Charles Ray, MD, PhD: Tips for Managing an Interventional Oncology Practice

Running an interventional oncology practice is a challenging endeavor that draws on multiple skill sets, from communicating with colleagues to implementing measures to assess and improve quality. IO360 interviewed Charles Ray, MD, PhD, about how to evaluate staff, attract patients, and ensure that the practice is providing the best care possible. Dr. Ray also reviewed some of the research underway by his colleagues. 

Dr. Ray is head of the department of radiology at the University of Illinois at Chicago and is a Guest Course Director at the Symposium on Clinical Interventional Oncology (CIO). He will be presenting on various interventional oncology topics at the 2018 CIO, which takes place February 3-4, 2018 in Hollywood, Florida

How does your lab communicate information to staff and physicians in order to stay organized and on top of change?

Communication is always key. No lab is perfect, including my lab, but one of our strategies is having timeouts before every procedure for all the techs, nurses, and physicians involved. We also have huddles once daily to go over cases, as well as rounds with the trainees to review the cases. In terms of broader change, we have meetings between the techs, nurses, and physicians on an ad hoc basis.

What strategies do you use for quality assurance?

We have a monthly morbidity and mortality conference to make sure that, from a physician’s standpoint, we’re providing the best services available. In terms of absolute quality measures, we’re still trying to figure out the most appropriate quality measure for our patients. I want to make sure our lab has meaningful quality measures and quality initiatives rather than just going through the motions.

Do you follow the times and dosages on recording agents?

We follow both. Medicare requires reporting on fluoroscopy time, but it’s also important to figure out what dose the patient is receiving.  A lot of that calculation has to do less with time and more with the amount of radiation the tube puts out.

To cover our bases, we record both times and dosages at our practice. Both are surrogates for patient dose because the tube output is a secondary measure for what the patient actually receives. We record fluoroscopy time to make sure we’re in compliance. However, I think the most important measure to record is the dose that the tube puts out during the procedure.

Do patients ever receive a higher than normal dose of radiation? How do you respond?

If patients receive more than three Gray (Gy) at our institution, we bring them back in clinic and check for a radiation burn, which is the most common problem. Each state has its own requirements for reporting which patients have been exposed to very high doses. In Illinois, our location, that requirement is for 5 Gy, so any patient who receives a 5 Gy dose or more is reported to the state, as well as being seen in clinic.

In terms of practice management, how do you handle procedure reports? Do you dictate them or use a tool?

In our practice, physicians are the ones who do the procedure reports. For the most part, we have templates for all our procedures. We use a combination of templates, structured reporting, and freeform.

Has your practice set up measures to contain costs?

Up until now the focus has mostly been on personnel, specifically making sure we have the correct number of personnel in the room. However, I’m concerned about scaling back personnel too extensively because that approach does not leave latitude for people calling out sick, etc. If there’s no wiggle room with your personnel, you run into problems. It’s a balancing act that’s constantly changing.

Have you found some effective measures in the past?

Time studies have been effective. We do use some lean measures to improve our efficiency in the lab, but with practice being so unpredictable on a daily basis, it’s a little difficult for us to find our sweet spot with personnel.

How does your practice attract patients? Has your institution formed an alliance?

On the oncology side, I think we have an alliance, particularly with our medical oncologists and hepatologists. The way we accomplish this is by running a multidisciplinary conference every week. It’s called a hepatobiliary conference. Most of it is for cancer patients, but it can be for anybody with a biliary or hepatic disease. The conference helps us develop a collaborative, team approach that allows patients to get what they need rather than what one specialty thinks they need.

How is staff competency evaluated?

Everyone undergoes an annual review, both on the tech and nurse side as well as on the physician side. On the physician side, we will do a peer review, which means that a certain number of cases every month or every quarter are reviewed by another interventional radiology attending. Any discrepancies between the attendings are vetted at the divisional level. In that way, we’re making sure that each of us is competent. In addition, we have the morbidity and mortality conference every month as well.

Is your lab involved in any research?

We are involved in a couple of trials, including immunotherapy for liver-directed treatments. In addition we have a very active researcher in translational research, Ron Gaba, who is our Vice Chair for Research and an interventional radiologist. He heads a lab that has almost completed a large animal (pig model) for intrahepatic liver tumor. Unlike the rat and rabbit models that we currently have, which have significant limitations, this is really a true HCC and metastatic disease large animal model. It’s the first of its kind. We’re working with some other national and international groups, and it’s pretty exciting. It really allows us to test more, everything from imaging of tumors, to devices that are used, to drugs that are used.

We already have multiple pigs that we’re working on. We’re still trying to figure out the best way to grow a tumor, whether it’s delivering the cells transarterially through the portal vein, direct percutaneous injection, but it’s well on its way. Once tumors can be easily and reproducibly induced, then we can start looking more to treatments.