Dr Juan Ballesteros

Consultant and Clinical Lead in Emergency Medicine

Emergency Department

Doncaster Royal Infirmary

Making the Business Casefor ULTRASOUND Scanners...and which machine to get?

Current USS market

How much do we spend?£40 million per annum

How many systems are purchased every year?1000 per annum / 250 tenders

Suppliers includeSonosite Hitachi Philips GEEasote Aloka Sonoscape ToshibaSiemens Medison Mindray BK MedUltrasonix Siui Zonare HP

OBJECTIVES

•Developing a business case•Identifying funding for the project•liaising with suppliers•Choosing your machine•Purchasing the machine•Starting up the service•Inheriting problems & avoiding them

Preparing the business case:

• Good research and an ordered and systematic way of thinking

• Establishing where are we now & where do we want to be

• Specifying what we really need

• Raising awareness and lobbying for support

• About getting the organisation and finance on your side!

• Getting approval of a budgetary figure

The business case

Economic Case

Use of radiology dept timeAbility to make rapid decisions

Reducing length of stayService provision & “payment by results”

Release of resources i.e.. Staff, OT, ITU and HDU time and beds

Avoiding costly mistakes (legal costs) by improving overall clinical care

NICE guidanceFunding

Quality in Clinical Care

Impact analysisService improvement

Audit

When working on the business case ,don’t forget to...

• Work within pre-set timescales• Do the necessary but focussed research• Look at experience from existing machines in your ED • Visit colleagues who you know are happy • Think and talk to colleagues about the possible applications • Do not go mad in getting every body involved• Think of future roles/responsibilities from the start• Do not raise false expectations – it backfires• Talk to suppliers and compile your wish list

At this stage,start talking to suppliers

• Attend events where there is a wide range suppliers and machines available

• Compile your wish list by talking to suppliers and other delegates – the basis for the spec.

• Get suppliers to visit you at the hospital and try to get machines on trial

• Do not commit yourself to any make at an early stage, you are limiting your options

• In the meantime, liaise with Trust supplies manager to find out about corporate purchasing rules and regulations

• 6 Month audit on CVP, Femoral Line Insertion and AAA

• 36 CVP lines – 12 unable to insert

• 96% attempted by SHOs

• 24 Femoral Lines – 6 unable to insert

• 16 AAA – delays to theatre – consultant referral / CT delays during out of hours

Audit of current practice

Impact Analysis...absolutely crucial

• On patients• On resources management• On service improvement• What if not

Highlight the positive and put a figure on where possible

Impact on Patient Care

• Improved quality of care• Reduction in length of stay• Alleviate the stress caused by uncertain / difficult diagnosis• Improved diagnosis so that patient can be treated quicker• Helps to make rapid decisions and move on

• Example: Effectiveness US guided central line insertion compared to that of landmark method – avoided 90 arterial punctures in 1K patients

Impact on resource management

• Use of radiology department time• Release of medical/clinical resources to be allocated to the care of

other patients• Improves bed allocation• Triggers need for staff training and accreditation on US• Supervision by peers, audit and performance monitoring• Encourage the old guard to get on with it• NICE guidance compliance

Impact on service provision

• Service provision & “payment by results”• Release of resources i.e. Staff, OT, ITU and HDU time• Helps to avoid costly mistakes (legal costs?)• Improves service provision and quality by having more staff

trained and accredited: CEM Level 1 and eventually Level 2• Audit and performance monitoring• NICE guidance compliance

What if we continuewithout it ?

• Look at real time clinical cases to highlight current difficulties and inadequacies in service

• Then highlight potential solutions relevant to having a departmental US machine

The business case: Do the Analysis

• SWOT• PEST• Stakeholders Analysis

SWOT Analysis

• Strengths: An additional tool for the ED to make a more accurateand timely initial assessment and diagnosis that willbring a better outcome for patients.

• Weaknesses: Initial cost

• Opportunities: To have the ability to provide a modern up-to-date service to patients and the ability to carry out modern examination which benefit the patients both in length of stay and recovery.

• Threats: Training needs have to be met

PEST Analysis

• Politically: The ability to carry out more complex assessment with areduced length of stay and better outcome for patients presenting at the ED. And improvement in the ability tomeet management targets(??)

• Economically: Savings realised on consultants and nurses time andreduced length of stay cost

• Socially: Less waiting time for patients at the ED, less risk leading to a better outcome (?) a faster diagnosis following more rapid treatment and less pain (??)

• Technology: State-of-the-art efficient equipment capable of delivering a modern service.

Stakeholders Analysis

• Internal Stakeholders: Will have Ultrasound Scanners to deliver a first class service to ED presentations this will also contribute to alleviate the stress caused by uncertain and difficult diagnosis.

• External Stakeholders: Patients would benefit from better outcomes and earlier discharge from the ED following Ultrasound procedures in a much modern service.

Financing the Project

• Trust’s purchasing, tender procedures and documents

• How much we need? When? Timescales?

• Sources of funding: PFI, Trust, ED, radiology, friends, charities

• Establish a budget before start talking seriously to suppliers

• Do not disclose your budget to suppliers too early, it might limit your negotiations

Presenting the Options

Option Advantages Disadvantages

1. DO NOTHING None Failure to realise advantages of using modern technology to reduce length of stay at the ED and better outcomes for patients.

2. PURCHASE Ultrasound Scanners at a cost of ££££

Be able to carry out rapid assessment and diagnosis at the ED with improved clinical outcomes and reduced length of stay

Cost

Leave all relevant parties in no doubt as to what is your preferred option !!

Which machine?

The choice is yours!

Make sure you makethe right choice for you!

• Clinical applications that are realistically needed• Workload - add factor for future use• Transducers/probes required• Scanning Capabilities• Physical features, especially for A&E (portability, screen size ,positioning...)• Measurement & Analysis features• Annotation, documentation and recording ability• Settings e.g. Magnification facility, depths of focal zones, etc.• Safety compliance

Nevertheless, do not forget to

• Go to a radiologist and a sonographer for advice• Look at the RC of Radiologists Standards for US Equipment 2005

Budget Considerations!

• Cost of machines as provided by suppliers

• Cost and provision of after sales technical support – very important to know from the beginning

• Cost of peripherals and maintenance

• Budgeting for review and replacement, within five years, is advisable

My advice...

• Be realistic and make your choice within time-scales and budget• Talk to reputable suppliers – they would like to retain you as a

satisfied customer• A supplier that understand the needs of the ED• Aim reasonably high and try not to compromise quality for

money• Make sure you can upgrade easily• Keep the Radiology Department on side...and very

importantly...keep the Customer-Supplier relationship alive and well!

• Keep an eye on how the technology progress

The machine is in the ED....now, make it a success story !

• Lead from the front or appoint a lead• Write standards, procedures and regulations• Audit trail and governance procedures• Make sure people use it but set tight control over usage –

responsibilities• Encourage colleagues to get accreditation• Document its use and benefits – it will help you when

buying more and replacing. • Keep the Radiology Department on side

Thank you !

Juan.ballesteros@dbh.nhs.uk