Patient Focus Approach

By Joseph Castillo B.Sc (Hons) radiography M.Sc (HCM)

The idea of this meeting is to on a journey in search of a system with which we can liberate ourselves from rising costs in health care, declining performance and obviously reduced patient satisfaction.

We will start with a probable situation:

"Imagine you are abroad for an important interview, and suddenly you remember that you forgot to have a haircut.  In a slight panic you go in search of a hairdresser.  You find one and enter. And while you are waiting your turn you start thinking about the outcome.  Well, after all, hairdressers are all trained the same aren't they?"

I have found it very difficult to talk about patient care, without discussing the supply/demand equation.  Every decision taken by management is likely to affect directly or indirectly patient care.  For example, adding tasks to radiographers (documentation, darkroom processing), without adjusting the appointment time, will definitely affect patient care. 

The modern hospital has no operational equivalent in industry.  It is a 24-hour hotel with no effective reservation system or demand forecasting.  The variety of potential services to a particular patient is incalculable. Some patients require high tech imaging and others require low tech imaging. On the other hand if we could try to compare hospital operations to an assembly line in manufacturing we will eventually observe the same fragmentation and specialization of the work force.  In the automobile factories of recent decades, one could find employees whose sole jobs were to attach chrome trim to the doors of vehicles coming down the line.  In hospitals today there are employees who only take ECG an nothing else, file x-rays but not process films, health assistants qualified to put data in a computer but not transport patients, radiographers who takes x-rays but unable to monitor patient vital signs.

But when hospital survey results are out, managers seem to speak always about the usual 'problems" - the unreasonable patient expectations and free for all healthcare, appointment queues and difficult work schemes, and shortage of staff.  So the question here is: Are hospital satisfaction surveys really measuring what they are supposed to measure?  Let us take one question into consideration.  "How was the service in the emergency  department? Poor fair good excellent.

The response to the question could be "It was great - all sixty minutes of it".   If we are serious we should ask better questions like" How long did you wait before any care was actually delivered? How many irrelevant questions did we seem to ask?  We should be asking questions regarding to expectations and perceptions.  The only statistics that are gathered, on which decisions are taken, seems to be the number of examinations carried out during the year. So what operational parameters should we be measuring?

The following are the most important parameters:

Turn around Time (TAT)- How long does a chest x-ray take, from the tine it is requested until this is back to the referring physician with the radiologist result? Is the period excessive?  Why?

Continuity of Care - A lot of staff seem to be interacting with the patient ( similar to an assembly line). This leads us to a crisis where nobody seems to owns the patient and therefore accountability is minimal.  Assessing the x-ray process in the emergency dept - how many hospital personnel must a patient meet before treatment is actually delivered?  The coordination of so many people in the care of one single patient is increasing the healthcare cost.

Is priority given to Institutional convenience or patient needs? - This is the last thing that we seem to care about. Our attitude seems to be that it is better to have six patients waiting.  Examples are numerous - triage in emergency department, ultrasound examinations.  Why do we have to take KUBs at 5:30 am?  Why do we have to take CXRs in ITU at 6:00 am daily?

It is an understanding of the impact of structure on cost and service performance which will help us take the real decision that enhance patient care.  Without this understanding, we are fated to continue to repeat the 'doom loop" of recent years - superficial change, leading to insignificant and temporary reductions in cost, followed by deterioration of service levels and further erosion of employee morale.

This is not easy, and so far our journey seem to be doomed, but there is light, there is hope.

The understanding

High cost and poor service is the product of compartmentalization

Let us look at a simple routine x-ray.  A routine x-ray examination entails around 20 minutes of a radiographers time and definitely less than 5 minutes of radiologist reading time.  Yet the whole process may take more than hour.  The process is affected by a structural  decision taken a long time ago to centralize routine radiology procedures in a department  At the time, when x-rays machines were large the decision was good.  However, today the decision needs rethinking. Lets think about our hospital.  Do you really need a watch to know the time.  It is very likely that if there is a queue of patients in front of room three (a general radiography room), than it is around 9:30 am. The patients waiting there probably have a scheduled appointment, but yet they have to wait.  Our investment in scheduling patients does not seem to pay off for patients or their physicians during peak hours. Why do we still need to bring patients down for a simple x-ray examination?

So where do we start

Structural idle time:  Hospital jobs tend to have extraordinary amounts of it.  The sources of structural idle time are compartmentalization (one radiographer assigned in each room, instead of teams); specialization (one radiographer doing chest x-rays only), and demand variability. (haphazarrd, forecastable, predictable, scheduleability)

Value added - how we spend our time. Let us have a macroscopic picture.

Medical -technical tasks - what we all think of healthcare.  How much time do we spend with patients?

Hotel services - includes the upkeep and maintenance of equipment, cleaning of rooms

Medical documentation - everything that goes into writing down clinical information

Institutional documentation - that which is not directly associated with clinical activities - memos

Scheduling and coordinating

Patient Transportation

Staff Transportation - going from ward to ward

Management and supervision

Ready for action - structural idle time

So far we have seen the supply side of the hospital operations equation.  We have to examine the most important part of the equation - the demand side.  It is our customer's needs that should shape the basic operating approach.  Patient focus approach begins with demand.

What is the demand made of in a radiology department:  High tech procedures or low tech procedures.  That is on any day what is the bulk of the examination made of?  How are we organizing our resources to meet this demand?  What are the patient needs?  Is it justified to have a patient brought down in the radiology department through corridors and elevators for a 15 minute job which could be easily done in the ward.

We have to ask, do we really need a centralized radiology department for routine work? Which units are requesting routine x-rays? How often?  Can we group patients in wards according to their needs?  An neurosurgery patient and an orthopaedic surgery patient have the same needs.  If we place the woards near each other and find a place for an x-ray room than we could have a radiographer doing ward rounds with orthopaedic and neuro surgeons.  The outcome is that requests will be done on demand with reduced waiting time.  Are the requests predictable?  Can we organize a protocol for triage?  If we organise protocols than we could have a fast track system for those patients who fall on their outstretched hand and have a possible fracture.  Radiographers will assist in this protocol by identifying suspected fractures with a red dot.  Obviously the casualty officer will remain accountable for the whole procedure, but the patient is cared for faster and better.

Restructuring

We will not solve our operational problems by implementing incremental superficial changes.  The following five steps provide a guideline to explore further our journey.  They are open for discussion.

First - medical, technical and clinical care is our business and we should devote as much of our resources to it as possible.

Second - eliminate unnecessary work in the operating structure.  Performing x-rays at full gallop will only increase structural idle time.  Meeting demands in a flexible way, rather than one fits all structure, allow us to make more progress

Third - Cross training, (introduce the multiskill practitioner - experienced radiographers that could perform a broader range of functions for each patient)

Fourth - Promote ownership and empowerment before pointing at accountability.

Fifth - Reduce management levels and increase hands on managers (introduce the advanced practitioners - radiographers who are clinically specialized in imaging modalities.)

The above steps will eventually free us to take the necessary steps to enhance the patient focus approach.

We will now go back to our hairdressing situation.  How are you feeling? Anxious probably? What are your reactions to the environment? Is it clean, efficient better than expected.  What are your reactions to the staff?  Are they courteous, knowledgeable efficient better than expected? Are the staff responsive to your need?  Do staff give individualised attention to clients?

Internal and externall customers using the various hospital department percieve the efficiency of that department on the following areas.

Tangibles - appearance of physical facilities, equipment, personnel; and communication material

Reliability - Ability to perform the promised service dependably and accuartely

Responsiveness - Willingness to help (internal and external) customers and provide prompt service

Assurance - knowledge and courtesy of employees and their ability to convey trust and confidence

Empathy - Caring individualised attention the employees provide to their patients and colleagues.

The quality of service depends greatly on the quality of the employees.  Many managers find it easier to cut costs rather than by improving appointment handling and punctuality.  It is extremely important to research the service quality within a hospital between the various department.  Employees in other departments who use the radiology department could offer insight on the conditions that affect the service as a whole.  The other departments especially wards, unlike patients, experience the delivery system on a daily basis.  Internal customer research serves as an early warning to identify when it is going to break.

In doing so, the employees are satisfied and obviously the patient is astisfied.

The journey stops here because if we want to continue the journey we have to make an organisational and behavioural change that is beyond the scope of today's lecture.  Take every opportunity to discuss and research whether this change is feasible and what will be the implications.  Thanks

Further Reading

Batchelor C ( 1994) Patient Satisfaction Studies Methodology, Management and Consumer Evaluation, International Journal of Health Care Quality Assurance Vol7, 7

Camilleri D, O'Callaghan M (1998) Comparing Public and Private Hospital care service quality, International Journal of Health Care Quality Assurance, vol 11, 4

Duncan KA (1994) Health Information and Health Reform, Jossey Bass Health Series, San Francisco

Ennis K (1999) Quality Management in Irish health care,  International journal of Health Care Quality Assurance, vol12, 6

Frost FA, Kumar M (2000) INTSERVQUAL - an international adaptation of the GAP model in a large service organisation, Journal of Services Marketing, 14, 5

Harry M, Schroeder R (2000) Six Sigma, Doubleday, New York

Heyman T (1994) Clinical Protocols are Key to Quality Health Care Delivery, International Journal of Health Care Quality Assurance, Vol 7, 7

Lathrop J. Philip (1993)  Restructuring Health Care, Booz-Allen Health Care, Inc, Jossey Bass Publishers, San Francisco

Lee-Ross D (1999) A comparison of service predispositions between NHS nurses and hospitality workers, International journal of Health Care Quality Assurance, vol 12, 3

Reeve J (1997) Sisters' and charge nurses' attitudes to quality, International Journal of Health Care quality assurance, vol10, 1

Studin I (1995) Srategic Healthcare Management, Irwin Professional Publishing