Jim Lipcamon

With no-show appointments averaging between 2%–5% in radiology departments, missed appointments are costly to an imaging department. You leave the day with a full schedule and by 2 PM the following day the schedule has more holes than a championship golf course.  

In an effort to get a better understanding of the no-show appointments, Twin Cities Community Hospital utilized lean daily management (LDM). Although we were following no-show rates for all modalities, two areas that were of particular interest were nuclear medicine and ultrasound because of associated isotope costs and OB ultrasound volume.

After gathering data for over one month, two significant findings were made; OB ultrasound appointments did have the highest no-show appointment rates and we uncovered a totally unexpected issue in nuclear medicine, which was related to inpatients. Since we use a nuclear pharmacy company to deliver isotopes, we were experiencing high stat delivery charges because the nuclear medicine technologist was not aware of the inpatient procedure before placing the order. The hospital is located in the Central California Coast and is approximately 200 miles from the nuclear pharmacy, which is located in North Los Angeles.

In further evaluating the data and the processes, we implemented the following which has proved beneficial:

• In doing daily reminder calls we have been able to determine some of the OB patients were admitted to the hospital for delivery. This has allowed those occupied appointments to be used by other outpatients. OB is a major service line at Twin Cities Community Hospital. 

• The labor and delivery unit is delivering a census report in the morning to centralized scheduling which uses it to cross reference outpatient appointments. Appointments occupied by patients on the labor and delivery unit are opened for outpatients.

• After 8 PM, the night shift technologist is to notify the nuclear medicine technologist of any inpatient nuclear medicine procedures so the doses can be ordered by 2 AM.  We have made the notification cutoff at midnight since we have only one nuclear medicine technologist.

• One issue that we discovered and not resolved is when the inpatient order is made for the next day in the electronic medical record, the patient name and procedure is not populating to the modality worklist.

We will continue to follow our no shows utilizing LDM to assess the process improvements we have made over the month of November.

Attention to no-show appointments is constantly at the forefront of a facilities agenda as demonstrated in a recent 

.  Insight is provided on the issues departments have with no shows. The authors reference a new study published by the 

done at Massachusetts General Hospital which analyzed over 54,000 appointments and found a no show rate of 6.5%. The article is informative and I highly recommend you read it.

Articles

No-show appointments are costly for radiology departments. 

Decreasing No-Show Rates in Radiology 

The “Sterile Cockpit Rule” is a Federal Aviation Administration (FAA) regulation that was implemented in 1981 after a series of accidents occurred when flight crews became distracted from unnecessary conversations during critical flight duties during takeoffs and landings. One such accident occurred in 1974 in Charlotte, NC, which resulted in 71 out of 82 lives being lost due to a pilot’s discussion on politics rather than focusing on the upcoming landing.

In another accident that occurred at Dallas-Fort Worth, a crash occurred that was linked to aircraft flaps not being down during takeoff. Fourteen lives were lost in this accident which was linked to nonessential conversation during the checklist procedure.

This FAA regulation states that flight crews are prohibited from activities or nonpertinent conversation during the critical phases of flight which encompasses taxi, takeoff, landing, and operations below 10,000 feet mean sea level. This regulation was recently expanded by the FAA to prohibit the use of personal tablets, smartphones, and laptops for personal use during the entire flight.

The health care industry has become a very complicated field with the same deadly opportunities for error due to distractions. Are there distractions while radiology nurses are drawing medications or taking medications out of drug dispensing systems, during the time out process, site marking for a biopsy or checking for medication allergies? Wrong site procedures and retained foreign objects continue to be an issue reported to the Joint Commission and state agencies. The Joint Commission cites inattention as a contributing factor to wrong site procedures.

Radiology is a minefield of opportunities for medical errors and the Sterile Cockpit philosophy can help improve patient safety when implemented in appropriate circumstances. This has been proven by the FAA through implementation of this regulation which has contributed to aviation safety by focusing on eliminating distractions during critical times of takeoffs and landings.

I recently e-mailed an article to my radiology staff on the FAA’s Sterile Cockpit regulation asking them for suggestions on circumstances other than those previously mentioned that this concept can be used and for engineering ideas on processes to implement it.

Adapting Use of The “Sterile Cockpit Rule” in Radiology

As leaders in our departments, we have a responsibility to ensure that we provide culturally competent, and patient- and family-centered care. The care we deliver in our departments must be provided with dignity and respect and to ensure safety and privacy for all patients and families who utilize our services. Until recently, patients who are lesbian, gay, bisexual, and transgender have been disregarded as health care consumers. LGBT individuals and their families reside in every county in the United States and they have an urgent need for access to welcoming, compassionate, and assuring health care provided by knowledgeable and sensitive health care providers. The Joint Commission felt that this is such an important issue, they developed a field guide: 

Advancing Effective Communication, Cultural Competence, and Patient-and Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community

, 56% of the LGB patients experienced some type of discrimination in health care and 70% of transgender or gender nonconforming patients surveyed have experienced some type of discrimination in health care. 

 has demonstrated that LGBT individuals experience disparities in care and face other barriers to equitable care, such as refusal of care, delayed or substandard care, mistreatment, inequitable policies and practices, little or no inclusion in health outreach or education, and inappropriate restrictions or limits on visitation.

Here are a few items that the Joint Commission has on their Checklist to Advance Effective Communication, Cultural Competence, and Patient-and Family-Centered Care for the LGBT Community in appendix A of their field guide. Each of the bullets below have listed processes to accomplish each bullet. The processes are too numerous to list in this blog.  I highly recommend reading the Joint Commission field guide.

 Integrate unique LGBT patient needs into new policies or modify existing policies.

 Create a welcoming environment that is inclusive of LGBT patients and families

 Avoid assumptions about sexual orientation and gender identity

 Identify opportunities to collect LGBT-relevant data and information during the health care encounter

 Collect feedback from LGBT patients and families and the surrounding LGBT community.

 Most importantly, offer educational opportunities that address LGBT health issues

 Ensure equitable treatment and inclusion for LGBT employees

There are many resources to help advance our staff’s knowledge and sensitivity regarding interactions with the LGBT community and families. Below is a list of resources that have great information regarding this topic:

Advancing Effective Communication, Cultural Competence, and Patient-and Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LBGT) Community and Field Guide

Healthcare Equality Index 2016 Promoting Equitable and Inclusive Care for Lesbian, Gay, Bisexual and Transgender Patients and Their Families 

Gay and Lesbian Medical Association (GLMAS)

My facility will be starting the journey towards advancing effective communication, cultural competence, and patient- and family-centered care for the LGBT community in 2017.  There will be a great deal of information to absorb, however, we will be better equipped to serve the health care needs of this overlooked community. 

Radiology practices and effective communication and patient-centered care for LGBT patients.

Communication, Patient-centered Care in Radiology for LGBT Community

As leaders in our imaging departments, one of our responsibilities is to help improve employee performance and mentor employees who aspire to be in leadership positions. The only way this can be done is through feedback.  A few months ago I was given an excellent handout by our CEO that I have found very helpful as a guide to providing feedback. The handout “The Ten Commandments of Feedback” is from 

 As we know, feedback can be positive or negative and is information provided about an individual’s performance or behavior. The way negative feedback is given is extremely important. As Frank A. Clark said “Criticism, like rain, should be gentle enough to nourish a man’s growth without destroying his roots.”  Here are ten commandments of feedback from the handbook that ideally will prevent an aggressive response or destroying an individual: 

1. Offer feedback on observed behavior, not on perceived attitudes.

2. Offer a description of what you saw and how you felt, rather than a judgement.

3. Focus on behavior which can be changed.

4. Choose which aspects are most important and limit yourself to those.

5. Ask questions rather than make statements.[[{"type":"media","view_mode":"media_crop","fid":"53401","attributes":{"alt":"Communication in radiology","class":"media-image media-image-right","id":"media_crop_387078881414","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"6671","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 110px; width: 170px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Â©igor kisselev/Shutterstock.com","typeof":"foaf:Image"}}]]

7. Comment on the things that an individual did well, as well as areas for improvement.

8. Relate all your feedback to specific items of behavior: do not waffle about general feelings or impressions.

10. Before offering any feedback, consider its value for the receiver, if there is none, keep quiet. 

Here is a very important concept; BUT break any of the commandments of feedback, providing that you understand the rule and its purpose and that what you propose to do is going to achieve your ends more efficiently, with regard to the individual.

The goal any time you are providing constructive criticism is to send the message in a way that the individual’s defense mechanisms don’t kick in and your message is heard.   Hopefully, you will find these ten suggestions helpful in giving you a different perspective when offering negative feedback.

As an imaging leader, it is important to communicate feedback appropriately. 