MBA Final Report

6
th
Draft

Optimization of Aga Khan University
Hospitals MRI and CT Scan Procedures
using Operations, Finance and Marketing
Concepts

IBA Student Team Ayaz Saleh, Haris Usama, M. Ahmed Anjum, Mohsin Ali
Sadiq
AKUH Team Mr. Syed Sohail, Ms. Nida Husain, Mr. Rehanullah Baig,
Muhammad Yusuf
IBA Project Coordinators Dr. Nasir Afghan and Mr. Asad Ilyas
Project Advisors Dr. Shahid Qureshi, Mr. Asad Ilyas and Professor David
Robb (SEM Tsinghua)

2

TABLE OF CONTENTS
List of Figures ............................................................................................................. 7
List of Tables .............................................................................................................. 9
List of Exhibits .......................................................................................................... 11
Acknowledgments .................................................................................................... 12
Abstract .................................................................................................................... 13
Foreword .................................................................................................................. 14
Executive Summary ................................................................................................. 17
Chapter 1 Project Introduction ............................................................................... 20
1.1 Aga Khan University Hospital ............................................................................. 21
1.2 Patient Types ..................................................................................................... 23
1.2.1 Emergency Patients ..................................................................................... 23
1.2.2 In-Patients .................................................................................................... 23
1.2.3 Out-Patients ................................................................................................. 23
1.2.4 Outside Referrals (OSRs) ............................................................................ 24
1.3 Department of Radiology .................................................................................... 25
1.4 Magnetic Resonance Imaging ............................................................................ 27
1.5 Computerized Tomography ................................................................................ 28
1.6 Project Premise .................................................................................................. 29
Chapter 2 Literature Review .................................................................................. 30
2.1 Case Study Quinte MRI ................................................................................ 31
2.1.1 Summary ...................................................................................................... 31
2.1.2 Issues ........................................................................................................... 31
3

2.1.3 Setting .......................................................................................................... 31
2.1.4 Solution ........................................................................................................ 31
2.2 Course Manual for Operations Management ..................................................... 32
2.2.1 Summary ...................................................................................................... 32
2.3 Other Literary Material ........................................................................................ 32
Chapter 3 Research Objectives, Methods, Tools and Limitations ......................... 33
3.1 Objectives .......................................................................................................... 34
3.1.1 Operations ................................................................................................... 34
3.1.2 Marketing ..................................................................................................... 34
3.1.3 Finance ........................................................................................................ 34
3.2 Methods ............................................................................................................. 35
3.2.1 Team Interviews ........................................................................................... 35
3.2.2 Data Mining .................................................................................................. 35
3.2.3 Observation of Work Practice ...................................................................... 35
3.2.3.1 Scheduling and Queuing........................................................................ 35
3.2.3.2 Time and Motion Study .......................................................................... 36
3.2.4 Patient Survey .............................................................................................. 36
3.2.5 Sensing ........................................................................................................ 37
3.3 Research Tool Design ........................................................................................ 38
3.3.1 Patient Survey .............................................................................................. 38
3.3.2 Time-Motion Study ....................................................................................... 38
3.4 Limitations .......................................................................................................... 40
3.4.1 Marketing ..................................................................................................... 40
3.4.2 Operations ................................................................................................... 40
4

3.4.3 Finance ........................................................................................................ 40
Chapter 4 Data Collection and Analysis ................................................................ 41
4.1 Observations ...................................................................................................... 42
4.1.1 Patient Survey .............................................................................................. 42
4.1.1.1 Ease of Getting Care ............................................................................. 42
4.1.1.2 Waiting Time ....................................................................................... 47
4.1.1.3 Staff (Receptionists, Technologists, Radiologists) ................................. 50
4.1.1.3 Facility.................................................................................................... 56
4.1.1.5 Pricing Structure .................................................................................... 60
4.1.1.6 Post Test ................................................................................................ 63
4.1.1.7 Referral ............................................................................................... 67
4.1.2 Time-Motion Study ....................................................................................... 68
4.1.2.1 MRI ........................................................................................................ 68
4.1.2.2 CT Scan ................................................................................................. 69
4.1.3 Scheduling and Queuing .............................................................................. 70
4.1.3.1 MRI ........................................................................................................ 70
4.1.3.2 CT Scan ................................................................................................. 71
4.3 Revenue Model .................................................................................................. 72
4.3.1 MRI Model .................................................................................................... 73
4.3.2 CT Scan Model ............................................................................................ 74
Chapter 5 Conclusions .......................................................................................... 75
5.1 Operations .......................................................................................................... 76
5.1.1 Interdependencies & Lack of Coordination .................................................. 76
5.1.2 Lack of Monitoring of Idle time ..................................................................... 76
5

5.1.3 Scheduling of Appointments ........................................................................ 76
5.2 Finance .............................................................................................................. 78
5.2.1 Lack of Data Analysis ................................................................................... 78
5.2.2 Complexity of the procedures ...................................................................... 78
5.3 Marketing ........................................................................................................... 79
5.3.1 Lack of innovative communications ............................................................. 79
5.3.2 Inappropriate pricing .................................................................................... 79
5.3.3 Lack of patient understanding of the quality of service ................................ 79
5.3.4 Lack of Doctors recommendations .............................................................. 79
5.3.5 Unethical Issues ........................................................................................... 80
Chapter 6 Recommendations ................................................................................ 82
6.1 Marketing ........................................................................................................... 83
6.1.1 Strategic Partnerships .................................................................................. 83
6.1.1.1 Price-Discount Partnerships .................................................................. 83
6.1.1.2 Communication Partnerships ................................................................. 83
6.1.2 Online Reporting .......................................................................................... 84
6.2 Operations ...................................................................................................... 85
6.2.1 Recommendations to enhance throughput .................................................. 85
6.2.1.1 Scheduling of procedures ...................................................................... 85
6.2.1.1 Recruitment for independence and improved coordination .................... 87
6.2.2 Staffing & work flow efficiency recommendations ........................................ 87
6.2.2.1 Staff Training on Hard Skills .................................................................. 87
6.2.2.2 Performance-based Incentives .............................................................. 88
6.2.2.3 Mentoring ............................................................................................... 88
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6.2.3 Patient Engagement Tactics ........................................................................ 88
6.2.3.1 Increase seating capacity ...................................................................... 88
6.2.3.2 Wi-Fi ...................................................................................................... 88
6.2.3.3 Information Booth .................................................................................. 89
6.2.3.4 Tuck Shop .............................................................................................. 89
6.2.3.5 Play Area and Mothers Nursing Center ................................................ 89
6.3 Finance .............................................................................................................. 90
6.3.1 Pricing Strategy ............................................................................................ 90
6.3.1.1 Loyalty Cards ......................................................................................... 90
6.3.1.2 Discounts based on Frequency of Procedures ...................................... 90
6.3.1.3 Discounts based on the time of the appointment ................................... 91
6.3 Need for Further Study ....................................................................................... 92
6.3.1 Cost Drivers Mapping................................................................................... 92
6.3.2 Employee Climate Survey ............................................................................ 92
6.3.3 AKUH Brand Assessment ............................................................................ 92
6.4 Road Map ........................................................................................................... 93
Bibliography ............................................................................................................. 95
Exhibits ..................................................................................................................... 96

7

LIST OF FIGURES
1

Figure 1.1 Patient Types. 23
Figure 4.1 - Ease of scheduling your exam.. 42
Figure 4.2 - Courtesy of receptionist answering telephone calls 43
Figure 4.3 Hours imaging center is open.. 44
Figure 4.4 Convenience of imaging center's location.. 45
Figure 4.5 - Parking space & distance to the clinic. 46
Figure 4.6 - Time in waiting room.. 47
Figure 4.7 - Waiting Time for test to be performed. 48
Figure 4.8 - Overall waiting time in imaging center. 49
Figure 4.9 - Courtesy of office staff 50
Figure 4.10 - Due attention given to you.. 51
Figure 4.11 Staff satisfied queries.. 52
Figure 4.12 - Good advice and treatment. 53
Figure 4.13 Staff being friendly and helpful.. 54
Figure 4.14 Staff answered your questions.. 55
Figure 4.15 - Neat and clean waiting room.. 56
Figure 4.16 - Comfort and safety while waiting 57
Figure 4.17 Cleanliness of the Washrooms 58
Figure 4.18 Privacy... 59
Figure 4.19 - MRI and CT Scan Prices are market competitive 60
Figure 4.20 - Prices are justified 61
Figure 4.21 - Preference for an alternative with lower price 62
Figure 4.22 - Timely Delivery of the results. 63
Figure 4.23 - Ease in collecting results 64
Figure 4.24 - Staffs guidance for setting an appointment 65
Figure 4.25 Post-Test Privacy 66
Figure 4.26 Recommending Radiology Services to Others. 67
Figure 4.27 - Average IDLE Time during the day (MRI) .. 70
Figure 4.28 - Average IDLE Time during the day (CT) . 71

1
Figures follow the nomenclature of Chapter Number
8

Figure 4.29 - Revenue Distribution among Procedures. 72
Figure 5.1 - Cause & Effect - Low Yield 80
Figure 6.1 - Cycle of Continual Improvement 94

9

LIST OF TABLES
2

Table 4.1 - Ease of scheduling your exam 42
Table 4.2 - Courtesy of receptionist answering telephone calls 43
Table 4.3 Hours imaging center is open 44
Table 4.4 Convenience of imaging center's location 45
Table 4.5 - Parking space & distance to the clinic 46
Table 4.6 - Time in waiting room 47
Table 4.7 - Waiting Time for test to be performed 48
Table 4.8 - Overall waiting time in imaging center. 49
Table 4.9 - Courtesy of office staff. 50
Table 4.10 - Due attention given to you 51
Table 4.11 Staff satisfied queries 52
Table 4.12 - Good advice and treatment 53
Table 4.13 Staff being friendly and helpful 54
Table 4.14 Staff answered your questions 55
Table 4.15 - Neat and clean waiting room 56
Table 4.16 - Comfort and safety while waiting 57
Table 4.17 Cleanliness of the Washrooms 58
Table 4.18 Privacy 59
Table 4.19 - MRI and CT Scan Prices are market competitive.. 60
Table 4.20 - Prices are justified 61
Table 4.21 - Preference for an alternative with lower price 62
Table 4.22 - Timely Delivery of the results 63
Table 4.23 - Ease in collecting results 64
Table 4.24 -Staffs guidance for setting an appointment 65
Table 4.25 Post-Test Privacy 66
Table 4.26 Recommending Radiology Services to Others 67
Table 4.27 MRI Time-Motion Study Summary (in minutes) 68
Table 4.28 CT Scan Time-Motion Study Summary (in minutes) 69
Table 4.29 MRI Average IDLE time during the day 70

2
Tables follow the nomenclature of Chapter Number
10

Table 4.30 CT Scan Average IDLE time during the day 71
Table 4.31 Revenue Distribution. 72
Table 5.1 - Conclusion Summary.. 81
Table 6.1 Scheduling according to Patient Type 86
Table 6.2 Pricing Strategy and Formula 91

11

LIST OF EXHIBITS
Exhibit 1- Survey Form for Patients Perception.. 97
Exhibit 2- Process Map for MRI Procedure. 98
Exhibit 3- Time-Motion Study Observations for MRI Procedure (in minutes) 99
Exhibit 4- Process Map for CT Scan Procedure 100
Exhibit 5- Time-Motion Study Observations for CT Scan Procedure (in minutes) 101
Exhibit 6- Procedure Description, Volumes and Charges MRI. 102
Exhibit 7- Procedure Description, Volumes and Charges - CT Scan. 105
Exhibit 8 - Procedure Description, Volumes and Charges NM. 108
Exhibit 9 - Procedure Description, Volumes and Charges SPEC 110
Exhibit 10 - Procedure Description, Volumes and Charges STD. 112
Exhibit 11 - Procedure Description, Volumes and Charges US 116
Exhibit 12 - Procedure Description, Volumes and Charges VIR.. 118

12

ACKNOWLEDGMENTS
Before beginning the final year project report, we would like to express our gratitude
and appreciation to all those people who helped us during the course of our
research.
We start by thanking the team of AKUH - Mr. Syed Sohail, Ms. Nida Husain, Syed
Rehanullah Baig, and Mr. M. Yusuf. Their team was always at our beck and call.
They specially made time for us from their busy schedules, provided the information
we needed and gave us the necessary administrative support to ensure our team
had no problems.
We also want to thank Dr. Shahid Qureshi, our project advisor at the beginning of the
project. A special note of thanks goes to Professor David Robb of SEM Tsinghua
who supported us with material and technical assistance during the project.
Last, but not the least, we would like to acknowledge Mr. Asad Ilyas and Dr. Nasir
Afghan, Project Coordinators at IBA. Mr. Asad Ilyas, who also became our primary
advisor after the interim presentation, was literally just a phonecall away. He was
always available for advice, support and words of encouragement. And Dr. Nasir
went out of his way to help the team in improving its reporting and presentation.
Their critique was most pivotal in setting the teams direction.
We sum up our token of appreciation by acknowledging all the secondary resources
used for our research and literature review.
13

ABSTRACT
Aga Khan University Hospital (AKUH) is one of the leading healthcare providers in
Pakistan. Equipped with state-of-the-art technology, the hospital invests heavily in
research and focuses on high quality service. Given its infrastructure, AKUH incurs
heavy costs that result in premium pricing. The hospital offers unique value in terms
of safety and health. It has an in-patient turnover of about 60,000 and services about
700,000 outpatients annually.
The hospital is currently expanding its facilities with significant investments in
increasing capacities of Emergency Room, Internal Clinics and Private Wings and
Wards. The Department of Radiology also has plans to add another Magnetic
Resonance Imaging (MRI) and Computerized Tomography (CT scan) machines by
the end of 2012. This initiative has been taken to distribute the patient load during
peak hours, improve lead times and compensate for unexpected problems.
The department has experienced a healthy increase of revenue over the years yet
the number of procedures per year has been fairly consistent. This is because there
is only one machine for MRI and CT Scan each. Other factors contributing to such
performance are the premium price-tag of radiology procedures, extraordinary
waiting time, low referrals from physicians and priority status of emergency patients
over those with appointments.

14

FOREWORD
Before starting the report formally, the team would like to outline the series of events
during the course of the project. Work on the MBA Project started off early in Fall
Semester of 2011 with a debriefing from the coordinators. They explained the
significance of the project, the purpose it served both academically and in job
placements as well as the problems the students of previous batches had
encountered. The students were then required to form their groups. At the same
time, our coordinators and faculty members were approaching various companies for
getting projects.
The team selection was based on a number of factors with the most obvious being
the instant chemistry the members shared from the beginning of our MBA program.
The team had experience studying in groups together and also shared warm social
ties. Another key reason why the group formation made sense was what each
member brought to the team; each had a unique work experience and academic
interest. Therefore, the cumulative skill set of the group was highly diversified.
After the team finalization, the next step was to select a project. Projects brought by
the coordinators were from both blue-chip and local companies and also ranged in
disciplines. Project selection followed the free market mechanism. Both the client
and the student group had to mutually agree to work with each other. Hence
appointments were setup with clients whose projects interested the group.
The student teams first meeting was with Aga Khan University Hospitals Radiology
Team. The synergy between the two groups was instant. The AKUH team had great
enthusiasm for the project and the student team was equally intrigued by the
possibility of working with one of the most prominent organizations in the country.
Both the student team and AKUH would later court several other prospects but none
would compare to the interaction the two had had with each other.
15

What fascinated the student group about the AKUH Radiology project was that it was
multifaceted in nature. It had a combination of operations management, finance and
marketing and it allowed the student group the opportunity to observe a small but
integral part of the Radiology Departments operations in its totality. During this time,
the team had also finalized its advisor Dr. Shahid Qureshi.
The project started off with the development of Terms of Reference a set of
guidelines for the project and a roadmap for the student team. This document
outlined the project deliverables, the responsibilities of both the client and the
student team and a brief description of the business concepts to be used. This
document was finalized and approved by December 2011.
The New Year started with grunt work on the project. The team was introduced to
the staff and the managers of different areas. Special security badges were made so
that the team members had 24-hour access to the facilities. A few weeks were spent
observing the information flow and business process. Data-mining was being done
simultaneously with AKUH team openly sharing the procedures operational data.
Off-the-premises, the team devised research tools for patients survey and time
motion study. Haris contacted his Professor of Operations from SEM Tsinghua, Mr.
David Robb, who recommended the Quinte Case for the student teams reference.
Development of Feedback survey requires focus groups with representatives of the
target population. However, it was not possible to get AKUH doctors in the same
room at the same time due to the massive daily workload. The team had to resort to
secondary sources to devise the feedback form.
The team frequently sought Mr. Asad Ilyas help for the financial aspects of the
project. He was adamant that the team should capture the cost drivers of the
procedures. He thought it would help the team to suggest better pricing strategies.
However, upon discussing the proposition with Mr. Syed Sohail, Senior Manager
Radiology Department, the team realized that capturing costs of healthcare provider
16

is a complete project within itself. Syed Sohail is an alumnus of Institute of Business
Administration. The team then sought the coordinators permission to pursue a
revenue model.
Field work started from February and went well into April. This included the time-
motion study and patient feedback of the patients. The team had an interim
presentation during the 2
nd
week of February with the coordinators on project
progress. The coordinators guided the team regarding the report format and future
direction. It was at this juncture that Mr. Asad Ilyas decided to become the teams
advisor.
Compilation of data, analysis and reporting started in May. The feedback from
physicians could not be collected because the survey form design was not reviewed
and approved by AKUH team. There was frequent interaction with the coordinators
during this phase with changes being made in the report according to their guidance.
The final report submission and presentation took place on 21
st
July, 2012.
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EXECUTIVE SUMMARY
Aga Khan University Hospital has been expanding its facilities since 2008 to cater to
the increase healthcare services demand. This has resulted in an increase in patient
load on all allied departments such as radiology, laboratory etc. The Emergency
Room capacity has been increased by 100% with plans to increase in-patient
capacity by 20% by the year end. The department of Radiology has plans to install
additional units of MRI and CT Scan Machines by the end of 2012.
The student project is multifaceted in nature touching on operations, finance and
marketing disciplines. Following are the research objectives:
- Recommend ways to maximize capacity utilization of existing set-up and
highlight areas of improvement in operational practices
- Recommend ways to increase the number of referrals from AKUH-based
physicians and outside referrals from physicians
- Develop differential pricing strategy to increase patient footprint using revenue
models
The project methods include Team Interviews, Data Mining, Observation of Work
Practice, Scheduling and Queuing, Time and Motion Study, Patient Survey and
Sensing.
Following are the conclusions of the study:
- Many interdependencies and a general lack of coordination were observed in
MRI and CT Scan operations.
- Machine Idle time was not being monitored especially in MRI procedures.
- Operational Staff was reluctant to schedule appointments after 7 pm.
- Data generated from the operations was not used for sophisticated reporting.
- Complexity of the procedures prevents the modeling of an individual
procedures cost.
18

- Unlike the rest of the healthcare industry, AKUH does not market directly to
the end patient using mass media.
- MRI and CT Scan procedures are among the most expensive procedures in
the country.
- Patients generally do not fully understand and appreciate the quality of the
hospitals services.
- Doctors generally do not tend recommend AKUH Radiologys services.
- Unethical practices in the healthcare industry has some impact AKUHs
revenue stream.
Following are the recommendations of the study:
1. Forge Strategic Partnerships with other businesses such as banks and social
clubs. This will improve the laboratorys visibility in the eyes of the end patient,
update them on the departments activities and provide them payment
solutions.
2. Introduce Online Reporting for Customer Convenience. This is a value added
service where the patients will not have to come back to receive their test
reports.
3. Hire independent anesthetist to eliminate interdependencies and recruit
separate staff for co-ordination. This will streamline the departments
processes through improved exchange of information and reduced
dependencies.
4. Train staff on soft skills and corporate identity through Capacity Building and
Mentoring. This is a key recommendation which will result in visible difference
in other initiatives. It will inculcate a sense of ownership and improve the
departments culture.
5. Schedule procedures based on the queuing model. The queuing model takes
into account the patient type. Through patient consent, appointments can be
19

given in a manner that ensures utilization in the off-peak hours as well as
reduces the waiting time of the customers.
6. Introduce performance-based incentives. This is meant to motivate the staff
even further through extrinsic rewards.
7. Increase seating capacity in the waiting area and provide free Wi-Fi service or
establish information booth. These initiatives are meant to improve the
customers waiting experience.
8. Introduce differential pricing model and offer discounts through Loyalty Cards
and discounts based on the frequency of procedures. This will improve the
departments image in terms of the prices it charges for its procedures and
also develop a sense of loyalty among the customers.

20

CHAPTER 1 PROJECT INTRODUCTION

21

1.1 AGA KHAN UNIVERSITY HOSPITAL
Aga Khan University Hospital (AKUH) started its operations in 1985. It is a
philanthropic, non-profit, private teaching institution committed to providing the best
possible option for diagnosis of disease and team management of patient care.
AKUHs multidisciplinary approach to diagnosis and care ensures a continuum of
safe and high-quality care for patients all services under one roof. The University
Hospital provides high quality patient care in a broad range of secondary and tertiary
services to over 50,000 hospitalized patients and to approximately 600,000
outpatients annually. AKUH remains a differentiated provider in the field of
healthcare. It has continued to excel because it provides quality services and is
keen to innovate. (Aga Khan University)
Following are some of the key highlights of the University Hospitals
accomplishments:
- AKUH is the first hospital in Pakistan to be awarded US Joint Commission
International accreditation (JCIA) for achieving and maintaining the highest
international quality standards in health care.
- AKUH is the first hospital in Pakistan to receive ISO 9001:2008 certification
for patient care and support services and ISO 22000:2005 certification for
specialized food safety standards.
- It is the only hospital that has a network of over 190 Laboratory Specimens
Collection Units across Pakistan and Afghanistan.
- The hospital performs over 7 million clinical laboratory tests performed.
- It is the only hospital in Sindh where over 120 patients diagnosed with hearing
impairment have received their Cochlear Implant.
- It has performed over 140 Bone Marrow Transplant (BMT) which were carried
out by highly skilled oncologists and haematologists with excellent outcomes
to date.
22

- AKUH is only hospital in the Province to offer Corrective Heart Surgery for
Children and Newborns with Congenital Heart Defects.
- Doctors appointment can be booked 24 hours a day, 7 days a week for clinics
at the main hospital and Clifton Medical Services.
- It has a 24-hour Drug and Poison Information Centre providing the most
updated information regarding medicines and their use and poison
management.

23

1.2 PATIENT TYPES
The patients can be categorized into three main categories:
1.2.1 EMERGENCY PATIENTS
These patients have priority status. They can arrive at any time and are
accommodated immediately for any procedure. These patients may or may not be
In-patients and maybe asked to spend time in the hospital depending on the post-
procedure state of their condition.
1.2.2 IN-PATIENTS
These are the patients that have already been admitted to the hospital. Their state
may allow scheduling flexibility.
1.2.3 OUT-PATIENTS
These are patients that come in for procedures specified by AKUHs doctors. These
patients can be divided into two further categories:
- Patients with prior appointments
- Patients without any appointment (walk-ins)

Figure 1.1 Patient Types
Patients
Inpatients
Emergency
Patients
Outpatients
Walk-ins
Patients with
Appointments
OSRs
Walk-ins
Patients with
Appointments
24

1.2.4 OUTSIDE REFERRALS (OSRS)
These are patients that come in for procedures specified by doctors outside AKUH.
These patients can be divided into two further categories:
- Patients with prior appointments
- Patients without any appointment (walk-ins)

25

1.3 DEPARTMENT OF RADIOLOGY
The Department of Radiology offers 24/7 services that cater to the needs of
inpatients, outpatients and outside referrals by providing the best possible and
modern diagnostic facilities in main Radiology (AKUH) and in off-campus facility of
Clifton Medical Services (CMS). It also provides services to French Medical Institute
for Children (FMIC), Kabul, Afghanistan through Tele-radiology.
The Department is certified by the Pakistan Nuclear Regulatory Authority (PNRA)
working under the regulatory requirements of International Atomic Energy Agency
(IAEA). On an international level, the Departments practices are certified by JCIA
and ISO 9001: 2008. For quality assurance and radiation safety, regular audits and
inspections are conducted by PNRA.
The Department caters to approximately 18,000 patients a month. It is fortified with a
team of Radiologists, Research faculty, Medical Physicists, trained/ licensed
Radiographers, Management Teams, Support Staff including receptionists, filing
clerks, transcriptionists, porters and secretaries. (Aga Khan University)
The departments service portfolio includes:
- General / Special Radiography
- Fluoroscopy
- Ortho-pantomography and Cephalometry
- Ultrasound
- Color Doppler
- CT Scan (64 Slice
3
)
- MRI (1.5 Tesla, 18 Channel, with Cardiac imaging applications, Cardiac MRI
and CTA
4
)

3
Explained Under Computerized Tomography
4
Computerized Tomographic Angiography
26

- Cerebral Coiling
- Whole Body Scanning
- Vascular Angiography
- Hepatobiliary
- Urologic, Neuro Intervention
- Digital Subtraction Angiography
- Nuclear Medicine
- Bone Densitometry
- Interventional Radiology
- Paediatric Radiology
- Women Imaging (Mammography/ Mammotome)
- Dexa Scan
The department has transitioned into fully digitalized radiology and is now equipped
with Picture Archiving and Communicating System (PACS). The General
radiography procedures inclusive of IVP
5
and Flouro are carried out on Computed
Radiography System (CR) and Digital Retrofit (DR) which has minimized the patient
waiting time, radiation dose, report turnaround time, film rejection rate, film loss and
increased throughput. (Aga Khan University)

5
Intravenous Pyelogram
27

1.4 MAGNETIC RESONANCE IMAGING
Magnetic resonance imaging (MRI), nuclear magnetic resonance imaging (NMRI), or
magnetic resonance tomography (MRT) is a medical imaging technique used in
radiology to visualize detailed internal structures. MRI makes use of the property of
nuclear magnetic resonance (NMR) to image nuclei of atoms inside the body.
An MRI machine uses a powerful magnetic field to align the magnetization of some
atomic nuclei in the body, and radio frequency fields to systematically alter the
alignment of this magnetization. This causes the nuclei to produce a rotating
magnetic field detectable by the scannerand this information is recorded to
construct an image of the scanned area of the body. 36 Magnetic field gradients
cause nuclei at different locations to rotate at different speeds. By using gradients in
different directions 2D images or 3D volumes can be obtained in any arbitrary
orientation.
MRI provides good contrast between the different soft tissues of the body, which
makes it especially useful in imaging the brain, muscles, the heart, and cancers
compared with other medical imaging techniques such as computed tomography
(CT) or X-rays. Unlike CT scans or traditional X-rays, MRI does not use ionizing
radiation. (William C. Shiel Jr.)

28

1.5 COMPUTERIZED TOMOGRAPHY
Computerized (or computed) tomography (CT Scan), formerly referred to as
computerized axial tomography (CAT) scan, is an X-ray procedure that combines
many X-ray images with the aid of a computer to generate cross-sectional views
and, if needed, three-dimensional images of the internal organs and structures of the
body. Computerized tomography is more commonly known by its abbreviated
names, CT scan or CAT scan. A CT scan is used to define normal and abnormal
structures in the body and/or assist in procedures by helping to accurately guide the
placement of instruments or treatments.
A large donut-shaped X-ray machine or scanner takes X-ray images at many
different angles around the body. These images are processed by a computer to
produce cross-sectional pictures of the body. In each of these pictures the body is
seen as an X-ray "slice" of the body, which is recorded on a film. This recorded
image is called a tomogram. "Computerized axial tomography" refers to the recorded
tomogram "sections" at different levels of the body.
The body, as seen on CT scan slices from the skin to the central part of the body
being examined, can be further "added" together to get a three-dimensional picture
of an organ or abnormal body structure. Following are some facts about the
procedure:
- CT scanning adds X-ray images with the aid of a computer to generate cross-
sectional views of anatomy.
- CT scanning can identify normal and abnormal structures and be used to
guide procedures.
- CT scanning is painless.
- Iodine-containing contrast material is sometimes used in CT scanning
(Melissa Conrad Stppler).
29

1.6 PROJECT PREMISE
AKUH has been expanding its facilities for the past 3 years. The Emergency Room
capacity has been doubled. Current plans in the work also include increasing the
volumes of internal clinics. The volume of In-patients is also rising. The department
of radiology also has expansion plans in the works with additional machines for MRI
and CT Scan (1 each) arriving by the end of 2012.
The Department of Radiology has also been recording increasing revenues on an
annual basis. Yet the number of MRI and CT Scan procedures per year have been
fairly consistent in the last 3 years. A number of factors contributing to this stagnancy
have been identified by the AKUH Radiology Team. Following are some key
reasons:
- There is only one machine for MRI and CT Scan each.
- The price tag of AKUHs services makes it difficult to attract patients on its
own.
- Out-patients from the clinics and walk-in patients are not fully catered.
- Emergencies require pushing the scheduled procedures back and patients
with appointments end up waiting longer.
- Recommendations of physicians to other facilities on account of prices and
some unclassified unethical practices.
AKUH Radiology Department has state-of-the-art facilities and high qualified field
staff
6
. Yet the patients do not seem to value the departments proposition. The
waiting time seems to compound the dissatisfaction from the high prices.

6
Radiologists and Technologists
30

CHAPTER 2 LITERATURE REVIEW

31

2.1 CASE STUDY QUINTE MRI
2.1.1 SUMMARY
Quinte MRI is a small service provider of medical diagnostic technologies. After just
six weeks in operation at a medical centre, the company developed an extensive
waiting list, and physicians began referring patients to competing facilities. Quinte
MRI's business development coordinators must provide recommendations and an
action plan to deal with this process and productivity problem in a setting with
extreme variability. (Carol Prahinski, 11/30/2009)
2.1.2 ISSUES
Bottlenecks; Scheduling; Process Analysis; Capacity Analysis
2.1.3 SETTING
United States, Small-Medium Enterprise, 2002
2.1.4 SOLUTION
The solution to these issues lies in regaining control of the scheduling process as
this is an integral part of the operations. Streamlining the scheduling process to
reduce variability and improve reliability is required here. The company needs to
introduce the use of technology to remove manual processes, improve process
efficiencies, minimize errors and improve communication across the business lines
of operation. Hiring a new employee is also recommended to support the scanning
operations as there is no backup or adequately trained support for the only
technologist running the operations.

32

2.2 COURSE MANUAL FOR OPERATIONS MANAGEMENT
2.2.1 SUMMARY
It is a course manual taught in university of Auckland and also at the SEM Tsinghua.
Their MBA programs provide hands on learning on basic principles of scheduling
such as demand forecasting, queuing theories, sampling data and other operation
concepts such as bottlenecks and demand vs. capacity management. (Robb, 2011)
2.3 OTHER LITERARY MATERIAL
Following is the list of literature reviewed during the course of this project:
- Marketing Research: An Applied Orientation (2009), 6
th
edition, by Naresh K.
Malhotra & Satyabhusan Dash
- Chapter 8 - Work Measurement from Operations Management (2006), 5
th

edition, by Russell & Bernard W. Taylor, III
- The Costs of CT Procedures in an Academic Radiology Department
Determined by an Activity-Based Costing (ABC) Method (2000) by
Nisenbaum, Harvey L.; Birnbaum, Bernard A.; Myers, Melissa M.; Grossman,
Robert I.; Gefter, Warren B.; Langlotz, Curtis P.

33

CHAPTER 3 RESEARCH OBJECTIVES, METHODS, TOOLS
AND LIMITATIONS

34

3.1 OBJECTIVES
The project is multi-tiered in nature. It primarily deals with the optimization of MRI
and CT Scan Procedures at AKUH Radiology Department; however, achieving it
requires deeper probing into the departments finances, operations and marketing.
Following are the key objectives of the project:
3.1.1 OPERATIONS
- Recommend measures to maximize capacity utilization of existing set-up
through queuing model and time-motion study
- Highlight key areas for improvement in operational practices.
3.1.2 MARKETING
- Recommend measures to increase the number of referrals from AKUH-based
physicians and outside referrals from physicians through feedback and
suggestions.
3.1.3 FINANCE
- Recommend differential pricing strategy to increase patient footprint using
revenue models

35

3.2 METHODS
3.2.1 TEAM INTERVIEWS
The student team spent ample time with the AKUH team before and after project
finalization. During these meetings, candid discussion took place and the AKUH
team readily shared information about their departments financial and operational
performance, the underlying problems, organizational structure, costing methods,
competitors actions and their codes of ethic. The information shared during these
sessions helped the team build context of the project and identify the areas of focus
for studying.
3.2.2 DATA MINING
The AKUH team was kind enough to share operational and finance data related to
the MRI and CT Scan procedures. These included:
- Budget Variance Report of each modality for the last 5 years.
- Price Lists for MRI and CT Procedures with their subcategories
7
along with
the proposed price list for 2012.
- Operational Logs
- Monthly Volumes of Procedures performed along with the referring source
- Yearly Volume Breakdown of Patients into In-patients and Outpatients for
2011.
3.2.3 OBSERVATION OF WORK PRACTICE
3.2.3.1 SCHEDULING AND QUEUING
Scheduling was assessed by taking multiple observations of patients arrivals, during
different times of the day. This data was compared with the operational logs of the

7
Price of each procedure varies with the body part being studied and procedural requirements such as anesthesia and
contrast.
36

department to check for variance. Average waiting time and queue size were
determined and effective changes in scheduling appointments have been devised.
3.2.3.2 TIME AND MOTION STUDY
To assess the average time of the processes specific to MRI and CT procedures, the
student team conducted time and motion study for selected procedures based on
their frequency. Time and Motion study involves breaking down of processes into
simpler sub-tasks and assessing their efficiency through timing. This allowed the
student team to highlight specific hindrances such as interdepartmental
dependencies, employee productivity and various other issues.
The method used to calculate the Standard Minute Value comprises of following
steps:
i) Establish Standard Job Steps
ii) Break down that certain procedure into small elements
iii) Time the elements and take several observations
iv) Rate the Operator
8

v) Calculate the average time
vi) Calculate standard time i.e. the product of average time & rate at which operator
is performing
vii) Compute the Standard Minute Value or Standard time i.e. Normal time * (1+Total
Allowance time)
9

3.2.4 PATIENT SURVEY
To determine the perception of patients regarding their experience of MRI and CT
procedures, the student team formulated a comprehensive survey questionnaire.

8
Not applicable to MRI and CT Scan Machines.
9
Formula applicable to Operator based machines only. Therefore, it is not applicable to MRI and CT
machine.
37

3.2.5 SENSING
The team spent a significant amount of time in the waiting area during the time-
motion study. This gave them the opportunity to informally interact with patients who
were waiting in the lounge. Patients were not told about the nature of the project and
they were casually asked about their overall experience of AKUH services.
While collecting patient survey, the team members were frequently moving across
the MRI and CT scan departments. This allowed the team to observe incognito the
procedures being performed from an operational perspective. On occasions when
the feedback was being gathered in the procedure areas, one team member would
record observations of idle time and average lead time.

38

3.3 RESEARCH TOOL DESIGN
The questionnaire comprised of following sections:
- Ease of getting care
- Waiting time
- Behaviour of staff
- Overall outlook of facility
- Price structure
- Post test experience
- Future referrals.
Each section has four to five questions to assess the respondents perceptions. All
questions are closed ended and based on five-point Likert scale
10
which allows to
record reliable responses and reduces the variability in the results. Another benefit is
the minimization of errors in analyzing and interpreting data.
We have employed traditional approach i.e. sampling without replace. In addition to
that cross sectional technique has been applied. Sample size is 200 respondents.
See Exhibit 1- Survey Form for Patients Perception
3.3.2 TIME-MOTION STUDY
A specific format was developed for Time-Motion Study of MRI and CT Procedures
which breaks down the entire process into the following elements:
- Approach to counter
- Registration
- Payment

10
Based on a scale of 1 to 5; 5 being strong agreement or excellent and 1 being strong disagreement or very poor.
39

- Waiting Time
- History
- Declaration form (In case of MRI)
- Changing room
- Waiting Time
- Procedure
Observations are recorded in minutes. Convenience sampling technique has been
used.
Total 28 MRI and 28 CT Scan procedures have been studied to get accurate
approximation of Standard Minute Value.

40

3.4 LIMITATIONS
Following are the limitations of the student project:
3.4.1 MARKETING
i) The student team could not conduct a focus group with patients and doctors before
research tool development.
11

ii) In many instances, responses were collected from the attendees of the patients
undergoing the procedures.
iii) Doctors Survey could not be conducted as the feedback form was not approved
in time.
iv) The patient survey of the patients does not take into account following their
demographics or patient type (In-patient, out-patient, emergency)
v) Sample Size was reduced to 150 from the initial estimate of 200 due to time
shortage.
3.4.2 OPERATIONS
i) Time-Motion Study does not take into account the multiple entrances to the
radiology floor and multiple service desks.
ii) Convenience sampling was adopted and highest occurrence procedures were
studied for Time-motion study. This is because there are many subcategories of MRI
and CT scan procedures depending on the body part being studied. Each procedure
has different time durations and level of medical staff/patients preparation.
3.4.3 FINANCE
i) The differential pricing strategy does not take into account the cost drivers
12
.

11
Getting patients for a focus group would have required going through AKUHs Ethics Committee and AKUH Doctors could not
be spared due to the workload.
12
Identifying cost drivers is a massive undertaking as it required going beyond the scope of procedures to include the
departments and eventually the entire hospitals costing.
41

CHAPTER 4 DATA COLLECTION AND ANALYSIS

42

4.1 OBSERVATIONS
Each table represents responses to a question on the survey form.
13

4.1.1.1 EASE OF GETTING CARE
Table 4.1 - Ease of scheduling your exam
Response Frequency %
Poor 18 12
Fair 17 11.3
Good 22 14.7
Very Good 65 43.3
Excellent 28 18.7
Total 150 100

Figure 4.1 Ease of scheduling your exam
14

Most of the respondents found it easy to schedule their examination for CT scan and
MRI. But about 38% did not find the process to be easy.

13
See Exhibit 1 - Survey Form for Patients Perception
14
LEGEND: 1 Excellent; 2 Very Good; 3 Good; 4 Fair; 5 Poor

43

Table 4.2 - Courtesy of receptionist answering telephone calls
Fair 2 1.3
Good 17 11.3
Very Good 59 39.3
Excellent 72 48
Total 150 100

Figure 4.2 Courtesy of receptionist
15

There was not a single respondent who complained about the receptionist being
impolite or rude. It has been rated excellent in general.

15

44

Table 4.3 - Hours imaging center is open
Fair 7 4.7
Good 36 24
Very Good 25 16.7
Excellent 82 54.7
Total 150 100

Figure 4.3 Imaging Center Hours
16

About 95% of the respondents generally found the imaging hours to be excellent,
very good or good. There was not a single patient who considered it to be poor.

16

45

Table 4.4 - Convenience of imaging center's location
Poor
2 1.3
Fair
24 16
Good
31 20.7
Very Good
25 16.7
Excellent
68 45.3
Total 150 100

Figure 4.4 Imaging Centers Location
17

About 72% of the respondents found it very convenient to locate the imaging center
where as only 1.2% of the respondents found it difficult to locate the imaging center.

17

46

Table 4.5 - Parking space & distance to the clinic
Poor
75 50
Fair
24 16
Good
21 14
Very Good
13 8.7
Excellent
17 11.3
Total 150 100

Figure 4.5 - Parking space & distance
18

Only 34% of the respondents considered parking space and distance to the clinic to
be convenient while the rest 66% did not.

18

47

4.1.1.2 WAITING TIME
Table 4.6 - Time in waiting room
Poor
58 38.7
Fair
37 24.7
Good
24 16
Very Good
25 16.7
Excellent
6 4
Total 150 100

Figure 4.6 Time in the Waiting Room
19

Most respondents (38.7%) considered the time in waiting room to be high. However,
only 5% considered it to be excellent.

19
48

Table 4.7 - Waiting Time for test to be performed
Poor
40 26.7
Fair
43 28.7
Good
18 12
Very Good
32 21.3
Excellent
17 11.3
Total 150 100

Figure 4.7 Waiting Time
20

Most of the respondents considered the waiting time for the test to be high as 55% of
them considered it to be either fair or poor. Only 11.3% considered it to be excellent.

20

49

Table 4.8 - Overall waiting time in imaging center
Poor
68 45.3
Fair
24 16
Good
22 14.7
Very Good
28 18.7
Excellent
8 5.3
Total 150 100

Figure 4.8 Waiting Time in the Imaging Center
21

The respondents considered the overall time in the imaging center to be very high as
more than 60% of them considered it either fair or poor while only 5.3% rated it to be
excellent.

21

50

4.1.1.3 STAFF (RECEPTIONISTS, TECHNOLOGISTS, RADIOLOGISTS)
Table 4.9 - Courtesy of office staff
Poor
1 0.7
Fair
5 3.3
Good
19 12.7
Very Good
49 32.7
Excellent
76 50.7
Total 150 100
Figure 4.9 Courtesy of Staff
22

The courtesy of the office staff was generally rated as very high. About 83.4% of the
respondents considered it to be either excellent or very good while only 0.7%
considered it to be poor.

22

51

Table 4.10 - Due attention given
Poor
2 1.3
Fair
6 4
Good
31 20.7
Very Good
73 48.7
Excellent
38 25.3
Total 150 100

Figure 4.10 - Parking space & distance
23

Respondents generally felt that the level of attention given to them was very
encouraging as 64% rated it to be either very good or excellent while only 1.3% rated
it as poor.

23

52

Table 4.11 Staff satisfied queries
Poor
2 1.3
Fair
6 4
Good
35 23.3
Very Good
53 35.3
Excellent
54 36
Total 150 100

Figure 4.11 Staff satisfied queries
24

Majority of the respondents felt that proper instructions were given to them during the
course of the procedure. 36% rated the staff as excellent whereas 35.3% rated them
as very good on this attribute.

24

53

Table 4.12 - Good advice and treatment
Poor
1 0.7
Fair
4 2.7
Good
34 22.7
Very Good
63 42
Excellent
48 32
Total 150 100

Figure 4.12 - Good advice and treatment
25

74% of the respondents rated the advice given by the staff as excellent or very good.

25

54

Table 4.13 Staff being friendly and helpful
Poor
1 0.7
Fair
7 4.7
Good
27 18
Very Good
40 26.7
Excellent
75 50
Total 150 100

Figure 4.13 Staff being friendly and helpful
26

Respondents are generally happy with the attitude of the staff with 76.7% rating it as
either excellent or very good.

26

55

Table 4.14 Staff answered your questions
Poor
2 1.3
Fair
6 4
Good
31 20.7
Very Good
39 26
Excellent
72 48
Total 150 100

Figure 4.14 Staff answered your questions
27

Respondents were satisfied with the staff in terms of having their queries addressed.
48% of the respondents rated the staff as excellent for this question.

27

56

4.1.1.3 FACILITY
Table 4.15 - Neat and clean waiting room
Fair
10 6.7
Good
30 20
Very Good
54 36
Excellent
56 37.3
Total 150 100

Figure 4.15 - Neat and clean waiting room
28

Generally, the respondents considered the waiting area to be very neat and clean as
almost about 75% of the respondents rated it to be either very good or excellent.

28

57

Table 4.16 - Comfort and safety while waiting
Poor 1 .7
Fair 5 3.3
Good 27 18.0
Very Good 48 32.0
Excellent 69 46.0
Total 150 100.0

Figure 4.16 - Comfort and safety while waiting
29

A vast majority of respondents felt that the level of comfort and safety in the waiting
area is highly commendable

29

58

Table 4.17 Cleanliness of the Washrooms
Poor
10 6.7
Fair
25 16.7
Good
50 33.3
Very Good
38 25.3
Excellent
27 18
Total 150 100

Figure 4.17 Cleanliness of the Washrooms
30

The majority of the respondents had a positive opinion to the above question. 33.3%
responded that the condition of the bathrooms was good. 43.3% rated it as either
excellent or very good and the rest rated it as poor or below standard.

30

59

Table 4.18 Privacy
Poor
7 4.7
Fair
22 14.7
Good
34 22.7
Very Good
35 23.3
Excellent
52 34.7
Total 150 100

Figure 4.18 Privacy
31

Majority of Respondents think that they have privacy while the tests are being
performed, while a very few have the opposite view.

31

60

4.1.1.5 PRICING STRUCTURE
Table 4.19 - MRI and CT Scan Prices are market competitive
Strongly Disagree 55 36.7
Disagree 53 34.7
Neutral 24 16
Agree 8 5.3
Strongly Agree 10 6.7
Total 150 100

Figure 4.19 - MRI and CT Scan Prices are market competitive
32

More than 70% of the respondents think that the prices charged are not market
competitive. There were very few who felt it was otherwise.

32
LEGEND: 1 Strongly Disagree; 2 Disagree; 3 Neutral; 4 Agree; 5 Strongly Agree

61

Table 4.20 - Prices are justified
Disagree 42 28
Neutral 23 15.3
Agree 4 2.7
Total 150 100

Figure 4.20 - Prices are justified
33

There was a strong consensus among the vast majority that the prices charged are
not just.

33

62

Table 4.21 - Preference for an alternative with lower price
Disagree 18 12
Neutral 26 17.3
Agree 22 14.7
Total 150 100

Figure 4.21 - Preference for an alternative with lower price
34

When asked if the respondent would prefer an alternative with lower price, almost
50% declined. 34% said that they would prefer an alternative with lower prices.

34

63

4.1.1.6 POST TEST
Table 4.22 - Timely Delivery of the results
Strongly Disagree 9 6
Disagree 3 2
Neutral 16 10.7
Agree 52 34.7
Total 150 100

Figure 4.22 - Timely Delivery of the results
35

In response to above statement, almost 47% strongly agreed, 35% agreed, 11%
were neutral, and only 8% replied in denial.

35

64

Table 4.23 - Ease in collecting results
Disagree 2 1.3
Neutral 14 9.3
Agree 65 43.3
Total 150 100

Figure 4.23 - Ease in collecting results
36

When asked about the ease of collecting results, the responses of majority of
respondents were highly satisfactory and a very few were of the opposite view.

36

65

Table 4.24 -Staffs guidance for setting an appointment
Disagree 4 2.7
Neutral 20 13.3
Agree 56 37.3
Total 150 100

Figure 4.24 -Staffs guidance for setting an appointment 1
37

In response to above question, almost 47% respondents strongly agreed, 38%
agreed, 14% replied in neutral and only 3% disagreed

37

66

Table 4.25 Post-Test Privacy
Disagree 9 6
Neutral 34 22.7
Agree 43 28.7
Total 150 100

Figure 4.25 - Post Test Privacy
38

When respondents were asked whether they have post test privacy while discussing
their case with the concerned person, almost 43% respondents strongly agreed and
29% respondents agreed, 23% were indifferent and only 6% respondents disagreed.

38

67

4.1.1.7 REFERRAL
Table 4.26 Recommending Radiology Services to Others
Response Frequency Percent
Disagree 4 2.7
Neutral 15 10
Agree 39 26
Strongly Agree 72 48
Total 150 100

Figure 4.26 - Recommending to others
39

As many as 48% respondents strongly agreed & 26% agreed with the idea of
recommending these diagnostic services to others; 10% were indifferent and only
13.3% respondents strongly disagreed with this statement.

39

68

4.1.2 TIME-MOTION STUDY
4.1.2.1 MRI
See Exhibit 2- Process Map for MRI Procedure.
See Exhibit 3- Time-Motion Study Observations for MRI Procedure (in minutes)

Following is a summary of the Time-Motion Study Observations for MRI.

Total Standard Time (Sum of standard time for all elements) = 182.02 minutes
Total Time in Hours = 3.03

40
Avg OT = Average Operation Time; Total NT = Total Net Time, Rating = for assigning handicap to operator (Kept constant at
100%); Allowance = Tolerance
Table 4.27 MRI Time-Motion Study Summary (in minutes)
40

Approach
to
counter
Registration Payment Wait History
Declaration
form
Changing
room
Wait Procedure
Avg OT 3.43 3.21 2.61 91.14 3.75 2.29 9.89 11.25 38.18
Rating 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00 1.00
Total NT 3.43 3.21 2.61 91 3.75 2.29 9.89 11.25 38.18
No.
Observations
28 28 28 28 28 28 28 28 28
% Allowance 1.05 1.10 1.05 1.10 1.10 1.10 1.10 1.10 1.10
Standard
Time
3.60 3.54 2.74 100 4.13 2.51 10.88 12.38 42.00
69

4.1.2.2 CT SCAN
See Exhibit 4- Process Map for CT Scan Procedure.
See Exhibit 5 - Time-Motion Study Observations for CT Scan Procedure (in minutes)
Following is a summary of the Time-Motion Study Observations for CT Scan.

Table 4.28 CT Scan Time-Motion Study Summary (in minutes)
41

Approach to
counter
Registration Payment
Waiting
time
History Wait Procedure
Avg OT 3.07 5.18 2.14 47.50 10.43 4.71 6.71
Rating 1.00 1.00 1.00 1.00 1.00 1.00 1.00
Total NT 3.07 5.18 2.14 48 10.43 4.71 6.71
No. Observations 28 28 28 28 28 28 28
% Allowance 1.05 1.05 1.05 1.05 1.05 1.05 1.05
Standard Time 3.23 5.44 2.25 50 10.95 4.95 7.05

Total Standard Time (sum standard time for all elements) = 83.74 minutes
Total Time in Hours = 1.40

41
Avg OT = Average Operation Time; Total NT = Total Net Time, Rating = for assigning handicap to operator (Kept constant at
100%); Allowance = Tolerance
70

9.5 10.1
8.1 7.8 8.1 8.3
10 9.7
6.9
12.8 13 14
40.6
54
81.6
0
20
40
60
80
100
9
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m
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u
t
e
s
)
Ti me of t he Day
Average IDLE time during the day
4.1.3 SCHEDULING AND QUEUING
4.1.3.1 MRI
Following observations are in minutes.
Table 4.29 MRI Average IDLE time during the day
42

Time of Day Avgs Stdev Quad Avg Quad Avg Stdev Variance
9AM-10AM 9.5 1.90
9.23 1.87
3.61
10AM11AM 10.1 1.52 2.32
11AM12PM 8.1 2.18 4.77
12PM-1PM 7.8 1.32
8.07 1.60
1.73
1PM-2PM 8.1 1.66 2.77
2PM-3PM 8.3 1.83 3.34
3PM-4PM 10 2.87
8.87 3.30
8.22
4PM-5PM 9.7 4.90 24.01
5PM-6PM 6.9 2.13 4.54
6PM-7PM 12.8 3.49
13.27 2.67
12.18
7PM-8PM 13 2.11 4.44
8PM-9PM 14 2.40 5.78
9PM-10PM 40.6 9.30
58.73 13.17
86.49
10PM-11PM 54 8.65 74.89
11PM-12AM 81.6 21.56 464.93

42
It should be noted that Machine utilization is maximum during 9:00 am to 6:00 pm. The Machine Idle time increases for one
odd procedure in case anesthesia needs to be administered.
Figure 4.27 - Average IDLE Time during the day (MRI)
71

4.1.3.2 CT SCAN
Following observations are in minutes.
Table 4.30 CT Scan Average IDLE time during the day
Time of Day Avgs Stedv Quad Avg Quad Avg Stedve Variance
9AM-10AM 5.2 1.75
5.83 1.80
3.07
10AM11AM 6.5 1.72 2.94
11AM12PM 5.8 1.93 3.73
12PM-1PM 5.7 1.16
6.57 1.34
1.34
1PM-2PM 6.8 1.48 2.18
2PM-3PM 7.2 1.40 1.96
3PM-4PM 7.1 1.79
6.80 2.01
3.21
4PM-5PM 6 1.49 2.22
5PM-6PM 7.3 2.75 7.57
6PM-7PM 12.6 2.01
11.27 2.72
4.04
7PM-8PM 12.6 3.31 10.93
8PM-9PM 8.6 2.84 8.04
9PM-10PM 10 3.40
18.07 5.72
11.56
10PM-11PM 15.4 5.06 25.60
11PM-12AM 28.8 8.69 75.51

Figure 4.28 - Average IDLE Time during the day (CT)
5.2
6.5
5.8 5.7
6.8
7.2 7.1
6
7.3
12.612.6
8.6
10
15.4
28.8
0
5
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15
20
25
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35
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Average IDLE time during the day
72

4.3 REVENUE MODEL
The revenue model has been devised using prices charged per procedure and the
number of procedures performed during the year 2011. It was further augmented by
the average procedural time calculated during the operations study.
This model takes into account factors such as total time the MRI and CT Machines
were used, total time available since the major influx of patients occurs between
9AM to 7PM (Day time) and the sparse population of patients come between 6PM till
9AM (Night Time).
Table 4.31 Revenue Distribution
43

Procedure Revenue in Rs.
CT 194,552,330
MRI 151,036,510
NM 27,726,320
SPEC 27,124,800
STD 144,920,390
US 143,750,090
VIR 60,204,620
TOTAL Radiology Revenue 749,315,060

Figure 4.29 - Revenue Distribution among Procedures

43
Developed from Exhibits 6 through 12

26%
20%
4% 4%
19%
19%
8%
CT
MRI
Nuclear Medicine
Spectroscopy
STD
UltraSound
VIR
73

4.3.1 MRI MODEL
MRI proportion 20%
Total # of Procedures 8351
Procedures performed during day (85%) 7,098
Procedures performed during night (15%) 1,253
Total Revenue Rs. 151,036,510
Average time / procedure 22.41
Total Time in Mins 187138
Time spent in doing procedures during day 159067.3
Time spent in doing procedures during night 28070.7
Avg revenue / procedure Rs. 18,086
Avg revenue / Min Rs. 807.09
Total Minutes Available 475200
Total Minutes Available Day 198000
Total Minutes Available Night 277200
Total Utilization (Time) Day 80%
Total Utilization (Time) Night 10%
Downtime (In minutes)
Downtime / Week (System restart etc) 420
Patient related issue (metal etc) / week 420
Misc Unavoidable lags 420
Total Downtime / week 1260
Total Downtime (Jan - Nov) 55440
Estimated Capacity (Less Downtimes, Lags etc)
Estimated Capacity 419760
Estimated Capacity (Day) 174900
Estimated Capacity (Night) 244860
Utilization (Estimated Capacity Day) 91%
Utilization (Estimated Capacity Night) 11%
1 % increase in capacity - increase in revenues Rs. 3,387,825
# Mins operational / month 17012.54545
1 % increase in capacity / Month (In minutes) 170
1% Increase in Capacity / Month (Procedures) 7.59
1% Increase in Capacity / Month (Revenue) Rs. 137,306

74

4.3.2 CT SCAN MODEL
CT Proportion 26%
Total # of Procedures 15555
Procedures performed during day (79%) 12,288
Procedures performed during night (21%) 3,267
Total Revenue Rs. 151,036,510
Average time / procedure 5.64
Total Time in Mins 87653
Time spent in doing procedures during day 69246
Time spent in doing procedures during night 18407
Avg revenue / procedure Rs. 9,710
Avg revenue / Min Rs. 1,723.12
Total Minutes Available 475200
Total Minutes Available Day 198000
Total Minutes Available Night 277200
Total Utilization (Time) Day 35%
Total Utilization (Time) Night 7%
Downtime (In minutes)
Downtime / Week (System restart etc) 420
Patient related issue (metal etc) / week 420
Misc Unavoidable lags 420
Total Downtime / week 1260
Total Downtime (Jan - Nov) 55440
Estimated Capacity (Less Downtimes, Lags etc)
Estimated Capacity 419760
Estimated Capacity (Day) 174900
Estimated Capacity (Night) 244860
Utilization (Estimated Capacity Day) 40%
Utilization (Estimated Capacity Night) 8%
1 % increase in capacity - increase in revenues Rs. 7,232,962
# Mins operational / month 7968.454545
1 % increase in capacity / Month (In minutes) 80
% Increase in Capacity / Month (Procedures) 14.14
1% Increase in Capacity / Month (Revenue) Rs. 137,306

75

CHAPTER 5 CONCLUSIONS

76

Following are the conclusions of the research study. These conclusions have been
drawn using the methods mentioned in Chapter 3. These gaps directly contribute to
under-par yield of MRI and CT Procedures.
5.1 OPERATIONS
5.1.1 INTERDEPENDENCIES & LACK OF COORDINATION
Certain MRI and CT procedures demand resources from other departments. For
example, an infants MRI requires the patient to be sedated. This requires the
presence of an Anesthetist. Moreover, if the patient is admitted in one of the wards
(i.e. in patient), the patient will move to the radiology department only when the ward
mobilizes him/her. Such interdependencies cause the most extensive delays
disrupting the entire pre-assigned schedule like a domino effect. The patient may or
may not be available on the scheduled time. The Anesthetist may not be available on
time as well.
5.1.2 LACK OF MONITORING OF IDLE TIME
It has been observed that at times the machine is left idle i.e. it is not in operation.
This is usually due to lack of coordination especially with the MRI in cases where
anesthesia is required. While the staff waits on the anesthetist or the anesthetist
administers the anesthesia to the patient and approves the procedure, the machine
is idly waiting for the incoming patient. This results in both disrupting of the schedule
and a loss in revenue as well.
5.1.3 SCHEDULING OF APPOINTMENTS
The radiology department, like most other departments in the hospital, functions
round the clock. The MRI and CT machines are operational 24-hours a day. Even
though the machine is active throughout the day, it has been observed that the staff
is conditioned to operate it during day time from 8AM to 7PM and they hesitate in
77

issuing appointments beyond that time. This results in an influx of patients during the
morning. Given the variability of the entire process, even minor delays in procedures
cause a lot of scheduling issues; it eventually results in the patient being dissatisfied
due to long waiting hours.

78

5.2 FINANCE
5.2.1 LACK OF DATA ANALYSIS
AKUH captures a significant quantity of data through their efficient Patient
Management System. This data could easily be used for sophisticated analysis in
order to identify areas of improvement. However, currently the data is being used for
conventional reporting only such as total number of procedures, frequency etc.
However it is not being used to track the number of conversions and other metrics
that could help identify gaps.
5.2.2 COMPLEXITY OF THE PROCEDURES
Each one of the units i.e. MRI and CT has approximately 90 to 100 different
procedures and there is very little uniformity among them
44
. It is very difficult to
develop a uniform costing model since each procedure might consume a different
level of resources. One may take 20 minutes while the other may take over an hour;
some require contrast dye to be administered, some require more time of the
reporting radiologist, some require anesthesia.
Then there are the problems allocating fixed expenses such as electricity,
depreciation, building costs etc. Without proper systems in place to determine
accurate estimates of cost per procedure, the department cannot be certain about
the procedure charge and how much discount can be offered.

44
Variation may be due to the body part being studied or the auxiliaries being used (contrasts, anesthesia).
79

5.3 MARKETING
5.3.1 LACK OF INNOVATIVE COMMUNICATIONS
AKUH follows a strict code of conduct when it comes to its communication strategy.
The hospital does not engage patients directly but markets its services through
industry publications. The only conventional advertising can be seen around the
hospital premises or the main road across its entrance.
Given the variety of mediums available and the changing business dynamics, the
hospital has been lagging in terms of engaging the patients directly.
5.3.2 INAPPROPRIATE PRICING
MRI and CT scan procedures at AKUH are among the most expensive in the
country. This is the single biggest factor contributing to the loss of prospective
patients. Infact, in some cases, the procedures at AKUH Radiology are 3 times as
expensive as those at other laboratories
45
.
5.3.3 LACK OF PATIENT UNDERSTANDING OF THE QUALITY OF SERVICE
Majority of the patients tend to rate the quality of healthcare services based on the
price and not in terms of the organizations performance. They fail to fully appreciate
the competent team of radiologists and technologists, the resources and the
environment at the departments disposal.
5.3.4 LACK OF DOCTORS RECOMMENDATIONS
AKUH Radiology ranks quite low on doctors list of preferred services. It may be on
account of the social class of patients they cater.

45
Zia uddin Hospital
80

5.3.5 UNETHICAL ISSUES
Issues of unethical practice in healthcare industry are widely known. Many
physicians (outside of AKUH) tend to recommend specific medicine and laboratories
and hospitals because of their prior arrangements with these businesses. AKUH
does not indulge in such unethical practices. Still, the hospital on the whole does
tend to lose revenue to such activities.
Following is a cause-and-effect diagram of the problems and their reasons for Low
Yield of MRI and CT Scan Procedures. This diagram has been determined through
the respective methodologies employed for each function.

Figure 5.1 - Cause & Effect - Low Yield
81

Table 5.1 - Conclusion Summary
Area Method Gaps
Operations
Team Interviews
Data Mining
Scheduling and Queuing
Time and Motion Study
Team Members Experience
Sensing
Interdependencies & Lack
of Coordination
Lack of Monitoring of Idle
time
Scheduling of
Appointments
Finance
Team Interviews
Data Mining
Lack of Data Analysis
Complexity of the
procedures
Marketing
Patient Survey
Team Interviews
Sensing
Lack of innovative
communications
Inappropriate pricing
Lack of patient
understanding of the
quality of service
Lack of Doctors
recommendations
Unethical Issues
82

CHAPTER 6 RECOMMENDATIONS

83

Based on the above study, the student team has devised the following
recommendations:
6.1 MARKETING
6.1.1 STRATEGIC PARTNERSHIPS
The department can explore the possibility of strategic partnerships options in the
following areas:
6.1.1.1 PRICE-DISCOUNT PARTNERSHIPS
It is common for service businesses to partner with banks and provide price
discounts to the customers who use their credit cards. These banks are usually long-
term or short-term creditors for the businesses. Transaction charge from credit cards
contributes to the interest payments to the banks on behalf of the organization hence
improving the debt repayment schedule. This trend has been observed in
restaurants.
AKUH Radiology department should look for such a strategic alliance with banks the
hospital does business with. This would allow the department to provide the much
needed price concession to the patient and help the organization in loan repayment.
6.1.1.2 COMMUNICATION PARTNERSHIPS
Hospitals have been partnering with various social clubs of Karachi to leverage their
periodic publication and advertise about their services. One example of such a
strategic partnership is OMI Hospital and Dreamworld with the formers
advertisement appearing in the latters monthly newsletters. Such communication
tends to be under the radar and helps in targeting particular segments of the
population.
84

AKUH follows strict ethics when it comes to marketing to the patients. But the
changing nature of healthcare business dictates that hospitals assure prospective
patients about the quality of their services.
Granted that being a healthcare provider, AKUH caters to patients regardless of their
economic background, but this strategy specifically targets the segment of the
population who are willing to pay any price and not compromise on the quality of
healthcare. Such communication will serve the following purposes:
- Reiterate the quality of service of AKUH Radiology Department
- Update patients about the latest developments
Choice of the social club will depend on the demographics
46
of the clubs clientele.
6.1.2 ONLINE REPORTING
The department has a sophisticated information system in place which allows access
to digital reports anywhere in the hospital. Building on this system, the department
should give the patients access to their reports online. This would require the
development of a portal or user interface on the hospital website. Patients can sign
into that portal using their names as IDs and their patient numbers as passwords.
Although the departments reporting is currently satisfactory, such an innovation will
serve as value addition for patients and eliminate their need to wait after the
procedure or to come back later for the reports.

46
Particular emphasis will be on residential area.
85

6.2 OPERATIONS
6.2.1 RECOMMENDATIONS TO ENHANCE THROUGHPUT
6.2.1.1 SCHEDULING OF PROCEDURES
Scheduling exercise should take into account the patient category to prevent
bottlenecks and prevent the need of patients waiting in queue. Following is the
method proposed to schedule different patients:
- Inpatients: These patients are admitted in AKUH and require radiology services.
Most of them can be made to wait as they have other ongoing procedures.
However, currently their procedures are scheduled during the day with other
patients. If emergency and walk-in patients start reporting, scheduling issues
arise.
This problem should be catered by assigning different time slots to inpatients. For
instance they may be scheduled between 6PM and 10PM daily.
- OSRs: Patients walking in the radiology department and requesting procedures
vary during the day. Peaks in their volumes have been noted between 12PM to
3PM. These patients can either be accommodated right then or might want to
come back at a later time after taking an appointment. In case they wish to have
their procedures right then, they should be told an accurate estimate of waiting
time. For this, the staff needs to be trained. If the patients have to wait for over 3
or 4 hours, a lunch or snacks coupon should be issued to them along with the
receipt as some of the patients travel long distances to be there.
- Out-patients: Out patients are referred to radiology from within AKUH by its
consulting physicians at in-clinics. One of the key aspects the radiology
department needs to work on is increasing in-house referrals. These patients
need to be given a priority. Better profiling of these patients, discounts if
86

necessary, feedbacks and availability of appointments from within the clinicians
office are some of the key areas that need to be focused on.

Table 6.1 Scheduling according to Patient Type
Patient Type Suggestion Rationale
Inpatients
A separate list should be issued for Inpatients and
their scheduling should start at 6PM till 10PM.
(refer to fig: 4.27 & 4.28)
An inpatient is usually available around the clock as they
are admitted in one of the wards at AKU. These patients
names are included in the daily list and
are accommodated during the peak time somewhere
between the procedures In patients will always have a
100% conversion rate and should be accommodated at
times when the demand is low.
Emergency
The waiting patients should be informed
immediately that they have received an
emergency case and their procedures would be
delayed.
No scheduling policy applies to emergency patients - they
need to be rolled in immediately.
Outpatients
with
appointments:
Appointments should be given out with an interval
of 30minutes each for MRI and 15minutes each
for CT.
The registration desk should also give out
appointments in the later hours of the day after
getting a patients consent.
Priority should be given to patients who require
their procedure to be done early as they would
need to consult with their doctor on a specific
date.
If appointments are given sooner than 30 or 15 minutes in
case of MRI & CT respectively This results in overlaps
that eventually cause delays.
During the day time, the capacity utilization is
approximately 80-90% for both the machines; it is during
night that the utilization falls to remarkable lower levels.
Our end goal is to increase referrals and retain existing
patients. The staff should try their level best to facilitate
patients.
Outpatients -
Walk-ins
Identify to them the queue length and estimated
waiting time.
If they want an immediate appointment, give it to
them and give them an estimate time before
procedure so that they can get other things done.
In case they do book themselves on waiting, offer
them cafeteria coupons; some may be asked to
come back after an hour or two. If they do not
want to wait & can go back and come at another
time, give them the first available spot during the
night shift.
It is always better to keep the patient informed informed
waiting is always more acceptable and reduces anxiety.
Waiting experience can be enhanced using customer
engagement techniques. Installing information kiosks,
handing out meal coupons etc.
If a patient insists he needs an appointment early, and
does not like to wait 4-5hours, he can be asked to come
at late night. It would considerably reduce his waiting time
and also enhance machine utilization.
Patients with
Financial
Needs
Train the staff to identify if a patient might walk
away due to financial constraints.
Engage patients instead of letting them go, try
offering discounts and call them at later hours.
Refer them to administration for better pitching.
If a patient pays 70% or 80% of the charge during a time
where the machine remains Idle most of the time, it would
result in higher conversion rates and enhance machine
utilization.

87

6.2.1.1 RECRUITMENT FOR INDEPENDENCE AND IMPROVED COORDINATION
Coordination lapses and dependency on other departments combine to serve as
bottlenecks for MRI and CT Procedures. The department needs reinforcement in
these areas for efficient operations.
There is an anesthesia department which caters to the entire hospital. This is
because the department deals with highly sensitive chemicals. An anesthetist is
assigned to the radiology department two days in a week but his availability is also
subject to the workload in other areas such as ER. Hence, administration of
anesthesia to the patients is eventually delayed. The radiology department should
hire an anesthetist to eliminate this interdependency.
The radiology department should also recruit separate staff for co-ordination with
other functions. These personnel will be stationed in other departments on behalf of
radiology services and will be responsible for the booking procedures slots after
confirming with the front desk.
6.2.2 STAFFING & WORK FLOW EFFICIENCY RECOMMENDATIONS
6.2.2.1 STAFF TRAINING ON HARD SKILLS
The staff is conditioned to give out appointments during the day time only. Usually
they do not offer the patient the option to get an appointment for a time after 8pm.
This results in an influx of patients during the peak hours and the machine remains
at minimal utilization (approx 10%) during the night time. Not utilizing this time also
results in patients being scheduled for later dates some are given a time 2 days
after the date originally sought. This results in reneging of the patient which
eventually translates into a lower turnover ratio.
Training of the staff should be done where they are made to realize the importance
of a lost customer how every lost patient translates into lost revenue. Another very
effective method may be to keep a feedback machine with three buttons (good, fair,
88

bad) at the reception; once the procedure has been performed, the patient can rate
the staff.
6.2.2.2 PERFORMANCE-BASED INCENTIVES
The department needs to develop a culture of rewarding and promoting exceptional
employee performance. Extrinsic rewards such as recognition through Star
Performers and monetary incentives based on volumes of procedures performed
during duty (without compromising on service quality) should be introduced. This
would automatically develop a culture of high performance.
6.2.2.3 MENTORING
AKUH Radiology should introduce the culture of mentoring junior staff. Star
performers, who can be considered ambassadors of the department, should mentor
other staff and make them realize the importance of their work. They must
encourage other team members to take genuine ownership of their work.
6.2.3 PATIENT ENGAGEMENT TACTICS
6.2.3.1 INCREASE SEATING CAPACITY
During the peak hours, it was often observed that people had to stand around the
waiting area due to the lack of empty seats. The department must increase its
seating capacity to improve the patient experience.
6.2.3.2 WI-FI
Given the increasing trend of accessing internet on mobile phones, the department
should give free Wi-Fi service to people in the waiting area. If the department feels
such a service would be abused, the service can be protected by password which
can then be printed on the patient receipt.

89

6.2.3.3 INFORMATION BOOTH
The department should develop an information booth around the waiting area. This
interactive space will give patients insights on radiology procedures, answers to
frequently asked questions, explain instructions of the procedures with graphical
representation and have general information about health and well being. It would
also serve as an indoor advertisement prop.
6.2.3.4 TUCK SHOP
The department should look to set up a separate tuck shop that stocks snack items
and refreshments. Patients who have to wait for long periods can redeem their
coupons here as well.
6.2.3.5 PLAY AREA AND MOTHERS NURSING CENTER
A separate play area can be established in the open area adjacent to the radiology
department. This would help engage young children who may have accompanied
their parents. The department should also look into establishing a nursing center for
mothers with infants.

90

6.3 FINANCE
6.3.1 PRICING STRATEGY
AKUH Radiology currently has the most expensive procedures in the city. Based on
the recurrent opinion that the price tags are high, following are the different discount
policies the department can adopt:
6.3.1.1 LOYALTY CARDS
There are a large number of patients who are loyal customers of AKUH. These
patients entrust the hospitals services with their well-being. This is especially true for
many oncology patients who get their chemotherapy and subsequent procedures
from AKUH. The hospitals MIS has data on these patients.
The radiology department should develop loyalty cards for such patients to reward
them for their trust in the AKUH brand. The amount of discounts provided would
depend can be associated with the frequency of procedure and the length of patient
relationship with the hospital e.g. 5% discount on every Xth MRI or CT Scan for a
patient who has been coming to AKUH (any service) for the past year, 10% discount
on every Xth MRI or CT Scan for a patient who has been coming to AKUH (any
service) for the past two years and so on. Such a scheme will increase patients
loyalty and preference for all hospital services.
6.3.1.2 DISCOUNTS BASED ON FREQUENCY OF PROCEDURES
Many patients have to frequent the MRI and CT scan procedures periodically e.g. In-
patients who have to get tested before and after a surgery. The department should
devise a formula for providing such frequent patients discounts e.g. 2% discount for
a second MRI or CT procedure within a months duration. This would increase
Patient Footprint of those who frequent MRI and CT Procedures

91

6.3.1.3 DISCOUNTS BASED ON THE TIME OF THE APPOINTMENT
When a patient is given the option to come at a later time for the procedure,
especially after 10:00 pm, he/she should be given an incentive. The incentive has to
be a price discount and it should be attractive enough to make patients want to come
at a later time. It can once again be a percentage of the procedure charge or a
bracket system for rupee amount incentive based either on the time of the night or
procedure charge can be developed according to the procedure charge.
Besides increasing the likelihood of patient footprint, it will also increase utilization of
machines during the late shifts.
Table 6.2 Pricing Strategy and Formula
Incentive Scheme Suggested Discounting Formula Maximum
Loyalty Cards 5% discounts on every other (alternating) MRI and
CT Procedures for patients availing AKUH
services for a year.

10% discounts on every other (alternating) MRI
and CT Procedures for patients availing AKUH
services for 2 years.
20% for
Loyalty of 4
years &
over.
Procedure-
frequency based
incentive
2% discount for 2
nd
procedure within a month
3% discount for 3
rd
procedure within a month

1.5% discount for 2
nd
procedure within 2 months
3.5% discount for 3
rd
procedure within 2 months
5%
Time-Based
Incentive
10:00 pm to 12:00 pm Rs. 500 discount
12:00 pm to 02:00 am Rs. 1000 discount
OR
10:00 pm to 12:00 pm 2.5% of procedure charge
12:00 pm to 02:00 am 5% of procedure charge
7.5%
Use of specific
credit cards
5% - 15% for using specific credit cards. 15%
92

6.3 NEED FOR FURTHER STUDY
AKUH should engage in the following studies both at the departmental as well as
hospital level for effective management:
6.3.1 COST DRIVERS MAPPING
The hospital needs to determine its cost drivers in order to capture the true costs of
each procedure. Given the expanding facilities, this would give the hospital the
opportunity to reevaluate its price list, set target return-on-investments for each
department and refine project evaluation criteria. This project cannot be conducted in
isolation at departmental level because of the hospitals Cost-Center/Profit Center
treatment of departments. Therefore, it would have to be an organization-wide
exercise.
6.3.2 EMPLOYEE CLIMATE SURVEY
At present, the employees exhibit signs of lethargy and lack of motivation. The
organization should engage in an employee climate survey which would help
determine staffs perception about the organization, their team members and
superiors. It would also help determine the problems they face on a daily basis and
identify areas of improvement in coordination and internal communication.
Such a study will not be a finger-pointing exercise but rather an internal health check
of the employees attitudes.
6.3.3 AKUH BRAND ASSESSMENT
In order to gauge the patient perception about AKUH brand and what it actually
represents, the hospital should undertake several brand studies such as brand
audits. The results of such exercises will help determine the resonance of AKUH
brand, its points-of-parity, and points-of-differentiation as compared to the rest of the
industry and serve as a platform for future brand initiatives.
93

6.4 ROAD MAP
The student project has identified several areas of improvement within the
operations of AKUH Radiology Department. But this report is just a starting point.
AKUH needs to undertake several functional and behavioral projects before it is able
to enjoy unprecedented return-on-investments. These projects would focus on
optimizing both the workforce through culture augmentation and capital resources
through effective utilization. More importantly, it would help set a map for future
strategy.
A good place to start would be engaging the studies under section 5.3. These
studies focus on key areas of finance, organizational behavior and company brand.
Next step would be to develop concrete action plans based on quantifiable
objectives or undertake special projects with sophisticated metrics depicting before-
and-after scenarios.
Then comes the hard work of actually putting things into motion and implementing
the developed change plans. This will be the biggest challenge for the organization
as a whole as there will be significance internal resistance. One way to deal bolster
motivation is to introduce intrinsic awards
47
. (Thomas, 2009) The final step is to
review the progress and suggest further improvements.
If AKUH decides to seriously pursue the studies under 5.3, the hospital will be well
on its way to becoming the genuine first-choice hospital for the masses.

47
The four intrinsic awards that drive employee engagement are Sense of meaningfulness, Sense of choice, Sense of
competence and Sense of progress.
94

Figure 6.1 - Cycle of Continual Improvement

Identification of Gaps
through Research
Action Plan for Gaps
Implementation
Review and Improve
Functional & Behavioral
Studies
Identified under Need for
further Study
Sophisticated Metrics
Corporate Dashboards
Management by Objectives
Most resistance
Performance based Incentives
Intrinsic Rewards
Compare against objectives
Go back to Study & Research
95

BIBLIOGRAPHY
Aga Khan University. (n.d.). Aga Khan University Hospital Overview. Retrieved 2012,
from http://hospitals.aku.edu/karachi/aboutus/HospitalOverview/Pages/Home.aspx
Aga Khan University. (n.d.). Department of Radiology. Retrieved 2012, from
http://hospitals.aku.edu/karachi/hospitaldepartments/Radiology/Pages/home.aspx
Aga Khan University. (n.d.). Radiology Services. Retrieved 2012, from
http://hospitals.aku.edu/karachi/hospitaldepartments/Radiology/Pages/radservices.a
spx
Carol Prahinski, J. S.-F. (11/30/2009). Quinte MRI. Ivey Publishing.
Melissa Conrad Stppler, M. (n.d.). Article on CAT Scan. Retrieved 2012, from
Medicinenet.com.
Robb, P. D. (2011). Course Manual for Operations Management.
Thomas, K. (2009, November-December). THE FOUR INTRINSIC REWARDS
THAT DRIVE EMPLOYEE ENGAGEMENT. Retrieved 2012, from
IveyBusinessJournal.com: http://www.iveybusinessjournal.com/topics/the-
workplace/the-four-intrinsic-rewards-that-drive-employee-engagement
William C. Shiel Jr., M. F. (n.d.). MRI Scan. Retrieved 2012, from Medicinenet.com:
http://www.medicinenet.com/mri_scan/article.htm

96

EXHIBITS

97

Exhibit 1- Survey Form for Patients Perception

1 Ease of scheduling your exam
5 4 3 2
1
2 Courtesy of receptionist answering telephone calls
5 4 3 2
1
3 Hours imaging center is open
5 4 3 2
1
4 Convenience of imaging center's location
5 4 3 2
1
5 Parking space & distance to the clinic
5 4 3 2
1
6 Time in waiting room
5 4 3 2
1
7 Waiting Time for test to be performed
5 4 3 2
1
8 Overall waiting time in imaging center
5 4 3 2
1
9 Courtesy of office staff
5 4 3 2
1
10 Due attention given to you
5 4 3 2
1
11 Explained what you wanted to know
5 4 3 2
1
12 Gave you good advice and treatment
5 4 3 2
1
13 Friendly and helpful to you
5 4 3 2
1
14
Answered your questions 5 4 3 2
1
15 Neat and clean waiting room
5 4 3 2
1
16 Comfort and safety while waiting
5 4 3 2
1
17 The Washrooms were clean
5 4 3 2
1
18 Privacy
5 4 3 2
1
Pricing Structure
Strongly Agree Agree Neutral Disagree
Strongly
Disagree
19 Do you think the prices are market competitive
5 4 3 2
1
20 Do you think that prices are Justified
5 4 3 2
1
21 Will you prefer an alternative with lower price
5 4 3 2
1
Post Test
22 The results were delivered on time
5 4 3 2
1
23 I was easily able to collect results
5 4 3 2
1
24 The staff guided me for setting an appointment with doctor
5 4 3 2
1
25 Privacy
5 4 3 2
1
Referral
Strongly Agree Agree Neutral Disagree
Strongly
Disagree
26 I would definitely recommend this diagnostic service to others
5 4 3 2
1
Ease of getting care
Waiting Time
Staff: (Receptionists, Technologist, Radiologist)
Facility
P
o
o
r
This research is carried out by students of Institute of Business Administration for academic purpose only.
Statement E
x
c
e
l
l
e
n
t
V
e
r
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98

Exhibit 2- Process Map for MRI Procedure

99

Exhibit 3- Time-Motion Study Observations for MRI Procedure (in minutes)
Cycle
Approach
to
counter
Registration Payment Wait History
Declaration
form
Changing
room
Wait Procedure
1 3 4 1 42 3 2 5 10 59
2 4 3 4 37 3 1 9 12 40
3 4 4 1 93 4 2 9 17 40
4 5 3 2 46 4 3 9 13 36
5 4 4 3 64 5 2 8 11 27
6 5 3 2 73 5 4 6 9 37
7 5 2 4 81 4 2 5 12 49
8 3 3 1 109 5 1 14 14 36
9 4 4 4 104 5 3 11 15 40
10 5 3 1 11 3 3 12 10 33
11 3 4 2 104 3 1 14 8 52
12 2 2 4 96 2 2 14 7 30
13 3 2 2 79 3 1 9 8 29
14 3 3 4 143 2 3 8 10 39
15 3 4 1 65 4 2 14 11 42
16 4 3 4 108 4 3 9 10 30
17 4 4 3 135 2 3 12 8 31
18 3 4 1 66 5 3 9 13 33
19 2 2 3 95 5 2 10 8 32
20 3 2 2 94 5 4 12 9 28
21 4 4 3 103 4 2 8 13 28
22 2 3 4 79 5 1 5 14 48
23 3 4 4 125 2 3 11 9 48
24 3 3 1 158 3 3 13 13 38
25 3 2 3 74 3 2 5 14 40
26 2 4 3 109 5 2 11 10 36
27 4 3 2 169 4 3 15 12 35
28 3 4 4 90 3 1 10 15 53

100

Exhibit 4- Process Map for CT Scan Procedure

101

Exhibit 5- Time-Motion Study Observations for CT Scan Procedure (in minutes)
Cycle
Approach
to
counter
Registration Payment
Waiting
time
History Wait Procedure
1 2 3 1 54 10 5 5
2 2 4 2 52 9 7 7
3 4 5 2 19 13 4 6
4 3 4 1 50 11 5 9
5 5 7 4 74 11 6 8
6 5 4 2 38 8 4 6
7 5 7 3 36 13 3 9
8 2 3 4 18 9 7 5
9 2 7 3 46 13 6 9
10 5 3 1 47 9 5 9
11 2 5 2 70 7 5 5
12 4 6 2 40 11 6 6
13 2 7 2 50 7 4 9
14 5 3 2 58 10 5 9
15 2 3 1 44 9 7 7
16 3 3 2 59 10 3 5
17 3 7 1 53 10 3 7
18 4 6 4 57 13 3 6
19 2 7 3 59 8 4 6
20 2 7 2 50 11 3 5
21 3 7 1 48 9 3 6
22 4 3 2 36 11 4 8
23 2 6 2 29 13 6 8
24 2 6 2 57 13 3 5
25 2 3 1 68 11 7 5
26 4 7 4 41 13 3 5
27 2 7 2 28 9 5 8
28 3 5 2 49 11 6 5
102

Exhibit 6- Procedure Description, Volumes and Charges - MRI
Sr. No Procedure Description
Volume
(Jan-
Nov
2011)
Charges
2011
1 ABDOMEN 90 16,020
2 ANKLE JOINT 29 16,020
3 ANKLE/FOOT (SINGLE) 0 16,020
4 ANKLE JOINTS (BOTH) 0 32,020
7 BREAST (BOTH) 10 25,880
8 BRAIN & BOLD IMAGING 1 37,380
9 BRAIN 2217 15,290
10 BRAIN & PERFUSION 0 36,010
11 BRAIN FOR BOLD IMAGING 4 30,020
12 BREAST 7 16,540
13 BRAIN FOR EPILEPSY 0 16,020
14 BRAIN FOR I.A.C 26 16,020
15 BRAIN FOR (M.S. & ENCEPHALITIS) 0 28,800
16 BRAIN FOR ORBITS 59 23,990
17 BRAIN FOR PERFUSION 1 21,600
18 BRAIN (SCREENING) 423 5,500
19 BRAIN FOR SEIZURES 1 20,020
20 BRAIN FOR SELLA 98 23,990
21 BRAIN FOR SPECTROSCOPY 49 18,770
22 BRAIN FOR TRAUMA 0 16,020
24 CERVICAL SPINE 446 14,750
25 CARDIAC MORPHOLOGY 27 21,620
27 CERVICAL SPINE (SCREENING) 223 6,650
28 ELBOW JOINT (SINGLE) 11 16,020
29 EXTREMITY (LONG BONE) 22 16,020
30 FEET 1 32,020
31 FEMUR 37 16,020
32 FEMURS (BOTH) 1 32,020
33 FOOT 29 16,020
34 FOREARM 8 16,020
35 HAND 11 16,020
36 HANDS (BOTH) 0 32,020
37 HEAD with MR ANGIOGRAPHY 1041 20,180
103

38 HEAD MRA ONLY 29 11,270
39 HEAD and NECK 24 25,150
40 HIP JOINT (SINGLE) 57 16,020
41 HUMERUS 15 16,020
42 HUMERUS (BOTH) 0 32,020
43 KNEES (BOTH) 19 32,880
44 KNEE (SINGLE) 279 16,450
45 LUMBAR SPINE (SCREENING) 487 6,830
46 LUMBAR SPINE 1264 14,750
47 METASTASIS EVALUATION 2 30,750
49 MR ANGIOGRAPHY 9 16,020
50 Abdomen with MRA & contrast 0 30,170
51 MRA ABDOMEN WITH CONTRAST ONLY 9 23,990
52 Abdomen,MRA&MRCP with contrast 0 32,120
53 MRA HEAD & NECK 3 28,300
54 MRA NECK ONLY 20 23,990
55 MRA PEREPHRAL 6 23,990
56 MRA SPINE WITH CONTRAST 0 23,990
57 MRA THORACIC AORTA 3 23,990
58 MRA WHOLE BODY (SCREENING) MRA PEREPHRAL 0 27,290
59 MR CHOLANGIOGRAPHY 119 16,450
60 MR CHOLANGIOGRAPHY & ABDOMEN 4 18,800
61 MRCP Limited. 3 11,540
62 MR FOLLOW UP /ADDL.ACQUISITION 95 10,480
63 MRI & MRA NECK WITH CONTRAST 2 28,010
64 MRI & MRA SPINE (ONE REGION ONLY) WITH CONTRAST 0 39,970
65 MRI & MRA THORAX 3 31,980
66 MRI & MRV BRAIN WITH CONTRAST 75 28,010
67 MR HEAD AND MRA HEAD & NECK 32 23,560
68 MR UROGRAPHY 1 14,410
69 MR UROGRAPHY with ABDOMEN 0 18,800
70 MRV BRAIN AND CONTRAST 17 23,990
71 MRV BRAIN WITHOUT CONTRAST 8 16,020
72 SINGLE SEQUENCE MRI 154 6,000
73 MUSCULOSKELETAL SURVEYS 0 34,140
74 NECK 25 15,900
75 PELVIS 276 16,910
76 PELVIS FOR CERVIX 1 16,450
104

77 PELVIS FOR BOTH HIP JOINTS 0 16,020
78 PELVIS FOR PAEDS (HIP SPICA) 0 16,020
79 PELVIS FOR PROSTATE 0 16,020
81 SINGLE JOINT 0 16,020
82 SHOULDERS (BOTH) 5 32,010
83 SHOULDER JOINT (SINGLE) 73 16,020
85 SURFACE MARKING 0 11,710
86 THORAX FOR BRACHIAL PLEXES 2 16,020
88 THORACIC SPINE 209 15,020
89 THORAX 6 16,020
90 TIBIA 39 16,020
91 TIBIA (BOTH) 0 32,010
92 THORACIC SPINE (SCREENING) 54 6,500
93 WRIST JOINT (SINGLE) 13 16,020
94 WHOLE SPINE WITH CONTRAST (ADULT) 20 41,160
95 WHOLE SPINE WITH COMPOSER & ONE REGION 1 32,010
96 WHOLE SPINE WITH COMPOSER & ONE REGION WITH CONT. 0 39,970
97 WHOLE SPINE WITH COMP. & ONE REGION WITH CONT.(P) 0 31,980
98 WHOLE SPINE WITH CONTRAST (PAEDS) 16 32,830
99 WHOLE SPINE WITH COMPOSER (SAG. ONLY) 0 13,800

105

Exhibit 7- Procedure Description, Volumes and Charges - CT Scan
Sr.
No
Procedure Description
Volume
(Jan-
Nov
2011)
Charges
2011
1 ANGIO AORTA WITH CONTRAST 44 20,470
2 ABDOMEN W & WITHOUT CONTRAST Y 52 19,820
3 ABDOMEN WITH CONTRAST 716 13,990
4 ABDOMEN WITHOUT CONTRAST 58 13,470
5 ABDOMEN WITH CONTRAST (PAEDIATRIC) 111 13,280
6 ABDOMEN & PELVIS WITH CONTRAST 2046 20,060
7 ABDO.& PELVIS WITHOUT CONTRAST 48 18,565
8 ABD & PEL WITH AND WITHOUT CON 10 25,740
9 ABD & PELVIS WITH CONTRAST (PAEDIATRICS) 75 20,510
10 ANAESTHESIA FEES - NON CRITICAL CARE 25 2,250
11 ANAESTHESIA FEES - CRITICAL CARE 206 3,500
12 ANGIO PERIPHERAL WITH CONTRAST 52 16,380
13 ADDITIONAL PIGTAIL CATHETER 13 8,610
14 ABD & PEL WITHOUT CONTRAST (PEADIATRICS) 0 18,110
15 ASPIRATION ADDL. TO CT WITHOUT CONTRAST 21 6,960
16 ASPIRATION ADDL. TO CT WITH CONTRAST 0 9,360
17 ABDOMEN WITHOUT CONTRAST (PEADIATRICS) 0 10,880
18 GUIDED BIOPSY (FNAC) WITHOUT CONTRAST 11 6,860
19 CORE BIOPSY WITHOUT CONTRAST 184 9,450
20 BONE MINERALS DENSITOMETRY WITHOUT CONTRAST 0 2,210
21 BRONCHOSCOPY WITHOUT CONTRAST 0 13,650
22 CORONARY ANGIOGRAPHY WITH CONTRAST 96 29,400
23 CTA AORTA-FEMORAL ARTERIES WITH CONTRAST 1 20,470
24 CHEST ABDOMEN AND PELVIS WITH CONTRAST 473 27,290
25 CAROTID WITH CONTRAST 26 16,380
26 CORE BIOPSY WITH CONTRAST 2 11,850
27 COELIAC GANGLION BLOCK WITHOUT CONTRAST 0 8,240
28 COELIAC GANGLION BLOCK WITH CONTRAST 0 10,640
29 CT GUIDED DRAIN PLACEMENT WITH CONTRAST 0 10,030
30 CHEST WITH & WITHOUT CONTRAST 1 20,850
31 CHEST WITH CONTRAST 1785 18,060
32 CT CHEST WITH CONTRAST (PAED) 147 12,770
33 CHEST HIGH RESOLUTION WITHOUT CONTRAST 311 15,400
106

34 CHEST WITH&WITHOUT CONT. PED 0 18,590
35 CHEST WITHOUT CONTRAST 64 16,930
36 CHEST WITHOUT CONTRAST (PED) 2 12,170
37 CTA RENAL ARTERIES WITH CONTRAST 5 20,470
38 COLONOSCOPY WITHOUT CONTRAST 10 17,740
39 CALCIUM SCORING WITHOUT CONTRAST 5 10,000
40 CALCIUM SCREENING WITHOUT CONTRAST 44 2,940
41 CERVICAL SPINE WITHOUT CONTRAST 161 13,260
42 C T CISTERNOGRAM WITHOUT IV CONTRAST 9 19,620
43 COPY ON CD. 351 1,430
44 CT EXPERIMENT (ANIMAL) 0 4,490
45 CT FILM (ADDITIONAL) 15 970
46 CT KUB WITHOUT CONTRAST 1740 7,090
47 CT ANGIOGRAPHY WITH CONTRAST 32 14,910
48 FACT WITHOUT CONTRAST 175 7,060
49 COLONOSCOPY WITH CONTRAST 0 20,140
50 CT GUIDED DRAIN PLACEMENT WITHOUT CONTRAST 15 7,630
51 EXTREMETIES WITH CONTRAST 8 15,870
52 EXTREMETIES WITHOUT CONTRAST 110 13,470
53 FACIAL REGION WITHOUT CONTRAST 89 17,640
54 FACIAL REGION WITH CONTRAST 1 20,040
55 GUIDED BIOPSY (FNAC) WITH CONTRAST 0 9,260
56 HEAD PLAIN & RAI 1 13,210
57 HEAD WITH AND WITHOUT CONTRAST 226 13,170
58 HEAD WITH CONTRAST 6 11,260
59 HEAD AND NECK WITH CONTRAST 306 17,520
60 HEAD WITHOUT CONTRAST 3213 8,090
61 HEAD, NECK AND CHEST-STAGING WITH CONTRAST 0 23,200
62 INTRA CRANIAL ARTERIES WITH CONTRAST 89 17,740
63 LIVER SPECIAL STUDY WITH CONTRAST 73 10,650
64 LIMITED SERIES (eg FOLLOW UP) 91 8,820
65 NON CARDIAC OVERVIEW CORONARY ANGIOGRAPHY 84 -
66 NECK WITHOUT CONTRAST 222 13,650
67 NECK WITH CONTRAST 92 16,050
68 ORBITS WITHOUT CONTRAST 39 14,960
69 ORBITS WITH CONTRAST 7 17,360
70 PLAIN CALCIUM SCORING WITHOUT CONTRAST 0 5,000
71 PELVIS WITH & WITHOUT CONTRAST 0 16,240
107

72 PELVIS WITH CONTRAST 43 14,400
73 PELVIS WITHOUT CONTRAST 33 13,260
74 PELVIMETRY WITHOUT CONTRAST 13 1,570
75 PITUTIARY FOSSA WITH CONTRAST 1 12,520
76 PARA NASAL SINUSES WITHOUT CONTRAST 68 14,310
77 PARANASAL SINUSES LTD.STUDY WITHOUT CONTRAST 283 6,360
78 PNS LTD.STUDIES WITH CONTRAST 4 7,110
79 PARANASAL SINUSES WITH CONTRAST 23 16,710
80 PERFUSION SCAN WITH AND WITHOUT CONTRAST 0 10,920
81 ADD.STUDY AREA OF INTEREST 617 8,240
82 RENAL ARTERY ANALYSIS WITH CONTRAST 5 8,240
83 SACRO ILIAC JOINTS WITHOUT CONTRAST 1 9,470
84 SACRO ILIAC JOINTS WITH CONTRAST 0 11,870
85 SECOND OPINION ON CT PROCEDURE 102 2,690
86 STROKE PROTOCOL WITH CONTRAST 0 17,060
87 SPINE WITHOUT CONTRAST 135 14,300
88 SPINE WITH & WITHOUT CONTRAST 2 16,350
89 SPINE WITH IV CONTRAST 3 16,350
90 SPINE WITH MYELODYE 8 16,510
91 STROKE PROTOCOL WITHOUT CONTRAST 0 14,660
92 TEMPORAL BONE (LTD. STUDY) WITH CONTRAST 0 11,090
93 TEMPORAL BONE/IAC WITH CONTRAST 2 18,750
94 TELERADIOGRAPHY (FMIC) 380 2,250
93 TEMPORAL BONE/IAC WITHOUT CONTRAST 32 16,350
96 TEMPORAL BONE (LTD.STUDY). WITHOUT CONTRAST 1 8,690
97 TRIPLE RULE OUT WITH CONTRAST 0 40,930
98 WHOLE BODY SCANNING WITH CONTRAST 0 36,840

108

Exhibit 8 - Procedure Description, Volumes and Charges NM
Volume
(Jan-Nov 2011)
Charges
2011
1 BONE SCINTIGRAPHY-WHOLE BODY. 997 10,310
2 BONE SCINTIGRAPHY-THREE PHASE. 0 10,470
3 BONE MINERAL DENSITY (BMD) 3551 2,550
4 BMD WITH LATERAL IMAGE 0 2,890
5 BMD (WHOLE BODY) 0 3,090
6 BRAIN SCINTIGRAPHY-FLOW AND PLANAR STUDY WITH DTPA 0 10,900
7 BRAIN SCINTIGRAPHY-PLANAR WITH DTPA. 3 10,900
8 BRAIN SCINTIGRAPHY-SPECT WITH HMPAO. 0 32,010
9 COPY ON CD 27 1,570
10 DEXA SCAN FOR LEAN BODY MASS 2 610
11 DEXA FOR NEURONAL REGULATION RESEARCH 0 1,210
12 FIRST PASS CARDIAC ANGIOGRAPHY. 0 10,900
13 GALLIUM SCINTIGRAPHY-WHOLE BODY. 2 41,990
14 HEPATOBILIARY SCINTIGRAPHY. 13 10,900
15 I 131 FOR HYPERTHYROIDISM(LOW DOSE THERAPY) 19 17,070
16 I 131 FOR THYROID ABLATION (OPD BASED). 0 27,130
17 I 131 FOR HYPERTHYROIDISM(HIGH DOSE THERAPY) 6 24,100
18 I 131 MIBG SCINTIGRAPHY. 5 46,880
19 I131 WHOLE BODY SCINTIGRAPHY. 18 10,900
20 LUNG PERFUSION SCINTIGRAPHY. 23 10,900
21 LIVER/SPLEEN SCINTIGRAPHY WITH COLLOID-PLANAR 0 10,900
22 LIVER/SPLEEN SCINTIGRAPHY WITH COLLOID-SPECT. 0 10,900
23 LIMITED NUCLEAR STUDY AREA OF INTEREST 165 4,500
24 LIMITED VOLUME ESTIMATION STUDY 9 5,160
25 MECKLES DIVERTICULUM SCINTIGRAPHY. 7 10,900
26 MED/SURG.SUPPLIES 4 -
27 MULTIGATED(MUGA)SCAN-REST ONLY. 9 10,900
28 NM FILM (ADDITIONAL) 4 970
29 P 32 FOR POLYCYTHEMIA VERA. 0 33,900
30 P 32 FOR BONE METASTASES. 0 33,900
31 PARATHYROID SCINTIGRAPHY WITH T1 201-Tc 99mm SUBTR 2 10,900
32 PARATHYROID SCINTIGRAPHY WITH SESTAMIBI. 23 10,900
33 RENAL SCINTIGRAPHY WITH CAPTOPRIL INTERVENTION. 0 13,130
34 RENAL SCINTIGRAPHY WITH DMSA-SPECT 4 10,900
35 RENAL SCINTIGRAPHY WITH DTPA/MAG3. 165 10,900
36 RENAL TRANSPLANT SCINTIGRAPHY WITH DTPA/MAG3 1 10,900
37 RENAL SCINTIGRAPHY WITH DMSA-PLANAR 34 10,900
38 RED BLOOD CELL LABEL SCINTIGRAPHY FOR HEMANGIOMA. 0 10,900
39 SCINTIMAMMAOGRAPHY-SPECT. 0 13,130
109

40 SPLEEN SCIN.WITH DENATURED RBC 0 10,900
41 SALIVARY GLAND SCINTIGRAPHY. 0 6,360
42 SCINTIGRAPHY FOR GASTROINTESTINAL BLEEDING. 44 10,900
43 SCINTIMAMMOGRAPHY-PLANAR. 0 10,900
44 SENTINEL NODE SCINTIGRAPHY. 69 10,900
45 SR 89 FOR BONE METASTASES. 0 238,690
46 THYROID SCIN.WITH TcO4/I131. 252 7,480
47 ESOPHAGEAL TRANSIT TIME 0 10,900
48 TESTICULAR SCINTIGRAPHY. 0 10,900
49 TOXIC GOITER ABLATION 72 5,000
50 WHITE BLOOD CELL LABELLED SCINTIGRAPHY Tc993 HMPAO. 0 53,300

110

Exhibit 9 - Procedure Description, Volumes and Charges SPEC
Volume
(Jan-Nov 2011)
Charges
2011
1 ADDED BIOPSY 0 10,370
2 ANAESTHESIA FEES 0 3,510
3 ANAESTHESIA FEES (CONSULTATION) 0 940
4 ARTHROGRAPHY FOR MRI 0 3,680
5 ADDITIONAL TITANIUM MARKER 0 13,050
6 BARIUM ENEMA SINGLE CONTRAST 142 4,350
7 BARIUM ENEMA DOUBLE CONTRAST 49 6,070
8 BARIUM MEAL 54 4,580
9 BARIUM MEAL AND FOLLOW THROUGH 44 6,630
10 BA.MEAL & SWALLOW 70 4,810
11 ESOPHAGOGRAM (SWALLOW) 435 3,250
12 BREAST SCREENING (SINGLE OBLIQUE) 71 1,700
13 CORE BIOPSY (ST) 10 9,860
14 COPY ON CD (SPECIAL PROCEDURES) 32 290
15 ADDL CONTRAST 0 205
16 CYSTOGRAM 23 5,840
17 DACRYOCYSTOGRAM BILATERAL 23 4,140
18 DACRYOCYSTOGRAM UNILATERAL 19 3,030
19 DEFECOGRAPHY 15 5,210
20 ESOPHAGEAL DILATATION 1 7,610
21 ERCP FLUORO COVERAGE 88 19,840
22 ERCP LIMITED 3 11,600
23 FEE FOR DR.ABDUL WAJID 0 -
24 FAILED SPECIAL PROCEDURE 49 2,550
25 FEE FOR DR.TURAB PISHORI 0 3,740
26 FEE FOR DOCTOR HAROON RASHID 0 -
27 FISTULOGRAM 31 3,550
28 MISCELLANEOUS USE FLUORO ROOM 257 3,620
29 FLUOROSCOPY & FILMS 0 3,550
30 FEE FOR DR.MEHNAZ NAVED SHAH 0 1,160
31 FINE NEEDLE ASPIRATION (ST) 0 10,370
32 GALACTOGRAM 2 4,620
33 GASTROGRAFIN ENEMA 19 11,590
34 GASTROGRAFIN (FOLLOW THROUGH) 8 11,590
35 GASTROGRAFIN MEAL 22 8,890
36 GASTROGRAFIN SWALLOW 60 6,360
37 GENITOGRAPHY 3 5,570
38 INTRAVENOUS UROGRAPHY 0 2,795
39 NON IONIC CONTRAST 0 1,025
111

42 HYSTEROSALPINGOGRAM 521 7,220
43 IVP / IVU 141 5,550
44 IVP LIMITED STUDY 0 4,040
45 MAMMOGRAM (BILATERAL) 1672 5,410
46 LOCALISATION (1ST.) NEEDLE 24 10,610
47 MAMMOGRAPHY LTD.STUDY 22 4,050
48 MAMMO.SINGLE/MAGNIFIED VIEW 157 1,270
49 LOCALISATION ADDL. NEEDLE 9 5,040
50 MAMMOGRAM (UNILATERAL) 587 3,820
51 MICTURATING CYSTOURETHROGRAM 148 5,840
52 MED/SRG SUPPLIES (RADIOLOGY) 269 -
53 MEDICAL/SURGICAL SUPPLIES 2 -
54 MEASUREMENT OF ROI UNDER FLUOROSCOPY 0 1,750
55 MAMMOGRAM (SCREENING) 320 2,840
56 MYELOGRAM ADDITIONAL AREA 0 2,030
57 MYELOGRAM CERVICAL 0 14,870
58 MYELOGRAM LUMBAR 0 14,870
59 MYELOGRAM THORCIC 0 14,870
60 NEPHROTOMOGRAPHY (HIGH DOSE) 0 6,820
61 NEPHROSTOGRAM 0 4,280
62 NON IONIC CONTRAST IO ML 5 660
63 NON IONIC CONTRAST 100 ML. 5 6,600
64 NON IONIC CONTRAST 20 ML 4 1,320
66 NON IONIC CONTRAST 80 ML. 1 5,280
67 OTHER TOMO 0 4,370
68 PEROPERATIVE CHOLANGIOGRAM 0 5,565
69 RETROGRADE PYELOGRAM 0 3,550
70 BARIUM FOLLOW THROUGH 21 4,470
71 SMALL BOWEL ENEMA 25 5,800
72 SIALOGRAM BILATERAL 2 4,110
73 SIALOGRAM UNILATERAL 4 3,290
74 SINOGRAM 18 3,130
75 SECOND OPINION ON SPECIAL PROCEDURE 7 610
76 SP FILM (ADDITIONAL) 5 970
77 STENTOGRAM 0 3,820
78 SURGICAL FEE FOR DR. JOOMA 1 -
79 T TUBE CHOLANGIOGRAM 12 3,820
80 TUBOGRAM 0 5,500
81 URETHROGRAM 141 5,840

112

Exhibit 10 - Procedure Description, Volumes and Charges STD
Volume
(Jan-Nov 2011)
Charges
2011
1 AC JOINTS BOTH 0 1,165
2 ABDOMEN (KUB)1 VIEW 3903 980
3 ABDOMEN (2 VIEWS) 819 1,500
4 ABDOMEN 3 VIEWS 5 1,780
5 ABDOMEN ERECT 101 1,020
6 ABDOMEN (ONE SIDE) 13 920
7 ADDL.1 VIEW 1257 560
8 LOWER EXTREMITY ANKLE 1064 1,020
9 BABYGRAM 70 990
10 BONE AGE (ADULT) 145 1,560
11 EXTREMITY (BONE AGE PED.) 388 1,020
12 USE OF C ARM 1 HR. OR LESS 1487 5,510
13 C ARM ADDL.HR. OR PART 657 2,570
14 CERVICAL SPINE (2 VIEWS 1383 1,610
15 CERVICAL SPINE 967 890
16 CERVICAL SPINE (3-5 VIEWS) 50 2,020
17 USE OF C ARM FOR 30 MIN.OR LESS 500 3,130
18 COPY ON CD (STANDARD PROCEDURES) 242 290
19 CEPHALOMETRY. 803 2,070
20 CHEST ROUTINE 35691 520
21 CHEST (2 VIEWS) 566 1,020
22 CHEST (3 VIEWS) 4 1,550
23 CHEST LATERAL 55 520
24 CHEST PORTABLE 28891 1,720
25 UPPER EXTREMITY CLAVICLE 79 820
26 COCCYX 56 1,010
27 UPPER EXTREMITY ELBOW 779 1,020
28 DUPLICATE FILM(S) 94 680
29 EXTREMITY (LONG FILM) 165 2,760
30 FACIAL BONES 20 1,560
31 LOWER EXTREMITY FEMUR 1278 1,240
32 UPPER EXTREMITY FINGER 326 520
33 LOWER EXTREMITY FOOT 1784 1,020
34 LOWER EXTREMITY FOOT (1 VIEW) 13 515
35 UPPER EXTREMITY FOREARM 602 1,010
36 ABDOMEN (KUB) 1 view 0 430
37 ABDOMEN 2 VIEWS 0 680
38 ADDITIONAL VIEWS 0 350
39 UPPER EXTREMITY HAND 1134 1,020
40 ANKLE 0 330
113

41 BABYGRAM 0 450
42 BONE AGE STUDY 0 525
43 CHEST 1 VIEW 0 375
44 CHEST 2 VIEWS 0 635
45 CHEST 3 VIEWS 0 990
46 COCCYX 0 350
47 CERVICAL SPINE ( 2 VIEWS) 0 680
48 CERVICAL SPINE (4 VIEWS) 0 1,220
49 LOWER EXTREMITY OSCALCIS 232 1,010
50 ELBOW 0 355
51 FACIAL BONES 0 635
52 FEMUR 0 635
53 FINGER 0 305
54 FOOT 0 360
55 FOREARM 0 355
56 HAND 0 360
57 HEEL 0 355
58 HIP JOINT (SINGLE) 0 530
59 HIP JOINTS (BOTH) 0 940
60 HUMERUS 0 635
61 PELVIS AP & LAT HIP 1280 1,450
62 LOWER EXTREMITY HIPS AP LAT 122 1,680
63 KNEE (2 VIEWS) 0 635
64 L. SPINE 0 740
65 MANDIBLE 0 645
66 MASTOID 0 650
67 NASAL BONE 0 330
68 PELVIS 0 370
69 PARANASAL SINUSES 0 645
70 RIBS (B) 0 650
71 RIBS (U) 0 345
72 SACRUM 0 635
73 SCAPHOID 0 360
74 SHOULDER 0 635
75 S.I.Js 0 635
76 SKULL (3 VIEWS) 0 990
77 SKYLINE VIEW KNEE. 0 345
78 SPINE ( 1 VIEW ) 0 375
79 STERNUM 0 330
80 TIBIA 0 635
81 T. L. SPINE 0 740
82 TOES 0 305
83 T. SPINE 0 740
84 UPPER EXTREMITY HUMERUS 505 1,105
114

85 WRIST 0 370
86 INTERNAL AUDITORY CANAL 1 2,120
87 CHEST (MED. EXAMINATION) 12192 870
88 LOWER EXTREMITY KNEE 1490 1,100
89 KNEE JOINTS BOTH 1129 1,750
90 KNEE WITH SKYLINE VIEW 463 1,500
91 KNEES BOTH & SKYLINE VIEWS 983 2,120
92 LUMBO SACRAL SPINE (2-3) VIEWS 2786 1,760
93 LUMBO SACRAL SPINE (4-5 VIEWS) 66 2,110
94 LATERAL SKULL 33 730
95 MANDIBLE 17 1,430
96 MASTOIDS 28 1,550
97 NASAL BONES 50 890
98 NECK SOFT TISSUE/ADENOIDS 254 890
99 NECK (FOREIGN BODY) 13 890
100 OPTIC FORAMEN 0 1,360
101 ORTHOPANTOMOGRAPHY 5389 1,350
102 ORBITS 10 1,260
103 ORBITS (F.B) LOCAL 1 1,500
104 LOWER EXTREMITY PATELLA 2 VIEW 4 1,060
105 PHARMACY CHARGES 93 -
106 PELVIS 1835 970
107 LATERAL PELVIMETRY ONLY 0 1,750
108 ABDOMEN PELVIMETRY (AP & LAT) 0 2,120
109 POST NASAL SPACE 7 640
110 PARA NASAL SINUSES (TWO VIEWS) 1133 1,060
111 PARA NASAL SINUSES (4 VIEWS) 0 1,400
112 PORTABLE 1620 1,200
113 RIBS BILATERAL 9 1,200
114 RIBS UNILATERAL 169 1,020
115 STERNO-CLAVICULAR JOINTS 4 1,030
116 SACRUM 26 1,060
117 SPINE SCOL. SERIES 4-5 FILMS 12 5,210
118 UPPER EXTREMITY SCAPULA 11 1,060
119 UPPER EXTREMITY SCAPHOID 66 1,060
120 SPINE SCOLIOSIS 2-3 VIEWS 53 2,360
121 SELLA TURCICA 1 840
122 UPPER EXTREMITY SHOULDER 1395 1,210
123 SACRO ILIAC JOINTS (AP) 2 1,010
124 SACRO ILIAC JOINTS (1-3 VIEWS) 60 1,430
125 SKULL 182 1,560
126 SKYLINE VIEW KNEE 4 740
127 SPINE (LONG FILM) 47 2,520
128 SPECIMEN RADIOGRAPHY 43 1,030
115

129 SPINE (1 VIEW) 71 1,020
130 STERNUM 7 1,010
131 LOWER EXTREMITY STRESS VIEWS 0 990
132 SURVEYS HEMATOLOGICAL 0 5,560
133 SURVEYS METASTATIC/SKELETAL 102 5,640
134 THORACIC INLET 55 1,710
135 TEMPORO MANDIBULAR JOINTS 30 1,650
136 THORACIC SPINE 570 1,750
137 THUMB 145 520
138 TIBIA 1485 1,240
139 THORACO-LUMBAR SPINE 27 1,910
140 LOWER EXTREMITY TOES 170 520
141 UPPER EXTREMITY WRIST 1149 1,010
142 ZYGOMATIC ARCHES 1 880

116

Exhibit 11 - Procedure Description, Volumes and Charges US
Volume
(Jan-Nov 2011)
Charges
2011
1 ABDOMEN WITH ASPIRATION/DRAIN - 5,480
2 ABDOMEN COMP WITH PELVIS 3,899 3,960
3 ADDED BIOPSY - 9,130
4 ASPIRATION AMNIOTIC FLUID - 4,480
5 AMNIOTIC FLUID INDEX 83 880
6 AMNIOCENTESIS (DR.J.PAL) - 2,500
7 ANAESTHESIA FEES 4 3,510
8 APPENDIX 167 1,080
9 ASCITIC TAP (THERAPUTIC) 82 6,750
10 ASPIRATION/DRAINAGE ADDITIONAL 4 3,150
11 DIAGNOSTIC ASPIRATION 457 2,720
12 BIOPSY (FNA) 292 3,780
13 BIOPHISICAL PROFILE 282 4,080
14 BIOPHYSICAL PROF.WITH DOPPLER 10 5,490
15 BIOPSY PROSTATE 86 6,730
16 BIOPSY (TRANS VAGINAL) - 3,290
17 BLADDER 939 1,400
18 BREAST 511 1,860
19 BREAST (BOTH) 826 3,290
20 BREAST ADDL.TO UNILATERAL MAMMOGRAPHY 156 1,170
21 BREASTS ADDL.TO BILATERAL MAMMOGRAPHY 680 1,350
22 BREASTS ADDL.TO LIMITED MAMMOGRAPHY 5 1,460
23 COLOR DOPPLER CAROTID 587 6,750
24 COLOR DOPPLER EXTREMITY 102 6,750
25 COLOR DOPPLER EXTREMITY (BOTH) 67 10,010
26 COLOR DOPPLER VISCERAL (RENAL/PORTAL VEIN) 124 6,750
27 CHEST 358 2,040
28 CHORIONIC VILLUS SAMPLING - 5,730
29 CVS(DR.J.PAL) - 6,250
30 CATHETER PLACEMENT FOR DRAIN 350 7,640
31 DOPPLER B/W 1,473 4,170
32 PENILE DOPPLER STUDIES 127 6,740
33 EXTREMITY 122 2,110
34 EYES ( BOTH ) - 1,350
35 EYE 2 900
36 FETAL ANOMALY SCAN 2,604 2,340
37 FAST ULTRASOUND 797 1,260
38 FAST ULTRASOUND PORTABLE 888 3,470
39 FETAL ANOMALY SCAN FOR TWIN PREGNANCY 16 4,550
40 FATTY LIVER SCREENING FOR RESEARCH STUDY 11 790
41 PELVIS,FOLLICLE GROWTH 20 1,340
117

42 FAILED PROCEDURE 21 980
43 HEAD 309 1,600
44 KIDNEYS 1,413 2,150
45 KIDNEYS URETERS & BLADDER 4,424 3,270
46 LIVER/G.BLADDER OR BOTH 2,747 2,020
47 LIMITED ULTRASOUND (ONE ORGAN) 573 2,150
48 LOCALISATION (1ST.) NEEDLE 26 10,020
49 LOCALISATION ADDL.NEEDLE 1 4,790
50 MED/SURG SUPPLIES 127 -
51 BIOPSY WITH MONOPTY GUN - 13,120
52 MUSCULOSKELETAL - 2,030
53 NECK 422 2,150
54 PELVIS FOR FEMALE 4,459 1,130
55 PELVIS / OBS. DOPPLER STUDIES 323 4,480
56 PELVIS FOR FEMALE(OBS.). 7,777 1,430
57 PELVIS (TRANSVAGINAL) 3,244 2,100
58 PELVIS FOR MALE 97 1,400
59 PLURAL ASP. UNDER ULTRASOUND ( THERAPUTIC ) 285 7,650
60 PORTABLE 1,963 3,290
61 INTRA-RECTAL PROSTATE 103 4,800
62 SPECIMEN SONOGRAPHY 17 1,010
63 SALINE SONOSALPINGOGRAPHY - 2,820
64 TESTES 545 2,150
65 THYROID 295 2,150
66 TRANSRECTAL (FEMALE) - 2,150
67 TRUCUT/SURECUT BIOPSY 448 7,320
68 TARGETED ULTRASOUND BREASTS 11 1,070
69 TARGETED ULTRASOUND BREAST 156 770
70 ABDOMEN 7,965 3,080
71 VARICOCELE/SCROTUM(COLOR DOP.) 150 4,800

118

Exhibit 12 - Procedure Description, Volumes and Charges VIR
Volume
(Jan-Nov 2011)
Charges
2011
1 ADDITIONAL ANGIO CATHETER 59 2,890
2 ANTEGRADE PYELOGRAM DIAGNOSTIC 0 8,370
3 ADDITIONAL SHEATH 14 2,290
4 ADDITIONAL WIRE. 26 1,840
5 ADDITIONAL ANGIOPLASTY BALLOON 28 24,130
6 ALCOHOL ABLATION 4 17,500
7 ADDITIONAL ANGIOGUARD 1 107,020
8 ABORT.ANGIO PROCEDURE 5 8,350
9 EMBOLIZATION WITH ADDL. CIOL 21 10,140
10 ADDITIONAL DETACHABLE BALLOON. 1 55,370
11 ADDITIONAL DETACHABLE COIL. 61 67,810
12 ADDITIONAL GUIDING CATHETER 2 10,650
13 ADDITIONAL HISTOACRYL 9 6,090
14 ADDITIONAL MICRO CATHETER 11 60,270
15 ADDITIONAL MICRO WIRE 3 34,450
16 ADDITIONAL PALMATZ STENT 0 95,370
17 ADDITIONAL PLATINUM COIL. 77 15,740
18 ADDITIONAL PVA 58 9,910
19 ADDITIONAL SMART STENT. 1 100,620
20 ANAESTHESIA FEES (FOR FIRST HOUR) 99 3,800
21 ANAESTHESIA FEES (EACH ADDL.HOUR) 139 3,000
22 ANGIO ADDL.RUN 2 3,810
23 AORTOGRAMS 2 RUN 0 36,500
24 ANGIOGRAM ABDOMEN 21 36,500
25 ANGIOGRAM CEREBRAL 63 36,500
26 CAROTID/ARCH ANGIOGRAM. 1 39,530
27 ANGIOGRAM U EXTREMITY 2 36,500
28 ANGIOGRAM FEMORAL (UNILATERAL) 14 36,500
29 ANGIOGRAM FEMORAL (BILATERAL). 2 39,530
30 ANGIOGRAM RENAL 2 36,500
31 ANGIOGRAM SPINAL 3 41,050
32 SINGLE VESSEL ANGIOGRAM 25 22,810
33 ANGIOGRAM THORACIC 2 36,500
34 ANGIOGRAM VISCERAL 11 36,500
35 ANGIOGRAM RENAL ( FOR DONAR ) 0 39,530
36 ASPIRATION (ADDL. TO FLUORO.) 1 6,090
37 ADDITIONAL WALL STENT 1 75,330
38 BILIARY DRAINAGE 35 24,390
119

39 BRAIN ANEURYSM COILING 25 162,870
40 BIOPSY 0 6,090
41 TRANSJUGULAR LIVER BIOPSY 1 21,290
42 BILIARY WALL STENTING 14 146,250
43 CHEMOEMBOLIZATION 39 41,940
44 CONSULTATION FEE (VIR) 195 1,170
45 CATHETER PLACEMENT FOR DRAIN 12 8,450
46 COPY ON CD (VIR PROCEDURES) 9 1,600
47 CHOLANGIOGRAM 77 3,750
48 CHOLECYSTOSTOMY 43 21,290
49 EMERGENCY PROCEDURE 102 5,530
50 EMBOLIZATION WITH ONE COIL 4 50,630
51 EMBOLIZATION WITH GEL 2 42,570
52 EMBOLIZATION WITH MICRO CATH. 134 85,180
53 FEE FOR DOCTOR EHSAN BARI 12 -
54 MISCELLANEOUS USE FLUORO ROOM IN VIR 75 7,610
55 GONADAL VEIN EMBOLIZATION 1 53,220
56 GASTROSTOMY 36 32,110
57 GASTROJEJUNOSTROMY. 0 43,120
58 GONADAL VENOGRAM 0 18,260
59 HICKMAN'S CATHETER PLACEMENT 87 28,130
60 INTRA ARTERIAL THROMBOLYSIS 0 57,770
61 IV CAVOGRAM 1 19,770
62 IVC FILTER INSERTION 27 76,010
63 JO CATH INSERTION 59 17,570
64 MED/SURG SUPPLIES ( RADIOLOGY ) 428 -
65 NERVE ROOT/ EPIDURAL INJECTION 1 13,110
66 NEPHROSTOMY (UNILATERAL) 55 25,850
67 NEPHROSTOMY (BILATERAL) 10 41,050
68 NEPHROSTOGRAM 29 4,260
69 NEPHROSTOMY REPLACEMENT 5 19,520
70 NON IONIC CONTRAST 10 ML 10 660
75 PORTA CATHETER PLACEMENT 0 34,960
76 PETROSAL SINUS SAMPLING 5 33,460
77 PERCUT REMV BILE DUCT STONE 1 32,580
78 PERC BILLIARY STENT 2 42,570
79 PICC LINE INSERTION 697 15,200
80 PTC DIAGNOSTIC 6 6,850
81 REN.VEIN SAMPLING 0 28,890
82 RF ABLATION 26 17,550
120

83 RECOVERY ROOM CHARGES 0 -
84 SILICONE PICC LINE INSERTION 0 19,770
85 SECOND OPINION ON VIR PROCEDURE. 0 2,630
86 SP. FILM (ADDITIONAL) 3 990
87 STENT DOUBLE PIGTAIL (BILAT.) 0 45,610
88 STENT DOUBLE PIGTAIL (UNILAT.) 16 28,890
89 TRANSJUGULAR SHUNT 0 190,010
90 TRUCUT BIOPSY 0 6,850
91 UTERINE ARTERY EMBOLIZATION 2 51,700
92 VASCULAR STENTING 10 175,500
93 VENOGRAM BILATERAL 8 11,410
94 VENOGRAM UNILATERAL 44 7,610

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