Business Case Beginnings

First there is the vision – interconnected laboratories running seamless workflows with their shiny, new systems. But next comes the question of funding. How do you convince those who control the purse strings to pay for it all?

We posed that question to Mike Langford, Principal Scientist at Spire Healthcare, an independent hospital group in the UK. In 2020, he was tasked with connecting a network of 39 private hospitals and two centralized histology labs via digital pathology workflows. With the system now successfully rolling out, he is well placed to share his experience of turning vision into reality.

When putting together a business case, where do you start?
 

You should start by describing the problem. For Spire, the problem started with turnaround times. If clinicians hold a clinic, say, every seven days, we need assurance that pathology results, including immunohistochemistry (IHC), hit this target every time.  

These targets were challenging when using physical slides. In our network, there can be up to 250 miles between hospitals and the main laboratory, which results in unavoidable time lost to transporting samples. Return of prepared slides from the lab back to a site, with onward transport to the pathologist’s location, creates an additional step – which can be removed by sending digital images.

When pathologists asked for additional testing, such as IHC, the slides followed the same journey all over again. We also found that specialist cases were being referred out of Spire for second opinions, which further slowed reporting. This was frustrating as Spire had the expertise but lacked a clear process to refer in house.

We also recognized the potential for AI to assist in making the whole pathway faster. So, our benefits statement was clear – digital pathology will support improved turnaround times, open rapid case sharing for second opinions and multidisciplinary teams, and allow introduction of AI tools.

When it comes to “selling” the project proposal, it’s worth focusing on more than the technology itself. In our case, this was not a project about digitizing a slide – we could do that 30 years ago – it was a complex project about digitalization of pathology, improved processes, connectivity, efficiency, and great teamwork. The fiscal case, of course, needed to be shown, but digital pathology is more about quality and standardization of process.

Future proofing also came into the business case. We are in transition – “digital pathology” will soon just become “pathology” again as the tools available become standard.

What else did you need to consider for the business case?
 

Having carefully stated the problem, you then need to propose the solution. Some of the details that went into our plan were:

• Executive buy-in – Sponsorship and a clear understanding of the vision at the highest organizational level were fundamental.
• Leadership – Development and release of time for the project and operational teams in histopathology and IT was essential to ensure ownership of the operational changes throughout the laboratory.
• Staffing levels – Digital processes add some extra in-laboratory steps, so new headcount targets were proposed.
• Seamless launch – Pathologists are hundreds of miles apart, so it was essential to be able to digitize everything, ensuring that macro images and request form images were all together from Day 1 of going live.
• Single workflow – We had to ensure that we could link patient data in our laboratory information management system (LIMS) with the digital image, which required an additional IT interface. At the next upgrade of our LIMS, a key consideration will be integration with other systems, including digital imaging, voice recognition, and AI.

Who did you include on the project team?
 

First came the sponsor – that was my role – with a bird’s eye view of the organization. I needed to work closely with a lab lead who was invested in the fine details of delivery. 

Finding an experienced project manager was essential – this was the most complex project that our PMO had ever undertaken. We also had an IT solution architect who attended every meeting and brought together technical IT teams for each step.

There is a huge cast behind the main team, of course – ops managers, IT specialists, quality, finance, procurement, and so on.

What contingency measures did you include?

Problems and setbacks are inevitable in any large project. Therefore, it’s essential to build some contingency into the proposal. In our case, the first slide scanners we trialed were not accepted and we had to restart the evaluation and contracting process from scratch.

On the subject of contracting – it always takes longer than expected. Despite revising the timelines for the second wave of scanners, progress on implementation slipped a year behind predictions. But what we lost in time, we gained in knowledge of the impact on lab operations. We found that digital pathology would add a half to a full day to our lab process, so we needed to be efficient. We learnt a lot about our histology pathway and what needed to change, and what we needed digital suppliers to offer. Now, with certain IT components not talking to each other, time has had to be added for tailoring the software to meet Spire’s needs.

My advice would be to set out in the proposal the elements over which you have control, and those over which you have only influence. It will be the latter that are more likely to go wrong and delay overall delivery.

What sort of objections did you encounter to the business case? Did it have to be revised?
 

A business case may need to go through several iterations before the project is agreed. For our project, we recognized that release of funds is challenging when you’re competing with capital spend on other assets, like CT and MRI scanners. We found that balancing the project cost against that of a major investment, such as an MRI scanner, was a good way to illustrate the spend.

We also looked at the total cost of ownership. Adding a slide scanner adds cost to each slide that is digitized. In addition, the ongoing storage costs are cumulative and hundreds of times more expensive than glass slide storage. We have made some predictions, but we will need to find more intelligent storage options and only retain key images.

How do you measure success?
 

Gaining feedback from end users is crucial to assessing a project's success. When Spire went through that process, we found that those pathologists who had used the new systems found them beneficial – just removing the burden of glass slides was a big win for them. But they did recognize the system needed improvements. In particular, they would like a single digital sign on. This will be especially important when AI is introduced, as that would be another screen to open.

What are your top tips for project sponsors?
 

• Get the right team – from blue sky thinkers to the very detail-oriented.
• Choose an experienced project manager to take ownership of the plan, and a steering committee to hold the project to account.
• Constantly engage stakeholders – sharing good news and bad.
• Choose the right suppliers (they might not be the cheapest!).
• Accept that it will take as long as it takes – it is hard work to install new systems and change processes to fit.