Pamela M. Harlem, MBA

An established radiology practice in a growing community has enjoyed positive relations with the two hospitals it serves and the community physicians. The radiologists pride themselves on their long history in the community and their ability to handle the growing complexity of medical imaging. Their competitors in the third hospital in the community also have an outpatient facility. That facility seems busy, but for the established practice, volume has slowed down. New physicians in the community seem more interested in access and subspecialization than relationships. The radiologists are not sure which of many paths to pursue in strengthening their position in the marketplace.

While hypothetical, this situation is not unlike what confronts many practices in today's highly competitive environment. Whether it's national teleradiology firms, big regional practices, or a midsized group down the street, the competition for image reading services is heating up, and a defining factor is excellent customer service.

Whether you work in a hospital, outpatient center, teleradiology environment or some mix of these, you surely have reflected on where you stand as a physician in your community that is, your service area. Take a moment to reflect on the following questions for yourself and your practice:

What does your competition offer in the way of customer service that you don't?

 Your market positioning and strategy will, in part, determine the focus of your customer service excellence.

Which subspecialties are growing or contracting in your service area, and why?

 The expertise and service levels within your practice should parallel the needs in the service area, not what is most convenient for the radiologist partners.

Who are your patients and what do they expect?

 Different patient demographics will have different expectations of what constitutes excellent customer service. Variables include: age, immigrant status, and patient type, such as chronic, acute, or temporarily injured.

What are the business goals of your practice?

 Achieving a certain net revenue is a common immediate goal; defining longer term business goals, such as technology acquisition and market penetration, are other components of sound business goals.

Taking stock of your practice allows you to reflect on who your customers are, what you provide that they value, and how they perceive you. When you address these, you are placing yourself in the strongest position to keep those customers loyal.

It would be a mistake to think of referring physicians as the only customer, as many radiologists do. Notwithstanding the complexity of third-party payers within healthcare, radiologists actually have three primary customers: patients, referring physicians, and those physicians' office staff. Any of these customers could decide that a radiologist is not meeting their needs as a customer and shift their demand elsewhere.

Vendors of equipment and technology know that they have to establish service level agreements with customers in order to calibrate expectations for all involved. But contractual SLAs are relatively new to radiology; as recently as 10 years ago, most contracts were gentlemen's agreements with vaguely defined-if any-service expectations.

Five years ago a midsized practice in the Midwest was surprised (and insulted) when hospital executives wanted the new contract to include measurable SLAs, such as stat reports in an hour and reports on emergency department patients within 90 minutes. With a strong reputation and other hospitals in its practice and market, the group decided not to engage with the hospital. The hospital found another group readily; two years later, the practice filled the gap in its revenue by contracting with another facility…with SLAs in the contract.

An SLA is a minimum standard to be met. Before you can consider offering excellent customer service, you need to be clear on your minimal criteria for service delivery.

You should define and establish SLAs for ap-pointment availability, results reporting, critical results reporting, quality assurance, and procedures to address clinical quality concerns (Table 1).

These basic criteria then need to be monitored regularly so that you meet the minimum expectations of your customers.

Providing excellent customer service means anticipating and exceeding the customer's needs and desires in several key areas: interpretations, report turnaround time, referring physician education, patient relationships, and quality transparency.

With respect to radiologists' interpretations, quality comprises two elements: accuracy and timeliness. Radiology practices should provide the same high level of quality reporting, regardless of the time of day of the exam, the radiologist dictating the findings, the referring practice, or the type of exam. In reality, this is not the case for most practices. Many practices balk at standardizing reports and exam scanning protocols and at creating too much or too little subspecialization.

Consider a practice that prides itself on having subspecialty radiologists in a community setting with loyal referring physicians. Referring physicians know that their patients are receiving excellent care. However, when one of the subspecialists is not on duty, which occurs every four to six weeks for at least a few days, another radiologist provides the interpretation. The substitute radiologists are skilled in their own right, but the variability in reports makes the referrers ill at ease. They call to talk to the subspecialists later, or they have patients wait for exams.

Meanwhile, a competitor takes advantage of this situation by hiring a teleradiology practice to provide standardized daytime subspecialty interpretations. The new service is marketed to referrers with the result that the original practice sees a slight dip in demand. Among the options for the original group are to accept some amount of leakage, hire additional subspecialists, deride the skills of the other radiology practice (not that anyone would do that, of course), or invest in developing standardized interpretation reports across the practice. Only the latter provides an attractive cost-benefit ratio.

Report turnaround needs to be virtually real-time for many customers. That is, they expect the report within an hour of exam completion, and certainly by end of day. What is a “report”? A final, signed interpretation. Preliminary reports are not excellent customer service; they're a stopgap measure.

Information systems today are better even than five years ago at being able to track report turnaround time. The data must be accurate and objective. Radiologists who review this for themselves frequently are more productive. More importantly, establishing a monitoring process on turnaround time and reporting it in marketing communications with referrers demonstrates an impressive level of service commitment and spurs customer loyalty.

Each radiologist and practice needs to come to terms with the role that radiologist accessibility to referrers plays in defining and differentiating the practice. Many tools have been developed, ranging from online ordering and decision support to good old-fashioned paper requisition forms. If you feel impeded in productivity due to interruptions from referrers, the problem likely lies in the processes of your practice. Proactive communications allow you more control and enable a higher level of customer service.

Education is a critical aspect of excellent customer service. Whether informally over a particular case or formally in a local seminar, education is an opportunity to improve the quality of referrals to your practice and build customer loyalty.

One practice in a rural setting benefited greatly from focusing on education programs for referrers. The practice was puzzled as to why its PET/CT volume was not growing relative to the demographics of its community. It turned out that, in an area with high rates of skin cancer, the dermatologic oncologists were not well-informed about the benefits of PET/CT. The practice's volumes took off after some educational sessions and the practice now makes a point of proactively educating referrers about other clinical advancements in radiology.

Two components of your practice relate directly to patient customer service: your individual availability and your website. Have you ever introduced yourself, face-to-face, with the “frequent flyer” patients, who come for routine outpatient exams on a regular basis.

What does your website offer patients? There are many practices out there with stellar websites. Many more practices have little to nothing on theirs beyond their locations and contact information for billing inquiries. At minimum you need radiologists' information and photos, exam descriptions, and links to helpful sites (Table 2).

What's next in the growing sophistication of Internet-based customer service? Blogging and twittering have taken communication to a new level. Wondering what you would say in a blog? One of my favorites is 

, the blog of Paul Levy, president and CEO of Beth Israel Deaconess Medical Center in Boston. I'm not sure how many patients or physicians read this blog and make customer decisions from it, but perhaps it's an outlet that will resonate for you or your practice.

Skeptics within radiology refer to the recent surge in attention to healthcare quality and outcomes as a “quality tsunami,” presumably for the havoc that could potentially be wreaked upon productivity, the murkiness of performance measures, and the fears of legal and financial aftershocks lurking over the horizon. The groundswell of fear and excitement remind me of the 1990s' discussion of PACS: “Will it hit us? If so, can we buffer its impact?” As we know, PACS gained momentum, became unstoppable, and is now indispensable. Likewise, quality is not going to drift gently off into the sunset.

Providing transparency to your customers regarding your measures to ensure quality places you on the leading edge of this inevitable trend, reduces the potential for litigation, and further promotes your message that medical imaging is not a commodity.

Measuring customer service satisfaction is similar to measuring minimum service standards in that you need to establish criteria, collect and analyze data, and report the findings within your practice and to your customers.

Practices may make periodic calls to patients to gain feedback on the patient experience, or practices may rely on their marketing person to informally provide feedback from referrers and their staffs. Hospitals conduct referrer surveys and patient satisfaction surveys, typically employing an outside firm.

You will want objective feedback from referring physicians. Feedback is most accurate when it is objective and representative of the full referring community. To exclude or dismiss feedback is to miss an opportunity to enhance your customer service. Be sure to survey:

• quality/accuracy of interpretation reports;

• hours of availability for patient appointments;

• radiologist availability for consultation (phone, in person, or e-mail as appropriate);

• timeliness of arrival for after-hour emergencies (as appropriate).

Conduct surveys and review the results regularly. There are many sources available for products and services in this area.

Thus far, we have focused on the radiology practice and, implicitly, outpatient facilities operated by practices. As more practices look to partner once again with their local hospitals, or find themselves relying heavily on hospital-based outpatient imaging, initiating a dialogue about customer service can be helpful.

Hospitals typically share survey results openly with their radiologists. Too frequently, radiology practices take a defensive stance regarding institutions' customer satisfaction surveys. Instead, radiologists should identify areas within their control to improve while working with hospital leadership to address other areas that arise as concerns.

Advocating for improvements in the context of a large institution can be frustrating. Empathy and a willingness to focus on solutions rather than problems can go a long way toward easing that frustration. The following areas are common challenges for hospitals in meeting their customers' expectations within radiology. The solutions offered are simple; they're not ideal, but are easy to implement in the short term. An empathetic radiologist can discuss these concerns with hospital administration.

. Avoiding the hospital registration process is frequently cited as the top reason to have a separate outpatient facility. Solution: Set up registration space within the radiology department, or have a beeper for a registration representative to come to radiology.

. Freestanding practices are generally recognized as being more nimble in this area. Many hospitals have less than one full-time staff person dedicated to assisting with the preauthorization process. That person typically is also following up on rejections. Solution: A cost-benefit analysis can demonstrate that a dedicated FTE quickly pays for itself.

. The radiology department may be a long walk from the hospital entrance, with no possibility of a side entrance, or it may be dispersed. Solution: Assign volunteer staff to accompany patients to their destination in radiology.

. The waiting room, exam rooms, and/or hallways are dismal. A competing outpatient facility has state-of-the-art design elements. Solution: Although you may not be able to conduct a complete overhaul, modest changes come right from Martha Stewart: paint, pictures, chairs, uncluttered storage units, and new magazines.

Articles

An established radiology practice in a growing community has enjoyed positive relations with the two hospitals it serves and the community physicians.

Pamela M. Harlem, MBA

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Hallmarks of Customer Service - A Practical Guide for Radiologists