Expediting the Turnaround of Radiology Reports

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Kazanjian3. Glenn. Laffel2. Kitt Shaffer1. Dan Williamson1. Piran. Aliabadi1. Albert E. GiIIis1 ...... Laffel GL, Blumenthal D. The case for using industrial quality.
775

Expediting the Turnaround of Radiology Reports: Use of Total Quality Management to Facilitate Radiologists’ Report Signing

Steven E. Seltzer1 Pauline Kelly1 Douglass F. Adams1 Brian F. Chiango1 Michael A. Viera1 Ethan Fener1 Ron Rondeau2 Nancy Kazanjian3 Glenn Laffel2 Kitt Shaffer1 Dan Williamson1 Piran Aliabadi1

Albert B. Leonard

E. GiIIis1 Holman1

OBJECTIVE. The purpose of this study was to determine agement techniques could be used to speed radiologists’

signing

whether total quality manperformance on the task of

reports.

SUBJECTS AND METHODS. Total quality management represents a group of tools that can be used to improve the functioning of complex processes In the workplace. The steps Involved in our total quality management project were as follows: (1 ) com-

mit to improving

radiologists’

performance,

(2) commission

an interdIsciplinary

team, (3) propose hypotheses for the causes of signing delays, (4) issues constraInIng performance (Pareto analysis), (5) intervene to atic problems in a test system, (6) evaluate the results of intervention report signing performance, and (7) hold the gains achieved by the

interdisciplinary study reports: (1 ) radiologists’ for signing (e.g., nights tionist and radiologist,

radiologist,

team identified absence from and weekends), (3) requirement

(4) lack of a system

study

IdentIfy the key correct systemon radiologists’ intervention. An

five key obstacles to prompt signing of the department when reports were available (2) dysfunctional hand-off between transcripthat

for signing

a fellow

by proxy

or resident

(if primary

sign

before

radiologist

a staff

is away),

lack of impact of signed report on clinical decision making. RESULTS. Interventions included (1) providing home computer terminals, (2) implementing a buddy system for proxy signing, (3) eliminating the requirement for a signature from a fellow or resident, (4) teaming groups of radiologists with specific transcriptionists, and (5) streamlining transcription service. When these enhancements were used in a test system, the mean time required to sign reports decreased 59% from 26.0 ± 8.4 hr (mean ± standard error) in the baseline period to 10.6 ± 2.9 hr (in the enhanced period, p = .05). CONCLUSION. We conclude that total quality management methods can accelerate radiologists’ signing of reports. (5) perceived

AJR 1994;162:775-781

Received October 4, 1993; sion December 3, 1993. 1Department of Radiology,

accepted

after

Harvard

revi-

Medical

School, Brigham and Women’s Hospital, 75 Francis St., Boston, MA 02115. Address correspondence to S. E. Seltzer. 2Department and Women’s 3Department Brigham

of Quality Hospital, of

and Women’s

Management,

Boston, Management Hospital,

Brigham

MA 02115. Engineering, Boston,

0361-803X/94/1 624-0775 © American Roentgen Ray Society

MA 02115.

Timely communication of the results of radiologic studies is a mission-critical task for any imaging department. Prompt reporting is a requirement in meeting the standards of the American College of Radiology, accreditation and regulatory agencies, and managed care organizations; it is also a critical element in the selection of a radiologist by a referring physician [1-3]. However, despite the acknowledged importance of speedy turnaround of radiology reports, problems and deficiencies in this process are thought to be quite common. In our department, turnaround time has traditionally been protracted, with the total time to generate a final report averaging 60-70 hr, and the time for the senior radiologist to edit and sign the report accounts for 30-35 hr of this process. These turnaround times have been stable for many years and have resisted change through traditional management methods. Total quality management (TQM) is a portfolio of management techniques that are used to minimize dysfunction in complex workplace systems. Developed and implemented first in industrial settings, notably in foreign automobile manufacturing, TOM

776

SELTZER

(also commonly referred to as continuous quality improvement or CQI) has recently been used with success in health care institutions [4-6] and, specifically, in radiology departments [79]. In a recent publication in AJR, Bluth et al. [10] found that TOM methods can help shorten report turnaround time. Their study and the report by Blunt [11] focused on the first phase of the report turnaround process, namely accelerating the delivery of films to radiologists to speed the interpretation process. Little work has been reported to date on the latter parts of the turnaround process, namely the radiologist’s editing and signature of radiology reports. Because physicians’ behavior is notoriously difficult to change, this last step is arguably the most intractable step in the process. Therefore, we set out to use TOM methods to attempt to accelerate report signature by the staff radiologist. We report the steps involved in this quality improvement process and the results obtained with interventions designed to expedite report signing.

Materials

and

Overview Figure

and Nomenclature

1 is a high-level

of the

institution. tems,

We

Sudbury,

(lDXrad,

in

and

films

dictation.

the

through

status

forwarded

Next,

and the

radiologist the

report

Sys-

system

VT). As an its status

is

When the imaging and itsstatus in the

the images

radiologist

at our

information process,

complete,

to the the

to dictated,

system.

reporting

“C.”Then

as

process

Burlington,

system.

it is termed

dictating,

information

the

information

is listed

and

When

radiology

are matched

with

for interpretation

uses

a bar-code

status

is designated

is transcribed

and

and reader

to

as “D”

in

designated

identified by the letter “P.” Last, the radiologist edits and the reportelectronically, changing itsstatusto final,designated with an “F.” Once final, the report is distributed electronically over the preliminary,

signs

hospital

information

system

or by mail

to the

referring

The Quality Improvement Step

physician.

The

radiology information system can be used to identify the timing of various steps in the reporting process.

-

STATUS:

C

P

F

P

which

to F

- --

FIg. 1 -Flow chart of report turnaround process. Radiology informatlon system provides data on duration of steps in process. Time taken for an examInation to be dictated and transcrIbed (C to P tIme) can be added to time taken for radiologist to edit and finalize the report (P to F time) to reach total report turnaround time (C to F time). Each of these metrics of =

the

cian

to change-To

the project, senior the speed sign their reports and developed the followmade

“signing

editing

report,

takes

start

a commitment

to improve

time,”

defined

and signature more

than

process

of physi-

of the transcribed

as the

radiology

24 hours.

Step 2. Commissioning a quality improvement team-Departmental managers commissioned a quality improvement team, which was an 11-member interdisciplinary group. These individuals included five radiologists, two technologist managers, the radiology information systems manager, the radiology quality management expert (who served as the group’s facilitator), and two hospital management specialists. The team met every 2 weeks for the 15-month of the

project.

quality-improvement

generation-The team

making

brainstorm

as many

potential

process

a flow

nature part of the report turnaround

chart

process.

reasons

began

of the

with

physician

the sig-

Then, the group met to

as possible

for delay

in sign-

ing of reports. A total of 14 main mechanisms and four submechanisms for delays in report signing were proposed and judged reasonable (via a process termed multivoting; Table 1). The

signature

process

was

studied

further

through

use

of a more

detailedflowchart.Reasons for delay in reportsigning were added at their

impact

points,

providing

the

team

with

a cause

and

effect

diagram (Fig.2). Step 4. Identifying the key issues and developing rational therapies for each-To validate and estimate the impact of each proposed mechanism for signing delay, we used two investigational tools. The first was to survey staff radiologists via written questionnaire and personal interview to elicit information about their current report-signing practices, as well as their ratings of the relative impor-

1: Fourteen

Possible

periods (radiologist

Double-signing

C to F

time taken for substeps in report turnaround this project. C = completed; D = dictated; P

Process

Reasons

for Delay

in Report

Signing

unavailable)

(trainee and staff)

No free time in workday to sign Radiologist not aware that reports are available Asynchrony between transcription and radiologist availability Lack of available terminal Low motivation, especially that caused by system problems Difficult logistics (many reports in queue that are unsigned by trainee)

‘#{248}

C to P

1994

Evenings/weekends Research days Vacation Off site ___________

METRICS:

April

To investigate the report-signing process and develop and implement procedures which would result in an explanation and reduction by 80% in the number of reports for

Blackout

liON

D

managers

with which radiologists ing mission statement:

TABLE

EPLET1ONDIAnON

1. Committing

departmental

Step 3. Hypothesis

(RTAS, Sudbury

system

AJR:162,

duration

reporting

DX Corporation,

its way

system

previous

dictation

radiology

is finished,

information

chart

a computerized

DECrad,

the

examination

change

a digital

MA) works

updated

flow

use

formerly

examination

the

Methods

of Report Signing Process

ET AL.

process was tabulated for preliminary; F = finalized.

Impersonal

process (lack of connectedness

between

and radiologist) Limited direct reward for signing promptly Drudgery (too many reports to correct; too many

No uniformity No “safety Unrealistic

in departmental

net” for overdue way of flagging

practices

to sign)

or standards

reports reports needing

transcriptionist

attention

EXPEDITING

AJR:162, April 1994

TURNAROUND

OF

RADIOLOGY

REPORTS

777

reasons for delay in signing. Thirty-five responded to the written survey; 12

mean (Fig. 4). These historical data were used to validate and rank the highest-rated candidate mechanisms for signing delay. To do

were interviewed in person. The radiologists’ ratings were then tabulated, and the mechanisms were displayed in a rank-ordered list of importance (often termed a Pareto diagram; Fig. 3).

this, the data were stratified according to the criterion under consideration. For example, in order to evaluate the role played by “blackout periods” (i.e. , times when reports were available for signature but the radiologist was not present in the department and was therefore unavailable to sign them), we compared the signing performance of staff radiologists who sign their reports from home on computer terminals with the performance of radiologists without such capability. Radiologists who can sign at home would be expected to be influenced far less by the blackout phenomenon than would those radiologists without that capability. Three staff radiologists sign reports from home; they ranked first (fastest), second, and fourth (out of 38) in their report-signing performance. This observation supported the notion that blackout periods were the most important impediments to signing. On the basis of the analysis of the questionnaires, interviews, and historic data, the quality-improvement team selected and prioritized (a so-called Pareto analysis) five key factors that appeared to

tance of the 14 hypothesized (92%) of 38 staff radiologists

The

second

investigational

tool

was

a review

of

report

signing

time data. The average preliminary to finalization (P to F) times for each of 38 staff radiologists were tabulated for a 6-month period from January 1 to June 30, 1991. The average time from the end of transcription to sign-off was 29.8 hr, with a standard deviation of 13.1 hr. The results are plotted as a control chart with upper and lower

control

limits

specified

as one

standard

lEII1 not

from

the

.

impede t

Reports

deviation

reads

to

_____________________

ACCESS

Reports

typed

report

designed

,ncorrrcdy

finalization

minimize

their

and

impact.

to redress

designed These

them

included

so-called factors

the

and

rational the

therapies interventions

following:

REPORTS

1 . Blackout periods. To reduce the amount of time when a radiologist could not sign reports, we proposed two interComputer

or teminal

down

ventions.

LOGIN

Terminal

t

not ava,lable TERMINAL

AVAILABLE

t

No decision

erated

Fig. 2.-Cause and effect diagram. This chart portrays a detailed and organized tabulation of potential reasons for delay in last step in reporting process,

namely,

signature

by a staff

The

first

was

to

provide

home-signing

equip-

ment, either a terminal or a personal computer and a highspeed modem. The second was to design a buddy system in which each radiologist teamed with another to formalize a back-up plan for report signature by proxy. 2. Double-signature requirement. To reduce the delay incurred waiting for a trainee to edit and sign the report first, we asked staff radiologists to sign without a trainee signature. 3. Asynchronous transcription-to-radiologist handoff. To smooth the interface between radiologists and transcriptionists, the team proposed that a more personalized form of transcription be provided by teaming specific transcriptionists with a group of radiologists. These transcriptionists would be instructed to accelerate the typing of reports gen-

radiologist.

Potential

by

their

radiologists

and

give

them

priority

over

other work. 4. Time and terminals. Where necessary, it was proposed that additional computer terminals be made available. 5. Low motivation. The provision of accelerated typing of reports was designed to boost radiologists’ motivation to sign reports promptly. It was thought that radiologists would be inclined to sign reports quickly if they thought that a final-

reasons

for delay are plotted In a hierarchy that Is represented by branching lines emanating from each step in the process. Pattern of branching lines gives rise to alternative name for this type of chart, a flshbone diagram.

ized

report

time frame

could

be made

that would

available

influence

to referring

clinical

decision

doctors

in a

making.

Step 5. Intervention-The

department chair and the hospital’s viceapproved the implementation of the proposed enhancements in a trial program. A test group of five body CT/MR radiologists from the abdominal imaging section were briefed about the quality-improvement program and agreed to participate. president

for clinical

operations

Step 6. Data collection tions.-The it

I

Fig. 3.-Pareto diagram shows relative Importance ascribed by staff radiologists to 18 factors that might Impede report finalizatIon. 1 = not important; 5 = very important. Pareto diagram allows one to select factors thought to have greatest Influence over a complex process.

the report radiologists benefited accelerated month

and analysis

to evaluate

the interven-

value of the interventions was assessed by comparing signing performance achieved by the five “experimental” during a 12-week “enhanced period” (during which they from

home

signing,

transcription) “baseline

period”

no double-signature to

their

(before

own the

requirement,

performance institution

during of

the

and a

enhance-

6-

778

SELTZER

ET AL.

AJR:162,

April 1994

Results

Gains

Achieved

Through

the Intervention

Global measures-Table experimental and control and

enhanced

periods.

2 contains radiologists

Each

of the

pertinent data for the during the baseline

five

experimental

radiol-

ogists reduced their mean signing time, whereas that for the control radiologist increased (Fig. 5). As a group, the experimental radiologists’ signing time in the enhanced period dropped

59%

from

the

statistically significant signing time increased Fig. 4.-Baseline report-signing performance by 37 staff radiologists between January and June 1991. Means ± 1 SD are Indicated in this control chart. Upper control limit (ucl) is 1 SD above mean; lower control limIt (Id) is 1 SD below mean. Performance falling outside of these boundaries is usually attributed more to Individual factors than to systematlc causes. C = control radiologist.

Four ability

of the five to sign

clinical

area

mental

group).

Four

and

the

measures

study

team

of signing

experimental radiologists, ment as a whole: 1 . Average

at least

performance

were

the control

time taken

2. Percentage

wanted

served as their had his perforan external conreading room as of the enhancehave been desirworking in this

five

in the

tabulated

radiologist,

to sign the report

and

(mean

line)

five

te

depart-

to

saw 19%

(P to F > 24 hr); 24 hr was established as the minimum performance standard for this step in the process. 3. Average time for complete report turnaround (mean P

24 hr. The

a corresponding (enhanced)

.

change

was

improved

in their

performance

of one

increase

in

the

from

proportion

16%

(base-

his

out-of-

of

radiologists improved their times, whereas the control (Fig. 6). For the experimental

Un.ii=poa

Lk1hI

:

P to F).

of reports taking more than 24 hr to sign

This

radiologists

within

bounds reports. Each of the five experimental average total report turnaround radiologist showed no change

experi-

for the

the

experimental

reports

period.

radiologist showed no substantial change. For the experimental group overall, the percentage of examinations considered out of bounds dropped from 34% in the baseline period to 13% in the enhanced period (p = .09). The control radiologist

ments). In this way, each of these five radiologists own internal control. Also, one additional radiologist mance measured in the two periods and served as trol. This “control” radiologist worked in the same the experimental radiologists, but received none ments (a larger number of external controls would able; however, there were only six radiologists

baseline

(p = .05). The control radiologist’s by 57% in the same time frame.

to F time).

4. Percentage of reports taking more than 48 hr to turn around completely (C to F > 48 hr); 48 hr was the standard for the entire turnaround process.

Fig. 5.-Mean

Step 7. Holding the gains-To evaluate the stability of gains made by the performance enhancements, we measured the same parameters recorded during the pilot program again during monthly follow-up assessments that started after the end of the 12-week pilot program and continued for 4 months. The performance of the experimental radiologists was compared with that of the department at large.

signature

(e.g.,

plain film

interpretation)

StatisticalAnalysis To evaluate

tailed of

the

their

the

Student’s five

radiologist

radiologists

and

that

of the

system

was

also

data in a form that did not allow comparisons were made.

used

the

on the signing in the

period.

enhanced

The

compared

department provided

we

data

in the baseline

radiologists

information

of interventions,

to compare

experimental

performance

experimental ogy

impact

t-test

statistical

summary

testing,

two-

period

with

performance

with

at large. these

paired,

performance

that

However,

of the

of the

control

the

radiol-

department-wide

so only qualitative

time (preliminary

(P] to finalized

[F] time) for

five experimental and one control radiologist In baseline and enhanced periods. Numbers above columns are numbers of reports audited. Differences in numbers of reports generated by each individual reflect frequency with which they were assigned to relatively high-volume areas

i Fig. 6.-Average

or low-volume

ones

(e.g.,

MR).

FrAil total report turnaround

ized [F] time) for five experimental and enhanced periods. Numbers audited.

time (completed [C] to finaland one control radiologist in baseline above columns are numbers of reports

AJR:162,

TABLE

April

EXPEDITING

1994

2: Radiologists’

Report-Signing

TURNAROUND

Percentage

B 31

B

E

6

54 81 30 6

6 40 8 4

72 125 56 46

27 13.5 ±7.1 19.0

39.0

59 20 8

22 11 7

5

27 26.0”

15 10.6

±8.4

±2.9

16.2

25.4

26 34.4 ± 12.9 15.8

32.4

37.7

35.4

Department Note-B = baseline period, E np .05 enhanced vs baseline.

=

enhanced

period,

P

=

preliminary,

F

=

finalized,

group as a whole, these times dropped by 40%, and this change was statistically significant (p = .04). Their average percentage of reports considered out of bounds for this parameter declined from 51% in the baseline period to 29% in the enhanced period (p = .01). The control radiologist improved also, dropping from 41% to 38% out of bounds. Figure 7 compares report turnaround times of the participating experimental radiologists with turnaround times for the

department

as a whole.

The

average

report

turnaround

for the department as a whole changed little between the baseline and enhanced periods, whereas the experimental radiologists significantly improved their turnaround time. Figure 8 shows the fine-grain detail (2- and 4-hr increments) in the distribution of report Signing times in the baseline and enhanced periods. In the baseline period, reportsigning activity followed a trimodal distribution with substantial numbers of reports being signed immediately (0-2 hr), within

1 day

(20-24

hr),

and

after

REPORTS

more

Mean C to F (hr)

E

2 3 4 Five experimental radiologists (weighted mean ± SE) Control radiologist

with

PtoF>24hr

Radiologist

-

RADIOLOGY

779

Performance

Mean P to F (hr)

1

OF

than

48

hr.

In the

-

B

C

=

Percentage

with

CtoF>48hr

Number

o f Reports

E

B

E

39 73 43 38

58 84 45 26

26 54 23 19

1315 933 964 1913

142 82.5” ± 19.2 81.0

73 49.1 ±8.1 80.5

62 51.0” ±9.6 41.4

1188 6,313

504 2,845

118.1

109.4

54.0

38 29.0 ±6.3 38.1 58.4

1,884 93,102

741 45,741

complete,

SE

=

B

E 846 324 488

683

standard error.

Individual radiologists.-The focus group of experimental radiologists indicated positive responses to the performance enhancements. They thought that the home-signing system was beneficial and generally acceptable, not overly intrusive on their personal time. Interestingly, the major constraint on home signing tended to be access to the telephone while at home. Home signing on weekday evenings was generally considered less of an imposition than on weekends. Few of the experimental radiologists logged-on to the radiology computer system more than once each weekend. Other components of the program were also rated highly, and enthusiasm was expressed about the likelihood of success in generalizing these components of the pilot program

departmentwide. Interviews with the radiologist who responded least well to the interventions suggested that his personal work habits were not well-suited to benefit from the enhancements provided in this test. For example, this individual frequently

enhanced period, the fraction of reports signed immediately rose substantially, and the heights of the secondary and tertiary peaks in report signing decreased.

0%

l

.

Fig. 7.-Comparison

C.=pu.ao

OPI1OOiiy

Sipo,

of total report

.S%__

IIi.F.i.1 .t.i__.t.

Fig. 8.-Fine-grain nary (P] to finalized

:

turnaround

j

.%k-b.-M.-

times

(completed

finalized [F] time) between experimental radiologists and department a whole. Numbers above columns are numbers of reports audited.

[C] to

as

_

.i .i

.1

details of distrIbution of signature times (prelimi[19 tIme In 2- and 4-hr Increments) for five experimen-

tal radiologists, comparing baseline wIth enhanced periods. Vertical dotted line shows 24-hr mark, time established as minimum standard for report signature, and cumulative percentage of reports signed within 24 hr is Indicated.

SELTZER

780

ET AL.

TOM ments

0!

P-nt

AJR:162,

approach in

our

has proved very

effective

complex

[P] to fifor ex-

works in his office late into the evening each work night. He commented that by the time he finished his writing and correspondence, he did not have the energy or motivation to sign reports upon returning home.

Holding

the Gains

During the monitoring periods after the end of the pilot program, some of the gains were lost (Fig. 9). The experimental radiologists still performed substantially better than during the control period, but not as well as during the pilot program itself. During the follow-up period, their average signature time increased by approximately 3 hr, indicating that about 20% of the gains realized by the enhancements were dissipated. Interestingly, the performance of the department as a whole also degraded by approximately 11% during the follow-up period, so that the substantial lead in performance achieved by experimental radiologists over other departmental radiologists continued throughout the follow-up periods.

Discussion TQM Principles The principles of TOM guided performance of this project and can be summarized in four major categories. First, TOM techniques focus on processes, not people. They rest on the assumption that problems encountered with complex, multifactorial workplace systems are attributable to weaknesses in the processes themselves, not to the people in the workplace. Second, TOM methods rely on involvement of a team of people who actually work with the processes under study and who represent all the professional roles involved. Third, TQM analytic tools are scientific in nature, and the diagnosis of process problems uses hypothesis testing. Fourth, TOM stresses the need for follow-up, ongoing monitoring, and continuous improvement.

TQM Strengths

and Limitations

In our hands, the principles of TOM payoff and epitomized the method’s

have had a substantial strengths. Use of the

1994

improve-

system.

The

approach encouraged interdisciplinary team building within the department. The objectivity of TOM was appealing to physicians and other team members who are comfortable with a data-driven, analytic approach to problem solving. The project was relatively low in hardware costs. The only equipment costs were computer terminals and high-speed modems for five radiology staff (up to $1200 per setup; some radiologists already owned personal computers or modems, thus saving costs). Despite the attractiveness

Fig. 9.-Ongoing monitoring. Signature time data (preliminary nalized [F] time) from follow-up monitoring perIods are displayed perimental radiologists and department as a whole.

in producing

departmental

April

tions

were

its specific

evident.

First,

objectives.

the

of the TOM approach, limitadid not quite reach all of

project

Although

significant

improvements

in

performance were realized, only a 60% reduction in reports taking more than 24 hr to sign was achieved, not the 80% target. Second, it proved difficult to hold the gains. Within 4 months in the monitoring period, 20% of the improved signing performance was lost. There was, in fact, a departmentwide trend toward deterioration in signing performance over the period of the study. From the baseline period in early 1991 to June 1992, the mean departmental signature time increased 31%; the control radiologist’s time increased 57% over approximately the same time frame. Third, it is possible that the gains achieved by the interventions were artifacts of the experimental environment (the so-called Hawthorne effect). Although such an effect was most likely present (it is almost unavoidable in behavioral science studies), the performance of the control radiologist would appear to indicate that its magnitude was small. The control radiologist was in the same environment as the experimental group-he worked in the same reading room and knew that his report-signing times were being monitored. However, the control radiologist’s signing times actually worsened during the test period, while the experimental group improved significantly. Fourth, a specific limitation of our experimental design (but not of TOM generally) was that all the interventions were applied at once. Therefore, it is not possible to determine their individual impact. We chose to implement all the enhancements simultaneously because we believed that they would act synergistically. We were also concerned that the impact of any individual enhancement would be too small

to measure.

It is possible for a critic of TOM to argue that other, more “traditional” management approaches might have been more successful than TOM. For example, some departments use monetary incentives to reward or punish staff members whose report-signing performance exceeds or falls short of an articulated standard of practice. These approaches may work well and are often most successful when targeted at influencing a specific behavior like report signing. Despite their simplicity, the adverse effects of use of these “carrot and stick” management tools are beginning to be better appreciated. Particularly when used to adjust the behavior of highly trained professionals, they tend to demoralize the staff and undermine their loyalty to the department

AJR:162,

April

EXPEDITING

1994

TURNAROUND

and the institution. In addition, use of traditional tools alone misses the opportunity to understand the processes that operate in complex human systems, and it is only by optimizing these processes that long-term improvements in the systems can be achieved. In conclusion, TQM was successful in leading to significant improvement in the report-signing process. Although the specifics of our quality improvement effort may not generalize to other imaging departments, TOM might be useful elsewhere. It is up to the readers to decide whether such management techniques would work for them and whether the benefits justify the costs. We believe that TOM can improve the functioning of complex departmental systems. An ongoing commitment to continuous quality improvement is important to sustain the gains achieved here and to make additional progress.

OF

REPORTS

781

REFERENCES 1 . ACR standards, diagnostic radiology resolution #5: 1991. Reston, vA American College of Radiology, 1991 2. Seltzer SE, Gillis AE, Chiango BF, et al. Marketing CT and MR imaging services in a large urban teaching hospital. Radiology 1992;183:529-534 3. Lopiano M, Stolz J, Sunshine J, Fisk T, Leepson E. Physician referrals to radiologists. AJR 1990;1 55:1327-1330 4. Berwick DM. Continuous improvement as an ideal in health care. N Engl J Med 1989:320:53-56 5. Goldsmith J. A radical prescription for hospitals. Harvard Bus Rev 1989; 67:104-111 6. Laffel GL, Blumenthal D. The case for using industrial quality management science in health care organizations. JAMA 1989:262:2869-2873 7. Paulin S. Total quality management in healthcare. Invest Radiol 1992;

27:101-1 02 8. Seltzer SE, Sack D, Kudera operations.

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ME, et al. Improved

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9. Chopra PS, Kandarpa cess in a cardiovascular and interventional Manage Health Care 1992;1 :21-28 10.

ACKNOWLEDGMENTS

RADIOLOGY

Bluth El, Havrilla M, Blakeman C. Quality to improve the timeliness of preoperative

radiology

the patient

radiology

film library

evaluation

department.

proQua!

improvement techniques: value chest radiographic reports. AJR

1993;160:995-998

The authors in manuscript

thank Susan McLaughlin preparation

and editing.

and Sally Edwards

for help

11. Blunt ML. Continuous 1992;11 :34-41

quality

improvement

for radiology.

Admin

Radio!