isease and treatment often causes pain and grief, but the way in which healthcare is organized also causes suffering. As authors Thomas H. Lee, MD, and Deirdre Mylod described,
“Patients experience avoidable suffering that comes from dysfunction in health care delivery ... a type [of suffering] that patients do not anticipate but is often accepted by caregivers as ‘part of life’ ... Patients endure waits for appointments, test results, and explanations, and even for their caregivers to communicate with one another about their care … All of this can feed anxiety, frustration, and fear.”
In January of 2014, Matthew Stein, MD, sat in the first lecture of a Value Improvement Leaders class. Stein had applied to participate in the course, curious about how lean and process-improvement principles could improve his Breast Imaging division. Each student had been challenged to apply their learning to a personal improvement effort.
One of the concepts introduced was “Voice of the Customer.” The class facilitators challenged participants to understand what patients want. While others in the class were debating, Stein knew the answer immediately. “I thought, I know what our patients want,” he remembered. “They want their mammography results. And they want them right away.”
Matthew Stein originally trained as a neuro-radiologist and immediately went into private practice in Grand Junction, Colorado. “Once in practice, I realized the biggest impact I was having on patients’ lives was not through neuroradiology or anything else I was doing,” he remembered. “The biggest impact was through screening. Working in the community, you would see women year after year. Some patients would tell me they hadn’t slept for days, waiting for their exam results. It became more and more important to me to help these patients.”
The experience inspired Stein to change course. He left community practice to train at the University of Washington, specializing in breast imaging. While in Seattle, he was impressed that the breast imaging clinic offered special appointments that included same-day results. Stein noticed that patients rapidly reserved these slots and that the patients always showed up. The experience remained with Stein, even years later. Could Huntsman Cancer Hospital deliver same-day results?
Typically, patients receive mailed results from their screening about a week after their mammography appointment. Because most screens result in normal outcomes, the radiologist’s interpretation is not performed urgently. Screen exams are often batch-interpreted to accommodate the schedule, sometimes later that same day and sometimes up to several days after the imaging was performed.
Providing same-day results would mean changing long-held beliefs. It would mean changing the culture of breast-imaging clinical delivery. It would mean changing how everyone—radiologists, radiology technologists, and support staff—made decisions and spent their time.
Step 1: Check your "change capital"
What would inspire the team to change their practice? Several investigators have noted the detrimental effects of expedited reporting on quality (higher rate of false-positive recalls, lowered cancer-detection rates) and service (decreased efficiency and throughput). Would the team have to work longer and harder? How could Stein work through these anticipated barriers successfully?
His next step was to introduce the idea of expedited results to the team. He was acutely aware of how much change the team had already experienced. Over the three years since Stein had joined the organization as section chief of breast imaging, he had heaped a ton of process change on the department, and, to their credit, they had made it work. But, the pace of change had created real stress. The team was good at hiding how hard it was for them, and Stein was driven to get the team where he wanted them to be. But had he used up his “change capital?” Would the team be resilient enough?
The dust from the last change had only recently settled. Stein felt like the team was starting to like him a little. So, he went into this change knowing that his change capital was very limited. Stein recalls, “I heard later, there were tears in the stairwell because of people trying to adjust to the new changes, to make them all work.”
Step 2: Create a compelling vision
Stein knew that if he could convey the benefit to patients, he could engage the team in yet another change. This time he would need to be passionate and persuasive. He would need to tie this change to the patient—to the anxiety the patients experienced. He would need to win over both the team and his colleagues. Stein had watched them all with their patients, and they had watched him as well. Everyone shared a deep commitment to individual patients and their outcomes. Stein knew that while the team didn’t always like him, they understood that his goal was to make things better for the patient. With this foundation of respect, Stein was sure he could bridge the divide.
Stein started with a special meeting. He had invited all the radiologists, the technologists, care coordinators, and schedulers. It would be an open forum. Stein spent the majority of the time focusing on why the change was important. Patient anxiety is a source of harm, and one could hear it in the words patients used to describe their experience.
The team response was mixed. While excited about the prospect of reducing patient anxiety around delayed results, feelings of terror arose as the list of barriers grew. How would they keep track of patients? Where would they put them? Would it add time to the exam? Would patients be sitting around in gowns all day? Stein acknowledged that all the details would need to be worked through and that together they would make it work.
Step 3: Engaging the team with the value equation
Stein knew he needed a partner, and the choice was obvious. Terri Neihart managed the mammography department and had been at his side through the changes of the past three years. He told her that this time, they also had another resource: his Value Improvement Leaders course coach, Luca Boi. Boi, a lean Six-Sigma Black Belt, could bring expertise that they hadn’t had before. If they combined forces, maybe this change could go more smoothly.
The work started immediately. Boi came to the first session and engaged the team in mapping their process. By the end of the first meeting, the team already better understood how their work flowed and how long it was really taking to get patients their results. Because the whole team was engaged, they were able to provide a complete picture of the details of the work. The process was outlined step by step. They committed to take only take one step at a time.
What would success look like? The team looked at the University of Utah’s Value Equation: Value = Quality + Service/Cost.
|Service:||The breast imaging clinic has historically performed in the top national 1%–2% of patient satisfaction. The team wanted to maintain their performance, but they also wanted to push themselves to find a proxy measure for anxiety. They identified amount of time spent waiting for final imaging results as a quantifiable measure of anxiety. The team collected baseline data by calling patients, and then used a stop watch to capture the time during the pilot.|
|Cost:||The team believed that success would mean completing this change with no additional staff.|
Step 4: Pilot, refine, implement
Once the team started meeting and discussing barriers, it got easier and easier. One addition that made the change seem more possible was a new Mammography Information System, implemented the year prior. Radiologists could now see, to a much higher degree of detail, where patients were in the process. They had the patient’s screening images right in front of them, and they could also see which patients were still in the lobby, often only a few feet away.
In April of 2014, after three months of planning, the team felt ready for a pilot. After extensive discussion, the team decided that the pilot would need to be the entire team for the entire day. There was no way to make it smaller; they would have to be all in.
Recalling the first day, Neihart remembers, “It was fun. We could see it working. What made it fun was understanding the challenge and meeting it. It ended up being easier than we had thought.” Stein and Neihart, both proponents of the power of appreciation, encouraged the team with positive feedback. But the glow of success was accompanied by daily problems. The team embraced real-time problem solving, making smaller adjustments all along. The team came up with new ideas. Neihart and Stein met weekly to review ideas and make changes. Some ideas worked, some didn’t.
Results and Reflection
After three months, the pilot ended. The team stepped back to assess their progress. When offered, 98% of women chose to participate in an appointment with expedited results. Wait times for normal results decreased from 6–7 days to less than 15 minutes. There were no ill effects on quality indicators or patient experience. Without adding staff, the team actually became more efficient as the number of screens interpreted per day increased by 5% over historic norms.
During the pilot, the team discovered that they could perform follow-up imaging and biopsies in the same day for patients with initial worrisome results. Patients now do not have to return on a different day for follow-up tests, and are spared many anxious, worried days in between. Other benefits also soon became clear: the scheduling backlog decreased since diagnostic exams and biopsies were occurring on the same day. The new process was fully implemented in July 2014.
Matthew Stein reflects, “Because of the success of the change, I feel like things have moved in the opposite direction. Our team is receptive. Whatever hardship we all have gone through, this effort has improved our relations. The team always respected me, but now I feel like the genuinely like me now.” Working on a project together built respect.
But the biggest measure of success for the team has been the feedback from patients. What do they think about the new process? The voice of the patient speaks loud and clear.
Voice of the patient (BEFORE the change):
"This has been a horrible experience . . . I have worried all week—calling and following up and no one bothered to respond to my requests that my scan be reviewed. If I had not called today, how many more days of precious time would have been wasted? I hope this information helps you to improve your services and have more sensitivity to the concerns and needs of your patients. Please don’t do this to someone else." —August 2013
Voice of the patient (AFTER the change):
"I want to comment that having the radiologist read my scans immediately was super important. It was so much better to go home knowing my results right away, rather than having to wait a week. For cancer screening, I think this is critically important, since the wait can be agonizing."—December 2014
"I am so impressed that I received my mammogram imaging results within 5–10 minutes of my exam. This demonstrates solid team work—your technician, radiologist, and support staff were working together fluidly. This level of patient service is world-class! THANK YOU!"—January 2015
"The experience of getting mammography is like none other in healthcare. For some reason, we go the extra mile to make sure that patients are comfortable, informed, and leave with test results for mammograms in a way that we don’t for any other type of disease. Why is it that I can show up for a screening test, have it done, read, and my results to me in 30 minutes for a mammogram, but not for any other medical condition? Radiology as a specialty should take a chapter from the mammography book because this type of care is patient centered, efficient, and makes me realize what the rest of my healthcare is lacking. Nice work to Huntsman and now the rest of UUHC needs to catch up."—May 2015
Above patient comments were collected on Press Ganey outpatient services surveys, accessed for this article in October 2015.
Contributor not pictured: Terri Neihart.