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

Improving Performance in a Nuclear
Cardiology Department

Doug LaFleu...
from cardiologists have included            and then offer recommendations for
an increase in the use of mid-level        ...
The Total Performance Sys-            Because the relationship map makes
tem (TPS) model as described by          these re...
Table 1
                               Tools Used and Purpose

     Tool           Vantage Point       Purpose
     Perfor...
Overview of the Project                 day protocol in their nuclear testing
   The project involved a cardiology      pr...
level variables that may affect it.        of all members of the process were
This included the overall goals of the     i...
key areas. All of these data were          Step 1—Create a Total
available to us.                           Performance Sy...
Table 2
                                             Trips

     Trip Number   Purpose                       Personnel Inv...
Figure 1. The Total Performance System diagram analysis
   of the nuclear test process which provides clarity on the parts...
patient satisfaction surveys were           being very well answered; 1 not an-
distributed to 20-25 patients per lo-     ...
key personnel. Each visit lasted two    as outlined previously were used dur-
days and the interviews each lasted     ing ...
variables would later be used to           the competitive marketplace. These
frame our recommendations and gain         r...
Table 3
                    A Throughput and Technique Matrix

                Target
                            Practice...
Table 4
                         Practices Collecting Outcome Data


                     1       2     3     4     5     ...
3. Were post-appointment steps              The highest gross revenue a single
causing a delay in the report being        ...
Figure 4. The measures chain.




98   Performance Improvement Quarterly
Volume 18, Number 1/2005
                           Figure 4. The measures chain (continued).




99
Table 5
              Potential Profitability with Quality Techniques
                      (Target Practice “is” Protocol)...
However, there was a lot of vari-     and how the data collected were used
ability and unpredictability while        to de...
Table 7
                Findings and Recommendations Summary

                       Finding                              ...
Finding 2                                goals also allows better decision
    The practice did not have a set of   making...
Figure 5. Management system goals.



quality techniques used showed no         dition to the standard nuclear test)
appre...
technicians preferred the quick be-      and formatted in a manner useful
cause in their opinion it gave a more    to the ...
Table 8
      Management System to Monitor and Manage Key Process
                          Indicators

                  ...
ogy departments using these tools.         challenges them to stay up to date on
As noted in this paper, it has been      ...
the ability of consultants to properly           Groups to the medical industry. He
diagnose problems, offer solutions,   ...
management, applied behavior
 analysis, and behavior-based safety
 and consults with large and small
 businesses on behavi...
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Improving Performance in a Nuclear Cardiology Department

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Improving Performance in a Nuclear Cardiology Department

  1. 1. Performance Improvement Quarterly, 18(1) pp. 83-109 Improving Performance in a Nuclear Cardiology Department Doug LaFleur Western Michigan University and MEDAxiom Karolyn Smalley MEDAxiom John Austin Western Michigan University ABSTRACT Improving performance in the tice. The tools we used are grounded in medical industry is an area that is behavioral systems analysis as well as ideally suited for the tools advocated in applied behavior analysis. The paper by the International Society of Per- describes how these tools help improve formance Improvement (ISPI). This the throughput of a department within paper describes an application of the a medical practice, while taking into tools that have been developed by Dale account that this department is one Brethower and Geary Rummler, two part of the entire medical practice, as pillars of the performance improve- well as the local and national medical ment industry. It allows the reader to community. Each tool utilized is shown follow a step-by-step approach in a proj- as it fits into the puzzle of solving the ect conducted within a cardiology prac- problem described by the client. Approximately 16,000 cardiolo- A 2004 issue of the Journal of the gists practice in the United States. American College of Cardiology These cardiologists are employed includes an introduction of the rec- by hospitals and cardiology prac- ommendations gathered by the task tices ranging in size from a single force that states, “Today there are practitioner to large groups of 30 jobs for practitioner and academic cardiologists or more. Each year ap- cardiologists in most regions of the proximately 850 first year fellows US. About 40% of the nation’s hospi- are admitted into training programs tals with 100 or more beds are seek- to supply this need. However, the ing cardiologists and about one half demand for cardiologists far exceeds of these institutions believe it is ‘very the supply, prompting the American hard to recruit them’” (Nainggolan, College of Cardiology (ACC) to estab- 2004, p. 1). Thus, hospitals and out- lish a task force to study the growing patient cardiology clinics have been shortage and to issue recommenda- searching for more efficient ways of tions on how to increase the num- providing patient care. Solutions to ber and efficiency of cardiologists. improve patient care and efficiency Volume 18, Number 1/2005 83
  2. 2. from cardiologists have included and then offer recommendations for an increase in the use of mid-level improvement. providers, merging of existing car- MEDAxiom is a subscription- diology practices to gain economies based company that collects cardi- of scale, as well as finding ways to ology specific data from practices improve the efficiency of existing nationwide and uses these data to processes within practices. benchmark practices against each The medical community has also other. The database includes proce- experienced continual decreases in dural as well as revenue, expense, reimbursements from insurance and income data. MEDAxiom had companies. This has been caused 48 cardiology practices contributing in part by the federal government’s to their database at the time of the interest in decreasing their reim- study. MEDAxiom also offers per- bursement expenses in the Medicare formance improvement services for program, which major insurance these practices. MEDAxiom’s mem- companies use as their guide to reim- berships are available to all practices bursement rates. Medicare decreases offering cardiology services in the have caused cardiology practices to United States. search for additional profit centers, This article highlights the analysis new testing modalities, and ancil- and recommendations phases of the lary services to maintain the income project and shows how various tools levels expected by their doctors. This and techniques that are common in trend is projected to continue with ad- our industry were used. The follow- ditional proposed cuts on the horizon ing five analysis tools and methods that will greatly impact the profit- were used in the project: (1) The Total ability of practices. In particular, Performance System, (2) The Perfor- nuclear cardiology is slated to receive mance Analysis Gap, (3) The Relation- cuts in reimbursement in the next ship Map, (4) The Process Map and few years. Measures Chain, and (5) The Process Nuclear cardiology is a highly ef- Management System. fective modality used to assess dam- The above tools were selected age from cardiac disease. For those because they are useful to create a practices that offer this service, it systematic analysis of an organiza- typically comprises roughly 20-35% tion. They provide a method for a prac- of their revenue. With proposed titioner to critically identify where Medicare payment cuts approaching, problems exist and the impact of the many practices have been evaluat- problem on the organization. These ing the effectiveness of providing techniques provide tools to identify this service in an efficient and the steps and major outputs of an or- highly profitable manner. Recently ganization and how they impact other a company (called MEDAxiom) was parts of the system. The consultant asked to perform an assessment of a uses this information to identify clear, nuclear department in a cardiology measurable outputs. These outputs practice located in a medium sized, may then be measured during and Midwestern city. The goal of this as- after the intervention to provide a sessment was to determine causes of means for data to be tracked and strat- a perceived problem of throughput egies adjusted to impact the data. 84 Performance Improvement Quarterly
  3. 3. The Total Performance Sys- Because the relationship map makes tem (TPS) model as described by these relationships visible, it shows Brethower (1982) serves as the what is going on in the “white space” framework for the use of all of the in the organizational chart. It helps other tools and models included in the analyst understand how work the intervention package utilized in currently gets done, helps to identify the study. The TPS allows the analyst disconnects, and highlights where dis- to use a systematic, dynamic process connects can be eliminated (Rummler to align all parts of the system and & Brache, 1990). It may also show identify output and feedback systems influences outside the organization that allow the system to change and (competition, government regulatory adapt to its environment. It is based agencies, etc.) that affect the perfor- upon the concept of general systems mance of the entity. This broadened theory, which defines a system as relationship map is also sometimes a complex of interacting elements referred to as a supersystem map. (Bertalanffy, 1968) and the relation- Process maps are useful for outlin- ships between these elements (Miller, ing a more micro, process level view 1978). This perspective allows each of how works gets done in an organi- vantage point of the system to be zation. This map clearly outlines the methodically analyzed. key inputs and outputs of the process, Rummler describes business and displays the steps that depart- problems as those indicated by a ments engage in to convert inputs clear gap between desired and actual into outputs and products (Rummler performance (Rummler & Brache, & Brache, 1990). 1990). In other words, when a de- A measures chain identifies the sired level of performance has been key measurement markers within identified and the actual level of each step of the process. It allows performance has been measured, the the analyst the ability to precisely difference between the desired level design in measurement points that and the actual level is identified as provide the process manager and the performance gap. If the desired key personnel a method to track and level of performance is greater than troubleshoot the process on a “real the actual level then there may be time” basis. The measures chain value in decreasing this gap in per- forms the base for the creation of a formance. The next step is identifying process management system. the impact of decreasing this gap A process management system and assigning a value to the impact. is a set of management tools (forms, If the value is such that it makes charts, etc.) that the process manager economic sense to decrease the gap and personnel use to plan, track and in performance (if the cost to fix the evaluate the process. In this project, it gap is less than the gain received by was initially created in the form of pa- an increase in performance) then an per charts, but these can eventually intervention may be implemented to be interwoven into the information decrease this gap. system of the organization. The relationship map identifies the Table 1 provides a list of the inputs and outputs of a system, and tools and the vantage point and how they interact with one another. purpose of each. Volume 18, Number 1/2005 85
  4. 4. Table 1 Tools Used and Purpose Tool Vantage Point Purpose Performance Macro level This identifies the gap between what is and what Analysis Gap 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 This tool is different from the others because in all levels, from addition to identifying inputs, outputs, and receivers macro level (as the others do) it helps to identify feedback (organizational necessary (from both the receivers of the output as level), to mid well as within the process) for the system to adapt level, to micro to changes over time. This is a tool that the analyst level (job level) 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 High Level This provides a wide vantage point showing units Map 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 A more micro view than the relationship map, it micro than the breaks down the pieces of the process to show their relationship relationship to each other. It focuses on one process level which often cuts across departments within an organization. Measures Super-micro Similar to the process map but drills down even Chain level, gets down further to identify how to measure the process. Often to the level of variables of quality, quantity, timeliness, or cost measurement are used. This provides the analyst with a method of key pieces of to identify what items should be managed in the output that is process. When developing a process management produced by the system, the analyst refers to the measures chain. process. Process Micro level, This is the system that is used by a process manager Management typically to manage the process. It may be a collection of System involves tools paper forms or a set of forms on a computer program. used by a Analyst references the measures chain to determine performer what should be measured and then designs forms to manage a accordingly. It may include forms for placing goals, system. forms for tracking progress, forms that need to be used daily to track progress, etc. 86 Performance Improvement Quarterly
  5. 5. Overview of the Project day protocol in their nuclear testing The project involved a cardiology process? practice located in the Midwestern 5. Does the group have an effec- United States. The practice consisted tive nuclear leadership and manage- of 37 cardiologists and employed ap- ment structure? proximately 220 people. They had been in business since 1967 and had In addition, the group physician been steadily growing in size (mea- leadership wanted improved prac- sured by the number of full time car- tice profitability. As current group diologists) since the early 1990s. They physicians retire over the next few had 15 cardiologists employed in 1992 years, the leadership foresaw a need and had added approximately three to recruit new physicians. A strong, per year through hiring or by merging financially healthy practice has with existing practices in their area. more choices of physicians they may The practice recently noticed that the recruit and hire than a less healthy throughput of their nuclear cardiology one. The leadership team believed department showed fewer patients that nuclear testing should play a key seen per cardiologist than an indus- role in providing that healthy stream try benchmarking database that they of revenue for the practice. were using for comparison purposes. The project was completed over This problem had been prevalent a 12-week period using two consul- for the last three to four years and tants. In all, four trips were made although they had tried to improve to the practice, ranging from one to the throughput using their existing three days each. Time between the management staff, they recently had trips was spent researching data decided to employ an outside consult- from other practices, contacting in- ing firm to analyze the cause and offer dustry professionals about research recommendations. A major goal of this on technical and process data, and engagement was to determine how developing the documentation. Each effectively and efficiently the nuclear trip to the practice was designed dif- testing process was working. Some of ferently and is described in detail the questions that they wished to have below. answered included the following: The first trip involved interviews with high level personnel of the 1. The nuclear testing process ap- practice. This included the physician pears to be less efficient than other president, the executive director, the groups. Is this perception accurate? If chief operating officer, and a clinical yes, what should be done about it? manager. Nuclear process physician 2. Why does it appear that the directors were also interviewed dur- nuclear test ordering of the practice ing this meeting. The purpose was lags behind other cardiology groups to get a high level overview of the in their local market area? process and to make sure that the 3. Has the nuclear testing process parts outside of the nuclear process overbuilt quality into the testing pro- were aligned with the nuclear pro- cess at the expense of throughput? cess itself. In other words, to check 4. Should the practice be using the system that the nuclear process a one-day protocol instead of a two- operates in and understand the high Volume 18, Number 1/2005 87
  6. 6. level variables that may affect it. of all members of the process were This included the overall goals of the interviewed including schedulers, practice and its long term strategies transcriptionists, receptionists, etc. (and if these included expansion of Questions focused on understanding the nuclear process). This type of how each employee contributed to the interviewing process allowed us the process. They were asked what was opportunity to use many of the tools working well, not working well, what described in this paper. The output of could be improved, etc. They were this step involved the development also asked to explain the key activi- of the TPS, macro level maps of the ties, accomplishments and responsi- practice, and an overall map of the bilities of their jobs. The interview nuclear process. During this trip, we questions were as follows: asked all interviewees the following questions: 1. How long have you been with the practice? 1. How long have you been with 2. What was your experience the practice? prior to joining the practice? 2. What was your experience 3. What is your role in the pro- prior to joining the practice? cess? 3. What is the mission of the 4. What do you have to produce practice? in the process (activities, accomplish- 4. What are the major goals of the ments, responsibilities)? practice? 5. What general steps do you 5. Who are your competitors? complete to perform your part of the 6. What is the mission of the process? nuclear testing process? 6. What is working well about the 7. What are the goals of the nuclear testing processes? What is nuclear testing process? not working well? 8. What information is tracked to 7. What needs to be improved? manage the nuclear testing process? 8. What is working well about 9. What is your role in the pro- your job (only in terms of your con- cess? tributions to the testing process)? 10. What is working well about 9. What needs to be improved? the nuclear testing processes? 11. What needs to be improved? Validation of the answers was 12. What is working well about obtained by cross checking the an- your job (only in terms of your con- swers with information gathered tributions to the testing process)? from other interviews as well as by 13. What needs to be improved? comparing them to objective data that were available. Objective data The second trip included a more were typically available via manage- detailed process-level investigation. ment reports that were being col- It included additional interviews of lected. MEDAxiom also had survey the managers of the process (both data that had been sent to them on a physician and non-physician) as well yearly basis that was used to create as nuclear technologists who worked benchmarking graphs comparing within the process. Representatives practices to each other in various 88 Performance Improvement Quarterly
  7. 7. key areas. All of these data were Step 1—Create a Total available to us. Performance System Diagram The third trip was the presenta- A Total Performance System tion of findings and recommenda- (TPS) model (Brethower, 1982) was tions. It was broken into two parts, created to analyze the nuclear test presenting to the management team process and to clearly represent the and presenting to the physicians who major parts of the system in a visual oversaw the process. manner. This analysis tool was ef- The fourth trip involved creating fective in identifying where further an environment wherein the practice investigation was necessary, and could implement the recommenda- highlighted the need for other, more tions. This was considered a separate detailed tools to be used in our analy- phase of the project and required sis. It also helped to identify what considerable up front work with the questions would need to be asked in major stakeholders. Meetings were the interview process. A TPS must required with various practice physi- have all seven parts in order to act cians (the nuclear directors) as well as a useful analysis tool. In addition, as with the management team. The the parts of the TPS must be aligned, meetings were also used to allow the linked and balanced. Figure 1 dis- physicians and others the opportu- plays the TPS model. nity to give the us their feedback on The following is a list of questions the recommendations so we could that the TPS model prompted us to make changes and adjustments as answer using our findings from the necessary. various interviews. This tool and the Table 2 provides a summary of the questions and answers it created trips, the purpose of each trip, and the were used extensively during the personnel involved in each trip. first and second visits, allowing us to While completing the trips, we understand the major elements of the worked through a step-by-step pro- practice and the process. cess that assured inclusion of the 1. What is the goal or mission of tools as described earlier in this the practice and of the nuclear testing paper. Steps were completed as process? This question was asked of sequentially as possible, although the physicians, the nuclear technolo- some steps could not be completed gists, and various administrators to until the all of the information had create some clarity on the goal of the been gathered. This often caused us process. We looked for consistency in to backtrack and gather the infor- their answers and overall themes. mation when it became available. Were the goals clear, agreed upon, In general, the sequence was as fol- and being vigorously pursued? Were lows: (1) Create a Total Performance the goals of the practice consistent System diagram, (2) conduct on-site with the goals of the nuclear depart- interviews, (3) create a relationship ment? map, (4) analyze local and national 2. What are the inputs to the nucle- practice trends, (5) develop a process ar testing process? What inputs were map of the nuclear testing process, (6) critical to the process? How did they develop a measures chain, (7) conduct compare to the industry exemplars of a gap analysis. this process? The inputs included the Volume 18, Number 1/2005 89
  8. 8. Table 2 Trips Trip Number Purpose Personnel Involved Trip 1 Gain a high level Interview high level personnel, including overview of the process physician president, executive director, and gain clarity on the chief operating officer, clinical manager, and overall practice goals. nuclear process manager. Gain an understanding of the overall goals of the process. Determine strategic fit of all goals. Trip 2 Gain clearer Interviews with process managers (both understanding of process physician and non-physician), nuclear goals. Gain clarity of technologists, schedulers, transcriptionists, roles and responsibilities receptionists. of workers within the process. Gain understanding of steps of the process. Gain understanding of protocol used within the process. Trip 3 Presentation of findings Presented to the management team and and recommendations. 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 Meet with key physicians who had vocal regarding objections to recommendations. Meet recommendations and with supporters of the recommendations analyze to make further (physician and non-physician). Meet recommendations with practice CEO as well as physician for implementation. president and nuclear department directors This phase included (physician). Later, after agreement from the time to allow key leadership, management team presented stakeholders time to recommendations to key process personnel. express their concerns. An understanding of the politics of the practice (and overall goals) was very valuable when positioning the recommendations. people used in the process, the equip- 3. What are all of the steps included ment, location, room sizes, and any in the process? Within the process, other items relative to the physical what were the outputs of each step layout of the nuclear lab. and how were these measured? These 90 Performance Improvement Quarterly
  9. 9. Figure 1. The Total Performance System diagram analysis of the nuclear test process which provides clarity on the parts of a system. answers would be later used to cre- to make changes to the process, as ate a process map and a measures they should be. chain. 6. Who receives these major out- 4. What is the major output of the puts? From the perspective of both process? This was later identified as a the nuclear process as well as the “report sent” to a referring physician. practice procedures, it was noted that What is the major output of the prac- patients and referring physicians tice? Is it consistent with the output were the major receivers of the output of the nuclear department? of the nuclear process. 5. What internal feedback data 7. What is currently measured to are collected? What data should be show the value of the outputs by the collected? How should the data be receivers of these outputs? This in- organized and used as feedback? cluded patient satisfaction and refer- This was later included in the man- ring physician satisfaction reports. We agement system that was created. As looked to see if this feedback was being in most of our nuclear projects, we received on a regular basis, how it was noted that some data were collected, being used, and if any decisions were but data collection is often fairly being made from this information. random and not systematically orga- Neither type of survey was currently nized to optimize the process. Most utilized so we created a patient satis- reports are either not closely exam- faction survey. A referring physician ined, or are lightly reviewed and put survey was not created because in aside. They are not typically used to past nuclear projects it had not been manage the process or as a means possible to obtain valid results. The Volume 18, Number 1/2005 91
  10. 10. patient satisfaction surveys were being very well answered; 1 not an- distributed to 20-25 patients per lo- swered well)? cation. Criteria for selecting patients 9. On a scale of 1 to 5, how helpful included providing an equal balance were the technicians and RNs at en- of men and women, a balance of in- abling you to complete the different patients and outpatients, a spread of steps of the test (5 being very helpful; ages from older to younger, inclusion 1 they were not helpful)? of two to three patients who required 10. From the time you arrived a pharmacological test, two patients until the time you left, how long did who weighed 250 pounds or more, and the appointment take? patients from an array of doctors (not 11. On a scale of 1 to 5, how easy just one or two). A script was written and convenient was the check out and distributed to the staff to use process (5 being very easy and conve- when asking for patient volunteers. nient; 1 inconvenient and difficult)? The survey was designed to 12. Once the nuclear test was include questions that referred to completed, how long did it take to get specific parts of the process. The ques- the test results? tions were as follows: 13. Who provided you with your results? 1. How long did you have to wait 14. How satisfied were you with for an appointment (day they called the whole nuclear test process (very or referring physician did until they satisfied, satisfied, or dissatisfied)? got in)? 15. What suggestions do you 2. On a scale of 1 to 5, how clear have for improving the nuclear test were the instructions you received to process? prepare you to take the test (5 being 16. Would you refer a member of very clear; 1 being least clear)? your family or a friend to this practice 3. Of the people who gave you for a nuclear test? instructions, who gave you the clear- 17. What else would you like to est understanding of how you were to tell us about your experience? prepare yourself for the test? 4. On a scale of 1 to 5, how helpful The surveys were collected by the was the reminder call (5 being most practice personnel and mailed to the helpful; 1 least helpful)? consultant team upon completion. 5. On a scale of 1 to 5, how easy Results were compiled and consis- and convenient was the check-in tent themes were identified where process (5 being very easy and conve- applicable. These themes were then nient; 1 inconvenient and difficult)? compared with data collected in the 6. How long did you have to wait interviews, observations, and from in the waiting room before you were management reports that had been called to begin your test? provided to us. 7. On a scale of 1 to 5 how clear was the video description of what Step 2—Conduct On-site would occur during the nuclear test (5 Interviews being very clear; 1 being unclear)? As previously noted, separate 8. On a scale of 1 to 5, how well visitation sessions were set up with were your questions answered (5 the practice to have us interview 92 Performance Improvement Quarterly
  11. 11. key personnel. Each visit lasted two as outlined previously were used dur- days and the interviews each lasted ing the interviews. approximately 40-50 minutes. A half hour was set aside between inter- Step 3—Create a Relationship views (whenever possible) for us to Map of the Process review their notes and add items The next step was to develop a re- as necessary. The interviews were lationship map (Rummler & Brache, scheduled to examine the process 1990) of the practice which was used from top to bottom from an opera- to identify the overall parts of the tional, management, and strategic system in which the nuclear testing perspective. Questions were asked process operated. Figure 2 shows a at a high level (the strategic level) macro view relationship map of the and systematically worked down to environment into which the target the process and, when necessary, to nuclear department fits, showing a the individual performer level. This ‘big picture’ of some of the variables gave us a more complete, systems that may have an impact on the perspective of the process. Questions nuclear department. Some of those Figure 2. A relationship map. Volume 18, Number 1/2005 93
  12. 12. variables would later be used to the competitive marketplace. These frame our recommendations and gain results were used to create Table 3. agreement to the implementation of our recommendations. For instance, Step 4—Analyze Local and the competitors’ use of quality tech- National Practice Trends niques was analyzed and a table of A major goal of the project was to this was developed and included as determine if the practice had over- a key recommendation. built quality into the testing process The relationship map allowed us at the expense of throughput. A ma- to gain more clarity on the environ- trix was created to compare the pro- ment in which the practice operated tocols of the target practice to other and to properly scan the environ- local practices to determine if the ment. It also prompted the creation target practice was performing more of additional questions that needed quality steps than their competitors. to be answered. Among the key ques- The matrix listed the protocols used tions that it prompted were: (e.g., a one day or two day protocol), the nuclear isotope used (the two 1. Who was the competition in the market leading brands are Cardiolite local market area and what protocols and Myoview) as well as items that were they using in their nuclear test- represent various quality techniques ing process? What was the through- used to assess cardiac damage. These put of competitors as compared to the included gated stress, TAC, quick, practice? and gated rest. All four of these are 2. Were there any government used to assess various elements of the regulations that would hamper our heart and how it functions. Lastly, the ability to recommend changes in pro- nuclear department was asked if the tocol or procedures used? What were Intersocietal Commission for the Ac- the industry leaders’ thoughts? creditation of Nuclear Medicine Lab- 3. What associations or governing oratories (ICANL) certification had bodies were important in nuclear car- been attained. ICANL is an industry diology? Did they have any protocols, accreditation process that some qual- standards, or recommendations for ity-conscious labs complete. Various throughput and quality? industry suppliers were contacted 4. What were the demographics of to determine throughput and tech- the marketplace in which the practice niques used in each location. The operated? Was it a growing market? matrix that was created is shown in Table 3. It should be noted that the ex- We then compared the target ercise of creating this map helped practice to other nuclear labs located us gain much needed clarity on the around the country on quality testing relationships between the parts of dimensions. A questionnaire was cre- the system. The process prompted the ated and sent out to all 48 practices identification of issues that weren’t who contributed to the MEDAxiom apparent before this process so ad- database. A total of 18 practices re- ditional questions were developed. sponded to this survey. Numerous In this case, it included questions pieces of information were collected that needed to be addressed about that were extremely valuable for the 94 Performance Improvement Quarterly
  13. 13. Table 3 A Throughput and Technique Matrix Target Practice 1 Practice 2 Practice 3 Practice 4 Practice 5 Practice 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. process. This process map shows the Among the notable items were: relationship between the inputs and outputs for each step of the process. • Eighteen out of 18 reported using It also clarifies how each output is a one-day rest/stress protocol and used as input for the next step of the all 18 completed gated stresses. process. This process map is often the • Five out of 18 reported utilizing only time that employees within the TAC, and four out of five stated process see each part as it relates to they used TAC on all patients. other parts, and it allows both the • Five out of the 18 reported using employees within the process and quick imaging. Of those five, none us the opportunity to gain clarity on did TAC in combination with quick the process steps. Figure 3 shows a imaging. In other words, practices map of the nuclear process used in that used extra quality techniques this practice. reported choosing between TAC The process map also prompted and quick; none used both. us to collect additional information concerning various steps. Among An example of the layout used is the questions created were the fol- included in Table 4. lowing: Step 5—Develop a Process Map 1. What forms are used in the of the Nuclear Testing Process check-in, and check-out phases of the A process map of the nuclear pro- process? cess was created and was reviewed 2. How much time does each step by the key members of the process to of the process require? How does this make corrections and adjustments. compare to other practices? Could This macro-level map helped to any of the steps be eliminated? If so, clarify the steps being used in the which ones? Volume 18, Number 1/2005 95
  14. 14. Table 4 Practices Collecting Outcome Data 1 2 3 4 5 6 7 8 9 Nuclear to 65- 94% 80% 86% 92% 85% 90% 75% 90% Cath Rating 70% 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 Yes Yes No No Yes Yes No Yes Accredited Figure 3. The nuclear test process. 96 Performance Improvement Quarterly
  15. 15. 3. Were post-appointment steps The highest gross revenue a single causing a delay in the report being head camera could produce per year sent? working ten hours a day would be 4. What do the reports look like? $1,728,000. The highest gross revenue Is the report satisfactory to the refer- a dual headed camera could produce ring physicians? per year working ten hours per day would be $2,808,000. However, if the Step 6—Develop a Measures quality techniques were reduced (to Chain include the TAC but not the Quick The measures chain was devel- study) and the camera was run contin- oped as a tool that allowed us to drill uously, the gross profit potential for a down and create additional clarity on single headed camera would increase the outputs of the process. The mea- to $2,160,000 and the gross profit po- sures chain took into account the ma- tential of a dual headed camera would jor steps of the process and identified increase to $4,320,000. Therefore, the each output. These outputs were then value to the practice of removing a analyzed and measures were created quality technique for a single headed using quality, quantity, timeliness, or camera could be up to $432,000 while cost as the key variables. This step the value to the practice of removing was extremely useful in the creation a quality technique for a dual headed of a management system which was camera could be up to $1,512,000. This included in the recommendations of represents the gap between the “is” the project. It was also useful when and the “should be” in the process. showing the management team the Obviously, the removal of a quality logic of the measures and how track- technique could create a high poten- ing measures could help them to tial risk for the practice. However, better manage the system. Figure 4 our analyses revealed that little addi- is an example of the measures chain tional information was being gained produced in this project. from conducting what amounted to a very costly quality practice. Further, Step 7—Create a Gap Analysis our benchmarking data revealed that A financial analysis was created most competitors were using only one highlighting the differences between technique and that experts in the tar- the “is” (i.e., current) nuclear protocols get firm strongly believed that only with a “proposed” nuclear protocol. one quality technique was needed. This analysis was completed to com- pare a single head camera and a dual Overview of the Nuclear head camera (two different types of Test Process nuclear cameras that were being used Consistent themes emerged from in the practice) that were each oper- interviews with the practice leader- ated during a ten-hour work day. ship and the practice referring physi- In an ideal world, without any cians. Some of the themes were that variability (with the camera running the quality of the practice nuclear continuously) and with the current studies was excellent but the process quality techniques being used, the required too much time and used gross profit potential was projected too many resources to achieve the as follows (see Tables 5 and 6). desired results (it was inefficient). Volume 18, Number 1/2005 97
  16. 16. Figure 4. The measures chain. 98 Performance Improvement Quarterly
  17. 17. Volume 18, Number 1/2005 Figure 4. The measures chain (continued). 99
  18. 18. 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 People at both locations appeared to inconvenient for some patients (im- be working well together as teams. pacting referring physician and pa- They respected each other, worked tient satisfaction). A concern was also collaboratively, and interchanged expressed regarding losing patients themselves at any task in the process to other cardiology groups (impacting if they had the skill and met certifi- long-term practice survival). cation requirements. They were all Consistent themes emerged from working to make the process as ef- interviews with nuclear leadership fective and efficient as possible while and those working in the process. producing quality test results. 100 Performance Improvement Quarterly
  19. 19. However, there was a lot of vari- and how the data collected were used ability and unpredictability while to develop the recommendations. The doing the work. Some of the vari- format used was to list findings and ability was created by patients: no include all pertinent data in the find- shows, same-day cancellations, and ings summary, then follow this with patient condition at the time of the the recommendation related to that appointment, to name a few. Some finding. Having the recommendations of the variability was created by the supported by the researched findings practice and non-practice referring provides much more validity to the physicians: no clinical information on recommendations, as often the data outpatients, incorrectly selected ra- that was used were supplied directly diopharmacological agents given the from the practice to us or directly to patient’s clinical condition, same-day MEDAxiom. Other data were from office visits, add-ons, and so forth. outside of the practice, from either Add four different protocols, a their competitors or from peers series of quality techniques used to around the country. This dimension acquire top-of-the line images, equip- also provided a degree of believability ment that may or may not be able to to the findings. Findings directly from complete the quality techniques, and a consulting team with no back-up different standards on when and how data may be taken less seriously by to conduct a pharmacological stress the client. This data-based technique test, by two nuclear medical directors, has proven to be very effective for and the variability and unpredict- us when making recommendations. ability again increases. Some of the key findings are sum- Statements by nuclear staff that marized in Table 7 and presented in they could not do any more and could greater detail below. not work any harder or faster were truths, given these conditions. In Finding 1 addition, the employee turnover rate No common goal or mission for the (which was deemed as high compared nuclear test process had been creat- to other practices) was predictable ed. During our interviews, there were and was expected to continue until inconsistent answers to the question, the process was brought under con- “What is the goal of the nuclear test trol. What follows are some of the process?” Some of the responses specific findings and the recommen- included: (a) to create the best di- dations that were presented to the agnosis of ischemia or non-ischemia practice as a result of the seven-step as safely and effectively as possible; analysis described above. (b) to check for blockages to see if further interventions are needed; (c) Findings and quality care for patients and quality Recommendations imaging; (d) to serve the practice and Summary the medical community in the detec- Various findings and recommen- tion of unknown heart disease and dations were proposed to the prac- the evaluation of the severity of the tice. We have included a few of the disease (these goals are to be carried recommendations here to provide an out by methods that will assure both understanding of the format used the highest accuracy and efficiency Volume 18, Number 1/2005 101
  20. 20. Table 7 Findings and Recommendations Summary Finding Recommendation(s) 1. There is no common goal or mission Create an agreed upon mission for the nuclear test process. statement for the nuclear test process. 2. There is not a set of operational goals Create a balanced set of operational that guide and direct performance of goals for the nuclear process. the nuclear test process. 3. CA completes more techniques to Systematically reduce the number of ensure quality than other local quality techniques that are used on cardiology practices, surveyed CLA an on-going basis. practices, and area hospitals. 4. There is no cohesive management Establish a management system for system that enables monitoring and the nuclear test process. managing the nuclear test process. possible with present techniques); mission statement for the nuclear (e) become efficient and decrease test process. It was: slowness; (f) to get objective data for subjective symptoms; (g) provide a The nuclear testing process quality, accurate nuclear study in the produces compassionate patient most cost-effective way possible while care and timely, high quality and accurate reports for patients and establishing and maintaining rela- referring physicians. These reports tionships with patients; (h) acquire are used to make objective decisions test results that are accurate with on subjective symptoms so patients clear definition and not descriptive, may enjoy the highest level of health timely (within five days from start possible and live longer, more pro- to finish), and convenient for patient ductive lives. (within one day without loss of qual- ity); and (i) correlate nuclear studies The mission for the process was cre- with catheterization lab results—it’s ated using a series of questions created the gatekeeper to the catheterization by Brethower (LaFleur & Brethower, lab. As can be seen, the answers were 1998) and were as follows: varied and mixed. 1. What is the name and major Recommendation 1 product of the organization, depart- Create an agreed-upon mission for ment or process? the nuclear test process. The purpose 2. Who receives the product/ser- of a mission statement is to provide vices? clear direction and focus for those 3. What do people do with the working in the process. It should products/services? align with the mission and values 4. How do people benefit from the of the practice. Using ideas from the products/services? goals gathered during the interviews, 5. How does society benefit from MEDAxiom created an example of a the products/services? 102 Performance Improvement Quarterly
  21. 21. Finding 2 goals also allows better decision The practice did not have a set of making about protocol changes and operational goals to guide and direct improvements to the process. The performance of the nuclear test pro- impact of suggested changes should cess. No goals were established annu- be considered across all goals rather ally for the nuclear test process. No than just one or two. If the changes planned versus actual performance are implemented, the operational summary reports were provided goals will provide information about to practice leadership and admin- the success of those changes. A clear istrative management. On-going and balanced set of operational goals information about the performance and summary reports can, therefore, of the process was not being tracked not only aid in planning, but they or communicated. Therefore, neither can aid in evaluation of implemented celebrations of victory nor timely changes. corrective action could take place. This left the process vulnerable to Finding 3 the optimization of one dimension— The target practice completed quality—at the expense of another more techniques to ensure quality dimension—throughput. than other local cardiology practices, other surveyed MEDAxiom practices, Recommendation 2 and area hospitals. The practice lead- Create a balanced set of opera- ership asked: “Are we going to a lot of tional goals and corresponding sum- effort to try to get the “perfect” nucle- mary reports. It was recommended ar study? And, in doing that have we that practice leadership determine added a lot of additional steps?” the operational goals for the nuclear Listed in Table 4 is informa- test process. These goals must align tion from nine of the MEDAxiom with the mission of the nuclear test practices that collect outcome data process and represent a balance correlating their nuclear tests re- between patient and referring physi- sults with catheterization procedure cian satisfaction, quality, efficiency findings. Nuclear test correlation to and throughput. Initially, these can catherizations is an industry recog- be preliminary goals which can be nized standard for determining the modified or negotiated once the effectiveness of the nuclear testing nuclear process management has process. This correlation is typically reviewed and provided feedback. In listed as a “false positive rate,” or some cases, goals should be subdivid- the percentage of nuclear tests that ed by location. Others may stay the show a positive level of heart disease same for both locations. See Figure 5 but that are later determined to be for an example of the potential goals false when the physician conducts and reports of measures. a catheterization procedure on the The establishment of operational patient. A high level of false positives goals and reports that show com- would indicate that many patients parisons of “planned” versus “actual” were being incorrectly diagnosed as performance provide a means for having heart disease that required a determining how well the process catheterization procedure. The find- is performing. A set of operational ings indicated that the additional Volume 18, Number 1/2005 103
  22. 22. Figure 5. Management system goals. quality techniques used showed no dition to the standard nuclear test) appreciable decreases in the number for patients. When practice nuclear of false positives. technicians were asked, “Which, Only two out of six of the ICANAL TAC or quick, helps the most with accredited practices who achieved an accuracy and quality of the images?” 85% or better on their false positive Three out of five said quick. Two out rating use additional quality tech- of five said the procedures were about niques. The remainder are able to even. When the two nuclear techs achieve excellent false-positive out- were forced to choose, one said TAC comes without using the additional helped more with quality and the techniques. other said quick. Next, the nuclear technicians were Recommendation 3 asked, “If you had to eliminate one, Systematically reduce the num- TAC or quick, which would it be?” All ber of quality techniques used on an five responded TAC. Two out of five on-going basis. In the near future, practice nuclear technicians would plan to eliminate either TAC or quick eliminate TAC because it gives the (two tests that were conducted in ad- same information as the quick. Two 104 Performance Improvement Quarterly
  23. 23. technicians preferred the quick be- and formatted in a manner useful cause in their opinion it gave a more to the parts of the practice which accurate and complete image of the needed them most. Data were col- heart. And, the fifth technician said lected throughout the practice but eliminating the TAC saved time. were not used to manage the nuclear To ensure that reducing the num- testing process. The data required ber of quality techniques does not to manage the nuclear test process harm the practice’s quality, it was were not readily available to those suggested that they use currently managing the process, nor were they tracked false-positive data to moni- formatted in a manner that provided tor test outcomes. In doing so, the information to different end users practice could identify an acceptable and stored in a central location for standard for its outcome rate (e.g., easy retrieval and review. Finally, 78%, 85%, or 92%), sort the data into there was no coherent, cohesive one-day and two-day protocols, and management system to oversee the then watch the trends over time. nuclear test process. It was suggested that the practice re-evaluate the current decision- Recommendation 4 making protocols used with patients. It was recommended that the The practice could establish proto- practice establish a management cols that will allow the use of TAC, system for the nuclear test process. quick, and gated rest as quality To do this, they would need to create techniques but in a more stringent a set of measures that could be used and limited way. Rather than recom- to monitor and manage the nuclear mending the wholesale elimination test process. These indicators should of a technique, it was suggested reflect the key sub-outputs of the pro- that the practice determine the best cess as defined by quality, quantity, method for each situation and use timeliness, or cost. A visual map of that method. Achieving a system- the key indicators is reflected in the atic reduction in quality techniques process measures chain (see Figure while monitoring the outcome data 4). Monitoring a select number of will ensure that the practice retains these key process indicators will cre- its emphasis on quality. ate a system whereby the variability of the process may be managed and Finding 4 adjusted to assure optimum perfor- No cohesive management system mance (see Figure 5 and Table 8). that enabled monitoring and manag- These process measures also ing the nuclear test process was being reflect areas noted in the findings used. Nuclear managers collected where substantial improvements in data on the number of nuclear tests the process may correlate with addi- completed by radiopharmacologi- tional revenue to the practice. For in- cal agents; percentage of schedules stance, in the area regarding rescans, utilized; and the number of staff and decreasing rescans a total of 14 per type of staff used. week would represent an additional Data about the nuclear test pro- $1,400,000 annual gross profit to the cess were spread throughout the practice. More closely monitoring and practice. The data were not collected managing the number of add-on slots Volume 18, Number 1/2005 105
  24. 24. Table 8 Management System to Monitor and Manage Key Process Indicators Standard to be Person Key Process Indicator Planned Monitored Determined By Responsible Productivity per camera for Nuclear Annually Weekly Nuclear Location A and B Manager Manager Add-ons for Location A Nuclear Annually Weekly Nuclear and B Manager Manager Cancellations for Location Nuclear Annually Weekly Nuclear A and B Manager Manager No-shows for Location A Nuclear Annually Weekly Nuclear and B Manager Manager Patient re-schedules for Nuclear Annually Weekly Nuclear Location A and B Manager Manager Number Outpatient Tests Nuclear Annually Weekly Employee A Completed Manager Backlog for Location A Nuclear Annually Weekly Employee A and B Manager Timeliness of reports sent Nuclear Annually Weekly Employee A to referring physicians Director and cancellations may also allow for Conclusion more patients to be treated by the In this paper, we attempted to practice. contribute to the behavior analysis It should also be noted that and behavioral systems analysis creating goals and managing the literature by documenting a recent timeliness of report completion may case study application in a step-by- contribute to an increase in the step manner. Although this paper number of new patients examined. ends with recommendations (rather The findings illustrated that this than organizationally relevant out- number was steadily decreasing. comes), it should be noted that the The findings also demonstrated that target practice is in the process of the reports were not always sent in implementing many of the recom- a timely manner. One reason for the mended solutions described herein. decrease in new patient numbers At the date of this writing, it was appeared to be related to the amount reported by the chief financial officer of time required to submit reports to of the practice that a few of the imple- referring physicians. By tracking and mented steps had already increased managing these areas more closely, the gross profitability of the practice the practice could realize additional by $100,000 per month. gross profit and better satisfied refer- A number of projects have been ring physicians. completed within nuclear cardiol- 106 Performance Improvement Quarterly
  25. 25. ogy departments using these tools. challenges them to stay up to date on As noted in this paper, it has been industry changes in protocols, equip- extremely effective to support these ment, and techniques to maximize tools with data to support the recom- their efficiency. mendations. This had often meant The use of these tools in the gathering data from various sources sequence provided should be use- either inside of their practices or out- ful in various small scale process side of their practices. Data outside redesign projects. Nuclear processes the practices has included subject that these tools have been used in matter experts, various data collec- typically have from 5 to 30 employees tion services available to the indus- involved in the process per practice try, data available from vendors, and location and have from seven to nine available competitive data. Using main steps. Some practices had two this type of data has helped create the to three locations and the projects impact necessary to influence physi- were still completed within 12 to 14 cians and administrators. Cardiolo- weeks. It was also helpful to use two gists have an extensive educational consultants in this type of process, as background that has shaped them it provided us with the opportunity to into using data for making critical split the duties and build the pieces clinical decisions. This has tied in necessary to complete the project in nicely into our approach of framing a three-month time frame. Feedback our recommendations with data from from these projects regarding the various sources. time frame seems to indicate that the In each nuclear process project customers can be patient for three that has been completed by these months, but any longer and the pro- authors, the most common missing cess seems to lag and cause concern piece has been a strong management from the major stakeholders. The pro- system which includes the use of cess as outlined should be effective for goals and feedback systems. Without other process projects encompassing these, nuclear processes often engage a similar number of employees and in a “push” system of trying to do as steps within a three-month time many tests per day as they can. This frame. The tools used in this project results in little creative thought in have also been used by their various finding smarter ways to improve the developers in very large-scale proj- throughput. Conversely, a process ects, however the number of consul- that includes clear goals set by upper tants and time frame would have to management and agreed upon by the be adjusted accordingly. process managers creates an envi- The tools in this paper have pro- ronment of “pull” goals, whereby the vided a strong foundation for all of process managers and employees are the work that we do in the cardiology challenged to find ways to accomplish field. We believe that these pieces the goals and manage the system to provide a fairly complete and system- hit their goals. Clear goals also put atic analysis of projects and allow us the focus on the process teams engag- the ability to offer organizationally ing in constructive problem solving relevant and data-based recommen- behaviors during their meetings. dations. Performance improvement This creates an environment that projects are complex as they involve Volume 18, Number 1/2005 107
  26. 26. the ability of consultants to properly Groups to the medical industry. He diagnose problems, offer solutions, holds a B.S. from Central Michigan and then guide the implementation University, an M.B.A. from Grand process. This paper has dealt with Valley State University, and an the first and second phase of this M.A. in Industrial Psychology and equation. However, a proper diagno- Ph.D. in Applied Behavior Analysis sis with valuable recommendations from Western Michigan Univer- makes the implementation process sity. Mailing address: 3920 Plateau much more effective. It is hoped that, Trace Ct., Grand Rapids, MI 49525. through providing an example, this Telephone: 616-706-6284. E-mail: paper may help others to understand dlafleur@medaxiom.com how to use of some of the tools of our industry to create organizational KAROLYN A. SMALLEY, a Per- change. formance and Instructional Sys- tems Consultant, helps improve References performance at the organization, Bertalanffy, L., von (1968). General process and job level. She spe- systems theory: Foundations, de- cializes in process improvement velopment, applications. New York: projects, performance manage- Braziller. ment systems, and instructional Brethower, D.M. (1982). The total per- formance system. In R.M. O’Brien, systems. For the past three years A.M. Dickinson, & M.P. Rosow (Eds.), she has worked with cardiol- Industrial behavior modification: A ogy practices enabling them to management handbook (pp. 350-369). achieve increased revenues, im- New York: Pergamon Press. proved continuity of patient care Lafleur, D.S., & Brethower, D.M. (1998). and patient satisfaction, and im- The transformation: Business strate- proved throughput without loss gies for the 21st century. Grand Rap- of quality. Prior to working as a ids: IMPACT GROUPworks. consultant, Karolyn managed the Miller, J.G. (1978). Living systems. New York: McGraw-Hill. Human Resources Development Nainggolan, L. (2004). ACC task force Department for an organization recommendations on shortage of car- having more than $7 billion in diologists. Heartwire, p. 1. annual sales. She is a graduate Rummler, G.A., & Brache, A.P. (1990). of Michigan State University, the Improving performance: How to man- programmed learning workshop age the white space on the organization of the University of Michigan, chart. San Francisco: Jossey-Bass. and the MA program in Indus- trial/Organizational Psychology DOUG LaFLEUR is a Vice-presi- at Western Michigan University. dent of Practice Development of Mailing address: 8190 Two Mile MEDAxiom. His interests are in all Road NE, Ada, MI 49301. E-mail: areas of human performance as re- karolynsmalley@earthlink.net lated to organizational settings, in- cluding the organizational, process JOHN AUSTIN, Ph.D. is an Associ- and individual levels. He specializes ate Professor of Psychology at West- in providing process improvement, ern Michigan University, where he strategic planning, and Impact teaches courses in performance 108 Performance Improvement Quarterly
  27. 27. 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: John.austin@wmich.edu Volume 18, Number 1/2005 109

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