Radiology
Department
Administration
Steven E. Seltzer, MD #{149}David Sack, RT #{149}Mary Ellen Kudera, BA #{149}Lynda E. Rudolph, MS Douglass F. Adams, MD #{149}Jack E. Meyer, MD #{149}Albert E. Gillis, RT, MBA #{149} Michael A. Viera, Margaret D. Phillips, MD #{149}Charles D. Healey, RT #{149}B. Leonard Holman, MD
Improved
Radiology
An interdisciplinary authors’ institution sign for a new film
task force at the developed a delibrary that placed heavy emphasis on service to its customers. The task force established locations and staffing for “satellite” inpatient film libraries organized by clinical specialties. Inpatient films were not permitted to be taken from the radiology department but were available for 24-hour viewing. Film locations were recorded in the radiology information system. Reorganization led to important improvements in film library operations and in the clinical staff’s opinion of film library service. Objective measures of performance, such as the fraction of requested films available for conferences, showed significant improvement (P < .001). Closer working relationships developed between film librarians, radiologists, and their clinical colleagues. Film library personnel were recruited more easily and stayed on the job longer. Several hundred thousand film-tracking transactions per year were recorded. The authors conclude that decentralization of certain film library activities improved many critical aspects of performance. Index
terms:
partmental ologists, Radiology
I
From
Radiology
and radiologists,
de-
management #{149}Radiology and design of radiological facilities 1992;
the
radi-
184:805-811
Department
of Radiology,
Medical
Harvard
School and Brigham and Women’s Hospital, 75 Francis St. Boston, MA 02115. Received January 7, 1992; revision requested February 21; revision received March 23; accepted April 13.
Address C
RSNA,
reprint 1992
requests
to S.E.S.
Film
T
Library
Operations’
quality of service that a department of radiology provides has an impact on the entire health care institution. Because the film library HE
is a centralized, diobogy and
core other
resource for clinical services,
ra-
radiology
film
AND
MATERIALS
ii-
braries often function suboptimally. Problems associated with them are diverse and many, but missing films, delays in film handling, and personneb shortcomings are commonly cited. Amelioration of these problems could enormously improve the efficiency of the radiology department and the full range of clinical services that depend on it. This efficiency is prized for the implications it has not only for better service but also for reduced costs of all patient care. Because the radiology ifirn library at our institution, a 720-bed, urban teaching hospital (see Table 1 for representative departmental statistics), suffered from many operational problems and because an opportunity existed to move the film library into a new physical plant, we set out to improve its function at the same time. To do this, a task force was convened to study film library operations, improve policies and procedures, and develop objective rneasurernents of the quality of its operations and services. The steps taken for improvement and the magnitude of their impact form the basis of this report.
METHODS
The film library improvement program followed classic principles for “breakthrough management” elucidated by Juran (1) and was also influenced by the principles
the quality of its operations has farreaching implications. Fast, reliable access to diagnostic images speeds patient evaluation and facilitates clinical decision making, which may in turn have an impact on length of stay, a critical determinant of cost and the adequacy of reimbursement. On the other hand, slow, unreliable access introduces delays that can impair efficient diagnosis and treatment and increase hospital stays and costs. Unfortunately,
RT
of the
method ness
Deming
management
(2). We first developed
of the
present
an aware-
drawbacks
in opera-
tions and then created a climate for a change in attitude that could lead to improvement. To make the needed breakthrough, radiology department managers and the hospital administrators formed a partnership that was committed to creating a better physical plant and supplying additional personnel as needed. A critical element of the changed attitude was the identification of the film library’s various users (eg, physicians, patients, and radiology department personnel) as “customers” and a commitment to serving them
better. and
Organization
The departmental pointed a six-member as the steering
Research management task force
and
diagnostic
apto serve
arms
of the
project. These members included the film library manager, the chief technologist, a radiology information system specialist, a hospital management engineer, and two staff radiologists. Additional department personnel were
needed oversee going
to address
specific
radiology
added as issues and to
film library operations on an onbasis. Consultants to the task force
were drawn from the medical staff of the institution and included the chief medical and surgical residents as well as primary care
and
specialty/consulting
physicians.
The task force used several important tools during its diagnostic assessment of film library operations. First, they interviewed the film library’s physician customers (both radiologists and consulting nonradiobogists) to identify areas needing improvement and elicit ideas for change. Second, they conducted a telephone survey of film library operations at seven similarby sized academic hospitals and visited
Abbreviation:
FTE
=
full-time
equivalent.
805
three others. Third, the management engineer organized and executed an operations study of the film library, identifying the range of functions executed and enumerating Flowcharts
tasks
similarly
sized
assigned
to personnel.
were used to analyze the movement of ifims. The number, quality, and organization of film library personnel were assessed and compared with those departments
of
in the region.
Fourth, a so-called Pareto analysis (isobation of the “vital few” problems from the “trivial many”) was performed to identify those deficiencies that caused the most problems. Finally, the task force consulted with architects to design a new space that would be conducive to efficiency and customer service. Recommendations Breakthrough
for
On the basis of the information gathered in the research phase, the task force developed recommendations to improve the quality and efficiency of film library operations, suggested new policies and procedures, designed a new organizationab structure and hierarchy, and oversaw development of the architectural plans for the new physical plant.
Evaluation The
task
force
developed
performance
measures to evaluate the quality of film library operations, to assess the impact of the new policies and procedures, and to provide data for ongoing monitoring and quality assurance. First,
a simple,
objective,
quantitative
measure of the overall quality and efficiency of film library operations was deveboped. This parameter was the percentage of films available for presentation at the triweekly medical x-ray conferences. At these conferences, radiologists meet with medical house staff to review imaging studies of medical inpatients. To be available for review, a study had to pass completely through the operations of the department, from execution through interpretation
through
filing,
and be retriev-
abbe by the film librarians. The operations study indicated that this last step in the process was the one that had the most bearing on whether a ifim was available for the conference, so it was thought to be a useful indicator. When a film was unavailable for the medical x-ray conference, the reason was tabulated. These data were collected for two time periods-the control
period
(4 months
before
#{149} Radiology
was given
18 medical
x-ray
in written
conference
form
to
tions.
attendees
(four attending physicians and 14 house and in verbal form to six radiologists (all attending physicians) and 14 nonradiobogist physicians (10 attending physicians and four chief residents) who used the ifim library. The written questionnaire elicited numerical ratings for 10 specific aspects of the medical x-ray conferences (on a scale of I to 5, with 1 = poor and 5 = excellent) and asked for feedback about ifim library services. The verbal interviews were similar-respondents were for their
subjective
opinions
about
policies
and
a
Control
Once successful new programs had been established, the objectives shifted to maintaining them and reestablishing control of the ifim library. To do this, several steps were taken. First, departmental management and the hospital administration chartered the continued existence of the committee
task
to oversee
force
of film li-
continued
tools
for monitoring
and transformed
into
ifim library
perfor-
Testing
The x2 test with the Yates correction was used to compare the availability of films for the medical x-ray conferences between
the control
and enhanced
periods
(3).
RESULTS Research
procedures.
Finally, a way was found to measure the use of the electronic aids designed to improve film library operations. A count of “tracking events”-the number of times that the location of a film or folder was updated in the radiology information system-was performed. It was believed that the frequency of such tracking events would indicate how quickly and how well ifims could be located, that is, whether any given film could be retrieved and reviewed in a timely fashion. For technical reasons, this audit could not be performed before the enhanced period.
multidisciplinary
were
Statistical
of film library services. While these surveys were administered in the enhanced period only, physicians in our survey group who had been in the hospital from the control to the enhanced periods were asked specifically about how the film library had changed following implemenof new
group
mance.
range
tation
a diverse
customers came together as a users that met monthly with the film limanager to provide feedback about operations and performance. Finally, the quality assessment measures developed for the evaluation phase of the program
staff)
asked
Second,
brary group brary
the task
force’s recommendations were formubated) and th,e enhanced period (12 months after the move to the new physicab plant)-which served as a measure of the impact of the new policies and procedures. Second, a semiquantitative, subjective measure of the quality of ifim library service to physicians was developed in the form of a customer satisfaction survey that was administered to two focus groups. 806
The survey
as a steering
film library
opera-
The task force’s diagnostic assessment, including the interviews, externab studies, internal operations study, and Pareto analysis, bed to a tabulation of the strengths and weaknesses of our institution’s film library. Six specific areas were cited as the vital few whose improvement would have the biggest impact. These were as follows: Centralized operations.-The film library used a centralized type of operational structure. All active films were ified in one central facility, and all personnel worked exclusively within the confines of the film library (2,973 ft2 [268 m21 of usable space). The benefits of such centralization were believed to derive mostly from economies of scale-a wide array of functional tasks were handled without much duplication of effort. The deficiencies in the system were attributed to the limited interface between the September1992
film library and its users within and beyond the radiology department. The physical interface itself was small-a half-door reception area staffed by a single person. The temporal interface was also limited-the library was not staffed on the third shift (11 PM to 7 iri). Most film library operations and personnel were hidden from the customer’s view, hampering development of professional working relationships. Film loan policy.-The study determined that the department’s liberal film loan policy undermined the iibrary’s major mission, namely, having films available for review. The loan of inpatient films was felt to be particu-
nish its public image. Unavailability of ifims was generally considered to be the “fault” of the ifim library. Poor morale contributed to a personnel turnover rate of 25%-30% per year. The best-qualified individuals were often the most difficult to retain.
The task mendations
force developed to redress the
larly
identified.
Some
problematic,
as these
were
in
great demand by radiologists and nonradiologists. If films were “signed out” and unavailable, the impact was far-reaching. Film tracking.-Although the radiology information system allowed for easy
updating
of ifim
location
data
by
means of light pens and bar codes, the use of these tools was inconsistent. This led to a loss of confidence in the value of the tracking system, leading to a negative feedback loop that dampened enthusiasm for tracking still further. Personnel organization.-The organizational structure of the library was found to be deficient in several areas. Our film library had a staff of 25, amounting to one full-time-equivalent (FTE) librarian for every 8,281 examinations performed annually. The library was found to be understaffed in comparison with other hospitals of similar size nationwide that were surveyed, which provided an average of one film librarian FTE for every 6,300 examinations performed annually. There were only three 1evebs (staff, supervisor, manager) in our film library job hierarchy, providing little, if any, opportunity for advancement and no well-defined career paths. The working relationships between film librarians and ifim library users (technologists, radiologists, nonradiologists)
were
considered
poor.
For instance, film librarians generally felt that they were not accorded appropriate respect by other hospital personnel. Radiologists and nonradiobogist physicians attributed systematic film library deficiencies to the poor motivation and low skill levels of the film library staff. Morale and image.-The task force’s external
consultants
confirmed
that
all of the perceived deficiencies in film library operations conspired to reduce the morale of its personnel and to tarVolume
184
#{149} Number
3
Service.-Dedication
to customer
service was not perceived to be the central mission of the film library. Its customers felt that their needs were frequently not met. Recommendations Breakthrough
and
for Implementation
of these
recomproblems were
it
mod-
eled after the design of the radiology film-management system at Los Angeles County-University of Southern California Medical Center (4). These included
the
following:
Physical plant.-The new physical plant contained 4,035 ft2 (363 m2) of usable space and was designed to facilitate the proposed operational improvements (Fig 1). The new space contained a large viewing room for medical and surgical inpatient ifims, the chest reading station, a “hot file” for recent examinations ( < 2 months old), a core library or main film filing area that held films from just over 2 years of examinations, and the main departmental conference room (an additional 600 ft2 [54 m21). Additional statistics for comparing the old and new physical plants are provided in Table 1. Decentralize operations.-The task force implemented a plan for development of sateffite film libraries that would contain all inpatient films. Four of the satellite libraries were sited outside of the main film library and included those for inpatients in the neurology/neurosurgery services (library sited in neuroradiobogy readmg room), the orthopedics/rheumatobogy services (library sited in skeletal radiology reading room), the medical/surgical/coronary intensive care units (library sited in patient care area near intensive care units), and the neonatal intensive care unit (library sited near this intensive care unit). Four satellite film libraries were sited inside the new main film library complex in the so-called viewing room. Each satellite library was composed of a mubtifilm viewer for displaying current examinations for specific medical and surgical inpatient services. Each of these sateffite ifim libraries was staffed during the daytime shift by a new category of film
librarian-”satellite librarian”whose responsibilities included maintaming and updating the active film files several times a day and locating requested films for referring physicians in their areas. When patients were discharged, their folders were returned to the main film library. The motivation for this decentralization was several-fold. First, it estabbished smaller, more efficient, miniature film libraries built around clinical inpatient services. Referring physicians could come to one place and see the current studies of all their inpatients. Second, it placed these satellite libraries in close physical proximity to the subspeciabty radiologists who had the best working relationships with their colleagues on the clinical services. Consultation was thereby enhanced. Third, it brought film librarians out of relatively invisible posts in the core film library and into the main department, where they too could develop working relationships with radiology and nonradiobogy staff. Finally, because of the added responsibilities given the satellite librarians, their jobs were pegged at a higher salary grade than those of the other film library staff and a fairly large additionab level in the organizational hierarchy was created, improving the prospective career ladder. No
dling were
changes
were
made
in the
of films of outpatients; still housed in the core
han-
these film li-
brary.
Restrictfilm recommended policy
flow.-The task and implemented
that
removed
no
from
diobogy
inpatient
the
(except
films
force a could
department
be
of ra-
to be taken
to the
op-
erating room). This move was made palatable to nonradiology physicians by pointing out that in return for asking them to come to the department to see films, there would be a high probability that the films they wanted would be on display at a viewing station (or satellite library) when they arrived. Additionally, the design of the film library’s conference facilities supported the conservation of films within its confines. The medical x-ray conferences
were
held
in the
viewing
room where the films were normally on display; thus, there was no need to move the films for these meetings. The larger conference room was used for intradepartmentab activities (again, the films for these meetings did not leave the film library area). This policy was enormously beneficial for radiology operations. No
changes
eral loan
policy
were
made
in the
bib-
for films of outpatients. Radiology
#{149} 807
Manager’s
Hot
Viewing
Office
Files
I
Room
Medical/Surgical Inpalienic
I Main
Film
Filing
Area
L
gro::l
Dimensions
1
LEGEND
_________
chest
Reading
Allernator
=
!
=Workst.ation
0
chai =Film
Slorage
=Hot
I
File
Figure 1. Schematic of new tic units are 23 x 20 m.
radiology
film library
Commitment to film tracking-By means of education, training, and persuasion, all radiology department members were encouraged to be more conscientious about film tracking. Implementation of the other new policies and procedures and a perceived commitment to improving the quality of film library operations created a positive feedback loop that encouraged tracking. Modify
personnel
organization-To
open the film library and its viewing rooms for 24 hours a day, to establish the post of satellite film librarian, and to bring staffing more on a par with that of other similarly sized hospitals in the area, the department was granted six new staff positions, bringing the total to 31 FTEs (one FTE per 6,672 examinations). To manage the expanded operation and to create an improved career ladder, three additional personnel grades were added. The six film library job titles now were manager, supervisor, assistant supervisor, satellite film librarian, senior 808
Radiology
#{149}
and
conference
center.
film librarian,
and
correspondence
L
Approximate
film
scale:
librarian.
secretary
A
was
also
added. The personnel organizational chart is illustrated in Figure 2. Improve morale and public relations.The morale and public image of the film library were boosted substantially by the changes made. The department established a Film Library Appreciation Day and worked with the film library manager to fund periodic morale boosters and events for the staff. Improve
service-Emphasis
placed on customer librarians attended workshops
tion’s sources.
conducted
department Many
on telephone
was
service. customer by
All film service the
of human also
attended
institu-
rea course
etiquette.
Otherfilm library operations-No changes were recommended
1/8 inch
=
general
1 ft (1 cm
=
1
1 m). Dimensions
diagnostic,
in met-
computed
tomog(MR) etc). Second, films from the completed examination were brought to the film library to be matched with the master film jacket
raphy (CT)/magnetic imaging, ambulatory,
that
contained
films
resonance
from
previous
examinations. (For prescheduled examinations, the master film jacket was pulled the night before the examination and forwarded to the appropriate technical area so that step two could be bypassed.) Third, the packet was delivered to a subspecialty area (eg, chest, bone, abdomen, etc) for interpretation. Finally, the films were sent back to the main film library for filing or, for inpatients, to the appropriate satellite film library for display and storage until the patient was discharged.
in sev-
eral other departmental practices. The flow of films within the radiology department involved several steps: First, the examination was performed in the designated technical area (eg,
The films tions
department
continued
from all subspecialty (except obstetric
to store
examinaultrasound)
the master film jacket. Films each examination were kept own subfolder.
in
from in their
September
1992
Figure
2.
Film library
personnel
organization
chart.
New
categories
are indicated
by shadowing
behind
terpreted (2%) (Fig 3). In the enhanced period, after implementation of the new policies and procedures, an average of 108.8 films per week (range, 63 to 132) were requested. Of these, only 1% were unavailable. The main reasons for failure were that the
12%
10%
8%
films
4%
2%
0% Enhanced
Control Period 3.
Availability
of films
for medical
x-ray
centage of films not available for conferences availability are compared between the control ods. OR = operating room.
Evaluation Medical
x-ray
conference-During
the control
period, an average of 105.6 week (range, 76-125) were requested for review at the medical x-ray conferences. Of these, 11% films
Volume
were
missing
(0.25%)
or not
yet
obtained provement
6%
Figure
boxes.
per
184
Number
#{149}
3
conferences.
Per-
and reasons for unand enhanced pen-
proved to be unavailable. The main reasons for failure were that the films were missing (4%), on loan (1%), or in the operating room (1%) or that the examination had not yet been performed (2%) or the resubts not yet in-
(0.25%) (Fig 3). The imin availability of films was statistically significant (P < .001). Tracking-The total number of tracking events averaged approximately 60,000 per month, which mdicated that each examination was tracked an average of four times between execution and final filing. Satisfaction survey-Levels of user satisfaction with the new film library systems and the medical x-ray conferences, as derived from written surveys and verbal interviews, were determined
to be high.
The
written
surveys were returned by all 18 conference attendees (100%). As shown in Table 2, the overall quality of film library service was rated as 3.78 on a scale of 1 to 5. The availability of films, the effectiveness of film library staff, and the ability to review all the films of a patient in one place at one time all received ratings of greater than 4.0. All ratings were higher than or equal Radiology
#{149} 809
to 3.5.
Subjective
data
from
the
verbal
interviews corroborated these findings. All respondents who were present during both the control and enhanced periods (n = 29) felt that film library performance had improved substantially after implementation of the new procedures (ratings ranged from “better” to “infiniteby better”). One interesting negative impact of decentralization of the inpatient film library was on the efficiency of physicians on busy medical or surgical speciabty services (eg, infectious diseases) who consulted on care of inpatients. Whereas these consultants formerly could view the films of all their patients in one location, they now had to visit the main film library as well as several separate satellite film libraries to see all the films (because the film location was determined by the affiliation of the patient’s primary physician). Most felt that this requirement was
not
burdensome
because
the
main film library’s central location within the department allowed the side trips to be short.
Control The film library steering committee and the users group continue to meet on a monthly basis. The customer satisfaction surveys are repeated monthly, and the medical x-ray conference audit is repeated semiannually; results of both are monitored by the film library manager. The new film library organization and commitment to development of management information data have allowed its manager and staff to participate in a variety of other departmental quality improvement projects.
DISCUSSION Managerial
Approaches
Social, economic, and political forces have created a climate for this country’s health care institutions that fosters competition and rewards cost containment. To cope successfully with these new imperatives, hospital managers are beginning to look to business for guidance and techniques. A growing trend is for hospitals to borrow management tools and approaches from other service industries. Among these approaches, two hold great currency for health care institutions in generab and radiology departments in particular. The first, popularized by Juran (1), is termed management breakthrough. The second, 810
Radiology
#{149}
popularized by W. Edwards Deming (2), has been linked to systems that strive for “total quality management.”
improved was ready
film library organization for implementation,
Both methods emphasize constantly improving the quality of goods or services provided to the customer. Both also emphasize use of statistical sampling techniques for diagnosis of problems and monitoring of performance. The Juran approach was used heavily by our film library task force. Juran identifies two general managerial objectives-breakthrough and control. He defines breakthrough as “change, a dynamic decisive movement to new, higher levels of performance” (1). The principles of management for breakthrough governed the first three phases of our task force’s work-research for diagnosis, formulation of recommendations for breakthrough, and evaluation of the results of new policies and procedures. Once breakthrough was accomplished, the focus of the task force shifted to reestablishment of control, a process Juran defines as “staying on course, adhering to standards, prevention of changes” (1). Finally, management information systems that allow managers to maintain informational control are established. The medical x-ray conference audit and the customer satisfaction survey represent two such tools. It is important to emphasize the robe played by radiologists in this quality improvement process. Initially, the department chairman led the way by identifying the problems with the film library and establishing a climate supportive of change. Five radiologists participated in the task force. One of these radiologists played the leading role in interviewing the film library’s customers within and beyond the radiology department. They all contributed materially to the formulation of the recommendations for improvement. Once the
public relations pare referring
obogist-technobogist
team
handled
a radithe
duties needed to prephysicians for the new system. Throughout the entire process, radiologists in departmental management established and maintamed the cooperative environment with the hospital administration that made the improvement program possible. Impact
and
Importance
Improvements in our film library have had a very positive impact on our department and, by extension, on the operation of the hospital’s many clinical services. We have both objective and subjective data to support this assertion. For example, the hiweekly medical x-ray conferences are important in guiding the decisions of the eight inpatient medical services. Improved availability of films for these conferences improved dissemination of diagnostic information and accelerated decision making. The opinion of both radiologists and nonradiologists (obtained by means of the customer satisfaction surveys, personal interviews, and informal feedback) was that the new programs had led to substantial improvements. This reaction, in turn, generalized to more positive opinions about the radiology department as a whole. We did not attempt to measure any economic impact of the changes in the film library. While the hospital did experience reductions in inpatient length of stay during the time of our project, evaluation of the relationship between this phenomenon and the improved functioning of the ifim bibrary was considered beyond the scope of this study. Similarly, we are not able to objectively estimate the relative contributions of the individual components of September
1992
the project. Certainly, the creation of a new physical plant and approval of new FTEs were important factors in the success of the film library improvement project. However, we do not believe that these valuable improvements were sufficient to guarantee success. Providing evidence for this
notion
is the
fact
that
under
our
old film library organizational plan, we actually had a number of full-time positions that were unfilled. Adding additional FTEs at that time might well have been futile. The working environment
was
sufficiently
distaste-
ful that it was difficult to recruit and retain competent employees. Only after the film library was renovated and reorganized were we able to fill both the old open positions as well as the new ones. The creation of the satellite film librarian position allowed us to promote the best personnel. It is also possible that some of the improvements in film library performance demonstrated by means of the medical x-ray conference statistics were attributable to the Hawthorne effect, which causes worker performance to improve simply because the workplace is being studied. However, we do have evidence to indicate that the improvements have, in fact, not been artifactual but sustainable over time, implying that the magnitude of such
an
effect
may
be
small.
Specifi-
cally, the audits of film availability for the medical x-ray conferences were performed
during
both
the
control
the department went through in making these changes was the critical factor. This process epitomized a smallscale total quality management project. It emphasized several important principles: It was carried out in an atmosphere that fostered change, it was participatory and multidisciplinary, and it relied on objective assessments and quantitative data in the diagnostic and monitoring phases. The success of the film library project spurred other departmental total quality management efforts, some of which have already provided or will provide insight into other aspects of the quality of film library operations. For example, a full-scale quality improvement project has been mounted to expedite the turnaround of finalized radiology reports. The diagnostic phase of this study broke down the entire process of producing, interpreting, and reporting radiographs into each component step. It found that 73% of films were matched by the film library and forwarded to interpretation
that
was
maintained
work
shifts.
cesses
has
routine
and
are
no longer deemed “experimental” by the personnel involved. The audits confirm that the improvements achieved by the film library organization have been sustained for a period of 2 years. We believe that each of the components of the film library reorganization played an important role in the project’s success but that the process
Volume
184
#{149} Number
3
level
over
from
within
1 hour
of performance all three
8-hour
Experience
A number of the key lessons learned from this project may generalize to circumstances in other institutions. The first is our focus on customer service. The users of film library services ers and
become
this
Lessons
and enhanced periods, so the improvement noted is likely to have been due to the organizational changes made. The medical x-ray conference audit and the customer satisfaction surveys are repeated on a semiannual and monthly basis, respectively. These monitoring prohave
stations
and
were were
identified as its customfully involved in the
project. This focus on customers is likely to help a department get more referrals. We know from an earlier marketing study of CT and MR imaging that provision of high-quality customer service to referring physicians the
capacity
ferral
patterns
same crue
type
from A second partnership
to influence
dramatically of positive
effect
their
radiology
Many
previous
gains. sense
de-
commondeveb-
oped without and without
a diagnostic process sufficient data. The ele-
ments
breakthrough
of the
process
took more than a year to develop and implement. Improvement was slow at first but accelerated with the implementation of each new program. A continuing challenge has been to ensure that the film library’s supervisory
positions
tions
that
actual
are
given
job
are consistent
complexity.
classifica-
with
It has
their
been
helpful
to point out that, unlike other “dencab” areas, the film library operates 24 hours a day and that the impact of any
dysfunction
is substantial
and
far-reaching. Over a period of 18 months, it has been necessary to upgrade the film library manager’s position twice to facilitate recruitment of qualified candidates. In summary, this film library improvement project demonstrated that the principles of customer service and quality improvement as well as breakthrough management techniques can be abstracted from industry and applied successfully to an operation in one of the most challenging areas of a modern hospital. It seems likely that these tools can find wide application in health care. U Acknowledgments:
The authors
McLaughlin
for manuscript
dan Kassirer
for supporting
view
of the manuscript, editorial assistance.
thank
preparation,
the project and
Jeffery
Susan Sheri-
and re-
Stoia
for
References 1.
Juran
2.
York: McGraw-Hill, 1964. Walton M. The Deming management
3.
method. New York: Dodd, Mead, Bahn AK. Basic medical statistics.
4.
of a
partmental management and the hospital administration. This team approach was helpful in creating the climate for change and in procuring needed resources. A third factor was patience and a commitment to a pro-
at analysis
of film library operonly marginal
They all focused on or intuitive solutions,
JM.
York: Grune ac-
efforts
and improvement ations had achieved
(5). The could
film library improvements. factor was the creation between
re-
cess.
5.
Hayman system Southern Radiol,
Managerial
& Stratton,
breakthrough.
New
1986. New
1972; 63-73.
AC. Radiology film-management at Los Angeles County-University California Medical Center. Appl November 1988; 29-32.
Seltzer SE, Gillis AE, Chiango BF, et al. Marketing CT and MR imaging services large urban teaching hospital. Radiology 1992;
of
in a
183:529-534.
Radiology
811
#{149}
Department
Administration
Steven E. Seltzer, MD #{149}David Sack, RT #{149}Mary Ellen Kudera, BA #{149}Lynda E. Rudolph, MS Douglass F. Adams, MD #{149}Jack E. Meyer, MD #{149}Albert E. Gillis, RT, MBA #{149} Michael A. Viera, Margaret D. Phillips, MD #{149}Charles D. Healey, RT #{149}B. Leonard Holman, MD
Improved
Radiology
An interdisciplinary authors’ institution sign for a new film
task force at the developed a delibrary that placed heavy emphasis on service to its customers. The task force established locations and staffing for “satellite” inpatient film libraries organized by clinical specialties. Inpatient films were not permitted to be taken from the radiology department but were available for 24-hour viewing. Film locations were recorded in the radiology information system. Reorganization led to important improvements in film library operations and in the clinical staff’s opinion of film library service. Objective measures of performance, such as the fraction of requested films available for conferences, showed significant improvement (P < .001). Closer working relationships developed between film librarians, radiologists, and their clinical colleagues. Film library personnel were recruited more easily and stayed on the job longer. Several hundred thousand film-tracking transactions per year were recorded. The authors conclude that decentralization of certain film library activities improved many critical aspects of performance. Index
terms:
partmental ologists, Radiology
I
From
Radiology
and radiologists,
de-
management #{149}Radiology and design of radiological facilities 1992;
the
radi-
184:805-811
Department
of Radiology,
Medical
Harvard
School and Brigham and Women’s Hospital, 75 Francis St. Boston, MA 02115. Received January 7, 1992; revision requested February 21; revision received March 23; accepted April 13.
Address C
RSNA,
reprint 1992
requests
to S.E.S.
Film
T
Library
Operations’
quality of service that a department of radiology provides has an impact on the entire health care institution. Because the film library HE
is a centralized, diobogy and
core other
resource for clinical services,
ra-
radiology
film
AND
MATERIALS
ii-
braries often function suboptimally. Problems associated with them are diverse and many, but missing films, delays in film handling, and personneb shortcomings are commonly cited. Amelioration of these problems could enormously improve the efficiency of the radiology department and the full range of clinical services that depend on it. This efficiency is prized for the implications it has not only for better service but also for reduced costs of all patient care. Because the radiology ifirn library at our institution, a 720-bed, urban teaching hospital (see Table 1 for representative departmental statistics), suffered from many operational problems and because an opportunity existed to move the film library into a new physical plant, we set out to improve its function at the same time. To do this, a task force was convened to study film library operations, improve policies and procedures, and develop objective rneasurernents of the quality of its operations and services. The steps taken for improvement and the magnitude of their impact form the basis of this report.
METHODS
The film library improvement program followed classic principles for “breakthrough management” elucidated by Juran (1) and was also influenced by the principles
the quality of its operations has farreaching implications. Fast, reliable access to diagnostic images speeds patient evaluation and facilitates clinical decision making, which may in turn have an impact on length of stay, a critical determinant of cost and the adequacy of reimbursement. On the other hand, slow, unreliable access introduces delays that can impair efficient diagnosis and treatment and increase hospital stays and costs. Unfortunately,
RT
of the
method ness
Deming
management
(2). We first developed
of the
present
an aware-
drawbacks
in opera-
tions and then created a climate for a change in attitude that could lead to improvement. To make the needed breakthrough, radiology department managers and the hospital administrators formed a partnership that was committed to creating a better physical plant and supplying additional personnel as needed. A critical element of the changed attitude was the identification of the film library’s various users (eg, physicians, patients, and radiology department personnel) as “customers” and a commitment to serving them
better. and
Organization
The departmental pointed a six-member as the steering
Research management task force
and
diagnostic
apto serve
arms
of the
project. These members included the film library manager, the chief technologist, a radiology information system specialist, a hospital management engineer, and two staff radiologists. Additional department personnel were
needed oversee going
to address
specific
radiology
added as issues and to
film library operations on an onbasis. Consultants to the task force
were drawn from the medical staff of the institution and included the chief medical and surgical residents as well as primary care
and
specialty/consulting
physicians.
The task force used several important tools during its diagnostic assessment of film library operations. First, they interviewed the film library’s physician customers (both radiologists and consulting nonradiobogists) to identify areas needing improvement and elicit ideas for change. Second, they conducted a telephone survey of film library operations at seven similarby sized academic hospitals and visited
Abbreviation:
FTE
=
full-time
equivalent.
805
three others. Third, the management engineer organized and executed an operations study of the film library, identifying the range of functions executed and enumerating Flowcharts
tasks
similarly
sized
assigned
to personnel.
were used to analyze the movement of ifims. The number, quality, and organization of film library personnel were assessed and compared with those departments
of
in the region.
Fourth, a so-called Pareto analysis (isobation of the “vital few” problems from the “trivial many”) was performed to identify those deficiencies that caused the most problems. Finally, the task force consulted with architects to design a new space that would be conducive to efficiency and customer service. Recommendations Breakthrough
for
On the basis of the information gathered in the research phase, the task force developed recommendations to improve the quality and efficiency of film library operations, suggested new policies and procedures, designed a new organizationab structure and hierarchy, and oversaw development of the architectural plans for the new physical plant.
Evaluation The
task
force
developed
performance
measures to evaluate the quality of film library operations, to assess the impact of the new policies and procedures, and to provide data for ongoing monitoring and quality assurance. First,
a simple,
objective,
quantitative
measure of the overall quality and efficiency of film library operations was deveboped. This parameter was the percentage of films available for presentation at the triweekly medical x-ray conferences. At these conferences, radiologists meet with medical house staff to review imaging studies of medical inpatients. To be available for review, a study had to pass completely through the operations of the department, from execution through interpretation
through
filing,
and be retriev-
abbe by the film librarians. The operations study indicated that this last step in the process was the one that had the most bearing on whether a ifim was available for the conference, so it was thought to be a useful indicator. When a film was unavailable for the medical x-ray conference, the reason was tabulated. These data were collected for two time periods-the control
period
(4 months
before
#{149} Radiology
was given
18 medical
x-ray
in written
conference
form
to
tions.
attendees
(four attending physicians and 14 house and in verbal form to six radiologists (all attending physicians) and 14 nonradiobogist physicians (10 attending physicians and four chief residents) who used the ifim library. The written questionnaire elicited numerical ratings for 10 specific aspects of the medical x-ray conferences (on a scale of I to 5, with 1 = poor and 5 = excellent) and asked for feedback about ifim library services. The verbal interviews were similar-respondents were for their
subjective
opinions
about
policies
and
a
Control
Once successful new programs had been established, the objectives shifted to maintaining them and reestablishing control of the ifim library. To do this, several steps were taken. First, departmental management and the hospital administration chartered the continued existence of the committee
task
to oversee
force
of film li-
continued
tools
for monitoring
and transformed
into
ifim library
perfor-
Testing
The x2 test with the Yates correction was used to compare the availability of films for the medical x-ray conferences between
the control
and enhanced
periods
(3).
RESULTS Research
procedures.
Finally, a way was found to measure the use of the electronic aids designed to improve film library operations. A count of “tracking events”-the number of times that the location of a film or folder was updated in the radiology information system-was performed. It was believed that the frequency of such tracking events would indicate how quickly and how well ifims could be located, that is, whether any given film could be retrieved and reviewed in a timely fashion. For technical reasons, this audit could not be performed before the enhanced period.
multidisciplinary
were
Statistical
of film library services. While these surveys were administered in the enhanced period only, physicians in our survey group who had been in the hospital from the control to the enhanced periods were asked specifically about how the film library had changed following implemenof new
group
mance.
range
tation
a diverse
customers came together as a users that met monthly with the film limanager to provide feedback about operations and performance. Finally, the quality assessment measures developed for the evaluation phase of the program
staff)
asked
Second,
brary group brary
the task
force’s recommendations were formubated) and th,e enhanced period (12 months after the move to the new physicab plant)-which served as a measure of the impact of the new policies and procedures. Second, a semiquantitative, subjective measure of the quality of ifim library service to physicians was developed in the form of a customer satisfaction survey that was administered to two focus groups. 806
The survey
as a steering
film library
opera-
The task force’s diagnostic assessment, including the interviews, externab studies, internal operations study, and Pareto analysis, bed to a tabulation of the strengths and weaknesses of our institution’s film library. Six specific areas were cited as the vital few whose improvement would have the biggest impact. These were as follows: Centralized operations.-The film library used a centralized type of operational structure. All active films were ified in one central facility, and all personnel worked exclusively within the confines of the film library (2,973 ft2 [268 m21 of usable space). The benefits of such centralization were believed to derive mostly from economies of scale-a wide array of functional tasks were handled without much duplication of effort. The deficiencies in the system were attributed to the limited interface between the September1992
film library and its users within and beyond the radiology department. The physical interface itself was small-a half-door reception area staffed by a single person. The temporal interface was also limited-the library was not staffed on the third shift (11 PM to 7 iri). Most film library operations and personnel were hidden from the customer’s view, hampering development of professional working relationships. Film loan policy.-The study determined that the department’s liberal film loan policy undermined the iibrary’s major mission, namely, having films available for review. The loan of inpatient films was felt to be particu-
nish its public image. Unavailability of ifims was generally considered to be the “fault” of the ifim library. Poor morale contributed to a personnel turnover rate of 25%-30% per year. The best-qualified individuals were often the most difficult to retain.
The task mendations
force developed to redress the
larly
identified.
Some
problematic,
as these
were
in
great demand by radiologists and nonradiologists. If films were “signed out” and unavailable, the impact was far-reaching. Film tracking.-Although the radiology information system allowed for easy
updating
of ifim
location
data
by
means of light pens and bar codes, the use of these tools was inconsistent. This led to a loss of confidence in the value of the tracking system, leading to a negative feedback loop that dampened enthusiasm for tracking still further. Personnel organization.-The organizational structure of the library was found to be deficient in several areas. Our film library had a staff of 25, amounting to one full-time-equivalent (FTE) librarian for every 8,281 examinations performed annually. The library was found to be understaffed in comparison with other hospitals of similar size nationwide that were surveyed, which provided an average of one film librarian FTE for every 6,300 examinations performed annually. There were only three 1evebs (staff, supervisor, manager) in our film library job hierarchy, providing little, if any, opportunity for advancement and no well-defined career paths. The working relationships between film librarians and ifim library users (technologists, radiologists, nonradiologists)
were
considered
poor.
For instance, film librarians generally felt that they were not accorded appropriate respect by other hospital personnel. Radiologists and nonradiobogist physicians attributed systematic film library deficiencies to the poor motivation and low skill levels of the film library staff. Morale and image.-The task force’s external
consultants
confirmed
that
all of the perceived deficiencies in film library operations conspired to reduce the morale of its personnel and to tarVolume
184
#{149} Number
3
Service.-Dedication
to customer
service was not perceived to be the central mission of the film library. Its customers felt that their needs were frequently not met. Recommendations Breakthrough
and
for Implementation
of these
recomproblems were
it
mod-
eled after the design of the radiology film-management system at Los Angeles County-University of Southern California Medical Center (4). These included
the
following:
Physical plant.-The new physical plant contained 4,035 ft2 (363 m2) of usable space and was designed to facilitate the proposed operational improvements (Fig 1). The new space contained a large viewing room for medical and surgical inpatient ifims, the chest reading station, a “hot file” for recent examinations ( < 2 months old), a core library or main film filing area that held films from just over 2 years of examinations, and the main departmental conference room (an additional 600 ft2 [54 m21). Additional statistics for comparing the old and new physical plants are provided in Table 1. Decentralize operations.-The task force implemented a plan for development of sateffite film libraries that would contain all inpatient films. Four of the satellite libraries were sited outside of the main film library and included those for inpatients in the neurology/neurosurgery services (library sited in neuroradiobogy readmg room), the orthopedics/rheumatobogy services (library sited in skeletal radiology reading room), the medical/surgical/coronary intensive care units (library sited in patient care area near intensive care units), and the neonatal intensive care unit (library sited near this intensive care unit). Four satellite film libraries were sited inside the new main film library complex in the so-called viewing room. Each satellite library was composed of a mubtifilm viewer for displaying current examinations for specific medical and surgical inpatient services. Each of these sateffite ifim libraries was staffed during the daytime shift by a new category of film
librarian-”satellite librarian”whose responsibilities included maintaming and updating the active film files several times a day and locating requested films for referring physicians in their areas. When patients were discharged, their folders were returned to the main film library. The motivation for this decentralization was several-fold. First, it estabbished smaller, more efficient, miniature film libraries built around clinical inpatient services. Referring physicians could come to one place and see the current studies of all their inpatients. Second, it placed these satellite libraries in close physical proximity to the subspeciabty radiologists who had the best working relationships with their colleagues on the clinical services. Consultation was thereby enhanced. Third, it brought film librarians out of relatively invisible posts in the core film library and into the main department, where they too could develop working relationships with radiology and nonradiobogy staff. Finally, because of the added responsibilities given the satellite librarians, their jobs were pegged at a higher salary grade than those of the other film library staff and a fairly large additionab level in the organizational hierarchy was created, improving the prospective career ladder. No
dling were
changes
were
made
in the
of films of outpatients; still housed in the core
han-
these film li-
brary.
Restrictfilm recommended policy
flow.-The task and implemented
that
removed
no
from
diobogy
inpatient
the
(except
films
force a could
department
be
of ra-
to be taken
to the
op-
erating room). This move was made palatable to nonradiology physicians by pointing out that in return for asking them to come to the department to see films, there would be a high probability that the films they wanted would be on display at a viewing station (or satellite library) when they arrived. Additionally, the design of the film library’s conference facilities supported the conservation of films within its confines. The medical x-ray conferences
were
held
in the
viewing
room where the films were normally on display; thus, there was no need to move the films for these meetings. The larger conference room was used for intradepartmentab activities (again, the films for these meetings did not leave the film library area). This policy was enormously beneficial for radiology operations. No
changes
eral loan
policy
were
made
in the
bib-
for films of outpatients. Radiology
#{149} 807
Manager’s
Hot
Viewing
Office
Files
I
Room
Medical/Surgical Inpalienic
I Main
Film
Filing
Area
L
gro::l
Dimensions
1
LEGEND
_________
chest
Reading
Allernator
=
!
=Workst.ation
0
chai =Film
Slorage
=Hot
I
File
Figure 1. Schematic of new tic units are 23 x 20 m.
radiology
film library
Commitment to film tracking-By means of education, training, and persuasion, all radiology department members were encouraged to be more conscientious about film tracking. Implementation of the other new policies and procedures and a perceived commitment to improving the quality of film library operations created a positive feedback loop that encouraged tracking. Modify
personnel
organization-To
open the film library and its viewing rooms for 24 hours a day, to establish the post of satellite film librarian, and to bring staffing more on a par with that of other similarly sized hospitals in the area, the department was granted six new staff positions, bringing the total to 31 FTEs (one FTE per 6,672 examinations). To manage the expanded operation and to create an improved career ladder, three additional personnel grades were added. The six film library job titles now were manager, supervisor, assistant supervisor, satellite film librarian, senior 808
Radiology
#{149}
and
conference
center.
film librarian,
and
correspondence
L
Approximate
film
scale:
librarian.
secretary
A
was
also
added. The personnel organizational chart is illustrated in Figure 2. Improve morale and public relations.The morale and public image of the film library were boosted substantially by the changes made. The department established a Film Library Appreciation Day and worked with the film library manager to fund periodic morale boosters and events for the staff. Improve
service-Emphasis
placed on customer librarians attended workshops
tion’s sources.
conducted
department Many
on telephone
was
service. customer by
All film service the
of human also
attended
institu-
rea course
etiquette.
Otherfilm library operations-No changes were recommended
1/8 inch
=
general
1 ft (1 cm
=
1
1 m). Dimensions
diagnostic,
in met-
computed
tomog(MR) etc). Second, films from the completed examination were brought to the film library to be matched with the master film jacket
raphy (CT)/magnetic imaging, ambulatory,
that
contained
films
resonance
from
previous
examinations. (For prescheduled examinations, the master film jacket was pulled the night before the examination and forwarded to the appropriate technical area so that step two could be bypassed.) Third, the packet was delivered to a subspecialty area (eg, chest, bone, abdomen, etc) for interpretation. Finally, the films were sent back to the main film library for filing or, for inpatients, to the appropriate satellite film library for display and storage until the patient was discharged.
in sev-
eral other departmental practices. The flow of films within the radiology department involved several steps: First, the examination was performed in the designated technical area (eg,
The films tions
department
continued
from all subspecialty (except obstetric
to store
examinaultrasound)
the master film jacket. Films each examination were kept own subfolder.
in
from in their
September
1992
Figure
2.
Film library
personnel
organization
chart.
New
categories
are indicated
by shadowing
behind
terpreted (2%) (Fig 3). In the enhanced period, after implementation of the new policies and procedures, an average of 108.8 films per week (range, 63 to 132) were requested. Of these, only 1% were unavailable. The main reasons for failure were that the
12%
10%
8%
films
4%
2%
0% Enhanced
Control Period 3.
Availability
of films
for medical
x-ray
centage of films not available for conferences availability are compared between the control ods. OR = operating room.
Evaluation Medical
x-ray
conference-During
the control
period, an average of 105.6 week (range, 76-125) were requested for review at the medical x-ray conferences. Of these, 11% films
Volume
were
missing
(0.25%)
or not
yet
obtained provement
6%
Figure
boxes.
per
184
Number
#{149}
3
conferences.
Per-
and reasons for unand enhanced pen-
proved to be unavailable. The main reasons for failure were that the films were missing (4%), on loan (1%), or in the operating room (1%) or that the examination had not yet been performed (2%) or the resubts not yet in-
(0.25%) (Fig 3). The imin availability of films was statistically significant (P < .001). Tracking-The total number of tracking events averaged approximately 60,000 per month, which mdicated that each examination was tracked an average of four times between execution and final filing. Satisfaction survey-Levels of user satisfaction with the new film library systems and the medical x-ray conferences, as derived from written surveys and verbal interviews, were determined
to be high.
The
written
surveys were returned by all 18 conference attendees (100%). As shown in Table 2, the overall quality of film library service was rated as 3.78 on a scale of 1 to 5. The availability of films, the effectiveness of film library staff, and the ability to review all the films of a patient in one place at one time all received ratings of greater than 4.0. All ratings were higher than or equal Radiology
#{149} 809
to 3.5.
Subjective
data
from
the
verbal
interviews corroborated these findings. All respondents who were present during both the control and enhanced periods (n = 29) felt that film library performance had improved substantially after implementation of the new procedures (ratings ranged from “better” to “infiniteby better”). One interesting negative impact of decentralization of the inpatient film library was on the efficiency of physicians on busy medical or surgical speciabty services (eg, infectious diseases) who consulted on care of inpatients. Whereas these consultants formerly could view the films of all their patients in one location, they now had to visit the main film library as well as several separate satellite film libraries to see all the films (because the film location was determined by the affiliation of the patient’s primary physician). Most felt that this requirement was
not
burdensome
because
the
main film library’s central location within the department allowed the side trips to be short.
Control The film library steering committee and the users group continue to meet on a monthly basis. The customer satisfaction surveys are repeated monthly, and the medical x-ray conference audit is repeated semiannually; results of both are monitored by the film library manager. The new film library organization and commitment to development of management information data have allowed its manager and staff to participate in a variety of other departmental quality improvement projects.
DISCUSSION Managerial
Approaches
Social, economic, and political forces have created a climate for this country’s health care institutions that fosters competition and rewards cost containment. To cope successfully with these new imperatives, hospital managers are beginning to look to business for guidance and techniques. A growing trend is for hospitals to borrow management tools and approaches from other service industries. Among these approaches, two hold great currency for health care institutions in generab and radiology departments in particular. The first, popularized by Juran (1), is termed management breakthrough. The second, 810
Radiology
#{149}
popularized by W. Edwards Deming (2), has been linked to systems that strive for “total quality management.”
improved was ready
film library organization for implementation,
Both methods emphasize constantly improving the quality of goods or services provided to the customer. Both also emphasize use of statistical sampling techniques for diagnosis of problems and monitoring of performance. The Juran approach was used heavily by our film library task force. Juran identifies two general managerial objectives-breakthrough and control. He defines breakthrough as “change, a dynamic decisive movement to new, higher levels of performance” (1). The principles of management for breakthrough governed the first three phases of our task force’s work-research for diagnosis, formulation of recommendations for breakthrough, and evaluation of the results of new policies and procedures. Once breakthrough was accomplished, the focus of the task force shifted to reestablishment of control, a process Juran defines as “staying on course, adhering to standards, prevention of changes” (1). Finally, management information systems that allow managers to maintain informational control are established. The medical x-ray conference audit and the customer satisfaction survey represent two such tools. It is important to emphasize the robe played by radiologists in this quality improvement process. Initially, the department chairman led the way by identifying the problems with the film library and establishing a climate supportive of change. Five radiologists participated in the task force. One of these radiologists played the leading role in interviewing the film library’s customers within and beyond the radiology department. They all contributed materially to the formulation of the recommendations for improvement. Once the
public relations pare referring
obogist-technobogist
team
handled
a radithe
duties needed to prephysicians for the new system. Throughout the entire process, radiologists in departmental management established and maintamed the cooperative environment with the hospital administration that made the improvement program possible. Impact
and
Importance
Improvements in our film library have had a very positive impact on our department and, by extension, on the operation of the hospital’s many clinical services. We have both objective and subjective data to support this assertion. For example, the hiweekly medical x-ray conferences are important in guiding the decisions of the eight inpatient medical services. Improved availability of films for these conferences improved dissemination of diagnostic information and accelerated decision making. The opinion of both radiologists and nonradiologists (obtained by means of the customer satisfaction surveys, personal interviews, and informal feedback) was that the new programs had led to substantial improvements. This reaction, in turn, generalized to more positive opinions about the radiology department as a whole. We did not attempt to measure any economic impact of the changes in the film library. While the hospital did experience reductions in inpatient length of stay during the time of our project, evaluation of the relationship between this phenomenon and the improved functioning of the ifim bibrary was considered beyond the scope of this study. Similarly, we are not able to objectively estimate the relative contributions of the individual components of September
1992
the project. Certainly, the creation of a new physical plant and approval of new FTEs were important factors in the success of the film library improvement project. However, we do not believe that these valuable improvements were sufficient to guarantee success. Providing evidence for this
notion
is the
fact
that
under
our
old film library organizational plan, we actually had a number of full-time positions that were unfilled. Adding additional FTEs at that time might well have been futile. The working environment
was
sufficiently
distaste-
ful that it was difficult to recruit and retain competent employees. Only after the film library was renovated and reorganized were we able to fill both the old open positions as well as the new ones. The creation of the satellite film librarian position allowed us to promote the best personnel. It is also possible that some of the improvements in film library performance demonstrated by means of the medical x-ray conference statistics were attributable to the Hawthorne effect, which causes worker performance to improve simply because the workplace is being studied. However, we do have evidence to indicate that the improvements have, in fact, not been artifactual but sustainable over time, implying that the magnitude of such
an
effect
may
be
small.
Specifi-
cally, the audits of film availability for the medical x-ray conferences were performed
during
both
the
control
the department went through in making these changes was the critical factor. This process epitomized a smallscale total quality management project. It emphasized several important principles: It was carried out in an atmosphere that fostered change, it was participatory and multidisciplinary, and it relied on objective assessments and quantitative data in the diagnostic and monitoring phases. The success of the film library project spurred other departmental total quality management efforts, some of which have already provided or will provide insight into other aspects of the quality of film library operations. For example, a full-scale quality improvement project has been mounted to expedite the turnaround of finalized radiology reports. The diagnostic phase of this study broke down the entire process of producing, interpreting, and reporting radiographs into each component step. It found that 73% of films were matched by the film library and forwarded to interpretation
that
was
maintained
work
shifts.
cesses
has
routine
and
are
no longer deemed “experimental” by the personnel involved. The audits confirm that the improvements achieved by the film library organization have been sustained for a period of 2 years. We believe that each of the components of the film library reorganization played an important role in the project’s success but that the process
Volume
184
#{149} Number
3
level
over
from
within
1 hour
of performance all three
8-hour
Experience
A number of the key lessons learned from this project may generalize to circumstances in other institutions. The first is our focus on customer service. The users of film library services ers and
become
this
Lessons
and enhanced periods, so the improvement noted is likely to have been due to the organizational changes made. The medical x-ray conference audit and the customer satisfaction surveys are repeated on a semiannual and monthly basis, respectively. These monitoring prohave
stations
and
were were
identified as its customfully involved in the
project. This focus on customers is likely to help a department get more referrals. We know from an earlier marketing study of CT and MR imaging that provision of high-quality customer service to referring physicians the
capacity
ferral
patterns
same crue
type
from A second partnership
to influence
dramatically of positive
effect
their
radiology
Many
previous
gains. sense
de-
commondeveb-
oped without and without
a diagnostic process sufficient data. The ele-
ments
breakthrough
of the
process
took more than a year to develop and implement. Improvement was slow at first but accelerated with the implementation of each new program. A continuing challenge has been to ensure that the film library’s supervisory
positions
tions
that
actual
are
given
job
are consistent
complexity.
classifica-
with
It has
their
been
helpful
to point out that, unlike other “dencab” areas, the film library operates 24 hours a day and that the impact of any
dysfunction
is substantial
and
far-reaching. Over a period of 18 months, it has been necessary to upgrade the film library manager’s position twice to facilitate recruitment of qualified candidates. In summary, this film library improvement project demonstrated that the principles of customer service and quality improvement as well as breakthrough management techniques can be abstracted from industry and applied successfully to an operation in one of the most challenging areas of a modern hospital. It seems likely that these tools can find wide application in health care. U Acknowledgments:
The authors
McLaughlin
for manuscript
dan Kassirer
for supporting
view
of the manuscript, editorial assistance.
thank
preparation,
the project and
Jeffery
Susan Sheri-
and re-
Stoia
for
References 1.
Juran
2.
York: McGraw-Hill, 1964. Walton M. The Deming management
3.
method. New York: Dodd, Mead, Bahn AK. Basic medical statistics.
4.
of a
partmental management and the hospital administration. This team approach was helpful in creating the climate for change and in procuring needed resources. A third factor was patience and a commitment to a pro-
at analysis
of film library operonly marginal
They all focused on or intuitive solutions,
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