A Radiologist's Charter That Cannot Be Executed: Riverside Imaging No-Shows
Riverside Imaging runs three MRI scanners across a hospital network and has an 18% no-show rate on outpatient appointments, against a 5% target. The radiology manager drafts a charter: 'To improve patient satisfaction by implementing best-practice scheduling and reducing no-shows, using Six Sigma.' There is no baseline metric definition, no stated financial or operational benefit, and scope covers all patients, all referrers and all three sites. The manager sponsors the project but has no authority over the central scheduling call centre, which reports to a different vice-president. Preliminary data: no-shows are 31% for appointments booked more than 30 days ahead and 7% for those booked within 7 days; 22% of no-show patients rebook within a week; scanner idle time costs an estimated $410 per unused hour. A reminder-text vendor contract is up for renewal in four months. The executive sponsor wants a go/no-go decision at the next steering committee.
1. Critique the charter as written and rewrite the problem statement and goal so they could survive a steering committee.
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The charter fails on four counts. The problem statement is a solution in disguise ('implement best-practice scheduling'); it states no gap, baseline or location. The goal is unmeasurable - satisfaction is named but no-show is the process metric. Scope is unbounded, which guarantees a project that cannot finish. And the sponsor lacks authority over the scheduling call centre, the process that most likely creates the defect. A workable rewrite: 'Outpatient MRI no-shows across three scanners averaged 18% in the last 12 months against a 5% target, consuming an estimated X scanner-hours and $Y in idle cost. Of these, appointments booked more than 30 days ahead show 31%. Goal: reduce overall no-show rate to 10% within 6 months and to 5% within 12 months, starting with the three highest-volume referrer groups. In scope: booking lead time, reminder process, rebooking. Out of scope: referral clinical criteria, scanner capacity expansion.' Add a sponsor with cross-functional authority or an agreed escalation path.
2. What should be in and out of scope, who must be on the team, and which Define-phase deliverables are still missing?
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In scope: the appointment request-to-attendance flow, booking lead-time rules, reminder channels and timing, cancellation and rebooking handling, and the three sites' scheduling practices. Out of scope (for now): clinical appropriateness of referrals, capital capacity, and transport or social determinants, which the team cannot change in 6 months - note them as constraints. Team: a process owner from central scheduling (essential, given the authority gap), a scheduler, a radiographer or technologist, a referrer representative, an analyst for the booking data, and the radiology manager as sponsor or co-sponsor with the VP who owns scheduling. Missing Define deliverables: a SIPOC covering booking to attendance; VOC translated into CTQs (appointment within X days, no wasted trip, timely result); a stakeholder analysis including the call centre and referrers; a validated baseline with a clear operational definition of 'no-show' (versus late cancellation) and a value-stream map of the booking process.
3. The manager wants patient satisfaction as the primary metric. How should you respond?
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Satisfaction is a legitimate but lagging and noisy outcome; it should be a secondary or balancing measure, not the primary one. Three reasons. First, it is not measurable at the process level the team controls - the team changes booking lead time and reminders, not the whole patient experience. Second, a survey may have too few responses to detect change within the project window, so the team cannot tell whether its changes worked. Third, optimising satisfaction can conflict with other CTQs, such as appointment availability or scanner utilisation, which is exactly why a balancing measure is needed. Recommend: primary metric = no-show rate with an operational definition and a data source; secondary metrics = lead time from request to appointment, reminder delivery rate, rebooking rate within 7 days; balancing measures = scanner utilisation, patient satisfaction, and staff overtime in scheduling. That structure lets the steering committee see whether gains in attendance are real or bought at the expense of access.