John Couris

Morton Plant Mease Health Care (MPM) is a not-for-profit health care system in the greater Tampa Bay area in Florida, serving Pinellas and Pasco counties. It consists of four hospitals (Morton Plant, Mease Dunedin, Mease Countryside, and North Bay Hospitals), 1,187 beds in total, and five multi-modality imaging centers (Bardmoor Imaging, Carlisle Diagnostic Imaging, Eastlake Imaging, Trinity Imaging, and the Susan Cheek Needler Breast Center). MPM is part of the BayCare Health System, which is the sixth largest not-for-profit and nonteaching health care system in the United States and the largest on Florida's west coast. The MPM health system contracts with 34 radiologists, and is projected to perform 484,700 (52% outpatient, 48% inpatient) procedures this year. The hospitals and imaging centers perform roughly 1,500 procedures per weekday with a medical imaging staff of 397 team members (clinical and nonclinical). In 2000, MPM's leadership team realized that its medical imaging service line was not meeting all of the community's needs and decided to modify its business processes. The first change was in leadership. MPM hired a new Vice President of Medical Imaging and Health Services, coauthor John Couris. Under new leadership, the medical imaging service line was completely revamped, measurably improving operations. This article will explain how the imaging service line was rebuilt to meet current and future needs of the community.

STATE OF OPERATIONS

During 1999, MPM installed a new radiology information system (RIS), reorganized the central scheduling department, created a central fileroom, and integrated the dictation system into the RIS, creating several issues. Referring physicians had concerns with the central scheduling processes: long hold times (70 seconds or more) and the complexity of the scheduling process (too many questions, long wait time while scheduling, and minimal availability for emergency add-ons). Physicians and team members were also dissatisfied with the film library and their ability to provide films and/or reports in a timely manner. The newly created central film library was in the process of merging three hospital folders into one new RIS master folder with a staff consisting of 18 agency employees. Folder turnaround times were taking up to 6 hours. Overall, team member morale was low because of high management and team member turnover (22% in 2000), pay scales were not competitive in the marketplace, and reward and recognition were not implemented consistently throughout medical imaging. Agency staffing was on the rise: 36,797 agency hours costing $1.5 million in 2000 and 55,209 agency hours costing $2.6 million in 2001. Medical imaging was struggling to provide comprehensive service to the community.

STEPS TAKEN: LEADERSHIP

First, MPM looked at infrastructure. The site managers were not able to spend any time in operations; instead their time was consumed with meetings and paperwork. Even with all the meetings, a communication plan was nonexistent between the nine locations and team members. MPM Medical Imaging needed to reengineer the managers' responsibilities to ensure that 70% of their time was spent in day-to-day operations and interacting with their internal customers (physicians and team members), and 30% spent on administrative work. To achieve this, two new director positions were created: Director of Operations, and Director of Nuclear Medicine and Clinical Support. Part of their responsibility was to assume some of the managers' duties, such as attending meetings, so the managers could get closer to their customers' needs and daily operations. Goals for meetings were developed to keep them organized and outcome-oriented. A new information structure was created, reducing the number of meetings from 20-30 a month to eight core meetings.

1. Weekly Vice President and Directors Meeting. Focuses on operations and productivity, with emphasis on mid-coursecorrections in the 3-year plan.
2. Monthly Impact Care Meeting. Quality improvement is discussed at a team member level for improving costs, service, and outcome.
3. Biweekly Service Program Meeting with Ambulatory Care Network Leadership Directors. Forum where all the directors in the MPM health system share ideas.
4. Weekly Operations Meeting. Run by the directors with managers, the purpose is  review of day-to-day activities regarding volume, staffing, and cost-saving actions.
5. Biweekly Medical Imaging Team Meeting. Run by the directors, this meeting addresses processes and day-to-day activities.
6. Quarterly Town Meetings. Held at each site with team members and run by the vice president and directors, this informal venue gives team members a chance to discuss concerns with upper management.
7. Monthly Radiologist Meeting. Addresses clinical operations.
8. Monthly Vice President Meeting with Practice President. The purpose is to stay connected with the radiologists' needs and attempt to be proactive in clinical and operational changes that are specific to that group.

Once the infrastructure was evaluated and redesigned, the medical imaging team began to focus on a more creative way to stay connected with the radiologists' needs. There were disconnects on new equipment purchases, process design, customer service issues, and clinical operations. To help link the radiologist and management teams together, modality specialist positions were created to work directly with the radiologists who specialize in the same modalities. For example, the MRI specialist is linked with the radiologist specializing in MRI to purchase new equipment and standardize processes across the sites. They have become partners in collaborating and innovating ways to improve medical imaging. This process continues today as medical imaging faces new challenges within the industry.

MPM Medical Imaging key players include, from left, David A. Nelson, director of operations; Dan Krop, MD, president of Radiology Associates of Clearwater; Beth Cushing, director of nuclear medicine; John Couris, vice president, medical imaging and health services; Fred Carolan, MD, president of Celestial Imaging; Robert Kline, MD, president of Clearwater Imaging Associates; Lori Cohen, director of business office operations; and Cecile Brewer, manager of quality improvement and education.

PROCESS IMPROVEMENT

Access, getting information in and out, was MPM's number one problem. Using an internal quality improvement process called FOCUS PDSA (find an opportunity, organize to improve, clarify current process, understand variation, select improvements, plan your actions, do the actions, study the results, and act on your conclusions), medical imaging began redesigning the central scheduling department with the customer as the focal point. The number of questions asked of the patient and the referring physician's office was reduced from 21 to 10. The 21 different phone numbers throughout the system to reach central scheduling were streamlined to two phone numbers: one for hospital-based and one for outpatient imaging. The phone tree intended to triage phone calls actually added 3 or 4 minutes to phone calls: it was eliminated. The bottom line is this: we reduced variations, but did not add staff.

The call abandonment rate was reduced from 11% in 1999 to 5.46% in 2001 (a 5.54% reduction), and 78,360 more phone calls were answered, a 31% increase. Central scheduling also decreased holding times by 67%from 70 seconds in 1999 to 23 seconds in 2001. Resource (room) capacity was increased by 15%. This was achieved through monitoring daily blocking of resources: unlimited access had been given to team members to open and close the nearly 150 procedure rooms across the system based on their personal scheduling needs. Establishing uniformity of examination durations (an ultrasound examination could be 1 hour at one site and 30 minutes at another site), and opening up resources according to coverage helped. A technologist was positioned in the central scheduling office to facilitate stat add-on patients and to clinically coordinate scheduling information, thus allowing for a quicker scheduling process. An online scheduling program began, allowing referring physicians to schedule their patients' examinations within their office. (The program is currently being tested within the health system, and results will be available in the next 6 months.) "One-Call Does It All" was developed, giving referring physicians a quicker and easier method to schedule patients. With One-Call, a physician office faxes crucial information for an appointment. MPM obtains authorization, contacts the patient to establish or confirm the appointment, and assures delivery of films and reports. Physician users were profiled based on the 80-20 rules (20% of referrers generate 80% of the business) to find out how they want their film packaged and when they want them delivered.

The next improvement step was reducing the variation of processes within the film library. The film library manager had no control over the file areas at the nine sites, leaving the system with a tremendous amount of variation in the processes. This variation led to inconsistencies within the film library, giving customers different levels of service depending on which site they visited. Management became centralized; instead of leading only the team members at the central film library, the manager is now in charge of all nine sites' film access personnel and processes. The next emphasis was on standardization of operational procedures. Team members began cross-training between sites, allowing them to work at any file area within the system, and educational courses were available for career advancement. One of the main process changes was the capability to request a folder for an add-on examination and have it at the site within 1 hour. Folder turnaround times decreased from 6 hours to 1 hour or less.

A report throughput committee was established using the FOCUS PDSA process. The average report turnaround time from examination completion to finalization took 35 hours. It has decreased on average to 20 hours or less, mainly by giving radiologists online access to sign reports from home. Through remote access software, a virtual desktop enables them to access the RIS via the Internet from any location. The complete to preliminary report turnaround time is on average 6.5 hours. To ensure the hospital personnel a same-day report, all of the preliminary reports automatically print to the floors and emergency departments based on patient location through a function of the RIS. For outpatient examinations, the report is auto-faxed or available online immediately after it is finalized through the BayCare Web MD, the MPM portal that enables referring physicians and their offices to access radiology reports and other clinical information online.

EMPLOYEE DEVELOPMENT

A Learning Needs Assessment was created to identify specific team members' educational needs. Focus groups were conducted with team members at all sites to gather detailed information. From this assessment, MPM Medical Imaging began to look at ways to lower agency staffing by improving recruitment and retention, and team member morale. The WOW Principles were initiated, designed to make the MPM experience fun for patients and employees by providing superiornot just goodcustomer service. They are demonstrated using CLASS (Care, Listen, Are ambassadors, Smile, Strive). The patients are recognized as a guest at each center (for example, flowers on holidays, and birthday bags) and team members are rewarded for going above and beyond the demonstration of merely good service. The WOW program is a pathway to continue the growth and development of service initiatives, prompting the launch of employee development programs. Earn As You Learn, a program for employees wishing to become radiology technologists, offers tuition assistance as well as a salary while attending college. The Lunch and Learn program offers events at every site for technologist continuing education credits. A quarterly newsletter is published for the team members, improving communications between the nine sites. A new pay scale and flexible work schedules on weekends for hospital technologists were enacted, and a Pay Per Skills program began for film library and patient access personnel, enabling them to advance within their professions. MPM Medical Imaging is focused on promoting within the system and created a partnership with team resources for a fast-tracking recruitment process. Medical imaging receives the resume immediately after it arrives in team resources and initiates the interview process. This multi-faceted recruitment and retention program has recently eliminated agency staffing in the organization and has positioned them not to utilize it in the future. Almost $500,000 was spent on agency staffing in 2002 year to date, a cost saving of $2.1 million from 2001. Agency hours went from 55,209 hours in 2001 to 10,621 hours year to date. The vacancy rate dropped from 22% in 2000, to 19% in 2001, and to 8.6% year to date. Also, throughout these improvements, the cost per procedure dropped 5% from $73.18 in 1999 to $69.75 in 2001. MPM's number of procedures grew from 384,000 in 1999 to 445,900 in 2001, an increase of 14%.

Table 1. Central scheduling improvement.

Table 2. Hospital and imaging center procedures.

Through extensive surveying of internal and external customers, MPM Medical Imaging monitors initiatives and improvements. Our scores on the surveys from Professional Research Consultant (PRC), Omaha, Neb, from the patient perspective, increased from 76.1% of respondents ranking the organization as "excellent" or "very good" in 1999, to 84.6% in 2001. The national average is 74.8%.

The Team Member As a Customer survey looks at service, communication, teamwork, supervision and management, compensation and benefits, staff development, job satisfaction and job security, quality, and corporate responsibility for employees. Overall, MPM climbed from a score of 2.76 to 3.55, with 4.0 being excellent. The Internal Customer Survey increased from 2.98 to 3.2 out of a possible 4.0. The Physician Survey looks at overall physician satisfaction and averaged 3.17 with a national database score of 3.01 and 4.0 being excellent. Scores from the outpatient centers on the Quality Data Management (QDM), Cleveland, a web-based customer service survey, were impressive. In Initiating Care, MPM averaged 87.0 with a database norm of 68.1, Receiving Care was 85.7 compared to 78.1, and Billing and Discharge was 96.6 with a norm of 74.1, all out of 100 being excellent. The QDM scores for the hospitals were just as impressive. According to the improvements in the various scores, MPM Medical Imaging is well on the way to meeting the needs of patients, physicians, and team members.

CURRENT, FUTURE IMPROVEMENTS

MPM Medical Imaging continues to monitor areas for improvement and initiate new programs. Staffing to Demand is now a proactive project, in which we are cross-training team members in other modalities and creating an internal pool of 40 team members to fill in as needed. The picture archiving and communications system (PACS) is scheduled for implementation in the beginning of the fourth quarter, allowing MPM to move digital images throughout the health care system. A voice recognition pilot will also begin in the fourth quarter in the nuclear medicine department, enabling MPM to shorten report turnaround times and reduce costs. Capital planning processes for aggressive equipment purchasing agreements is ongoing. These are only a few of the new initiatives. The journey is far from over as MPM Medical Imaging continues to identify areas for improvement, but with this team they will continue to excel. It is the team (directors, managers, technologists, patient access personnel, film librarians, and central schedulers), its ability to recognize opportunities for improvement, and its willingness to change by developing new processes that make MPM Medical Imaging what it is today and will be in the future.

None of this would have been achievable without the dedication and commitment of the Medical Imaging leadership team.

Sharon L. Streng, RM, CT, is radiology information system and operational senior analyst at Morton Plant Mease Health Care, Clearwater, Fla. She is responsible in part for the tactical implementation of the radiology information system, PACS, voice recognition, and the operational processes focused on work flow.

John Couris is vice president, medical imaging and health services.