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Noninterpretive Skills for Radiology Residents |
1 Department of Radiology, Columbia University, 630 W. 168th St., New York, NY 10032.
Received February 25, 2000;
accepted after revision March 21, 2000.
This is the fifth in a series of noninterpretive skills for residents in
diagnostic radiology from the American College of Radiology and the
Association of Program Directors in Radiology. Editor: Jannette Collins.
Introduction
 Top Introduction Objective I: Know the...Objective II: Know How...Objective III: Know How...Objective IV: Understand the...References |
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Objective I: Know the Factors on Which Customers Base Their
Evaluation of the Quality of Service
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TopIntroductionObjective I: Know the...Objective II: Know How...Objective III: Know How...Objective IV: Understand the...References |
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Reliability relates directly to the provision of consistently accurate interpretations of radiologic examinations that relate appropriately to the clinical context in which the examination was ordered. The correct examination must be performed and the correct views must be obtained to answer as many of the pertinent clinical questions as possible on a consistent basis. The radiologic interpretations and communication of these results must consistently be of high quality, regardless of which radiologist in a group is providing a particular service. High-quality service must be available at all times, including nights, weekends, and holidays.
With respect to responsiveness, timeliness is critical in the provision of radiologic services, as it is in the nonmedical service industry. Timeliness in radiology practice is reflected in patients' accessibility to procedures and the availability of reports after procedures. Can patients get on your schedule within a day or so after their request or is the wait longer? Are delays in the availability of radiologic services prolonging the average length of stay in a hospital? How long is the time from patient arrival for an examination to delivery of a final signed report to a referring physician (i.e., the report turnaround time)? The availability of final reports within 24 hr of the examination is a typical industry standard. Are all unexpected findings of significance communicated directly to the referring physician in advance of the report? Does your scheduling office answer the telephone promptly (three rings) and courteously and provide a pleasant experience to the person requesting the examination? This chain of events, from scheduling to the arrival of a final report, must work in synchrony in a timely and professional manner for radiologic services to be truly responsive.
With respect to assurance, your actions and the actions of your employees who interact with patients, with other physicians, and with the public represent the quality of your business. Customers want to feel that they are dealing with the best. To convey that sense to customers requires a combination of style and substance [1]. You need not only to have a good set of radiologic skills, but also to know the limits within which your practice can provide the requested services and how to get the required services for your customers, even if you cannot provide the services yourself. Patients also will feel assured if your office staff knows the "rules of the road" in today's complicated payment environment. Which examinations require precertification? What are the payment policies and how do they differ among managed care payers? The more that your staff can relieve patients of such burdens, the more assured patients will be that they are dealing with high-quality professionals. By listening to the needs of the referring physician and patient and helping solve their problems in a confident caring style, your practice will provide the assurance that you are indeed on par with the best. This will go a long way to bring you and your practice the repeated business and respect that you desire.
Regarding empathy, people who are vulnerable, fragile, or emotional—this includes most patients—want to communicate and interact with responsible caring people even in the electronically sophisticated era in which we live. Patients want and need to be treated as individuals by other individuals, rather than as items by an impersonal organization. Large organizational size does not necessarily mean that personalized empathetic care cannot be rendered: witness the ongoing success of the ever-expanding Mayo Clinic. In radiology, some of the most important interactions take place between patients and nonphysician personnel such as clerks at the sign-in desk, the scheduling staff, the office nurses, and the technologists. It is imperative for radiologists to work with all personnel continually to ensure that they know and practice the principles of patient-friendly courteous service. Their interactions with patients reflect the attitudes and commitments of the radiologists. If your office or hospital staff does not represent you appropriately, then you are likely to have a suboptimal reputation despite whatever else you might do personally to provide the best radiologic services and interpretations possible.
One major component of "tangibles" in radiology relates to the quality of the imaging equipment and the images themselves. One frequently hears about the competition between practice A, which has the newest and best pulse sequences on the highest field MR imaging system on the clinical market, and practice B, which has a somewhat older MR imaging system. Undoubtedly, the medical equipment industry will continue to produce high-quality imaging systems and to create situations in which practices need to update or purchase new equipment to keep their tangible value high. Clearly, the quality of a practice's radiology equipment and the way that equipment is used are key tangible factors. The American College of Radiology Standards and Accreditation Programs are strong evidence of the importance of these issues. Equipment and its use are not, however, the only tangibles of note to patients. For example, does your practice or hospital have ample parking? Is the parking area easily accessible, clean, and well lighted? Are the building and grounds around your practice clean and well kept? Similarly, how clean and inviting is the waiting room? Is the billing process clear to patients? Do bills arrive in timely fashion and are they readily understandable? These and similar ancillary tangible factors will have a surprisingly large impact on the patient's opinion of your practice because the patient's experience of service is much broader than the core skill brought by radiologists themselves. The referral that resulted in the patient coming to your office probably was based to some extent on that primary skill, but it also was based on many of these secondary factors. Patients typically report to their primary doctors about their satisfaction with referral services and may ask to go elsewhere in the future if they have been treated badly or have had an inconvenient experience. To provide the type of experience that patients need, you and your office staff must address the entire patient experience.
Objective II: Know How to Identify Your Customers
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TopIntroductionObjective I: Know the...Objective II: Know How...Objective III: Know How...Objective IV: Understand the...References |
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Referring physicians are another obvious and important type of external customer. They provide revenue indirectly through referrals. They want convenient and timely access for their patients to whatever imaging study might be required. Referring physicians want accurate and timely reporting of results and many also want the radiologist to serve frequently as a consultant. They want their patients to be pleased with the overall experience. Referring physicians also want few, if any, inconveniences for themselves, their office staff, and their patients. In other words, getting a radiologic service has to be as obstruction-free and timely as possible.
Another important class of customer, which may seem external at times and internal at others, is the hospital administration. In hospitalbased radiology practices, the funding for equipment, facilities, support personnel, and many other items comes from the administration. This means that many of the issues that impact the patient's perception of radiologic services and of radiologists depend on the support and cooperation of the administration. Administration typically wants radiologists to provide timely, accurate, and cost-effective diagnostic and interventional services; to be readily available and to report promptly; and to please patients and referring physicians in a variety of ways. They also want the radiology leaders to convey and interpret (favorably, if possible) institutional issues to other staff radiologists and to the radiology support staff. It is extremely important that the radiology leaders work closely and productively with this class of customers because this cooperation determines to a large degree the potential for improving local conditions. This hospital-based situation contrasts with that of private radiologist-owned outpatient facilities where these matters are typically controlled solely by the radiologist owners. This arrangement is, in fact, one of the major appeals for such a practice setting. In medical school-based practices, the university administration is yet another customer, usually with somewhat different ideas about what constitutes effective performance—for example, education and research. None of these institutional administrative customers are truly internal to the radiology practice, but the impact that their decisions can have and the intricate ways in which their domains overlap with those of radiologists may make it seem so.
Your practice also will have many true internal customers—that is, individuals who exist entirely within your organization. These people are those whom you serve and who serve you. At times these relationships change: the service provider becomes the customer and vice versa. For example, the radiologist is an internal customer of the film clerk whose job it is to locate and hang comparison films for interpreting the day's new cases. The film clerk becomes a customer of the radiologist when the radiologist is required to return films so they can be filed. Many more examples could be provided of similarly changing relationships between internal providers and internal customers. According to Rosenbluth and Peters [2], the way that a service organization deals with these internal relationships will have a major impact on the organization's ability to deal with its many external customers. In fact, Rosenbluth and Peters advocate that more attention be placed on internal customers than external customers. Their perspective serves to emphasize that a focused empowered workforce is one of the best ways to guarantee efficient and productive operations and excellent service to external customers. Employees who are happy in their work will focus more effectively on the external customers and yield a better overall performance for your practice. This is true at every level of an organization. Leaders need to be as conversant with the issues of the workers at the grassroots as with their high-level colleagues, and leaders must consistently strive for workforce (i.e., internal customer) satisfaction at all levels.
Occasionally an individual or organization that might be viewed as a direct competitor will be a complementary customer. For example, a competitor might stimulate awareness in the community of a new approach or procedure that was previously unused or unknown. Two competing radiology practices might acquire the same technical modules necessary to provide high-quality cardiac MR imaging. Both would publicize the availability and the advantages of these new approaches, perhaps in independent advertisements. Both sources of publicity, although arising from independent groups, would complement one another by creating a market for these services that did not previously exist. Within that new market, the two groups still would compete for whatever business had been created, but the overall market would be an expanded and larger one than the one that existed before their complementary actions. These are the principles of "co-opetition," a relatively new way of thinking about relationships in the business community [3].
These examples point out that the business of radiology is at least as complex as the business of many other types of organizations and is broadly dependent on many non-interpretive skills. There are many types of external and internal customers and all must be dealt with effectively to achieve and sustain success.
Objective III: Know How to Measure the Satisfaction of Your
Customers
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TopIntroductionObjective I: Know the...Objective II: Know How...Objective III: Know How...Objective IV: Understand the...References |
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Who should be surveyed, about what, and how often? Both patient and referring physician satisfaction should be monitored periodically, as should employee satisfaction. For example, issues that might be pertinent to patients would include the courtesy and professionalism of the personnel at all levels including reception and scheduling staff, the cashier, transport personnel, the technologist, and the radiologist; the waiting time for an appointment; the cleanliness and décor of the facilities and examination room; and the explanation and convenience of the billing process. These examples have been included in satisfaction surveys of patients and physicians at the New York Presbyterian Hospital. Note that the survey inquires about multiple experiences along the continuum of care and service experienced by the patient from the time the appointment is made until the final bill is received and paid. Generally, patients are asked to rate the issues of significance on a 5-point best-to-worst scale. Additional space is allowed for comments. A survey may be handed to patients before they leave. This method avoids mailing costs and allows a more extensive survey to be obtained cost-effectively. Surveys mailed to the patient after the encounter also are effective but are generally associated with a lower response rate.
Figure 1 shows the information requested as part of a postcard survey that we perform twice a year in our private practice office, the hospital outpatient practice, and a technique-based (positron emission tomography) university practice. The response rate generally has been 25-30%. Mailing a survey to the patient after the fact probably creates the least biased situation. According to Hall [4], a telephone survey is the most likely to involve bias and is less likely to elicit criticism. Patients have been shown in controlled studies to be less willing to criticize their health care in an interview than when provided the anonymity of a written survey [4]. If a survey is mailed to the patient's home after the visit, the survey should be sent within weeks and a self-addressed stamped return envelope or return-mail postcard should be provided. The results should be tallied and presented to the practice in relation to its own past performance, industry standards, and results from other nearby practices. In my experience, surveys of this type are quite useful. At a minimum, these data should be gathered at least every 6 months; quarterly or even monthly data-gathering is not rare in certain practice environments. From these results, practice managers and physician leaders should have ample information with which to respond and to improve their practices accordingly.
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Referring physicians also must be satisfied and generally are harder to please than patients. For example, the convenience of the scheduling process and the availability of appointments at desirable times impact significantly on the referring physician's office. Likewise, the amount of time that a patient waits for an examination in radiology is an important issue. The availability of timely reports and the availability of images for personal review also are important. The referring physician's office also is concerned about the billing process, because this is one of the most sensitive areas for patient complaints. Ultimately, the referring physician is threatened by patient dissatisfaction with radiologic services because this could cause the patient to seek primary services elsewhere. Similarly, referring physicians are concerned about the patient's impression of the experience in radiology, the ease of access to facilities, the cleanliness of those facilities, and the courtesy provided during the reception. Referring physicians also are concerned with the quality of the images produced by the staff and particularly with the ability of technologists to interact courteously and effectively with their patients. Referring physicians are concerned with the quality of radiologic consultations and written reports and the availability of radiologists at all times to effectively cover emergency situations. Any of these issues would be appropriate items to include in a referring physician satisfaction survey.
Regarding the internal radiology staff, issues related to quality of life in the workplace are important and could serve as the basis for periodic surveys. During a strategic planning evaluation 3 years ago in our department, a committee composed of two radiologists, a technologist, a secretary, a technical supervisor, and two senior radiology administrators identified a number of items critical to job satisfaction. These items included communication, which the committee thought should be frequent, open, and in a climate of trust and candor at all levels. Also cited were needs for well-defined job responsibilities and accountability. The committee believed that job descriptions should be clear and should be upgraded periodically. Regular in-service training was recommended, including a focus on customer relations. The committee also urged that employees be formally recognized for good work. Recognition might include announcements (e.g., "employee of the month"), letters of commendation, bonuses, or other forms of recognition. They also wanted a forum for getting problems in the open such as a suggestion box. Because of this process, we initiated open "town" meetings every 6 months between the Chair with the Technical Director and the staff. All staff are invited to a series of meetings repeated at times convenient to various shifts and work sites. These periodic open meetings probably are not as unbiased a way to assess staff satisfaction as anonymous written surveys, but they have been well received. They represent our attempt to encourage the internal staff to be engaged and positive. As Rosenbluth and Peters [2] indicate, an effective internal staff is one of the most powerful assets for any business intent on serving its external customers well.
Objective IV: Understand the Need to Balance Interpersonal and
Technologic Skills in Practice
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TopIntroductionObjective I: Know the...Objective II: Know How...Objective III: Know How...Objective IV: Understand the...References |
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These needs and how they interplay with the image of the individual radiologist and of the discipline have been summarized in recent review by Gunderman [6]. Gunderman deals in part with the issues of ethics in radiology, which are the subject of another module in this series. In the context of the emphasis of this article on service and patients, it seems relevant to explore the relationship between caring for patients as a whole (i.e., humanism) and the dedication required for excellent service. Gunderman believes that the primary loyalty of the radiologist must be to the health of the patient. Although he also understands the need for sound business practices, he believes these issues must always be subordinated to patient welfare.
At first glance, a radiology resident might believe that such issues are somewhat peripheral to the daily practice of radiology and not pertinent in a practical sense. There are numerous examples, however, of daily events in radiology that relate to this principle. For example, should the final cases be dictated before you go home or can they wait until tomorrow? Should you take the time to sign your reports now or can they wait while you deal with other issues? It is difficult to contact the physician's office, so should you persist in your attempts to communicate an unexpected finding or can you rely on the referring doctor to read your report? Numerous other examples can be imagined of decisions that are made multiple times each day by radiologists and radiology residents. A consistent awareness that cases represent people and empathy for the situations of these people are more likely, I believe, to result in a decision of dedication to the patient's well-being despite the potential inconvenience or difficulty for the radiologist. When remoteness from the patient—perhaps rationalized through the need for objectivity—becomes pervasive, the radiologists is likely to find it more difficult to justify the clinical persistence that is often needed and universally respected.
Jacobson, Gunderman, and I agree that radiologists need to come down strongly on the side of patients. An appropriate balance between interpretive objectivity and involvement with the entire patient is needed for optimum results. This approach also will engender respect from customers and will enhance the image of radiology as a discipline.
As indicated, the relative lack of direct patient contact in various aspects of radiology practice makes it more difficult for patients to perceive the high quality of the services they are receiving. Patients relate satisfaction more directly to the interpersonal aspects of their medical encounters than to their experiences with "testing" [7]. This fact makes it even more important that radiologists understand and implement the principles of outstanding service—reliability, responsiveness, assurance, empathy, and tangibles. Radiologists must know all their customers and regularly determine their satisfaction. Radiologists also must exhibit unwavering dedication to service and to their patients. Such skills will become even more critical in the future. Organizations that purport to represent the public already are demanding evidence of continuing competence among practicing physicians [8]. Interpersonal patient-related skills are frequently cited in such proposals and will be important for radiologists as well as many other types of physicians. As one reviews such new materials and reflects on service-related principles, it becomes clear that technical skills alone in radiology are not sufficient. Dedication to service and to patients will be needed for future success in radiology.
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TopIntroductionObjective I: Know the...Objective II: Know How...Objective III: Know How...Objective IV: Understand the...References |
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