Until a short time ago, Advocate Condell Medical Center (ACMC) in Libertyville, Illinois, was in the bottom quartile in customer satisfaction. Its growth was stunted, at best, and annual losses of $50 million had become the norm. The radiology department was a shambles. Today, however, the picture is far more rosy. The hospital now ranks among the top 10% of comparable institutions in outpatient-imaging patient satisfaction, according to Press Ganey. With revenues growing at a steady clip, the radiology department alone has increased cash collections by $1 million per year. The catalysts: initiatives and solutions implemented in accordance with an operations/service-excellence model and a roadmap for sustainable excellence that supports the execution of these changes. Airica Steed, EdD, MBA, RN, CSSMBB, was formerly vice president of professional services and operations excellence at Advocate Healthcare Corp, the hospital’s parent company, and currently serves as enterprise chief experience officer and clinical assistant professor, health policy and administration, at the University of Illinois Hospital & Health Sciences System in Chicago. Steed co-presented “Achieving World-class Service in Imaging by Embracing Transformational Excellence” on August 14 at the AHRA 2012 Annual Meeting and Exposition in Orlando, Florida. She chronicled the transformation undergone by ACMC and its radiology department. Configured within what Steed deems a Malcolm Baldrige National Quality Award framework, ACMC’s operations/ service-excellence model is employee led and takes into account the hospital’s main customers—patients and their families—as well as physicians and employees. It calls for harnessing the Six Sigma™ method and its DMAIC (for define, measure, analyze, improve, and control) approach. DMAIC calls for eliminating waste and for streamlining and standardizing operations; integrating people, processes, knowledge, and technology; migrating from a punitive culture, in which sticks rather than carrots dominate, to one that emphasizes high levels of performance; and instituting accountable leadership. The roadmap used at ACMC lays out steps to be taken in the course of applying the model. These include establishing a reason for action, reviewing current performance (with applicable comparisons), identifying root-cause opportunities, and designing solutions that address identified problems. Other steps encompass celebrating outcomes and quick wins, performing pilot testing and implementing solutions, developing best (and next) practices and empowering those who will assist the organization in achieving them, monitoring and sustaining performance, ensuring continuous improvement and learning, and sharing lessons learned. Building an Infrastructure The radiology department’s transformation initiative began with the establishment of an infrastructure for improvement without which, Steed says, creating change would have proved impossible. “We knew that neither change nor excellence happens in a vacuum,” Steed says. Comprising leaders’ buy-in; comparative research on departmental performance (conducted in-house, through reviews of pertinent literature, and at conferences); and a set of multidisciplinary teams, “The infrastructure was essential to going forward,” Steed says. To get leaders on board, Steed and her colleagues presented clear rationales for an imaging-services overhaul. In the radiology department, the reasons extended far beyond customer dissatisfaction. The intake process was cumbersome (at best), with multiple steps and phone calls required to accomplish the task. “It wasn’t uncommon for patients to spend over an hour, be transferred to what seemed like 15 million people, and take a million different steps before they were finished,” Steed says. “It is not an exaggeration to say that if I were eight months pregnant and needed an ultrasound—well, good luck getting it done in time.” Waiting times after scheduling were equally excessive; for example, report-turnaround time exceeded 16 hours. No-show rates exceeded 6%, and patients’ frustration with being unable to reach a live person by phone resulted in a high percentage of abandoned appointments. A root-cause survey—conducted as part of the research component—revealed that only 53% of appointments fell into the preregistered category. In addition, the department faced high rates of claim denial, significant bad debt, and poor morale among physicians and staff. Multidisciplinary teams were formed to afford all constituents a voice in the improvement process, thereby empowering them and aligning them with an employee-led, customer-focused model. Front-end employees were enlisted to participate—with department leaders and imaging professionals—in teams appointed to execute front-end changes; other staff members joined the teams dedicated to their areas. To attain the goal of patient-centered operation called for in the model, patients and their families were invited to participate in the teams as well. On the Front Lines Following the completion of the infrastructure, solutions for front-end scheduling and registration problems were formulated. At the time, the two processes were treated separately, with four employees handling scheduling alone and patients required to speak with different staff members to make appointments and move through the registration scenario. “We considered whether it would be more efficient to combine scheduling with registration or to keep them separate,” Steed notes. For the purpose of empowerment and as a morale booster, staff members were charged with devising a solution. They opted for a one-stop method that they believed would best mitigate inefficiencies and enhance the patient experience. Appointment scheduling and registration now occur during a single phone call, minimizing patients’ frustration (and appointment abandonment) and ensuring that 100% of appointments are registered ahead of the day of service. Reminder phone calls are placed to patients 24 to 48 hours prior to their appointments; messages conveyed include explicit instructions for exam preparation, a brief description of what to expect when undergoing the planned procedure, and encouragement to contact the department with any questions. Physicians, who were forced to endure a system rife with inefficiencies prior to this transformation, can schedule exams using a dedicated phone line. This, however, is just the tip of the iceberg for front-end improvements. FastPass, a VIP-style check-in mechanism, enables patients to check in rapidly, at one desk, rather than starting the process in one room and finishing it elsewhere, as was previously the norm. Precertification and financial clearance for high-value services are obtained one day before scheduled appointments to prevent check-in headaches and lessen the likelihood of claim denial. “What we did here was to take hospitality principles and bring them to the radiology department,” Steed says. “When patients walk through the door, everything is ready for them. All the work has been done. There is no long line at the counter.” Among other measures, hours of operation were expanded to match the demand for service, providing a wider range of convenient time slots to keep patients and referring clinicians away from competing imaging providers. Scheduling was modified to match actual service times, and a stacked scheduling method was implemented. Steed says, “The last thing we wanted to do was to schedule one patient for a procedure at 8 am, but the next, not until 4 pm. We wanted an appointment at 8 am to be followed by appointments at 8:30, 9, and 9:30. It’s a much more sensible system.” To minimize traffic surges and delays caused by unscheduled appointments, the department created a reserve of set appointment slots for walk-in and emergency-department patients, based on past patterns. Steed also put the brakes on scheduling same-day high-value services to optimize reimbursement through preauthorization and limit what had been considerable losses. Moreover, technology has been deployed, as the model dictates, to spark positive change. For example, voice-recognition technology with self-editing capabilities was deployed to speed up report turnaround and bolster satisfaction among patients and referrers. Scheduling software was refined to support the stacked-appointments system. In a somewhat different vein, to protect patients’ privacy and guard against embarrassment, the radiology department has abolished the traditional practice of calling names and specifying procedures in the waiting room. Instead, front-desk personnel record such patient identifiers as age, gender, and clothing when individuals arrive. The information is transmitted to personnel with patients’ paperwork and used to spot them as they wait. “Screaming out patients’ names and announcing, within anyone’s earshot, what procedure they would be undergoing definitely was not a contributor to a good patient experience,” Steed says. In contrast, many individuals, she adds, “are very comfortable when a technologist comes up to them and quietly says, ‘You’re [name] and you’re here for this procedure, right? I’m [name], and I will be doing your exam today.’” Required Operations Supporting these solutions is a fixed strategy for operations and excellence, also instituted according to the model. Among other practices, the strategy entails check-in and exit interviews conducted by department leaders. During the former, individuals sitting in the waiting room are asked whether they will be undergoing an exam or are accompanying someone who is currently doing so—and how long they have been there. Patients whose waits appear excessive are told that the elapsed time exceeds the acceptable standard and that the leader will check on them again in a few minutes. They are also assured that if they have not been summoned by a technologist before the leader returns, he or she will address the problem. In exit interviews, leaders ask patients to assess the service that they received and whether it was delivered as promised. Patients also are asked whether technologists introduced themselves and explained the duration of the exam. “We take a very proactive approach because, in line with the model, excellence cannot be sustained without continuous improvement and learning,” Steed states. “There is always room for that.” In a similar way, the hospital uses follow-up phone calls to obtain further insight into patients’ experiences and to elicit useful feedback. Mailed thank-you cards serve the same purpose. Consistent with the mission to reward and empower staff, employees receive individual recognition when returned cards indicate that they, in particular, have provided a high caliber of service. Moreover, daily staff huddles and weekly action meetings are held to identify pressing issues and devise means of addressing them before they escalate. Weekly meetings include radiologists, along with members of the leadership team. “The difference, now, is that if there is an issue, the huddles and the meetings allow us to determine right away how to resolve it,” Steed explains. Significant Improvement In addition to propelling ACMC’s diagnostic-imaging customer-service ratings from the bottom quartile to the top 10% among comparable hospitals, these strategic and operational initiatives sparked a 50% improvement in staff and physician satisfaction, Steed notes. Overall procedure-volume growth rose by 8% in the first year after model implementation, exceeding initial expectations. It’s just as significant that the radiology department has seen a decrease in the incidence of no-show patients from 6% to less than 1.5%. Patients’ waiting times have been reduced from more than 30 minutes to an average of fewer than 10 minutes, the abandoned call rate is down by 70%, and 100% of appointments are preregistered. Steed says that experience and the positive outcome of ACMC’s radiology-department turnaround bring to bear a number of lessons that other imaging service providers should heed when attempting to achieve similar results. She advises, “Understand and communicate reasons: Understand your business, strengths, and opportunities, as well as who your customers are. Don’t discount any customer groups—many of our staff members were identified as our customers, to our surprise. Insist on required accountability. Be transparent in your goals. Remember that the model is there for everyone—not just leaders— to see.” Process-improvement steps, she adds, need to be translated and communicated into easy-to-understand language. Radiology-department constituents in charge of change, Steed continues, must ensure that the new culture is driven by high-level performance, with a relentless commitment to excellence and a refusal to accept mediocrity. Frontline staff must be empowered and engaged by being given the tools to solve problems on the spot and a license to think and act like CEOs. Creativity, next-practice thinking, and learning by doing should be encouraged, at all costs, to support top-tier performance and maintain a positive morale. Steed advises leaders to provide support, feedback, and praise, in addition to addressing mistakes and missteps with constructive criticism (rather than punitive measures or language). “Change requires accountability, excellent behaviors, and superior processes,” Steed concludes. “Strong leadership demands vision, willingness, and adaptability. Transformation is a journey—not a place.”