues. The costs not covered by external revenue would then need to be covered by a transfer price.

There will need to be some data collection and analysis required to understand the impact of this private patient revenue.

It is recognised that some LHDs may have already developed alternate approaches to transfer pricing.

The MIDS Data Collection and Financial Outcomes tool

Appendix15hasbeendevelopedtocollectdataonstaffingprofiles,equipment,costsandactivity.

This tool will then produce the following:

• 10yearequipmentreplacementschedule• Financialsummary–budget• Suggestedtransferpricing

For those MIDS services that provide both radiology and nuclear medicine, the only common worksheets are equipment and staff establishment. Activity, costs, revenue, supporting budgets and suggested transfer pricing have been separated by specialty, as it is assumed that separate budgets will be required and there should be a separate transfer price, however the principles of the worksheets are the same.

This tool has been provided to support or supplement existing resources. It is anticipated that a number of LHDs will have systems and processes in place to provide this information. This tool shouldbeusedeithertosupplementexistingsystemswheredeficienciesexist,provideaninterimsolutionwhereafinalsolutionisyettobeimplemented,orprovidethoseLHDslesswelladvancedwith tools to support the implementation of the MIDS model.

ItisassumedthatthoseutilisingthistoolwillbeproficientinMSExcel.ThistoolwasdevelopedusingMS Excel 2010.

Are there any additional infrastructure and/or equipment needs?

As part of the planning process, the MIDS implementation team should identify any additional infrastructure needs. This should include consideration of where best to accommodate the MIDS executiveteamwithintheLHD,availableofficespace,technologyandadministrativeresources.

Using the MIDS Data Collection and Financial Outcomes tool

This tool contains a number of linked worksheets.

Theworksheetislocked.Datacanonlybeenteredintocellsshadedgrey.Allotherfieldsareprotected.

ACI can be contacted for an unprotected version if considered necessary however this is not recommendedduetothecomplexityofthefinancialmodelandsupportingworksheets.


1. DateThisworksheetdrivesthelatestfinancialyearforwhichdataisavailableshownonallrelatedworksheets.Thefirststepistoupdatethisfield.Thislinkstoalloftheworksheets.

2. Audit trailThis worksheet is provided as an audit trail for the source documents used. This worksheet does not link to any other worksheets.

3. Drop Box ListsA number of worksheets are formatted to use drop boxes to maintain integrity of coded data. This worksheet has the master list of drop box codes which can be amended. It is important to note that thefilemustbesavedpriortoanyneworamendedcodestakingeffect.Thisworksheetlinksto:• Equipmentdatainput• Financialdatainput–thesametableisusedforbothRadiologyandNuclearMedicine• Activitydatainput–Radiology• Activitydatainput–NM

4. Equipment Data InputThe purpose of this worksheet is to capture all relevant information about medical imaging capital equipment irrespective of ownership, as an interim tool. This data is used to compile the 10 Year Equipment Replacement Schedule in a following worksheet. The NSW Ministry of Health is currently working on a standardised 10 year strategic management system for equipment which will then replace this worksheet, once it has been trialled and released.

The following data elements are suggested for each item of medical imaging equipment – those elementsmarkedwithanasterix(*)aredeemedmandatorytoensureintegrityoftheEquipment10Year Replacement Schedule generated:

• Facility/Location• Type*• Vendor• Model• Serialnumber• Assetgroup• Assetnumber• Ownershipmodel*• Datemanufactured• Dateacquired*• Leaseyears(inmonths)ifequipment ownershipmodelisleased*

• Upgraded• Writtendownvalue• Annualleasepayment• Indicativereplacementtype*• Indicativereplacementvendor• Indicativereplacementmodel• Indicativereplacementdate*• Indicativereplacementcost*• Indicativeownershipmodel*• Leaseyears(inmonths)ifindicative ownershipmodelisleased*

The equipment type list is suggested only and can be amended through worksheet 3 – Drop Box Lists. Please note that the worksheet will need to be saved and updated prior to the changes taking effect.

tip:

à ReviewtheDropBoxListsinthefirstinstance.LiaisewiththeRISManager to ensure the tables align with existing systems or can be mapped accordingly.


ThereisalsoaCPIfieldthatshouldbepopulated,asthiswillbeusedaspartofthecalculationsoftheindicative replacement cost in the Equipment 10 year Replacement Schedule.

It is important to note that for the lease end date to be calculated properly on existing equipment, both the date acquired and date manufactured dates must be entered even if these dates are the same.

This worksheet will calculate the Current Lease End Date, and the Indicative Lease End Date for indicative replacement, age of equipment in months, and the number of months left until the indicative replacement date for that item of equipment.

This worksheet is linked to the Equipment 10 Year RS worksheet.

5. Equipment 10 Year RSThe purpose of this worksheet is to provide a 10 year schedule of the indicative capital requirements on a year by year basis. This worksheet is generated automatically from the information input into the Equipment Data Input worksheet.

It should be noted that for items where the indicative ownership model is leasing, that there will be no capital replacement costs during the term of the indicative lease. This is based on the assumption that the costs of that lease will be part of the operating budget. However, for that item of equipment therearereplacementcostsallowedforinthefinancialyearoftheindicativeleaseexpiringifthatfallswithin the 10 year replacement schedule period.

If any results are considered inaccurate or suspect, the data in the supporting worksheet Equipment DataInputshouldbereviewedinthefirstinstance.

This worksheet does not link to any further worksheets.

6. Financial Data Input – R and Financial Data Input – NMThepurposeoftheseworksheetsistocollectandcollateallfinancialdatapertainingtoradiology(R)andnuclearmedicine(NM)toinformdevelopmentofafinancialmodelandbudget.

Costdatacollectionmaybelimitedtoaminimumof1yearfinancialdata.Thistoolallowsupto3yearsfinancialdataforcomparisonpurposesanditisrecommendedthatthisapproachbetaken.

The following data elements are suggested for each cost line item – those elements marked with an asterix(*)aredeemedmandatorytosupportintegrityoftheFinancialSummary–BudgetandtheTransfer Pricing worksheets.

• Costcentre• Costtype*• Expenseline• Adjustingitemcomments

• FYxactuals(xbeingthefinancialyear indicated as per Date worksheet)• FYx-1actutals• FYx-2actuals

The cost type list is suggested only and can be amended through worksheet 3 – Drop Box Lists. Please note that the worksheet will need to be saved and updated prior to the changes taking effect.

This worksheet links into the respective Financial Budget – Summary worksheet for each specialty group as denoted.


7. FinancialBudget–Summary(R)andFinancialBudget–Summary(NM)ThepurposeoftheseworksheetsistodevelopaFinancialSummaryofthepreviousfinancialyearswhichtheninformabudgetforthenextfinancialyearforeachspecialtyarea.

ThefiguresinputintotherespectiveFinancialDataInputsheetsareconsolidatedbyCostTypecodeandbyfinancialyear.ThesefiguresarethenadjustedbasedonCPI,ProductivitySavingsandPrivatePatientRevenuechangeforecasttoformthenextfinancialyearbudget.

TheamountthatwillneedtobecoveredbyUserCharges(TransferPricing)isthedifferencebetweentotal cost and all other revenues.

TheamountsforbudgetedNon-UserCharges,Surchargesandanyotherrevenuecosttypeasdefinedhavebeenleftfortheusertoinputbasedontheirbestinformationasthesewillvaryfromyearto year. Non-user charges may include sundry revenue, grants, donations, etc.

Privatepatientfeesareabletobeamendedbasedona%ofthelastfinancialyearthroughthePrivateRevenue Increase Target – cell D4.

Salariesandwagesareabletobeamendedbasedona%ofthelastfinancialyearthroughtheExpense CPI% - Salaries and Wages – cell D7. Depreciation and operating lease cost lines have been left for the user to input based on best information available and the decisions made about whether MIDS will include total, limited or no capital components. The remainder of the expense lines areabletobeamendedbasedona%ofthelastfinancialyearthroughtheExpenseCPI%-OtherExpenses – cell D8.

If the LHD requires any productivity savings these can be included through entering the required % in the Productivity Savings % - cell D10.

If there are any results considered inaccurate or suspect, the data in the respective supporting worksheet FinancialDataInputandthePrivateRevenueSSworksheetsshouldbereviewedinthefirstinstance.

These worksheets are linked to the respective Transfer Pricing worksheets.

8. Staff Establishment Data Input The purpose of this worksheet is to develop a schedule of all staff to ensure that the full staff establishmentforMIDSisidentifiedandrecordedtosupportthetransferprocess.Thisshouldalsobeusedasacrosschecktotherespectivefinancialsummariestoensurethatthesalariesandwagescomponent seems reasonable. It is recommended this be done initially at staff member level to ensure all MI staff is accounted for.

The following data elements are suggested for each staff member:

• Costcentre• Awardcode• Department• Firstname

• Lastname• Employeestartdate• FTEequivalent• Annualsalary

This worksheet is not linked to any other worksheet.


9. Activity Data Input – Radiology and Nuclear MedicineThe purpose of these worksheets is to collate activity information in a form that will allow trend analysis to be undertaken. This worksheet also captures data which is then used for the Private Revenue – SS worksheets.

Itisrecommendedthatactivitydatabesourcedforatleast2financialyears,and3ifatallpossible.

This information should be able to be collected from the RIS system.

The minimum information required for this worksheet is:

• ThenumberofexaminationsbyMBSbyphysiciantype(staffspecialistorVMO)perfinancial year.Thedataalsoneedtoreflectthenumberofbillableinpatientexaminationsandthe number of billable outpatient examinations

• ThemodalityassociatedwitheachMBSitem.

• ThecurrentMBSscheduledrateat100%.Thisinformstheamountofbillablerevenue calculated.

There is an option to report the number of examinations outside of the business normal operating hours. Some LHDs have implemented a system of tiered charging based on whether the service is delivered within normal operating hours or outside of these hours. Any LHD considering this approach should include this data for subsequent analysis of approach.

Once all the data is input, it is consolidated within the Modality Activity – Radiology and Modality Activity – NM sheets at modality level to allow activity trend analysis to be undertaken.

This data will also allow indicative private patient revenue to be calculated, to support transfer pricing.

This worksheet links to the Private Revenue – SS worksheets.

10.PrivateRevenueSS–(R)and(NM)The purpose of these worksheets is to determine the proportion of Staff Specialist private patient revenue that would be generated for MIDS (old infrastructure fee). If for any reason, MIDS is unable to retain this revenue then this worksheet should be ignored, as additional revenue will only be recognised if there are any values in the Infrastructure Fee % column. Not including this revenue in the MIDS will have the impact of increasing the transfer price which will be less acceptable to referrers.

These worksheets are populated by data input in the respective Activity Data Input worksheets.

Advice should be sought from the Head of the Specialist Clinical Departments and/or LHD Finance team about the % Infrastructure Fee applicable per modality in case of any special agreements. This should then be entered into the Infrastructure Fee % column accordingly for all rows.

This worksheet must be matched to the Private Revenue calculated within the respective Financial Summary Budget worksheets.


11.TransferPricing–(R)and(NM)The purpose of these worksheets is to determine the transfer price for the speciality.

Underthistool,thetransferpriceiscalculatedasapercentageofMBS,basedontheamountofestimated costs once all external revenues including private patient infrastructure fees have been taken into consideration. This methodology is simple and relatively easy to administer, and MBS is well understood by all key stakeholder and provides some relativity.

The transfer price is derived automatically from the information provided in the respective Financial Budget – Summary worksheets and the notional revenue at 100% as determined by the respective Activity Data – Input worksheets.

If any results are considered inaccurate or suspect the data in the supporting worksheet Financial Budget–SummaryandActivityData-Inputshouldbereviewedinthefirstinstance.

MIDS workload measurement

Appendix 16 has been developed to assist Radiologists to capture non-reporting as well as reporting activities on an annual basis. The framework of this tool could be adapted to capture workload of other imaging staff as well as an interim measure.

The Royal Australian and New Zealand College of Radiologists (RANZCR) is trialling new Relative ValueUnits(RVUs)forRadiologistsandexpectsthesetobeavailablein2014.Theycanthenbesubstitutedinthistool.RVUswillbeutilisedbytheCollegeintheaccreditationprocessandRANZCRhas informally recommended that a minimum of 30% of the Radiologists’ time in a public teaching hospitalshouldbespentonnon-reportingactivities.ThenewRVUswillincludeRadiographersandNurses as well.

It will be useful to refer to the Report of the Radiology Workforce Project, a joint endeavour of the Workforce Planning and Development Branch of the Ministry for Health and the ACI Radiology Network, due for release early 2014.

Using the MIDS workload measurement tool

This tool contains a number of linked worksheets. It is recommended that individual Radiologists estimate non-reporting activity annually for the year ahead.

RVUswillneedtobeallocatedtoMBSitemnumbersinRIS(includingsomefortime-takenRVUs)sothat reporting activity can be captured on a daily basis.

The Clinical Director would then coordinate into an overall workplan to ensure that the expected workload of the facility is covered by the Radiologist team.

1. Staff Specialist HoursThis worksheet estimates the number of working weeks in the coming year for each Radiologist. How much TESL and other leave do they intend to take? It also captures the number of working hours at the facility on a weekly basis and hence the weekly working pattern is established.


2. MeetingsRadiologists are expected to attend multiple Multidisciplinary Team (MDT) meetings with referring departments. Other regular meetings may include those held within Medical Imaging, administrative, LHD, facility, Pillars and Ministry of Health. Known meetings are entered on a weekly, monthly, quarterly and annual basis. Number of meetings and length of time for each is estimated.

3. ConsultationWith the increase in interventional procedures and more acute patients, Radiologists are required to consult with referring clinicians more regularly both formally and informally. In addition, they need to be available to consult with MI staff on best patient care within the department.

4. TeachingAtteachinghospitals,RadiologyTraineestakefiveyearstotrain;NuclearMedicineAdvancedTraineesanother two years. The more time spent with Trainees, the better able they are to assist with reporting and other workload. Consultants undertake formal and informal teaching sessions for Trainees and other MI staff with time allowed for preparation.

5. Other non-reporting activitiesResearch, quality assurance activities such as audits and double reporting, working at home, etc. are captured in this worksheet.

6. ReportingRadiologistsidentifythemodalitiesinwhichtheyregularlywork.ExistingPitman-JonesmodalityRVUsareidentifiedwithcorrelatingnumberofreportsperhour.ThistoolcalculatesRVUsperhourat30.

ForIR,INR,proceduralCTandMRI,fluoro,operatingtheatres,on-call,unusuallycomplexand/ortime-consumingexaminations(inclpaeds,GA,etc.)RVUsarecalculatedbythetimetheytaketocompleteasthiscanvarywidely,ie.30perhour.Time-basedRVUsmayneedtobeaddedasitemnumbers in RIS.

7. Summary The individual Radiologist’s summary page shows working weeks for the coming year, working hours per week, percentage non-reporting activity hours of the total hours per week and variance to agreed, appropriate range of non-reporting hours.


Appendix15:DatacollectionandfinancialoutcomestoolAppendix 16: Workload measurement template

tip:

à Appendix 15 shows a sample only of working spreadsheets which can be found on the ACI website at www.aci.health.nsw.gov.au/resources then click on Clinicians and Managers, then Radiology or Nuclear Medicine


steP 4: key stAkeHoLDer consuLtAtions

Developing an understanding of key customer perceptions and expectations

Oneofthekeysuccessfactorsidentifiedfromconsultationswiththesectorwashavingasoundunderstanding of key stakeholder expectations. One of the greatest sources of dissatisfaction is having unmet expectations. Identifying the MI key stakeholder expectations will then allow the MI service to undertake a gap analysis, identify unmet expectations and determine if these can be met within available resources. If all expectations cannot be managed within current resourcing constraints,theimpactofnotmeetingthoseexpectationshastobeidentified.

Appendix 9 contains the Key Stakeholder mapping template, and should be used as a guide when determining who should participate in the consultations. All referring clinical departments should be included in the consultation process, as well as LHD executive and the General Managers of all facilities.

Appendix 17 contains a template of the guideline for the stakeholder consultations. This template should reviewed and amended accordingly prior to the consultations.

Appendix 18 contains a template to record the outcome of the consultation process. These outcomes will assist informing the service delivery gap analysis which is suggested as the next step in this process.

Understandingtheexpectationsandanyadditionalcostsofmeetingunmetexpectationscanbethesubject of further discussions with key stakeholders. The aim is to determine if they would support an increase in resourcing impacting upon the eventual transfer price, or reach agreement on what should be the service expectations if additional resourcing is not supported.

Operational indicators can then be developed to monitor performance against agreed expectations as part of Phase 3, and this could be formalised as part of a service delivery agreement if deemed appropriate.

steP 5: Determine Any current or PotentiAL gAPs in service Provision, AnD How mi couLD ADDress tHese gAPs

Start considering how the medical imaging service could meet current and future service demands mostefficientlyandeffectively

The activity data collected as part of Step 3 should be trended to determine indicative future activity levels. This trending should be informed by any known changes in clinical activity which may impact upon service demand such as changes to clinical care, LHD service planning, and external competitor activity.

Work could be undertaken to understand if all MI equipment is currently operating at full capacity based on current service availability. This would require some data analysis of the workload of each particular piece of equipment during standard hours of operation over a set period of time, compared tothebenchmarkworkloadbasedonspecificmodality.Thisanalysiswouldquantifyworkloadandcould be used as part of a business case for any future equipment acquisitions. Consideration shouldalwaysbegiventoadditionalstaffingneedsshouldadditionalequipmentbeacquired.


Currentgapsinkeystakeholderexpectationsofservicedeliveryshouldnowhavebeenidentifiedthrough the consultation process. Scenario testing could be undertaken to determine the impact of any adjustment to service availability, and the cost impact if unable to be managed within existing resource constraints.

The results of this data analysis will inform future service planning, and should also be used as part of the feedback process as part of Step 6.

steP 6: communicAte resuLts of consuLtAtions

Continue engagement process with key stakeholders

Results of the consultations should be fed back to key stakeholders.

These communications could be in the form of:

• Anewslettertoallexternalclinicaldepartmentheadsadvisingofthekeyfindingsfromthe consultations and any recommendations arising• Presentationsatkeycommitteemeetings• Furtheroneononediscussionswithspecificdepartments

Providing both positive and negative feedback on the consultation process will be useful in engaging the key stakeholders for the potential changes ahead.


Revisit Appendix 9: Stakeholder mapping template - Completed

Appendix 17: Guidelines for stakeholder consultation process template

Appendix 18: Outcomes of stakeholder consultation process template


steP 7: Determine reADiness for miDs moDeL

Determine if the medical imaging service is ready for the change

An assessment should be undertaken to determine readiness for change. This assessment should be undertaken at the LHD, Facility and Medical Imaging levels. The results of this assessment should inform the Implementation Team about the level of current readiness.

Thisassessmentshouldconsiderthevariouselementsthatwouldinfluencereadinessforchange,ratecurrent readiness, identify enablers and barriers to change, and any recommended actions to address anyidentifiedbarriersand/orimprovethecurrentreadinessrating.

The MIDS Implementation Team should consider the results of this assessment, consider and develop strategies to address any issues arising, prior to commencing Phase 3 if the decision is to proceed with MIDS implementation.


Appendix 19: Readiness for MIDS template


cHeckList


Have you:

Obtained ongoing Executive sponsorship for the project Established the LHD’s objectives and readiness for change Definedwhatcostswillbeincluded,andwhatwillbeexcludedintheoperatingbudget. For those overhead costs to be included, there is an agreed methodology for cost allocation to MI Collected all the following information for all in scope MI services across the LHD including: • MIcosts • MIstaffestablishment • MIequipment • MIactivityincludingprivatepatientactivity Calculated preliminary operating budget and indicative transfer price Undertakenkeystakeholderconsultationsandcompiledtheresultsofthoseconsultations Undertakengapanalysisofserviceprovisionandunderstoodthelevelofresourcingrequiredto addressanyidentifieddeficiencies Communicated the results of the stakeholder consultations Determined MI readiness to implement the MIDS model Identifiedandmanagedanyrisk




phase 3: plan for the operation of the Mids Model

ThepurposeofthisphaseistodefineanddocumenttheplanningrequiredtoimplementtheMIDSmodel in your LHD.

Activities

There are nine key activities to consider in developing implementation resources for the MIDS model. These are:

step 1: Confirmclinicalgovernancearrangementsstep 2: Confirmoperationalarrangements-delegations,responsibilities,etc.step 3: Develop a MIDS Strategic Plan and a MIDS business planstep 4: ConfirmthefinancialmodelforMIDSandfinalisetransferpricestep 5: LHDsignsofffirstyearoperatingbudgetstep 6: Determine the monitoring measures needed for the MIDS modelstep 7: Undertakefinalstakeholdercommunication/educationstep 8: Definetheprocessesandprocedurestobedocumentedstep 9: Develop MIDS evaluation framework

steP 1: confirm cLinicAL governAnce ArrAngements

Who is responsible for clinical governance of MIDS?

ThestructuresforclinicaloversightoftheMIDSclinicalactivitiesshouldbewelldefinedsothiscanbeincluded as part of the communications to key stakeholders.

Implementation of the MIDS with reporting back to the LHD can result in a lack of understanding about clinical governance and the accountabilities. There needs to be a consideration of the needs of each professional group to have linkages and accountabilities to ensure clinical care is delivered to appropriate standards.

Formalising the lines of clinical accountabilities and ensuring appropriate clinical governance structures will assist to ensure appropriate clinical care and reduce any concerns by clinical stakeholders regarding quality of care. The LHD Director of Clinical Governance should be consulted as part of this process.

Appendix 20 contains an organisational chart template which includes clinical governance arrangements. However, these should be considered indicative, and are provided as a starting point forfurtherdiscussion.TheMIDSmodelaimstoachievefinancialandclinicalbalance.

Finalising clinical governance will assist in developing the communications and educational packages to be developed as part of Step 7 of this process.


steP 2: confirm oPerAtionAL ArrAngements - DeLegAtions, resPonsibiLities, etc.

WhoisresponsiblefortheoperationalandfinancialgovernanceofMIDS?

ThestructuresforoperationalandfinancialoversightofMIDSactivitiesshouldbewelldefinedsothiscan be included as part of the communications to key stakeholders to promote understanding. The LHDexecutiveresponsibleforfinancialreportingshouldbeconsultedaspartofthisprocess.

Thiswillinformtheappropriatefinancialstructuresandreportingthatwillneedtobedevelopedtosupport the implementation.

Appendix20containsanorganisationalcharttemplatewhichincludesoperationalandfinancialgovernance arrangements however these should be considered indicative, and are provided as a startingpointforfurtherdiscussion.TheMIDSmodelaimstoachievefinancialandclinicalbalance.

Formalisingthelinesofoperationalandfinancialaccountabilitieswillinformthelevelofdelegationappropriate for the MIDS Executive Director and/or Business Manager. Appendix 21 contains a template which outlines some of the delegations that should be considered for the MIDS Executive, and should be considered as indicative. This has been provided as a starting point for further discussion with the appropriate LHD Executive.

As revenue is a key component of the MIDS model, there should be discussions with the LHD on who will be responsible for managing the revenue cycle, and how this would be monitored. Appendix 22 contains a relevant template.

Finalising governance structures will assist in developing the communications and educational packages to be developed as part of Step 7 of this process. This will also inform the development of thespecificreportingrequiredtosupportMIDSaspartofStep10ofthisprocess.

steP 3: DeveLoP A miDs strAtegic PLAn AnD A miDs business PLAn

What are the strategic objectives of MIDS and how will these be operationalised?

The strategic objectives of the MIDS should be formalised as part of a Strategic Plan. It is recommendedthataspecificgoalbeincludedaboutmaintainingsoundcommunicationswithkeystakeholders to promote and maximise engagement under the MIDS model.


Appendix 20: MIDS organisation chart templateAppendix 21: MIDS delegations template


A 1-2 year Business Plan should be developed including:

• Actionitemstooperationalisethestrategicplan• Timeframesforeachactionitem• Whoisresponsibleforensuringcompletionofeachactionitem• Themeasureusedtodeterminesuccess/achievementoftheactionitem

TemplateshavenotbeenprovidedasitisassumedthateachLHDwillhavetheirownspecifictemplates for strategic and business plans.

steP 4: confirm tHe finAnciAL moDeL for miDs AnD finALise trAnsfer Price

Whatwillbethefinalbudgetandtransferprice?

ThefinancialmodeldevelopedaspartofPhase2Step3shouldnowbereviewedtoensurethattherearesufficientresourcesavailabletoachievethestrategicandbusinessplans.Adjustmentsshouldbemadetoreflectanynecessaryadditionalexpenditureintheproposedbudget,whichwillformthe basis for development of the proposed transfer price. The proposed transfer price should also nowbefinalised.ItisrecommendedthatthisbeworkshoppedwithkeyrepresentativesoftheLHDfinancialteamtoensureunderstanding.

ThereshouldalsobediscussionsaboutthemechanismsforcapitalprovisioningwithLHDfinanceifthe transfer pricing includes a capital component.

The rationale for each adjustment should be clearly documented to support discussions to obtain approval as part of Step 5.

steP 5: LHD signs off first yeAr oPerAting buDget

Obtaining LHD approval to move forward

TheMIDSstrategicplan,businessplan,andfinancialmodelincludingproposedbudgetandtransfer pricing should now be presented to the LHD Executive for endorsement and approval. The MIDS operating budget and associated transfer pricing will need to be reviewed and signed off on annualised basis.


RevisitAppendix15:Datacollectionandfinancialoutcomestool – Financial budget summary - input completed and Transfer pricing worksheets


steP 6: Determine tHe monitoring meAsures neeDeD for tHe miDs moDeL

Whatarethenecessaryoperational,financialandqualityandactivitymeasurestoprovideoversight of MIDS

Systems and processes will need to be developed to ensure appropriate monitoring and measuring of MIDS performance. This will include internal and external monitoring.

1. MIDS The MIDS executive team needs to ensure that measures are put in place to allow them to monitor theoperational,financial,qualityandactivityindicatorsoftheservicetoprovideacomprehensivebalancedviewofperformance.FortheMIDSexecutivethesemeasuresshouldbesufficientlyhighlevel to provide an overall view of performance, but targeted to identify potential areas of concern which should then become an area of focus for more detailed analysis. This reporting structure should also be considered at the department level, so that cost centre managers are also given a balanced view of their department’s performance.

This information could include: Operational indicators such as:• Activityperfulltimeequivalent• Weightedactivityperfulltimeequivalent

Financial indicators such as:• Labourcostsperactivity• Labourcostsas%ofrevenue• %Privateandcompensablepatients• MIDSfinancialperformance(surplus/deficit)• MIDSperformanceasa%ofrevenue

Quality indicators such as:• Reportsnotavailabletoreferringdoctorwithin24hours• UnplannedadmissionstohospitalpostIRprocedures• %IRprocedureswithsedationincidents• IIMSreportsas%oftotalexams• %Formalreportswhichcontradictinformalreports

Access indicators such as:• %EDrequestsnotmetwithin2hours• %Otherurgentrequestsnotmetwithin2hours• Reportturnaroundtime


RevisitAppendix15:Datacollectionandfinancialoutcomestool – Financial budget summary - input completed and Transfer pricing worksheets


ThisshouldbesupportedbyahighlevelProfitandLossstatementincludingvariancetobudget,andrevenue monitoring including debtor ageing. Revenue is an important consideration for this service. It is important that the MIDS executive retain some visibility over revenue collections if the responsibility for MI revenue management is not devolved to this service.

Thereportingcycleshouldalsobeconsidered.Operational,activityandfinancialindicatorsshouldbereported on a monthly basis. Consideration should be given for reporting quality indicators in line with the standard clinical performance indicator reporting cycle.

Additional indicators may be developed to monitor service delivery as evidence of performance against key stakeholder expectations.

A performance monitoring and reporting template (Appendix 22) has been developed for consideration,althoughitisrecognisedthattheLHDshouldhaveestablishedfinancialreportingsystems.

WorkshouldnowbeundertakenwithFinanceandICTtoensurethenewfinancialstructureswillbeimplementedforfuturefinancialreportingwhenMIDSisimplemented.

2. LHD ExecutiveReports should be provided to the LHD executive to provide some visibility of MI performance. It is recommended that this reporting be at the facility level, to provide the facility managers with some overview of MI performance at the facility level. This report could be supplemented by access indicators at the facility level if deemed appropriate.

A template has been developed at the facility level (Appendix 23), which shows the number of examinations by modality, and the total charge for the period, YTD and comparisons to budget if an activity budget has been developed.

There are supporting tables that show the examinations by modality by department and the charges by modality by department.

3. ReferrersReports should be provided to the referrers to provide visibility of MI performance, and the associated costs under a transfer pricing environment (Appendix 23).

Providing transparency of costs should provide some incentive for high level users to examine usage anddetermineifthisisthemosteffectiveutilisationofscarcefinancialresources.

It is suggested that there be three levels of reporting provided to referrers:• Summaryreportingbymodality,showingactivityandcostonamonthlybasis.Thisshould includeYTDfiguresandbudgetvarianceifbudgetisallocated• Summaryreportingbyreferringdoctorshowingactivity,cost,averageactivityperpatient, average cost per patient and activity and costs YTD on a monthly basis• Detailedreportingbydoctorbymodalityshowingactivityandcostonamonthlybasis

DiscussionsshouldbeheldwiththeRISmanager,FinanceandICTrepresentativestofinalisereporting requirements and plan implementation.


steP 7: unDertAke finAL stAkeHoLDer communicAtion / eDucAtion

Continue engagement process with key stakeholders

Taking into account all previous steps, stakeholders should now be informed of the details of the approvedMIDSbusinessmodelincludingfinaltransferpriceandsamplesofreportstheywillreceive.

As always it is recommended that the communications utilise a variety of methods to ensure the message is received.

steP 8: Define tHe Processes AnD ProceDures to be DocumenteD

WhatspecificprocedureswillneedtobewrittentosupportMIDS

When developing new processes it is important that they be documented to ensure there is no operational ambiguity. Developing documented procedures of key operational processes is an important part of a quality management system and vital to assist the health facility maintains accreditation.

Asnewprocessesaredevelopeditisimportanttodefinewhichprocessesshouldbedocumented.Consideration should be given to the key processes that are being developed to support the MIDS model.

A checklist of key processes has been developed as part of the toolkit. This should be considered indicative.

Asakeyprocessisidentifiedfordocumentation,considerationshouldbegivenastohowthiswillberesourced, and who will approve the materials developed.


Appendix 22: Performance monitoring and reporting toolAppendix 23: MIDS LHD and Referrer report template

tip:

à Whenfirstprovidingreferrerswithreports,itwouldbeusefultoprovide detailed reports until the users become familiar with the data, and develop an understanding of key benchmarks. Once departmental benchmarks have been developed then detailed reporting can be on an exception basis.



Appendix15:DatacollectionandfinancialoutcomestoolAppendix 16: Workload measurement template


Appendix 25: MIDS Evaluation Framework template

tip:

à Liaise with the department responsible for ensuring the LHD/Facility maintains accreditation. This department will be able to provide advice and may be able to assist in the development of procedures to support key processes

à DiagnosticImagingAccreditationScheme(DIAS)requirementsmust also be considered

à Key processes may include input from representatives from other departments i.e. revenue cycle management.

steP 9: DeveLoP miDs evALuAtion frAmework

Establishing baseline measures for subsequent evaluation

Objectives for change were established as part of Phase 1, Step 1. These objectives should now bereviewed,amendedifrequiredandthenratifiedbytheMIDSImplementationTeamforuseasobjectives to evaluate the success of the implementation of the MIDS model.

For each objective there should be an expected outcome. It is important that a baseline be developed prior to the MIDS implementation, so the MIDS executive and LHD can determine if there has been change, and if so has the change been effective in reaching expected outcomes.

Methodology and measures for determining baseline and subsequent changes will need to be developed. There needs to be consideration of existing data that may inform some measures. Consideration should also be given to the frequency of the measures – customer satisfaction may be measured annually whereas other measures may be done less frequently.

It is important to note that change takes time. It is recommended that an interim evaluation be undertaken18monthsafterintroduction,andafinalevaluationbeundertakenatabout3yearsafterintroduction, as changes of this magnitude will take some time to become embedded and accepted. Datesforbaseline,interimandfinalevaluationshouldbedeterminedaspartofthisplanningprocess,as well as a mechanism for KPI reporting.


cHeckList


Have you:

Obtained ongoing Executive sponsorship for the project Finalised clinical governance for MIDS FinalisedoperationalandfinancialgovernanceforMIDS Developed a MIDS Strategic Plan and MIDS Business Plan ConfirmedtheMIDSfinancialmodelincludingfinaltransferprice Received LHD sign off on the proposed MIDS budget and transfer pricing DevelopedthemonitoringmeasuresforMIDSincludingoperational,financialqualityandactivity measures Communicated to internal and external stakeholders about the details of the approved MIDS model DefinedtheprocessesandproceduresthatwillneedtobedocumentedaspartofPhase4 Developed the evaluation framework to determine if the implementation of MIDS achieves the stated objectives in the short, medium and long term.




phase 4: iMpleMent and Monitor

The purpose of this phase is to implement, test and revise the model, to monitor and manage the change by the collection, analysis and reporting on monitoring measures.

Activities

There are eight key activities to consider implementing and evaluating the MIDS model. These are:

step 1: Establish a permanent Management Committee step 2: Procure equipment if requiredstep 3: Evaluate workforce step 4: Monitor the change management associated with MIDS implementation step 5: Report regularly to LHD, referrers and MIDS cost centre managersstep 6: Revisit the Communications Plan and request feedback from stakeholdersstep 7: Review and evaluate effectiveness of the MIDS modelstep 8: Make necessary adjustments annually

Who is responsible for implementation of MIDS, monitoring and evaluation?

The MIDS Executive is responsible for transitioning the MIDS project from planning to implementation. This will build upon the work already undertaken in the previous phases of this project.

steP 1: estAbLisH A PermAnent mAnAgement committee

Disband the implementation team and establish a MIDS Management Committee (see Appendix 10). The MIDS Management Committee is responsible for annual sign off of MIDS budget, etc. and to arbitrate if and when required.

steP 2: Procure equiPment if requireD

Within the 10 year plan for MI equipment, determine which items require replacing now and in the future. Decide whether to purchase or lease and what levels of service are required per item.

steP 3: evALuAte workforce

Determine which staff are the most appropriate and cost effective to undertake the workload demand in the facility. Is restructuring required and how will this be managed?


steP 4: monitor tHe cHAnge mAnAgement AssociAteD witH miDs imPLementAtion

Monitor the implementation of changes with the MIDS model

steP 5: rePort reguLArLy to LHD, referrers AnD miDs cost centre mAnAgers

Deliver regular reports to referrers, the LHD and cost centre managers

steP 6: revisit tHe communicAtions PLAn AnD request feeDbAck from stAkeHoLDers

Request feedback from stakeholders

steP 7: review AnD evALuAte effectiveness of tHe miDs moDeL

Ongoing review and evaluation to determine the effectiveness of the MIDS Model

steP 8: mAke necessAry ADjustments AnnuALLy

Usingthepreviousyear’soperatingbudget,adjustingforknownchangingcircumstances,calculateanysurplusoranyadditionaldeficitsandrecalculatetransferprice


Agency for Clinical Innovation

The ACI website holds the actual working resources depicted in the Appendices.www.aci.health.nsw.gov.au/resources then click on Clinicians and Managers, then Radiology or Nuclear Medicine.

Business and Assets Branch, Ministry of Health (BAS, MoH)

http://internal.health.nsw.gov.au/operations/apmd/

The following link provides useful information on the projects ongoing in BAS Branch; most updates that are posted in this section are also distributed throughout the ACI Radiology & Nuclear Medicine Network.

http://procurementportal.moh.health.nsw.gov.au/ministryprograms/Pages/Medical-Imaging.aspx

With regard to operating leases, we do not encourage LHDs to procure outside of the Standing Offer Agreement as the agreement provides a safeguard in the form of comprehensive terms and conditions.TheSOAismanagedbyNSWPublicWorksisnotsupportiveoffinanceleases,onlyoperating leases that comply with appropriate accounting standards.

The below link will provide access to NSW Public Works and the services they offer.

www.publicworks.nsw.gov.au/infrastructure-engineering/electromedical-engineering

Finance Branch, Ministry of Health

FinanceBranchhasaleadroleofcoordinatingandmonitoringthefinancialperformanceoftheNSWpublic health system within the overall strategic planning framework. Advice should be sought for accounting practices to support MIDS

http://internal.hea.nsw.gov.au/finance/

UsefUl links


cmbsCommonwealthMedicalBenefitsSchemeLHD Local Health Districtmbs MedicalBenefitsSchememi Medical ImagingmiDs Medical Imaging District Servicesncos Net Cost of Salesnm Nuclear MedicinesoA Standing Offer Agreement

glossary of terMs / abbreviations


appendices

Appendix 1: LHD Objectives for changeAppendix 2: LHD Readiness for ChangeAppendix 3: Position description – Executive Director, MIDSAppendix 4: Position description – Business Manager, MIDSAppendix 5: Project team structureAppendix 6: Project governance structureAppendix 7: Project Status report templateAppendix 8: Budget templateAppendix 9: Stakeholder mapping templateAppendix 10: Implementation plan templateAppendix 11: Communications plan templateAppendix 12: Risk register templateAppendix 13: MIDS service delivery checklistAppendix 14: MIDS cost considerations checklistAppendix 15: Datacollection&financialoutcomestool •Costdatacollection–byspecialty •Activitydatacollection–byspecialty •Staffingprofile •Equipmentdatacollection •10yearequipmentreplacementschedule •Privaterevenue–byspecialty •Budget–byspecialty •Transferpricecalculator–byspecialtyAppendix 16: Workload measurementAppendix 17: Guidelines for stakeholder consultation processAppendix 18: Outcomes of stakeholder consultation process templateAppendix 19: Readiness for MIDS templateAppendix 20: MIDS organisation chart templateAppendix 21: MIDS delegations templateAppendix 22: Performance monitoring and reportingAppendix 23: MIDS LHD and Referrer reportAppendix 24: Checklist of key processes and procedures to be developedAppendix 25: MIDS Evaluation Framework template


appendix 1: lhd objectives for change

PurposeToprovidetherationaleforimplementingtheMIDSmodelwithintheLHD,andwhatbenefitsareexpectedasaresult.Understandingtheobjectivesforchangewillinformdevelopmentofappropriate communications to stakeholders and establish baseline measures and the collection of data. Monitoring and reporting (Appendix 22) can then be developed to ensure those objectives can be assessed and measured.

This assessment and measures can then form the basis for evaluation of the implemented MIDS model after a 12-18 month period (Appendix 25).

When should this be completed?These objectives for change should be completed at the start of Phase 1.


* To be used in Appendix 25 - MIDS evaluation framework


appendix 2: lhd readiness for change

Purpose:To determine where the LHD is placed in preparation for implementation of a MIDS model

When should this be completed?At the commencement of the project


appendix 3: position description – execUtive director, Mids

PurposeTo provide a Position Description (PD) for this permanent position. After implementation, this person will continue in an executive leadership role to strategically and operationally manage the MIDS, in partnership with the Clinical Lead(s). A more comprehensive Duty Statement may be added for clarity and detail.

When should this be completed?Recruitment for this position should occur at the beginning of the project so the successful applicant can contribute to the implementation, ideally in the role of Project Manager.

Rationale for Reporting Structure in the PDIt is critical that this position forms an equal partnership with the MIDS Clinical Director(s) and Lead(s) of the various Medical Imaging (MI) departments which comprise the MIDS. For this reason, their title is Executive (or Business) Director so as not to be confused with the Clinical Director. While the Executive Director’s focus is on strategic business operations, this can never overshadow patient care and safety. It is important to remember that regardless of business arrangements, MI departments remain a public hospital service and an integral part of the hospital just like all other medical and surgical specialties.

The Executive Director reports to the same member of the (LHD) Executive as the Clinical Lead(s).


appendix 4: position description – bUsiness Manager, Mids

PurposeTo provide a Position Description (PD) for this permanent position. After assisting with implementation, this person will continue in a support role to the Executive Director, MIDS and be responsible for the financial,administrativeandinformationsystemsfunctionsofthe(LHD)MIDS.AmorecomprehensiveDuty Statement may be added for clarity and detail.

Should a single hospital choose to implement the MIDS model, this position may stand alone without an Executive Director.

When should this be completed?Recruitment for this position should occur at the beginning of the project so the successful applicant can contribute to the implementation.

Rationale for Reporting Structure in the PDThis position has a vital role in assisting the Executive Director achieve business goals with data collection and reporting a focus.


appendix 5: project teaM strUctUre

PurposeTo have an established team that is dedicated and accountable to the project.

When should this be completed?This will occur at the beginning of the project in Phase 1.

Example project structure


appendix 6: project governance strUctUre

PurposeTo help manage, direct and understand who will be accountable for the Medical Imaging District Services (MIDS) model being developed and implemented.

When should this be completed?This will occur at the beginning of the project in Phase 1.

Example governance structure


appendix 7: project statUs report teMplate

PurposeThe project status report acts as a tracking tool to make sure the team and project are progressing on time against your established time frames at each stage. It also helps to highlight what risks could affect the progress of the project and how they can be resolved.

When should this be completed?Fortnightly project progress updates are recommended.

Example project status report next page


appendix 8: bUdget teMplate

Purpose:Outline any budget requirements that may be incurred while establishing the Medical Imaging District Services (MIDS) model. It is however most likely that project costs will be absorbed into the LHD’s operational budget utilising existing resources.

When should this be completed?This should be completed on commencement of the project in Phase 1 and reviewed again in phase 3whenoperationalisationoftheMIDSmodelisconfirmedandresourcerequirementsunderstood.

Example project budget template on next page


appendix 9: stakeholder Mapping teMplate

PurposeIt is an essential part of any implementation project to identify individuals or groups likely to affect or be affected by the MIDS model. A stakeholder mapping exercise will help identify your stakeholders according to their impact on the MIDS model and the impact the MIDS model will have on them. It can also highlight potential barriers to the project and facilitate the engagement of all relevant stakeholders in communications to improve their understanding of what you are trying to achieve. Identifying your stakeholder groups will feed into your communication plan.

The stakeholder map will allow you to track stakeholder engagement throughout the project, including who they are, when they need to be informed, and what requirements they need. Identifying those stakeholders that may be resistant to the MIDS model during this activity will help feed into your risk register.

When should this be completed?ItshouldbeoneofthefirstactivitiestheimplementationteamundertakesinPhase1.Itshouldbeprovided to the Executive Project Sponsor and LHD as part of the initial planning documents.


Stakeholder Mapping


appendix 10: iMpleMentation plan teMplate

PurposeTo provide a step-by-step outline of each task in each phase in the implementation of the MIDS model. It will outline who is responsible for each step and when the step needs to be completed by and highlight if there are any resources that will be needed to help the process.

When should this be completed?The implementation plan should be completed in Phase 1 after mapping of stakeholders.


appendix 11: coMMUnications plan teMplate

Purpose:To help get the right message delivered to the right audiences at the right time. The communication plan is not the implementation plan; it is complementary to the implementation plan. The communication plan will help clarify:

• Projectgoalsandobjectives• Keyaudiences,messagesandcommunicationchannels• Stakeholders’rolesintheproject• ThatstaffarereceivingconsistentinformationabouttheMIDSmodel.

It is essential to have documented evidence of consultations with stakeholders. The communication plan provides this opportunity and will feed into the risk register.

When should this be completed?Once the implementation plan has been developed in Phase 1 and there is understanding of how the project will run, the communication plan should then be developed.


appendix 12: risk register teMplate

Purpose:To highlight any risks early in the project that may jeopardise progress.

Typically a risk register contains:

• Adescriptionoftherisk• Theimpactoftherisk,shoulditoccur• Theprobabilityofitsoccurrence• Asummaryoftheplannedresponse,shouldtheeventoccur• Asummaryofthemitigation(theactionstakeninadvancetoreducetheprobabilityand/or impact of the event) • Actionsby(personaccountable)andduedate.

When should this be completed?This should be complete in Phase 1. However the register should be constantly updated throughout the project, particularly at the beginning of each phase.


appendix 13: Mids service delivery checklist

PurposeThis checklist will inform all stakeholders what services, clinical and other, the MIDS will provide. With finalagreementonservicestobeprovided,thereisanexpectationthatsufficientresourceswillbeapproved within the operating budget to provide those services.

Based on equipment in rooms, you may wish to add more detail by attaching a full list of procedures to be offered.

If a modality is excluded, it is assumed that either the hospital doesn’t offer it or another department does, external to MIDS.

Clinical support services are those where the examinations are not included in MIDS activity but staffingandcostsareincludedintheMIDSoperatingbudget.Listimagingservicesandstaffwhichare provided by MIDS to other departments.

Non-reporting services are crucial components of providing imaging services in a public health setting.

When should this be completed?This should be completed early in Phase 2.


appendix 14: Mids cost considerations checklist

PurposeThistemplatewillinformthedevelopmentoftheeventualtransferprice.Thefirstsectioninformsthelevel of capital that will need to be included in the development of the transfer price. The second section highlights the direct costs that may or may not be included in the transfer price. The third sectionidentifieswhichoverheadcostsmayormaynotbeincluded,andshouldinitiatediscussionsabout the preferred methodology for determining the costs to be included for the MIDS operating budget and therefore transfer pricing, which will be captured in the Cost data collection template in Appendix 15.

The checklist should be completed for each facility within the LHD as costs may vary.

If any of the costs included in the operating budget change, there needs to be a mechanism to adjust the transfer price accordingly.

When should this be completed?This should be completed at the beginning of Phase 2 and revisited annually.


appendix 15: data collection & financial oUtcoMes tool

PurposeThis tool has been developed to support data collection for costs, revenue, activity, staff and equipment.Thecostandrevenuedatawillfeedintoafinancialsummarybudget,andthiscombinedwith private activity data informing indicative private revenue will determine a proposed transfer price, based on net cost of service as a % of MBS. This tool allows for separate budget and transfer price for radiology and nuclear medicine.

Samples of the different worksheets are shown below.

When should this be completed?This should be completed as part of Phase 2. This tool will be revisited as part of Phase 3.


Sample Drop Box Lists


Equipment Data Input – Part 1




Equipment 10 Year RS


Financial Data Input – Radiology


PrivateRevenue(SS)-Radiology


Financial Summary – Budget Radiology

Transfer Pricing – Radiology


appendix 16: workload MeasUreMent

PurposeThe purpose of this template is to measure all activities undertaken by the Radiologist based on theRelativeValueUnits(RVUs)developedbyPitman-Jonesin2006.Similartemplatescouldbedeveloped for Nurses, Radiographers and support staff. The Royal Australian and New Zealand CollegeofRadiologists(RANZCR)isupdatingtheRadiologistRVUsandthisversion,expectedin2014, will include workload measurement for Nurses and Radiographers.

It is designed as a once a year, in advance, snap shot of a particular Radiologist’s workload. The Clinical Director would then coordinate into an overall workplan to ensure that the workload of the facility is covered by the Radiologist team.

ItwillrequireRVUstobeallocatedtoMBSitemsinRISincludingsomefortime-takenRVUs.

When should this be completed?This should be completed as part of Phase 2.


appendix 17: gUidelines for stakeholder consUltation process

PurposeTo inform the MIDS team of the current expectations of MI services from the key stakeholders, whowillhavebeenidentifiedthroughtheStakeholdermappingprocessaspartofPhase1.Acritical component of the MIDS implementation process is to understand current expectations. UnderstandingcurrentexpectationsoftheMIservicewillallowMIDSmanagementtodetermineifexpectationscanbedeliveredwithincurrentresourcing.Anysubsequentgapscanbeidentified.Further discussions with stakeholders will determine if they would support an increase in resourcing which would have an impact upon the eventual transfer price, or reach agreement on what should be the service expectations if additional resourcing is not supported. Operational indicators can then be developed to monitor performance against agreed expectations as part of Phase 3.

When should this be completed?These consultations should be conducted as part of Phase 2. A template for recording the outcomes of the stakeholder consultation process is included as Appendix 18.


appendix 18: oUtcoMes of stakeholder consUltation process teMplate

PurposeTo record the feedback from key stakeholders following stakeholder consultations and supports the Stakeholder Consultation Guidelines as part of Appendix 17. This will quantify current expectations, which will then form the basis of analysis to identify gaps in service delivery and determine if expectationscanbedeliveredwithincurrentresourcing.Theidentificationofanygapswhichcannotbe met within current resourcing can then be the subject of further discussions with stakeholders. These discussions should determine if the key stakeholders would support an increase in resourcing which would have an impact upon the eventual transfer price, or reach agreement on what should be the service expectations if additional resourcing is not supported. Operational indicators can then be developed to monitor performance against agreed expectations as part of Phase 3.

When should this be completed?These consultations should be conducted as part of Phase 2.


appendix 19: readiness for Mids teMplate

PurposeTo determine where the LHD, facilities and Medical Imaging departments are placed in preparation for the implementation of the MIDS model. This will help identify potential mitigation strategies and enablers for project acceptance.

When should this be completed?This should be completed once all data has been collected and analysed, and stakeholder consultations completed at the end of Phase 2.


appendix 20: Mids organisation chart teMplate

PurposeTo determine the appropriate governance structures of the LHD MIDS. It is important to ensure there issoundclinical,operationalandfinancialgovernanceoftheMIDS.AMIDSExecutiveManagementCommittee, meeting twice a year could include key stakeholders, such as members of the local Clinical Council, representation from the LHD human resources area, the LHD Executive Sponsors of the MIDS, a MI Clinical Director and the MIDS Executive Director to ensure there is sound clinical, operationalandfinancialgovernance.

Thisorganisationalchartalsoreflectsprofessionalaccountabilitiesformedicalandnursingservicestothe respective LHD executives, ensuring there is appropriate professional governance.

It is recommended that the clinical and business leads in the MIDS work side-by-side to ensure thecorrectbalanceundertheLHD’sguidance.ThisorganisationalchartalsoreflectsthattheMIDSExecutive Director will work in partnership with the Hospital GMs to ensure MI services are delivered in line with agreed expectations.

This organisational chart should be used as part of the communicational/educational packages developed as part of Step 8.

When should this be completed?This should be completed at the beginning of Phase 3.


appendix 21: Mids delegations teMplate

PurposeThis checklist will inform thinking about the level of delegations for key MIDS Executives. This checklist should then be used as the basis for discussions with the LHD.



appendix 22: perforMance Monitoring and reporting

PurposeThis tool provides a template for MIDS performance monitoring and reporting. These reports can be used by MIDS executive, and can also be devolved to cost centre manager level where appropriate.

The reports are focused around the following indicators:

• Operational• Financial• Quality• Access

Data for these reports should be collected as a baseline prior to implementation. Refer also to Appendices 1 Objectives for Change and 25 MIDS Evaluation Framework which address the LHD’s stated objectives and expected outcomes.



appendix 23: Mids lhd and referrer report

PurposeRoutine reporting should be provided to the LHD and all referring departments about MIDS service utilisation and hence cost of Medical Imaging services. The LHD Report will provide information at facility and department level. The MIDS Referrer report will be at facility and department level, and will also be able to be provided at referring doctor level to allow customers to drill down and further examine the utilisation patterns of high cost referrers.

When should this be completed?These reports should be developed as part of phase three.


appendix 24: checklist of key processes and procedUres to be developed

PurposeThis checklist will inform what key processes will need to be developed and procedures implemented to support the smooth operation of the MIDS model.

This list focuses upon business processes only and should be considered indicative.



appendix 25: Mids evalUation fraMework teMplate

PurposeTo allow an evaluation of the Medical Imaging District Service after implementation to determine if the implementation of MIDS has achieved stated objectives. Baselines will need to be established prior toimplementationtoallowsubsequentcomparisonstobedrawn.Thefirsttwocolumnswouldbepopulated from the information collected in Appendix 1 LHD Objectives for Change and should also consider the following indicators in Appendix 22 - Performance Monitoring and Reporting:

• Operational• Financial• Quality• Access

Data for these reports should be collected as a baseline prior to implementation.

When should this be completed?The framework for MIDS Evaluation should be completed at the end of Phase 3.


* Refer to Appendix 1 - LHD objectives for change

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