Many radiology departments already employ picture archiving and communications systems (PACS), at least to some degree. Most of the remainder are planning to do so. Naturally, all of these facilities need to plan for appropriate PACS staffing. To date, however, ideal-and even adequate-levels of PACS support have been poorly defined and difficult to determine in advance. This leads to underestimates of staffing needs during the planning phases of PACS projects, followed by nearly constant struggles to attract, train, and retain PACS staff. While there is no formula that every enterprise can apply in order to plan for its staffing needs precisely, it is possible to obtain a closer match between PACS needs and available personnel by evaluating those needs carefully (and securing a staffing budget that will permit them to be met).

There are, of course, several motivations for PACS implementation that may apply to a given institution. These include solving the problems that produce complaints from the department's customers, ending the delays associated with obtaining images and the reports that accompany them, and providing for the future expansion of facilities. In addition, PACS may be needed to help the department provide service to remote sites and to create a centralized reading location for radiologists who have subspecialty expertise to offer to outlying facilities. The relative importance of these needs will affect the amount of staff time required to support PACS.

THE SUPPORT PROBLEM

Radiology department staff members at many hospitals have reported that they were recruited within their departments when PACS support was first needed. They are now being expected to implement and run PACS, with no help in sight. Often, a single PACS full-time equivalent (FTE) must cover around-the-clock calls, including holidays and weekends. This overwhelmed person may have no hand in PACS planning, perhaps being given the date of an upcoming shipment of PACS equipment (which means an increase in the number of PACS users) without prior warning. Many of these individuals did not receive significant increases in compensation when they were given PACS-related responsibilities, and some received no increases at all. Even after they have gained experience in working with PACS, they may not see more money; as a result, they may also begin to feel resentment, and they may seek new positions within or outside the institution.

Initially, these employees may see their assignment to the PACS project as a privilege, especially because it gives them an opportunity to learn to work with cutting-edge technology. These employees often burn out quickly, however, when they are expected to perform the duties called for by their original full-time jobs in addition to providing PACS support. They may even be expected to run the radiology information system (RIS) as a side project, as well. Because many radiology departments already expect very high productivity from their employees, it may simply be impossible for the designated PACS-support personnel  to fit more duties into the work day. While it is true that remote support from vendors is only a phone call away, PACS gets physicians used to the timely delivery of high-quality images. This makes them even less tolerant when the delivery of images is delayed, especially where the intensive care unit (ICU) is concerned.

STAFFING EXPERIENCE

As the PACS manager for Texas Children's Hospital, Houston, which is located in a large-scale medical center, I am always in danger of losing PACS employees. Neighboring hospitals are just embarking on their PACS implementations. After their vendors leave, they must face the reality that someone has to run their systems, so I must ensure that they do not find my employees to be the most convenient source of staff.

At Texas Children's Hospital, PACS installation began in 1991 with ultrasound. In 1997, CT, MRI, computed radiography (CR), and fluoroscopy were added, along with a RIS interface. Nuclear medicine, portable CR, and two external health centers were added to the system in 2000.

In 1993, the institution's policy was to find the hidden talent within the radiology department, assigning shared, part-time PACS duties to individuals who were already part of the staff. This was a positive step in that it created new job opportunities, titles, and duties within the facility. Unfortunately, this policy also had disadvantages. Because accepting a PACS position was considered to be a lateral career move, compensation did not increase (although work responsibility did). As a result, the PACS program experienced considerable turnover among dissatisfied employees. One PACS staff member even applied for a secretarial position within the institution because it paid more.

A better approach was adopted in 1999, when turnover levels became unsustainable. A strategic planning committee was needed to guide the PACS campaign. In particular, the committee focused on the creation of a 5-year plan that covered all aspects of PACS implementation and ongoing operation, from hardware allocation to service provision. The committee included the institution's chief radiologist, the radiology director and assistant director, the RIS manager, the PACS coordinator, a neuroradiologist, and the ultrasound team leader.

The first task was to decipher the code used by the institution's human resources compensation committee to determine pay grades. Job descriptions were written in a way that would permit additional compensation (and did, in fact, increase pay by seven levels). As part of those job descriptions, justification for around-the-clock PACS support where it was needed (as in the operating room and ICU) was submitted. A PACS service having a reporting structure comparable to that of clinical services was created, along with a separate cost center for PACS staff.

When the Texas Children's Hospital PACS service was designed, estimates of the staff time required to support PACS were based on the premise that only the day shift would need PACS employees to train users, staff a telephone help desk for users, add new modalities to the system, or work on long-term improvements. The formula included calculating how many FTEs it would take to support 24-hour operations like the operating rooms and the ICU.  Coverage for weekends, evening shifts, and night shifts was provided through an on-call mechanism initially, but evening and night employees were later hired. In addition, it was apparent that the PACS service would need a secretary and a team leader or a manager. At the time, the author served as team leader for ultrasound and the PACS analyst. The incentive to perform both functions was the lure of ultimately serving as PACS manager.

SOLVING THE PROBLEM

Ideally, of course, a facility will know approximately how many FTEs to assign to PACS support before the system is installed. In predicting the necessary level of staff support, the PACS committee should consider the size of the imaging operation, including the number of customers; typical and peak work loads; whether image acquisition and interpretation are centralized or widely scattered; and the degree to which around-the-clock operation is needed. In addition, the committee must take into consideration the PACS vendor's ability to provide service and training, since the facility will need to compensate for any deficits in vendor support.

External PACS support cannot provide complete coverage of the institution's needs. The availability of remote service from the vendor is unquestionably useful, but it should not be thought of as a replacement for on-site staff support. At Texas Children's Hospital, however, the on-site engineering services provided by the vendor do not replace employees that the hospital would otherwise have to recruit, train, and retain on its own.

The PACS customer base at Texas Children's Hospital now consists of 300 review-station users and 1,000 Web-browser users of the system. This level of use is supported by the PACS vendor with two on-site service engineers who cover day and evening shifts. The institution supports PACS by employing

• one PACS manager;

• one PACS administrator, who serves as the team leader;

• six PACS analysts (two for day shifts, two for weekends, one for evening shifts, and one for night shifts);

• one PACS technologist; and

• one trainer.

•one PACS secretary

The thorough training of PACS analysts is a must; there are very few people who have the experience needed to perform this function. At Texas Children's Hospital, PACS analysts are required to complete the PACS vendor's course for system administrators, in addition to a second course covering the Digital Imaging and Communications in Medicine standard (which applies to data interchange among the PACS and imaging modalities). Nonetheless, on-the-job training is still the most important form of preparation for the position; this training investment makes it still more important to retain trained staff.

While sufficient monetary compensation for PACS support staff is clearly important, other incentives can help the hospital recruit and retain personnel to fill these roles. In some settings, especially where there is heavy competition for employees who have computer skills, these additional job attractions may even be deciding factors in recruitment and retention. The chance for ongoing professional development is among these nonmonetary incentives; so are pleasant facilities with sufficient space to work, the prospect of promotion or other types of career advancement, and the availability of support staff who can remove burdensome, low-level tasks from the shoulders of PACS personnel.

CONCLUSION

It is imperative that PACS be supported by employees who are not attempting to fit their PACS duties in among their other job functions. The rationale for dedicated PACS FTEs parallels the rationale that originally motivated the facility to acquire PACS capabilities: to resolve customer complaints, to prevent delays in access to images and reports, and to expand service to additional areas and remote sites.

PACS administrators all run the risk of losing FTEs. This kind of loss includes the experience and working knowledge of the system carried by the individuals who leave their positions. This type of crisis can be averted by creating PACS jobs that pay well and that lead to further career opportunities, as well as by increasing the number of FTEs devoted solely to PACS.

In the future, PACS support staff may be shared between institutions in order to make the best possible use of their time. Many hospitals may consider their Information Services department to have  staff available to support the PACS, but the reality is that these employees already have fulltime jobs. The application service provider model, in which PACS service, support, and certain types of off-site equipment are provided entirely by a vendor under contract to a facility, may decrease the PACS staffing needs of many organizations. At the other extreme, some hospitals may choose to assume complete responsibility for PACS by training and using their own engineering support personnel. For a number of PACS users, however, the chosen approach will lie somewhere between these two points, with both internal and vendor-supplied PACS support required for years to come.

Rosemary Honea, RTR, RDMS, is PACS manager, Texas Children’s Hospital, Houston. This article was based on a presentation at the annual meeting of the Society of Computer Applications in Radiology, May 4, 2001, Salt Lake City, Utah.