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Using Lean Six Sigma to Improve Hospital Based, Outpatient Imaging Satisfaction Angelic P. McDonald, MSRS, CRA, RTand Randy Kirk, MA

EXECUTIVE SUMMARY Within the hospital based imaging department at Methodist Willowbrook, outpatient, inpatient, and emergency patients are all performed on the same equipment with the same staff.The criti- cal nature of the patient is the deciding factor as to who gets done first and in what order procedures are performed.

After an aggressive adoption of Inten- tional Tools, the imaging department was finally able to move from a two year mean Press Ganey, outpatient satisfac- tion average score of 91.2 and UHC percentile ranking of 37th to a mean average of 92.1 and corresponding UHC ranking of 60th percentile.

It was at the 60th percentile ranking that the department flat lined. Using the Six Sigma DMAIC process, opportunity for further improvement was identified. A two week focus pilot was conducted spe- cifically on areas identified through the Six Sigma process. The department was able to jump to 88th percentile ranking and a mean of 93.7.

With pay for performance focusing on outpatient satisfaction and a financial incentive to improving and maintaining the highest scores, it was important to know where the imaging department should apply its financial resources to obtain the greatest impact.

i f l C pay-for-performance culture has placed a financial incentive to ensuring outcomes meet both quality and service expectations, thus creating a value-based purchasing program (value = quality/ cost).' "Patient satisfaction is fairly easily measured by asking the patient, but the factors that each patient uses in this as- sessment are much harder to ascertain."^ Leaders sometimes find themselves showing staff unsatisfactory scores and inadvertedly creating a negative envi- ronment around patient satisfaction. But what are patients really looking for? "What patients care about most are not the things that health professionals often think they care about. Instead, foremost in their minds was the sense of vulner- ability and helplessness imposed by hos- pitalization and having to be dependent on others for the most basic of daily activities."'

Patients are looking for an experience in healthcare, but why and how can that experience be created? The United States has been moving to what is economically known as an "Experience Economy" where service is personalized for the guest and away from an agrarian econ- omy of where the basics are provided."* Many businesses in the United States cre- ate this experience for their consumers. There is someone to say, "Good morn- ing" or "How may I help you?" On the way out, the customer probably receives a.

"Thank you, come back again." Some- times, there are coupons geared toward something the customer can purchase in the future because those that bought the product will probably be interested in another product.

In general, customers have been trained to expect these details and expe- riences when out in many different pur- chasing situations. In healthcare, though, the nature of our business comes inher- ent with many challenges. Patients do not know the "whys" for a procedure. They do not know our names. They become frustrated with having to rewrite infor- mation over and over again even though it was shared recently. Then to compound the situation, we ask them to wait. Wait to be registered, wait to have their exam performed, and wait to get their results.

Questions on patient satisfaction surveys and the HCAHPS survey often focus on the process, procedure, safety, and the time it takes to deliver the ser- vice. Healthcare providers are pressured by time, funds, and other topics beyond a person's ability to control. The expecta- tion of the patient in a healthcare situ- ation is that the professional will com- municate what they need to know and that the healthcare provider will focus on their feelings and be a support dur- ing their times of need. What healthcare professionals tend to focus on is the list of things to do and the medical care to be

3 8 J A N U A R Y / F E B R U A R Y 2 0 1 3 • R A D I O L O G Y M A N A G E M E N T

provided. Patient expectations are about individual, personal situations and are looking for the "event" of healthcare. Creating a "WOW" moment for the pa- tient in healthcare should be the goal. It is not necessarily about give-a-ways or firee coffee. Finding ways for sustainability of the experience and the creation of new ways to implement an experience is never ending. It is about the behaviors of staff, the smooth process, and the consistency of both which will create that event for the patient.

Methodist Willowbrook Hospital in Houston, Texas aggressively adopted "Intentional Tools," which are a com- bination of specific scripting and man- age-up techniques addressing questions on the Press Caney survey used during patient hand offs. These combined tools are used to improve patient satisfaction. Using the Six Sigma DMAIC (Define, Measure, Analyze, Improve, and Control) process, opportunities for improvement were identified. A two week focus pilot was conducted specifically on areas iden- tified through the Six Sigma process.

Define while many hospitals have dedicated outpatient imaging centers to separate service lines, the imaging department at Methodist Willowbrook is a hospital based outpatient imaging department. This means it shares both staff and room resources for outpatients with the hospital inpatients and emergency room patients. Table 1 shows a breakdown of volume by modality and patient type.

92.3

I Mean Average

, UHC Peer Group Rank

2009 2010 2011 2012

F i g u r e 1 • Outpatient satisfaction metrics.

Press Ganey is the service used to measure patient satisfaction. For the last two years, the imaging department (consisting of MRI, CT, ultrasound, nu- clear medicine, and x-ray) had a mean outpatient score of 91.2, placing them in the 37th percentile ranking with Univer- sity HealthSystem Consortium (UHC is an alliance of 116 academic medical centers and 276 of their affiliated hospi- tals representing approximately 90% of the nation's non-profit academic medi- cal centers). Manimography and bone density are considered a separate service line and, due to their dedicated outpa- tient service type, were not included in this study.

Measure Methodist Wilowbrook has been able to make improvements in outpatient satis- faction metrics (Figure 1 ), but with the bar continuing to rise for superior scores there was a need for a more focused approach.

• TABLE 1.

Volume by %

Inpatient

Outpatient

Volume by modality and patient type.

1 22.1%

44.4%

33.5%

16.1%

20.1%

63.8%

25.8%

60.5%

13.7%

35.2%

49.0%

15.8%

25.7%

18.4%

55.9%

To ensure initiatives were focused, a retrospective review of outpatient im- aging Press Ganey data was conducted for the time period of January 1, 2012 through June 30, 2012 (Figure 2). Each element captured on the survey was up- loaded as variables into an SPSS statistical software program. Once loaded, correla- tional analysis was performed to identify variables which could predict the overall score with some statistical certainty.

Analyze What was discovered was that a single question could predict the overall score of the survey with statistical significance in three categories. The question was: "Minutes after appointment hefore called to test area." The patient could select one of six options: 0-5 minutes, 6-10 minutes, 11-15 minutes, 16-30 minutes, 31-60 minutes, or 61+ minutes.

Patients who selected 0-5 minutes scored the department a 94.36 with a standard deviation (SD) of 2.136. Those who selected 6-10 minutes scored the department an average of 94.98 with an SD of 1.609 and those who selected 31- 60 minutes scored the department 85.32 with an SD of 12.9255. See Figure 3. It is also important to note that the findings of both the 0-5 minutes and the 31-60 minutes were statistically significant to .001. The selection of 6-10 was statisti- cally significant to .05. These findings were consistent with a 2010 study where long wait times were defined as greater than 15 minutes delay.̂

R A D I O L O G Y M A N A G E M E N T J A N U A R Y / F E B R U A R Y 2 0 1 3 3 9

Using Lean Six Sigma to Improve Hospital Based, Outpatient Imaging Satisfaction

100.0-

20.0-

0-5 Min 6-10 Min 11-15 Min 16-30 Min 31-60 Min 61-i-Min MinAftAppt

Legend StdOverall - T i i e Imaging Departments AVERAGE mean for tiiat group MinAftAppt - Minutes after appointment, before called to test area

F i g u r e 2 • Retrospective Review of Outpatient imaging Press Ganey Data

A multidisciplinary group was cre- ated to use Six Sigma techniques to identify areas of opportunity to reduce a patient's appointment time to proce- dure start time. First, the workflow was outlined from the time the patient made the appointment to the time the test was performed. (Figure 4.) As outlined, the committee identified key areas of interest that could potentially impact a patient's procedure start time. These opportunities fell into one of four categories: schedul- ing, registration, imaging (referring to the common local reception/waiting area of all modalities), and the specific modality.

Improve Next, the pilot workflow was outlined from the time the patient made the ap- pointment to the time the test was per- formed. (Figure 5.)

Scheduling: Defining Appointment Times Defining the appointment time seemed like it would carry the most impact. It was identified that there were numer- ous ways for this to be interpreted by the patient. Is it the time the patient is scheduled to be on the table? Is it the time the patient arrives on campus? Is it the time the patient is first greeted by healthcare personnel?

Compound this with how the ap- pointment time is communicated and there is a canvas of failure opportuni- ties. All appointments are scheduled over the phone whether it is by the pa- tients themselves or their physicians. Feedback from the schedulers was that, most often, a great deal of distraction can be heard over the phone during ei- ther workflow.

Emailing an itinerary to the patient was proposed. Much work was done to

improve the patient preparation instruc- tions that are tagged to each test type in the scheduling program in anticipation of this pilot. While a great deal of time was spent to improve this process, it was un- able to be rolled out during this pilot due to delays in the legal process to ensure HIPAA laws would still be respected.

Registration: No Orders or Wrong Orders Patient access outlined the steps taken when a patient arrived without orders or the orders they arrived with needed clarification or modification. This was a very complicated process which involved a non-clinical registrar calling the phy- sician's office, asking for an order, and waiting for a written fax to arrive. This could cause significant delays during the registration process. The alternative to this would be for the imaging nurse or a licensed imaging technologist in the department to be contacted and in- formed of the need for a new order. The imaging nurse or the licensed imaging professional could be the one to call the physician's office and take a verbal order while waiting for the final order to arrive. Using the approved verbal order process, a temporary order would be documented in order to move the patient along more efficiently. The physician's office would be alerted of the need for a written order as soon as possible. Both would return to patient access for final documentation.

Registration: Prioritizing Scheduled Patients When patients arrived on campus, it was discovered that they were registered as they signed in. There was no priority to register a scheduled patient over a walk in. This first come, first served registra- tion process created operational chal- lenges when it impacted a scheduled time in a department juggling emergency and inpatients, as well. Patient access took the lead on this by creating a priority index for those patients who had a scheduled appointment. Walk-in patients would be worked in as quickly as possible, but priority was given to those that were ex- pected at a particular time.

4 Q J A N U A R Y / F E B R U A R Y 2 0 1 3 • R A D I O L O G Y M A N A G E M E N T

Histogram for MinAftAppi = 0-5 Min

Histogram for MinAftAppt = 6-10 Min

Mean = 94,36 Std.Dev.a 2.136

1 0 - Mean = 94.98 Std. Dev. = 1.609

= 30

88.0 90.0 92.0 94.0 StdOverall

96.0 98.0 92.0 94.0 96.0 StdOverall

98.0

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Histogram for MinAffAppt = 31-60 Min

— 1—

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Mean = 85.32 Std. Dev. = 12.925 N=27

40.0 60.0 80.0 StdOverall

100.0

Legend StdOverall = Ranking of surveys returned by UHC Mean categories Frequency = Number of surveys returned per category MinAftAppt = Minutes atter appointment, before called to test area Mean = UHC Mean Std Dev = Standard Deviation N = Number of surveys returned

F i g u r e 3 • Analysis of question "Minutes after appointment before called to test area"

Imaging: Communicating PrepTime as Start Time The CT department identified a poten- tially significant variance in interpretation of procedure start times when it came to the drinking of oral contrast. Examples

were given of patients interpreting the drinking times as an additional delay. So the committee created some very specific scripting used when starting the drinking process to ensure the patient understood the test had begun. The script was as such:

"We are starting your exam now at . Your exam consists of two parts. Part one is the drinking phase and part two is the scan phase." The department's goal in do- ing this was to put into the mind of the pa- tient that the exam had started "on time."

R A D I O L O G Y M A N A G E M E N T J A N U A R Y / F E B R U A R Y 2 0 1 3 41

Using Lean Six Sigma to Improve Hospital Based, Outpatient Imaging Satisfactid.

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R A D I O L O G Y M A N A G E M E N T • J A N U A R Y / F E B R U A R Y 2 0 1 3 4 3

Using Lean Six Sigma to Improve Hospital Based, Outpatient Imaging Satisfaction

^ ^ H CT 1 unit in ER 2 units in hosp

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US 1 unit in ER 3 units in hosp 1 unit portable

6:30-3 7-5:30 9-5:30 10-9:30 3-11:30

2 units in hosp 7-3:30 9-7:30

Figure 6 • staffing matrix per imaging resource.

Modality: Monitor Atrium Logs for Patient Arrival on Campus At times, a patient may arrive late or be held in the access area a little longer than anticipated. Thus, their scheduled time to be on the imaging equipment might be delayed. In the case of longer procedures such as MRI, if the modality relinquishes the equipment for another patient it could add up to 45 minutes of additional delay in the process.

The departments needed an accurate notification system to alert them of the moment the patient arrived on campus and each phase of the registration pro- cess. The access department maintains an "atrium log" in each pavilion. This log documents the patient name, arriv- al time, time to registration, and time completed in registration. The depart- ment leads and the imaging receptionist were given read only access to these logs

Baseline Data

I <15 min I >15 min

during the pilot period. The hope was that, with continued monitoring, the departments could prepare for patient arrivals.

Modality: Staffing Structures Many hospital-based imaging depart- ments provide staff to meet the needs of a hospital's inpatient and emergency room needs. The outpatient population seems to be an incidental that is worked in and around the needs of these other departments. This is the case for Meth- odist Wilowbrook as well. (Figure 6.) Where possible, a dedicated technologist was identified for outpatient services within each modality. Diagnostic radi- ology was the only modality that, due to the existing allocations, there was no opportunity to use the current staffing, provide a dedicated outpatient technolo- gist, and not potentially impact service to

Pilot Data

<15 min >15 min

Figure 7 • Start time improvement.

other hospital service lines. So during the two week pilot a person was brought in for that purpose.

For the pilot period, the dedicated outpatient technologist was given the task to meet, greet, and interview pa- tients within five minutes of arrival in the imaging department. The priority of this service line was given significant importance equal to that of the emer- gency room. (Figure 7.)

Upon reviewing the selection pro- cess staff used to decide which case to perform, it was found that staff often chose to allow the outpatient to wait in order to perform inpatient procedures even when the case was not of a critical nature. It went against the nature of a clinical professional to perform a stable outpatient before a hospitalized patient even when the hospitalized patient was not critical. By assigning a person in each modality to prioritize outpatients, that individual recognized the priority was the outpatient and did not have to feel he was performing poor patient care by putting a stable outpatient be- fore an inpatient.

The most recent data was extracted on October 23, 2012. For a two week period, the number of collected surveys to date only equals 33. Considering the average monthly collection is 140 sur- veys, 33 makes up 47% of what typically comes in for a two week period. Nuclear medicine could not be evaluated because

4 4 J A N U A R Y / F E B R U A R Y 2 0 1 3 • R A D I O L O G Y M A N A G E M E N T

12.0

10.0

8.0

6.0

4.0

2.0

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• Baseline

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Data

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89.4

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Pilot Data

0-5 6-10 11-15 16-30 31-60 61 + min min min min min min

• • n per wk - • - Std Overall Mean

100

96.8

I 87.5

T T T

92.1 mean - 6 0 * percentile rani<

F i g u r e 8 • Patient satisfaction scores, baseline compared to the pilot period.

0-5 6-10 11-15 16-30 31-60 60+ min min min min min min

• • n per wk - • - Std Overall

93.7 mean - 8 8 * percentile rani<

100

of lack of survey return. The ñndings are consistent with the initial correlation analysis and those found in the 2010 study.^ The 6-10 minute delay demon- strates the highest patient satisfaction scores. (Figure 8.)

Control The patient's perceived appointment time to procedure start time delay was found to be a significant predictor to the overall mean score. While overall sur- vey response for this two week pilot was down, the department was ahle to obtain a mean average of 93.7 and a UHC per- centile rank of 88th.

Perceived appointment time and per- ceived start times are important distinc- tions that warrant emphasis. Both the baseline and pilot data acquired in this study came from Press Ganey and was completed by the patient without a dedi- cated tracking system available to them. Perception may not be reality, but it is the measure that truly matters in patient satisfaction.

Sustainability of these scores for an extended period of time will re- quire some adjustments. To continue to provide a start time under 10 min- utes there has to be, at a minimum, a dedicated person for outpatients if not dedicated room resources. With some

renegotiating, four of the five modali- ties could reallocate a dedicated person to the outpatient service line. One of the five, diagnostic radiology, had to add 20 hours a week during peak hours to ac- complish this. For continued control, this should be considered as part of the permanent staffing vision.

There is an opportunity to truly impact daily operation with the atrium logs and access to them. Unfortunately, during the pilot, the logs proved extremely difficult to maintain and navigate. The logs cre- ated were simply an expanded Excel file that did not update automatically so the modalities had to log off and log on re- peatedly throughout the day to look for updates. For continued control, access is seeking a permanent solution.

Finally, knowing that 10 minutes makes a difference, there has to be a dedicated escalation process for any patient waiting longer than this. It can not be an escalation process based upon dissatisfaction, but based upon a 10 minute window. This timeframe makes a difference and, beyond that, patients will reflect their dissatisfaction on the survey. *•*

References 'Agency for Healthcare Research and Quality.

Evaluating the impact of value-based pur- chasing: A guide for purchasers. 2002.

AHRQ Publication No. 02-0029. Available at: http://www.ahrq.gov/qual/valuebased/ evalvbpl.htm#basics. Accessed November 26,2012.

F̂eddock C, Baüey P, Griffith C, Lineberry M, Wilson J. Is time spent with the physician associated with parent dissatisfaction due to long waiting times? Evaluation & the Health Professions. 2010;33:216-225.

'Malkin I. A Visual Reference for Evidence- Based Design. The Center For Health Design. 2008.

''Pine 1, Gilmore J. The Experience Economy. Harvard Business School Press, Boston. 1999.

Angelic P. McDonald, MSRS, CRA, RT received her masters in radiologie sciences through Midwestern State University and is currently working on her PhD in heaith studies through Texas Women's University. She began her imaging career in the United States Air Force as a radiologie technologist and continued in imaging as aCTand MRI technologist before pursuing imaging management. She is currently the director of imaging at Methodist Wiilowbrook Hospitai in Houston, TX and can be contacted at [email protected].

Randy Kirk, MA received his masters in science in instructionai and performance technology from Boise State University. Randy is a graduate of Corporate Coach University and is certified in organizational development by DePaul University. He is presentiy working on his certification in evidence-based design and is an organizational effectiveness specialist. Before joining The Methodist Hospital in 2001, Randy had severai different roles, from assistant director of patient access to leadership coach at the University of Texas Medicai Branch in Gaiveston, TX.

R A D I O L O G Y M A N A G E M E N T • J A N U A R Y / F E B R U A R Y 2 0 1 3 4 5

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