RADIOLOGY
IMPROVEMENT
S U M M I T
20
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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Straw Man Proposal #2
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.
Questions for the group to consider:
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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Straw Man Proposal #3
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.
Questions for the group to consider:
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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Straw Man Proposal #4
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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Questions for the group to consider:
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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Straw Man Proposal #5
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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Questions for the group to consider:
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
Attendee Institution
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
26
Attendee Institution
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
The Institute of Medicine
Just Culture
Sidney Dekker
Managing the Risks of
Organizational Accidents
James Reason
Pre-Accident Investigations
Todd Conklin
To Err is Human
The Institute of Medicine
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
29
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.