So specifically for my topic, it's going to be on medical student education, attracting improvement minded students. So for the learning objectives for today, we'll be exploring implementation of quality improvement education to the medical student curriculum, and understanding features of highly successful QI curricula. So the big question is, how do you track medical students to quality improvement? And the answer is actually really simple. The biggest things are to improve their engagement and their knowledge. And there's been a big call, even among medical students, for more QI education too, and more stakeholder involvement all throughout. And so engagement and knowledge is really going to improve medical students' confidence. They're going to want to interact more, they want to continue on, they keep going at it. And having engagement and knowledge, even as a medical student, if you can recall back to, sometimes that's tough to be able to get to. You feel like you're on the sideline trying to observe as much knowledge, but you don't feel like you're always giving the biggest impact. So we can show that they can have impact with quality improvement. They'll want to continue joining in. And it's actually how I started my initial journey into quality improvement. In medical school, I joined in on a project in which I helped to improve the positive predictive value for CTPE studies, and we increased from one month where the positive predictive value was 0% up to 22% by mandatory reporting of WELL scores every time you ordered on that. And as a medical student, to have that much impact on day-to-day processes was phenomenal. And it definitely drew me in into more quality improvement in the future. So when we have these medical students who do want to be joined in, and we want to incorporate this medical student quality improvement curriculum, we want to get them to that treasure of increased involvement in the future. But there are challenges to this implementation that have been discussed within the literature. This includes having mentorship. Is there faculty available who actually have the knowledge base to be able to do it and want to do it? There's also the initial buy-in. Do the medical students actually want to do this? Do they have enough of a positive background or knowledge to be able to go in and want to do quality improvement? And do medical students have the clinical experience to be able to apply that knowledge into quality improvement? Do they need to have more clinical experience? Do they need to know how these processes work? And a lot of people have debated into this. And also the educational burden. Medical students have to go through so much. Even reflecting back, I feel like I didn't do that much in medical school. But looking at an example of medical school curriculum, even back at my home institution of Creighton University, just year one is just insane with how much you learn. And year two is just as big. And then third and fourth year, filled with all your clerkships, taking all your tests, and then also applying for residency. There's a lot already on their plate. But there was actually a great systematic review that was performed by Perry and John in which they looked at about 20 different medical student curriculum. And they found that, really consistently, a lot of these curriculum were well accepted by medical students. Additionally, they all showed increased satisfaction, attitudes, and knowledge in QI. And that goes hand in hand with increased confidence. And that's what we're really looking for, for these medical students, so that they will be more willing to engage in the future. Additionally, there were positive changes in learner behavior. And additionally, improvement in processes of care. A lot of the studies, although they may have mentioned increased patient outcomes, this really wasn't proven or really focused on much in a lot of these studies out there. But the big thing, again, I really want to nail down is that these curricula have shown that satisfaction, attitudes, and knowledge increasing. And that is absolutely key. So additional benefits of medical student QI involvement, a lot of the ones for this study had shown that 84% of providers felt that medical students were effective, which is great. Because then at that point, medical students don't feel like a burden. And these mentors who were involved in this education are going to want to continue. Additionally, there were positive impacts on clinic efficiency and atmosphere, which is great. This is going to help improve the whole culture of safety wherever these medical students are involved. But one of the most striking features was that students participated in other associated QI activities after the program. So these are all from different studies, but really shows the positive impact of having a medical student curriculum for QI doesn't just impact medical students, but those around them. And within the study, a lot of the intervention designs had a variety of QI content that they showed. Everything from continuous QI to process mapping. In addition, the content was typically delivered from didactics with a mix of small group discussions. And a fewer ones had some online modules that were mixed in as well. But one of the big takeaways was that all except one had QI curricula with an experiential component. And that's so great for them to be able to get their hands on on this QI material and then being able to reflect on it too. And that's another key factor for attracting medical students. Some of the most positive learning outcome factors that were discovered by the study included courses that took place in ambulatory hospital settings. And this helps them gain that clinical experience that they may not have naturally gotten from their third and fourth year. Additionally, those that took place with didactics and small groups also had experiential learning components. And this is a resounding, echoing theme that keeps going on is experiential learning within all these studies. Additionally, a lot of the more positive curricula included quality of care, continuous QI, process mapping, and audit and feedback exercises. And having a positive learning environment was also shown to be very effective in which there's already an established institutional culture of quality and safety because you want to be surrounded by this. It's not just either whatever department you're in that's doing it, but the entire institution. Just like learning a language, it's the best learning you get is when you're completely gross in that environment. And then having role models too is also important. And this doesn't include just having attendings, but even hospital executives showing that there are all these multiple stakeholders and they all want to improve quality and to being great role models for medical students. Also having an adequate information system support, because you don't want medical students to be struggling with the system. You want them to have all the tools possible to show them how great it can be. Additionally, there was a great study that was shown, and it was a Cambridge pilot study looking at near peer mentors in which they had younger junior faculty teaching medical students. They targeted second year post graduates. It was about 111 fifth year medical students. And with this, there's a three hour interactive workshop and they did a multitude of QI exercises from driver diagrams to stakeholder engagements. And one of the interesting things for this is that there was improved confidence in quality improvement, which is again being shown over and over in all these studies. And 86% of those medical students who undertook this showed a preference for near peer mentors. They said it was just so much more of a relaxing environment for them to be able to do it. And these near peer mentors were better able to relate what the medical students were going through and deliver the content effectively. But another theme is this dual benefit of this medical student curriculum, which they showed that junior doctors also had improved confidence in teaching knowledge of quality improvement, and that's great. So they're gaining a benefit. In addition, these junior doctors were more likely to engage in further QI endeavors in the future, which is awesome because you're bringing them back in over and over again. So it's this great cycle of attracting medical students and keeping the faculty who are involved within it. But then the question becomes, when is too early for medical students? And some studies have shown that there's no major difference between preclinical and clinical years for QI knowledge for medical students, and that the more prior exposure that we give them to the QI knowledge, the better benefit that they get, and they get more knowledge in the future. And that's all going to turn into more confidence for them. There was also a great study in which they looked at early exposure to, and they interviewed 12 faculty who are very experienced in quality improvement, specifically teaching first-year medical students who can be pretty tough to initially do because they haven't had those experiences to build on. But they had some important lessons in there, and these include having meaningful roles with active engagement for medical students. You don't want them sitting in the back, like not doing very much or just doing emails. You want them interacting with everyone to really feel like they're a vital member of the team. Additionally, project selection is also vital, in which you want to make sure the project can be as successful as possible and able to work around the already rigorous schedule that medical students have. Additionally, faculty can co-learn systems improvement along with them. They don't need to be experts in quality improvement. A lot of faculty felt like they were able to learn. But what's more important than their systems improvement knowledge is being able to facilitate these small group discussions and enriching the medical students' learning environment. Additionally, faculty need contextual knowledge and strong relationship with their students. They need to know what the medical students' schedules are like, what is the environment and culture of their institution, and having a long-term relationship with these medical students is going to be a bigger success factor. There was also another previously published paper from Dartmouth on their medical student QI curriculum, in which they called it the Quality Improvement in Health Care Systems Curriculum. And in the first year, they had about two hours of initial introduction, which showed things like just initial basic concepts of improvement, patient-centered care, and outcomes. And year two is where the bulk of this learning really took place for up to about 34 hours. They had a mix of group sessions, looking at different things, including practices like system issues for door-to-balloon time. But the majority bulk of this time took place in the Health Leader Practical Elective, in which they had a small group running a project with a site coach, and they alternated between group work and site work, too. And at the very end of it, they would present to the site and have a poster. And they had a multitude of projects, everything from varying from looking at colonoscopy testing to OB, from vaccines. And one of the ones that I really want to highlight is the increasing rate of urine specimens in first trimester pregnancy in community OB clinic, in which they were able to increase the urine screening testing rate from 55% to 80%. And this was sustained for multiple years. To have medical students be involved in a project and have those changes is phenomenal. And the big takeaway from their curriculum that they stated was medical students can change systems and influence patient outcomes. And for a medical student to have that feeling to be able to do that, that will absolutely drive them to keep coming back to more and more QI. So in conclusion, early continued engagement of medical students in QI is both feasible and can improve their future interactions in QI endeavors. And that's all. Here are my references. My name is Mark Willis. I am the Associate Chair of Quality Improvement at Stanford University. And so in honor of the World Cup, let's talk about our goals for this talk today. So we're going to review the components of an effective approach to trainee QI education, and then we're going to compare and contrast the characteristics of a successful QI curriculum. And so here we have a pipeline, that's what we're talking about today. I want to point out that this is a continuum. It's continuous and it's long. It's longitudinal. It's not silos. We're not talking about creating silos, whether or not UME, GME, CME, and then also to not at individual institutions. And I think the more that we think about it this way, the better off we all will be. And so the easiest thing to do is for us to come here, be inspired at RS&A, go home and do nothing. That's easy to do. But change management plays a huge role in us being able to go back and effectively implement some of these things. And so Simon Sinek says, if we're going to inspire people to actually make change, we have to start with why they need to change. And so I just want to touch on a few things about why we need to actually jump on board with this concept of creating this pipeline. And so Deming talked about a concept, which he said, if you're going to change the prevailing system, you have to change the prevailing system of education. And what he's getting at is we have to go upstream. If we continue to work downstream in our day-to-day practices, we are not going to be successful in making big, substantial changes over time. And so building upon what Roman talked about, this is Abraham Flexner. He gave us the foundational elements of our medical education system, which is followed in the US and many other places around the world. And it really starts with basic sciences, and then the clinical sciences are an apprenticeship model of education. And the thing is, and this has really played out in the United States, is that we have a physician workforce that is very highly trained and does an amazing job of taking care of complex patients at the very, very end of their disease state. But the problem is we have not done a good job educating physicians on how to actually take care of patients. Now this has led to a huge movement by the American Medical Association to introduce health system science as the third pillar of medical education. And you'll see that this runs through everything that's being talked about today. Now I don't have time to go into that today. I would refer you to this academic medicine article if you want to learn more about the domains and the cross-cutting domains of health system science. But I will tell you that improvement science is the engine that can power this. It powers every single aspect of health system science. Now moving on to how we actually can do this, I'll have a few suggestions. The first one is, let's all not run home and start giving didactic lectures about quality improvement. That's not going to solve this. Let's focus on active learning. Roman has already given this, has outlined many of these things in his talk, and I'll build on that further. Secondly, so Kern outlined six steps for curriculum development. But as I said, change management is critical. One of the leading authors in this space is Cotter. And so I would refer you to this article in academic medicine if you want to learn more about how to actually develop a curriculum, but then actually implement it. Because without the implementation, without the execution, that curriculum will not be successful. Now in quality improvement, there has been a systemic review done which outlines many of the things needed to be successful. The first one I'll highlight is time. Time is our most precious resource. If we and our departments don't allocate time to quality improvement education, it will not be viewed as being important by our learners. Okay? If we focus all of our time on the clinical practice of medicine and give no time to quality improvement education, it will not be viewed as being important. The second one is setting learner expectations. If you want to implement a quality improvement curricula at your institution, I will say the toughest time is going to be in the first four years when your residents did not come and with the expectation they would be involved with improvement activities. Okay? If you can make it past that first cycle, and you can get to the point where when they arrive, they either have the expectation or quickly develop the expectation of being involved with quality improvement, you have made it over the tipping point, and you are probably going to be very successful. Next I'll say that get your learners involved in improvement activities that they are passionate about, and then mentor them, coach them, and support them. And the last thing is sustainability. You have to have a mechanism to take their improvement project and then make it part of the system. It has to be sustainable. If they do a project, they invest a lot of time, and then once the project is over, things just drift back to the way they were before, you are not going to have a good culture that learners want to be involved in quality improvement because they are going to think, well, this is just a waste of time. I spent all this time, and then a year later, things are just back to the way they were before. Next thing, what are we going to do? Well, I'll highlight our approach at Stanford. Number one, our goal is that every resident that graduates from our residency will have a foundational knowledge in Deming's four domains, which he referred to as the profound knowledge. We are very fortunate. We have a great team, and there are team members here with us today, and I will say that I'm so thankful for all of them because we really do all work together to make this happen. So our approach is this. We really work from the very beginning of residency to help our trainees take ideas that they have and then formulate them into a project proposal. We vet them, and then ultimately, we strongly encourage them to participate in one of our structured quality improvement courses. We're very fortunate that David Larson has been leading this effort at Stanford for many years, and we have institutional programs, which he's developed, but also, too, in radiology, we have a program called 52 and 52. It's a cohort-style program that takes them through about a three-month cohort that teaches them how to do a quality improvement project. So this is the experiential learning that Roman referred to. We really, really focus on methodology. Sure, we want their project to be successful. We want their outcomes to make a change, but at the end of the day, we really want them to understand the methodology so then we can scale improvement within our department through our learners as they learn and grow. The next thing I'll say is our current approach, we started talking about it about the end of 2019, then COVID hit, we had to shut down our program, but then we opened things back up in 2021, but you can see the number of trainees that we have going through our structured learning programs has dramatically increased. And I think the number one thing that I look at here and I see that I'm most proud of, and also too I'm very interested to continue to follow this, is the orange at the very top of these two bars are the number of learners, trainees that have come back to do a second project, often leading the project, because that's not a requirement. But they had such a great experience the first time, they wanted to come back and actually lead a team and get the leadership side of quality improvement also. Now I'll freely admit, we have a great team at Stanford, we have a lot of resources, we're very fortunate, but you don't have to have all of that to create a program for your residents. At my previous institution, I did, you know, it was very simple. I would say, I would recommend if you don't have a lot of people and a lot of resources, just start with the IHI model for improvement, it's very simple and it's very easy to implement. You know, I would create some sort of way for the trainees to showcase what they've done at the end. So what we did is we had faculty come to the presentations, I created a very simple rubric that they would give feedback on their project. And over the course of those five years, 47 resident projects, quality improvement projects, many of them had multiple residents involved, and 35 of those resulted in QI abstracts presented and shared broadly, and or RS&A quality reports, and then four QI publications by residents. Now what are some of the things that can cause you some pitfalls? So number one, when trainees do a project, they don't inherently automatically understand the concept of continuous quality improvement. In our history of scientific learning, we don't usually do that. We just do a pre and a post, and then we want to show that what we did made a difference. So you really have to make sure that they understand that concept of continuous quality improvement, really, really encourage them to at least do two PDSA cycles during their project at a minimum, because it will really kind of solidify that in their learning scaffold. The next thing along those same lines is this, I love this IHAI chart, because it highlights the differences between scientific investigation and improvement science. You know, as trainees start to do a project, you know, they want to have this huge N, they want to start doing statistical analysis, and really help them to start to understand the difference between improvement science and doing something to show a statistical significance in a controlled environment. Lastly, again, as I said before, please don't go back and start giving a bunch of didactic lectures. One way that you can create a way for trainees to share what they've done, while also teaching other trainees about quality improvement, if you've implemented something like this, is to create an environment where they can share. This can still be done within the normal conference schedule of the residency. All of these things that you see up here are examples taken from training projects. So when you see a fishbone diagram, when you see a process map, when you see a run chart, these are taken from our training projects. And so, you know, that's something I think that we all could hope to eventually get to. Also, too, I've asked some experts in quality improvement from around the country to also present projects at this showcase, also when we've done it the past two years. And so, you know, what's the result of that? Well, I don't have a lot of data, we've only done it for a couple years, and obviously not everyone responds to a survey, but the survey scores have been good. And also, too, I love that one of the quotes that was submitted with one of these, and this trainee, I assume, was probably a first-year resident, but they sound like they really enjoyed the conference. I'm guessing probably would not have gotten a comment like this had I just given a didactic lecture during their normal lecture schedule. And so, you know, what's the secret sauce? So first off, like I said before, set learner expectations. If you're going to try to do this, make it part of your recruitment process. Make it part of your first day of orientation for first-year residents. The other thing is make sure your improvement team and your education office are on the same page. Work hand-in-hand together to make this happen. It's extremely critical. The trainees can't be being told two different things or getting two different messages from the improvement team and the education office. The next thing, value-added learning. If you want to know more about this concept, Jed Gonzalo from Penn State Hershey has written multiple articles about this. I would look it up. But we can't let our health system and our hospitals think that trainees are a drain on the system. They add a tremendous amount of value to healthcare. We have to showcase that. We need to market that. And we can do that by sharing quality improvement activities with the leaders of our hospitals and health systems. Again, make it learner-centered. Don't just force them to be on a project or just sign them up for a project. It doesn't have to be their idea, but you can show them the projects that your department is planning to do and or what's your strategic plan, what are you going to be working on in the next year, and then they can develop projects that align with that. Faculty mentorship has been shown to be critical, and institutional support has been shown to be critical. This plays in with that whole concept of marketing what they're doing to add value. Sustain the improvements. Celebrate their successes. And the last thing I will say, if there's one thing you want to do, is consider developing a quality chief resident. The two that I've had the fortune of working with at Stanford have been invaluable to me and our improvement team. And I would say it creates that near-peer concept that Roman talked about, which has been shown to be very important to trainees. So with that, thank you so much. All right. My name is Akriti Khanna, and I'm at Mayo Clinic in Rochester, Minnesota. And I'm going to be talking about leadership without a title. I'm going to start my presentation with this quote from Lessons on Leadership that's quite powerful and empowering. Here's the agenda for our talk. We will be discussing a leadership skill set, learning from leaders around you, setting yourself up for leadership roles, and practical ways to get involved. Often early and at the start of our training, we're consumed by learning radiology and understanding the workflow and skills necessary to be a competent resident. While the clinical side is extremely important, we also want to build additional areas of interest, whether it's education, research, quality improvement, or an area of clinical expertise. For those interested in leadership, it can be challenging to get involved in these arenas that seem to be more for experienced and senior staff. These positions can seem out of reach, and we end up feeling like these are goals that we cannot strive towards. However, getting your feet wet and learning about leadership is within your reach. There are a lot of things we can do, even early on in our careers, to help cultivate leadership skills and to make ourselves valuable in the department. We're going to be discussing developing a leadership skill set, which is your toolbox for leadership. In talking about leadership skills, I want to touch on a few important concepts that I've detailed in this slide and will talk more about. Emotional intelligence is an extremely important skill set to have, not only for a leader, but also important in our interactions with patients, clinicians, trainees, and all the health care staff that we work with daily. The components of emotional intelligence include being self-aware, work on being good at introspection and being aware of your own strengths and weaknesses. Try to be a good self-regulator. Work on choosing your words carefully, effective conflict resolution, and remaining open to changes at the workplace. Work on staying strongly motivated and persevering with adversity. Everyone has setbacks and rough days, but being able to stay the course during those times is a very important skill. Develop skills to be empathetic and interested in others. One practical way to develop this habit is to offer sincere thanks and appreciation to multiple people every week. The last component is social skills. Develop a strong ability to build and maintain interpersonal relationships. When it comes to leadership, we need to think beyond high achievement. Being a high-achieving individual at clinical work, research, and education doesn't necessarily mean that one will excel as a leader. This is because the access for leadership is very different. It involves articulating a meaningful vision, working with others, and aligning people with diverse points of view. As a leader, you should have a strong desire to work with and collaborate with others. Leaders also exhibit a real passion for the mission that they are a part of and want to grow it. Lastly, most leaders really care about the development of their colleagues and want to make success a part of their personal missions. One important concept I want to talk about is the difference between the approach of a physician versus a physician leader. A physician is a practicing radiologist for the day and focused on getting through the work list. In this role, we have to be action-oriented, inclined towards a short-term perspective, accustomed to making decisions quickly and alone, operating as an advocate for the patient, and identifying with our profession. A physician leader, on the other hand, needs to be more focused on planning than action, working proactively, having a long-term outlook, delegating to others, operating collaboratively, and identifying with the organization. These differences are important to highlight because one needs to channel a different approach depending on which hat we're wearing for that day. It is really meaningful to join an organization with a desire to help it accomplish its mission and maybe even do it better. To begin with, you want to be observant of how things are done around you and the current state of affairs. Then you start to notice gaps, areas or processes that might be inefficient, and possible weak points in the organization. However, what you really want to spend your time and energy thinking of is solutions rather than harping on the problems. Are there small tweaks that you think might make a big difference in the organization or workflow? Try to brainstorm and think how you can make the organization better for everyone around you. In developing your leadership skills, you also want to work on developing a team-based approach. After all, a leader is a part of the group that they belong to, so it's important to work in conjunction with others. Early in training and career, I think it's extremely valuable to work as a team player on several projects in order to become an effective team leader. At the end of the day, whether it's apparent to us or not, radiology and medicine really are team sports. Though we as a radiologist interpret the imaging, many people work towards that goal. The technologist performed the study and acquired the images, the imaging company made the scanner that was used, the nurse was overseeing the patient and ensured their safety, the clinician ordered the study that was performed, and ultimately the patient came to their appointment to get these images. In this way, the group really has to work towards a unified goal. You have to understand those around you and the valuable role that they play. In your day-to-day work, try to incorporate others' thoughts into your decisions and outlook. You should aim to evaluate an issue from multiple different perspectives. Another important part of being a leader is learning from successful leaders around you. One of the really nice things in residency is that you're exposed to so many different leaders and leadership styles. This includes leaders of the department, leaders within each division, resident leaders, and hospital-wide organizational leaders. When I reflect on my training, I can think of several leaders that I really look up to. Each of the bullet points that I've listed represents a different leader and their unique successful characteristics. On this slide, I tried to identify and highlight some of the common traits that hold true for all of these successful leaders. The common themes I've noticed in leaders is that they have a strong commitment to their leadership role, they have similar admirable character traits, they always lead by example, they stay humble, they prioritize others over self, and are skilled communicators. Most of them continue to practice in their clinical profession, so they don't run the risk of losing touch with the work of their colleagues. We're gonna discuss some practical tips on how to position yourself as a leader. Here, I have five key steps to help make you a front-runner for leadership roles based on the Katapuram paper that I've listed. First, be visible. Try not to stay tucked away in your dark reading room. When possible, discuss interesting cases with the referring physician, attend multidisciplinary conferences so your colleagues can get to know you, and see if there's any research that you can collaborate on. Next, be available. Try to be the radiologist who takes the time to help other specialties by explaining findings, by agreeing to add on cases, or by staying late to help. It seems like the radiologists who are willing to go that extra mile are so strongly respected by everyone, and are natural fits for leadership positions. Network and ask. Along with observing leaders around you, also talk to them and get to know them. Ask them about their path to leadership, and find out what inspired them. Ask if any of these people would be interested in mentoring you. Next, respect everyone. We interact with so many people every day, from other radiologists, clinicians, patients, to radiology techs, nurses, and administrative assistants, and so on. Always be respectful to everyone. Leaders are often chosen for their ability to be fair and kind to everyone, regardless of their role, background, or any other factor. Lastly, educate yourself. There's a lot of excellent information on leadership that already exists. Within the realm of radiology, resources include the Radiology Leadership Institute, webinars for continuing medical education, or articles relevant to radiology leadership. We're gonna discuss how to get involved and take those first steps towards leadership. There are a lot of small steps you can take to start leading. Ask those around you if there are any projects that you could help with. Are there any QI projects underway that could use an extra set of hands? You can try to find roles within your organization to develop some of these skills. This could include a leadership position in your residency class. It can be an organization for residents and fellows, or the State Radiologic Society. Ask those around you if they know of ways that you can get involved in organizations that they are a part of. If you can't find a role, see if there are small processes that you can improve. As a resident and junior staff, you're so aware of the day-to-day work and possible inefficiencies in the system. Is there a small thing that you could change to help the group? Consider banding together with a few peers to see if you can find a better way to do things. Also, don't put pressure on yourself to find a leadership role right away. Your goal is to get your foot in the door and learn how things work in your organization. Once you get your feet wet with small projects or roles, you can then collaborate with other leaders. Part of getting mentorship and being a leader is also giving back yourself. There's always someone who's a few steps behind you, residents, medical students, college students, who can learn from your experience. Share your path with them and be there as a resource for them. Giving back to your community is a great way to further develop some of your leadership skills. As a quick recap, here are the key points that we discussed during the short talk. I wanna leave you with this final quote. As we know, not all leaders have titles and not all leadership titles are true leaders. Leadership really is a mindset and cultivating that mindset can begin at any stage in your career. My personal belief is that if you work on building your toolbox and being sincere, the rest will fall into place. These are my references. Thank you. My name is Nellie Tan and I'm at Mayo Clinic, Arizona. And I'm going to be talking about sort of giving you perspective of a junior faculty in quality improvement. And we will start off with two audience response questions and I'll answer those questions towards the middle end of the talk. And we'll be reviewing what has already been alluded to, which is this idea of collaboration and interdependence, as well as how I view quality improvement and really a framework for solving problems and quality as part of a larger umbrella of health services research and some of the tips that I learned along the way that maybe perhaps can be helpful for other junior faculty or younger trainees. So the first question, what is the most common mistake made by would-be improvers attempting to make improvements? Failure to engage leadership? Lack of resources? Failure of execution or lack of cultural awareness? Most common mistakes made by rookies, starting off. Great. And the final question, quality improvement science is a component of what? Health communication, dissemination, implementation, or more kind of our standard science such as randomized controlled trials? Good. So my background is in research and I've had formal research training statistics. And when I was a first year staff, I worked at a very high volume tertiary care level one trauma center, super busy practice. And we had phenomenal residents. And the senior residents took all overnight and generated preliminary reports that the staff then reviewed the next morning. And as a first year faculty, I had observed a few important misses and it happens to all of us. And I wanted to know, well, do the patient's outcomes change whether they showed up at night or during the daytime because we had this model of preliminary reads issued by our senior residents. And when you make an observation like that or you see something that could be a pain point, what are you going to do next? And I think we would approach this all kind of slightly differently. And before I share with you what I did, I will tell you that I identify myself as a doer. And I suspect many of you here do as well because we are here in a quality improvement session. And what I did was I submitted an IRB to study this question because my background is in research. And so I did that. And then I get this kind of unusual phone call and by a leader asking to meet with me to review this IRB application that I submitted. And I was a first-year attending and I was a little nervous. So as someone who's kind of new, there's a lot of things at risk. I could be antagonizing people, perhaps lose capital. You're kind of walking in a tightrope. And what happens if there's no support? What happens to this question that I have that I want to answer? And I came to learn that the hard way that the first step in any kinds of process improvement or quality improvement, anytime there's a problem that you observe, the first step is stakeholder engagement. So I had to change and transition from a doer mindset to a leader mindset because at the end of the day, it feels like we work in silos but we are all interdependent. And the things that I do, the questions that I study affect those around me. And the things they do affect me. And at the end of the day, the more synergistic and aligned we can become, the more effective we can be at moving forward and improving patient care. So for me, quality improvement was the framework that I used to help me bridge from where I was to where I wanted to be. And it gave me the tools that I needed to frame the question, frame how I was gonna approach this question or a problem that I saw and observed that I wanted to fix. And people who have done this over and over again can spot it from the get-go. For rookies like me, there are certain things that will be destined in your project to failure or success. And here are the top five factors that can attribute to a successful project or a flop. The first step is leadership buy-in. And this is the most common mistake made by rookies because leaders set the vision and I think oftentimes rookies fail to recognize where they are versus where they are part of this larger collaboration framework, larger picture. Resources, protected time, access to data, all of those things are key to ensuring a successful project. Methods, ensuring that you're taking on and implementing appropriate, robust approaches so that the data is, there's integrity in the data. Execution, making sure there's appropriate project management resources or at least steps in place. And lastly, cultural awareness. Because depending on where you are, you can predict the reactions of how these projects could impact the stakeholders and be strategic about when and how to engage them. So the most common mistake made by would-be improvers is failure to engage leadership. Because change disrupts organization and that's the reason why it has to be a hands-on leadership activity. Because the leader sets the vision and if you don't have that buy-in from the get-go, the project will fail. So for me, that's what quality improvement or more trying to solve problems was for me. It was learning how to be a leader and doing it through experiential learning and working at it through the various project, learning and reapplying what I've learned. There are two mistakes that one can make along the road to truth. It's not going all the way and not starting. I had already started my project and I wanted to go to the end. And so the next thing I did was to then seek help and support. It's amazing that the medical school curriculums now have quality improvement embedded. I didn't have that training. And so for me, it was learning trial by error. So I went ahead and sought help and reached out to mentors and colleagues at and outside my institution. And they challenged me. They said, well, these are the things at stakes. Now, what do you do the next time it's gonna happen when a leader challenges you on a project that you're trying to launch and to try to answer? And so I went ahead and found allies, others who supported and aligned with the vision of the goals. And through that, we were able to assuage concerns and get everyone to be on the same page so that everyone was in alignment. And so I came to learn that quality improvement, as Mark said, is a different kind of research. It's part of a larger framework of implementation work that's encompassed within health services research. And I'm gonna argue that this approach is actually more impactful, maybe the most impactful on the day-to-day patient care that we do compared to more standard research that we've more commonly learned in the past. So quality improvement science is part of implementation. And implementation science has a robust framework for how to go move forward, as already partly highlighted on the prior talks. And for me, I think these types of projects where you're trying to make life better for yourself, improve patient care, fix a problem that you see kind of touches on key elements that bring us fulfillment. You learn things about yourself that you may have not known before. And you develop your potential. You learn new leadership skills and working with people. And it gives you a purpose because you want to make it better. You want to make life easier. You want to make patient, you want to improve patient care and in pursuit of excellence. And it's a lot of work. It's a lot of work. But at the end of the day, you achieve something together with a team and it's fun. And that enjoyment kind of fuels you towards moving forward and continuing that effort. So as a junior faculty, and maybe more than that, sometimes you just want to stop and you get discouraged and you want to just stall. It's hard. And I think it's important to keep moving and keep trying because eventually it's going to break through and something will work and you learn and you get better. And these early wins can then build that momentum and propel you so that eventually you don't have to put as much work forward to have more impact because you're smarter and you're better and you're more effective. And I think it's wonderful to be sort of in the early career, early training period, because these are the earliest year. These are the most important years because they set your trajectory. And so the skills that will empower you beyond your clinical practice, right? Because quality improvement skills are life skills, right? It's a framework for how to solve and make things better. And the byproduct of this effort is what we get for promotion, right? You get your scholarly output. You get funding, things like that. But really at the core of it is something more. You're chasing for something more important and promotion comes as a sequelae, not the end goal. And it always helps to have money, I came to learn. It's a lot easier and a lot better to have funds. And for those who are looking to secure some funds, I've been really lucky to be able to secure several awards for quality improvement projects. But this book has gotten me to those awards. And I have multiple copies and I read this book every time I write a grant. And I would encourage you to look into this book. He's an ophthalmologist and sat on the NIH section for 20 years and he just gives you the lowdown of how to get your grant funded, which is fantastic. So this is a summary of what we discussed and the importance of not going for, I don't see quality improvement as a career. I see it as a tool to help you solve problems. And so if you want to solve problems, if you want to make life better for yourself, your colleague, improve patient care, then this is the tools that you need to make it a lot easier and make it more effective for you and some of the tips that I have. Special thanks to Matt Davenport who had been my, who had mentored me and was probably had the most impact in my early first few years as faculty. He was gracious in his time and expertise and guiding me and spending hours and hours on the phone talking to me through challenging scenarios and cases and really helping me and clarifying things for me. And of course, David Larson, my first introduction to quality improvement was when I studied for the radiology boards and opened that non-interpretive section booklet, I think written by David, and it made so much sense. And I'm so grateful for his leadership and making sure that we in the young and maybe eventually future leaders have that education because of him. Thank you so much. It's an honor to be here. Thank you for the invitation. On behalf of the committee, you guys having me come is really an honor to get to share with the group some of the things that I wish people had told me when I got started and also share some of the learnings that I've been fortunate to have over the last few years. So my focus is really gonna be on building a QI career and a pipeline in private practice. That was my experience prior to joining the Mayo Clinic. So learning objectives, we're gonna articulate the importance of developing a pipeline and also a framework for how private practice radiologists and really any radiologist can think about getting involved in quality. So some of you may be familiar that Mayo Clinic, Roman and I and Nellie will be heading back to Arizona. There is a massive work that was done to take water and bring it to the desert. And as I think about this talk, I think about building a QI pipeline, right? So tremendous investments required. My colleagues, distinguished colleagues that have spoken before me have outlined all of the hard work that's necessary to get to this point. And in doing that, new opportunities emerge, right? We get to sort of pay it forwards as everyone watching this will as well. There's a huge payoff and an enduring impact. And in this case, it allowed the desert, from the desert to emerge Phoenix, Arizona, right? So would not have been possible otherwise without that literal pipeline. Now let's talk a little bit more figuratively about pipelines and QI. So my role at Kaiser Permanente ultimately was the national chair for radiology and value advisor for radiology. And we looked at this aggressively from the quality perspective, how are we gonna generate quality and value? So we think about improving outcomes, improving quality, improving safety, improving the patient experience, themes have all been talked about. We also wanna minimize some of the less helpful aspects of value creation, cost, hassle, delays, resources. And then we expanded on that in the framework that we developed to think about making things personalized and convenient for patients, adds value, making care that's hospitable and high-tech and virtual and integrated across departments. And then also decreasing hassles and costs and efficiency. So this is sort of the argument to do quality improvement in your practice and private practice and in any practice. Right, so what are the framework that we're going to talk about? There are at least seven steps to this. And some of these have been hit on. We'll talk one slide about each topic and then take a break. So first step, I think, and these are fairly sequential in my mind, is about mentorship. So Nellie and I disclosed the impact that David and others have had on us. And what is the role of mentors? I also had mentors inside my department. My quality chair prior to me was a big mentor. What are they gonna do? They're gonna help you understand the group's culture. This is critical, right? You can only work with your culture. You can't really be going against it. You need to evolve it over time. You have to understand it. They're also gonna help you prepare for outcomes that you want, right? So if you become partner, if you get promoted, if you become a little bit more influential, and those things will help you further some of your goals. They'll also help you identify unmet needs of the team. They might have been there longer than you, and they might have a higher level understanding of what opportunities are in your midst. So definitely ask these types of questions of your mentor. They might also help explain the priorities of the practice and the enterprise. This is critical. I'll hit on it a little bit later too. If you're rowing in line with the priorities of your organization, you're gonna get a lot further, right? You should really be aware of what their priorities are because funding, resources, interest, impact all come along on those pathways. Identify potential leadership opportunities that are aligned with your interests, right? Perhaps they'll know about emerging opportunities and connect you in. They'll also identify resources to support your QI efforts, right? Money is not everything. You can do a lot with no money, but if you have some resources and support and team members, you're likely to get a little further. Introduce newer radiologists to key leaders, right? Introductions, networking, a big role that mentors will play and they'll also help you gain traction generally in your organization by having support and making that clear and allowing you to access some time and some resources. Next about closing skill gaps, right? There was a talk, Akrathy earlier was talking to us about self-awareness, right? Understanding yourself. I'll extend that a little bit to understand what do you know about QI skills, right? So what do you really understand? What do you not understand? And then, and there are several domains. I've sort of spelled a few of them out, but ask yourself, do you need some formal training? Do you need to go to a QI course? Do you need to do more of the sessions at RSNA or Rankin Ray? Might you be interested in the RLI certificate through the ACR or is there an advanced degree that's of interest? I learned a lot about statistics, QI, leadership in my MBA program. That being said, it's not necessary to do QI. You can get those skills anywhere. And then we talked a bit about state of mind, right? You wanna, Nelly talked a lot about this and I really loved it. You know, you embrace solving problems, you have a growth mindset, you're looking forwards and that is your perspective when you go to work. I'd add a little bit of positivity to the mix too. Okay, so now about collaborating, right? I love to throw in a few cartoons here and there. So effective QI leaders will collaborate within and outside their department, building relationships and achieving a lasting impact. This is, I think, really, really important, right? So what do you need to do first? You have to collaborate with your fellow radiologists. These are sequential, right? Have the radiologists, get to know them. And then once you're doing well in that front, expand it to horizontally, I'm sorry, vertically, in your department, your staff, your nurses, your technologists, your leaders, your managers, your supervisors, work with them. Improve the processes within your vertical column of work, your silo and radiology. And then once you've done that a bit, expand it outwards into other specialties. You'll develop so many skills, you'll develop an understanding, deep understanding of your department, and you'll understand how to integrate care horizontally to create real value for your patients. Identify improvement opportunities. So talk to people, that's really the key. Listen to others. Sure, you'll make some observations, but if you see things that aren't a priority to anyone else, you won't go far with that. So also keep in mind that it's hard to predict which project will be the most embraced by various teams. So have a few things out there, right? I think that one of the key takeaways from Mark's presentation is get out there and do a lot of QI work, right? And some of this will be more successful than others, but the key is to get out there and get everyone engaged and start doing stuff. And so having more than one thing going is a recommendation early on. Look around, listen to your team, see what problems you can solve and what would be a positive impact. One thing that I can't help but put a plug in for is peer learning. That's been a special interest of mine. If you present something like peer learning as an alternative to score-based peer review as I did, you might find that everyone gets really excited about that because they really see it as an opportunity. If you're not familiar with what that is, Google ACR peer learning resources, and you'll see myself, Nelly, and others talking about it. Align with key priorities. Understand the key priorities of your organization. Align what you do with those priorities. Then you'll get resources and you'll be aligned with everyone in your organization and you'll be helping forward organizational goals rather than just your personal ones. Improve your practice. Again, this is the theme. Get out there and start doing stuff. Apply improvement methodologies. This is, I think, a helpful article that puts a lot of tools there. A fairly comprehensive list in a lot of ways. But you need to start small, where your skills are, where your team's skills are, and just keep growing. Early step. Understand, what does your practice do well? What do they do less well, right? Fundamental question. Next, we're gonna talk a little bit about strategic prioritization. So you'll start to come, as you're following this framework, you'll start identifying lots of needs of your organization and you'll identify lots of opportunities to improve and you'll identify your organization's priorities and maybe people that are interested in projects. You can't do everything. And the more you try to do, the less you'll get done. So you want to hone down what it is that's of interest and focus on those things. Look at it as an X, Y scatter plot. Evaluate the potential impact of goals of every project you're thinking about. If it's gonna impact your department and your enterprise's goals, that might have real value for you to consider. It'll have high impact on goals. And then think about the difficulty to implement, right? If you're gonna change a few words on a pick list in PowerScribe, that's pretty straightforward to implement. But if you're going to create management of all incidental findings across nine different departments for every patient on every imaging study, that's much harder. They may both generate lots of return on goals, but know that the latter will be up there in that challenge area. So examples, start with quick wins. You're gonna improve your goals. You're not gonna waste a lot of resources. People are gonna see a change. Those protocol changes, reporting templates are a great place to go. Once you've honed that and built some inertia and momentum, got some purchase moving forwards, standardized management of specific imaging findings, right? A little bit more complicated, might involve a few different people in the mix, and it's gonna impact your goals even more. After that, you could think about more longitudinal things. You know, we did multidisciplinary care pathways across specialties. For us, that was something that was really impactful. And we did some incidental finding tracking that's gonna be published under an implementation science article in JCR in just a couple of months. I think it is available next month. Kill ideas. You don't wanna get waylaid in this. This is where QI goes to die, right? You're not making a difference on your goals, and you're just floundering around. So avoid that altogether. If you start following this framework, you'll get to this last step, and you will be shifting or evolving your culture. Know that you cannot do all of the improvement work in your organization. You have to get other people excited and engaged. You have to tell your stories. Emphasize your impact. Don't be a showboater, but make it known that improvements are happening. Nurture others' interests and develop their QI competencies. In doing that, you will not be sort of this one-man band, which a few of us have done over time, and it's not a great sound, and it's not a great strategy for your back. So get a team, do this collaboratively. Summary, those are all the things we talked about. Mentors, closing skill gaps, collaborating, identifying opportunities, aligning with key priorities, improving your practice. We talked about prioritizing your work and your time, and shifting your culture. Thank you so much for your time.

quality improvement

medical education

student engagement

curriculum integration

mentorship

experiential learning

student leadership

healthcare challenges

continuous improvement