RADIOLOGY IMPROVEMENT SUMMIT - Stanford...

RADIOLOGY

IMPROVEMENT

S U M M I T

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16

February 19

th-20

th | Quadrus Conference Center |

2400 Sand Hill Road Menlo Park, CA 94205

Dear Colleague,

We are delighted that you could join us at the 2016 Radiology Improvement Summit sponsored by the Stanford

Department of Radiology and supported by the RSNA Research and Education Foundation.

To continue to thrive as a specialty, we must learn how to work effectively in a complex environment, which

requires that we master new ways of working and new ways of improving. To do this well, we have a lot to learn

from each other and from diverse fields outside of healthcare.

At this conference, we hope to:

Create a vision and roadmap for improvement in radiology for the next decade

Discuss how to support local radiology practices in building effective improvement programs

Outline important improvement concepts and methodologies

Share and learn about best practices from others seeking to improve

Create lasting relationships centered on improvement

This summit is aimed at teams of radiology professionals who are serious about improvement and who would like

to help shape the agenda for radiology improvement for the coming decade. This includes radiologists,

technologists, administrative leaders, QI support staff, and others.

It is an exciting time in radiology. Thank you for your continued efforts to transform your organization and our

field for the better!

Warmly,

David B. Larson, MD, MBA

Program Chair

We sincerely appreciate the support of those who have made this meeting possible.

Program Committee

James R. Duncan (Washington Univ, St. Louis)

C. Matthew Hawkins (Emory)

Neville Irani (Univ Kansas)

Nadja Kadom (Emory)

Karl N. Krecke (Mayo)

David B. Larson (Stanford)

Alexander J. Towbin (Cincinnati Children’s)

Stanford University

Sanjiv Sam Gambhir (Radiology Dept. Chair)

Improvement Team at Stanford

Dot Cordova

Kandice Garcia

Jake Mickelsen

Lauren Sederberg

Sergio Sousa

Stanford Health Care Leadership

Joni Schott (Administrative Director)

Shirley Weber (Vice President)

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Program

Friday, February 19, 2016

7:15 Breakfast

The Next Decade of Radiology Improvement

Moderator: David Larson

8:00 Welcome and Overview David Larson

The Need for Improvement in Radiology

8:20 Improvement as a Discipline Neville Irani

8:40 Knowledge and Skills Needed for Improvement James Duncan

9:00 Implementing an Improvement Program Karl Krecke

9:20 Supporting All Roles in Improvement Matthew Hawkins, Nadja Kadom

9:40 The Philosophy of Improvement David Larson

10:00 Break

Organizational Improvement in Radiology: The Integrated Radiology QI Program

Moderator: Matthew Hawkins

10:10 Experience at Stanford Kandice Garcia

10:20 Experience at Radiology Imaging Associates (Denver) David Dungan

10:30 Experience at the Mayo Clinic Laura Tibor

10:40 Panel Discussion Speakers and other invitees

Innovative Improvement Initiatives in Radiology

Moderator: Matthew Hawkins

11:00 Staffing Optimization through Simulation at MD Anderson Joey Steele

11:15 CR Dose Optimization at Cincinnati Children’s Hospital Rachel Smith

11:30 Collaborating with Referring Clinicians at NYU Danny Kim

11:45 Exclusive Vendor Contracts at Intermountain Healthcare Curt Littleford

12:00 Lunch

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Friday, February 19, 2016 (continued)

Improvement in Action

Moderator: Alexander Towbin

1:00 The Daily Management System in Radiology Lane Donnelly

1:30 A Radiology Peer Learning Program (in Place of Peer Review) Richard Sharpe

2:00 Break

Moderated Small Group Discussions

2:15 Group A: Elements of an Intellectual and Practical Discipline of Improvement in Radiology

2:15 Group B: Domains of Knowledge and Skill Needed for Organizational Improvement in Radiology

2:15 Group C: The Local Improvement Framework

2:15 Group D: Levels of Interest and Engagement in Improvement

2:15 Group E: Core Tenets of a Philosophy of Continuous Improvement in Radiology

3:15 Break

Small Group Discussion Report-out

Moderator: David Larson

3:30 Group A Neville Irani

3:45 Group B James Duncan

4:00 Group C Karl Krecke

4:15 Group D Matthew Hawkins, Nadja Kadom

4:30 Group E David Larson

4:45 Wrap up and Housekeeping David Larson

4:55 Reception

6:30 End of the Day

(Dinner on your own; we will make reservations at local restaurants)

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Saturday, February 20, 2016

7:00 Optional Excel Lab (for registered attendees) Jake Mickelsen

7:15 Breakfast

8:00 Welcome back David Larson

The “Realizing Improvement through Team Empowerment” (RITE) Program

Moderator: Jake Mickelsen

8:10 The Stanford RITE Program David Larson, Jake Mickelsen

8:45 Decreasing the Time to Transport Patients from Radiology Judi Contento

9:00 Improving Breast Positioning in Mammography Christina Chen and Pat Cowart

9:15 Improving Administrative Assistant Effectiveness Susie Spielman and Tracy Burke

9:30 Decreasing Wait Times in Mammography Pat Cowart

9:45 Decreasing the Time to Image Stroke Patients Daisha Marsh

10:00 Break

Informatics in Improvement

Moderator: Alex Towbin

10:10 Using Analytics to Understand Performance Nabile Safdar

10:35 Comparing Performance Data for Learning and Improvement Safwan Halabi

11:00 Examples of Informatics in Improvement Alex Towbin

Wrap-up

11:30 Roadmap for the Future David Larson

12:00 End of the Program

Lunch (optional—provided for those who wish to stay)

1:00 Informal Discussions (optional—attendees are welcome to linger longer)

4:00 End of the Day

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Presenters

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Presenters

Tracy Burk Administrative Assistant, Nuclear Medicine, Department of Radiology, Stanford University, Stanford, California

Christina A. Chen, MD Radiology Resident, Department of Radiology, Stanford University, Stanford, California

Patricia Cowart, RT Mammography Technologist, Technical Coordinator, Imaging Services, Stanford Healthcare, Stanford, California

Lane F. Donnelly, MD Pediatric Radiologist, Chief Quality Officer, Hospital-Based Services, Texas Children’s Hospital, Houston, Texas

James R. Duncan, MD, PhD Interventional Radiologist, Vice Chair for Quality and Safety, Department of Radiology, Washington University, St. Louis, Missouri

David H. Dungan, MD Neuroradiologist, Chief Medical Officer, Quality Assurance Chair, Radiology Imaging Associates, Denver, Colorado

Kandice Garcia, RN Quality Improvement Manager, Imaging Services, Stanford Healthcare, Stanford, California

Safwan S. Halabi, MD Pediatric Radiologist, Director of Pediatric Radiology Informatics, Department of Radiology, Stanford University, Stanford, California

C. Matthew Hawkins, MD Pediatric Interventional Radiologist, Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia

Neville Irani Pediatric Radiologist, Director of Quality and Performance Improvement, Department of Radiology, University of Kansas Medical Center (KUMC), Kansas City, Kansas

Nadja Kadom, MD Pediatric Neuroradiologist, Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia

Danny Kim, MD Abdominal Imager, Director of Quality and Safety, Department of Radiology, New York University

Karl N. Krecke, MD Neuroradiologist, Vice Chair, Department of Radiology, Mayo Clinc, Rochester, Minnesota

David B. Larson, MD, MBA Pediatric Radiologist, Associate Chair for Performance Improvement, Department of Radiology, Stanford University, Stanford, California

Curt Littleford Assistant Vice President, Imaging Services, Intermountain Healthcare, Salt Lake City, Utah

Daisha Marsh Imaging Supervisor, Imaging Services, Stanford Healthcare, Stanford, California

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Presenters (continued)

L. Jake Mickelsen Quality Improvement Education Manager, Imaging Services, Stanford Healthcare, Stanford, California

Nabile M. Safdar, MD, MPH Pediatric Radiologist, Vice Chair for Imaging Informatics, Department of Radiology and Imaging Sciences, Emory University, Atlanta, Georgia

Richard E. Sharpe, MD Breast Imager, Department Value Advisor, Medical Imaging, Kaiser Permanente, Denver, Colorado

Rachel Smith Quality Assurance and Compliance Manager, Department of Radiology, Cincinnati Children’s Hospital and Medical Center, Cincinnati, Ohio

Susan B. Spielman Director of Strategic Initiatives, Department of Radiology, Stanford University, Stanford, California

Joseph R. Steele, MD Interventional Radiologist, Deputy Division Head, Division of Diagnostic Imaging, MD Anderson, Houston, Texas

Laura Tibor Quality Improvement Specialist, Department of Radiology, Mayo Clinic, Rochester, Minnesota

Alexander J. Towbin MD Pediatric Radiologist, Neil D. Johnson Chair of Radiology Informatics, Cincinnati Children’s Hospital and Medical Center, Cincinnati, Ohio

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Pre-Meeting Review

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Dear Colleague,

Welcome to the 2016 Radiology Improvement Summit, “Creating a Thriving Discipline in Radiology Improvement.”

We are excited to have you join us! At this summit, we hope to create a vision for improvement in radiology in the

next decade and beyond. To hit the ground running at the conference, we ask you to review this document prior

to the meeting and be prepared for an active discussion.

In order to develop such a vision, we have created a rough draft for some of the concepts we think are most

important to discuss. In this document, we lay out the case for what we see are the reasons that we need such a

conference and what we hope the conference will enable us to do. We also provide five “straw man proposals”

for concepts we would like to discuss. At the conference, we will look for your input to help modify and refine the

material which we hope to publish as a white paper.

After you have read the introduction, we encourage you to review the five straw man proposals and come to the

meeting prepared to discuss and improve upon at least one or two of them. At the meeting, you will be asked to

join one of five breakout sessions, corresponding to the straw man proposals below.

Thank you again for your engagement; we’re looking forward to seeing you soon!

2016 Radiology Improvement Summit Program Committee

James R. Duncan, MD, PhD C. Matthew Hawkins MD Neville Irani, MD Nadja Kadom, MD

Karl N. Krecke, MD David B. Larson, MD, MBA (Program Chair) Alexander J. Towbin, MD

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Introduction

Why has improvement become so urgent?

Simply stated, radiology is growing. Like all of healthcare, radiology is much more complex than it was even just a

few years ago. This is due to advances in technology, increases in medical knowledge, increasing numbers of

specialists who must coordinate their efforts, increasing chronic conditions, and greater demand for faster and

more reliable service, to name a few causes.

At the same time, the demand for improved performance and greater efficiency in radiology is rapidly mounting,

as it is for all of healthcare. The increasing cost of medical care, much of it due to waste, has become a major

burden on our society. Despite the high costs, our performance is often suboptimal. Medical errors continue to

occur, including in radiology, as summarized by the 2015 IOM report on diagnostic errors. The urgency for

improvement is greater than ever.

As in most areas of healthcare, the practice of radiology has historically been viewed primarily as an “individual

sport,” with radiologists, technologists, administrators, and support staff working relatively independently. While

this has worked reasonably well in the past, we have outgrown that model. Modern medicine is a team sport. The

quality of care our patients receive now depends on our ability to seamlessly coordinate our efforts in complex

organizations. This means we need to evolve as organizations and to improve how we work.

Improvement in complex organizations is much more than just a platitude. There is a science to improvement that

was begun nearly a century ago at Western Electric by Walter Shewhart in the 1920s, and further advanced by

other pioneers such as W. Edwards Deming, Joseph Juran, and Philip Crosby. It has revolutionized manufacturing

and service industries around the world. While it has made some inroads into medicine, it has only just begun to

be applied in radiology.

Our goal is to bring such concepts into radiology in a more systematic fashion for the benefit of our stakeholders,

our professionals, our staff, and, most of all, for our patients.

What is the role of quality?

We define quality as consistent excellent performance. In the past, quality efforts in medicine have mostly been

based on a philosophy of “quality assurance” (QA), which implicitly assumes that poor performance occurs

relatively rarely and when it does, maintaining quality is generally a matter of fixing the specific causes of those

problems. Those in charge of QA have often focused their energies on investigating and monitoring incidents,

inspecting and auditing performance, and ensuring regulatory compliance. QA managers generally worked

separately from (and sometimes in conflict with) operational managers. Operations was in charge of operations

and quality was in charge of quality. Thus, by and large, quality worked at the periphery.

While this approach may be tenable in simple environments, it does not lead to consistent excellent performance

in complex organizations. Modern improvement paradigms recognize that deficiencies in quality, service, and

efficiencies are a natural byproduct of normal day-to-day work in a complex system and not due to aberrant

performance. Therefore, those who wish to significantly improve quality, service, and efficiency must have this

mission integrated into the core structure of their organization. Fixing problems as they arise simply results in

putting out fires rather than removing the causes of the fires. To be effective, quality cannot live at the periphery

of the organization; it must be a core philosophy around which operational decisions are made.

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How should concepts of improvement be applied in radiology?

Professional and academic organizations in Radiology are beginning to take a strong interest in quality, with a

proliferation of learning opportunities, including weekend courses, poster and presentation sessions at scientific

meetings, and publications in peer-reviewed journals. While this is a great start, there needs to be coalescence to

form a true “discipline.”

Consider clinical subspecialties. Radiology subspecialties such as abdominal imaging, breast imaging, and pediatric

imaging (for example) can be considered to be “disciplines.” Specific training and certification programs exist for

these disciplines. Professionals who complete these programs and regularly practice in the fields are recognized

as subspecialists of the larger discipline of radiology. They create professional and academic societies with regular

conferences and peer-reviewed journals. They have a shared set of ethics. Experts come to be recognized in the

field, who create and are the guardians of a body of knowledge that continually evolves. The skills needed to be

successful are widely recognized by this group. Healthcare organizations recognize the value of these

subspecialists by recruiting and formally supporting their efforts.

We are not there yet with quality improvement in radiology. There are few, if any, dedicated training programs in

quality improvement similar to those of clinical subspecialties. There are currently no widely agreed-upon criteria

that need to be met to be regarded as a qualified practitioner in the field. A body of published knowledge has

begun to form, but it does not seem to be coalescing in a manner similar to that of most subspecialties. Perhaps

most significantly, organizational leaders do not recognize, hire, and support quality improvement practitioners in

a consistent manner. Aspiring quality improvement practitioners often do not know what training is needed or

how to get the training and organizational leaders often do not know how to put such individuals to effective use

in their organizations.

Some of the questions that need to be answered include:

What core elements need to be in place to create a “discipline” in quality improvement in radiology? How

can we establish those elements?

What types of skills and domains of knowledge does an improvement leader need to master in order to

be effective? How can that those be obtained?

How should improvement efforts be organized within a given practice, hospital, health system, or other

local organization to be most effective?

What are different roles in improvement and what do they need to be successful?

What are the core tenets that underlie the philosophy of continuous improvement in radiology?

Our vision for improvement in radiology

We believe that improvement is best accomplished in organizations by defined improvement teams of engaged

practicing professionals and staff supported and taught by skilled leaders. Such an approach leads to a satisfying

working environment, higher clinical quality, greater efficiency, and a better patient experience. These

improvement teams and programs form the core of the discipline.

Collectively, our efforts should be focused on helping radiology practices build effective improvement programs

that are integrated within a larger care delivery system. This includes developing and sharing effective paradigms

and practices, curating an evolving body of knowledge, defining successful career paths, providing education and

training opportunities, and creating lasting relationships centered on improvement.

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Straw Man Proposal #1

Elements of an Intellectual and Practical Discipline of Improvement in Radiology

Like any field, improvement in radiology can be thought of as an intellectual and practical discipline. Successful

disciplines generally include the following elements:

A core philosophy

An evolving body of knowledge based on scholarly work

Active exchange of ideas showcasing innovation and excellence

A recognized knowledge base and skill set that practitioners are expected to master

A community of experts and expertise

Networks of peer relationships, knowledge sharing, and mentorship

Education and training opportunities

Well-defined career opportunities at venues that have an infrastructure to put the skillset to effective use.

We believe that the primary objective of a discipline in improvement in radiology is to help enable local teams to

effect improvement in their local environments. Strength in each of these areas will help accomplish this.

Questions for the group to consider:

1. Are the proposed elements of a “discipline” for improvement those that will most likely lead to success?

2. What current structures are in place for each element? Are they sufficient?

For example, do we have an adequate evolving body of knowledge based on scholarly work?

What training or certification would such a person be expected to have?

Are well-defined career opportunities available? Ho would one learn about them?

3. What are our most significant needs?

In other words, what would be most helpful to help you establish and build your local

improvement program?

4. What are specific ways those needs might be fulfilled?

How can we start small and build as necessary?

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Domains of Knowledge and Skill Needed for Organizational Improvement in Radiology

“A specialist is a man who knows more and more about less and less” (William J. Mayo). If each specialized area of

radiology is considered a subspecialty, then performance improvement in radiology might be considered a

“superspecialty” (Paul Nagy). In other words, rather than gaining more focused specialized knowledge,

improvement requires the mastery of skills and knowledge outside of the field of radiology.

We propose the following domains of knowledge and skill that an improvement leader needs to be effective,

based on Deming’s concept of “profound knowledge.”

Practice and Management of Radiology

The requisite knowledge of an imaging professional, including a solid understanding of imaging physics,

technical considerations, imaging appearance of normal anatomy and pathology, imaging-guided

procedures, and imaging information systems including RIS, PACS, and EHR.

Radiology-specific knowledge related to safety, quality assurance, regulatory compliance aspects, etc.

Processes and Systems

Understanding of how work is accomplished through processes and how many interdependent processes

and people interact within systems to achieve shared aims.

Ability to assess a process and find opportunities for improvement.

Ability to create effective feedback loops to drive process and system improvement.

Understanding of concepts and techniques related to high reliability.

Performance Measurement, Data, and Variation

Ability to determine value from the perspective of the customer.

Ability to monitor an organization’s performance in terms of how well it consistently delivers value.

Ability to generate, transfer, store, process, and display data in ways that drive improvement.

Understanding of process-related statistics. Ability to differentiate signal from noise in performance data.

Ability to learn from past performance to predict future performance (predictive modeling).

Developing Practical Knowledge for Improvement

Ability to recognize and articulate problems relative to a desired state.

Understanding of how to investigate, document, and analyze the current state of a process relative to the

desired state.

Ability to effectively apply iterative problem-solving methods.

Ability to solve problems collaboratively in teams.

Ability to learn from others within and external to the institution and adopt best practices accordingly.

Ability to implement improvements in a way that they will be sustained.

Effective project management knowledge and skills.

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Organizational Psychology

Ability to translate disparate individual desires into a shared vision, based on customer values.

Ability to garner support of leadership and also relate to front line practitioners and staff.

Understanding of and ability to capture individuals’ intrinsic motivation rather than relying on extrinsic

motivation. The ability to lead and inspire rather than relying on carrots and sticks.

Ability to build consensus and facilitate teamwork, especially among diverse individuals.

Ability to shepherd an organization through change, anticipating and mitigating interpersonal conflict.

Understanding of organizational culture and ability to change it for the better.

Understanding of effective organizational design, including reporting structures, roles, job descriptions,

and accountability mechanisms.

Understanding of the learning sciences, including the development and maintenance of skill and

expertise.

Ability to coach others to solve problems rather than solving problems for them.

An understanding of how to facilitate effective communication in an organization, including one-to-one,

one-to-many, and many-to-many communications, by a variety of media.


1. Evaluate each domain and consider whether it should be retained as is, modified, or excluded.

2. What additional domains should be included?

3. If you were to outline an “improvement science” curriculum, how well would it match this list?

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The Local Improvement Framework

Organizations that have proven most effective at achieving excellence on a consistent basis have the capability of

engaging the individuals on the front line on a daily basis to manage and to continuously improve the organization

in meaningful ways. However, some areas of performance require greater attention than what can be

accomplished through daily management and improvement efforts; these require focused improvement

initiatives.

To be effective, these activities must be well-coordinated and supported by the organization. This requires a

common methodology for both daily management and improvement activities, as well as strong expertise in the

subject matter (in this case, imaging). Maintaining these activities over the long term also requires strong

leadership support.

However, while everyone should be involved in daily management and improvement, not everyone needs to be a

master at improvement methodology. We propose that improvement works well with different levels of

engagement from 1) everyone in the organization, 2) improvement project leaders, 3) clinical, administrative, and

improvement leaders, and 4) advanced improvement experts.

Daily Management and Improvement

Everyone should participate in daily management and improvement.

Everyone should contribute locally to methods that lead to consistent excellence in imaging through the

iterative PDSA cycle and learning from others outside the institution.

Clinical and administrative leaders should help create and reinforce a supportive environment.

Local improvement leaders should teach improvement methods to everyone in the local organization,

with the support of clinical and administrative leaders.

Clinical and administrative leaders should institute effective management methods with the support of

local improvement leaders.

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Focused Improvement Projects

Everyone should understand basic improvement methodology.

Everyone who wishes should be able to serve as an improvement project leader, with support of a coach

(under the direction of the local improvement leader).

Everyone should contribute locally to methods that lead to consistent excellence in imaging through the

iterative PDSA cycle and learning from others outside the institution.

Clinical and administrative leaders should help create and reinforce a supportive environment.

Local improvement leaders should oversee local education and training in improvement methods.

Local improvement leaders and coaches should have an advanced understanding of improvement.

Broader Environment

Advanced improvement experts should curate a body of knowledge of general daily

management/improvement methods.

Advanced imaging experts should curate a body of knowledge of specific methods for achieving

consistent excellence in imaging, supported by advanced improvement experts.

Everyone who wishes should be allowed to contribute meaningfully to the body of knowledge of specific

methods for achieving consistent excellence in imaging (usually with support from local improvement

leaders).

Advanced improvement experts should direct training programs for local improvement leaders.

Advanced improvement experts should provide guidance for basic improvement methodology that

everyone should learn.


1. For those who have attempted it, is this overall framework on track?

Suggest modifications as appropriate.

2. Discuss each section: are these the right levels of participation for each group? Please draw on the Levels

of Interest and Engagement in Improvement proposal.

3. Who needs to understand and support this approach at the local level to make this a reality?

4. What are the key elements needed to set up a successful local improvement program in radiology?

What support is needed to make such a program successful?

5. What additional questions should we seek to answer to refine this model?

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Levels of Interest and Engagement in Improvement

While everyone should be familiar with some concepts of improvement, it would be unreasonable to think that

everyone in all organizations should become experts in improvement methodology. Rather, organizations can

develop strong improvement programs with individuals at a variety of levels of interest and engagement. The

following is a rough categorization of the different levels that tend to exist in an organization.

Level (%)

Group Description Knowledge and skills Tools needed Min. time invested equivalent

1

100%

Team Members (Everyone)

All staff (including practicing radiologists, nurses, technologists, and staff, including students and trainees)

Basic improvement and daily management methodology

Basic education program, structured environment, mentorship

Introductory material or equivalent

2

10-30%

Improvement Project Leaders

Anyone with interest in the topic and QI leadership qualities; often self-selected; future leaders

Intermediate improvement and daily management methods and concepts

Training program, coaching/mentorship, data collection and analysis, strong leadership support

Guided practical and didactic experience

3

5-20%

Designated Leaders

Clinical/Administrative leaders and managers: (e.g. department leaders, section chiefs, administrative and technical leaders and managers)

Ability to effectively utilize an improvement team to accomplish strategic goals, ability to foster a supportive environment

Improvement teams and leaders; strategic plan; resource allocation including dedicated funding

Equivalent of 1-3 college courses in study and practice

Improvement leaders and managers: Those with dedicated improvement role (e.g. radiology quality leaders, QI coaches)

Strong knowledge of improvement and daily management concepts and methods

Dedicated time; strong organizational support; data tools; educational and networking opportunities

Equivalent of fellowship (year or greater of dedicated training)

4

1-5%

Advanced Improvement Experts

Those who regularly publish, present, and teach nationally; those who curate the body of knowledge; those who shape the field

Deep knowledge of improvement science; active scholarship; master teacher of QI methods; ability to review others’ work

Dedicated time; research support; access to data, data visualization and analysis; venues to present and publish; strong networks

Equivalent of two years of dedicated study (equivalent to masters or PhD)

Individuals at every level should be supported in their roles and have the ability to move from one level to

another as desired. This may be through training programs, networks and communities, meetings, etc.

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1. Recognizing that this is just a model, is this the best way to stratify different types of individuals in

improvement?

2. Are these the right descriptions and level of knowledge and skill for each level?

3. What type of preparation and support does each group need to be effective at their respective levels?

Please draw on the Local Improvement Framework proposal.

4. How might those needs be fulfilled at both the local level and more broadly? Be specific.

5. What mechanisms might be established to help individuals move to higher levels as they desire? Be

specific.

6. What specific roles should local clinical and administrative leaders create to use individuals at each level

most effectively?

7. What types of training programs would best prepare individuals for those roles?

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Core Tenets of a Philosophy of Continuous Improvement in Radiology

Concepts of “quality,” “value,” and “improvement” refer to what should be in rather than simply what is. If we are

to successfully establish a shared culture of improvement, it is important that the core philosophical values upon

which our improvement efforts are based be commonly understood. We propose the following tenets of a

philosophy of continuous improvement in radiology.

Purpose

The fundamental purpose of radiology is to save and improve lives with imaging and imaging-guided

procedures.

Whom we serve

Patients and their loved ones are the ultimate recipients of our work, to whom we are ultimately

accountable.

We also serve our referring clinicians, who are our patients' fiduciaries and advocates.

The question, “What is best for the patient?” is the fundamental basis for all of our actions and decisions.

Value

Value is a function of quality, experience, and cost as it relates to patient needs and desires.

Value is defined by those who receive a service, not by those who provide it.

Value is not necessarily synonymous with revenue or profit.

We constantly strive to increase value to our patients and referring clinicians and to decrease waste.

Providing imaging services to patients is a privilege, not a right. It is a privilege which must continuously

be earned.

Systems

Our patients experience a whole system of care. Radiology’s role is critical, but it is only one element in a

complex healthcare system.

Without deliberate and sustained coordination efforts, complex systems naturally tend to be fragmented,

inconsistent, and inefficient, often to the detriment of patient care.

It is our ethical obligation to coordinate closely with others in the healthcare system to provide patients

and families with a seamless experience.

Complex systems are best managed by local teams who are empowered and who work intelligently to

achieve shared aims in a supportive structure.

Teams and teamwork

Healthcare, as well as healthcare improvement, is a team sport. As imaging professionals, we collaborate

with, teach, and learn from each other.

Our referring clinicians are our respected colleagues and collaborators, not our adversaries or rivals.

Each member of the imaging team is important and deserving of respect, including physicians, nurses,

technical and administrative personnel, and support staff.

Behavior that undermines teamwork undermines patient care.

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Character

Effective organizational improvement is based on characteristics of integrity, intelligence, diligence, and

humility.

Improvement is fundamentally an exercise in humility. The first step to improvement is to seek out, admit

to, and commit to improving our deficiencies.

Quality

Excellence and consistency are critical dimensions of quality.

Without deliberate efforts to maintain consistency, processes naturally tend to produce varied results.

Quality cannot be assumed. To objectively verify quality, it must be defined, measured, and monitored.

Performance measurement alone generally does not drive meaningful improvement, though sincere

improvement efforts usually incorporate performance measurement.

Achieving excellence in a complex environment depends on a combination of individual skill, effective

standardized processes and procedures, and well-developed systems, supported by a healthy culture.

The Science and Practice of Improvement

Like other disciplines, improvement should be rigorous. Ideas and theories should be systematically

tested and refined and their results should be researched and published following constructive peer

review.

Specifically, the effectiveness of policies and programs in achieving their stated objectives should be

tested and validated before being mandated on a broad scale.

Improvement is a form of change; the science of organizational improvement is largely the science of

organizational change.

The primary role of an improvement leader is to help the organization change so that it better fulfills its

collective vision.

Managing and communicating information are critical to the effective practice of radiology.

A wealth of knowledge in managing and improving radiology performance is to be found outside radiology

and outside healthcare.

Like any area of expertise, the science and practice of improvement are not intuitive; they generally

require years of study and practice to master.

Leadership and Management

The discipline of organizational improvement is tightly intertwined with the disciplines of leadership and

management.

The leader of an organization is ultimately responsible for performance and performance improvement.

Leaders should foster and support an environment that is conducive to improvement.

Individual engagement rather than compliance is required to consistently achieve excellence in complex

organizations.

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1. Evaluate each tenet and consider whether it should be retained as is, modified, or excluded.

2. What additional tenets should be included?

3. Develop a few scenarios for which a core philosophy of improvement would be helpful.

Example: When evaluating its improvement initiatives, a practice finds that it spends most of its

“improvement” energies on pursuing increased reimbursement. However, the fundamental

purpose of radiology is to save and improve lives, not to maximize reimbursement. The primary

question should be, “what is best for the patient.” Therefore, the practice decides to redirect the

focus of its improvement efforts on improving performance in ways that are meaningful to

patients.

Example: A radiology department undertakes an effort to decrease the time to scan patients in

the emergency department. In the process, deep-seated hostility between the technologists and

the nurses is discovered as an impediment to the effort. The administrative director gathers the

technologist and nursing leaders and explicitly calls out the fact that the dysfunctional behaviors

and attitudes undermine the core tenet of teamwork. The leaders decide to make specific efforts

to foster better collaboration and teamwork between the groups.

Example: A committee of a radiology professional society seeks ways to improve performance

across the profession. In doing this, they seek to create a panel of performance measures to be

written into legislation and implemented across the country, with the belief that more

measurement will drive improvement. However, two principles give committee members pause:

1) the principle that performance measurement alone generally does not drive meaningful

improvement and 2) the principle that the effectiveness of policies and programs should be

tested before being mandated on a broad scale. The committee chooses to recommend a series

of pilots that can demonstrate the program’s effectiveness before recommending its

implementation through legislation.

23

All Meeting Attendees

24

Attendee Institution

Alex Towbin Cincinnati Children's Hospital

Rachel Smith Cincinnati Children's Hospital

Anh Duong Emory

Kimberly Applegate Emory

Matt Hawkins Emory

Nabile Safdar Emory

Nadja Kadom Emory

Pratik Rachh Emory

Curt Littleford Intermountain Healthcare

Deanna Welch Intermountain Healthcare

Richard Sharpe Kaiser Permanente Colorado

Ashima Lall Mainline Health System

Emma Simpson Mainline Health System

Fran Diegnan Mainline Health System

Lan Nguyen Mainline Health System

Laura Tibor Mayo Clinic

Julie Cravath Mayo Clinic

Karl Krecke Mayo Clinic

Nick Kurup Mayo Clinic

Yoan Kagoma McMaster

Aziz Benamar MD Anderson

Joseph Steele MD Anderson

Danny Kim NYUMC

Michael Recht NYUMC

Franklyn Luke Penn State

Michael Bruno Penn State

Timothy Yanchuck Penn State

Vicki Rooney Penn State

David Dungan Radiology Imaging Associates

Gabrielle Langlinais Radiology Imaging Associates

Gwendolyn Dooley Radiology Imaging Associates

Nicole Kirkweg Radiology Imaging Associates

Aleksandr Kalnins Stanford

Alice Lirette Stanford

Beverley Newman Stanford

Christina Chen Stanford

Claudia Cooper Stanford

Curtis Langlotz Stanford

Daisha Marsh Stanford

Daniel Rubin Stanford

David Hovsepian Stanford

David Larson Stanford

Denise Cortez Stanford

Dorothy Cordova Stanford

Gale Evans Stanford

Glen Seidel Stanford

25


Jake Mickelsen Stanford

Joni Schott Stanford

Judi Contento Stanford

Kandice Garcia Stanford

Kevin Vantrees Stanford

Lauren Sederberg Stanford

Lori Hart Stanford

Mary Robertson Stanford

Patricia Cowart Stanford

Robyn Netz Stanford

Safwan Halabi Stanford

Sergio Sousa Stanford

Shirley Weber Stanford

Shreyas Vasanawala Stanford

Sunita Pal Stanford

Susan Kopiwoda Stanford

Susie Spielman Stanford

Teresa Nelson Stanford

Tracy Burk Stanford

Yvonne Casillas Stanford

Zina Payman Stanford

Nancy Coats St. Joseph Heritage Healthcare

Lane Donnelly Texas Children's Hospital

Christopher Hess UCSF

Cindy Lee UCSF

Heather Nichols UCSF

Marc Kohli UCSF

Becky Allen University of Cincinnati

Bruce Mahoney University of Cincinnati

Robert Ernst University of Cincinnati

Shari Steffen-Lecky University of Cincinnati

Jonathan Flug University of Colorado

Kimberly Smith University of Kansas

Neville Irani University of Kansas

Patricia Sanders-Hall University of Kansas

Philip Johnson University of Kansas

Tim Schneider University of Kansas

Steven Baccei University of Massachusetts

Bill Boonn University of Pennsylvania

Charles Kahn University of Pennsylvania

Po-Hao Chen University of Pennsylvania

Brian Fox University of Texas Southwestern

Jeannie Kwon University of Texas Southwestern

Timothy Booth University of Texas Southwestern

Merry Monarrez VHA Loma Linda

Erik Strom VHA Minneapolis

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Jane Keel VHA Minneapolis

Julie Brown VHA Minneapolis

Mary Shaw VHA Minneapolis

John Etcheverry VHA San Francisco

Karen Hemeon Virginia Mason

Lucy Glenn Virginia Mason

Jim Duncan Washington U in St. Louis

Jay Pahade Yale

David Facchini Yale New Haven Hospital

27

Recommended Book List

28

Recommended Book List

IMPROVEMENT METHODS

Creating a Lean Culture

David Mann

How to Measure Anything

Douglas W. Hubbard

Learning to See

Mike Rother and John Shook

Managing to Learn

John Shook

The New Economics

W. Edwards Deming

Out of the Crisis

W. Edwards Deming

Understanding Variation

Donald J. Wheeler

HEALTHCARE IMPROVEMENT

Better

Atul Gawande

If Disney Ran Your Hospital

Fred Lee

The Healthcare Data Guide

Lloyd B. Provost and Sandra

Murray

The Improvement Guide

Gerald J. Langley et al.

Nudge

Richard H. Thaler and Cass R.

Sunstein

SAFETY

Crossing the Quality Chasm

The Institute of Medicine

The Field Guide to

Understanding ‘Human Error’

Sidney Dekker

Improving Diagnosis in

Healthcare


Just Culture

Sidney Dekker

Managing the Risks of

Organizational Accidents

James Reason

Pre-Accident Investigations

Todd Conklin

To Err is Human


Whack a Mole

David Marx

CHANGE

The Art of Constructive

Confrontation

John Hoover & Roger P.

DiSilvestro

Drive

Daniel H. Pink

Influencer

Joseph Grenny, Kerry Patterson,

David Maxfield, Ron McMillan,

and Al Switzler

Leading Change

John Kotter

Our Iceberg is Melting

John Kotter

The Power of Habit

Charles Duhigg

Punished by Rewards

Alfie Kohn

Switch

Chip Heath and Dan Heath

ORGANIZATIONAL RESEARCH

The Five Dysfunctions of a

Team

Patrick Lencioni

Organizational Culture and

Leadership

Edgar Schein

The Practice of Adaptive

Leadership

The Harvard Business Review

Project Management

The Harvard Business Review

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ORGANIZATIONAL DESIGN,

MANAGEMENT & LEARNING

Collaboration

Morten Hansen

The Fifth Discipline

Peter Senge

Give and Take

Adam Grant

Good to Great

James C. Collins

Leading Terms

J. Richard Hackman

DATA VISUALIZATION

Information Dashboard Design

Stephen Few

Now You See It

Stephen Few

Show Me the Numbers

Stephen Few

The Visual Display of

Quantitative Information

Edward Tufte

INFORMATION THEORY &

COMPLEXITY

Complexity

M. Mitchell Waldrop

The Tipping Point

Malcom Gladwell

INNOVATION/CREATIVITY

Creativity, Inc.

Amy Wallace and Edwin Catmull

Diffusion of Innovations

Everett Rogers

The Idea Factory

Jon Gertner

Imagine

Jonah Lehrer

The Progress Principle

Teresa Amabile & Steven

Kramer

Where Good Ideas Come From

Steven Johnson

Adapt

Tim Hartford

EXPERTISE

The Cambridge Book of

Expertise and Expert

Performance

K. Anders Ericsson, Neil

Charness, Robert R. Hoffman,

and Paul J. Feltovich

The Talent Code

Daniel Coyle

Why We Make Mistakes

Joseph T. Hallinan

OTHER

The 7 Habits of Highly Effective

People

Stephen Covey

The Design of Everyday Things

Don Norman

My Life and Work: An

Autobiography of Henry Ford

Henry Ford

Orbiting the Giant Hairball

Gordon Mackenzie

The Southwest Airlines Way

Jody Hoffer Gittell

Thinking, Fast and Slow

Daniel Kahneman

Workplace Management

Taiichi Ohno

Thank you for your continued efforts

to transform our field for the better.

RADIOLOGY IMPROVEMENT SUMMIT - Stanford...

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