Number crunchers at radiology practices might occasionally lose sleep over the complex nature of performance assessment, but that’s nothing, compared with the sleepless nights experienced by women who learn of possible breast abnormalities. In his work as regional radiology department chief at Kaiser Permanente (KP) Colorado in Denver, Greg Mogel, MD, instinctively knows this, and he sets the tone accordingly.
It’s not that Mogel neglects the hardcore financial metrics—far from it. It’s just that the 15-year radiology veteran is convinced that the organization can do it all (and do it well). The philosophy is embraced from the top down, thanks to a KP culture that puts sleepless nights on par with productivity-based metrics.
The sleepless-night indicator is no mere platitude. It is measured, refined, and reported to top leaders. The clock starts ticking the moment a woman is told her that mammogram is abnormal (or when a palpable abnormality is found), and it runs until the time of the biopsy. With so many moving parts, the sleepless-nights initiative is nothing less than a large interdisciplinary project that involves several populations within the radiology department.
To improve overall performance at KP, Alise Vanoyen, MD, mammography section chief; Rachel Biller, CPMG, radiology business manager at KP Colorado; and Mogel examined the situation and recommended behavior changes for radiologists, mammography technologists, schedulers, equipment purchasers, and even equipment distributors. “This initiative has led to new jobs, such as breast coordinators and navigators,” Mogel says. “Sleepless nights is a highly studied metric. It is a number we calculate internally every two weeks and report to the top of the leadership chain.”
Reducing Sleepless Nights
The potential for delays and long nights is enormous due to the numerous handoffs from discovery to diagnosis. Many of these handoffs occur in the department—and, sometimes, across departments.
“We have reduced sleepless nights by about 30% within the department of radiology,” Mogel says. “Did that improve patient care? That is self-evident. It is humane, and the highest value in medicine, to reduce suffering and uncertainty for women in that situation. Does it improve the financial bottom line? Perhaps, but probably not; you could say that as we improve the process for patients, it will amount to good word of mouth for the facility.”
According to Biller, schedulers are given scripts with an eye toward reducing the amount of time for call-backs, and this speeds up the second round of imaging after an abnormality is discovered on a screening mammogram. Same-day biopsies are now a regular part of the workflow as a direct result of studying performance-assessment measures.
Quickly substantiating the abnormality through additional appropriate imaging is part of that workflow, as is carrying out all compliance work necessary to get orders (up to and including biopsy) from physicians outside the department.
“In the past month, we have begun doing an increasing number of same-day or fast-track biopsies,” Mogel reports. “This is something that does not happen very frequently anywhere. We are collecting the data, and we will have numbers to compare our August timing, for example, to our May timing. We follow the numbers closely. Every fast-track biopsy means a woman is only waiting for the pathology report, which is literally out of the hands of the radiology department.”
Mogel points out that breast imaging, since it is largely based on a screening modality, is inherently different from other areas of radiology. He believes that much can be learned from mammography’s standardization of follow-up care, as outlined in the ACR BI-RADS® criteria.
The role of a mammographer ultimately represents a much more defined and repeatable task than that of a radiologist covering many modalities. “Generalizing performance assessment is difficult across specific tasks within the same radiology department, let alone across different radiology departments with different financial realities, pressures, payor mixes, and responsibilities to the ordering clinicians,” Mogel acknowledges.
He continues, “The ACR would like to reproduce the success it has had in the standardization of mammography in CT and MRI. I, too, dream of that day. There currently are no BI-RADS equivalents for chest CT. There is no widely agreed-upon protocol for cardiac MRI. These fields are much more