Proposal Paper Radiology FINAL

Running head: Proposal for Quality Assessment, Radiology

Proposal for Quality Assessment, Radiology

Aimee Bissonette

Baker College

2Proposal for Quality Assessment, Radiology

Outline

I. Introduction

a. Purpose and Scope

II. Background

a. Munson Medical Center

b. Vision, Mission and Core Values

III. Conceptual Framework

a. Definition of Quality

b. Quality within Radiology

c. Introduction of Baldrige Criteria

IV. Baldrige Criteria

a. Criteria 1, Leadership

b. Criteria 2, Strategic Planning

1. Development of Action Plans

c. Criteria 3, Customer Focus

d. Criteria 4, Measurement, Analysis, and Improvement of Organizational

Performance

e. Criteria 5, Workforce Focus

f. Criteria 6, Operational Focus

g. Criteria 7, Results

V. Implementation Process

a. 10 Steps

VI. Conclusion


Introduction

The purpose of this proposal is to identify, initiate and improve overall quality within the

department of radiology at Munson Medical Center. Healthcare in general is a continuing

process of change over time. Within a healthcare organization there is a presence of dynamic

complexity, which reveals characteristics that must be considered when assessing overall quality.

In our organization, the individual parts that form our departments can affect the system as a

whole especially when considering the level of quality that is delivered to our customers.

Assessing quality in the department of radiology will reveal how one of the individual parts of

the system is contributing to the systems overall mission, vision and values of Munson Medical

Center.

The scope of this proposal will acknowledge the continued need to assess quality, identify

methods to assess and offer suggestions to pursue improved overall quality within the

department of radiology. This proposal will discuss, identify and utilize criteria identified within

the Baldrige Performance Excellence Program. With the use of our current tools, Lean, Six

Sigma, and the Balanced Scorecard, the Baldrige criteria will guide us to use a focused and

systematical approach to performance management that will lead us to results;

Delivery of ever-improving value to patients and other customers, contributing to

improved medical imaging and excellent quality care.

Improvement of overall departmental effectiveness and capabilities.

Organizational, departmental and personal learning (Grizzell & Blazey, 2004)

Munson Medical Center has a history of receiving national recognition for the

extraordinary level of care it delivers. Until this year Munson has been named one of the top 100


hospitals in the nation. Although our organization did not receive this coveted recognition this

year we are still committed to exceptional quality and service. Through these awards and

repeated recognition Munson has earned a reputation locally and nationally as an organization

that dedicates it resources to maintaining and improving the quality of healthcare delivered to our

customers. In order to maintain this reputation Munson must continue to pursue an elite level of

quality across the organization.

Background

Munson Medical Center is a 391 bed non-profit hospital with the only level II Trauma

center north of Grand Rapids, Michigan. There are 420 physicians that make up the medical

staff and over 3,700 employees to deliver excellent quality care to the surrounding community.

Located in Traverse City, Michigan Munson is surrounded by rural areas with smaller hospitals

that depend on Munson’s presence. Munson along with these smaller facilities service 22

counties across northern Michigan. Tight coupling of local hospitals along with Munson offers

the ability to ensure quality and better service to the communities. (Munson, n.d.)

The vision of Munson Medical Center is “connecting northern Michigan with value and

trust in health care” this vision is seen by the extensive relationships between the surrounding

hospitals. Creating a core foundation that fosters trust and leadership among the surrounding

hospitals and communities exhibits Munson’s mission; “Munson Healthcare and its partners

work together to provide superior quality care and promote community health.” (Munson, n.d.)

Munson was first founded in 1915 by James Decker Munson, MD and since that time

Munson has continually strived to remain a leader in quality and earning the trust of northern

Michigan by continually delivering excellent quality care by focusing on its defined core values;


Patients – our first priority

People – our greatest resource for achieving excellence

Accountability – to those we serve and one another

Respect – how we treat others

Stewardship – to continue to meet our mission

Compassion – the way we meet the needs of others (Munson, n.d.)

Conceptual Framework

The mission, vision and core values are expected to be pursued and consistently achieved

throughout the system. In order to access quality within the system, criteria specific to each

department within the system must be identified, established and measured. Lean Thinking and

6 Sigma; Define-Measure-Analyze-Improve-Control (DMAIC) are tools utilized to improve

overall quality. The department of radiology is expected to uphold the same criteria expected of

the entire system. Radiology possesses specific attributes that are unique to the system as a

whole. Acknowledging and understanding these differences that integrates radiology with the

“rest” of the healthcare team deliverance of exceptional quality healthcare will be valuable in the

complete assessment of quality.

In order to assess quality it is necessary to define quality. The Agency for Healthcare

Research and Quality has identified 5 specific problems areas through peer-reviewed research.

(AHRQ, 2002)

Variation in services – although evidence-based practice has evolved it is evident

there is still much variation among regional and smaller areas putting this method to

use.


Underuse of services – people are not receiving the necessary care and suffer because

so.

Overuse of services – people receive healthcare services that are not medically

necessary, increases overall costs.

Misuse of services – people who are injured during treatment.

Disparities in quality – quality affects all populations however with ethnic and racial

minority populations there is marked deficiencies.

Although these 5 areas encompasses healthcare as a whole, they also relate to every service of

care within the realm of “healthcare”. Determining the areas within radiology that contribute to

these factors will assist in improving the entire care given to our customers. In a recent article

“Informatics in Radiology: Measuring and Improving Quality in Radiology: Meeting the

Challenge with Informatics” it identifies three trends occurring within radiology:

Radiology is more visible and central in healthcare delivery

Exponential growth in medical imaging

Imaging in increasingly performed by non-radiologists or by radiologists at remote

locations who may not have access to the same information as local practitioners. (Rubin,

2011)

According to Rubin, “the need for quality assessment and quality assurance in radiology has

consequently moved to the forefront”. Therefore the need to assess and assure quality within

radiology has become a factor in:

1. Utilization – Is there an overuse or underuse of our services?

2. Medical Errors – Do we have a misuse of our services?


3. Patient Safety – Are we committed to patient safety? Are we moving toward evidence-

based practices? (Rubin, 2011)

In order to answer these questions it is necessary to dig deep into the organizations overall

culture and ask self-reflective questions that relate to the principles identified within the Baldrige

criteria. The use of the Baldrige criteria will assist in developing a conceptual framework that

considers key dependent and independent components affecting the system as a whole. Our

Leadership is the hub that identifies the path in which the system is striving to achieve. Within

our system lays the individual parts or departments that must define what is relevant to be

measured and how these measurements can be used to improve overall quality. With the wide

use of imaging services throughout the hospital and its effect on patient’s total care, quality

assurance is a focus with internal and external stakeholders with increased pressure from

regulatory agencies, Centers for Medicare and Medicaid (CMS), payers and professional

societies. (Abujudeh, Kaewlai, Asfaw and Thrall, 2010)


Baldrige (2013)

As identified in the above diagram, Leadership represents the core in which engages all aspects

of the other criteria. Leadership must support the assessment, commit the resources needed and

ultimately utilize the end results to improve and repeat the process when needed. Essentially it’s

a never-ending process that provides continued improvement in overall quality.

Considering the trends identified earlier we must develop questions, seek out the answers

by establishing criteria to measure, and then quantify and analyze the outcomes. Using our

current methodologies, i.e., Lean, Six Sigma and the Balanced Scorecard with pillars that

represent the organizations strategic themes will provide fundamental tools to continuously work

toward excellent quality. The criteria outlined in the Baldrige Performance Excellence Program

and tools already in place will maximize performance and quality.

The Baldrige criteria should not be confused as just another tool but rather a management

system that integrates these tools to maximize our efforts. The tools that are currently in place

Leadership

Strategic Planning

Customer Focus

Measurement

Staff Focus

Process Management

Organizational Results


have provided significant results and pursuing the use of Baldrige criteria should provide the

level of excellence we are seeking as an organization and a department. Let’s consider the core

values that the Baldrige criteria are based on;

Visionary Leadership, Customer Driven, Social Responsibility, Organizational and

Personal Learning, Managing for Innovation, Management by Fact, Valuing Employees

and Partners, Agility, Systems Perspective, Focus on Results and Creating Value, and

Focus on the Future.

Each of these core values are represented within the Baldrige criteria which offers a systematic

approach and methods that will improve overall results. (Grizzell & Blazey, 2004)

Category 1 of Baldrige Criteria;

Identifying Leadership within Radiology

With the conceptual framework in mind, Leadership is the central component that directs

our path. Radiology must know what is expected of us now and in the future. Realizing the flow

of information must go both ways, from leadership to frontline staff and frontline staff to

leadership. Leadership must communicate objectives that reflect factors relevant to;

Legal Compliance, ethics and risks

Conservation of resources

Societal responsibility

Community involvement

Community health related to radiology services


Management oversees these factors and reviews the “whole picture” and is responsible in

identifying trends with the use of key indicators that when measured will reflect a positive or

negative impact. It is necessary to consider resources and how they may be best used for short

and long term needs with staff, technology, suppliers and any other collaboration effort.

(Baldrige, 2013)

Questions that should be considered and answered within this category include;

Who are Leaders and their roles?

How does the regulatory environment affect our services?

What are our strengths and weaknesses, as a department and as individual modalities?

Who are our competitors?

How is technology changing? Are we staying with improvements or are we lagging

behind?

There are detailed Key Performance Indicators (KPIs) directly associated with

Leadership and the remainder of the Baldrige criteria and can be reviewed in the Appendix.

These indicators relate to radiology and should be reviewed and considered as critical

components in answering questions related to each of the Baldrige criteria.


Strategic Plan Identification, Understanding and Implementing within Radiology

Understanding what is included within the organizations Strategic Themes will assist

radiology to create clear and specific goals for the department as a whole. The pillars within the

Balanced Scoreboard for the organization are;


Staff & Physicians

Quality

Customer

Operational & Financial

Growth

Using these pillars as the strategic themes for identifying radiology’s targeted areas; leadership is

responsible in defining objectives and creating action plans. The use of three core process; (1)

Clinical/Medical/Technical Processes, (2) Operational/Patient & Client Flow Processes, (3)

Administrative Decision-Making Processes, is part of total quality. The Baldrige criteria will

contribute to expanding our focus into other criteria that will broaden our scope of overall

quality. Each criterion has specific activities and components that effectively are working

toward achieving the same results and are aligned with overall organization and department

strategic directions. (Kelly, 2011).

According to the strategic dashboard;

1. MHC will promote system-wide quality by developing standards, identifying

measures and improving access, service and outcomes for patients.

2. MHC will improve access & services for patients by meeting inpatient and outpatient

demand.

Considering these statements, what are the objectives of radiology? When identifying

our objectives, creating goals, and action plans consideration should be given to asking

questions and self-reflection that focuses on:

What are our drivers of customer engagement?


What are our patient’s health statuses?

What are our markets and our market share? Where can we expand?

Are we patient focused?

An in-depth review of our operations using benchmarking as a tool

Speed, Responsiveness, and Flexibility

Are we implementing improvement and the necessary learning into our work

processes?

Once leaders have identified objectives, forming goals will be the next step followed by

developing action plans.

Development of Action Plans

1. Identify our resources and analyze specific financial criteria determined useful in goals

and objectives.

2. What are our performance measurements?

3. Are these measurements current for the listed objectives?

As identified in the Baldrige Health Care Criteria; “specific analyses will vary…what are chosen

should help assess the financial viability of our current operations and the viability of and risks

associated with our decided action plans.” (Baldrige, 2013)


Customer Focus


Radiology has multiple modalities that service different types of patients. Our patients

vary in age, ethnicity, generational and financial diversity. Therefore, when defining a patient

within radiology the type of modality that is used must be considered. Each modality is unique

and understanding who their patient is will assist in defining where improvement can be best

achieved. It is important to keep the organizations core values in mind, beginning with “The

Patient – our first priority” (Munson, n.d.)

According to an article in the American Journal of Roentgenology titled “Customer

Service and Satisfaction in Radiology” there are five key factors that affect customers overall

satisfaction;

Reliability – provide the service that was promised and to do so accurately

Responsiveness – the ability assist a customer promptly

Assurance – having the sense of competence and courtesy from the provider

Empathy- caring and attention deserved to each customer

Tangibles – appearance of facilities, technology and accessibility (Alderson,

2010)

Frontline staff is who has face to face contact with patients/customers in the radiology

department they are best able to perceive where issues lay in the patient flow process that may

affect overall quality of care. Enabling or empowering our staff with the ability to resolve issues

during a patient’s service time will assist in ensuring a positive experience, however it is

necessary to discover root causes that lead to unpleasant experiences. Having tools in place, i.e.

patient surveys, for our staff to hand to patients directly after their procedure/scan will improve


the quality of feedback received. Patient surveys should consist of relevant items pertaining to

radiology in general.

A methodology that the system has incorporated within the strategic theme of “customer”

is the use of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS).

Structuring a short and simple survey that focuses on a specific question that target an area of

low satisfaction reflected within the hospital wide surveys will assist radiology in determining;

a) Is it a problem area specific to radiology?

b) If it is discovered to be an area of concern – what processes need to be reviewed and

structured to achieve increased patient satisfaction?

For the current fiscal year, system wide HCAHPS focus has been Noise, identified under

question 9 of the 27 question survey. The question states: “During this hospital stay, how often

was the area around your room quiet at night?” (HCAHPS, n.d.) As some may be quick to

assume that noise is not a problem within radiology, however as staff how can we be assured it is

not? Therefore it is necessary to ask the patient. Including a question regarding noise level with

a radiology-specific survey will determine the importance of this problem and if it is necessary to

set a goal and action plan.

Radiology is a vital component of the healthcare team, understanding our customers’

uniqueness will contribute to building strong customer relationships, what we do for one patient

may not always be right for another. Since the patient/customer mix varies within radiology it is

necessary to establish methods for customer’s feedback, suggestions and complaints. How we

collect this information may vary within the department however it all must have the ability to be

measured and analyzed.


What methods are employed to enrich customer relationships within radiology?

What methods are utilized to receive customer feedback?

Can these methods be standardized?

What are the KPI’s for patient feedback?

Category 4 of Baldrige Criteria:

Measurement, Analysis, and Improvement of Organizational Performance

Radiology has much it can quantify, identifying the items that are most useful to obtain

the necessary information to understand our needs and priorities, stretch our goals and promote

major improvements is key. According to a recent article found in RadioGraphics authors,

Abujudeh et al, discuss the importance of incorporating KPIs specifically geared toward

radiology. Radiology specific indicators may align with the organizations key indicators

however there are others that are unique to radiology. The author’s state;

Defining radiology-specific KPIs should be a collaborative effort of the radiology

department and the hospital administration…Priority should be given to the KPIs that are

considered by both the hospital and the radiology department to align most closely with the

institutional strategy and vision. (Abujudeh et al., 2010)

As a department the different modalities must work together to establish specific KPIs.

Abujudeh et al explains in great detail the importance of performance indicators and identifies

four specific strategic areas with corresponding committees.

Patient Safety and Quality of Care – Relates to Baldrige Criteria within Leadership and

Governance and Workforce Processes


Customer Service - Relates to Baldrige Criteria within Customer Focus

Operations Management – Relates to Baldrige Criteria within Radiology Processes and

Workforce Processes

Financial Management – Relates to Baldrige Criteria within Financial and Market

Results

Breaking these four categories down to specific KPIs as Abujudeh et al has done (refer to

Appendix) will assist in the components outlined in the Baldrige criteria. There are specific

areas that must be considered when measuring and analyzing data. According to Baldrige

Criteria;

The use of Comparative Data

- Identify where we stand relative to our competitors

- The use of benchmarking will provide the impetus for significant

improvement or change

- Comparing our performances frequently will lead to better understand of our

processes and performances

- Projecting comparative performances will assist in identifying our

department’s advantages and reveal problem areas where innovation is most

needed.

Selecting and Using Comparative data

- Identify our needs and priorities

- Establish criteria for comparisons

- Use data and information to stretch goals

Reviewing Performance


- Review of current and future performance, translating the information into

action plans, this is tied to our key objectives, core competencies and

measures of success.

Analyzing Performance

- What analyses are we currently using? Are they providing us a clear

understanding of performance and needed actions?

Aligning Analysis, Performance Review and Planning

- Are we aligning all of our work between analyses, performance and

planning?

Understanding Causality

- As a department we must understand how processes affect other processes

and results. Changing one action can contribute to other implications.

(Baldrige, 2013)

The ability to know and understand why and what we select to measure for performance

measurement will support departmental planning and improvement. The use of measurement

and analysis through benchmarking is an essential component of assessing our overall quality

within radiology.

Please refer to the Appendix for an in-depth review of specific key indicators and metrics

that correlate with each. These key indicators are divided into categories that reflect those

detailed under Baldrige criteria category 7 of Results.


Workforce Focus


This criterion focuses on how we empower our employees to assist the organization in

delivering optimal healthcare. In an article titled, “Create a Work Environment That Encourages

Employee Engagement”, author Sally Heathfield states; “engaged employees are more

productive, customer-focused, and profit-generating and employers are more likely to retain

them.” With this statement in mind, leaders within radiology must commit to engaging our staff.

However we must have staff that desire to be engaged. Our staff must possess a strong work

ethic, current employees and those hired in the future. Author Erin Schreiner states; “People

who possess a strong work ethic embody certain principles that guide their work behavior,

leading them to produce high-quality work consistently and without the prodding that some

individuals require to stay on track.” (Schreiner, n.d.) According to Schreiner a strong work ethic

can be identified by five characteristics;

1. Reliability

2. Dedication.

3. Productivity

4. Cooperation

5. Character

These characteristics will be seen throughout an employees work. Factors that display these

characteristics are integrity; the building of trustworthy relationships, sense of responsibility;

owning their job, personal responsibility and level of work done, emphasis on quality; the ability

to produce exceptionally quality work, discipline; the ability to stay focused and complete a task

successfully, and finally last but not least the sense of teamwork; working together to obtain

goals and deliver quality work. (Jenkins, n.d.)


If we expect our employees to possess these qualities we must foster an atmosphere that

will allow our staff to be engaged and feel confident in their choices. There are specific methods

to create a work environment where employees are engaged. Keeping our employees engaged

all the time, expect accountability and measure their outcomes of performances, focus on results,

and the goals for radiology should align with the goals of the employee. “Most importantly

employment engagement is alive and fruitful when the department is committed to leadership

development in performance development plans that are performance-driven and offer

succession plans.” (Heathfield, n.d.)

The systems strategic themes related to workforce can be identified within the pillar of

staff & physicians which include;

Employee Turnover

RN Turnover

RN Vacancy

Reflecting the main pillar of the system radiology’s turnover rate currently is not necessarily a

concern. Understanding the factors that contribute to low turnover rate could lead to be useful

knowledge in future years. Inquiring and understanding our employee’s goals, aspirations, and

overall satisfaction will be determined by reviewing employee reviews and employee

engagement surveys.

The word radiology is a word that is most commonly used to describe any procedure

done within the department of radiology. Each modality represents a team and each team

represents radiology as a whole. Our focus in radiology must be establishing criterion that

focuses on the entire department, breaking down the barriers among modalities, crossing the


lines to engage in relationships outside of each other’s modalities. As a department we must be

aware of these invisible walls that are built between modalities and converge on methods that

will harvest integration with one another.


Operations Focus

This criterion reviews our key imaging services and the work processes within the

radiology department. How do our processes integrate with overall quality and the delivery of

care within the organization? These processes include activities related with;

1. Patient care - patient flow, scheduling and tracking

2. Materials Management – Consumables and resource management

3. Function – Activities and sub processes

4. Operations – Equipment application systems, devices and tools

5. Information – Data, documents and data models

6. Organization – Human Resources, staff, roles, and organizational models

7. Location – Rooms and work places

8. Flow – Sequences of activities, and process models

9. Control – Rules, regulatory, accreditation functions, political, economic, and time

constraints (Wendler & Loef 2001)

Utilizing the Six Sigma DMAIC process will assist radiology to dig deeply into rooted causes

that create the highest impact problems. Essentially it can be used to improve one process or

scaled to attack a department wide problem. Using Six Sigma will “enhance the

predictability of positive outcomes whether clinical or operational…the approach is flexible


and saleable” (Cherry & Seshadri, 2000). Although Six Sigma is utilized throughout our

organization integrating it into radiology processes will take the initiative of leadership, staff

and customer feedback to identify workflow and processes that are faulted. Consider a

“work-flow” as “the automation of a business process, in whole or part, during which

documents, information or work items are passed from one participant to another for action,

according to a set of procedural rules” (Wendler & Loef 2001)

The systems strategic themes related to Operations can be identified within the pillar of

Operations & Financial which include;

Fundraising

Labor Cost as % of Net Operating Revenue

Operating Margin %

Operating Income

Net Operating Revenue per Adjusted Discharge

Medicare Traditional Case Mix Index

Considering these system wide pillars, radiology has specific operational/financial indicators that

must be tracked and shared with senior leadership. Are we tracking the accurate information?

Are we cost conscious? Is our work area “safe”? Is our technology advanced where we are

providing the best service with the best use of resources?


Results


The final criterion includes the scrutinizing of our results from measurements of our

KPIs. These KPIs are referenced in the Appendix and classifies the KPIs by criteria. These

measurements take into consideration the uniqueness of radiology and represent the relationships

between customer focus, workforce, financial/market performance and radiology

quality/performance/processes.

The strategic theme related to results would be the entire balance scorecard, however if

the system is continually striving for excellence it will most notably be reflected under the pillar

of Growth. The items identified to be measured within the pillar of growth for system wide

measurements do not bare relevance to radiology. However, it is necessary to be diligent in

measuring and determining where growth is or is not occurring within the radiology department.

It could be suggested that the development of a balanced scorecard specific for radiology

containing useful and interdependent KPIs would contribute to continuing quality and

performance improvements.

Ultimately our results will reflect the overall use of tools implemented into our workflow

processes. The use of Lean thinking and the application of Six Sigma to improve our overall

quality will provide results to determine if we are more competitive, more effective, and if we

are using our results in essence to devise improved strategies, that lead to action plans that

quantify desired outcomes.

Implementation Process

Radiology plays an important role in the complete delivery of healthcare. Medical

imaging accounts for 7.5% of health care spending in the United States. Considering the costs

alone it is necessary to assess our own radiology department with Lean thinking and the use of


Six Sigma with more deeply rooted issues or problems. The use of Lean Thinking and Six

Sigma are tools that can breed results that will contribute to improved overall bottom line.

However, healthcare in general isn’t only concerned about costs, it is necessary to consider the

operation as a whole and the quality provided. In order to utilize tools that will assist in

delivering desired outcomes, utilizing the Baldrige Criteria will provide an assessment of our

current system and determine the maturity and effectiveness of our current management system.

According to Baldrige.com there are 10 steps to implementing the detailed criteria. The

first is determining our requirement; internal assessment, apply for a state/local award or

Baldrige Award Application, next is determining internal, external or internal/external combo for

production and support. The second step is to decide our process; this step is the determination

of who will be involved, when assessing will take place and for how long. Step three is

allocation of resources, support, research, writing and editing. These duties take hours and

appropriate persons need to be trained and relieved of other duties during the assessment period.

The next step is planning the research, understanding each criterion, identify who is best to

answer specific questions, be organized, determine an interviewer and finally set-up the

interviews. Do the research is step five and includes just that, take the time and do the research

with results that are relevant. The following step is writing responses most of these responses

will link with one another, with the final criteria involving graphs, benchmarks and goals for the

KPIs we discussed in criteria 1-6. Step 7 is refining of the assessment, allow team members to

critique. The next step involves evaluating the assessment obtaining an unbiased perspective can

breathe a fresh perspective into the assessment. The ninth step is acting on the evaluation, the

list of opportunities for improvements, prioritizing these opportunities, developing action plans


and tackling them. Finally, plan the next assessment, ideally this is an ongoing process, with re-

assessments, re-evaluations, that lead to continual improvement. (George, 2013)

Conclusion

Radiology is an ever-changing field with advances in technology, procedural, and

workflow processes. Considering the multiple medical imaging tests performed within the

different modalities, the need to assess overall quality is not a choice but rather a necessity to

determine if we are meeting goals and objectives related to our customers, employees, operations

and the strategic plans outlined by senior management.

Using the Baldrige criteria to assess the overall quality will lead our department to

improved performances that will breed desired outcomes/results. The Baldrige Criteria is

identified as a systems-based approach that offers the ability to improve practices, processes and

results. If these objectives are met, it could only contribute to the overall strength of the

organization. The radiology department is a critical component of the overall healthcare delivery

team within the organization. Identifying our leadership, understanding what our organizations

goals consist of and how radiology coincides with those, and what our customer’s requirements

are will assist in developing a culture of excellence throughout the radiology department.

The use of the Baldrige Criteria for a self-assessment will provoke all of us to become

involved with the answering of the specific questions identified within the assessment. We will

identify those areas we excel in and those we don’t; hence realizing there is room for

improvement. Improving areas that we are lacking will contribute to overall organizational

performance excellence. It is necessary to understand that the Baldrige criteria is not another

tool or a set of mandates of how we should proceed with our services, rather it consists of self-


reflection that allows identification of processes currently are intact and where improvement is

needed in order for our department to excel.

Our radiology department along with our organization as a whole already utilizes tools

that are identified as useful resources in Baldrige-based Culture. “Waste is eliminated from

processes through Lean Thinking, processes are moved toward perfection using Six Sigma, and

progress is measured using a Balanced Scorecard to assess results” ( Grizzell & Blazey, 2004).

With these tools already in place across our organization a self-assessment utilizing the Baldrige

criteria will be provide our department with answers to the specific questions asked that will lead

us to increased overall quality for all of our customers.

Consideration should be given to the multiple changes forthcoming with the

implementation of the Patient Protection and Affordable Care Act (PPACA) and the importance

of self-assessing and assuring excellent quality in every facet of our organization. Variables

change regularly including patient’s expectations, competition, reimbursements, technology, and

standards within quality oversight organizations. As a leader within Radiology the choice to

pursue self-assessment utilizing the criteria identified throughout this paper will offer the ability

for our department to take the next step toward excellent quality for our organization and most

importantly our patients. By utilizing a performance management system such at the Baldrige

criteria will allow us to maintain our organization’s position in the community’s view and an

edge above the competition that has recently entered our large service area.

If the use of the Baldrige criteria to access quality is decided, the process of

implementation should be utilized to ensure maximum effectiveness. Implementing the use of

the Baldrige criteria to assess total quality within the radiology department will take initiative,


support and appropriate resources allotted from senior leadership to frontline employees. Even

though radiology is just a part of the whole, if each department within our system can grasp and

pursue the use of this performance management system to improve department wide processes,

the ability to contribute to improving overall system wide quality will be a continuous process

that becomes embedded into our workflows and culture.

References

Alderson, P. (2000) Customer Service and Satisfaction in Radiology. American Journal of Roentgenology, 175(2), 319-323. Retrieved from http://www.ajronline.org/doi/full/10.2214/ajr.175.2.1750319

AHRQ. (2002) Improving Health Care Quality: FactSheet 2002. Agency for Healthcare Research and Quality, Rockville, MD. Retrieved from http://www.ahrq.gov/research/findings/factsheets/errors-safety/improving-quality/index.html

Abujudeh, H., Kaewlai, R., Asfaw, B., Thrall,J., (2010). Quality Initiatives: Key Performance Indicators for Measuring and Improving Radiology Department Performance. RadioGraphics, 30,571-580. Retrieved from http://radiographics.rsna.org/content/30/3/571.full

http://www.ajronline.org/doi/full/10.2214/ajr.175.2.1750319


Cherry, J. & Seshadri, S. (2000) Six Sigma: Using Statistics to Reduce Process Variability and Costs in Radiology. Radiology Management,2000, 42-45. Retrieved from http://www.certificationxpert.com/files/expertise/sigmadiology.pdf

George, S. (2013) 10 Steps to an Effective Baldrige Assessment. Retrieved from http://www.baldrige.com/baldrige-process/10-steps-to-an-effective-baldrige-assessment/

Grizzell, P & Blazey, M. (2004). Alignment of the Malcolm Baldrige Criteria for Performance Excellence with Six Sigma, Lean Thinking and Balanced Scorecard. Retrieved from http://www.studergroup.com/content/tools_and_knowledge/baldrige_resources/files/BaldrigeSixSigmaalignmentdistcopy(healthcare).pdf

Baldrige. (2013). 2013-2014 Baldrige Criteria for Performance Excellence, Category and Item Commentary. Retrieved from http://www.nist.gov/baldrige/publications/upload/Category-and-Item-Commentary_BNP.pdf

HCAHPS. (n.d.) Appendix D CAHPS Hospital Survey (English). Retrieved from http://www.hcahpsonline.org/Files/Appendix%20D%20-%20CAHPS%20Hospital%20Survey%20(English).pdf

Heathfield, S. (n.d.) Create a Work Environment That Encourages Employee Engagement. Retrieved from http://humanresources.about.com/od/Employee-Engagement/qt/Employee-Engagement.htm

Jenkins, A. (n.d.) Five Factors that Demonstrate a Strong Work Ethic. Retrieve from http://smallbusiness.chron.com/5-factors-demonstrate-strong-work-ethic-15976.html

Kelly, D. (2011). Applying Quality Management in Healthcare: A Systems Approach. (3rd ed.) Chicago. Health Administration Press.

Munson. (n.d.) Mission and Vision. Retrieved from http://www.munsonhealthcare.org/?id=30&sid=2

Rubin, D. (2011). Informatics in Radiology: Measuring and Improving Quality in Radiology: Meeting the Challenge with Informatics. RadioGraphics,31, 1511-1527. Retrieved from http://radiographics.rsna.org/content/31/6/1511.full

Shreiner, E. (n.d.) Five Characteristics of a Good Work Ethic. Retrieved from http://smallbusiness.chron.com/five-characteristics-good-work-ethic-10382.html

http://www.nist.gov/baldrige/publications/upload/Category-and-Item-Commentary_BNP.pdf

http://www.nist.gov/baldrige/publications/upload/Category-and-Item-Commentary_BNP.pdf


Wendler, T. & Loef, C., (2001) Workflow Management – Integration Technology for Efficient Radiology. MedicaMundi 45(4), 41-48, Retrieved from http://www.healthcare.philips.com/pwc_hc/main/about/assets/Docs/medicamundi/mm_vol45_no4/MM_45-4_Workflow.pdf

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Appendix

Information below highlights specific areas identified throughout the Baldrige criteria that should be considered for tracking, measuring, analyzing, and reporting. Radiology contributes different attributes to the system as a whole, understanding this will assist in determining what, how and when information should be gathered, reviewed and reported. The information provided was gathered in a recent article referenced within this proposal. The information provided was arranged differently within the context of the article cited however offers a wealth of information for our uses within the radiology department. Data derived from Abujudeh et al, 2010.

Baldrige Identified

Results/Strategic Area/Committee

Duties Key Factor/Related KPIs Metric Suggestions

Radiology Processes Results/KPIs

Utilization Measures of

operations with the department

Information technology Measures

pertaining to state of information technology.

Resource utilization and productivityEquipment idle time, Equipment utilization, Equipment staffing levelProfessional staff productivity, Technical staff productivity

Informatics supportDowntime, Data integrity, Service provisionResources used, Technology replacement and project management

ResourcesEquipment quality, availability, diversity, staffing levels

% of time when equipment is unavailable due to unscheduled downtime

Ratio of # of hours available to # of hours in use Ratio of # imaging staff to # number of machines # of reports generated (RVUs) per full-time radiologist # of examinations performed (RVUs) per full time technologist Hours of schedule downtime for maintenance, total time of

unscheduled downtime # of instance and volume of lost data or images # of different systems and # of users supported, volume of data

managed, # of appropriate/inappropriate service calls filed, average delay in response to service call

Avg. age (months) in major imaging and IT systems, # of late-generation imaging devices, variance in # of hours of scheduled maintenance per manufacturer

Machine downtime not due to scheduled maintenance # of machine manufacturers represented Ratio of imaging staff to imaging machines

Customer Focus Results/KPIs

Establish and review existing and potential measures that pertain to patient, employee, and system-wide satisfaction with service provided

Patient surveys Physician yearly

surveys /complaints

Patient experienceOutpatient service, access, safetyInpatient service

Referring physicians and their staffSatisfaction, Report turnaround time, Comments

PatientsSatisfaction, Outpatient access, Comments

Survey of patients receiving pre-appointment exam info and education, measurement of waiting time from patient arrival to beginning of exam, measurement of appointment delay from scheduled exam time to beginning of exam, outpatient report turnaround time

Appointment availability # of incidents resulting in patient injury Inpatient report turnaround time, inpatient imaging turnaround time Survey of referring physicians, survey of their staff Outpatient report turnaround time, inpatient report turnaround time # of complaints, requests and compliments received by telephone or

emailLeadership and Establish and review

existing and potential Employee development % of jobs with competency-based assessment, % of staff who have

completed competency assessment, % of staff who meet or exceed

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Governance Results/KPIs

measures that directly and indirectly pertain to patient safety.

Patient fallsHand hygiene

Innovation Measures of

developing of new programs and initiative

Education Measures

reflecting department-provided training and credentialing with clinical and nonclinical staff

Research Measures

pertaining to research activities

Licensing and certification, Education access and useApplication and transfer of knowledgeEmployee empowerment

Patient SafetyCompliance with directives, Policy formulationIncident reporting

DiversityFunction, Age, Ethnicity , Level of education

Continuing EducationAccess and Utilization

Harassment-free work environment

continuing education requirements, % of staff licensed (ARRT, NMTCB), % of staff with a master’s degree, % of divisions with a Technologist III, % of clinicians with a PhD

# of courses or training sessions request and delivered, # of training seats available, % of training seas filled, % of staff attending training courses

% of courses with measured outcomes, % of course evaluations completed, # of academic papers written and published, # of presentations delivered internally and externally, % of fulltime staff who are preceptors, % of fulltime staff who are student mentors.

# of staff who have moved to new positions or roles within the institution, ratio of avg # of active council members to total # of staff, # of percentage of non-managerial staff in leadership positions on strategic councils, # of suggestions from staff, # of process improvement initiatives undertaken and # of those completed.

# of new quality and safety projects completed, rates of compliance with JCAHO and HIPAA requirements and institutional policies

# of new or updated quality and safety policies, avg age of policies, age of oldest active policy

Total number of incident reports Patient satisfaction with quality and safety of care # of teams or projects including representative of 3 or more areas of

function Age measured in years as the mean and standard deviation across the

department Demographic variance from the population served % of radiology department staff with each academic degree, compared

with % of staff with the same degree in other departments of the hospital

Comparison of annual number of reported incidents or complaints of harassment with national statistics

Annual numbers of course and training programs offered % of staff participating (department wide and per modality)

Financial & Market Results/KPIs

Cont. Financial & Market Results/KPIs

Measures pertaining financial management within the department and growth.

Net IncomeRevenue, Expense

Variance from budgetRevenue. Expense

Fiscal efficiencyEfficient use of labor and assets

Billing effectivenessTotal rejections, Effectiveness of precertification process

Demand generation

Measure of total amount billed, measure or estimate of total amount reimburse

Measure of fixed costs, measure of variable costs, and measure of costs due to errors

Variance between actual revenue and revenue line in budget Variance between actual expense and expense line in budget Ratio of total labor costs to total revenue Net return on total assets Total amount of bills rejected by insurers Difference between cost of precertification and revenue collected for

pre-certified examinations Numbers of new referring physicians recruited inside and outside an

institution Total # of current referring physicians inside and outside an institution Total # of referrals from all physicians

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No. of new referrers, Total no. of referrersDemand generated, Effort expendedAnalyses and forecastsEffort expended, Quality

Total # of initiative undertaken to increase demand and awareness # of analyses and forecasts provided Deviation of actual results from forecasts provided, # of analyses used

by management

Workforce Focused Results/KPIs

Clinical PerformanceDepartment wide success ratesModality success ratesCommunication with referring physicians

Compensation and recognitionRecognition of performance excellenceActual and relative pay scales

Work-life BalanceVacation utilization, WorkloadCommute, Variety of work

ParticipationStaff influence on department governance

Attrition and retentionStaffing Level. Continuity of StaffingStaff turnover

Employee Satisfaction

Peer review of image interpretation by staff, correlation of radiologic findings with pathologic findings, complications rate

False-positive rates, peer review agreement rate, % of examinations with unnecessary recommendations

Audits of email alerts sent to physicians, rate of compliance with standardized protocols, and rate of compliance with report quality standards

# of vacation days available, ratio of vacation days used to days available

Avg. overtime hours worked/employee Avg. hours spent commuting to work/employee Avg. # of different examination types performed by technologist Unique count of council members % of full-time positions not filled by full-time employees # of temporary employees divided by total # of positions, avg. years

of service Attrition rate (number of staff who retired, resigned or died in the

previous year Numeric rating on a scale of 1-10

Proposal Paper Radiology FINAL

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