Driving the Bus: A Radiology Case Study Utilizing Rich Picture

Diagramming and CATWOE to Capture Staff Perceptions and

Inform Service Improvement Scenarios

Mary Conlon

1,2 a

, Owen Molloy

1,2 b

and Nora ZolzerBryce

1,2

College of Engineering and Informatics, National University of Ireland, Galway, Ireland

Irish Wheelchair Association, Ireland

Keywords: Workload, Simulation Modelling.

Abstract: Introduction: Demand for computed tomography (CT) services is increasing. This empirical work in a CT

setting, examines how qualitative methods were used to identify staff perceptions and opportunities for

service improvement. The use of soft systems methodologies (SSM) as an action research tool in radiology

is considered. Methods: Hospital Staff were interviewed to create a root definition of the CT service. In a

diagramming session, a rich picture (RP) was created and augmented with staff input. Utilizing the RP, a

session was facilitated with radiology decision makers to identify a list of culturally desirable and feasible

process improvement scenarios. Results: Root definitions were created of the CT service from the

perspective of the staff. The RP graphically illustrated the key features of the CT service and represented a

shared understanding of the service. A targeted set of culturally feasible and desirable service improvement

recommendations were identified. Four directly attributable implemented workflow changes were identified.

Conclusion: RP diagramming provided an opportunity to involve staff in research while capturing their

perceptions and resulted in a shared understanding as well as targeted opportunities for CT service

improvement. The implemented workflow changes resulting from the SSM approach demonstrated its use

as an action research tool.

https://orcid.org/0000-0001-7241-8869

https://orcid.org/0000-0002-8781-9742

1 INTRODUCTION

The challenges facing CT service provision are

many. Resources are limited and the demand for

Radiology and CT services is increasing year on

year. (Conlon & Molloy, 2019; Granja, Almada-

Lobo, Janela, Seabra, & Mendes, 2014)

The number of over 65 year olds will double

between 2011 and 2031 and the increasing

prevalence of diabetes and obesity among young

people suggests that future elderly cohorts might

suffer from a range of co-morbidities. (Lakdawalla,

Bhattacharya, & Goldman, 2004; Sturm et al., 2007)

(Central Statistics Office., 2015). The calculation of

radiology workload is inherently reductionist in that

it is based on medical requests for imaging of

different body parts. (Rcsi, 2011; Reeves, 2005)

(Reeves, 2005) Radiology workload assessment in

terms of numbers of examinations completed is a

reductionist and crude measurement (MacDonald,

Cowan, Floyd, & Graham, 2013; Naylor, 1992;

Ondategui-Parra et al., 2004; Pitman, Cowan, Floyd,

& Munro, 2018; RCSI, 2011; Sunshine &

Burkhardt, 2000). This work examines the

intertwined elements of a CT service including the

motivations and priorities of those involved in the

service using tools from soft systems methodology

(SSM) to identify opportunities for service

improvement (Crowe, Brown, et al., 2017). SSM is a

well-established action research approach and

requires one to use the experience itself as a research

object and to extract learning through conscious

reflection. This process leads to action in a never

ending learning cycle: once the action is taken, a

new situation with new characteristics arises and the

learning process starts again (Rodriguez-Ulloa &

Paucar-Caceres, 2005).

Conlon, M., Molloy, O. and ZolzerBryce, N.

Driving the Bus: A Radiology Case Study Utilizing Rich Picture Diagramming and CATWOE to Capture Staff Perceptions and Inform Service Improvement Scenarios.

DOI: 10.5220/0010145600880099

In Proceedings of the 12th International Joint Conference on Knowledge Discovery, Knowledge Engineering and Knowledge Management (IC3K 2020) - Volume 3: KMIS, pages 88-99

ISBN: 978-989-758-474-9

 2020 by SCITEPRESS – Science and Technology Publications, Lda. All r ights reserved

In this case study, SSM tools are used to create a

shared understanding of the CT service, as part of a

larger operations research (OR) project utilizing

simulation modelling. Operations research (OR) is

the art of applying analytical methods to the solution

of complex management problems(Ackermann,

2012a). OR has the potential to improve radiology

workflows and systems and can capture human

responses to work pressure (Greasley & Owen, n.d.;

Oliva, 2002)

(Booker, O’Connell, Desai, &

Duddalwar, 2016; Van Lent et al., 2012). The SSM

tools used are CATWOE and rich picture (RP)

diagramming. CATWOE focuses on creating a root

definition of a service from varying perspectives,

aiming to illicit perspectives on an issue by

identifying the Customers, Actors, Transformation,

Weltanschauung/Worldview, Owner and

Environmental constraints (Crowe, Brown, et al.,

n.d.; Lamé, Jouini, Stal-Le Cardinal, & Lam, 2019).

Rich picture (RP) diagramming allows groups to

explore their information flows, communications,

subconscious, occult sentiments and conflicted

understandings(Rodriguez-Ulloa & Paucar-Caceres,

2005) (Bell, Berg, & Morse, n.d.; Berg, 2015). RP

diagrams use cartoon like freeform drawings to

enact or provoke knowledge and reflection and

therefore allow a problem situation to be viewed in a

more structured way, without commitment to any

particular solution(Peter Checkland, 1985) (P

Checkland, 1999). The purpose of a RP is to firstly

determine what is learnt in the process of its

construction and secondly to use the picture as a

means of conveying a message or sharing an

understanding. Crowe et al created a RP diagram

from interview recordings in a mixed methods case

study to analyze the service provided to infants with

congenital heart disease (CHD), see figure 1(REF).

In the subsection of the RP, the hospital, the various

staff, patient and family are represented along with

their fears and concerns and perceived issues. They

concluded that RP diagramming facilitated the work

in acknowledging and working with multiple

perspectives systematically while considering

feasible and culturally desirable targeted service

improvements (Crowe, Brown, et al., 2017).

Figure 1: Subsection of RP diagram Crowe et al, 2016.

Driving the Bus: A Radiology Case Study Utilizing Rich Picture Diagramming and CATWOE to Capture Staff Perceptions and Inform

Service Improvement Scenarios

RP diagramming in healthcare has facilitated the

provision services and education (Crowe et al.,

2017; Goebel, Cristancho, & Driman, 2019). There

is however a paucity of literature using SSM

techniques to formally capture the staff experience

of providing CT and other diagnostic imagining

services. SSM has the potential to allow staff to

share their experience of service delivery (Bate,

2000). To summaries, the research paper objectives

are as follows:

1. To elicit knowledge relating to the factors

affecting CT service delivery from staff and

create a shared understanding of the CT

service using RPs and CATWOE statements.

2. To identify potentially feasible and culturally

desirable targeted service improvements for

use in an OR projects using simulation

modelling to address the increasing demand

for CT.

3. To identify implemented workflow changes

which resulted from the use of the SSM tools.

4. To produce a RP diagram for dissemination.

2 METHODS

A SSM approach was deemed appropriate given its

focus on engaging multiple staff perspectives and its

ability to illicit information and potential simulations

(Peter Checkland, 1999). Data was collected over a

one month period using semi-structured interviews

and RP diagramming sessions.

The case study hospital provides a 24/7 acute

surgical, medical and critical care service with

emergency and maternity services and has

approximately 100 inpatient beds. In radiology, a

single CT scanner provides a scheduled service from

8.30am to 5pm and a 24 hour emergency service for

inpatients and accident and emergency patients.

Approval to conduct the study was obtained from

the hospital management team. Informed consent

was sought from all participants and this consent

was approved by hospital management. The

researcher had ten years experience in CT and was

employed for four years in the CT department prior

to commencing the research work. All data was

anonymized and stored in line with local data

protection guidelines. Figure 2 outlines the

methodological approach taken.

2.1 CATWOE

A 20 minute PowerPoint introduction was provided

to staff on the use of SSM, RP diagramming and

CATWOE, staff were provided with examples of RP

diagrams (Crowe, Knowles, et al., n.d.). Interviews

were conducted to elicit information from staff

regarding the important aspects of the service by

Figure 2: Process of RP building.

1.Powerpoint

IntroductiontoSSM

2.StaffInterviews

usingCATWOE

structure

3.StaffRP

Diagramming

session

4.Additionof

CATWOEdatatoRP

5.SoftcopyRP

design

6.Reviewofissues

(RP)andconstraints

(CATWOE)with

staff

7.Decisionmaker

RPdiagramming

8.FinalRPinput

andverification

9.Identificationof

service

improvements

KMIS 2020 - 12th International Conference on Knowledge Management and Information Systems

Table 1: CATWOE pneumonic explanation.

CATWOE Explanation

Customers

Beneficiaries of service or

transformation process (T)

Actors

Who carries out the service or

transformation process

Transformation

process

What occurs to inputs in the

process

Worldview

The worldview - why the service or

transformation process is important

Owners

Those who can stop the service or

transformation process

Environment Environmental constraints

identifying the customers, actions, transformation

process, worldview, owners and environmental

constraints (CATWOE) of the CT service(Crowe,

Brown, et al., n.d.). Convenience sampling was used

to recruit interview participants (n=5), which

included a CT clinical specialist, a department

manager, a hospital referrer, a porter and a nurse.

Staff were interviewed individually in their place of

work and the interview schedule was based on the

SSM pneumonic CATWOE (Peter Checkland, 1985,

1999). Notes were taken on a pre-printed document

with sections for each part of the CATWOE

pneumonic (Table 1).

2.2 RP Diagramming

In step 3, the CT clinical specialist, two senior CT

radiographers, department nurse and one radiologist

were directly involved in the RP session. The

facilitator was a member of staff from the radiology

department. During a 35 minute picturing session,

participants were presented with a blank page and a

set of colored markers, and were asked to draw

freehand graphics representing their interpretation of

the service(Berg, 2015). Participants were instructed

to avoid the use of text where possible(Bell et al.,

n.d.). Questions were encouraged throughout the

session. The facilitator prompted throughout so as to

uncover difficult to observe workflows and

communications. Where text could not be avoided

comments and speech bubbles were written directly

onto the RP poster as well as a list of perceived

issues generated. While not directly involved in the

RP session, the worldview and environmental

constraints of the porter and the nurse obtained from

the structured interviews were added to the RP by

the facilitator (step 4).

2.3 Creating the Soft Copy RP and

Validation

In order to create a version of the RP which could be

disseminated outside of the case study, drawings

were created to represent the hand drawings of staff

(step 5). These were scanned and imported into

Microsoft Publisher for arranging. Where text was

used these comments were typed and added to the

softcopy version. Once completed the RP was

presented to staff members. The purpose of this was

to allow participants to talk through the diagram,

discuss insights and to confirm and refine the RP

diagram(Bell et al., n.d.; Berg, 2015). Suggested

changes were made and once again shown to staff

for verification.

In step 6 the list of perceived issues generated

during the RP diagramming session and the

constraints identified in the CATWOE statements

were reviewed by the participants and scrutinized so

as to identify important aspects of the

service(Howick & Ackermann, 2011; Rashwan,

2017).

Driving the Bus: A Radiology Case Study Utilizing Rich Picture Diagramming and CATWOE to Capture Staff Perceptions and Inform

Service Improvement Scenarios

2.4 Targeted Set of Service

Improvement Opportunities

A guided discussion with radiology decision makers

(Radiology manger and Clinical Director) was

arranged in which the soft copy version of the RP

diagram and the original staff diagram were

presented. The intention of showing both was to

reassure participants of the informal nature of the

drawings whilst also providing the clarity of the

“cleaned up” version. Decision makers were

afforded the opportunity to contribute to the RP

(step 7) and asked to identify a targeted set of

culturally feasible and desirable changes to the

service (step 9). Decision makers were prompted to

consider potential changes to the CT schedule, the

number of CT scanners, the addition of staff and

skill mix of staff etc (Crowe, Knowles, et al., n.d.).

3 RESULTS

3.1 RP Diagram

The softy copy final version of the RP (Figure 3)

captures the key features of the CT service, such as

staff activities, the process, the environment, the

delays, distractions and external factors contributing

to workload and affecting service delivery. A clock

and phone are visible in each room to represent the

time sensitive nature of the work and constant “often

repetitive” communications occurring between staff.

Background chatter whilst scanning is a common

occurrence.

A clear definition is made between the inpatient

and outpatient services by placing these groups on

separate floors of the hospital. The inpatient service

includes the acute medical assessment unit and

accident and emergency department, whose patient’s

generally require an immediate service. The

experience of the GP in the community is depicted

and their awareness of growing waiting lists. GP and

outpatient waiting lists appear as an external factor

as these do not impact the daily operations of the

service and were a concern at management/decision

maker level. A graphic representing an inpatient

depicts how patient complexity varies in terms of a

patient’s care needs, infectiousness, mobility and

exam complexity. The outpatients are seen to be

experiencing delays and the staff are conscious of

the inconvenience a delay causes and feel

responsible.

The frustration of the staff nurse as they seek to

confirm a patient’s future scan time is also depicted.

They just want a verbal answer and do not want to

refer to the information system; they may not

remember their password or may imagine a phone

call is quicker than logging on to the RIS/PACS.

Bad habits have appeared over the years and they are

conditioned to expect verbal confirmation of a time.

They are under pressure to ensure a scan happens in

a timely manner because they know discharge is

dependent on it or are aware the patient is waiting a

long time or is deteriorating.

External factors affecting service provision are

grouped to the left of the diagram and appear outside

of the drawing of the hospital. It was agreed to

locate waiting lists as external as they were not a

concern for CT service provision on a daily basis.

Age and infection and chronic diseases and

newspaper headline also appear externally.

3.2 Contributing Example

The RP diagram shown in Figure 3 represents

various contributions by participants. For example,

one radiographer (MD) created their own drawing

using the metaphor of a bus Figure 4. The halo

represents the radiographer arriving to work like an

“angel”. Conscious of staying ahead of demand, the

radiographer arrives early to prepare the necessary

blood results and information required for each

patient request. This all changes by 11am however at

which point their “heart is broken” and their “brow

furrowed” due to the number of phone calls and

interruptions.

This radiographer is also represented in the RP

diagram in Figure 3 and is seen to have many items

on their mind. Phone calls result where a referring

doctor is looking for another phone number or where

they are seeking verbal confirmation of a scan time

which may already be available on the Radiology

Information System (RIS). They describe being the

lead radiographer in CT as like being the driver of a

bus with other staff on board. If the bus goes into

third gear there will be casualties – speed kills. If

they stay in first or second gear everyone is smiling

at the end of the day. The mantra of the radiographer

is “one man, one job”, while it may be possible to

scan (acquire images), plan (schedule work) and run

(transfer patients, test intravenous lines, inject,

position patients etc), errors are an inevitably of that.

KMIS 2020 - 12th International Conference on Knowledge Management and Information Systems

Figure 3: Soft Copy RP Diagram created by the research team and validated by participants and staff.

3.3 Perceived Issues and Constraints of

the Service

Table 3 presents a sample of the total issues and

constraints (n=32) identified by staff during the RP

diagramming and CATWOE interviews.

Driving the Bus: A Radiology Case Study Utilizing Rich Picture Diagramming and CATWOE to Capture Staff Perceptions and Inform

Service Improvement Scenarios

Figure 4: The Bus - A Radiographer's metaphor for the CT service.

Table 2: Sample of service issues and constraints.

Source Perceived Issue

Clinical

Specialist

Overall demand is increasing and the CT service has multiple referral sources with

patients of varying priority, priority may change over time. Constant reprioritization is

required.

Phone calls and visits from the various referral sources cause time delays and

distract radiographers who are scanning. Staff want verbal confirmation of scan times

even though this information is available on the RIS.

Radiographer1 In order to have all the information I need to hand; I have to transcribe information

onto a paper schedule. Some use the RIS but this works for me and saves me from

going in and out of multiple screens, multiple times or relying on my memory.

Delays occur when staff are not available for the manual transfer of patients from

their bed/trolley to the CT scanner and back again.

Radiographer2 The skill mix amongst the radiographers and percentage of staff able to cannulate

and inject patients has been depleted due to recent staffing changes.

Delays result where transportation is not immediately available for inpatients, this

may be due to porter or wheelchair shortages or where patients on the wards are not

ready to leave the ward when the patient arrives.

Radiographer3 Quite often someone forgets to arrange transportation for the inpatients who are

drinking on the wards. There can be up to 3 calls per inpatient to arrange preparation

and transportation and to discuss whatever time’s been allocated to them.

We need a dedicated workstation for planning – there are constant demands for the

PC from multiple staff which breaks concentration when planning. The Lab system and

RIS/PACS systems should be side by side or on the same PC.

Porter: At break times we may only have one porter covering several areas

Patients are not always ready to be transported when we arrive on the ward and we

have to ring back to CT to explain, or we think they are going to need a wheelchair but

we arrive and they need a bed.

Manager: Waiting lists are increasing and so is demand.

The CT scanner is old and its tube is no longer fully covered under service contract.

Nurse Post colonoscopy we provide a hot drink and a sandwich. We have to ring the

canteen for this and the tea is often cold on arrival.

KMIS 2020 - 12th International Conference on Knowledge Management and Information Systems

3.4 Changes as a Result of the RP

Four changes were implemented following the use

of the SSM tools.

1. Clinical specialist – Issue (1)

A handover tool was designed for staff to ensure that

information relating to patients requiring a scan was

not lost between the day and night shift who may not

see each other. Such information may include

inpatients being prepped with oral contrast in

advance of a scan or requiring hydration or repeated

blood tests.

2. Clinical specialist – Issue (2)

Ward staff were offered RIS/PACS training and

advised to consult the RIS/PACS for to check if a

time had been allocated to an inpatient scan request.

The practice of verbally informing ward staff of

scheduled times ceased.

3. Radiographer 3 – Issue (1)

The method of arranging transportation for

inpatients requiring oral contrast was changed.

Previously a radiographer was responsible for

arranging transportation for inpatients 10 minutes in

advance of the scan so as to ensure no delay. Post

research the healthcare assistants undertook to notify

clerical staff of the intended scanning time and the

need for transportation.

4. Nurse - Issue (1)

Post CT examinations such as CT colonoscopy and

CT cardiac angiogram patients were previously

provided with refreshments such as Tea and

scone/sandwich. One phone call to the canteen was

made per patient and delays were common. Changes

were made where a daily delivery of sandwiches and

juice boxes to CT was arranged and the necessity to

place individual orders removed. A targeted set of

potential service improvement scenarios were iden-

tified in the final step of the methodology (Table 3).

4 DISCUSSION

4.1 General Study Reflection

This paper sought to elicit knowledge from

radiology staff while creating a shared

understanding of the CT service using RPs and

CATWOE statements and to identify potentially

feasible and culturally desirable targeted service

improvements. This study showed that the important

aspects of a service could be represented on a RP

Table 3: Potential service improvement scenarios.

Service Improvement Scenario Benefits

Extended CT Schedule: Changing the CT

Schedule from 8.30 to 5 to 8am to 8pm.

Outpatient capacity increased, waiting lists

decreased. Dedicated outpatient and GP block booking

possible minimizing disruption from inpatient demand.

Addition of a permanent second CT scanner Inpatient and outpatient cohorts will have

dedicated scanners.

Less infection control related downtime on

outpatient scanner. Waiting lists will be decreased.

The addition of more preparation and observation

space.

Combined simulation:

The addition of a temporary mobile second

scanner to be located in the car park.

Replace old scanner with new permanent

scanner.

Run two scanners until a point in time where

the waiting list is reduced to effectively zero.

Removed temporary scanner and introduce an

extended day 8am to 8pm scanning scheduled on

the new scanner.

Waiting list is addressed. The extended schedule

would allow outpatients to be blocked booked

minimising interaction between the cohorts. The

extended should address the current increase in

demand though waiting list would be expected to

accumulate again.

Driving the Bus: A Radiology Case Study Utilizing Rich Picture Diagramming and CATWOE to Capture Staff Perceptions and Inform

Service Improvement Scenarios

diagram and that the process of creating and

validating the RP was a powerful means for staff to

reflect on the service they worked in. The final RP

considered multiple perspectives and reflected a

multitude of perceived problems, service constraints

and factors contributing to workload (P Checkland,

1999; Lewis, 1992) (Rcsi, 2011). The SSM approach

adopted yielded insights rather than testable results

and required the researcher to work with groups

when deciding on what to include (Ackermann,

2012b).

The final RP was constructed using the software

Microsoft paint and Microsoft publisher which

contravenes the predominantly freeform and

unstructured nature favored for RP generation(Berg,

2015). As the purpose of the model was to convey a

shared understanding and to disseminate to a wider

community a more professional finish and clarity

was required. The RP however does not purport to

describe every CT department’s service claiming

instead to be a representation of the reality of those

interviewed(Bell et al., n.d.; Rodriguez-Ulloa &

Paucar-Caceres, 2005). While RPs are usually

considered merely a by-product of the process of

investigation, as a communication tool the final RP

fulfils its purpose of communicating the shared

understanding and perspectives of the healthcare

staff(P Checkland, 1999; Fougner & Habib, 2008;

Lewis, 1992) . This RP is the first of its kind as no

other rich picture of a CT service has been found for

objective comparison.

Waiting lists have purposefully been described as

an external factor as they are not a concern for those

directly involved in providing the service on a daily

basis. They are an unintended consequence or

emergent behavior related to the increase in demand

and become a managerial or governance problem

over time (Marshall et al., n.d.; Sterman, 1994).

Examples have been provided of four immediate

changes which resulted from the RP diagramming

process. This reaffirms RP diagramming as a vehicle

for action research, changing the problem situation in

the very process of researching it (Morrison &

Lilford, 2001; Rose, 1997). These changes were not

imposed, or even knowable in advance(Bate, 2000).

Gaining buy-in for the project was aided by ensuring

that important and relevant issues were identified, and

that the work resulted in quick tangible changes and

benefits to the department(P R Harper & Pitt, 2004).

4.2 Challenges

The full list of perceived issues highlights the

challenges facing modern radiology departments and

these challenges will not be solved by this study.

While we cannot analyze all the issues within the

scope of this study, one issue is elaborated on; the

staff experience of how the RIS and PACS support

workflow. Feedback indicated that the information

system did not adequately support the CT workflow.

Staff highlighted how RIS information regarding the

patient’s blood results needed to be verified on a

separate laboratory information system and how at

the point of scanning a radiographer was required to

toggle between two screens to ensure that they had

visibility of the clinical history and comments and

blood results/prompts. As a workaround some

radiographers were found to use a paper schedule to

organize the daily list and document the blood

results and other considerations such as pregnancy

and infection status on said paper schedule, thus

evidencing a gap between how the system is used

and how it was intended to be used (Unertl,

Weinger, Johnson, & Lorenzi, 2009). Radiology

staff also listed the non compliance of ward staff

regards checking the status of CT scan times on the

RIS as an issue which resulted in phone call

interruptions and distractions. The ability of the

department to scan patients is constrained by the

effort required to safely organize inpatient exams

and further research is required into the ergonomics

of the information system (Unertl et al., 2009).

4.3 Targeted Service Improvement

Recommendations

Consensus was reached on three culturally desirable

and feasible service improvement recommendations

(Table 4). RP diagramming provided a strategic

opportunity for meaningful decision-maker

involvement allowing a tangible space to discuss and

negotiate worthwhile recommendations for change

(Bell et al., n.d.). While some argue that SSM is not

a decision making tool and rather a post hoc measure

to justify the status quo (Bergvall-Kareborn, 2002) it

did, in this case study, arrive at a service

improvement recommendation (number 3) that had

not previously been considered by either facilitator

or management staff. Benefits of the inclusion of

decision makers in the research project included

providing them with an opportunity to internalize

research knowledge, promotion of trust and interest

in the project, higher likelihood of implementation

and a more meaningful focus than it might otherwise

have had (Paul Robert Harper & Pitt, 2004; Monks,

Robinson, & Kotiadis, 2016; Ross, Lavis,

Rodriguez, Woodside, & Denis, 2003).

KMIS 2020 - 12th International Conference on Knowledge Management and Information Systems

4.4 Research Limitations and Further

Work

In operations research lacunae are gaps where deep

fundamental questions remain unanswered

(Ormerod, 2014). SSM requires the OR researcher to

ask whether the voice of all the affected was

included. A limitation of this work is that the voice

of the patient and general practitioner (GP) was not

included in the process of creating a RP diagram

(Ormerod, 2014). While the seniority and experience

of participating staff was high, staff were primarily

chosen for interview based on their availability.

SSM is subjective in nature with the researcher

acting as a research tool. In this case the researcher

was employed as a CT radiographer in the case

study department for over six years, ensuring

proximity with staff in both a physical and social

sense and minimizing the potential impact of the

Hawthorn effect. (McCarney et al., 2007) Future

work will focus on the testing of the targeted set of

service improvements scenarios in a simulation

model of the radiology service.

5 CONCLUSIONS

The creation of a RP provided an opportunity for

staff to reflect on the environment they work in and

service they provide and resulted in some immediate

workflow changes. While the RP may not resonate

fully with every CT department’s service it provides

an effective tool for sharing this department’s

experience of service provision and is a useful

alternative to a text based description of a CT

service. As well as identifying specific service

improvements the list of perceived issues presents

decision makers with multiple areas for

improvement. Rich picture diagramming and SSM

permit radiographers to consider the “familiar

landscape” of a radiology department with “new

eyes” (Proust, 1934).

ACKNOWLEDGEMENTS

We would like to acknowledge the support and

assistance of the staff in Portiuncula Hospital,

Ballinasloe, Co Galway.

Thank you sincerely to the creator of the "Driver

of the Bus", Senior Radiographer, Maeve Darcy and

to CT Clinical Specialist, Avril Hanley.

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