Biomed Imaging Interv J 2007; 3(3):e24
© 2007 Biomedical Imaging and
Quality service in radiology
J Hoe, DMRD,FRCR,FAMS
Medi-Rad Associates Ltd, Mt. Elizabeth Medical Centre, Singapore
Radiology is part of the service industry and as a service
provider one needs to understand quality and delivery of service. This includes
knowledge of customer service, customer satisfaction and all its related issues
as well as quality assurance and improvement issues.
Service quality and delivery in radiology are closely
related but not the same. Nevertheless, both are required for customer
Academic and institutional radiology departments are now
often considered as revenue centres in their hospitals. A cost centre is a unit
or department in an organisation for which a manager is assigned responsibility
for managing costs. Revenue generation is not the main concern of the
department but cost control is of utmost importance. They are also often called
support centres. With a revenue or profit centre, maximum revenues are generated
and minimum expenses are incurred. The manager�s role is to maximise profit
while minimising losses. Salary packages of academics also often include a
clinical component. Senior radiologists need to have an understanding of the
financial aspects as well as service aspects of a radiology department.
The difference between service quality and service delivery
Service quality and service delivery is not the same.
Service quality is part of service delivery, and one of the components of service
Service quality can be defined as service that meets or
exceeds the needs and expectations of a customer, making the customer happy.
Good service quality is not the same as good quality control or quality
Good customer service can be defined as the ability of an
organisation to constantly and consistently give their customers what they want
and need, while excellent customer service means the organisation is able to
constantly and consistently exceed the customer�s expectations.
Quality control is the process of checking on products (and
sometimes services) to see if they meet requirements. This is usually carried
out after the products have been manufactured. This concept does not usually
apply to service industries like radiology departments. However, quality
control does deal with some radiology issues such as acceptance testing of
equipment and measurement of film processing parameters and calibration.
Quality assurance describes the introduction of
documentation, and standardisation of quality systems and procedures to give
customers confidence that the services would
meet their expectations. Quality assurance means assurance of minimum
quality standards, which are set by an external regulatory body and enforced
through accreditation or certification combined with regular inspections.
It is achieved by designing processes and procedures,
regularly checking and providing feedback and certification. Traditional
quality assurance usually focuses on maintaining a quality level based on
standards set by an external body e.g., ISO 9000-9002 standards, Joint
Commission on Accreditation of Healthcare Organizations (JCAHO)-Joint
Commission International (JCI) accreditation. Quality assurance helps to reinforce
standards of care, and focuses on the individual provider as the source of poor
Quality improvement is developed locally in response to the
needs of the organisation or department. Quality improvement or continuous
quality improvement (CQI) is a process that focuses on the processes of
delivery of care and continuous improvement of performance indicators in
radiology. These programs are part of total quality management (TQM), which is
an approach that seeks to continuously improve every service that is provided
and is an umbrella that covers all kinds of quality activities. It involves the
concept of improving quality, rather than assuring it.
The essential elements of CQI are improving customer service;
by breaking down the process into steps i.e., collecting and analysing the
data; experimentation to test the implementation of ideas; and using teamwork
to come up with solutions . A good summary of quality was recently published
The increased costs of implementing a quality program in a
department may be offset by increased patient revenues or cost efficiencies
Ways to improve service delivery in a radiology department
There are several basic steps in the process of improving service
quality as well as service delivery in a radiology department.
Understand how to identify the customer(s) of the
This is important, as only by identifying the customer, can
the customers� needs be determined and processes put in place to satisfy the
customers. This may seem easy or intuitive as most would assume that the user
of radiology services is the primary customer. However, it is important to know
who are the primary customers and who are the secondary customers of the
department. For an institutional radiology department, the customer could be a
person, department or an organisation. This includes patients and their
families, physicians, the hospital, hospital employees, other hospital
departments, department employees as well as payers e.g., insurance companies,
the federal or state government, Ministry of Health, etc. (Table 2).
All these customers want different things e.g., patients
want short waiting times, medical staff want fast and reliable reports, the
hospital wants reliability and safety, the Ministry of Health or state/federal
government usually want lower costs. Hospital administration also usually wants
radiologists to provide fast, accurate and cost-effective services, and to keep
patients and referring physicians happy. In an academic radiology department,
the university administration is another customer, usually with different ideas
about what constitutes effective service and performance � for example,
education and research. In government and state-run and financed hospitals and
departments, the main customer is the government which is mainly concerned
about the cost of the services provided and compliance with regulations.
Often, the patient may not be the primary customer but is
the one who has the potential to create most problems for a department if their
demands are not met. A recent review has highlighted the importance of patients
and the service to them . Doctors tend to focus on patients as the primary
customers but actually the referring physicians are probably more important so
most departments should pay more attention to the needs of the referring
doctors, as they should really be considered the primary customer of an
institutional radiology department.
In private practice, the primary customer is the referring
physician as he or she determines the need for the tests and refers the
patient. It is the physician�s decisions that generate the demand for radiology
examinations . The patient is usually only the consumer of the service, hence
is usually the secondary customer. However, as the secondary customer, the
patient is also usually the person paying for the service unless payment is
made by a third party e.g., private insurance, government subsidy or government
reimbursement. Patients are sent to the department by their doctor and usually
do not make the decision about where they go for their radiology examinations.
Customers can also be divided into internal or external
customers e.g., doctors in the department (radiologists) and doctors from other
departments in the hospital (referring physicians). The practice will likely already
have many internal customers, that is people who are within the organisation.
These people are those whom the radiologist serves and vice versa. The internal
customers are also very important and all departments need to have training
programs for them and empower them to provide efficient service to external
customers. Employees who are happy in their work will focus more effectively on
the external customers.
Understand how customers assess radiology services
There are five main factors that determine customer
satisfaction with radiology services :
Reliability � ability to provide the service as promised to the
customer and to do so accurately. In radiology, this means correct examination
must be performed so that the correct views can be obtained. The report must be
accurate and of high quality, regardless of who is reporting e.g., resident or
consultant, and the report must answer the clinical problem of the patient.
Responsiveness � willingness and ability to help customers
promptly. In radiology, this means being able to get appointments for patients
quickly as well as sending the films and report soon after the examination to the
referring doctor. Long waiting times for appointments and taking more than a
couple of hours to generate an urgent report is generally not acceptable in
Assurance � the customer must feel comfortable with the
competence of the service provider. Customers must get the feeling that they
are receiving the best service and must have confidence in the service. In
radiology, this means that the staff must not only be technically competent but
must also have interpersonal skills, as they must be able to interact with both
patients and referring physicians. Many radiologists do not bother to interact
or talk to patients but the need for this interaction is growing, especially
with interventional procedures.
Empathy � the radiologist needs to show some degree of caring and
attention to customers. This again highlights the importance of interpersonal
skills, which starts from front desk reception staff to the radiologist.
Tangibles � the physical appearance of the department and
facilities, and the quality of the equipment. In radiology, because of high
capital cost of equipment, it is not always possible to have the best equipment
but it is always important that the available equipment is used correctly and
the quality of work produced is of high quality. It is not advisable to take
too many shortcuts to save money e.g., performing a couple of pulse sequences
of a MRI scan and filming only a few images of the sequences on hard copy.
As discussed earlier, the main and primary customer of a
private radiology department is the referring physician. Physician referral
decisions are usually complex and influenced by a few main issues, such as the
radiology practice�s professional quality; its helpfulness and support to the
referring physician�s practice; its degree of personal convenience and
familiarity to the referring physician, and its success at sending a satisfied
patient back to the referring physician.
In a survey of referring physicians and the factors that
make them refer patients to radiology groups in private practice, the most
important factors in order of importance were found to be ability to schedule
patients quickly; personal familiarity with radiologist; speed in receiving
results as well as quality and accuracy of the radiologist  (Table 3). The two
most important factors that made a referring physician change the radiology
provider were delays in scheduling patients or in reporting.
Price of the radiology examination was not considered a
major factor in the survey. In most developed countries, patients usually have
their radiology examinations partly or fully paid for by a third party, such as
insurance companies or the government. However, in many other countries,
pricing of radiological exams is a major consideration as patients pay for
their own investigations and referring physicians often only refer patients to
the cheapest provider. It is important to make the physicians realise that the
cheapest provider may not always be able to provide the best quality exams
because of the lower cost of technology involved. In many countries,
commissions are often also paid to the referring physician for sending a patient
to the radiology practice. This practice is unethical as well as illegal, and
it can also significantly affect the referral process. This serves to reinforce
that the main customer of a private radiology provider is the referring
Institutional radiologists should also realise that even
referring physicians often have same feelings as private practice physicians
about their department service, and would be willing to change service
providers. In a study of preferences of users of institutional radiology
services, which assessed the implications for retention and extension of impact
on referral base, it was found that 33% of referring physicians would change
their radiology service provider if their scheduling expectations were not met .
In another survey of referring physicians using CT and MR services of an
academic radiology department, the main areas of concern were again long waiting
time to get an appointment slot, long waiting time for the radiology exams to
be performed and delays in getting the reports or lack of promptness for
communication of important findings .
It is obvious again that long waiting time for radiology appointments is simply
not acceptable even in an institution. The department should not assume that
referring physicians in the hospital are captive customers and will always
refer only to the department. For inpatients and interventional procedures,
this is obviously not usually possible and they are forced to use the
department, but it is also not uncommon for institutional physicians to refer
their patients, especially fee paying or private patients, to another private
radiology service provider.
Understand how to identify customers� needs and assess
Customers� needs and expectations are always changing, therefore
capturing or finding out their needs is a dynamic process. Appropriate
questionnaires or surveys can be used to obtain accurate and reliable data on
customers� needs and expectations, and provide judgment of the quality of
Questionnaires need to be properly developed: they need to
be short, easy to self-administer, questions must be quantitative and allow for
multiple choices, and wording of questions is very important.
Radiologists should also measure the department logistics to
get an idea of some of the many processes in the department that can cause
problems that affect customer satisfaction. Possible starting points for
improved service delivery are reduced patient waiting time in appointments for
various radiology exams and reduced report turn around time.
Understanding the customer�s needs and expectations
regarding quality of services is an essential part of improving service
delivery. Various levels of customer�s expectations can be classified:
Basic assumed level of quality of service � Physician expects to
get a radiology report within 24 hours. The patient assumes that the correct
radiology exam has been done.
Intermediate level of satisfaction � Physician receives a written
report within 24 hours but receives a phone call immediately after the exam when
the exam reveals unexpected findings. The patient receives prompt attention at
the reception desk and the examination is carried out quickly.
Highest level of expectation and customer satisfaction � Patient
receives prompt and courteous attention by the reception staff, is happy with
the caring and courteous treatment during the examination and is pleased to
receive an educational pamphlet regarding the exam while the referring
physician was able to review his or her patient�s examination films and report
within an hour after the radiology exam.
Good customer service has been defined as the ability of a
department to constantly and consistently give the customer what they want and
need while excellent customer service means the ability of a department to
constantly and consistently exceed the customer�s expectation. If one were to
be honest, most radiologists would probably agree that most institutional
departments are barely able to provide good customer service.
A recommendation for institutions that want to improve their
service delivery is to firstly clarify the mission of their department and then
adopt a mission statement, so that the radiologist and the staff know the prime
function of the department. Is it to provide research or to provide customer
service and revenue? Then the institution should plan, adopt and implement this
philosophy for the department. Next, a formal customer satisfaction program and
team should be designed and implemented also in addition to pursuing certain
regulatory status for the department e.g., ISO 9002, JCAHO-JCI accreditation,
etc. Once these processes are in place, marketing of the radiology services to
external and internal customers will be more effective .
It is important that the people working in the facility
understand customer satisfaction and service delivery. Aside from proper
training of the radiographers and support staff, it is important to identify
the correct type of radiologists who are going to work in a private practice because
having the adequate technical skills alone is not enough to be successful in
the private sector. The radiologist needs to be able to interact with referring
physicians, patients and colleagues much more than in an institutional or
department setting where many responsibilities are delegated to residents and
many radiologists do not want to talk to the patients or the referring physicians.
Subspecialty-trained radiologists who are well-qualified and has recognized
peer respect and patient-friendly skills in addition to being dynamic and
outgoing, will always find employment easily in the private sector. The requirement
for a successful practice is radiologists driven by service delivery.
Practice management indicators can also be used as tools to
evaluate the department�s progress towards its goals. Performance movement
indicators are objective tools that evaluate and assess key components of an
organisation by setting performance goals and tracking performance over time
. In radiology, these indicators include categories such as
productivity, finance, patient safety, access to examinations, radiology
reporting, and customer satisfaction. Once specific indicators in each of these
categories have been selected, data collection methods should be incorporated
into the routine department processes. To improve the quality of service, these
indicators should also be benchmarked. Most commonly used indicators in radiology
reporting are report turn around time, transcription time and signature time. For
customer satisfaction, the most commonly used indicators are patient
complaints, patient satisfaction and patient waiting time. Referring physician
satisfaction and employee satisfaction were used in less than half of the departments
surveyed . For productivity, the most commonly used indicator is
examination volume while for financial status, general expenses is most
commonly used. More specific performance indicators may be developed for the department
so its performance can be better monitored.
It is necessary for the radiologist to understand the
difference between service quality and service delivery in radiology. Quality
in service is only one component of service delivery in radiology. Knowledge of
quality assurance in radiology and knowing how to implement and maintain a
quality level based on standards set by an external body e.g., JCI, as well as knowing
how to implement continuous quality improvement programs (part of TQM) in the
department are also important . All these processes and programs
need to be implemented to ensure high quality in service and good service
delivery to customers besides improving financial performance of the
department. The increased costs of implementing a quality program in a
department may be offset by increased patient revenues or cost efficiencies
Table 1 Quality Management in Radiology - definition of commonly used terms.
Table 2 Customers of a Radiology Department.
Table 3 Most Important Factors in Selecting a Radiologist (modified after Lopiano et al )
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|Received 12 May 2007; accepted 18 May 2007
Correspondence: Medi-Rad Associates Ltd, 3 Mt Elizabeth, #01-01 Mt Elizabeth Medical Centre, Singapore 228510, Singapore. Tel.: +65-67312728; Fax: +65-67327776; E-mail: firstname.lastname@example.org (John Hoe).
Please cite as: Hoe J,
Quality service in radiology, Biomed Imaging Interv J 2007; 3(3):e24
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