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
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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!