A CT Scan of Quality
By
Mark S. Lerner
I sat and stared at the sentences on the customer service questionnaire as if
by thought I could rearrange the letters to make words more of my liking. It
was obvious from what the mother had written that she was justifiably
furious. Her son had a c.a.t. scan in our department last week. The
appointment was scheduled for 12:00 noon. At 2:30 p.m. the exam was
eventually done, this after keeping the 5-year-old child from having anything
to eat or drink from midnight the night before. But what was so disheartening
to me as radiology administrator was that this was the third such incident of
this kind in as many weeks. I had been hired by Children's Hospital a couple
of months ago so the issue of delays in our c.a.t. scan service constituted
the first major problem in my new position. I am anxious to find a solution
so that I can help our patients, and at the same time I was interested in
making a good impression with my boss and demonstrating to others that I am a
good manager. But what actions should I take? The first step I knew was to
try and discover the facts.
Ever since I became a supervisor in the early 1980's I have been interested
in what we mean by quality in management. We all recognize good managers.
Some of us have been fortunate enough to work with one. We also easily
identify those who are not so good and can point to the characteristics
managers exhibit which lessen our opinion of their work. But this seems to
me a contradiction. If we know what makes a good manager then why are there
so few of them? My curiosity led to reading a book by Robert Persig entitled
Zen and the Art of Motorcycle Maintenance.1 The implications of his ideas for
those of us who have leadership roles in organizations cannot be overstated.
I start my investigation of the parent's complaint. The supervisor of the
area explains that the problem arose because the mother wanted us to attempt
the exam without sedation, even though the age of her child fell within our
criteria for its use. She tried to complete the study but there was too much
motion on the images. The child then had to be sedated and a time for the
scan had to be found between other scheduled patients. The supervisor also
states that the mother misunderstood the patient preparation requirement and
was told over the telephone that she could have given her son clear liquids
up until two hours before test. This all seemed reasonable to me, but it
doesn't account for all the criticisms.
Persig was also immersed in an investigation, one that was remarkably broad
in scope. He sought to understand quality, not just in management, but in
everything. He wanted to know how we define what is good. Persig observed
that quality has two components, the romantic and the classic. Romantic
quality equates to aesthetics, incorporating the overall appearance or design
of an object. For example, the romantic is the scene depicted in a painting
or the style of a house.
Classic quality corresponds to the substance of an object. In the example of
the painting the classic includes the specifications of the paint or the
rules governing the style of the piece of work. Classic quality for a home
comprises the materials used to construct it and their interrelationship in
contributing towards the final product.
When I first read of the Persig's dissection of quality into the romantic and
classic I saw the applicability of his ideas to radiology. We have all met
technologists who tend to focus on either patient care (romantic quality) or
technical expertise (classic quality). Persig asserted that true quality
went beyond either the classic or the romantic but was a unity of the two.
This is true with technologists. The highly rated ones find a way to
complete excellent images at the same time that they deliver first rate
customer service. If we apply Persig's ideas to our original question as to
what makes a good manager, it appears that we just have to merge our skills
in executing the romantic and classic aspects of our job. I'm afraid,
however, it is not that simple.
I should have known that we were going to get complaints regarding our c.a.t.
scan section. The department's head nurse came to talk to me weeks ago to
say that she has been noticing patients and families experiencing long
waiting times to have their studies. She also was distressed that her staff
finds out only at the last minute of newly scheduled patients requiring
sedation. The nurse contrasted our poor customer service in this area with
what she explained was efficient patient flow in MRI. The difference in the
way exams were completed, according to her, was that a nurse coordinated the
schedule in MRI while a technologist was in charge in ca.t. scan. Her
opinion was that we should replicate the MRI operational model in C.T.
I immediately recognized value in her suggestion. In my experience when
modalities were directed by a nurse, such as I had seen in the past with a
cardiac catheterization lab and special procedures suite, the workflow was
more structured and patients' medical needs were more closely anticipated.
Still, her analogy between c.a.t. scan and MRI was not perfect. In MRI
almost all pediatric patients are sedated and therefore it makes sense to
have nursing take the lead role. But this is not the case in c.a.t. scan.
In addition, taking the scheduling of patients away from c.a.t. scan
technologists would bruise some egos. I told her that I need some time to
think it over.
Persig began his study of what constitutes the good during a period in which
he was a university rhetoric professor. He tried teaching writing using
traditional methods but he was not satisfied with the final products. He
found that his pupils were simply imitating his examples. After struggling
with this problem in his mind he eventually inverted his system. Persig told
his new students to complete assignments to the best of their ability without
first instructing them on the principles of composition. In response to the
question by some, "Well, how to do know what is good?" he responded, "You
know what quality is." After the essays were finished he read them to his
class and had them select those with quality. He found almost universal
agreement on which papers to include. He then worked with the students to
identify the techniques that could help them improve their creative writing
skills, the same techniques that he had purposely not discussed with them
earlier.
What Persig discovered is that it is not the joining of the classic and
romantic that form quality, but our awareness of quality that allows us to
discern its classic and romantic characteristics. This point can be further
illustrated using the example of the house. How many times have we noticed
homes in which the design elements have romantic or classic quality but after
they are thrown together the sum has far less value then each of the
individual sections? We think that if we start with quality parts then they
must add to a quality whole. Persig realized that it is only the whole that
determines which parts are necessary.
This is why quality cannot be defined. It is through quality that we see the
world. Any attempt to give a definition will result in something less then
the totality of what quality represents.
Now let's apply these concepts to management.
Managers are usually goal-oriented individuals. When there is a task to be
done we seek to perform in rapid fashion all of the separate steps that will
lead to its accomplishment. We react similarly in our attempt to reach
excellence in our profession. We work by recipe. Tell us what makes up a
good manager and we'll make every effort to incorporate them into our job
performance. And there are plenty of people telling us that recipes map the
path to success. A recent search of Barnes and Noble's on-line bookstore
returned over 37,000 books on management. Consultants are quick to feed us
blueprints we can use to better our organizations. We have implemented total
quality management in its various forms throughout businesses of all kinds
and sizes. But thanks to Persig we can see why all of the books,
consultants, and quality programs often fail to produce the expected results.
Its because we have attempted to create quality backwards.
The right way to improve quality, according to Persig, is demonstrated by the
suggestion of the head nurse. Her aim was to achieve quality in the way we
perform c.a.t. scans. Her search for a solution led her to identify a new
procedure (classic quality) for our patient flow process, which she was
confident would then improve the perception (romantic quality) of our
customer service.
The Chairman of the department calls me into his office. He has received
another complaint regarding patient care in c.a.t. scan identical to those we
have seen in the past. This parent has sent a letter to the hospital's
administrator. The Chairman tells me that we need to make an immediate
change in the way we are doing business. I tell him about the head nurse's
proposal and recommend its acceptance. He's receptive to the idea because it
is so different from what we have done in the past. However, he has some
concerns. The Chairman says that it might make it appear that the nurse was
the technologist's supervisor. He also wonders if we are shifting
responsibility away from those who should really be held accountable. But
after a few minutes of discussion, and in light of all of the problems we
have been having, he agrees to give it a try. This meeting takes place on a
Thursday afternoon and we decide to have the plan in place by the following
Monday. I leave his office to begin talking with those who will be involved
in the implementation. I begin to think that this problem may be fixed after
all.
Since we cannot obtain quality by recipe, we need to understand how it is
achieved. We long to be able to "see the big picture," "think outside the
box," seek "continuous improvement," and utilize the other supervisory skills
recommended by the experts. The author explains that we first need to reach a
peace of mind:
The reason for this is that peace of mind is a prerequisite for a perception
of that Quality which is beyond romantic Quality and classic Quality and
which unites the two, and which must accompany the work as it proceeds. The
way to see what looks good and understand the reasons it looks good, and to
be at one with this goodness as the work proceeds, is to cultivate an inner
quietness, a peace of mind so that the goodness can shine through..2
Anything that promotes or interferes with our development of this peace of
mind will impact our ability to be quality managers. This says much about
the culture of the organization in which we practice our profession, the
relationship we have with our superiors, and, most significantly, the values,
behaviors, and attitudes we bring to our work environment.
We put in place our new organizational structure for c.a.t. scan as planned.
The C.T. nurse becomes the patient flow coordinator handling all of the calls
for add-on cases, works with the technologist to decide where they will be
placed on the schedule, greets all patients and families on arrival in the
department, and is the first individual who troubleshoots customer service
issues.
The first couple of weeks do not go well. A nurse expresses to others that
she is being asked to do things that are outside the responsibilities of her
job. Technologists say they are unsure why such a decision has been made and
that the modality will never run well if they are not in charge. The head
nurse comes to me with doubts that we have done the right thing.
But we persist and after two months of meetings with the staff to review our
progress, we begin to see positive results. We receive statistics for the
number of patients scanned over the most recent month and there has been a
tremendous increase over the last time these figures were reported. But most
importantly we have received not one customer service complaint. Instead,
now all I read are compliments! Among the comments appearing now on our
questionnaires are those such as "you are so nice" and "you did a first class
job." But the one that I stared at the longest simply said, "big improvement
since the last time we were here." This survey, I think, I will save.
Notes
1Persig, Robert. Zen and the Art of Motorcycle Maintenance. (New
York: William Morrow and Company, 1974). This year is the twenty-fifth
anniversary of the book's publication.
2Persig 288.
.
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