Hello, everyone. I'm Jonathan Flug from the Mayo Clinic in Arizona. I will be serving as the moderator for MSQI 33, the Quality Improvement Symposium this year, with the title High Functioning Multidisciplinary Teams, Role and Value of the Radiologist. I'd like to thank Dr. Bettina Siebert for putting this program together and inviting me to be the moderator. I'm going to take just two minutes here to introduce our speakers and then turn the floor over to them. Our first speaker will be Dr. Hannah Zafar from the University of Pennsylvania, and her topic will be Patient and Family, Partners in High Functioning Teams. Next we'll hear from Dr. Ashley Aiken from Emory, who will be speaking about Tumor Board and the Multidisciplinary Clinic. Next will be Dr. Andrew Rosenkranz from NYU, whose topic will be the Radiology Consult, Virtual or Integrated. Next will be Dr. James Rawson from Beth Israel Deaconess Medical Center in Boston, whose topic will be High Functioning Multidisciplinary Teams in Trauma and Stroke. And our last speaker will be Dr. Lane Donnelly from Stanford University School of Medicine, whose talk will be the Social and Technical Domains of Culture as they pertain to teams. I hope you all enjoy the content we've put forward for you here today, and I invite you all to see our other Quality Improvement Symposiums as well as our Quality Improvement Report section of the meeting. Thank you, and I look forward to seeing you all in person in future years. Hello, my name is Hannah Zafar, and thank you for joining me today, where I'll be talking about patients and families, partners, and high functioning teams. I have several disclosures to make, but the most important disclosure I have to make is that I fully recognize the collective expertise across this entire virtual audience far exceeds my individual expertise. And I want to welcome and invite all of you to please share with me your thoughts and reflections about what does and does not work for you in this lecture with me through social media and email so that I can learn from you. Two learning objectives for today. I hope that you can walk away and describe two examples of how high functioning patient and provider teams can improve healthcare delivery and research, and also give three best practices to how we can build these types of teams. So why do patient and provider partnerships matter? Well, there's a strong body of research that shows us that teams that include patients can improve clinical outcomes. Here I have one such paper. It's a meta-analysis of 35 randomized controlled trials comparing quality improvement strategies for diabetes between interventions that were designed with patients, so co-produced with patients, versus usual care where patients were not involved with the intervention. And they found that interventions designed by patients were associated with improved blood glucose, blood pressure, and lipid levels for type 2 diabetics. Teams including patients can also improve quality outcomes. So while redesigning their neuroscience inpatient service, one healthcare system employed a team, a high functioning team of patient and providers, and they found that that was associated with increased patient satisfaction, decreased medical errors, and decreased staff turnover. Including patients and teams can also improve all stages of research from study design, to recruitment, to analysis, and dissemination. Some of you in the audience may be familiar with the REMOTE trial back in 2011 where Pfizer wanted to study the use of Detrol on patients with overactive bladder. They launched a very aggressive online recruitment protocol using social media and the internet in order to get their patients, in order to meet their target for patient recruitment. However, they fell short in part because they forgot to think about their patient demographic. They were targeting older women with overactive bladder, and at least at that time that demographic was not engaged in social media and had an online, significant enough online presence, so they were forced to switch over to more traditional or conventional offline recruitment tools. Why is this important to us? Well, you can imagine if they had just employed, if they had just included several of the target patients that they were going for in their study design, they might have saved themselves a lot of time and money. What are some of the best practice approaches that we can use in order to build these high functioning teams? Let's go over a couple. The first is engage patients early, early in the design process. On the left-hand side of the screen, we have what we don't want to do, but what we typically do, which is that we have a small group of individuals who define what are the issues that are important that we're going to tackle? What is the outcome that we want to see? Then they come up with an action plan that they push out to patients and providers expecting them to buy into the choices made by this small team of individuals. What we want to do is what we see on the right-hand side of the screen, which is we want to engage patients and providers early on in these teams, right? We want them to co-produce. What are the issues that matter to them? What are the shared outcomes that make sense? Then come up with an action plan that reflects those choices collectively. Number two, we want to build diverse teams. Why? Diverse teams are more likely to be innovative and creative. We know that diverse teams are more likely to bridge the disparate silos that oftentimes exist within healthcare. That's going to be important because it allows us to create those networks that are going to be able to tackle those complex problems within healthcare. Finally, diverse teams are more likely to have individuals who are going to challenge assumptions, who are going to push back gently, who are going to ask, what is it that we are and aren't thinking about right now in our discussion? You can imagine how that might have been of value to the research team coming up with the overactive bladder drug that we discussed several slides ago. Number three, we want to deliberately and intentionally build psychological safety within our teams. If you remember nothing else from this lecture, I hope that you'll remember this slide. It's so important to build psychological safety, particularly when you have patients and family caregivers who perceive themselves to be at a lower status relative to the clinicians who may be on the team. This particular study highlights, I think, the importance of psychological safety in predicting engagements in quality improvement work more so than leader inclusiveness. If we want to have teams of patients and family caregivers who are leaning in, who are actively participating, who are bringing their full selves to our teams and our meetings and our projects, we need to make sure that we create psychological safety. I think intuitively this sentiment makes a lot of sense to those of us who are watching this today. And I know it resonates with me personally, and it also reminds me of this quote from Maya Angelou, people will forget what you said, people will forget what you did, but people will never forget how you made them feel. We need to create teams with psychological safety so that patients and family caregivers feel comfortable sharing their thoughts and opinions fully so that we can capitalize on the diversity that we're capturing by including these members on our teams. Number four, we need to speak clearly. Oftentimes in healthcare we use a lot of technical terms and jargon, and that can really lose patients. So, this particular figure was taken from a study where over 100 patients were shown 800 different types of radiology reports, and what they found is that unclear language was the most commonly cited problem by patients to understanding radiology reports. And I put this here because you can easily see how this could extrapolate to say that patients would understand more of what we were discussing, or patients are more likely to understand what we're discussing in patient and provider teams if we just use simple language. Now, for some of you in the audience, you may feel like a lot of what I'm discussing today is all the way out in left field because you feel so removed from having any direct patient engagement, and it turns out you're not alone. A survey that came out several years ago found that less than one-third of radiology practices were regularly engaging patients directly. Interestingly, the same survey found that 90% of radiologists want to promote the role of imaging in health and care to patients. However, the same study found that time and workload were perceived to be the biggest barriers to having radiologists engage directly with patients. So what are the things that we can do at the monitor in our everyday practice for those of us who aren't having the same opportunities to engage with patients? Well, two thoughts for you. The first is maximizing imaging protocols. Now, I know this isn't something glamorous, but so important for patient care to make sure that we do the right study on the right patient at the right time. Why? We want to avoid patients having to come back multiple times to have different imaging exams all geared towards answering the same clinical question. Number two, we want to reduce radiation dose. And number three, for those of us who work in large health care systems, you want to make sure that patients are getting the same imaging protocol, the same imaging exam, regardless of whether they're going to different facilities or different scanners. And finally, we want to create radiology reports that patients can understand. A lot of health systems have begun to develop online portals so that patients can have direct access to radiology reports. Some systems have even begun to play around a little bit with the idea of taking key images from studies and embedding them within radiology reports. A lot of high-tech solutions, I would say, which is really great and creative, but one of the simplest solutions, one of the simplest low-tech solutions that's available to us right at our fingertips is to use our keyboards and our dictaphones to create shorter reports. This figure is taken from the same study that I referred to earlier with the 100 patients who are looking at the 800 different radiology reports, and they found an inverse relationship between patient comprehension and the length of the radiology report. So in other words, brevity is equal to clarity, and that is something that we all have direct control over every day. So, of our two learning objectives, I hope that we've been able to go over how some of the data about how patient and provider teams can improve health care delivery and research, and also cover some best practices on how we can build high-functioning teams, and for those of us who may not be in patient-facing roles, to at least improve health care and delivery to our patient population. On that note, thank you very much for your time, your participation, your engagement, and again, I would welcome you to please share your thoughts and reflections on this lecture with me through social media and email. I'd like to start by thanking Bettina Stewart for organizing and inviting me to speak in this quality symposium. While I could talk for hours on our multidisciplinary clinic, I will try to give you the highlights in just over 10 minutes. Whether you interact with a multidisciplinary team in a weekly tumor board, sporadic consults, or in an embedded clinic like ours, each interaction can positively impact patient care, strengthen relationships, and help you grow as a management-focused, added-value radiologist. A multidisciplinary clinic is one which patients are seen by more than one subspecialty. Over the years, as disease management has become more long-term and complex, and therapies have improved, and outcomes have become multidimensional, it's become more clear how limited the relevance of a single specialty is in the overall management of disease. Simply put, it takes a village, and this has led to a shift towards a multidisciplinary approach for decision-making, particularly in fields such as oncology. For the next 10 minutes, I'd like to tell you the story of our head-and-neck MDC at Emory. This is the story of how a multidisciplinary initiative that began at Emory many years ago has positively impacted our referring clinicians, our patients, our practice model, and ultimately us. It's the story of a teamwork, trust, commitment to process improvement, a story that began many years before 2012, and before my time at Emory, when my mentor, Dr. Hudgens, carved out a head-and-neck imaging subspecialty service, and developed long-lasting relationships with our ENT group. Our head-and-neck imaging group was initially embedded in the ENT clinics in 2012. There, we were surrounded by the surgeons, the head-neck surgeons, the sinus surgeons, the laryngologist, and the otologist. We developed robust personal connections and trust, and in 2019, we moved into a multidisciplinary clinic to optimize and focus on head-and-neck cancer care. Our MDC discussion is essentially a mini-tumor board with all the relevant subspecialists present in our clinic daily, where we will review imaging, and our goal is to streamline treatment planning as a one-stop shop for patients. Discussion improves decision-making by closing the knowledge gap of all of these members. In fact, we often joke that we're cross-training for each other's subspecialties, and I challenge our trainees to know the treatment plan before MDC. Will they choose surgery or CRT, and even the surgical plan for resection and reconstruction? The more we know as radiologists, the more value we can add for our patients. Shared decision-making in an MDC team does have potential pitfalls, such as groupthink and or dominant personalities, so team members do need to balance their individual opinions and goals for patient care with their role as a team member with shared decision-making responsibility, and I believe you will hear more about this from Dr. Donnelly at the end of this session. Our team started by studying the patient journey and learning about waits and delays, and our initial data showed a time from first contact to treatment start of 51 days, and from the first visit to the treatment plan of 18 days, because patients often see more than one specialist, and then they wait for the weekly Tuesday tumor board for a comprehensive plan. The old workflow, as we just discussed, involves seeing multiple specialists at different times, then filling in the imaging gaps also at different days and different times, then waiting for a weekly tumor board discussion. In the new workflow, new cancer patients are referred directly to head and neck MDC. They are pre-screened for any missing imaging, and we have coordinated same-day slots so that on the MDC day, patients complete any missing imaging, see all the referring subspecialists, and then are also discussed in our MDC tumor board. It's a one-stop shop for the patient. Our initial data with this new clinic and approach shows a 27% reduction in time from the first contact to treatment plan, and we are continuing to improve. The key feature here in the middle is that all the team members are available in one space and on the same day to plan treatment, so that the median time from their first visit to their treatment plan is essentially zero, shaving off 18 days from the pre-MDC data collection. Here's a picture of our multidisciplinary work room, which we affectionately call the fishbowl, and this is where all of our surgeons and oncologists, but also nurse practitioners, speech pathologists, and social workers are usually sitting. Obviously, some of this has changed in the COVID era. Around the corner is our head and neck reading room so that we can get up, and this facilitates conversations throughout the day. Here's our embedded reading room, which currently has five packs, often with two faculty, one fellow, and one resident, some of which are currently working remotely due to COVID. We're planning a third move into our cancer center where we'll have eight packs and a carved-out enclave for consults to decrease interruptions to the surrounding head and neck radiology team members. And for years, we've had a candy bowl, a tradition started by Dr. Hudgens and has definitely been effective at strengthening these multidisciplinary relationships. From an imaging standpoint, two key pieces of this workflow optimization have been the efficient immediate image upload of outside studies to PACS for review and holding same-day slots for missing imaging for MDC patients. Radiologists do receive a list of MDC patients in the morning for pre-review if needed. Here's the clinic workflow to give you some perspective of when this mini-tumor board happens after patient arrival, rooming, and the clinical exam. The tumor board has all four MD disciplines, the radiation and medical oncologists, surgeons, and the radiologists present for PATH and clinical exam and imaging review. Our MDC tumor board sees four to six patients a day. We have two afternoon tumor boards where we see two to three patients each. Initially, our nurse practitioner will present the history and clinical exam with the entire team. And in this picture, you can see one of our head and neck radiologists, Dr. Wu, presenting the imaging. We'll determine if there's any need for additional imaging or biopsy, and then talk about the best course of treatment for the patient to present a unified message. The primary role of the radiologist is as a diagnostic specialist and an expert consultant to ensure that the appropriate imaging is obtained in order to determine the accurate imaging staging for the best treatment plan. And we have all the clinical notes and exam information available to us at the time of our MDC tumor board. Occasionally, radiologists will be asked to show the MDC patients their imaging when the surgeon or oncologist feels that it will benefit that particular patient. We more often have discussions with patients in the surveillance time period, but when patients do need reassurance, radiology consultation can be very helpful. A few years ago, we surveyed 21 patients who'd had this experience. Patients' responses before consultation are shown in teal and after in purple. We found that patients gained a better understanding of the radiologist's role and their imaging post-consultation. But perhaps most striking is the percentage of patients who wanted to hear radiology results from the referring clinician instead of the radiologist before. And then after consultation, over 80% wanted to hear their results from their radiologist. While I'm a huge advocate of this type of embedded practice to facilitate communication, especially as the best model for complex subspecialty patient care in order to highlight the radiologist's value, I would not be complete to discuss all the goals and advantages without mentioning the obvious obstacles of a convenient time, space, and knowledge gaps that may cause anxiety for radiologists. So I want to highlight the embedded clinics and the MDC and structured reporting as potential enablers. The embedded clinic obviously solves the problem of physical proximity to referrers and patients, and it also shortens the time needed to get information about our patients. As you will hear from Dr. Rosenkranz, perhaps our increased familiarity with virtual conferencing may also facilitate these multidisciplinary teams in the future, where physical proximity is not a viable option. Adequate staffing is also an important enabler to this model. You need redundancy during these afternoon tumor boards. So even if we do not have two head and neck faculty on the service, we will communicate via Microsoft Teams to our entire neuroradiology division so that they can help us with our radiology reading list. The MDC team model and shared decision addresses insufficient knowledge, helping radiologists become more comfortable with management and therefore aligning us with our referred clinicians in terms of a treatment plan. Standardized reporting with a consensus management steps that are built in can also help us to address any gaps in knowledge. In summary, the MDC gives the radiologists the opportunity to guide patient care in real time, thereby seeing their own impact. And as expert consultants, this can be empowering and affect how our referrers see our role. The MDC streamlines and coordinates care for our patients and allows radiologists to occasionally directly communicate with them, increasing the patient's trust in the care that we provide. It models consultation and teamwork to the next generation of radiologists. And finally, it brings us closer to the meaning of our work and makes us better radiologists. I want to acknowledge my partners, Dr. Bonio and Dr. Wu and the entire head and neck multidisciplinary team. And thank you all for tuning into this session on multidisciplinary teams. I'm Andy Rosenkranz and my talk is entitled the radiology consult virtual or integrated. I have no relevant financial disclosures. The modern digital radiology reading environment has tremendous benefits in terms of workflow and efficiency, but also poses challenges. This is indicated by a series of editorials and statements in the radiology literature that focused on the invisible radiologist, the radiologist becoming isolated from our referring physicians. In this talk, I'll focus on a couple of strategies to address this. The first of which will be to maintain that same level of interaction, but doing it all virtually. And I'll present this in the context of how we've handled it in my institution. We have many, we're very geographically dispersed with many practice locations throughout the New York City metropolitan region, the various boroughs and into Long Island. When we think of the optimal digital communication approach needs to be easy for the refer to reach the appropriate radiologist with minimal disruption to the radiologist workflow. There should be a shared real-time image viewing ability that occurs within existing IT environments. The refer stays in the EHR and the radiologist stays within the PACS. We've deemed this the virtual consult. The way this works, the refer initiates the session. It can do this from the imaging report within the EHR. It links the refer to the subspecialty radiologist with instant messaging like chat and optional screen share. This is what it would look like. The refer is looking at this report. They click this button to start the virtual consult. They select which subspecialty radiologist they're interested in and communicating with. Both the referrer and the radiologist see this panel. They both click to accept and it puts them into conference with one another where they can now virtually text or chat back and forth about the case, ask questions and have other discussions. There's an option to share the screen if doing this, it allows the radiologist to scroll through the images. As they comment on things, point to findings, the referrer can take control and point to findings on the images where they may have a question. So we have the virtual consult available 24 seven for ED patients and normal weekday hours for outpatients. It's accessible throughout the enterprise, including in geographically remote locations. From the main location, one radiologist per subspecialty designates themselves as this section's virtual consultant. The consult request occurs in context. The exam accession is automatically transferred to the consult tool and open in the radiologist packs all in one click. The referrer doesn't need to actually relay any study information. The radiologist doesn't need to enter the study information. So this avoids delays in entering or opening the wrong study. Then upon completing the consult, the radiologist is automatically returned to the prior case that they were addicted. The referrer's response to this has been incredibly positive. 90% said it was easy to use. 85% said it enhanced their integration with the radiologist into clinical care. 85% found it helpful to have this access to the subspecialty radiologist. 80% said improved understanding of the report. 70% valued the direct screen share. Some quotes from referrers. This let them ask quick questions that they would otherwise have gone unasked because of time constraints. They could see a significant finding and contact the radiologist, moving quickly and not waiting for the report. They may have had questions on subtle findings. The service was helpful, given their location where they couldn't just drop by their reading room. It was super helpful to discuss something in a non-urgent fashion, off hours. They still like to go to radiology, but they'll use this tool when that isn't feasible. So benefits, it's an opportunity to answer questions, provide clarifications, discuss significance of incidental findings, discuss follow-up recommendations, and for the radiologist actually to get additional clinical information. Ultimately, this will enhance the referrer's understanding of the report. Where it's been most useful, off-site locations, after hours, when there's lack of time for the referrer to physically travel to radiology, ultimately any situation in which the traditional radiological consultation is difficult or impossible. It's really had a key role in the ED. It's a fast-paced environment. There's imaging for a wide variety of substantialities. The imaging results impact immediate patient management, and also the ability to contact the radiologist before official exam interpretation. I know this may seem really simple, but to compare it versus a traditional phone call, if you're trying to refer us to call the radiologist, you have to figure out who to call, what number, hope the radiologist is reachable and available at that moment. There may be a delay, whether transferred or waiting. All those hassles are bypassed with the virtual consult, and the radiologist can be in their virtual consult concurrently while making other phone calls. So I'm gonna switch gears and talk about maybe a much more simplistic approach to maintaining integration with our referrers, at least one that doesn't require advanced technologies to implement, and this is the embedded reading room. So PAX enables us to interpret images at locations remote from the radiology department. So one option is to establish a reading room directly within the referrer's practice location, the integrator embedded reading room. This could be somewhere in the hospital, in a physician office, and it lets the referrer have quicker access at the point of care. One institution published about how they did this in their ENT referrer office. We've done this in an outpatient urology clinic, where the reading room was within 10 feet of the space used by the urologist between patient encounters to review the EHR consult with nursing staff. We have a radiologist there for half the day. They actively interpret exams from a work list in PAX. So they're really just moving their location, and it didn't require additional staffing. When we monitored this, they would get up to eight consults per shift, about half the time to look at an exam that the patient brought in on a disc from outside, and occasionally, the referrer would actually bring in the patient to directly review a study with the radiologist in the embedded reading room. Now, the outside exams is really one of the big values we found from this. It was often very difficult for the referrers to handle those discs on their own, just variable protocols. They found the software difficult or tedious. And with these timely consults, the referrer could incorporate the re-review more readily into patient management during that single office visit, versus otherwise, they would do the visit with the patient and later contact the radiologist to review the outside study and get back to the patient. And before this, potentially the referrer couldn't get a prompt reinterpretation, maybe even just reorder the study as a, as actually for them, an easier way to get an internal interpretation, whereas that could be addressed through the embedded reading room. So the response to this was very positive, over 90% of referrers said the consults benefited patient care. Majority of the consults changed management. The large majority said they were more likely not consult a radiologist for an outside exam. Over half said they were less likely to reorder the outside study. Other benefits, more appropriate follow-up testing and a source of interdepartmental collaborative research. So I put this all within the context of RSNA CARES, Imaging 3.0, the imaging value chain, that as radiologists, we engage in added value activities beyond standard image interpretation and reporting. Our role doesn't end when we just sign off the report. We're called upon to participate in other care activities and communications to ensure the referrer understands the report and is in position to take appropriate action. These forms of consultation will address the concern of the invisible radiologist in the era of digital radiology. So I presented two solutions, the virtual consult and the integrated reading room. These are complimentary, not mutually exclusive. The radiologist could be in an embedded reading room and be available for virtual consults, for example. When you implement these in your practice, you have to recognize that this will take time, that you really want the radiologist to be able to have substantive communications using these mechanisms and set their expected case volume accordingly. Ultimately, you need to understand your practice needs and environment and collaborate with referrer groups in planning these initiatives locally. So thank you for your attention and hopefully this talk was helpful. Today, I'm gonna be talking with you about high functioning teams and I'm gonna use trauma teams and stroke teams as an example. When we talk about trauma, there are multiple stakeholders and the trauma events occur across a variety of locations. Time is critical and we'll talk about the golden hour. When you think about the multiple stakeholders involved in a trauma team, you not only have surgeons, emergency department, radiology, but you also have emergency medical services which are outside of the hospital. You have the patient and family and then you also have all of the recovery with OT and PT and a variety of other stakeholders. Adam's colleague described the golden hour. He said, there's a golden hour between life and death. If you're critically injured, you have less than 60 minutes to survive. You might not die right then, but it may be three days or two weeks later. But something has happened in your body that's irreparable. This principle of getting trauma patients into care quickly is fundamental to the trauma team and the trauma center concepts. Trauma centers are accredited by the Committee on Trauma, which is part of the American College of Surgeons. Their report resources for the optimal care of the injured patients is a valuable resource that's available online. And there are over 400 trauma centers that receive certificate of verification that they've met the standards of the Committee on Trauma. There is a difference between a trauma center and a trauma network. A trauma center is more of a hospital and local regional support services. A trauma network is coordination across multiple hospitals and multiple regions to provide a network of services for a geographic region. Do trauma centers and trauma networks in this team-based approach make a difference? Well, states that have a statewide trauma system have lower mortality and decreased permanent disabilities in the severely injured patients. This isn't a US phenomenon. If you look in London, as they rolled out a trauma network, they saw a significant improvement in adjustment in the number of trauma centers. They saw a significant improvement in adjusted mortality. Or look in Israel, when they worked on their national trauma system, they were able to reduce inpatient death rates. If we shift to stroke, we see many of the same elements. This is a multi-stakeholder challenge. It involves multiple locations. And again, time is critical. Many of the same stakeholders are here, but you see obviously neurology and neurosurgery playing a greater role in stroke care. But we have the same issue with multiple locations, whether it's in the patient's home, or their transport to the hospital, or ultimately using the multiple services within a hospital or the recovery services afterwards. And time is a critical factor as well. In the Helsinki trial, it was shown that each minute of onset to treatment time saved an average of 1.8 days of extra healthy life. When you start to scale that up in the cohort that they studied, every 15-minute decrease in time of treatment delay actually added the equivalent of a month of additional disability. And that's a significant return on investment, realizing that you were going to do the treatment anyway if you just got it started 15 minutes earlier. You had a huge benefit to the patient and clinical outcomes. So how do you coordinate all of these complex moving pieces? In 2010, AHA released their report, Target Stroke, 2010, Time Lost is Brain Lost. And they argued to initiate a CT scan within 25 minutes of the patient's arrival to the emergency room. At the time this came out, there were many people arguing it wasn't possible to do, or it was too costly or too difficult to do. But what you saw across the country is multiple patients in the same room across the country is multiple services working together. 25 minutes isn't a long time when you think about the time to register a patient in an emergency room, do an initial physician assessment, transport the patient to the radiology department, get them on the CT table and actually scan them. All of these things take time and there are existing processes for those tasks. And those have to be reviewed and revisited. I think what's really impressive is when you look from the 2010 release of this report to 2017, we weren't talking about whether 25 minutes was possible. In Radiographics in 2017, there was an article that was talking about reducing the time from 20 minutes to less than 15 minutes. We were already able to get to 25 minutes. That's a significant change in processes and a degree of collaboration from a group of people who are focused as a stroke team on improving the outcomes for the patients. And that shorter time to initiate a CT scan has been replicated at multiple sites and published in multiple journals. So what are the common elements? If you look at a trauma team or a stroke team, what you'll see is this is an accreditation-based process that has a team-based approach. It emphasizes interdisciplinary collaborative teams. There's standardization of care and there's a culture and a commitment to continuous quality improvement. These are some of the elements that are in common with high-performing teams. And I would argue that the trauma teams and the stroke teams in healthcare get high-performing team results. I think the question we should ask ourselves is if we can create high-performing teams in trauma and stroke, why don't we have high-performing teams everywhere in medicine? What were the barriers we were able to overcome in trauma and stroke teams? And how did we do that? How can we replicate those successes in other areas in healthcare? I wanna thank- Hello, everybody. My name is Lane Donnelly. I'm the Chief Quality Officer at Stanford Children's Health and a Professor of Radiology and Pediatrics and Associate Dean at the Stanford University School of Medicine. It's my pleasure to talk to you today about the social and technical domains of team culture. When we think about team function, there's a debate as to what is the most important thing to concentrate on to improve that? Do you attack that through focusing on your processes or focusing directly on your culture? And to discuss that, I'd like to talk about two different people's approach. The first is John Shook. John was the first American employee for Toyota in Japan. He was one of the first people for Toyota in Japan. He was responsible for introducing the Toyota production system at NUMMI, which was the joint venture between Toyota and General Motors in Fremont, California in the 1980s. And based on those experiences, he's really become one of the lean experts internationally. And he's published many different articles and books, but Managing to Learn is one of the ones that he's best known for. If you ask John, John's obviously a process guy. And if you asked him how to improve your team, he would say probably focus on your processes. If you build your cultural expectations into your processes, that's a way to get you there. Conversely, these are pictures of Edgar Schein. Edgar Schein is a MIT professor emeritus. He's regarded as being one of the fathers of organizational development and has taught us a lot about organizational culture. He's written many excellent books, including Humble Inquiry and Helping. And unfortunately for us, he lives here in Palo Alto and is available to us when we're discussing such things. Well, I had the opportunity to serve on a panel at a meeting that we had here at Stanford that was sort of a debate, touting the benefits of focusing on process and on culture to try to drive improvement. And Edgar and John pictured here were part of that debate. And really everybody recognizes that both are important contributors. And the question is, is where to focus? So through that and discussions after that debate, we all have come to the agreement that to foster team culture, you really need to think about two different domains. One is the technical domain, the task processes and how the work is being done, and the social domain, how those doing the work interact. And if you want optimal execution, we'll serve you best if you have deliberate consideration of both the technical domain and the social domain. So let's talk about the technical domain. Again, how the work is being done. There are many benefits to thinking about this aspect of improving team. You can build your cultural expectations for your leaders and your team members into your processes. You define your processes to shape your culture. It's meaningful because our work is our professional purpose, obviously in healthcare, that is taking care of patients. So if you work on those processes, everybody can relate to that in a meaningful sense. And it's actionable. Sometimes when people try to focus on improving their culture directly, it can be difficult to figure out what the next action steps are. But when you're focused on improving your processes, that's something that is very actionable. There are many things in the technical domain that you can work on to help shape culture. Some of them are listed here, your daily management systems, how you attack problem solving accountability, how you do goal setting and deployment, having a process to recognize people for the good work. And in radiology, we've talked a lot about peer learning versus peer review. I think that's a great example. How you set up your systems to promote the reporting of errors and issues, and that you study those errors and issues purely on making the system better. Just some examples, daily management systems, huddles have become embedded into many of our healthcare systems. They're a great way to show your leaders and team members that we want to work from visible data to drive accountability in identifying problems and solving those problems and things along those lines. When we have initiatives to have discipline around the focus of the aim, we've all heard about SMART goals, specific, measurable, attainable, relevant, and timely. Here's an example, a decreased days until the next available appointment for cardiac MR with anesthesia by 85%, from 45 days to seven days by April 1st, 2021. That's a very measurable and attainable thing and has a time bound aspect to it. Driving A3 thinking as we try to solve our problems. We've benefited from thinking about the buckets of actions that we're taking into these four categories, standardization, data transparency, accountability, and coordination. That's another thing you can do process-wise to drive culture. And then taking the things that we have that focus on improvement and sequestering those from our actions around evaluating individual provider competence. And this gets to the whole peer learning aspect of things as well. Now, when you focus on all of those things, obviously, sometimes you don't completely come to the point where you get to the culture that you want. And so you may need other tactics to help you with the social domain, how your team members interact. And there are many things that you can do to focus on this, but certainly some of those are leadership techniques, safety or high reliability tactics or trainings, team training, wellness efforts, all those things would fit into this category. As far as leadership training, there are many different types of leadership training and many reading materials that you can look at. One of the things I think that they all emphasize is being a good listener, that listening is the key to respect, demonstrates empathy and builds trust. And trust is obviously the key to high team function. Edgar, who we mentioned earlier in Humble Inquiry, talks about the gentle art of asking instead of telling that you wanna draw someone out of asking questions to which you do not already know the answer of building a relationship based on curiosity and interest in the other person. We have embedded error prevention strategies and to help our teams function in a more highly reliable sense. We use the HPI methods. Many of these are familiar to you. This is adapted to our children's hospital in an approach we call Mission Zero, but the name game, making sure everybody knows each other's names when you start each meeting, eating, ARC, SBAR, things that you're all familiar with. We have a teamwork advisory committee. The framework we use is based on team steps, but obviously team training is very important to having highly functioning teams. And then wellness. We are fortunate at the Stanford University to have the Stanford WellMD Center. And they look at things through three different aspects. One is a culture of wellness where we have shared values, behaviors, and leadership qualities that prioritize personal and professional growth, community, and compassion for self and others. The second is efficiency of practice. Obviously people get frustrated when that's not the case. So focusing on that is a key component to wellness. And then personal resilience. And when we focus on each of those three areas, we can drive professional fulfillment. So in summary, to create a highly functioning team culture, you will benefit from focusing on both the technical domain, task processes, and how the work is actually being done, as well as the social domain, how those doing the work interact. Thank you very much for your attention, and enjoy the rest of the course.

multidisciplinary teams

radiologist role

patient care

health outcomes

collaboration

virtual consults

team culture

healthcare delivery