Radiology administrators are facing some tough problems in the current medical environment. The recent tight labor market has been accompanied by cost increases and reduced sources of capital. New modalities have increased both patient demand and radiologists’ knowledge base and credentialing requirements. Add to that the traditional woes besetting any business-communication difficulties, conflict resolution, and employee recruitment and retention-and administrators have daunting challenges ahead.

In response to the increasing pressure to provide and maintain timely services at radiology facilities around the country, expert administrators are proving themselves by coming up with creative solutions. Decisions in Axis Imaging News spoke with four talented administrators, each of whom has created an innovative program that not only serves to ease the problems within their facility, but readily serves as a model to other radiology departments combating the same issues.

Patient Satisfaction: Lehigh Valley Hospital, Allentown, Pa

Shiela M. Sferrella, MAS, RTR

“There is a shift in health care these days,” says Sheila M. Sferrella, MAS, RTR, fellow and president-elect of the American Healthcare Radiology Administrators, and administrator in the Department of Radiology at Lehigh Valley Hospital, Allentown, Pa. “Patients used to go somewhere because it was the best in providing treatment; 15 years ago, you never heard about patient satisfaction. Today, we pay bonuses to staff if we meet patient satisfaction targets.”

Sferrella came to Lehigh Valley Hospital 4 years ago, after a career that included working as a technologist and then supervising CT, MRI, and neuroangioplasty at the University of Maryland, Baltimore, and then serving as director of radiology at Germantown Hospital and Pennsylvania Hospital, Philadelphia. At the time, Lehigh was planning the opening of the $52 million Jaindl Building in January 2000. The entire first floor was to contain a diagnostic care center housing seven departments as well as nuclear medicine.

“The institution is all about patient-centered care, and the redesign was to better address that in outpatient services. However, 6 months away from the opening, we were not even close to being ready,” Sferrella says. Due to her experience, chief operating officer Lou Leibhaber requested that she take over the project.

“The COO had three goals in mind: to have the best patient satisfaction in Lehigh Valley, to be in the top 10% of employee and physician satisfaction, and to redesign the departments at the same or lesser [operating] cost as they were currently spending,” she says. “We also had to mesh the needs of departments used to doing things their own way who now were sharing common waiting areas, common scheduling areas, and so on. It was an impossible task.”

Through information gleaned from the Disney Institute’s Professional Development Program, it proved not to be impossible after all. The focus was to be on service as the guiding principle. In honor of their principle’s source, the team used an original song format to present their ideas to senior management.

“We used ‘The Beauty and the Beast’ as inspiration,” she says.

Sferrella and her team started by coming up with the ideal patient encounter, which they divided into preencounter, encounter, and postencounter elements. The encounter revolved around a patient wait-time of no greater than 15 minutes at any point during their care. The Disney management principles also stress development of a theme. The diagnostic care center is structured around “Be Our Guest,” and the radiology department’s subtheme is “We create a lasting image of caring, compassion, and service excellence by providing answers with our diagnostic tests for customers of all ages.”

The team then spent months using a computer simulation model to analyze the logistics and processes, continuing to meet 20 hours per week to transfer the ideas from their computer model to reality. Although the original project timeline was 4-5 weeks, Sferrella says the program really required 12 months to complete, though her team managed it in 6.

“Every person working in that center underwent a 6-hour Disney-style orientation to fully understand customer service principles,” Sferrella says. “There are a lot of hospitals where you can get good care. Assuming quality is equal, service is what sets us apart and that is the area in which we pride ourselves.”

Baseline Measured

Prior to the physical move, the team took baseline measures for employee, physician, and patient satisfaction as seven separate areas. The results from Lehigh’s first employee satisfaction survey showed that the institution needed to work on communication, which inspired a reward recognition program for staff members. Although the hospital previously had such a program, Sferrella wanted it to be more comprehensive.

“This year we started using our PRIDE principles (privacy, respect, involvement, dignity, and empathy) as our criteria for a job well done. Patients or coworkers can nominate staff members for their work, and all positive comments are entered into their records,” she says.

Monthly prizes and quarterly checks of $150 are given to top employees. Sferrella also maintains communication with a biweekly newsletter called “Lasting Images” that includes technician tips, a message from the chairman or a staff radiologist, reward recognition information, and news from within the institution. Patient satisfaction is evaluated constantly in the form of surveys.

“If the service here is lousy, our managers want to know what they can do for the patients to change that experience. We send flowers and a letter of apology to any patients unhappy with their level of care and try to get them back as patients in the future,” she says. “These patient surveys give us an opportunity to change policies, because if those policies prevent people from doing the right thing, then we need to change them.”

Sferrella is still the driving force of operations management or, as she calls herself, “an eternal pain about keeping the diagnostic care center and radiology department the best in Lehigh Valley.

“Normally, when you want to try new things in a department, people resist. But never once has anyone here said, ‘We don’t want to do that.’ I’ve worked in a lot of places, and the staff here does a grade-A job of making patients feel welcome,” Sferrella says. “That kind of supportive attitude is key in employee satisfaction. And if the employees are happy, customer service will flow from that.”

Staff Training: Dartmouth Hitchcock Medical Center, Lebanon, NH

Many radiology departments throughout the country are struggling to find a way to cope with the severe technologist shortage. In 1996, the American Registry of Radiologic Technologists issued new certification requirements for technologists for attaining annual evidence of continuing education. At that time, Dartmouth Hitchcock Medical Center, Lebanon, NH, had 70 technologists on staff, and each individual then had to secure 12 continuing education units (CEUs) annually in order to maintain his or her certification. While CEUs can be obtained by sending staff to off-site conferences, that requires adequate staffing levels and a major financial commitment by the hospital or the individual technologist.

Nancy Lotian

Nancy Lothian, clinical operations manager at Dartmouth Hitchcock Medical Center,? found a way to tackle this dilemma. She developed an innovative education program focused on helping technologists in the New England area more readily obtain their necessary credentials.

“[A vendor] started its Training In Partnerships programs to address this issue, with companies able to select 12 video conferences via satellite annually,” Lothian says. “While those programs are great, the facilities must have [that vendor’s] equipment. Also from our standpoint, we could not get every technologist to attend those teleconferences one Wednesday each month from 3 PM to 4 PM. We had to create another means to bring the education to our people.”

Lothian conceived of an in-house program featuring a mix of topics. She gathered an education committee comprised of one technician from each of the medical center’s imaging areas-MRI, CT, interventional radiology, ultrasound, nuclear medicine, mammography, and diagnostic radiology-that regularly brainstorms and comes up with ideas for lectures concerning the hottest issues in radiology. The conferences, which feature seven lectures, are held on two Saturdays a year in order to enhance attendance. Attendance has grown from 25 to 30 technicians from Dartmouth Hitchcock Medical Center initially to 60 to 80 attendees today, only a third of whom are center employees.

Program Has Grown

Over the years, the program has grown to feature a well-rounded curriculum that uses its own radiologists as well as speakers from various other regions and specialties. Lecture content has branched away from radiology to include talks on infection control, radiation safety, and how breast cancer affects the family. This was accomplished without adding program management or educational staff. Incidental costs are covered by tuition and vendor educational grants.

“We also focus on pediatrics because a major Joint Commission requirement is different age-related competencies,” Lothian says. “We try once in a while to focus on radiology nursing as well, and those lectures are approved by our nursing education committee. We also focus on mammography every other fall because mammographers have to have six of 12 credits specific to mammography. Since we have seven full-time mammography technicians, we have to provide them with that opportunity.

“And we are leaning toward more electronic imaging to start understanding that technology. Overall, we want to know what we have to do to learn to better do our jobs,” she says.

“I don’t know of any other hospital in the region that does this,” Lothian continues. “We don’t do it to make money. We charge $75, which equates to seven credits. The event is held from 8 AM to 4 PM and includes lunch. Those fees just cover our costs. Sometimes we make a little money and sometimes we lose a little.”

Any leftover money is placed into a non-interest-bearing account that pays for conference advertising, flight fees for the speakers, and sometimes to help individuals attend the conferences.

“This format is pretty unique. There is no one else in the area doing this and we are proud of our group and the fact that the region now looks to us to provide their staff with these opportunities,” Lothian says. “It’s a real feather in our cap as far as educating regional radiographers, and the program is likewise a testament to our commitment to our employees in regard to their continuing education needs.”

Overcrowded Conditions: Memorial Hospital, Colorado Springs, Colo

Up until May 2001, Memorial Hospital in Colorado Springs, Colo, was suffering from a number of problems that are increasingly affecting all realms of the health care industry: overcrowded conditions, a dearth of patient parking, and a bottleneck in patient admissions and registration.

Sandra Anderson

“We had exceeded our capacity to provide good service, we had reduced our ability to grow and improve our image, and the word was out that Memorial was too busy and too crowded,” says Sandra Anderson, director of outpatient radiology services. “The entire hospital had very crowded conditions, and in radiology alone, we have seen an incremental increase of 8% every year from 1994 to 2000. We knew we needed to expand capacity.”

There was no room to expand within the hospital itself, so in 1997 the hospital entered into a partnership with a vendor to create a 24,500-square-foot outpatient radiology imaging center. The new imaging center, located a few miles away at Printers Park Medical Plaza, features direct digital radiography and fluoroscopy, ultrasound, nuclear medicine, CT, MRI, mammography, and a picture archiving and communications system (PACS). A PACS training room also is located at the remote site, which is equipped with a patient intravenous prep room and a six-bay nursing suite for patients who need pre- and post-procedure nursing care. The new center likewise houses outpatient adult and pediatric rehabilitation, wound care and disease management, pulmonary rehabilitation services, a radiology school, and physician office practices.

“As part of our contract with [the vendor], we signed a 7-year nonobsolescence agreement, and that ensures that they will keep us current on technology at a reduced cost,” Anderson says. In return, the center serves as a showcase site where the vendor can bring prospective customers to tour the facility.

Memorial Hospital Outpatient Radiology and Imaging Center at Printers Park

“This was an expensive endeavor-the capital required was $10 million-and we wanted only one vendor to be accountable for all of the equipment,” she says. “We also wanted direct digital capture for radiology, and since we are a city hospital, that would have been too expensive for what our budget would allow. The agreement with [the vendor] enabled the hospital to get about a 15% discount on equipment.”

While Anderson allows that the center’s first month up and running has included “some hiccups,” such as dealing with logistics for getting supplies, the staff is nonetheless caring for about 200 patients per 10 hour day and patient response has been favorable.

“We tailor the work done based on the patients’ other needs,” Anderson says, noting that many patients still can be seen in the hospital if they have needs better met in that environment. “There are eight radiological suites still operating at the hospital with two CTs, one MRI, a three-room nuclear medicine suite, mammography, and ECGs.”

With the new center, Anderson says the department is able to do more business development and secure more contracts.

“From a staff standpoint,? the move to an outside location has improved employee morale because everyone is not pressured to squeeze in patients,” she notes. “Billing is still handled through patient financial services at the hospital, and scheduling is centralized.

“Prior to this, inpatients, outpatients, and emergency department patients all had to wait for openings to get into radiology, so instead of doing NPO [nothing by mouth] patients first thing in the morning, they frequently would have to be done after lunch,” she says. “Now, if we are not able to get patients in within their requested time frame, we have a scheduling request in-box and staff members in the various modalities make a point of calling patients back within an hour to let them know when we can work them in.

“We have created a nice work environment at our outpatient and hospital settings, whereas before we were doing a disservice to all our patients because we were so busy,” Anderson says. “Now we have taken a load off the hospital, we respect the patient’s time, and we get them in and out in a timely manner.”

Departmental Determination: University of Utah, Salt Lake City

Mark D. Domalewski

The management of radiology services is typically hospital-based, but at the University of Utah, the department recently has been placed under the day-to-day control of radiologists. The impetus for this fundamental shift in management structure was not a problem encountered by the university and its Department of Radiology. Rather, it was the perception on the part of the radiology group that there was an opportunity to manage the technological aspect of radiology more effectively, with more profit, and with higher customer satisfaction, according to Mark D. Domalewski, CFO, Department of Radiology.

“It is a fairly common perception among radiologists in a hospital that they can do it better than the hospital, so we took on the challenge rather than just saying it,” he says. “Historically the technologist and the radiologist often work for different bosses. Now everyone reports to the chairman of the department so that everyone gets direction from a common source.”

In 1997, after a 9-month negotiation in which both the administration and the department worked to come up with an acceptable financial model, the shift was under way. The initial model, which has since changed, was simply a sharing of incremental profits, Domalewski says. The shared profits do not go into the radiologists’ pockets, but are redirected into the program at their discretion.

“We defined a baseline of profitability for the radiology enterprise as it existed and any incremental profits would then be shared 50-50. It worked wonderfully, because our incremental profit line went way up,” he says. “Now we are in a position where we have changed the model to one of more accurately aligning incentives so that things continue to improve.”

Domalewski says that throughout the process, the hospital administration was very forward-thinking in understanding radiologists’ competencies and putting faith in them.

“They were also looking for better ways to do things,” Domalewski says. “For hospitals to survive, facets such as customer, employee, and referring physician satisfaction are being incentivized. The way the management contract is now set up is unique. A baseline level of reimbursement exists for radiologists for the time they spend running the department, and incentive thresholds are provided as well.

“For instance, we are working on decreasing hospital length-of-stay, so we measure how long radiology patients take to get through the system and we incentivize that,” he says. “Historically, we worked with the inpatients at the end of the day and that process did not require doing much to decrease length of stay. Now, at 7 AM, we call all the floors of the hospital to see if there are inpatients that need to be imaged in order to be discharged today. That is a complete shift in mind-set.”

Although from a patient perspective this shift is completely invisible, there have been changes noted in physician behavior.

“There is no longer a perception of ‘This is the hospital’s money and we’ll get them to buy this equipment.’ Now we look at it from a rational decision-making process and if it makes sense we buy it,” Domalewski says. “I think this puts the hospital in a much better position as well, because it can look at the equipment requests and know that they have gone through a lot of thought about whether it’s worth spending the money.”

The bottom line for radiology is up as a result of this shift, so that benefits the hospital as well, Domalewski reports. Referring physician satisfaction results are up dramatically. And Domalewski notes that when radiology asks for additional resources for a new project or piece of equipment, the department now is a credible witness because it is financially vested as well.

“If it is just a new toy, it costs everyone,” he says.

Most of the changes wrought by the management shift are at the employee level. Staffing decisions are now made by the radiologists and as a result of having day-to-day control, the radiology department also has developed a number of innovative employee-focused programs.

“We have set aside money from the budget, which we give to a team of employees to dispense in an employee reward and recognition program. They decide how to distribute that to their peers and their level of creativity has been amazing,” Domalewski says. “Every quarter, these employees host an award ceremony, which is usually structured in a theatrical way, and hand out awards for attendance, compassion, collaborative work, and patient advocacy. We survey our employees every 2 years in a rigorous way and as a result of this particular program and the fact that the doctors and the technologists are part of the same team, satisfaction is up dramatically.”

The most pleasing part about the change to Domalewski has been the ease with which the hospital administration and the radiology department have worked.

“Never once has this process been antagonistic,” he says. “It has been a truly collaborative relationship with the hospital administration. They have been willing to take a risk and now they are looking at ways to replicate the model and tweak it. We have presented this idea at national meetings, and we get calls from interested academic institutions. I think the hospital likes this new model.”

Elizabeth Finch is a contributing writer for Decisions in Axis Imaging News.