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Original Research |
1 Hospital Administration, Brigham and Women's Hospital, Harvard Medical School,
Boston, MA 02120.
2 Department of Radiology, Brigham and Women's Hospital, Harvard Medical School,
1620 Tremont St., Boston, MA 02120.
Received June 21, 2005;
accepted after revision September 18, 2005.
Address correspondence to S. M. Erturk
(mehmeterturk{at}superonline.com).
Abstract
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MATERIALS AND METHODS. We performed a cross-sectional study using a validated survey sent to Society of Chairmen of Academic Radiology Departments (SCARD) members and studied type, frequency of monitoring, and use of preset standards for evaluation of quality indicators. Statistical methods were descriptive summary statistics, chi-square test, analysis of variance, and Spearman's rank correlation test.
RESULTS. The response rate was 42% (55/132). Most responding hospitals were from the Northeast (20/55, 36.4%) and Midwest (18/55, 32.7%). About 58% (32/55) of the responding hospitals had more than 500 beds in operation; 50.9% (28/55) of the radiology departments performed 200,000-400,000 examinations per year. Among the 80% of departments (44/55) that monitored patient satisfaction, only 49.1% and 45.5% assessed referring physician and employee satisfaction, respectively. The most frequently monitored customer satisfaction indicator, patient satisfaction, was monitored quarterly or less frequently by 70.5% (31/44) of departments; about 45.5% (20/44) had preset standards for this indicator. MRI and CT were monitored for patient appointment access by 80% (44/55) and 72.7% (40/55) of departments, respectively; 59.1% (26/44) and 62.5% (25/40) of departments applied preset standards to these indicators, respectively. The reporting-time indicator monitored most frequently was report turnaround time (45/55, 81.8%). None of the differences in mean numbers and monitoring frequencies of the indicators and the use of preset standards to evaluate them by region and size of departments were significant (p >0.05).
CONCLUSION. Use of quality management indicators, particularly customer satisfaction indicators, is not a fully standardized and established process for academic radiology departments in the United States.
Keywords: academic radiology • radiology practice
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Previous studies evaluating quality issues in health care identified two main components of quality: technical quality and quality of delivery of health care services [3]. In radiology, in particular, the term "customer" refers not only to patients but also to referring physicians and employees. Regular surveillance of their satisfaction promotes understanding of customer perceptions and helps to identify problems and to evaluate the service provided by a radiology department [4, 5]. In this context, in radiology as in nonmedical service industries, timeliness is especially critical for customer satisfaction; timeliness in radiology practice is reflected in patients' accessibility to procedures and the availability of reports after these procedures [4]. Defining standards of "good practice" for all these concepts is especially important because only then are comparisons possible.
Traditionally, the primary focus of quality assurance programs in radiology has been technical quality, and it is commonplace to monitor equipment and procedures to prevent and reduce errors [6] as required by government regulations or accreditation processes. The conceptualization of quality in the medical literature generally tends to be from the technical perspective [3]. However, quality management requires a more holistic approach that focuses on continual improvement of the processes associated with providing goods or services that meet or exceed customer expectations [7]. In this context, evaluation of the quality of the health product as perceived by the customers is crucial.
In the present study, we tried to determine whether academic radiology departments in the United States perform regular measurements and comparisons with preset standards to evaluate their customers' perception of the quality of the product they deliver. We focused on indicators monitoring customer satisfaction and timeliness of the service.
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We conducted a pilot study in four teaching hospitals to test the questionnaire to determine and correct any problems. Before pilot testing, we obtained approval from the president of the Society of Chairmen of Academic Radiology Departments (SCARD). On the basis of the responses obtained from the pilot study, we modified the original questionnaire and then sent the final survey to all 132 members of SCARD. All individuals who were sent the questionnaire were informed of the purpose of our study. The responses were kept confidential and anonymous, and every hospital was assigned an identification number by the webmaster. The process was automated, and questionnaires were automatically sent again to nonresponding hospitals. The investigators had access only to the final database with identification numbers. The electronic questionnaire was designed so that the responder was unable to advance to the next question without answering the previous question. Thus, all questionnaires that were returned were answered completely.
The questionnaire initially assessed the general organizational characteristics of the institutions surveyed, including region, number of beds, and radiologic examination volume. Then, three categories of quality indicators, including customer satisfaction indicators, patients' access to imaging techniques, and radiology reporting time were studied. For each category, types of indicators, monitoring frequency of these indicators, and use of preset standards to evaluate these indicators were studied.
The indicators surveyed in the customer satisfaction category were patient satisfaction, patient complaints, patient waiting time (time from arrival in the department to the beginning of the examination), referring physician satisfaction, and employee satisfaction. The techniques regarding patients' access questioned were MRI, CT, mammography, and nuclear medicine. Finally, the following radiology reporting time indicators were surveyed: transcription time (time from examination completion to interpretation and dictation), signature time (review plus final signature), and overall report turnaround time (from completion of examination to final report).
Statistical Methods
First, a descriptive analysis was performed to assess the general
characteristics of the responding institutions and the number, type,
monitoring frequency, and use of preset standards of delivery quality
indicators. Second, departments were grouped according to geographic region.
The type and mean number of indicators, the frequency of their use, and the
presence of preset standards were compared by analysis of variance and
chi-square tests. Third, departments were grouped by examination volume and
number of beds in their hospitals. The types of indicators, the frequencies of
their use, and the presence of preset standards were compared by the
chi-square test. Fourth, nonparametric correlation analysis with the
Spearman's rank correlation coefficient (r) was performed to assess
whether the number of measured indicators in each category was correlated with
the size of the hospital defined as the number of beds and volume of the
radiologic examinations.
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Of hospitals that responded, 32 (58%) hospitals had more than 500 beds in operation; 21 (38%) had 200 to 500, and two (4%) had fewer than 200.
Ten (18.2%) of the responding radiology departments performed more than
400,000 examinations per year, 28 (
51%) performed 200,000 to 400,000, 14
(25.5%) performed 100,000 to 200,000 examinations, and three (5.5%) performed
fewer than 100,000 examinations.
Customer Satisfaction Indicators
The mean number of customer satisfaction indicators used was 3.2 (out of
5). For these indicators (Table
1), 46 (83.6%) departments monitored patient complaints, 44 (80%)
monitored patient satisfaction, 35 (63.6%) monitored patient waiting time, 27
(49.1%) monitored referring physician satisfaction, and 25 (45.5%) monitored
employee satisfaction.
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These indicators were monitored weekly, biweekly, monthly, quarterly, or at longer intervals (Fig. 1). The two most frequently monitored indicators, patient satisfaction and patient complaints, were monitored quarterly or at longer intervals by 31 (70.5%) of 44 and 26 (56.5%) of 46 departments, respectively. Twenty (46%) departments had preset standards for patient satisfaction (Table 2).
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Patient Appointment Access to Techniques
The mean number of techniques monitored for patient appointment access was
2.7. MRI and CT were monitored for patient appointment access by 44 (80%) and
40 (72.7%) departments, respectively. MRI was monitored monthly or at longer
intervals by 25 (56.8%) of 44 departments
(Fig. 2). For patient
appointment access, 26 (59.1%) of 44 departments had preset standards for MRI,
25 (62.5%) of 40 departments had preset standards for CT, and 25 (65.8%) of 38
departments had preset standards for mammography.
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Quality generally consists of two related but distinct components [9]: technical or outcome quality and service delivery as perceived by the customer. Technical quality is measured in terms of how well the service is performed. Competence and expertise are major determinants of technical quality [3]. In radiology, a product of "good" technical quality is accurate diagnostic information obtained at the lowest possible exposure to all hazardous factors and at a minimal, realistic cost. Repeat exposures due to poor image quality, for example, by increasing patient risk and cost, lower the quality of the product [10]. Adverse reactions due to contrast material are also considered in this context. In radiology, regular monitoring of technical quality indicators such as repeat rate, pathology correlation, and frequency of adverse reactions is commonplace.
The second component of quality, measured in terms of service delivery as perceived by the customer [9], is sometimes referred to as delivery quality and differs from the technical quality by also including the subjective experience of the customer with the product.
In radiology, the customers are not only patients but are also referring physicians and employees of the department, and their satisfaction is based on impressions formed at all points of contact with the institution. In particular, because patients lack the knowledge to assess technical quality, typically their quality judgment is based entirely on their subjective experiences throughout the process, necessitating the measurement and assurance of both quality components in a radiology department. Nevertheless, in the medical literature, the conceptualization of quality tends to be from the technical perspective [3].
A study by Nelson et al. [11] suggests that 17-27% of the variation in financial performance of hospitals can be explained by dimensions of quality as perceived by the patients. Another study on customers' perception of quality and satisfaction from the marketing perspective showed that quality drives satisfaction, which drives customer behavior and eventually the financial performance of organizations, including hospitals [12]. Therefore, it is essential to monitor patient satisfaction by means of frequent measurements and the use of standards. In our study, numerous academic radiology departments monitored patient satisfaction, patient complaints, and patient waiting time. However, the majority of departments monitored these indicators only quarterly and, perhaps more important, did not have any preset standards for these indicators.
Referring physicians are also obvious and important customers of radiology departments [4]. They provide revenue indirectly through referrals. In addition to a service of good technical quality, they want their patients to be pleased with the overall experience. Our survey results showed that only 49% of the responding academic radiology departments monitored referring physician satisfaction.
According to Rosenbluth and Peters [13], the way a service organization treats its employees has a major impact on the organization's ability to deal with its customers. In other words, employees are internal customers and their satisfaction has a direct impact on the satisfaction of both patients and referring physicians [14]. Nevertheless, our survey showed that only 45.5% of departments monitored this valuable indicator. Furthermore, employee satisfaction was monitored infrequently, and only 44% of these departments applied standards.
A market research study conducted by the American College of Radiology (ACR) in 1989 showed that "the ability to schedule patients quickly" and "the speed in receiving results" were two of the most important factors in the selection of a radiologist by referring physicians [15]. An efficient patient scheduling system that meets and exceeds the expectations of referring physicians and patients might provide a radiology department with an important competitive advantage through consolidating and expanding the referring physician base [16]. In fact, patients' timely accessibility to imaging procedures is critical for the satisfaction of both patients and referring physicians. Our survey showed that 80%, 72.7%, and 69.1% of departments monitored MRI, CT, and mammography, respectively, for patient access. In comparison with the customer satisfaction indicators, relatively high percentages of departments applied preset standards for patients' access to different techniques and monitored these indicators more frequently.
The transcribed report is the most conspicuous and permanent product of a radiology department [17]. The quick and efficient provision of a final diagnostic imaging report is a critical task for every radiology department, and timely reporting is included in the ACR's "Standard for Communication— Diagnostic Radiology" [18]. Typically, a report is dictated at the completion of a radiologic examination and subsequently transcribed and either entered directly into a computer network or printed. Finally, it is verified and signed by the radiologist. Delays at any step along this pathway might lead to dissatisfied clinicians and patients [19]. Therefore, an analysis of the various phases of the reporting process through indicators is crucial and allows the department to identify the bottlenecks in the process and take corrective measures [17, 20]. We found that, compared with the customer satisfaction indicators, the average number of reporting-time indicators used by academic radiology departments was high and that the majority of departments monitored these indicators relatively more frequently (mostly monthly) and applied preset standards.
We think the better results obtained in the categories of patients' access to the techniques and radiology reporting categories than in the customer satisfaction category are due to the consideration by departments of indicators in the former two categories not only as quality indicators but also as important measurements of productivity [8]. Moreover, customer satisfaction is a relatively more difficult and subjective category to measure.
Our results show that the majority of academic radiology departments studied in our survey tried to monitor the quality of their services. Many departments measured customer satisfaction, excluding referring physician and employee satisfaction, patients' access to techniques, and radiology reporting time. However, patients' access to the techniques and radiology reporting time were more effectively monitored and compared with preset standards or to specific goals of departments than was customer satisfaction. Half of the departments did not apply any preset standards to customer satisfaction indicators that would permit comparisons. Furthermore, the majority of departments monitored customer satisfaction only quarterly or even less frequently. Moreover, most departments underestimated the two key concepts of referring physician and employee satisfaction.
In conclusion, when customer satisfaction indicators, particularly referring physician and employee satisfaction, are considered, comprehensive quality monitoring through indicators is not a fully standardized and established process for academic radiology departments in the United States.
In our opinion, it is critical for academic radiology departments to establish comprehensive and standardized processes for assessing customer satisfaction because academic environments have the responsibility to foster state-of-the-art and high-quality clinical practice.
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