30420140502001

International Journal of Industrial Engineering Research and Development (IJIERD), ISSN 0976 –
6979(Print), ISSN 0976 – 6987(Online), Volume 5, Issue 2, March - April (2014), pp. 01-17 © IAEME
1
WORKLOAD AND PRODUCTIVITY MEASUREMENT FOR
NUCLEAR MEDICINE DEPARTMENTS IN THE GULF COUNTRIES’
HOSPITALS
Salman A. Salman*
, Saad M.A. Suliman**, Mansour E. AbouGamila***
*
University of Bahrain, Department of Mechanical Engineering, Manama, Bahrain
**University of Bahrain, Department of Mechanical Engineering, Manama, Bahrain
***Arabian Gulf University, Manama, 26671, Kingdom of Bahrain
ABSTRACT
One of the most important corner stones for efficient performance management is
performance measurement. This paper focuses on productivity measurement of Nuclear
Medicine (NM) Sections at four different hospitals in Gulf countries. The main purpose of
this study is to create a measuring unit that fairly represents each nuclear medicine procedure
weight. The scope of this study was not limited to the physicians but it has involved
specialists and nurses at Nuclear Medicine Sections. Moreover, the study has attempted to
link workload metrics with other financial indicators such as periodic expenses, paid hours,
and equipment depreciation to monitor the cost efficiency, operational efficiency, equipment
utilization, and staffing issues. A model has been developed through multi-steps to establish
the relative value unit (RVU) for measurement of nuclear medicine physicians, specialists,
and nurses productivities. The model has been applied to measure the productivity level of
the mentioned staff categories during January and February, 2013. The results showed that
nurses’ productivity can be measured by the number of procedures’ performed and using of
RVU model for this staff category does not make any difference. However, RVU model
showed significant difference in physicians’ and specialists’ productivity in comparison with
the number of performed procedures metric. The sensitivity analysis showed that minimal
changes in the time factor will result in a significant change in the weight (RVU) of the
procedures but the maximum adjustment factor has less effect. Moreover, the study was
unable to measure the weight that is relative to the patient condition, patient age, and special
requirements for certain procedures.
INTERNATIONAL JOURNAL OF INDUSTRIAL ENGINEERING
RESEARCH AND DEVELOPMENT (IJIERD)
ISSN 0976 – 6979 (Print)
ISSN 0976 – 6987 (Online)
Volume 5, Issue 2, March - April (2014), pp. 01-17
© IAEME: www.iaeme.com/ijierd.asp
Journal Impact Factor (2014): 5.7971 (Calculated by GISI)
www.jifactor.com
IJIERD
© I A E M E

2
Keywords: Medical Imaging, Relative Value Unit, Nuclear Medicine, Productivity
Measures.
1. INTRODUCTION
The world of healthcare providing institutes is changing dramatically due to multiple
reasons including significant demand increase, knowledge growth, technology advances, and
cost inflation (Maitino, 2010). Due to these reasons, healthcare management is a very
complicated area of management and subsequently efficient leadership is always required
(Chan, 2002). One of the most important corner stones for efficient leadership is performance
management which is based on performance measurement. Performance measurement is a
wide term that involves productivity measurement.
Productivity can be defined as a measurement tool used to represent the production
efficiency. Regularly productivity is expressed as an average, articulating the total yield
divided by the total input (Bair and Gwin, 1985). In clinical field, the yield or the output
could be the number of treated patients, number of patient visits, number of performed
diagnostic procedures, customer satisfaction, or generated revenue. In the other hand, the
input could be the time, variable expenses, staff salaries, or fixed cost (e.g. facility rent
expense).The capability to gauge each clinical staff work performed, productivity, or
contributions toward the organizational mission and objectives has become an importance
facing all hospital departments— in non-profitable, profitable, and academic settings. In non-
profit organization, measurement of individual productivity and work performance is
important for staffing issues, staff evaluation, and building futuristic strategic plans such as
expansion and budgeting. In profitable hospital, measurement of individual staff productivity
is mainly needed to measure the compensation, cost measurement, and pricing the provided
services. In academic settings, such as university hospitals or research centers, productivity
measurement is more complicated where the variability of the output is very high. The main
purpose of measuring the individual academic staff productivity is to have an integrated
figure about his/her productivity beside his/her clinical output. Moreover, in research centers,
specifically, productivity measurement is important to track each researcher contribution in
certain research projects.
This paper aims to drive clear and uniform principles of measuring workload at one
section of the medical imaging department at four specialist hospitals in Gulf countries. The
most challenging part of this issue is that the workload emerges from the interaction between
the requirements of the procedures (diagnostic/ therapeutic), the circumstances under which it
is performed (e.g. radiation exposure), the skills and perceptions of the operator. Thus, the
workload cannot be measured only by counting the number of patients, or number of
procedures. Many factors should be incorporated to end with representative and fair workload
measures. One of the most useful tools used to measure medical imaging procedures’ weight
is known as Relative Value Unit (RVU). Simply, this tool measures the weight of a process
relative to another standard procedure. This analytical method helps managers to measure
productivity using historical data to derive meaningful benchmarks by removing subjectivity
such as differences in work habits among operators (physicians, technologists, and nurses)
and differences in the time, skills, and drawbacks required to perform one examination
compared to another. This tool is also practical for cost segmentation per RVU in terms of
salary cost (paid hours), equipment depreciation cost, operating supply cost, maintenance
cost, and administrative cost. The hospitals under the study use a very basic method to
calculate the workload and individual productivity by counting the number of patients or

3
number of procedures. This method is not valid due to its inability to represent the workload
and productivity where different procedures required different weights and workloads. The
dramatic increase in medical imaging procedures utilization, and subsequently, the vivid
increased cost raise the requirement for an accurate, to certain limit, measurement tool of the
workload (output) and the productivity in all hospital departments. The RVU system
established by Medicare (American Medical Association, 1988) is built according to
standardized protocols and procedures used in Europe and in the United States. The RVU
value for each service is used for physician reimbursement. Thus, RVU values involves not
just the work done by the physician, but also the liability expenses and the procedures
expenses which are not incurred by the facility. Due to all these differences, Medicare RVU
values cannot be directly applied to the hospitals under the study.
The need to establish a dedicated RVU/ productivity system or model for medical staff at the
hospitals under the study is originated as follows:
• Establish a RVU based productivity measurement system for nuclear medicine
section.
• Compare the currently used method (number of patients/procedures) with the
proposed one (RVU model).
• Link workload measure (RVU) with other financial indicators such as periodic
expenses (i.e. variable and fixed costs), paid working hours, and equipment
depreciation to monitor the cost efficiency, operational efficiency, and equipment
utilization; respectively.
2. LITERATURE REVIEW
Bair and Gwin (1985) stated that productivity data facilitate the ability to increase
efficiency by integrating financial and planning information to ensure more fiscally viable
products and services without sacrificing the quality of care. In the budgeting process,
productivity data provide additional information about direct and indirect expenses. These
expenses are correlated to program objectives and projections regarding caseload size.
Productivity measurement also provides useful information on average length of treatment,
staffing patterns, reimbursement patterns, diagnostic groups, and treatment outcomes.
Analyzing these data provides information that can assist in personnel projections, improving
staff effectiveness, creating new programs, and containing or reducing costs.
The first productivity measurement metric is the number of patient visits per
physician. This tool measures the number of patients who are allocated and registered to
specific physician. In specific, patient visits per physician expresses critical indicators of
whether physicians are using office resources and schedules reasonably, identifying those
who require careful inspection. Number of patient visit per physician does not include only
new patient and returning patient, but it includes also patient on the panel. The advantage of
this tool is that it is quick and easy to be measured. It is usually used to compare workload
between specialties. However, this metric is not fair where it is highly dependent on the equal
patient access among all physicians. Also, it does not consider the provided procedures per
visit, collaboration and complexity of the patient condition or the provided procedures.
Therefore, patient visit per physician is not used usually as a primary productivity

4
benchmark, but it is important in understanding operational factors that contribute in business
growth.
The second metric, Total Volume per Current Procedural Terminology (CPT) Code
by Service Category is another clinical productivity measure used to evaluate individual and
group productivity. This term represents the number of billed or unbilled patient visits during
the economic year. In contrast to the number of patients visit per physician, this metric links
patient visit or service with the significant contact between a health care provider such as
physician, specialist, or nurses where advice, procedure, service, or treatment occurs. In each
patient visit, all billed or unbilled CPT codes will be recorded. Due to this reason, this metric
is considered as a readily and quick measure representing the time spent in each patient visit
with detailed description of provided procedures, treatment, or services. The main drawback
of this metric is that its values are highly dependent on the specialty and are not comparable
between different specialties (American Medical Association, 1998).
The third metric, Total Net Fee-for-service Revenue measures staff productivity in
terms of the real income their services, procedures, or treatment created. It includes the
revenue collected from patients and third-party payers for services provided to full fee-for-
service (FFS). This metric has an essential role in drawing of new budget plans and pricing
strategies. Indirectly, Total Net Fee-for-service Revenue reports can be considered as early
warning signals for changes in productivity levels (Albertsen and Atkinson, 2000).
The fourth metric, Total Patient-care Gross Charges are the total value of all medical or
surgical services provided to all patients by the organization before contractual adjustments
required by third party payers or other adjustments during defined reporting period. The most
difficult part of this measure is the fact that changes in the charges schedule can skew results
from period to another and this needs to be taken into consideration (Albertsen and Atkinson,
2000; American Medical Association, 1998).
The fifth metric is the procedure relative value unit (RVU). Simply, this tool measures
the weight of a process relative to another standard procedure. This analytical technique aids
managers to measure productivity using historical data to develop expressive and meaningful
benchmarks by eliminating subjectivity such as differences in work practices among
operators (physicians, technologists, and nurses) and differences in the time, skills, and
drawbacks required to perform one exam compared to another. Clinical services, which are
described by Healthcare Common Procedure Coding System (HCPCS) codes and Current
Procedural Terminology (CPT) codes, vary from those that involve considerable amounts of
time and effort, clinical staff, and specialized equipment, to those that need little physician
time and minimal other resources. Accordingly, RVU calculation mainly depends on
weighing the involvement of these factors in each clinical service. Specifically, for each
clinical service described by CPT, Medicare determines RVUs for three types of resources
which are physician work, practice expense, and professional physician malpractice.
The RVU of these three components of clinical services’ weights contribute
differently. Physician work, practice expenses, and professional physician malpractice
comprise 52, 44, and 4 percent of total Medicare expenditures on physician clinical services,
respectively (Hsiao et al, 1988).Work RVU includes the duration of the provided services,
technical skill and effort needed, mental effort and judgment required, and stress to provide a
service.
The work RVU for a diagnostic angiography is more than twice the work RVU for an
intermediate office patient visit because the angiography requires more physician time and
effort than the visit. Moreover, each clinical service RVU should be reviewed every five
years to update the work RVU for the relative service. The value of each code (standard

5
numeric for each procedure in the CPT) can change if the components of service have
changed during the former years. A code with a higher work RVU requires more time, more
efforts, more skills or some combination of these three (Glass & Anderson, 2002; Moorefield
et al, 1993; Hsiao et al, 1988).Practice expense of RVUs refer to the non-physician clinical
(i.e. nurses and radiology technician) and nonclinical (i.e. secretary) staff of the practice, as
well as it accounts for expenses for equipment, building space, and office supplies (Health
Care Financing Administration, 1991).
The practice expense RVU related with the diagnostic angiography is higher than the
practice expense RVU for the intermediate office patient visit. For the angiography, the
practice expense RVU, is primarily indirect expenses, like administrative staff, building, and
office supplies; however, it does not include medical supplies, clinical staff, and equipment
where they are incurred by the facility. The RVUs for the office patient visit include clinical
staff time and the equipment and supplies typically used during a visit, as well as a share of
the indirect expenses of a physician practice. All these expenses are not incurred by the
facility. Thus, the practice expense RVU for an office patient visit per unit of time is higher
than that for angiography for the same unit of time (Moorefield et al, 1993). Malpractice
RVU refers to the cost of professional liability expenses. This is commonly the smallest
component of the RVU where it represents around 4% of the total RVU.
The malpractice RVUs are based on malpractice insurance premium data composed
from commercial and physician-owned insurers. Since malpractice insurance rates can
radically change over the years, both significant increases and decreases depending on the
part of the country and specialty. It is critical to update premium costs in calculating the
malpractice RVUs every five years (Health Care Financing Administration, 1991).Relative
Value Unit model has been used successfully in measuring academic and research activities
(D’Alessandri et. al., 2000). Importantly, several attempts to accurately assess academic
production have produced few noteworthy results, in large due to the lack of RVU type
metrics to assess nonclinical performance. One of the most useful attempts to measure
academic activity weight quantifies all components of an individual’s academic activity;
weights them by approximation of effort, influence, and value to the division’s objectives;
and then sums the values to deliver a net academic RVU. The concept and methodology are
based on the clinical work RVU that has been discussed earlier. Each activity or achievement
is allocated with a relative percentage of effort (on the basis of time and degree of complexity
in performing that activity) and an academic weight (which can differ along with division
objectives) that are multiplied together to arrive at a total academic RVU (Lu and Arenson,
2005).
3. RELATIVE VALUE UNIT DEVELOPMENT METHODOLOGY
This paper focuses on the most important key players at any nuclear medicine section
who are the physicians (NM radiologists), specialists (NM technologists), and nurses. To find
out a representative RVU value for each nuclear medicine procedure, some essential
information need to be clarified and agreed upon by the stakeholders of these four nuclear
medicine sections. First of all, all nuclear medicine procedures need to be listed. Second, all
stakeholders should agree upon the main variables which are involved in each procedure with
their involvement extent. After collecting all these information, RVUs can be calculated for
each procedure and evaluated by sensitivity analysis.
The main steps that have been taken to estimate a uniform and fair RVU value for
each nuclear medicine procedures are described below.

6
3.1. Listing nuclear medicine procedures’ names and codes
Due to the variability of the services provided by the four Nuclear Medicine Sections
which were involved in this investigation, the list of procedures’ names and codes were taken
from the section with the biggest number of procedures. They are 78 medical procedures.
3.2. Determining the variables and their involvement extent in each procedure
To investigate the variables that should be included in the study to determine the
weight of each procedure; fifteen interviews with Nuclear Medicine Sections’ chairpersons
and decision makers have been conducted. The aims of these interviews were to 1) assess
their impression about the currently used method of calculating the section workload and
staff productivity, 2) Obtain their opinion about the Medicare RVU model and its importance
in measuring the workload and productivity, 3) determine the variables need to be assessed to
calculate fair and representative RVU for each Nuclear Medicine procedure that suit the
hospitals’ requirements, and 4) determine the weight of each variable. The main criteria for a
variable inclusion were:
• The variable should be measurable;
• The variable should be well defined or specific;
• The variable should be related to the procedure nature and not to the patient condition.
The basic unit for each procedure represents the value of the procedure in terms of the
main factor. The remaining other factors should be given weights based on their involvement
in each procedure. The interviews with the Nuclear Medicine Sections’ chairpersons attempt
to establish a weight for each variable. The selection of the variable weight is depending on
the majority agreement.
The fifteen conducted interviews showed that the “number of performed procedures”
metrics is the method used in most specialized hospitals. This reflects that performance
measurement at Nuclear Medicine Sections in the region of concern is basic and simple.
However, thirteen out of fifteen of the interviewed decision makers don’t believe that the last
metrics is fair and wise. Only two of them believe on it and think it gives a general view
about the productivity. Moreover, the thirteen decision makers who believe in RVU model
suggested that all factors contributing in the weight of each procedure should be incorporated.
In other words, the length of the procedure (time) should not be the only factor that would be
considered in calculating nuclear medicine procedure weight (RVU). The thirteen decision
makers agreed that time, risk, complexity should be scaled and added to the procedure weight
in accordance to their involvement extent. Twelve out of thirteen believed that the required
skills and knowledge could distinct between the procedures. It is important to mention that
the interviewees’ response does not reflect the importance or the weight of the factor itself
rather than that the factor should be considered in the RVU calculation formula. Importantly,
twelve out of thirteen decision makers believed that time factor should be the basic factor and
the other contributing factors should have a maximum adjustment index of 30% of the
procedure basic weight or value. One out of thirteen believed that the contributing factors
should have a maximum adjustment factor of 50% of the procedure basic weight or value.
Based on the main questions asked during the interviews with the thirteen
chairpersons, it has been decided to direct the project towards adopting professional RVU for

7
nuclear medicine procedures. Moreover, four factors will be included in the criteria. The
chosen factors are: time, radiation exposure (risk), complexity, and required knowledge and
skills. Many researchers, such as Merzich and Nagy (2007), advocate using the time factor as
a basic factor to calculate the weight (RVU) of any procedure. Accordingly, it has been
decided to consider the time factor as the base to calculate the RVU for each procedure. The
other three factors will add maximally 30 percent of the basic value of each procedure that
will be distributed equally between the three factors.
a. Procedure duration (Time Input)
The duration (effective time) required to prepare the patient, perform the requested
procedure, and report the findings which are relevant to Nurses, Nuclear medicine
Technologists, and Nuclear Medicine Physicians; respectively, has been tabulated. This data
has been collected from the department procedure protocols’ logs which includes all details
about all procedures performed at the department. Many researchers, such as Merzich and
Nagy (2007), advocate using the time factor as a basic factor to calculate the weight (RVU)
of any procedure. Accordingly, it has been decided to consider the time factor as the base to
calculate the RVU for each procedure. With this data, it has been assumed that the procedure
will require the same duration with all patients regardless his/her condition.
b. Radiation exposure factor (Risk Factor)
Due to the difference in the radioactive materials used for each procedure, it is
suggested to assign different weight for each procedure in accordance to the energy of the
radioactive material; the higher radioactive material energy the higher risk involved in the
procedure and vice versa. The range of the energies used in Nuclear Medicine starts from 100
to 600 KeV. In accordance, all radioactive materials with energy between 100-300 KeV will
be considered in the “Mild Risk” category (M), while all radioactive materials with energy
more than 300 will be considered in the “High Risk” category (H). Procedures that do not
expose the staff with radiation will be considered in “No Risk” category (N).
c. Complexity factor
This factor is highly subjective due to the difference of staff standpoint for each
procedure. Accordingly, this factor will be measured by surveying all NM staff available. The
staff will be required to categorize each procedure in one of three categories: Not complicated
(N), Mildly complicated (M), and Highly complicated (H). The categorization is based on the
comparison with the standard procedure which is Chest X-ray.
d. Knowledge and skills required
Again, this factor is highly subjective due to the difference of staff standpoint for each
procedure. Accordingly, this factor will be measured by surveying NM staff available. The
staff is required to categorize each procedure in one of the three categories in terms of the
requirement for knowledge and skills in comparison to the Chest X-ray procedure: No
knowledge and skills (N), Mild knowledge and skills (M), and High knowledge and skills
(H).
3.3.Relative value unit formulation
Calculation of Nuclear Medicine procedures’ RVUs will depend basically on the
effective time for each procedure relative to each staff category (Physician, Specialist, and
Nurse). The first step in calculating RVU is to establish the basic values on which each

8
procedure RVU should be built. For this purpose, the duration of the procedure, for each staff
category is compared with the duration of a standard procedure in medical imaging,
specifically the “Chest X-ray” procedure. In other words, patient preparation by NM nurse,
procedure performing by NM specialist/technologist, and case reporting by NM physician are
compared with the standard time to prepare a patient in Nuclear Medicine Sections, the
standard time for performing a “ chest X-ray” by an X-ray technologist, and the standard time
to report a “ chest X-ray” by radiologist. These standard times are according to the practice of
the Medical Imaging Department of the concerned hospital. Thus, since chest X-ray requires
10 minutes to be performed and 5 minutes to be reported, then the nuclear medicine
procedure performing time and reporting time will be relative to 10 minutes and 5 minutes,
respectively. Regarding to the nursing time, since Chest X-ray procedure does not include
patient preparation by a nurse and all Nuclear Medicine procedures require 15 minutes of
patient preparation according to the protocols of hospitals under the study, then patient
preparation part for all procedures will be relative to 15 minutes. After finding the basic
values for all Nuclear Medicine procedures, a specific weight will be added in accordance to
the agreed weight given to each factor involvement extent as in Table 1:
Table 1: Factors involvement extents and the associated weight percentages
The Factor Involvement Extent
Factor 1 (Risk) No (0%) Mild (5%) High (10%)
Factor 2 (Complexity) No (0%) Mild (5%) High (10%)
Factor 3 (Skills) No (0%) Mild (5%) High (10%)
Basically, the RVU for each procedure will be calculated according to the following
formulae:
Basic Value = (Procedure Duration/Standard time) …………………………................... (1)
RVU = Basic Value + (Basic value X(Factor 1 Involvement extent % + Factor 2 Involvement
extent % + Factor 3 Involvement extent))
..................................................................... (2)
4. RESULT AND DISCUSSION
4.1.Relative value unit calculation
To calculate RVU for each procedure, the basic unit and the involvement extent of
each factor in each procedure are required. Table 2, Table 3, and Table 4 shows some RVU
calculations for NM Specialists, Physicians and Nurses; respectively, according to formulae
1and 2.

9
Table 2: Specialist RVU for some NM procedures
Procedure Title and Code
Basic
Unit
Risk
Factor
Complexity
Factor
Knowledge
and Skills
Required
Factor
RVU
30882 NM CNS-Brain death Scan 6 5.0% 5.0% 10.0% 7.2
30881
NM CNS-Brain perfusion
scan
6 5.0% 5.0% 10.0% 7.2
30869 NM CNS-Cisternogram 6 5.0% 10.0% 10.0% 7.5
30905 NM CNS-CSF Leak Study 12 5.0% 10.0% 10.0% 15
30830
NM CVS-Cardiac (MUGA)
Scan
6 5.0% 5.0% 5.0% 6.9
30825
NM CVS-Cardiac First Pass
Study
3 5.0% 5.0% 5.0% 3.45
30826
NM CVS-Cardiac Infarct
Scan
3 5.0% 5.0% 5.0% 3.45
30827
NM CVS-Cardiac Perfusion
Imaging (Rest)
4 5.0% 5.0% 10.0% 4.8
30844
NM Therapy-Thyroid
cancer Ablation with I-131
10 10.0% 0.0% 5.0% 11.5
30843
NM Therapy-
Thyrotoxicosis with I-131
10 10.0% 0.0% 5.0% 11.5
30916
NM Therapy-Sr89 for
Symptomatic bone
metastases
6 10.0% 0.0% 5.0% 6.9
30901
NM Therapy-Y90 Colloid
Knee Left
6 10.0% 0.0% 10.0% 7.2
30865
NM Therapy-Y90
Microsphere for liver tumor
11 10.0% 0.0% 10.0% 13.2
30917
NM Therapy-Y90
Octreotide for
Neuroendocrine tumor
9 10.0% 10.0% 10.0% 11.7
30890
NM Therapy-Y90 Zevalin
for Lymphoma
9 10.0% 5.0% 10.0%
11.2
5
30902
Knee Right
2 10.0% 5.0% 10.0% 2.5

10
Table 3: Physician RVU for some NM procedures
Exam Code
Basic
Unit
Risk
Factor
Complexity
Factor
Knowledge
and Skills
Required
Factor
RVU
30882
NM CNS-Brain death
Scan
6 0.0% 5.0% 10.0% 6.9
30881
NM CNS-Brain perfusion
scan
6 0.0% 5.0% 10.0% 6.9
30869 NM CNS-Cisternogram 6 0.0% 10.0% 10.0% 7.2
30905
NM CNS-CSF Leak
Study
6 0.0% 10.0% 10.0% 7.2
30830
NM CVS-Cardiac
(MUGA) Scan
6 0.0% 5.0% 5.0% 6.6
30825
NM CVS-Cardiac First
Pass Study
6 0.0% 5.0% 5.0% 6.6
30826
NM CVS-Cardiac Infarct
Scan
6 0.0% 5.0% 5.0% 6.6
30827
NM CVS-Cardiac
Perfusion Imaging (Rest)
6 0.0% 10.0% 10.0% 7.2
30844
NM Therapy-Thyroid
cancer Ablation with I-
131
6 0.0% 5.0% 10.0% 6.9
30843
NM Therapy-
Thyrotoxicosis with I-131
6 0.0% 5.0% 10.0% 6.9
30916
NM Therapy-Sr89 for
Symptomatic bone
metastases
6 0.0% 0.0% 10.0% 6.6
30901
Knee Left
24 10.0% 0.0% 10.0% 28.8
30865
NM Therapy-Y90
Microsphere for liver
tumor
24 10.0% 5.0% 10.0% 30
30917
NM Therapy-Y90
Octreotide for
Neuroendocrine tumor
24 10.0% 5.0% 10.0% 30
30890
NM Therapy-Y90
Zevalin for Lymphoma
24 10.0% 5.0% 10.0% 30
30902
Knee Right
24 10.0% 10.0% 10.0% 31.2
Table 4: Nurses RVU for some NM procedures

11
Exam Code
Basic
Unit
Risk
Factor
Complexity
Factor
Knowledge
and Skills
Required
Factor
RVU
30882
NM CNS-Brain
death Scan
1 5.0% 0.0% 0.0% 1.05
30881
NM CNS-Brain
perfusion scan
1 5.0% 0.0% 0.0% 1.05
30869
NM CNS-
Cisternogram
1 5.0% 0.0% 0.0% 1.05
30905
NM CNS-CSF Leak
Study
1 5.0% 0.0% 0.0% 1.05
30830
NM CVS-Cardiac
(MUGA) Scan
1 5.0% 0.0% 0.0% 1.05
30825
NM CVS-Cardiac
First Pass Study
1 5.0% 0.0% 0.0% 1.05
30826
NM CVS-Cardiac
Infarct Scan
1 5.0% 0.0% 0.0% 1.05
30827
NM CVS-Cardiac
Perfusion Imaging
(Rest)
1 5.0% 0.0% 0.0% 1.05
30844
NM Therapy-
Thyroid cancer
Ablation with I-131
1 10.0% 0.0% 0.0% 1.1
30843
NM Therapy-
Thyrotoxicosis with
I-131
1 10.0% 0.0% 0.0% 1.1
30916
NM Therapy-Sr89
for Symptomatic
bone metastases
1 10.0% 0.0% 0.0% 1.1
30901
NM Therapy-Y90
Colloid Knee Left
1 10.0% 0.0% 0.0% 1.1
30865
NM Therapy-Y90
Microsphere for liver
tumor
1 10.0% 0.0% 0.0% 1.1
30917
NM Therapy-Y90
Octreotide for
Neuroendocrine
tumor
1 10.0% 0.0% 0.0% 1.1
30890
NM Therapy-Y90
Zevalin for
Lymphoma
1 10.0% 0.0% 0.0% 1.1
30902
NM Therapy-Y90
Colloid Knee Right
1 10.0% 0.0% 0.0% 1.1

12
The range of RVU’s for the specialists are from 2.5 to 11.7 and for the physicians are
from 6.6 to 31.2 and for the nurses are from 1.05 to 1.1. The variations in their RVU’s are
due to the nature of the activities to be done in each procedure by each of them, where the
time required, risk factor, complexity factor and the knowledge and skills required factor are
different.
4.2.RVU developed approach versus Medicare’s approach
As mentioned above the methodology of calculating the weight of each procedure was
mainly dependent on the time required to perform the procedure. Moreover, a maximum
adjustment factor of 30 percent was added to represent the contribution of other important
factors which are risk, complexity, and the required knowledge and skills. Each one of these
three factors has different involvement extent in each procedure. Thus, the involvement
extent was categorized into three levels: no involvement, mild involvement, and high
involvement. Each involvement level was represented with a specific weight: 0 percent for no
involvement, 5 percent for mild involvement, and 10 percent for high involvement.
On the other hand, Medicare Nuclear Medicine Sub-committee reviewed the RVUs
for all Nuclear Medicine Procedures that are defined on Current Procedure Terminology
(CPT) book in 2009 (Mathews and McGinty, 2010). The weight of each procedure was
calculated based on time, used equipment, liability expenses, and other expenses that are not
incurred by the facility where the procedure is performed. Medicare model considers pre-
procedure time, dose processing, and radiation protection survey which are done in our case
by NM nurses, radiopharmacists, and nuclear medicine physicists; respectively. Considering
these components as a part of procedure performance will increase the required time for each
procedure and subsequently will increase its weight or it’s RVU. The second difference,
Medicare has agreed that RVU will be relative to 5 minutes unit of time. Thus, after
determining the total amount of time required for each procedure, the basic value of each
procedure was calculated by dividing the total amount by 5 minutes unit of time. The third
difference, Medicare adds extra RVU for procedures that need special equipment in a step to
consider the equipment factor. Medicare system adds 1 RVU for all procedures’ weights
which require either thyroid probe, ventilation imaging equipment, well-counter, or other
probes. It also adds 5 RVUs to the procedures which needs basic imaging camera or non-
SPECT imaging equipment. Ten RVUs are added to all procedures which need basic SPECT
camera. Such a change in the procedure weight is required to increase the RVU of the
procedure which should be reflected in its price. In our case, adding extra RVU for the type
of the required equipment is not relevant because the model is belt to measure the weight of
the procedures regardless its expenses. Fourth difference, Medicare adds liability expenses,
which is named as malpractice RVU, to the work RVU and expenses RVU.
4.3. Sensitivity analysis
The sensitivity analysis was used to investigate the influence of changing the two
uncertainties the study involves (Procedure’s time and maximum adjustment factor) on the
final result of the RVU. Because of the huge data and the big number of procedures the
project involves, one procedure has been chosen to investigate the `effect of changing one of
the uncertainties on the final RVU value. The reporting time of “NM Tumor-sentinel Node
Imaging (Colorectal)” procedure (Exam code: 30874) was used for this purpose. The
highlighted yellow column and row show the procedure reporting time by a nuclear medicine
physician and the agreed maximum adjustment factor; respectively. The highlighted column
and row show the effect of changing the value of time or the maximum adjustment factor on

13
the final procedure reporting RVU. Table 5 shows the changes of the adjusted RVU for the
mentioned procedure with changes of its reporting time and the maximum adjustment factor.
Table 5: The influence of changing procedure time and maximum adjustment factor on the
final result of the RVU
4.3. Application of relative value unit
To explain the application of Relative Value Unit Model, the performed procedures at
specific hospital in Gulf countries during January and February 2013 has been summarized as
shown in Table 6. This table is used specifically to investigate the difference in calculating
the workload of Nuclear medicine departments by using both metrics: “Number of
Procedures per month” and “Relative Value Unit”. All these measurements are based on the
suggested procedures’ weights that are created by the proposed RVU model.
The table has been used to compare between the staff productivity in terms of number
of procedures and RVU. It’s clear from Table 6that the productivity of February in terms of
number of procedures was slightly higher than the productivity of January. Interestingly,
although the number of performed procedures in February 2013 was slightly higher than
January 2013, the RVU model shows the opposite of these results. The RVU model sates that
the productivity of specialists and physicians were higher in January 2013 by more than 25%
and 15%; respectively. Moreover, the RVU model shows insignificant increase in nurses’
productivity in February 2013 in comparison to that of January. These results suggest that the
RVU model is very important to measure the specialists’ and physicians’ productivity.
However, Nuclear Medicine nurses’ productivity can be measured simply by the number of
patients. This is due to the fact that patient preparation part is almost the same in all nuclear
medicine procedures.
Reporting Time for Procedure 30874
Percentage of Change -40% -30% -20% -10% 30min 10% 20% 30% 40%
Basic Value 3.6 4.2 4.8 5.4 6 6.6 7.2 7.8 8.4
MaximumAdjustmentFactor
0% 3.6 4.2 4.8 5.4 6 6.6 7.2 7.8 8.4
AdjustedRVU
10% 3.96 4.62 5.28 5.94 6.6 7.26 7.92 8.58 9.24
20% 4.32 5.04 5.76 6.48 7.2 7.92 8.64 9.36 10.08
30% 4.68 5.46 6.24 7.02 7.8 8.58 9.36 10.14 10.92
40% 5.04 5.88 6.72 7.56 8.4 9.24 10.08 10.92 11.76
50% 5.4 6.3 7.2 8.1 9 9.9 10.8 11.7 12.6
60% 5.76 6.72 7.68 8.64 9.6 10.56 11.52 12.48 13.44
70% 6.12 7.14 8.16 9.18 10.2 11.22 12.24 13.26 14.28

14
Table 6: Lists of performed procedures in during January and February 2013 at specific
hospital in Gulf countries
Exam
Code
Jan-13 Feb-13 Jan-13 Feb-13
No. of
Procedures
No. of
Procedures
Nurse
RVU
Specialist
RVU
Physician
RVU
Nurse
RVU
Specialist
RVU
Physicia
n RVU
30882 3 1 3.15 21.6 20.7 1.05 7.2 6.9
30881 0 2 0 0 0 2.1 14.4 13.8
30830 2 4 2.1 13.8 13.2 4.2 27.6 26.4
30827 10 25 10.5 48 72 26.25 120 180
30828 10 5 10.5 75 72 5.25 37.5 36
30838 15 1 15.75 346.88 108 1.05 23.13 7.2
30840 7 9 7.35 56.35 46.2 9.45 72.45 59.4
30847 2 25 2.1 10.35 13.2 26.25 129.38 165
30858 4 0 4.2 46 26.4 0 0 0
30857 2 1 2.1 25 13.2 1.05 12.5 6.6
30862 1 1 1.05 8.05 6.6 1.05 8.05 6.6
30849 1 0 1.05 12 6.6 0 0 0
30893 2 5 2.1 24 13.2 5.25 60 33
30894 1 7 1.05 8.4 6.6 7.35 58.8 46.2
30922 5 10 5.25 42 33 10.5 84 66
30925 10 19 10.5 84 66 19.95 159.6 125.4
30887 9 0 9.9 216.45 64.8 0 0 0
30912 9 3 9.45 112.5 64.8 3.15 37.5 21.6
30903 8 10 8.8 70 86.4 11 87.5 108
30883 3 5 3.3 26.25 32.4 5.5 43.75 54
30835 4 2 4.4 35 43.2 2.2 17.5 21.6
30918 1 5 1.1 10 10.8 5.5 50 54
30891 99 80 108.9 866.25 1069.2 88 700 864
30844 8 5 8.8 92 55.2 5.5 57.5 34.5
30902 6 0 6.6 15 187.2 0 0 0
TOTA
L
222 225 240 2264.88 2130.9 241.6 1808.35 1936.2
Moreover, the productivity of two nuclear medicine physicians has been compared by
using the number of procedures and RVU metrics for February 2013. As it is shown in Table
7, Physician A has reported 54 procedures compared to 43 procedures have been reported by
Physician B. In accordance, the productivity ratio between A/B is 1.25, thus Physician A is
working 25% more than Physician B in terms of number of reported procedures during that
month. However, when the same comparison is made by using the proposed RVU system the
scenario is different. Physician A has reported 561.3 RVU in comparison to 675 RVU has
been reported by Physician B. Thus, the productivity ratio between B/A is 1.2, thus Physician
B has produced 20% more than Physician A during the same month in terms of RVU.

15
Table 7: The productivity of two Physicians (A & B) given by Number of procedures and
RVU during February 2013 at specific hospital in Gulf countries
Physician A Physician B
Procedure
Code
Number of
Procedures
RVU Total
RVU
Procedure
Code
Number of
Procedures
RVU Total
RVU
30882 4 6.9 27.6 30882 1 6.9 6.9
30881 7 6.9 48.3 30881 1 6.9 6.9
30869 2 7.2 14.4 30869 2 7.2 14.4
30903 1 10.8 10.8 30903 4 10.8 43.2
30883 2 10.8 21.6 30883 4 10.8 43.2
30835 2 10.8 21.6 30835 6 10.8 64.8
30918 4 10.8 43.2 30918 4 10.8 43.2
30891 5 10.8 54 30891 2 10.8 21.6
30901 1 28.8 28.8 30901 3 28.8 86.4
30865 1 30 30 30865 2 30 60
30917 1 30 30 30917 3 30 90
30890 1 30 30 30890 1 30 30
30902 2 31.2 62.4 30902 4 31.2 124.8
30862 4 6.6 26.4 30862 1 6.6 6.6
30849 5 6.6 33 30849 2 6.6 13.2
30863 5 6.6 33 30863 1 6.6 6.6
30859 7 6.6 46.2 30859 2 6.6 13.2
Total 54 561.3 43 675
Similar productivity analysis has been made for two nuclear medicine specialists. As
it is shown in Table 8, Specialist C has performed 95 procedures compared to 64 procedures
have been performed by Specialist D. In accordance, the productivity ratio between C/D is
1.48, thus, Specialist C is working 48% more than Specialist D in terms of number of
procedures performed during that month. However, when the same comparison is made by
using the proposed RVU system. Specialist C has performed 702.5 RVU in comparison to
843.03 RVU for Specialist D. In accordance, the productivity ratio between D/C is 1.2, thus
Specialist D has performed 20% more than Specialist C during the same month in terms of
RVU.
The previous examples show that the number of procedures performed or reported
does not represent the productivity of the nuclear medicine specialists or physicians where
the nature of the procedures differs significantly. The RVU model may not be 100 percent
accurate in representing the actual productivity; however it is much near to it, than the
number of procedures.

16
Table 8: The productivity of two Specialists (C & D) given by Number of procedures and
RVU during February 2013at specific hospital in Gulf countries
Specialist C Specialist D
Procedure
Code
Number of
Procedures
RVU Total
RVU
Procedure
Code
Number of
Procedures
RVU Total
RVU
30882 5 7.2 36 30882 2 7.2 14.4
30881 2 7.2 14.4 30881 1 7.2 7.2
30869 1 7.5 7.5 30869 2 7.5 15
30905 1 15 15 30905 6 15 90
30830 5 6.9 34.5 30830 1 6.9 6.9
30825 10 3.45 34.5 30825 5 3.45 17.25
30826 15 3.45 51.75 30826 3 3.45 10.35
30827 6 4.8 28.8 30827 2 4.8 9.6
30831 5 12.65 63.25 30831 9 12.65 113.85
30838 1 23.13 23.13 30838 9 23.13 208.13
30837 2 23.13 46.25 30837 8 23.13 185
30840 4 8.05 32.2 30840 1 8.05 8.05
30879 1 48 48 30879 1 48 48
30893 1 12 12 30893 1 12 12
30894 8 8.4 67.2 30894 3 8.4 25.2
30895 7 7.2 50.4 30895 2 7.2 14.4
30832 9 7.2 64.8 30832 1 7.2 7.2
30822 3 8.75 26.25 30822 4 8.75 35
30921 9 5.18 46.58 30921 3 5.175 15.53
Total 95 702.5 64 843.05
5. CONCLUSION AND RECOMMENDATION
RVU values can vary from system to another and some would criticize its preciseness
but for many it can be quite valuable and crucial for measuring changes in activity or
productivity from one period to another; or the comparative productivity of staff performing
similar activities in one department or at different hospitals. Having a unified unit to measure
the output of Nuclear Medicine departments at different hospitals will support strategic
planning at higher level (Ministry of Health), decision making, and budgeting. As it has been
discussed, the established RVU model is more reliable in measuring Nuclear Medicine
Physician and Specialist productivity than depending on the number of patients or procedures
metrics. However, nurses’ productivity can be measured fairly by using number of patient’s
metrics due to the standardized tasks they perform in all Nuclear Medicine Procedures. As it
has been deliberated, RVU has many applications that support the management at different
levels. It is very helpful to determine the needed manpower, compare cost effectiveness from
different prospective, and assess the operation efficiency.
For future studies, it is highly recommended to validate the main uncertainty of this
model which is the time per procedure factor (reporting time, procedure time, and patient

17
preparation time) which is taken from the standard protocol of one hospital without
validation. Moreover, more factors can be included to the weight of the procedure; such as
patient age, patient condition, quality of the outcomes and other factors which are related to
the patient condition.
REFERENCES
1. Maitino AJ, Levin D, Parker L, Rao VM, Sunshine J. (2010). Nationwide trends in
rates of utilization of noninvasive diagnostic imaging among the medicare population
between 1993 and 1999. Radiology; 227: 113.
2. Chan, S. (2002). The Importance of strategy for the evolving field of radiology.
Radiology, 224: 639-648.
3. Bair, J. and Gwin C. (1985). A productivity systems guide for occupational therapy.
Rockville, MD: The American Occupational Therapy Association, Inc.
4. American Medical Association. physicians' current procedural terminology: CPT 1998.
Standard Edition. Chicago, IL: AMA, 1998.
5. Albertsen P, Atkinson B (2000). Measuring contributions to the clinical mission of
medical schools and teaching hospitals. Academic Medicine, 75 (12): 1231-1237.
6. Hsiao WC, Braun P, Yntema D, Becker ER (1988). Estimating physicians’ work for a
resource-based relative value scale. N Engl J Med; 319:835-41.
7. Glass KP, Anderson JR (2002). Relative value units: from A to Z. J Med Pract
Manage; 17:225-8.
8. Moorefield JM, MacEwan DW, Sunshine JH (1993). The radiology relative value
scale: its development and implications. Radiology; 187:317-26.
9. Health Care Financing Administration (1991). Medicare program: fee schedule for
physician services: proposed rule. Fed Reg; 56:25792-862.
10. D’Alessandri RM, Albertsen P, Atkinson BF (2000). Measuring contributions to the
clinical mission of medical schools and teaching hospitals. Acad Med; 75:1231-7.
11. Lu Y and Arenson H (2005). The academic radiologist’s clinical productivity: an
update. AcadRadiol; 12:1211-23.
12. Merzich R, & Nagy P.G. (2007). The Academic RVU: A System for Measuring
Academic Productivity. J Am Coll Radiology 4:471-478.
13. Mathews A. and McGinty T. (2010). Physician panel prescribes the fees paid by
medicare". The Wall Street Journal, 56:25792-862.

30420140502001

Recommandé

Recommandé

Contenu connexe

Tendances

Tendances (20)

En vedette

En vedette (8)

Similaire à 30420140502001

Similaire à 30420140502001 (20)

Plus de IAEME Publication

Plus de IAEME Publication (20)

Dernier

Dernier (20)

30420140502001