improving performance in a nuclear cardiology department

Volume 18, Number 1/2005 83

Improving Performance in a Nuclear Cardiology Department

Doug LaFleurWestern Michigan University and MEDAxiom

Karolyn SmalleyMEDAxiom

John AustinWestern Michigan University

ABSTRACT

Improving performance in the medical industry is an area that is ideally suited for the tools advocated by the International Society of Per-formance Improvement (ISPI). This paper describes an application of the tools that have been developed by Dale Brethower and Geary Rummler, two pillars of the performance improve-ment industry. It allows the reader to follow a step-by-step approach in a proj-ect conducted within a cardiology prac-

tice. The tools we used are grounded in behavioral systems analysis as well as in applied behavior analysis. The paper describes how these tools help improve the throughput of a department within a medical practice, while taking into account that this department is one part of the entire medical practice, as well as the local and national medical community. Each tool utilized is shown as it fits into the puzzle of solving the problem described by the client.

Approximately 16,000 cardiolo-gists practice in the United States. These cardiologists are employed by hospitals and cardiology prac-tices ranging in size from a single practitioner to large groups of 30 cardiologists or more. Each year ap-proximately 850 first year fellows are admitted into training programs to supply this need. However, the demand for cardiologists far exceeds the supply, prompting the American College of Cardiology (ACC) to estab-lish a task force to study the growing shortage and to issue recommenda-tions on how to increase the num-ber and efficiency of cardiologists.

A 2004 issue of the Journal of the American College of Cardiology includes an introduction of the rec-ommendations gathered by the task force that states, “Today there are jobs for practitioner and academic cardiologists in most regions of the US. About 40% of the nation’s hospi-tals with 100 or more beds are seek-ing cardiologists and about one half of these institutions believe it is ‘very hard to recruit them’” (Nainggolan, 2004, p. 1). Thus, hospitals and out-patient cardiology clinics have been searching for more efficient ways of providing patient care. Solutions to improve patient care and efficiency

Performance Improvement Quarterly, 18(1) pp. 83-109

84 Performance Improvement Quarterly

from cardiologists have included an increase in the use of mid-level providers, merging of existing car-diology practices to gain economies of scale, as well as finding ways to improve the efficiency of existing processes within practices.

The medical community has also experienced continual decreases in reimbursements from insurance companies. This has been caused in part by the federal government’s interest in decreasing their reim-bursement expenses in the Medicare program, which major insurance companies use as their guide to reim-bursement rates. Medicare decreases have caused cardiology practices to search for additional profit centers, new testing modalities, and ancil-lary services to maintain the income levels expected by their doctors. This trend is projected to continue with ad-ditional proposed cuts on the horizon that will greatly impact the profit-ability of practices. In particular, nuclear cardiology is slated to receive cuts in reimbursement in the next few years.

Nuclear cardiology is a highly ef-fective modality used to assess dam-age from cardiac disease. For those practices that offer this service, it typically comprises roughly 20-35% of their revenue. With proposed Medicare payment cuts approaching, many practices have been evaluat-ing the effectiveness of providing this service in an efficient and highly profitable manner. Recently a company (called MEDAxiom) was asked to perform an assessment of a nuclear department in a cardiology practice located in a medium sized, Midwestern city. The goal of this as-sessment was to determine causes of a perceived problem of throughput

and then offer recommendations for improvement.

MEDAxiom is a subscription-based company that collects cardi-ology specific data from practices nationwide and uses these data to benchmark practices against each other. The database includes proce-dural as well as revenue, expense, and income data. MEDAxiom had 48 cardiology practices contributing to their database at the time of the study. MEDAxiom also offers per-formance improvement services for these practices. MEDAxiom’s mem-berships are available to all practices offering cardiology services in the United States.

This article highlights the analysis and recommendations phases of the project and shows how various tools and techniques that are common in our industry were used. The follow-ing five analysis tools and methods were used in the project: (1) The Total Performance System, (2) The Perfor-mance Analysis Gap, (3) The Relation-ship Map, (4) The Process Map and Measures Chain, and (5) The Process Management System.

The above tools were selected because they are useful to create a systematic analysis of an organiza-tion. They provide a method for a prac-titioner to critically identify where problems exist and the impact of the problem on the organization. These techniques provide tools to identify the steps and major outputs of an or-ganization and how they impact other parts of the system. The consultant uses this information to identify clear, measurable outputs. These outputs may then be measured during and after the intervention to provide a means for data to be tracked and strat-egies adjusted to impact the data.


The Total Performance Sys-tem (TPS) model as described by Brethower (1982) serves as the framework for the use of all of the other tools and models included in the intervention package utilized in the study. The TPS allows the analyst to use a systematic, dynamic process to align all parts of the system and identify output and feedback systems that allow the system to change and adapt to its environment. It is based upon the concept of general systems theory, which defines a system as a complex of interacting elements (Bertalanffy, 1968) and the relation-ships between these elements (Miller, 1978). This perspective allows each vantage point of the system to be methodically analyzed.

Rummler describes business problems as those indicated by a clear gap between desired and actual performance (Rummler & Brache, 1990). In other words, when a de-sired level of performance has been identified and the actual level of performance has been measured, the difference between the desired level and the actual level is identified as the performance gap. If the desired level of performance is greater than the actual level then there may be value in decreasing this gap in per-formance. The next step is identifying the impact of decreasing this gap and assigning a value to the impact. If the value is such that it makes economic sense to decrease the gap in performance (if the cost to fix the gap is less than the gain received by an increase in performance) then an intervention may be implemented to decrease this gap.

The relationship map identifies the inputs and outputs of a system, and how they interact with one another.

Because the relationship map makes these relationships visible, it shows what is going on in the “white space” in the organizational chart. It helps the analyst understand how work currently gets done, helps to identify disconnects, and highlights where dis-connects can be eliminated (Rummler & Brache, 1990). It may also show influences outside the organization (competition, government regulatory agencies, etc.) that affect the perfor-mance of the entity. This broadened relationship map is also sometimes referred to as a supersystem map.

Process maps are useful for outlin-ing a more micro, process level view of how works gets done in an organi-zation. This map clearly outlines the key inputs and outputs of the process, and displays the steps that depart-ments engage in to convert inputs into outputs and products (Rummler & Brache, 1990).

A measures chain identifies the key measurement markers within each step of the process. It allows the analyst the ability to precisely design in measurement points that provide the process manager and key personnel a method to track and troubleshoot the process on a “real time” basis. The measures chain forms the base for the creation of a process management system.

A process management system is a set of management tools (forms, charts, etc.) that the process manager and personnel use to plan, track and evaluate the process. In this project, it was initially created in the form of pa-per charts, but these can eventually be interwoven into the information system of the organization.

Table 1 provides a list of the tools and the vantage point and purpose of each.


Table 1 Tools Used and Purpose

Tool Vantage Point Purpose

Performance Analysis Gap

Macro level This identifies the gap between what is and what should be and is often an objective number (often a monetary figure) that can be used to influence decision makers. It is also used to identify baseline data and may be used to identify goals that would indicate the success in the project.

TPS May be used at all levels, from macro level (organizational level), to mid level, to micro level (job level)

This tool is different from the others because in addition to identifying inputs, outputs, and receivers (as the others do) it helps to identify feedback necessary (from both the receivers of the output as well as within the process) for the system to adapt to changes over time. This is a tool that the analyst may use throughout the project, to clarify thinking and to provide insight into what should be tracked and monitored to keep the process adapting to changes in its environment.

Relationship Map

High Level This provides a wide vantage point showing units of an organization and how each one has output that is an input to another. Provides a macro level view of a system or business. It may also include variables outside the organization that influence the entity (competitors, regulatory agencies, etc.). When showing outside environmental influences, it is often referred to as a supersystem map.

Process map Mid-level, more micro than the relationship level

A more micro view than the relationship map, it breaks down the pieces of the process to show their relationship to each other. It focuses on one process which often cuts across departments within an organization.

Measures Chain

Super-micro level, gets down to the level of measurement of key pieces of output that is produced by the process.

Similar to the process map but drills down even further to identify how to measure the process. Often variables of quality, quantity, timeliness, or cost are used. This provides the analyst with a method to identify what items should be managed in the process. When developing a process management system, the analyst refers to the measures chain.

Process Management System

Micro level, typically involves tools used by a performer to manage a system.

This is the system that is used by a process manager to manage the process. It may be a collection of paper forms or a set of forms on a computer program. Analyst references the measures chain to determine what should be measured and then designs forms accordingly. It may include forms for placing goals, forms for tracking progress, forms that need to be used daily to track progress, etc.


Overview of the ProjectThe project involved a cardiology

practice located in the Midwestern United States. The practice consisted of 37 cardiologists and employed ap-proximately 220 people. They had been in business since 1967 and had been steadily growing in size (mea-sured by the number of full time car-diologists) since the early 1990s. They had 15 cardiologists employed in 1992 and had added approximately three per year through hiring or by merging with existing practices in their area. The practice recently noticed that the throughput of their nuclear cardiology department showed fewer patients seen per cardiologist than an indus-try benchmarking database that they were using for comparison purposes. This problem had been prevalent for the last three to four years and although they had tried to improve the throughput using their existing management staff, they recently had decided to employ an outside consult-ing firm to analyze the cause and offer recommendations. A major goal of this engagement was to determine how effectively and efficiently the nuclear testing process was working. Some of the questions that they wished to have answered included the following:

1. The nuclear testing process ap-pears to be less efficient than other groups. Is this perception accurate? If yes, what should be done about it?

2. Why does it appear that the nuclear test ordering of the practice lags behind other cardiology groups in their local market area?

3. Has the nuclear testing process overbuilt quality into the testing pro-cess at the expense of throughput?

4. Should the practice be using a one-day protocol instead of a two-

day protocol in their nuclear testing process?

5. Does the group have an effec-tive nuclear leadership and manage-ment structure?

In addition, the group physician leadership wanted improved prac-tice profitability. As current group physicians retire over the next few years, the leadership foresaw a need to recruit new physicians. A strong, financially healthy practice has more choices of physicians they may recruit and hire than a less healthy one. The leadership team believed that nuclear testing should play a key role in providing that healthy stream of revenue for the practice.

The project was completed over a 12-week period using two consul-tants. In all, four trips were made to the practice, ranging from one to three days each. Time between the trips was spent researching data from other practices, contacting in-dustry professionals about research on technical and process data, and developing the documentation. Each trip to the practice was designed dif-ferently and is described in detail below.

The first trip involved interviews with high level personnel of the practice. This included the physician president, the executive director, the chief operating officer, and a clinical manager. Nuclear process physician directors were also interviewed dur-ing this meeting. The purpose was to get a high level overview of the process and to make sure that the parts outside of the nuclear process were aligned with the nuclear pro-cess itself. In other words, to check the system that the nuclear process operates in and understand the high


level variables that may affect it. This included the overall goals of the practice and its long term strategies (and if these included expansion of the nuclear process). This type of interviewing process allowed us the opportunity to use many of the tools described in this paper. The output of this step involved the development of the TPS, macro level maps of the practice, and an overall map of the nuclear process. During this trip, we asked all interviewees the following questions:

1. How long have you been with the practice?

2. What was your experience prior to joining the practice?

3. What is the mission of the practice?

4. What are the major goals of the practice?

5. Who are your competitors?6. What is the mission of the

nuclear testing process?7. What are the goals of the

nuclear testing process?8. What information is tracked to

manage the nuclear testing process?9. What is your role in the pro-

cess?10. What is working well about

the nuclear testing processes?11. What needs to be improved?12. What is working well about

your job (only in terms of your con-tributions to the testing process)?

13. What needs to be improved?

The second trip included a more detailed process-level investigation. It included additional interviews of the managers of the process (both physician and non-physician) as well as nuclear technologists who worked within the process. Representatives

of all members of the process were interviewed including schedulers, transcriptionists, receptionists, etc. Questions focused on understanding how each employee contributed to the process. They were asked what was working well, not working well, what could be improved, etc. They were also asked to explain the key activi-ties, accomplishments and responsi-bilities of their jobs. The interview questions were as follows:

1. How long have you been with the practice?

2. What was your experience prior to joining the practice?

3. What is your role in the pro-cess?

4. What do you have to produce in the process (activities, accomplish-ments, responsibilities)?

5. What general steps do you complete to perform your part of the process?

6. What is working well about the nuclear testing processes? What is not working well?

7. What needs to be improved?8. What is working well about

your job (only in terms of your con-tributions to the testing process)?

9. What needs to be improved?

Validation of the answers was obtained by cross checking the an-swers with information gathered from other interviews as well as by comparing them to objective data that were available. Objective data were typically available via manage-ment reports that were being col-lected. MEDAxiom also had survey data that had been sent to them on a yearly basis that was used to create benchmarking graphs comparing practices to each other in various


key areas. All of these data were available to us.

The third trip was the presenta-tion of findings and recommenda-tions. It was broken into two parts, presenting to the management team and presenting to the physicians who oversaw the process.

The fourth trip involved creating an environment wherein the practice could implement the recommenda-tions. This was considered a separate phase of the project and required considerable up front work with the major stakeholders. Meetings were required with various practice physi-cians (the nuclear directors) as well as with the management team. The meetings were also used to allow the physicians and others the opportu-nity to give the us their feedback on the recommendations so we could make changes and adjustments as necessary.

Table 2 provides a summary of the trips, the purpose of each trip, and the personnel involved in each trip.

While completing the trips, we worked through a step-by-step pro-cess that assured inclusion of the tools as described earlier in this paper. Steps were completed as sequentially as possible, although some steps could not be completed until the all of the information had been gathered. This often caused us to backtrack and gather the infor-mation when it became available. In general, the sequence was as fol-lows: (1) Create a Total Performance System diagram, (2) conduct on-site interviews, (3) create a relationship map, (4) analyze local and national practice trends, (5) develop a process map of the nuclear testing process, (6) develop a measures chain, (7) conduct a gap analysis.

Step 1—Create a Total Performance System Diagram

A Total Performance System (TPS) model (Brethower, 1982) was created to analyze the nuclear test process and to clearly represent the major parts of the system in a visual manner. This analysis tool was ef-fective in identifying where further investigation was necessary, and highlighted the need for other, more detailed tools to be used in our analy-sis. It also helped to identify what questions would need to be asked in the interview process. A TPS must have all seven parts in order to act as a useful analysis tool. In addition, the parts of the TPS must be aligned, linked and balanced. Figure 1 dis-plays the TPS model.

The following is a list of questions that the TPS model prompted us to answer using our findings from the various interviews. This tool and the questions and answers it created were used extensively during the first and second visits, allowing us to understand the major elements of the practice and the process.

1. What is the goal or mission of the practice and of the nuclear testing process? This question was asked of the physicians, the nuclear technolo-gists, and various administrators to create some clarity on the goal of the process. We looked for consistency in their answers and overall themes. Were the goals clear, agreed upon, and being vigorously pursued? Were the goals of the practice consistent with the goals of the nuclear depart-ment?

2. What are the inputs to the nucle-ar testing process? What inputs were critical to the process? How did they compare to the industry exemplars of this process? The inputs included the


Table 2 Trips

Trip Number Purpose Personnel Involved

Trip 1 Gain a high level overview of the process and gain clarity on the overall practice goals. Gain an understanding of the overall goals of the process. Determine strategic fit of all goals.

Interview high level personnel, including physician president, executive director, chief operating officer, clinical manager, and nuclear process manager.

Trip 2 Gain clearer understanding of process goals. Gain clarity of roles and responsibilities of workers within the process. Gain understanding of steps of the process. Gain understanding of protocol used within the process.

Interviews with process managers (both physician and non-physician), nuclear technologists, schedulers, transcriptionists, receptionists.

Trip 3 Presentation of findings and recommendations.

Presented to the management team and presented to the physicians who oversaw the process. The management team and physician process leaders were informed of findings and recommendations and given time to accept or reject before recommendations were shared with the staff.

Trip 4 Obtain feedback regarding recommendations and analyze to make further recommendations for implementation. This phase included time to allow key stakeholders time to express their concerns. An understanding of the politics of the practice (and overall goals) was very valuable when positioning the recommendations.

Meet with key physicians who had vocal objections to recommendations. Meet with supporters of the recommendations (physician and non-physician). Meet with practice CEO as well as physician president and nuclear department directors (physician). Later, after agreement from the leadership, management team presented recommendations to key process personnel.

people used in the process, the equip-ment, location, room sizes, and any other items relative to the physical layout of the nuclear lab.

3. What are all of the steps included in the process? Within the process, what were the outputs of each step and how were these measured? These


answers would be later used to cre-ate a process map and a measures chain.

4. What is the major output of the process? This was later identified as a “report sent” to a referring physician. What is the major output of the prac-tice? Is it consistent with the output of the nuclear department?

5. What internal feedback data are collected? What data should be collected? How should the data be organized and used as feedback? This was later included in the man-agement system that was created. As in most of our nuclear projects, we noted that some data were collected, but data collection is often fairly random and not systematically orga-nized to optimize the process. Most reports are either not closely exam-ined, or are lightly reviewed and put aside. They are not typically used to manage the process or as a means

to make changes to the process, as they should be.

6. Who receives these major out-puts? From the perspective of both the nuclear process as well as the practice procedures, it was noted that patients and referring physicians were the major receivers of the output of the nuclear process.

7. What is currently measured to show the value of the outputs by the receivers of these outputs? This in-cluded patient satisfaction and refer-ring physician satisfaction reports. We looked to see if this feedback was being received on a regular basis, how it was being used, and if any decisions were being made from this information. Neither type of survey was currently utilized so we created a patient satis-faction survey. A referring physician survey was not created because in past nuclear projects it had not been possible to obtain valid results. The

Figure 1. The Total Performance System diagram analysis of the nuclear test process which provides clarity on the parts

of a system.


patient satisfaction surveys were distributed to 20-25 patients per lo-cation. Criteria for selecting patients included providing an equal balance of men and women, a balance of in-patients and outpatients, a spread of ages from older to younger, inclusion of two to three patients who required a pharmacological test, two patients who weighed 250 pounds or more, and patients from an array of doctors (not just one or two). A script was written and distributed to the staff to use when asking for patient volunteers.

The survey was designed to include questions that referred to specific parts of the process. The ques-tions were as follows:

1. How long did you have to wait for an appointment (day they called or referring physician did until they got in)?

2. On a scale of 1 to 5, how clear were the instructions you received to prepare you to take the test (5 being very clear; 1 being least clear)?

3. Of the people who gave you instructions, who gave you the clear-est understanding of how you were to prepare yourself for the test?

4. On a scale of 1 to 5, how helpful was the reminder call (5 being most helpful; 1 least helpful)?

5. On a scale of 1 to 5, how easy and convenient was the check-in process (5 being very easy and conve-nient; 1 inconvenient and difficult)?

6. How long did you have to wait in the waiting room before you were called to begin your test?

7. On a scale of 1 to 5 how clear was the video description of what would occur during the nuclear test (5 being very clear; 1 being unclear)?

8. On a scale of 1 to 5, how well were your questions answered (5

being very well answered; 1 not an-swered well)?

9. On a scale of 1 to 5, how helpful were the technicians and RNs at en-abling you to complete the different steps of the test (5 being very helpful; 1 they were not helpful)?

10. From the time you arrived until the time you left, how long did the appointment take?

11. On a scale of 1 to 5, how easy and convenient was the check out process (5 being very easy and conve-nient; 1 inconvenient and difficult)?

12. Once the nuclear test was completed, how long did it take to get the test results?

13. Who provided you with your results?

14. How satisfied were you with the whole nuclear test process (very satisfied, satisfied, or dissatisfied)?

15. What suggestions do you have for improving the nuclear test process?

16. Would you refer a member of your family or a friend to this practice for a nuclear test?

17. What else would you like to tell us about your experience?

The surveys were collected by the practice personnel and mailed to the consultant team upon completion. Results were compiled and consis-tent themes were identified where applicable. These themes were then compared with data collected in the interviews, observations, and from management reports that had been provided to us.

Step 2—Conduct On-site Interviews

As previously noted, separate visitation sessions were set up with the practice to have us interview


key personnel. Each visit lasted two days and the interviews each lasted approximately 40-50 minutes. A half hour was set aside between inter-views (whenever possible) for us to review their notes and add items as necessary. The interviews were scheduled to examine the process from top to bottom from an opera-tional, management, and strategic perspective. Questions were asked at a high level (the strategic level) and systematically worked down to the process and, when necessary, to the individual performer level. This gave us a more complete, systems perspective of the process. Questions

as outlined previously were used dur-ing the interviews.

Step 3—Create a Relationship Map of the Process

The next step was to develop a re-lationship map (Rummler & Brache, 1990) of the practice which was used to identify the overall parts of the system in which the nuclear testing process operated. Figure 2 shows a macro view relationship map of the environment into which the target nuclear department fits, showing a ‘big picture’ of some of the variables that may have an impact on the nuclear department. Some of those

Figure 2. A relationship map.


variables would later be used to frame our recommendations and gain agreement to the implementation of our recommendations. For instance, the competitors’ use of quality tech-niques was analyzed and a table of this was developed and included as a key recommendation.

The relationship map allowed us to gain more clarity on the environ-ment in which the practice operated and to properly scan the environ-ment. It also prompted the creation of additional questions that needed to be answered. Among the key ques-tions that it prompted were:

1. Who was the competition in the local market area and what protocols were they using in their nuclear test-ing process? What was the through-put of competitors as compared to the practice?

2. Were there any government regulations that would hamper our ability to recommend changes in pro-tocol or procedures used? What were the industry leaders’ thoughts?

3. What associations or governing bodies were important in nuclear car-diology? Did they have any protocols, standards, or recommendations for throughput and quality?

4. What were the demographics of the marketplace in which the practice operated? Was it a growing market?

It should be noted that the ex-

ercise of creating this map helped us gain much needed clarity on the relationships between the parts of the system. The process prompted the identification of issues that weren’t apparent before this process so ad-ditional questions were developed. In this case, it included questions that needed to be addressed about

the competitive marketplace. These results were used to create Table 3.

Step 4—Analyze Local and National Practice Trends

A major goal of the project was to determine if the practice had over-built quality into the testing process at the expense of throughput. A ma-trix was created to compare the pro-tocols of the target practice to other local practices to determine if the target practice was performing more quality steps than their competitors. The matrix listed the protocols used (e.g., a one day or two day protocol), the nuclear isotope used (the two market leading brands are Cardiolite and Myoview) as well as items that represent various quality techniques used to assess cardiac damage. These included gated stress, TAC, quick, and gated rest. All four of these are used to assess various elements of the heart and how it functions. Lastly, the nuclear department was asked if the Intersocietal Commission for the Ac-creditation of Nuclear Medicine Lab-oratories (ICANL) certification had been attained. ICANL is an industry accreditation process that some qual-ity-conscious labs complete. Various industry suppliers were contacted to determine throughput and tech-niques used in each location. The matrix that was created is shown in Table 3.

We then compared the target practice to other nuclear labs located around the country on quality testing dimensions. A questionnaire was cre-ated and sent out to all 48 practices who contributed to the MEDAxiom database. A total of 18 practices re-sponded to this survey. Numerous pieces of information were collected that were extremely valuable for the


Table 3 A Throughput and Technique Matrix

Target Practice Practice 1 Practice 2 Practice 3 Practice 4 Practice 5

Protocol 2-Day 1-Day 1-Day 1-Day 1-Day 2-Day

Isotope Cardiolite Cardiolite Cardiolite Myoview Cardiolite Cardiolite

Gated Stress Yes Yes Yes Yes Yes Yes

TAC Yes No No No No Yes

Quick Yes No No Occasionally No No

Gated Rest No No No No No No

ICANL Accredited No No No No No No

recommendation phase of the project. Among the notable items were:

• Eighteen out of 18 reported using a one-day rest/stress protocol and all 18 completed gated stresses.

• Five out of 18 reported utilizing TAC, and four out of five stated they used TAC on all patients.

• Five out of the 18 reported using quick imaging. Of those five, none did TAC in combination with quick imaging. In other words, practices that used extra quality techniques reported choosing between TAC and quick; none used both.

An example of the layout used is included in Table 4.

Step 5—Develop a Process Map of the Nuclear Testing Process

A process map of the nuclear pro-cess was created and was reviewed by the key members of the process to make corrections and adjustments. This macro-level map helped to clarify the steps being used in the

process. This process map shows the relationship between the inputs and outputs for each step of the process. It also clarifies how each output is used as input for the next step of the process. This process map is often the only time that employees within the process see each part as it relates to other parts, and it allows both the employees within the process and us the opportunity to gain clarity on the process steps. Figure 3 shows a map of the nuclear process used in this practice.

The process map also prompted us to collect additional information concerning various steps. Among the questions created were the fol-lowing:

1. What forms are used in the check-in, and check-out phases of the process?

2. How much time does each step of the process require? How does this compare to other practices? Could any of the steps be eliminated? If so, which ones?


Figure 3. The nuclear test process.

Table 4 Practices Collecting Outcome Data

1 2 3 4 5 6 7 8 9

Nuclear to Cath Rating 94% 80% 86% 92% 85% 90% 75% 65-

70% 90%

Gated Stress Yes Yes Yes Yes Yes Yes Yes Yes Yes

TAC No No Yes Yes No Yes No No No

Quick No No No No No -1% No 1% 6%

ICANL Accredited Yes Yes No No Yes Yes No Yes


3. Were post-appointment steps causing a delay in the report being sent?

4. What do the reports look like? Is the report satisfactory to the refer-ring physicians?

Step 6—Develop a Measures Chain

The measures chain was devel-oped as a tool that allowed us to drill down and create additional clarity on the outputs of the process. The mea-sures chain took into account the ma-jor steps of the process and identified each output. These outputs were then analyzed and measures were created using quality, quantity, timeliness, or cost as the key variables. This step was extremely useful in the creation of a management system which was included in the recommendations of the project. It was also useful when showing the management team the logic of the measures and how track-ing measures could help them to better manage the system. Figure 4 is an example of the measures chain produced in this project.

Step 7—Create a Gap AnalysisA financial analysis was created

highlighting the differences between the “is” (i.e., current) nuclear protocols with a “proposed” nuclear protocol. This analysis was completed to com-pare a single head camera and a dual head camera (two different types of nuclear cameras that were being used in the practice) that were each oper-ated during a ten-hour work day.

In an ideal world, without any variability (with the camera running continuously) and with the current quality techniques being used, the gross profit potential was projected as follows (see Tables 5 and 6).

The highest gross revenue a single head camera could produce per year working ten hours a day would be $1,728,000. The highest gross revenue a dual headed camera could produce per year working ten hours per day would be $2,808,000. However, if the quality techniques were reduced (to include the TAC but not the Quick study) and the camera was run contin-uously, the gross profit potential for a single headed camera would increase to $2,160,000 and the gross profit po-tential of a dual headed camera would increase to $4,320,000. Therefore, the value to the practice of removing a quality technique for a single headed camera could be up to $432,000 while the value to the practice of removing a quality technique for a dual headed camera could be up to $1,512,000. This represents the gap between the “is” and the “should be” in the process.

Obviously, the removal of a quality technique could create a high poten-tial risk for the practice. However, our analyses revealed that little addi-tional information was being gained from conducting what amounted to a very costly quality practice. Further, our benchmarking data revealed that most competitors were using only one technique and that experts in the tar-get firm strongly believed that only one quality technique was needed.

Overview of the Nuclear Test Process

Consistent themes emerged from interviews with the practice leader-ship and the practice referring physi-cians. Some of the themes were that the quality of the practice nuclear studies was excellent but the process required too much time and used too many resources to achieve the desired results (it was inefficient).


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Table 5 Potential Profitability with Quality Techniques

(Target Practice “is” Protocol)

10-Hour Day

Camera Single* Dual

# Patients/day 8 13

# Patients/wk 40 65

# Patients annually** (48 Weeks) 1920 3120

$900 per test $1,728,000 $2,808,000

* single head camera = 30 minute stress and 30 minute rest per patient; dual head camera = 15 minute stress and 15 minutes rest per patient.

** Calculations were based on 48 weeks in the year. Assumptions were made about number of holidays the practice was closed and time was allotted for maintenance of cameras.

Table 6 Potential Profitability without Quality Techniques

(a Proposed Protocol)

10-Hour Day

Camera Single* Dual

# Patients/day 10 20

# Patients/wk 50 100

# Patients annually** (48 Weeks) 2400 4800

$900 per test $2,160,000 $4,320,000

* single head camera = 30 minute stress and 30 minute rest per patient; dual head camera = 15 minute stress and 15 minutes rest per patient.

** Calculations were based on 48 weeks in the year. Assumptions were made about the number of holidays the practice was closed and time was allotted for maintenance of cameras.

The process was time consuming and inconvenient for some patients (im-pacting referring physician and pa-tient satisfaction). A concern was also expressed regarding losing patients to other cardiology groups (impacting long-term practice survival).

Consistent themes emerged from interviews with nuclear leadership and those working in the process.

People at both locations appeared to be working well together as teams. They respected each other, worked collaboratively, and interchanged themselves at any task in the process if they had the skill and met certifi-cation requirements. They were all working to make the process as ef-fective and efficient as possible while producing quality test results.


However, there was a lot of vari-ability and unpredictability while doing the work. Some of the vari-ability was created by patients: no shows, same-day cancellations, and patient condition at the time of the appointment, to name a few. Some of the variability was created by the practice and non-practice referring physicians: no clinical information on outpatients, incorrectly selected ra-diopharmacological agents given the patient’s clinical condition, same-day office visits, add-ons, and so forth.

Add four different protocols, a series of quality techniques used to acquire top-of-the line images, equip-ment that may or may not be able to complete the quality techniques, and different standards on when and how to conduct a pharmacological stress test, by two nuclear medical directors, and the variability and unpredict-ability again increases.

Statements by nuclear staff that they could not do any more and could not work any harder or faster were truths, given these conditions. In addition, the employee turnover rate (which was deemed as high compared to other practices) was predictable and was expected to continue until the process was brought under con-trol. What follows are some of the specific findings and the recommen-dations that were presented to the practice as a result of the seven-step analysis described above.

Findings and Recommendations

SummaryVarious findings and recommen-

dations were proposed to the prac-tice. We have included a few of the recommendations here to provide an understanding of the format used

and how the data collected were used to develop the recommendations. The format used was to list findings and include all pertinent data in the find-ings summary, then follow this with the recommendation related to that finding. Having the recommendations supported by the researched findings provides much more validity to the recommendations, as often the data that was used were supplied directly from the practice to us or directly to MEDAxiom. Other data were from outside of the practice, from either their competitors or from peers around the country. This dimension also provided a degree of believability to the findings. Findings directly from a consulting team with no back-up data may be taken less seriously by the client. This data-based technique has proven to be very effective for us when making recommendations. Some of the key findings are sum-marized in Table 7 and presented in greater detail below.

Finding 1No common goal or mission for the

nuclear test process had been creat-ed. During our interviews, there were inconsistent answers to the question, “What is the goal of the nuclear test process?” Some of the responses included: (a) to create the best di-agnosis of ischemia or non-ischemia as safely and effectively as possible; (b) to check for blockages to see if further interventions are needed; (c) quality care for patients and quality imaging; (d) to serve the practice and the medical community in the detec-tion of unknown heart disease and the evaluation of the severity of the disease (these goals are to be carried out by methods that will assure both the highest accuracy and efficiency


possible with present techniques); (e) become efficient and decrease slowness; (f) to get objective data for subjective symptoms; (g) provide a quality, accurate nuclear study in the most cost-effective way possible while establishing and maintaining rela-tionships with patients; (h) acquire test results that are accurate with clear definition and not descriptive, timely (within five days from start to finish), and convenient for patient (within one day without loss of qual-ity); and (i) correlate nuclear studies with catheterization lab results—it’s the gatekeeper to the catheterization lab. As can be seen, the answers were varied and mixed.

Recommendation 1Create an agreed-upon mission for

the nuclear test process. The purpose of a mission statement is to provide clear direction and focus for those working in the process. It should align with the mission and values of the practice. Using ideas from the goals gathered during the interviews, MEDAxiom created an example of a

mission statement for the nuclear test process. It was:

The nuclear testing process produces compassionate patient care and timely, high quality and accurate reports for patients and referring physicians. These reports are used to make objective decisions on subjective symptoms so patients may enjoy the highest level of health possible and live longer, more pro-ductive lives.

The mission for the process was cre-ated using a series of questions created by Brethower (LaFleur & Brethower, 1998) and were as follows:

1. What is the name and major product of the organization, depart-ment or process?

2. Who receives the product/ser-vices?

3. What do people do with the products/services?

4. How do people benefit from the products/services?

5. How does society benefit from the products/services?

Table 7 Findings and Recommendations Summary

Finding Recommendation(s)

1. There is no common goal or mission for the nuclear test process.

Create an agreed upon mission statement for the nuclear test process.

2. There is not a set of operational goals that guide and direct performance of the nuclear test process.

Create a balanced set of operational goals for the nuclear process.

3. CA completes more techniques to ensure quality than other local cardiology practices, surveyed CLA practices, and area hospitals.

Systematically reduce the number of quality techniques that are used on an on-going basis.

4. There is no cohesive management system that enables monitoring and managing the nuclear test process.

Establish a management system for the nuclear test process.


Finding 2The practice did not have a set of

operational goals to guide and direct performance of the nuclear test pro-cess. No goals were established annu-ally for the nuclear test process. No planned versus actual performance summary reports were provided to practice leadership and admin-istrative management. On-going information about the performance of the process was not being tracked or communicated. Therefore, neither celebrations of victory nor timely corrective action could take place. This left the process vulnerable to the optimization of one dimension—quality—at the expense of another dimension—throughput.

Recommendation 2Create a balanced set of opera-

tional goals and corresponding sum-mary reports. It was recommended that practice leadership determine the operational goals for the nuclear test process. These goals must align with the mission of the nuclear test process and represent a balance between patient and referring physi-cian satisfaction, quality, efficiency and throughput. Initially, these can be preliminary goals which can be modified or negotiated once the nuclear process management has reviewed and provided feedback. In some cases, goals should be subdivid-ed by location. Others may stay the same for both locations. See Figure 5 for an example of the potential goals and reports of measures.

The establishment of operational goals and reports that show com-parisons of “planned” versus “actual” performance provide a means for determining how well the process is performing. A set of operational

goals also allows better decision making about protocol changes and improvements to the process. The impact of suggested changes should be considered across all goals rather than just one or two. If the changes are implemented, the operational goals will provide information about the success of those changes. A clear and balanced set of operational goals and summary reports can, therefore, not only aid in planning, but they can aid in evaluation of implemented changes.

Finding 3The target practice completed

more techniques to ensure quality than other local cardiology practices, other surveyed MEDAxiom practices, and area hospitals. The practice lead-ership asked: “Are we going to a lot of effort to try to get the “perfect” nucle-ar study? And, in doing that have we added a lot of additional steps?”

Listed in Table 4 is informa-tion from nine of the MEDAxiom practices that collect outcome data correlating their nuclear tests re-sults with catheterization procedure findings. Nuclear test correlation to catherizations is an industry recog-nized standard for determining the effectiveness of the nuclear testing process. This correlation is typically listed as a “false positive rate,” or the percentage of nuclear tests that show a positive level of heart disease but that are later determined to be false when the physician conducts a catheterization procedure on the patient. A high level of false positives would indicate that many patients were being incorrectly diagnosed as having heart disease that required a catheterization procedure. The find-ings indicated that the additional


Figure 5. Management system goals.

quality techniques used showed no appreciable decreases in the number of false positives.

Only two out of six of the ICANAL accredited practices who achieved an 85% or better on their false positive rating use additional quality tech-niques. The remainder are able to achieve excellent false-positive out-comes without using the additional techniques.

Recommendation 3Systematically reduce the num-

ber of quality techniques used on an on-going basis. In the near future, plan to eliminate either TAC or quick (two tests that were conducted in ad-

dition to the standard nuclear test) for patients. When practice nuclear technicians were asked, “Which, TAC or quick, helps the most with accuracy and quality of the images?” Three out of five said quick. Two out of five said the procedures were about even. When the two nuclear techs were forced to choose, one said TAC helped more with quality and the other said quick.

Next, the nuclear technicians were asked, “If you had to eliminate one, TAC or quick, which would it be?” All five responded TAC. Two out of five practice nuclear technicians would eliminate TAC because it gives the same information as the quick. Two


technicians preferred the quick be-cause in their opinion it gave a more accurate and complete image of the heart. And, the fifth technician said eliminating the TAC saved time.

To ensure that reducing the num-ber of quality techniques does not harm the practice’s quality, it was suggested that they use currently tracked false-positive data to moni-tor test outcomes. In doing so, the practice could identify an acceptable standard for its outcome rate (e.g., 78%, 85%, or 92%), sort the data into one-day and two-day protocols, and then watch the trends over time.

It was suggested that the practice re-evaluate the current decision-making protocols used with patients. The practice could establish proto-cols that will allow the use of TAC, quick, and gated rest as quality techniques but in a more stringent and limited way. Rather than recom-mending the wholesale elimination of a technique, it was suggested that the practice determine the best method for each situation and use that method. Achieving a system-atic reduction in quality techniques while monitoring the outcome data will ensure that the practice retains its emphasis on quality.

Finding 4No cohesive management system

that enabled monitoring and manag-ing the nuclear test process was being used. Nuclear managers collected data on the number of nuclear tests completed by radiopharmacologi-cal agents; percentage of schedules utilized; and the number of staff and type of staff used.

Data about the nuclear test pro-cess were spread throughout the practice. The data were not collected

and formatted in a manner useful to the parts of the practice which needed them most. Data were col-lected throughout the practice but were not used to manage the nuclear testing process. The data required to manage the nuclear test process were not readily available to those managing the process, nor were they formatted in a manner that provided information to different end users and stored in a central location for easy retrieval and review. Finally, there was no coherent, cohesive management system to oversee the nuclear test process.

Recommendation 4It was recommended that the

practice establish a management system for the nuclear test process. To do this, they would need to create a set of measures that could be used to monitor and manage the nuclear test process. These indicators should reflect the key sub-outputs of the pro-cess as defined by quality, quantity, timeliness, or cost. A visual map of the key indicators is reflected in the process measures chain (see Figure 4). Monitoring a select number of these key process indicators will cre-ate a system whereby the variability of the process may be managed and adjusted to assure optimum perfor-mance (see Figure 5 and Table 8).

These process measures also reflect areas noted in the findings where substantial improvements in the process may correlate with addi-tional revenue to the practice. For in-stance, in the area regarding rescans, decreasing rescans a total of 14 per week would represent an additional $1,400,000 annual gross profit to the practice. More closely monitoring and managing the number of add-on slots


and cancellations may also allow for more patients to be treated by the practice.

It should also be noted that creating goals and managing the timeliness of report completion may contribute to an increase in the number of new patients examined. The findings illustrated that this number was steadily decreasing. The findings also demonstrated that the reports were not always sent in a timely manner. One reason for the decrease in new patient numbers appeared to be related to the amount of time required to submit reports to referring physicians. By tracking and managing these areas more closely, the practice could realize additional gross profit and better satisfied refer-ring physicians.

ConclusionIn this paper, we attempted to

contribute to the behavior analysis and behavioral systems analysis literature by documenting a recent case study application in a step-by-step manner. Although this paper ends with recommendations (rather than organizationally relevant out-comes), it should be noted that the target practice is in the process of implementing many of the recom-mended solutions described herein. At the date of this writing, it was reported by the chief financial officer of the practice that a few of the imple-mented steps had already increased the gross profitability of the practice by $100,000 per month.

A number of projects have been completed within nuclear cardiol-

Table 8 Management System to Monitor and Manage Key Process

Indicators

Key Process Indicator Standard to be Determined By Planned Monitored Person

Responsible

Productivity per camera for Location A and B

Nuclear Manager

Annually Weekly Nuclear Manager

Add-ons for Location A and B

Nuclear Manager


Cancellations for Location A and B

Nuclear Manager


No-shows for Location A and B

Nuclear Manager


Patient re-schedules for Location A and B

Nuclear Manager


Number Outpatient Tests Completed

Nuclear Manager

Annually Weekly Employee A

Backlog for Location A and B

Nuclear Manager


Timeliness of reports sent to referring physicians

Nuclear Director



ogy departments using these tools. As noted in this paper, it has been extremely effective to support these tools with data to support the recom-mendations. This had often meant gathering data from various sources either inside of their practices or out-side of their practices. Data outside the practices has included subject matter experts, various data collec-tion services available to the indus-try, data available from vendors, and available competitive data. Using this type of data has helped create the impact necessary to influence physi-cians and administrators. Cardiolo-gists have an extensive educational background that has shaped them into using data for making critical clinical decisions. This has tied in nicely into our approach of framing our recommendations with data from various sources.

In each nuclear process project that has been completed by these authors, the most common missing piece has been a strong management system which includes the use of goals and feedback systems. Without these, nuclear processes often engage in a “push” system of trying to do as many tests per day as they can. This results in little creative thought in finding smarter ways to improve the throughput. Conversely, a process that includes clear goals set by upper management and agreed upon by the process managers creates an envi-ronment of “pull” goals, whereby the process managers and employees are challenged to find ways to accomplish the goals and manage the system to hit their goals. Clear goals also put the focus on the process teams engag-ing in constructive problem solving behaviors during their meetings. This creates an environment that

challenges them to stay up to date on industry changes in protocols, equip-ment, and techniques to maximize their efficiency.

The use of these tools in the sequence provided should be use-ful in various small scale process redesign projects. Nuclear processes that these tools have been used in typically have from 5 to 30 employees involved in the process per practice location and have from seven to nine main steps. Some practices had two to three locations and the projects were still completed within 12 to 14 weeks. It was also helpful to use two consultants in this type of process, as it provided us with the opportunity to split the duties and build the pieces necessary to complete the project in a three-month time frame. Feedback from these projects regarding the time frame seems to indicate that the customers can be patient for three months, but any longer and the pro-cess seems to lag and cause concern from the major stakeholders. The pro-cess as outlined should be effective for other process projects encompassing a similar number of employees and steps within a three-month time frame. The tools used in this project have also been used by their various developers in very large-scale proj-ects, however the number of consul-tants and time frame would have to be adjusted accordingly.

The tools in this paper have pro-vided a strong foundation for all of the work that we do in the cardiology field. We believe that these pieces provide a fairly complete and system-atic analysis of projects and allow us the ability to offer organizationally relevant and data-based recommen-dations. Performance improvement projects are complex as they involve


the ability of consultants to properly diagnose problems, offer solutions, and then guide the implementation process. This paper has dealt with the first and second phase of this equation. However, a proper diagno-sis with valuable recommendations makes the implementation process much more effective. It is hoped that, through providing an example, this paper may help others to understand how to use of some of the tools of our industry to create organizational change.

ReferencesBertalanffy, L., von (1968). General

systems theory: Foundations, de-velopment, applications. New York: Braziller.

Brethower, D.M. (1982). The total per-formance system. In R.M. O’Brien, A.M. Dickinson, & M.P. Rosow (Eds.), Industrial behavior modification: A management handbook (pp. 350-369). New York: Pergamon Press.

Lafleur, D.S., & Brethower, D.M. (1998). The transformation: Business strate-gies for the 21st century. Grand Rap-ids: IMPACT GROUPworks.

Miller, J.G. (1978). Living systems. New York: McGraw-Hill.

Nainggolan, L. (2004). ACC task force recommendations on shortage of car-diologists. Heartwire, p. 1.

Rummler, G.A., & Brache, A.P. (1990). Improving performance: How to man-age the white space on the organization chart. San Francisco: Jossey-Bass.

DOUG LaFLEUR is a Vice-presi-dent of Practice Development of MEDAxiom. His interests are in all areas of human performance as re-lated to organizational settings, in-cluding the organizational, process and individual levels. He specializes in providing process improvement, strategic planning, and Impact

Groups to the medical industry. He holds a B.S. from Central Michigan University, an M.B.A. from Grand Valley State University, and an M.A. in Industrial Psychology and Ph.D. in Applied Behavior Analysis from Western Michigan Univer-sity. Mailing address: 3920 Plateau Trace Ct., Grand Rapids, MI 49525. Telephone: 616-706-6284. E-mail: [email protected]

KAROLYN A. SMALLEY, a Per-formance and Instructional Sys-tems Consultant, helps improve performance at the organization, process and job level. She spe-cializes in process improvement projects, performance manage-ment systems, and instructional systems. For the past three years she has worked with cardiol-ogy practices enabling them to achieve increased revenues, im-proved continuity of patient care and patient satisfaction, and im-proved throughput without loss of quality. Prior to working as a consultant, Karolyn managed the Human Resources Development Department for an organization having more than $7 billion in annual sales. She is a graduate of Michigan State University, the programmed learning workshop of the University of Michigan, and the MA program in Indus-trial/Organizational Psychology at Western Michigan University. Mailing address: 8190 Two Mile Road NE, Ada, MI 49301. E-mail: [email protected]

JOHN AUSTIN, Ph.D. is an Associ-ate Professor of Psychology at West-ern Michigan University, where he teaches courses in performance


management, applied behavior analysis, and behavior-based safety and consults with large and small businesses on behavioral safety and performance improvement systems. He holds a B.A. from the University of Notre Dame and a M.S. and Ph.D. from Florida State University. Dr. Austin is co-editor of the Journal of Organizational Behavior Management, an edito-rial board member for the Journal of Applied Behavior Analysis, Per-formance Improvement Quarterly, Journal of Safety Research, In-ternational Journal of Behavioral Safety, Revista de Rsicología de la Universidad de Chile, and Interna-tional Journal of Behavioral Con-sultation and Therapy. He is also the Director of the OBM Network (www.obmnetwork.com). Mailing address: Western Michigan Uni-versity, Department of Psychol-ogy, Kalamazoo, MI 49008. E-mail:[email protected]

improving performance in a nuclear cardiology department

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