“Mammography is a loss leader, particularly screening mammography.”
“We have a 13-week backlog of screening appointments and can’t seem to make any headway.”
“We seem to be perpetually short of mammography technologists.”
“We schedule screening mammograms at 30-minute intervals and we are still off schedule by the afternoon.”
The foregoing comments are common at the nation’s more than 10,000 licensed mammography sites. Although they may seem unrelated, there is a common thread that ties them all together. That common element is the productivity of the mammography technologist. This article will discuss productivity with respect to screening mammography and demonstrate techniques that will allow radiology practices or breast centers to successfully answer all of the challenges posed by the preceding comments.
Productivity is a business term that is not often utilized in medicine. The reason, it may be surmised, is that the word productivity conjures up visions of assembly lines and the like, a vision that is not consistent with the traditional view of highly individualized medical care. Stripped of the factory connotations, however, productivity, as the term is commonly used, is simply the quantitative measure of how effectively the resources of a given process are being utilized. Health care, in fact, routinely uses productivity measures in several areas (eg, staffing ratios, operating room turn time).
Productivity measurements are meaningless without contextual reference. There is no value, for example, in knowing that the staffing ratio for a given nursing unit is 5.2 beds/nurse, without knowing the acuity of the patients on that unit. By the same token, a productivity measure has value only when its inputs are analyzed and optimized. A 30-minute screening mammogram, for example, is neither good nor bad. It is merely a starting point for further analysis.
Influences On Productivity
In the analysis of productivity, it is necessary to look carefully at all of the elements that constrain it. Because productivity is essentially the measurement of production per unit of time, this process requires that each of the resources of production be examined for its limitation on productivity. In the case of screening mammography, primary attention focuses immediately on the equipment/room and the technologist. When looking at these separately, it is immediately clear that the mammography equipment is not a limiting factor (within reason) because it is technically possible to produce a screening film series in 5 minutes or less.
Turning one’s attention to the technologist, it becomes quickly apparent that the patient throughput, or time that it takes to deliver the care for which the patient has made the appointment, in this case the screening mammogram, is the direct function of: (1) how effectively the technologist performs her assigned tasks; and (2) what tasks the technologist is assigned. It is clearly impossible to deliver a 15- or even 20-minute mammogram if the tasks to be performed by the technologist take 30 minutes.
The operative phrase in the preceding paragraph is “assigned tasks.” It is important because the next requirement of productivity analysis is to closely examine these tasks in comparison to the tasks that only the technologist may perform. The following is a list of tasks that are commonly performed by the mammography technologist:
- Greet the patient in the reception area and accompany her to the dressing area;
- Move the patient from the dressing area to the mammography room;
- Take the patient’s breast history;
- Remind the patient of the importance of breast self-examination and an annual clinical breast examination;
- Position the patient;
- Expose the mammograms;
- Accompany the patient back to the dressing area;
- Develop the films;
- Notify the patient that she is free to leave;
- Hang the films for the radiologist to read;
- Stock the dressing areas with gowns and remove soiled gowns (shared);
- Stock film supplies (shared);
- Clean the break room; and,
- Pull films for the following day’s appointments.
The three tasks that are presented in italics are the only ones listed that require the level of technical training and, not coincidentally, the compensation of the mammography technologist. If responsibility for the balance of these tasks can be shifted to more appropriate personnel, the technologist’s time per screening mammogram can be reduced. Because less time is required, the cost per examination is decreased. Table 1 illustrates the effect of decreasing the screening interval, or appointment time, from 30 minutes to 15 minutes in a facility that dedicates three mammography units to screening.
Note in Table 1 that all costs have been kept constant except: (1) three medical assistant full-time equivalents (FTEs) have been added to assist the technologists; (2) two more clerical FTEs have also been added to assist with additional filing volume, etc, at the increased capacity; and (3) variable costs (eg, film, developer, laundry, supplies, etc) have been increased to reflect the higher utilization volume at capacity. Compensation rates were estimated at $21/hour for mammography technologists, and $9/hour for clerical/medical assistant FTEs. Benefits are assumed to be 25% of payroll costs. It should also be noted that this is an efficient department and that, while occupancy costs are included in Other Fixed Costs, there is no overhead allocation of marketing or other costs that might be allocated in a hospital or private radiology practice.
The projected savings of $15/screening mammogram is the functional equivalent of an increase in the Medicare reimbursement rate for screening mammography from its current rate of $66 to $81. That is an increase of almost 23%, well beyond the dreams of even the most optimistic physician or administrator. The projected savings also carries no additional collection cost, is not subject to any withholds or co-pays, and accrues at the time of service, not payment.
It should be evident that before the process of changing the paradigm for screening mammography can begin, it is necessary that the practice or department know and understand its costs. A full discussion of cost analysis is beyond the scope of this article; however, it involves basic accounting principles and can be accomplished without undue effort.
Before proceeding, it should be noted that the projections are given for fully productive mammography units. In the 30-minute paradigm, this assumes that 15 examinations are performed in an 8-hour period, and in the 15-minute paradigm, 30 examinations are performed. One-half hour per day per mammography unit/technologist is allocated to quality assurance.
As important as the projected savings per mammogram are, the increase in capacity will be more important to many practices and departments. Most of the mammography programs reviewed by the author have current scheduling backlogs for screening mammograms of 8-12 weeks, and the popular press has reported delays of 8-12 months in one popular program. Delays of 4-plus weeks begin to impact the ability of women to comply with the recommendation of annual mammography, and it can readily be argued that extended delays in scheduling may result in women becoming completely noncompliant by missing an annual mammogram. At best, these restrictions on access constitute bad service; at worst, they are an active disservice. Programs that increase scheduling convenience will find that the new capacity is rapidly absorbed by new patients as well as returning patients.
Capacity is found through productivity gains, or it is built. Adding capacity in screening mammography in the conventional fashion is especially difficult because it entails adding physical space, additional technology, and a qualified mammography technologist, with the latter being the most formidable task in many communities. Add to these obstacles reimbursement that is often below cost and adding capacity is not in the plans for most practices and departments. Increasing the sense of urgency, many of the mammography units now in use will no longer meet Mammography Quality Standards Act requirements as of October 28, 2002. (Full text of MQSA regulations can be found at www.fda.
gov/cdrh/mammography/frmamcom2.html.) Further implementation of the Final Rule on that date will require either that the equipment be replaced, or that its capacity be replaced. Becoming more productive allows the capacity to be replaced without the cost of new mammography equipment.
Stop!!
After one reviews the numbers, the benefits of increasing productivity in screening mammography are so apparent that the first impulse is to immediately begin scheduling screening appointments on a 15-minute cycle time. After about 6 months, programs that have tried this approach typically begin to wonder why they are losing staff, and a few months later they are concerned that they cannot hire or retain staff.
The first step in the quest for screening mammography productivity is a thorough analysis of the process of delivering a screening mammogram from the scheduling call through the delivery of the report: who is doing what and how long is it taking them? While most of the focus will be on the tasks currently being performed by the mammography technologist, it is important to view the entire process as a continuum and each task from the perspective of who can best and most cost-effectively perform that task. Other potential savings will often become evident during this process.
The analysis must not be judgmental in any way. Some passive-aggressive behavior is to be expected — do not feed it. Always remember that the result being sought is not more work out of anyone, it is to find ways to facilitate more productivity. There is a huge, but sometimes misunderstood difference. Physicians and administrators must be very supportive during this process. It is especially helpful to commit, in advance, to hiring such additional support personnel as may be needed.
A word of caution is in order with regard to salary schedules. The mammography technologist who was paid market rate and producing one screening mammogram every 30 minutes will be underpaid when she is producing a mammogram every 15 minutes. Productivity increases generate substantial revenues and these should be shared with those who make them happen. This proposition makes sense not only philosophically, it is good business. Mammography technologists are highly skilled and in great national demand. Remember that productivity leverages the talents of people and the capacity of equipment. Therefore, the only real downside of increased productivity is the increased impact of downtime. If only the savings from the 15-minute schedule are considered, each day it takes to replace a technologist costs $450. By contrast, increasing the salary rate by a total of $2/hour only increases the cost per mammogram by slightly more than 50 cents.
Increasing mammography productivity is a process that must involve all of those affected as participants. To be effective, each participant must understand the new vision for care, and participate in development of the mechanisms for realizing that vision. Tasking must not only be carefully analyzed, but technologists should also be a part of the process of defining work roles, not only for themselves, but for the medical assistants that will assist them by performing some of the tasks that the technologists currently perform. It is unreasonable, for example, to expect a technologist to accept development of films by a noncertified assistant, unless she has provided input into the training and quality assurance specifics required for that position. The participatory process creates significant collateral benefits in the enthusiasm that comes from employee ownership of the vision of care.
Increased productivity also involves the professional side of the practice or radiology department. It does no good to create a 15-minute cycle time if the practice standard is that a radiologist will read each film before the patient is released. Likewise, a screening mammogram is a screening mammogram. Extra views are not taken, nor are films reviewed for other than technical quality before the patient is released.
While the foregoing may seem like a diminution of quality for programs that now provide reading of screening mammograms before the patient leaves the office, this is not the case. Screening mammography patients are, by definition, asymptomatic. Less than 1% of these women have breast cancer and less than 10% of those screened should require further diagnostic testing. Screening mammography patients are primarily interested in: (1) perceived quality; and (2) on-time appointments. It is difficult to deliver on-time appointments within the 30-minute screening paradigm if additional views are taken, and it is impossible with shorter cycle times. Thus, to accommodate those few patients who will need additional views, the majority of patients will perceive the poor service of a late appointment.
Screening mammography is a wellness procedure, conceptually much like a pap smear. Test results are expected to be normal, and the patient expects to be promptly notified if there is any concern that would prompt further diagnostic efforts. This expectation can be readily met through batch reading of screening mammograms. In a batch reading paradigm, current and the prior year’s films for a group of patients are loaded on a motorized mammography workstation for interpretation and reporting at one, uninterrupted sitting. Batch reading is highly effective clinically, giving the physician the opportunity to focus completely on the subtleties of the screening mammogram, and it is also highly effective financially, as the physician can read and report each patient in 30-60 seconds. This translates to revenue production of approximately $1,300-2,500/hour, with a professional revenue allocation of $22/mammogram (computed at 1/3 of the Medicare reimbursement rate). Professional productivity on this level compares favorably with other radiology procedures.
Political Considerations
As with almost everything in medicine, there are political considerations that must be addressed as a part of the reengineering process. Change is never easy, and the process described herein involves fundamental change. Whenever change affects the relationships between people, the realignment is called politics, and the past always has the largest constituency. This is natural and should not be confused with outright rejection or obstruction. The vision is much harder for many people to see than the status quo and, however appealing the potential financial and service quality gains appear, the prospect of moving from the known to the unknown is difficult. It is often helpful to bring in outside consulting help to assist with the evaluation and to facilitate the process. Consultants in this area can bring not only expertise, but experience with similar problems and new solutions in similar circumstances across the nation. Such help often can save considerable time and money by identifying and resolving potential political and other issues that would otherwise delay or derail a program in its efforts to redefine the delivery of care.
Conclusion
Reengineering breast radiology to optimize productivity is complex but achievable in all practices and radiology departments. Its basic requirements are: (1) commitment by administration and physicians; (2) a process of evaluation and work design; (3) implementation; and (4) commitment by administration and physicians. Yes, the first and last of these requirements are the same. This is to emphasize the continuing nature of the commitment that is required until the vision becomes realized. Once the vision of cost-effective care is realized, screening mammography will come out from under the cloud of being considered a loss leader and the process will become natural. The new status quo will be effective for patients, satisfying for employees, and profitable for the radiology practice or department.
The analysis process through which the screening mammography paradigm is changed will develop a set of numbers, similar to Table 1, whereby the before and after cost of a mammogram can be compared. This provides a running target whereby all involved have a way of knowing how well they are doing in achieving the new vision. Using the 15-minute interval template, 15,000 mammograms times $15 is $225,000. Loss leader? Hardly.
Gerald R. Kolb, JD, [ [email protected]] is CEO of Breast Health Management Inc, Bend, OR.
