Care Redesign

How Care Redesign and Process Improvement Can Reduce Patient Fear

Case Study · October 16, 2018

A breast imaging team that provides same-day screening mammography results, additional breast imaging, and breast biopsies will minimize patients’ fear and boost satisfaction. But leadership must commit to accepting increased variability in patient load and reduced RVU revenue from radiologists.

Key Takeaways

  1. Identify a simple, patient-centered goal for the team.

  2. Recruit staff members who thrive in a flexible team-based environment.

  3. Create standardized, evidence-based care so staff can confidently communicate how the same-day service works.

  4. Review outcomes with the team to address opportunities for improvement.

  5. Communicate early and frequently with referring physicians so they understand and support the same-day service and your willingness to accept add-on patients for same-day evaluations.

  6. Demonstrate that a patient-centered, same-day service model can be profitable for the institution and facilitate staff and physician retention.

The Challenge

Care redesign and process improvement to take costs out of health care are widespread today — but what if the same disciplined approach was taken to reduce patients’ fear? What if care were redesigned with the purpose of detection and elimination, where possible, of the anxiety and uncertainty that a patient experiences, and is so often accepted as a part of care, but really need not be?

We know that patient fear can be reduced because we see the way clinicians take care of their own when they are in frightening situations. That was the epiphany that led to the same-day breast biopsy program at Baylor College of Medicine’s Lester and Sue Smith Breast Center, and now a few other organizations. At most institutions, including Baylor before 2007, when women have an abnormal screening mammogram, they find out after they have gone home, and they usually have their biopsies sometime in the next 2 weeks. As any woman who has been through this process can tell you, even with the same-day scheduling, when the wait is only overnight, that night is a long one.

Typical Breast Imaging Workflow in the United States from abnormal mammogram to breast biopsy

  Click To Enlarge.

We could not help but notice at Baylor that when it was a doctor or a doctor’s wife, things happened differently. The woman didn’t leave. The breast biopsy was done right away. The difference in the amount and the duration of fear and uncertainty that regular patients faced, compared with this special care was, well, embarrassing and unacceptable.

The Goal

So at Baylor Clinic, an outpatient facility in the Texas Medical Center in Houston, we redesigned our care with the goal of reducing unnecessary patient fear. Since 2007, most women having breast cancer screening can have their mammograms, speak with the radiologist, and have any additional imaging or biopsy on the same day. We minimize the number of times women leave the imaging room, because patients have told us that going out to the waiting area and being called back for more imaging is alarming. The radiologist tells the patient the biopsy results via telephone, usually the next day. We also help set up the oncology or surgery appointment, if she needs one. We’ve been doing it for 10 years, and patients and their families love it.

The Execution

The idea is simple — obvious, really. But barriers keep other organizations from doing this. The biggest challenge to implementation is that revenue generation by the radiologist is lower than if the radiologist was just reading images in a basement room, rather than actively participating in care, and reading images in real time with the patient still in the imaging room. To implement such a program, organizational leaders have to make a strategy leap. They have to believe that there will be business rewards from redesigning care to reduce patient fear, even if it reduces reimbursement.

The business case for our model is market share growth. We are surrounded by five breast imaging centers within an approximately 1-mile radius (including a nationally known cancer center), and nobody else offers same-day breast biopsy for abnormal screening mammograms. Because mothers are usually the health care decision-makers for the family, we have not only retained the women who come to the breast center, but we’ve retained their families, too.

Our referring physicians know that, when seeing a woman with a breast complaint, they can send her over to us for a same-day evaluation — even if she doesn’t have a mammogram appointment. Our patients and referring physicians are relieved to have the results on the same day, and they spread the word about our program to their friends and colleagues.

We also had to make a cultural leap, because inherent to any same-day model is unpredictability. We may do anywhere from 0 to 7 biopsies in a day. It takes real commitment to the same-day goal, and that commitment requires flexibility in how one looks at one’s job. We tell our staff that they will be able to eat their lunch every day — but it may not be at lunchtime. Our staff come to us and stay if, and only if, they take pride in being part of a team that is ready to be flexible to reduce the number of sleepless nights for women and their families.

Same-Day Breast Biopsy Workflow at Baylor College of Medicine

  Click To Enlarge.

To accommodate an unpredictable patient schedule, we standardize our work as much as possible to reduce rework and waste. Our patients with breast problems have the same order (diagnostic mammogram with ultrasound or biopsy if needed) to reduce any time between steps in the process. Scheduled patients with breast problems are seen in the morning because they are more likely to need a breast biopsy, giving us more time to do it all on the same day. Imaging and management protocols are evidence-based and standardized via consensus with technologists, radiologists, and referring physicians.

Another strategy we use to reduce patient fear is early and frequent communication. Because our management protocols are standardized, technologists can confidently communicate with patients about wait times and next steps. When a breast biopsy is indicated, the radiologist talks to the patient when she is clothed and sitting at eye-level with the physician. At the time of biopsy recommendation, the radiologist gives what we call a warning shot about the likelihood of cancer to the patient (and her family, if available), which can improve the patient experience.

The radiologist describes next steps, including telephoned results (usually the next business day) and navigation to an oncologist or surgeon. Breast biopsy results are reviewed and communicated to the patient by the next available radiologist, rather than waiting for the original radiologist to return to clinic, to minimize a patient’s wait time for results. This workflow also provides an internal peer review of radiologist performance, driving quality improvement.

Scaling Up Same-Day Breast Biopsy

Addressing a patient’s needs in the same day takes work and commitment by a team. But there have been upsides: Growth. Pride. Lower turnover. And we extended the process to Harris Health System, a public health care system providing primary, specialty, and hospital care to the nearly 4 million residents of Harris County, Texas; Baylor physicians provide care at several of the system’s clinics and hospitals. At Harris Health in 2010, the median time between abnormal screening mammogram to needle biopsy was 89 days.

Within 18 months of collaboration between Baylor physicians and Harris Health staff, using a modified version of our same-day program, we were offering same-day biopsies to safety-net referrals at our diagnostic center. The barriers of productivity and unpredictability were similar, and so were the solutions: Create a flexible team committed to a common same-day goal, based upon standardized work and continuous effort to improve outcomes.

The Team

Our core team of front-desk staff, mammography and sonography technologists, nurses, pathologists, and breast imaging radiologists was supported by our management team and referring physicians. Although each person on the team has an area of expertise, all are cross-trained to minimize any bottlenecks in the same-day process. All breast imaging radiologists share the same skill set and use standardized reporting. Each mammography technologist can perform a biopsy on the patient she may have met during the mammogram, which can alleviate some of the patient’s fear because they have already developed a bond. We have created a cross-training program for our mammography technologists so they are certified to perform breast ultrasounds. Our technologists can also assist with procedures if our nurse is busy.

Baylor Clinic Patient Experience Overall Ranking for Academic Centers that do breast biopsy

  Click To Enlarge.

The Metrics

We regularly review our outcomes and alter our workflows to drive improvement. Because of the Mammographic Quality and Standards Act, we have metrics that are benchmarked, such as recall rate and cancer detection rate. In 2017, our recall rate was 6.2% (benchmarks are between 5–12%). Our cancer detection rate was 6.1 cancers per 1,000 women screened (benchmarks are >2 cancers per 1,000 women). We regularly review our patient experience scores, which are also benchmarked (Press Ganey Associates). When compared to our academic peers, our overall patient experience ranking has been above the 96th percentile for 3 years.

Although we do not have access to a market share analysis, we recently partnered with a competing breast center that demonstrated a fall in volume corresponding to the growth of Baylor Clinic’s same-day program. Patients’ likelihood to recommend relative to competitors in our region also points to success of the same-day program. Revenue has also trended upward, supporting the popularity of the program with patients.

Breast Imaging Exam Volumes by Year at Baylor Clinic and Competing Texas Medical Center

  Click To Enlarge.

Baylor Breast Clinic Patient Likelihood of Recommending Practice Ranking for Region

  Click To Enlarge.

Baylor Clinic Same-Day Breast Imaging Revenue by Year

  Click To Enlarge.

Where to Start

For caregivers interested in creating a same-day breast biopsy program, leadership buy-in is critical and should be obtained early. Outline the entire episode of care from the patient’s perspective. Engage stakeholders involved in the episode of care (referring physicians, technologists, compliance officers, billing, front-desk staff, pathologists, and radiologists) to optimize efficiency, reduce bottlenecks, and identify opportunities for cross-training to support a flexible workflow. Build metrics into the workflow (e.g., patient experience or revenue) to guide process improvement and demonstrate the business case for leadership. Finally, celebrate successes with the team and leadership to sustain the program.

Next Steps

Our team-based approach to patient-centered care can serve as a template for other diseases, such as thyroid nodules or prostate cancer. A patient-centered sustainable and scalable program can be achieved via a simple common goal, standardized work, and an engaged team.


Acknowledgements: The author wishes to express her gratitude for the support of Lester and Sue Smith, the dedication of the Baylor breast imaging team, and the patients who have shared their experiences with us so we may give them better care.

Call for submissions:

Now inviting expert articles, longform articles, and case studies for peer review


A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

More From Care Redesign
Mapping a Technology Strategy for Bundled Payment Care Using a Value-Driven Framework

Harnessing Emerging Information Technology for Bundled Payment Care Using a Value-Driven Framework

A four-part framework developed by physicians at Partners HealthCare provides a stepwise process for assessing and integrating technologies to effectively use data through a continuous patient experience.

UCLA Health CKD Risk Stratification and Management

Proactively Catching the Declining Patient

A coordinated effort by UCLA leaders to identify a high-cost population with chronic kidney disease and to modify care processes and personnel has led to improved health and reduced utilization.

Telehealth and remote monitoring are little used and ineffective for chronic disease care

Survey Snapshot: Treating Chronic Disease Proactively

Though survey respondents don’t indicate strong use of telehealth and remote monitoring, NEJM Catalyst Insights Council members discuss the ways they’re using these tools to monitor chronic disease, with good results.

Platforming Health Care Operations - Consumer-Driven Health Care - Business-Minded Optimizations

Platforming Health Care to Transform Care Delivery

Health care leaders need to focus less on ownership and control of the delivery process, and more on outcomes, cost efficiency, and customer experience.

Shah05_ integrated systems innovation pullquote

Build vs. Buy: What Should Health Systems Do?

The consolidation craze continues, but vertical integration has yet to demonstrate real progress toward the Triple Aim. Health care leaders would do well to consider innovative approaches that are working in other industries, including the tech-enabled full stack model.

Diagram Illustrating the COPD Care Pathway at Allegheny General Hospital

End-to-End Care for COPD Patients that Improves Outcomes and Lowers Costs

Allegheny General Hospital created a comprehensive solution for patients with chronic obstructive pulmonary disease (COPD) that led to improved clinical outcomes, reduced hospital admissions and readmissions, and a resultant decrease in the total cost of care.

David Blumenthal and Bob Galvin head shots

Ripe for Disruption: Why and How Big Players in the Private Sector Are Taking on Health Care

For big tech companies like Amazon, Apple, and Google, the health care sector looks ripe for disruption. Two executives working in different parts of the health care ecosystem discuss what this means for patients and doctors, including the positives and unintended consequences.

Top challenges facing chronic disease management care - insufficient time and care coordination

Care Redesign Survey: To Improve Chronic Disease Care, Change the Payment Model

Many health care organizations are reasonably effective in treating chronic diseases, but they are limited from doing better by fee-for-service payment, which remains the predominant payment model in the United States. This report serves as a snapshot in time, showing the intent of health care providers to be proactive in treating chronic disease, but limitations in their ability to address population health.

Nirav Shah head shot Stanford - AI in medicine and team care

What AI Means for Doctors and Doctoring

Physicians must hone the “four Cs” — critical thinking, communication, collaboration, and creativity — when leveraging AI as a new partner in their care teams.

End of Life EOL Palliative Care in the ED for Patients with Advanced Cancer - Process Map - MD Anderson Cancer Center

Patient-Centered Care at the End of Life in the ED

How MD Anderson Cancer Center is improving end-of-life care in an unlikely place: the emergency department.


A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »


Design Thinking

20 Articles

Taxonomy of the Patient Voice

While health care pursues the important trend of putting patients at the center of care,…

How Artificial Intelligence Is Changing Health…

The development of intelligent machines holds great promise for making health care delivery more accurate,…

Proactively Catching the Declining Patient

A coordinated effort by UCLA leaders to identify a high-cost population with chronic kidney disease…

Insights Council

Have a voice. Join other health care leaders effecting change, shaping tomorrow.

Apply Now