Radiology and the Patient Experience: Oxymoronic or Exigent?

The Hospital Consumer Assessment of Healthcare Providers and Systems, or HCAHPS, survey—now driving a portion of hospital revenue—touches radiology only tangentially, so it would be convenient to leave the patient experience to someone else. That was not the path of the University of Michigan Medical Center (Ann Arbor), which began exploring the idea of patient experience about five years ago, under the leadership of Ella Kazerooni, MD. The radiologist became interested, at the time, in the idea of service excellence, but discovered that the subject of patient satisfaction became controversial very quickly, in the setting of radiology.

“It’s easy to put in questions to patients (and their families and visitors who come with them) about the operations of the experience and the way that they were treated,” she notes. “There are other elements of the patient experience, though, that the radiology community may feel less comfortable with, such as the availability of radiologists to speak
to patients if they have questions about an exam.”

The medical center was considering an institution-wide service-excellence initiative and investigated bringing in an outside company to train all employees, but was moving forward slowly, at the time. Subsequently, Kazerooni and her colleagues developed a service-excellence group composed of hospital staff, representatives of all imaging modalities and each physician-specialty division, and house officers—as well as support services such as IT, engineering, and media services: all in all, a large group.

The group began by discussing the concept of service excellence as a term for everything from employee engagement to patient satisfaction and the patient experience. Members read The New Gold Standard: 5 Leadership Principles for Creating a Legendary Customer Experience Courtesy of the Ritz-Carlton Hotel Company (McGraw-Hill, 2008) and considered which principles resonated with them, as leaders in the health-care enterprise.

The group built its program from the ground up, learning from others within the institution, developing a service excellence-statement and attestation that resonated with what people in the radiology department thought was important, and coordinating with the strategic plan and goals of the health system. “It took between 12 and 18 months, and there were lots of skeptics at the time,” Kazerooni recalls—people who asked what the group was doing, why it was meeting, and why it needed to do this. She says, “Others simply said that they knew what was good medical care, and this was just superficial fluff.”

She continues, “Taking our time and making it our own made it that much more an embraceable program. When we launched it, it felt like it was us. It was our program; it was something that we believed in and wanted to do.”

Platform and Planks

The program was based on core service statements that resonated with staff about how to treat patients; how to smile through the phone and on email; and how to close out each encounter (whether on the phone, in person, or by email) when it relates to a patient-care experience. “It’s about treating each other well; treating our colleagues well, across the health system; treating our referring physicians well and exceeding their expectations; and, certainly, meeting (if not exceeding) the needs of our own patients,” she says.

A gold card printed with the belief statements was developed, and staff members carry it behind their ID badges. A one-page attestation of the belief statement must be read, discussed with a manager, and signed by all newly hired personnel and by all staff and faculty members at their annual reviews. A thank-you/closure card also was printed, with a radiology motif on one side and a note thanking the patient for choosing radiology at the University of Michigan on the other. The card bears the name of the last person to speak with the patient (technologist, staff person, or physician); the date when the patient can expect to get his or her results; and a reminder to the patient to ask any unanswered questions.

“It wasn’t a very expensive program,” Kazerooni reports. “I think some of the misconceptions about a patient-experience program are that it has to be expensive, that you have to spend a lot of time putting it into place and training people, and that you can’t do this by yourself. I disagree with all of those myths. It’s really more of a mental and emotional commitment.”

Having a champion with the energy, passion, and authenticity to refuse to take no for an answer also is important. In fact, “just say yes” is one of the patient-experience program’s core service statements.

In order to assess patient satisfaction, Kazerooni and her colleagues reorganized a standard survey that had been used for years to follow the flow that a patient experiences throughout a radiology encounter more closely—from scheduling and prearrival instructions to parking, getting to the radiology department, being greeted on arrival, the technical or procedural experience, and how the experience closed. Some general questions were included, such as whether the patient would recommend the department to a friend or family member, which the institution tracks for all departments.

The program was implemented in October 2009, with the department’s next patient-satisfaction month approaching the following January. “The committee was advised that we needed to put cookies and water in the reception area if we wanted to see great results,” Kazerooni recalls. “We hemmed and hawed and looked at what it would cost. We decided that really wasn’t what we were getting at; we really wanted to find out how we were doing.”

In the past, the radiology department had averaged a score of 88—above average for the institution, but not outstanding. Three months after the program was launched, the department achieved a 97 score on its patient-satisfaction survey, making it the number-one department in the health system. “It was tremendous that we hit that mark, that the program was embraced by the staff, and that we didn’t have to bribe people with cookies and water,” Kazerooni says.

Old Versus New

Prior to implementation of the service-excellence program, service problems came to light primarily when a patient went to the office of patient safety, when management filed a complaint, or when a health-system staff member filled out an incident report. “One of the things that we hoped for is that we would not have as many of those high-level complaints for which we had to do service recovery,” Kazerooni explains.

To be prepared, the department implemented an improved service-recovery program: Everyone knows what the options are and how to manage a patient through difficult circumstances: by using positive (not negative) words, by offering choice and opportunity, and by listening. “A CT scanner could break, and we might have to reschedule patients, but we do it proactively, we do it with a plan in place, and we do it in a positive way (as opposed to a negative way),” Kazerooni explains. “What we’ve found is that we do almost no service recovery today—because we don’t have to do it.”

For Kazerooni, one of the most surprising (and important) results of the initiative has been improvement in both the employee experience and the department’s relationship with referring physicians. “We did a session on managing up and managing others who may not be in your scope of influence,” she reports. For the staff, that could mean managing up to a physician who might not have been engaged yet in service excellence. For a physician, that could mean working with a physician or staff in another department.

These skills have been a tremendous boost to relations with emergency medicine. “We have a large volume of patients coming in under acute circumstances and stressful situations, so this has done a lot to improve our relationships with our emergency-medicine colleagues, independent of our patients’ better experiences,” Kazerooni says. “Simultaneously, we ran two programs with the emergency department on reducing the time needed to complete a requested CT or MRI exam, which brought people together; while the time required to get the exams fell substantially, the more long-standing outcome was relationship building.”

Another unexpected result of the program has been the reluctance of some physicians to take responsibility for the patient experience. “That was my other surprise: the need to be patient with the physicians as they become more engaged with the patient experience,” she notes. “In many ways, diagnostic-radiology physicians, in general, have abdicated responsibility for the patient experience to the technical and nursing staff, over the years, engaging only in areas that involved direct patient contact due to the nature of the exams (such as interventional radiology, fluoroscopy, or diagnostic mammography).”

She continues, “Even in those areas, the patient experience begins long before the physician first meets the patient, and it continues afterward. Radiologists need to be engaged in all aspects of the patient experience, from beginning to end—not just the quality of direct medical care or of the radiology reports that they generate.”

At the health-system level, the service-excellence program put the radiology department on the map. The administration asked the radiology department to help launch the program throughout the health system in the ambulatory-care clinics—a significant benefit, in these uncertain times in health care.