Improving hospital-based programs II.

III. Justify the Program's Existence

"The allied health administrator must be prepared to justify the institution's expense of sponsoring hospital-based educational programs."

--Dan Shock

Those comments were made by a radiography program administrator in an article published in Radiologic Technology in 1990, (20) and they still hold true today. Hospital-based radiography programs exist to educate and train highly qualified radiographers. Doing so without regard to the financial impact a program has on the sponsoring and affiliate organizations ultimately has spelled the demise of many certificate programs. To remain viable, hospital executives must have a clear understanding of the program's financial benefits.

Return on Investment

In business circles, executives weigh the financial impact of an investment based on a projected dollar return over time. This return is simply termed return on investment, or ROI, which is calculated along with intangible benefits in a business case to justify an investment. Executives may decide in favor of an investment if the business case projects an agreeable ROI.

Hospital-based radiography programs are an investment. The sponsoring and affiliate organizations invest time and money in supporting the program. Hospital-based educational programs exist because of the organization's support.

Cost Avoidance

Radiography programs do not necessarily exist just to generate a profit. However, when executives are encouraged to cut costs, such programs are at risk due to their fixed-cost nature. Unfortunately, many program directors have not given due diligence to justifying their programs financially. Financial justification for educational programs is based primarily on avoiding costs that would be incurred if the program did not exist. These costs include but are not limited to:

* Marketing and advertising dollars associated with recruiting technologists or graduates from other programs for vacant positions.

* Orientation expenses associated with a training period for new employees, generally 4 to 6 weeks.

* Temporary staffing costs incurred when the demand for technologists greatly exceeds supply.

* Costs associated with reduced overtime and higher-salary PRN use.

In and of themselves, avoided or reduced costs associated with hiring program graduates cannot justify a program's existence. Programs also must look for revenue streams and cost-sharing arrangements constantly to offset their fixed operating expenses.

Revenue Streams Tuition

Revenue sources alone should not be expected to offset the program's operating expenses, yet they are essential in justifying the program's existence. The most notable revenue source is student tuition. The amount of tuition charged per student should be balanced between keeping the program competitive with the market and offsetting a portion of the program's operating expenses.

CMS Reimbursement

Another potentially significant revenue stream is CMS (Centers for Medicare and Medicaid Services) reimbursement for medical education expenses. The Medicare Code of Federal Regulations, CFR Section 413.85, allows for payments to hospitals under Medicare Part A for the cost of allied health education programs that meet the Medicare definition of approved educational activities. (21) Medicare's share of the hospital's radiography program is determined as a percentage of program costs compared to inpatient and outpatient radiology charges. This reimbursement can offset much of the program's operating expenses and significantly justify the program's existence.

Charitable Sources

Programs also might wish to explore educational grants and charitable sources of funding. Equipment manufacturers and contrast media vendors routinely budget grant money for donations to nonprofit organizations for education and training purposes. Such funding can be very valuable in offsetting expenses associated with the educational process. However, to avoid conflicts of interest, pharmaceutical and equipment manufacturers must follow business practices that meet PhRMA (Pharmaceutical Research and Manufacturers of America) and NEMA (National Electrical Manufacturers Association) guidelines. (22, 23) It would behoove program directors to become familiar with these guidelines and any internal policies on corporate relations before applying for or accepting grants.

Cost Sharing

Interestingly, while the Preston and Comello study revealed that 70.6% of the 160 respondents indicated that their program had multiple clinical education sites, a staggering 75.8% of the 91 respondents who had multiple sites indicated that these sites did not support the program financially.' It is difficult to imagine how a program can yield a positive ROI when clinical sites do not provide financial support.

The nature of the corporate relationship between the program sponsor and affiliated clinical sites will determine the cost-sharing arrangement. If an enterprise-wide structure is developed in which clinical sites are affiliated with the program sponsor and the clinical sites are eligible for CMS reimbursement for program expenses, then those organizations can shoulder a greater portion of program-related expenses. Conversely, if clinical affiliates are not eligible for CMS reimbursement, more of the expenses should remain with the sponsoring entity because those costs will be captured when submitting expenses for CMS reimbursement.

Annual Financial Performance

Once the program has maximized its revenue stream, established a cost-sharing arrangement with affiliated clinical sites and determined what expenses are avoided as a result of hiring program graduates, program officials can determine the overall financial impact the program has on its affiliate organizations.

Determining the annual financial return for the program will depend on an agreed-upon benchmark for comparison, such as total program return relative to no educational affiliation or relative to a college affiliation. A more relevant benchmark would be to compare the hospital-based program with a college-based program affiliation because most hospitals align with some program, given recent and forecasted shortages of technologists. If this is the case, program officials should carve out expenses, such as clinical faculty salaries, that would be incurred if the hospital were affiliated with a college or university program. Thus, when an annual return is calculated, it will represent dollars saved as a result of sponsoring the program as opposed to affiliating with a college or university.

Once a financial return is calculated, program officials must communicate these results to executives in affiliated organizations. Ideally, this communication should be in the form of an annual report.

Intangibles

Hospital-based programs justify their existence in part through the fact that they are not restricted by university credit-hour limitations. This enables students to complete more clinical and didactic contact hours than in comparable associate-degree programs. However, care must be exercised because more clinical or classroom hours do not equate necessarily to greater skill or competency. Program officials must be mindful of accreditation standards involving clinical resources, educational validity of program activities and program assessment of student outcomes. Nonetheless, the additional clinical and class time can be a valuable asset if used conscientiously. This additional clinic time also benefits the organization by allowing it to "try out" students as potential employees. Thus, the program becomes a human resource filter for the organization.

The hospital-based program also justifies its existence through its unique advantage of having core faculty on hand at clinical sites. By having didactic faculty on site where clinical rotations are performed, faculty are better positioned to diagnose student deficiencies and implement correctives as needed. This observation is not meant to denigrate college-based programs, but to elevate this advantage of the hospital-based program.

Other intangible benefits of hospital-based programs include the following:

* Sponsoring and affiliating hospitals have greater influence over program structure, curriculum and operations.

* Program officials can assist imaging departments with the education and training needs of practicing technologists by conducting educational needs analyses and educational in-services.

* Hospital-based programs are well positioned to help affiliate hospitals establish training and education pathways for medical imaging modalities such as sonography, nuclear medicine and mammography.

* Program faculty can serve on department or organizational committees or assume other roles in medical imaging, provided such activities do not negatively affect their primary role as program faculty.

IV. Strategic Vision

"Vision without action is a dream. Action without vision is simply passing the time. Action with vision is making a positive difference."

--Joel Barker

As the hospital-based program evolves in structure and organization, establishes multiple clinical education sites and justifies its existence, program officials must begin to look at other ways the program can support its sponsoring and affiliate organizations and the communities they serve. Hospital-based radiography program officials cannot afford to be myopic regarding the purpose of their existence and must champion the educational needs in medical imaging beyond entry-level radiography training. The program must develop a strategic vision.

What Is Strategic Vision ?

There are 2 important aspects of strategic vision: the vision statement and the strategic vision plan. Burr Nanus of the University of Southern California defined strategic vision as "a realistic, credible, attractive future for an organization." (24) By developing a vision statement, hospital-based radiography programs can position themselves favorably within their respective organizations.

The vision statement also must support the radiography program's mission statement. In other words, strategic efforts should never compromise the core reason for the program's existence, which is to provide quality education and training for entry-level employment in radiography.

For hospital-based program directors to lead their programs using strategic vision, some introspection regarding their own leadership abilities is prudent. In their description of the most important characteristics of effective leadership, Kouzes and Posner identified the ability to inspire a shared vision as 1 of the 5 key traits. (25)

Strategic vision is a trait of effective leadership that largely goes unrecognized. In a recent assessment of program director satisfaction with leadership skills, Aaron did not include strategic vision as a core responsibility of department chairmen, (26) yet the hospital-based program director is perhaps the best positioned individual to assess the program's future role.

Establishing Medical Imaging Pathways

Although a vision statement can be broad and nonspecific, it should provide the impetus for the program to examine medical imaging training needs for many years to come. Clearly, medical imaging is becoming a complex, multifaceted and dynamic profession with unique educational needs. Radiography program officials must be willing to look beyond the core radiography program and establish pathways for training in various medical imaging modalities. In doing so, a careful examination of imaging technology, trends, demands and predictions for the next 20 years is prudent.

Imaging Trends

Radiologic Technologist Shortage

For several years, most hospitals and imaging centers in the United States felt the impact of an inadequate supply of qualified radiographers to fill vacant positions. Although national radiologic technologist vacancy rates declined to 4.9% in 2006, vacancy rates were as high as 18% in 2000. (27) Vacant technologist positions have several effects, most notably reduced patient care and increased costs. In a 2002 national survey, 70% of radiographers stated that quality of patient care suffered as a result of the shortage and 37% further stated that patients might have been at risk as a result. (28)

Education programs must be prepared to flex enrollment numbers to mitigate the effects of a technologist shortage or saturation. This has proven difficult, given the planning involved with revising enrollment numbers, and essentially makes it a 3-year process for a 2-year program.

Demand for Services

The current ease in demand for technologists will be short-lived if predictions regarding future demands for medical imaging services hold true. Medical imaging is experiencing an ever-increasing demand for services. Medical imaging services have increased between 3% and 4% annually for several decades. Since the 1960s, imaging procedures have increased from 36 procedures per 100 people each year to 130 procedures per 100 people each year in the 1990s. (29)

Long-term projections show that imaging services will increase by 140% by the year 2020 compared with 2000 levels. (29) In addition, some experts have projected that the use of modalities such as computed tomography (CT), positron emission tomography (PET) and magnetic resonance (MR) imaging will grow significantly over the next several years. (30) This demand for imaging services is the result of an aging patient population and technological advances in medical imaging.

Aging Population

Currently, baby boomers (ie, anyone born between 1946 and 1964) number nearly 80 million, or roughly 29% of the U.S. population. By 2030 the number of people aged 65 years or older is expected to double and the octogenarian population will triple. (29) As a result, the incidence of age-related diseases such as cancer and heart disease will increase, placing additional strain on health care resources.

As the general population's age increases, so does that of the technologist population. The strain placed on medical imaging due to the demand for services will only be exacerbated by the aging technologist population. Currently, the national mean age of technologists is 41 years. Only 14.5% of radiographers practicing in 2001 were 30 years or younger. (29) Thus, fewer radiographers will be available to fill vacancies as baby boomers retire.

Technological Advances

Technological advances in medical imaging offer physicians a comprehensive array of diagnostic tools. Today, 64-slice CT units are common and 256-slice units currently are installed for beta testing, further reducing exam time and improving patient throughput. MR imaging units with 3 T (tesla) magnets are available and offer stunning soft-tissue detail not seen on 1.5 T units. (31) Ultrasound advances in 4-D imaging make it an attractive imaging tool. In addition, MR and ultrasound are both attractive diagnostic tools due to their use of nonionizing energies, which eliminate potential negative effects associated with ionizing x-rays. Other advances in medical imaging include full-field digital mammography, interventional radiology and PET.

Molecular imaging uses a variety of agents and techniques, including PET and MR, to examine "specific genes, enzymes, cell structures or molecular processes and produce amplified signals that can be detected and observed." (32) Essentially, molecular imaging reveals the physiological process leading to disease rather than the disease itself. Molecular imaging will continue to evolve and usher medical imaging into a new era of preventive medicine.

As these nascent technologies emerge toward clinical application, new and innovative means of combining various imaging technologies also will surface. These so-called hybrid, or fused, imaging technologies will offer unprecedented imagery of disease form and function. CT and PET were first hybridized in 1998, and this technology is gaining clinical acceptance rapidly. (33) Future hybrid technologies include single-photon emission tomography (SPECT)-CT (33) and x-ray-MR. (34)

Training Conundrum

These technological advances not only usher in greater demand for medical imaging services, but also create training and education challenges: Technologists must be adept at computer applications, knowledgeable of the physical principles and clinical applications of the given modality and well versed in cross-sectional anatomy and imaging pathology. Historically, hospitals cross-trained individuals in imaging modalities while working "on the job." These organizations risk spending considerable time and money to cross-train individuals only to have the trained individuals leave for higher-paying positions. Further exacerbating this issue is the lack of didactic education to promote a comprehensive understanding of the modality, leaving the cross-trained technologist to seek out educational resources if certification in the modality is to be attained.

Pathways to Medical Imaging Training

Once all of the imaging trends have been considered, pathways to modality-specific training and education appropriate to the sponsoring and affiliate organizations should be established. To determine appropriate pathways, a needs analysis that encompasses all medical imaging modalities should be conducted. The needs analysis should include feedback from all parties with vested interests in this training, from executives to operational managers. Feedback should target past, current and future volume trends, recruitment challenges and educational needs. A scan of all educational resources in the region also is necessary.

[FIGURE OMITTED]

This feedback then can be used to determine which pathways are most appropriate for each organization. The hospital-based radiography program is well positioned to conduct this analysis, establish these pathways and bridge radiography with other imaging modalities. Program graduates thus can pursue established pathways to modalities of interest beyond their 2-year training in radiography. Not only does a formal education process improve the quality of imaging services provided and produce technologists who are ready for certification, but it also reduces competition for entry-level radiography positions among program graduates and reduces the expenses associated with on-the-job training. To illustrate, a medical pathway flow chart is provided in the Figure.

V. Program Exposure

"If you're trying to persuade people to do something, or buy something, it seems to me you should use their language, the language in which they think."

--David Ogilvy

Program officials dedicate a lot of time and effort to examining and improving the hospital-based radiography program's organization and structure, developing an enterprise-wide program model, justifying the program's existence and carrying out a strategic vision for the program. However, the benefits of this time and effort diminish when program officials do not market their program's successes. Effective marketing strategies can keep the program in the collective consciousness of internal and external customers. To remain viable over time, hospital-based program officials must keep their program visible.

External Marketing

Effective external marketing strategies not only attract viable candidates for admission, but also promote the sponsoring and affiliate organizations to the public. Effective external marketing of the program can be accomplished through a variety of means, including a Web site and printed brochures. The author strongly advocates that hospital-based programs develop a comprehensive Web site to reduce the costs associated with printing and mailing brochures.

Hospital-based program faculty also should consider submitting articles to professional publications. Sadly, hospital-based radiography faculty are not well-represented in professional publications. A cursory review of 10 issues of Radiologic Technology published in 2005 and 2006 revealed that hospital-based program faculty authored or coauthored only 2 of 41 peer-reviewed articles and only 5 of 43 other articles. In addition to advancing the profession and contributing to the body of professional knowledge, hospital-based program faculty should consider professional publishing to elevate the value of their programs in the eyes of executive leaders within their respective organizations.

Internal Marketing

Equally important as marketing the program externally is marketing the program internally to key stakeholders. First, programs need to determine what to market, to what extent and with whom this information should be shared. At the least, the program should market information regarding program quality and justification. To market program quality, the author recommends publishing an annual quality report. Ideally this report will communicate how the program fared in meeting its annual goals and what corrective actions, if any, are required. This report should be shared with advisory board members and other key stakeholders as deemed necessary.

To market program justification, program directors should consider publishing an annual executive report. Not only does the report contain financial ROI benefits of the program, but it is also another opportunity for program officials to communicate the program's mission, vision and strategies. This report should be shared with executive sponsors and other key stakeholders, as deemed necessary.

Program directors also should meet regularly with executive leaders and medical imaging management to discuss program feedback, successes, challenges and ways the program can support the sponsoring and affiliate organizations outside the program's core purpose. Program faculty also should consider engaging nursing and other clinical leaders to offer educational services related to medical imaging and radiation safety. Program directors should update governing and executive councils briefly but regularly regarding the program.

Changing History

The dangers of ambivalence and inertia despite emerging data to reflect the seriousness of an issue are illustrated by the following scenario: Place a frog in boiling water and it will jump out immediately, yet drop it in lukewarm water and bring the water to a boil slowly and the frog will stay in the water until rescued. (35)

This analogy could aptly describe the relative lack of action from the hospital-based medical imaging community given the precipitous decline in hospital-based radiography programs. Certificate programs have been on the decline since at least 1970. Some would like to see the demise of hospital-based education programs. Through program attrition, they may very well get their wish.

It is time that hospital-based radiography program directors understand these dynamics, not as an academic exercise, but at a visceral level, and take action to stave off this decline. Several articles have been published that discuss perceptions regarding hospital-based program viability, yet few have offered prescriptive strategies. By carefully examining their own leadership abilities and implementing the strategies discussed in this article, program directors could stop or even reverse the decline in hospital-based programs as other organizations realize the benefits of sponsoring their own programs or affiliating with existing hospital-based programs. Program directors cannot afford to be indifferent on these issues, lest their own programs suffer the same fate as the too many programs that already have closed.

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Mark Adkins, MSEd, R.T.(R)(QM), is director of the St Vincent Health St Joseph Hospital radiography program in central Indiana. This article is an excerpt from a comprehensive white paper on strengthening hospital-based program viability. The first part in the series was published in the main version of the January/February issue of Radiologic Technology. The entire original article can be accessed at www.stvincent.org/education/radiography/downloads.