So the key word in my presentation is the big one. We're working on linking these effects to make sure we optimize our practices. So we want to talk about lean philosophy. We want to give you something that you can take home and start engaging. I'm going to touch briefly on what I call the lean don'ts, the deepest pitfalls that will not help you gain acceptance and will make people very skeptical of your motives. And ultimately, we want to weave together this sense of an improved workflow and a smoother workflow for quality and safety and operational excellence. They really all go together. So what are we really talking about? Well, healthcare quality leadership, we're trying to improve our standard processes. If you really sit back and look at medical standard processes, they are not terribly reliable if we look at them in a manufacturing sense. Most things that happen, happen at about the 90th percentile for reproducibility. Things happen smoothly about 90% of the time, maybe not quite 90% of the time. And even though we're dealing with people who are far less predictable than a sheet of steel that comes into Ford Motors, nevertheless, there are still many aspects of that process that we can standardize for the benefit of our customers. We're looking for a perfect process, and we want to get rid of random variation that really is individual-based and not intentional, if you will. The beauty is, though, that we work with an incredibly talented group of people who are all highly educated. Many of them are under the same sorts of CME, ongoing education, lifetime learning that we do, and they're very dedicated. And our goal is to leverage our relationships with them to bring their expertise to the fore and help them help us take great care of our patients. So what is quality? Sorry, we've got to back way up. My presentation in general is about the 300,000-foot view of lean. So quality is what makes our customer happy. The AHRQ says it's to do the right thing, the right time, the right way for the right person, and we want the best possible result. But the emphasis is right thing, right time, right way, right person. So our top-line vision is to satisfy our customers. We want them to have a satisfying experience. We want to meet desire for our services. That's probably one of the biggest dissatisfiers is they can't access our services. We want their experience to be smooth, and we want them to be at a high reliability. We don't want to be making it up as we go along. Let me stop for a minute and just talk about customers. When I'm talking about customers, I'm talking about our patients and their families, the referring providers, maybe a little further down the hospital or institution, and ultimately the insurers and payers. When we're talking about lean, I want to emphasize, and I think it's critically important, that our coworkers are not our customers. If you live in the process, you influence that process every day. Little changes, little nuances, quality becomes about quality of life and not quality for the customer. I want you to look at your teammates as relay partners but not customers. You're partners in this process, but let's save the word customer for a more exclusive group. Here's the current state of medicine in most areas of the country. We have separate, isolated towers of knowledge, each area with a high level of expertise, but not necessarily good communication in between. And this could be the referring doc, our tech, our nurse, ourselves, any variation of combinations of very knowledgeable people who don't necessarily communicate well across the platforms. And that's where we get into problems with handoffs. Handoffs are one of the most common problems when we come down to quality and safety, and we have to make effective handoffs. You cannot win the relay race if the baton doesn't cross the line at the end. You could be the fastest team on paper, you could be the smartest team, you could be the most amazing team, but if the baton doesn't get exchanged each time and cross the line, you don't win. And especially we don't want to hand off, maybe worse to hand off a piece of dynamite than to simply drop the baton. So we want to go away from this sense of isolated experts, and we want to think more about our processes as a relay. And within that relay, we have experts doing their particular jobs, and then we have to be very careful to make sure that we do the handoffs correctly. And the handoff, even though it's a one-way handoff, in reality it's a two-way negotiation. It's what do I need you to hand me, and what do you need to know to give me what I need? So the critical part is you've got experts, rather than in towers, you've got experts at the same level, doing their best, doing their standard work, but making sure the exchanges are beautiful. It's not a race. I do hesitate a little bit to use the analogy of the 400-meter relay, because it's not a race. In reality, I think our people, our colleagues, sense too much that quality is about speed and quality is about expense reduction, and it's not. Quality is about standard work, elimination of waste, and good handoffs. So our strategy, we're going to bring Lean into the picture, and the thing we're looking for here, again, is not this monolithic thing called Lean, but rather a sense of Lean philosophy that engages our frontline staff, because it really is ultimately a grassroots activity. The experts on the floor know what they need to do their work, and they know what they can hand to the next person. They own and design the standard work. It's not prescriptive. It's a set of principles, a set of guidelines, a sense of perfect flow, but ultimately the expert works through their piece of it before they hand it off. And your staff's very aware of this. They know that poor processes lead them astray. We have had a bit of a recent problem with MR metallic problems, where because the table is so dang heavy, and if you disconnect it and connect it too many times, the pins bend. So over time, in our musculoskeletal practice, and in other parts of the practice, I don't want to pick on MSK, but crutches were getting closer and closer to the magnet, and walkers were getting closer and closer to the magnet, because it was easier in the sense of the worker to control that crutch than it was to uncouple the table, haul the 400-pound thing out to put the patient on it, and try to make sure the pins realigned when they got in there. So poor processes will lead staff to do things that are not necessarily intentional. Ultimately, we want smooth workflow for everybody. We want you in the zone. We want you doing what you do best. And we want to have a world where 90% of the time things just plug right along. It's not going to be 100% of the time. People are different. People are not sheets of steel. You need to have time built in to deal with the exceptions that invariably will come along. So when we're talking about standard work, we're talking about intentional activity. Look at your workflow. Look at the steps. Do they make sense? One of my favorite quotes is, just because we've always done it this way doesn't mean it isn't stupid. And there are a lot of things that we do that we do out of habit, and we haven't looked at them intentionally and said, exactly why do we do that again? And especially in the conversion from paper to computers, there's a lot of redundancy that still exists there that no one's ever flushed out because we've always done it that way. And this is the one item that I hear routinely, and it's frightening, but at the same time it's great to hear people talk about it. It's a miracle more things don't go wrong around here. And when you look around, you find silly things. The Office of Access Management, the door is locked. Place deliveries here, right over the trash can. If you look around and you're intentional, you see problems. So what we're going to target is unsmooth flow. What's unsmooth flow? Anything that's ambiguous, anything that requires our colleagues to go back and redo or refine or take a guess, which happens frequently. Anything that's overloaded, too much activity for the workflow, under-resourced. Multitasking is one of my favorites. Multitasking, in a lot of people's view, is a wonderful asset. I'm a great multitasker. No, you're not. Nobody multitasks. All you're doing is, you're very good at reprioritizing and shifting in and out, but there's no such thing as multitasking, in our strategy. And where individual work style is the norm. We want less John Wayne and more Texas Rangers. We don't want individual work style as the standard practice. So what's in it for you? Or what's in it for your colleagues? Well, ultimately, if we do this right, we're going to reduce interruptions, we're going to reduce rework, we're going to reduce multitasking, and we should have a more reliable work day. We should have more reliable performance of our individual team members. We're going to have a much greater sense of teamwork and communication across the team, because fundamentally, as Ella pointed out, with the five-minute huddles, that's a fundamental part of making sure everybody's on the same page. We want to be in the zone. We want to be doing our work without being pelted with random BBs from unknown locations. And we want to have time for outliers. This is health care. We're taking care of patients. They are unpredictable. Quality killers, my lean don'ts. Here's a good bottom-line example of a really crappy project. Don't set up a project that's goal is to reduce FTE by 10%. You will not get buy-in by your colleagues. You will not get support. You will confuse the quality message with cost reduction. They are not the same thing. I think in reality, as we look at quality more and more, there's not a lot of cost reduction. There is some, but in general, we're talking about improving process, improving standard work. So do not focus on personnel reduction. Do not reward success with more work. Do not use multitasking as a strategy. And don't plan or obsess that every patient is going to be standard and every patient is going to fit into standard flow. It won't happen. Roger Resar from IHI basically says, kind of in the Pareto principle manner, 80% of patients are standard, 20% are special. So you have to have that built into your sense of workflow. It can't be so optimized that it doesn't actually fit your patients. You have to be prepared for unexpected things. Fundamentally, if you make these mistakes, you will really harm the culture. You'll really harm acceptance. We've experienced this at Mayo full bore. When we got started with process improvement and lean 10 years ago, we were making nice progress. The recession hit. All of a sudden, everything became emphasized on leased people, leased resources. And that's a really difficult message to match up with quality. And so we can't use lean as a subterfuge for personnel reduction, et cetera. They're different. You've got to handle them. They have to happen, but they're different. All right, the core lean principles. Remember, follow the dotted lines. Smooth standardized workflow, which you get to by elimination of waste. Waste is anything that really doesn't need to be done and anything that if the customer was watching you do your work, they would say, I'm not paying for that. That's waste. Non-value added processes. People are not waste. I'm going to go back to that again. People are not waste. So again, this is not about right sizing your workforce. It's about elimination of the processes that make your employees, make your coworkers inefficient. And respect for the team. You have incredibly talented knowledge workers, and the team is the key to your success. Tools are great. We can talk about tools, and I'm actually trying really hard not to talk about any tools in this half hour, but ultimately it's about culture, it's about relationships, and it's about smooth flow. So what do we mean by smooth flow, and what do we mean by looking at processes in this fashion? Well, step number one is you want to look at the process from end to end. If you just look at your piece, if you just look at the piece of the leadoff person in that relay, you don't have an adequate sense of what we're trying to improve. You need to look at it from well before you do your piece to well after you do your piece, and you have to understand the pieces in between. You don't have to know them in incredibly fine detail, but you have to know, again, you're the leadoff person. How is the handoff going to occur? What's your piece of it? You can adapt on the fly if circumstances change, but you still have to make the good handoff, and you have to support the next person in line. We're going to map patient and information flow, and they don't flow together. It would be nice if it does, but it doesn't. And so you've got patient flow, and then you've got information flow. Each one of those requires the same expert handling and expert handoffs to be effective. And we want to emphasize something called first-time quality. First-time quality, in my point of view at least, is when I get done with my part, is every item there that the next person needs to do their part? Not 4 out of 5, 3 out of 5, I don't really care, they can figure out the other part, but rather I know what they need, I'm going to give them what they need. That's first-time quality. And you can look at it exclusively at the tail end as the ultimate product, but really first-time quality exists anytime there's a handoff. Are you handing off the critical information to the next piece? Are you minimizing rework? So this is just a very high-level, important really in the detail diagram of our MRI flow. And our fundamental principle here is respecting the patient's time and situation. So we're talking about our customer, and we're talking about what satisfies our customer. We have to be respectful of their time and their individual circumstances. And the process has to be designed to deal with both of those things. And so as we look at it, it doesn't have to be real fancy. We're just looking at the basic patient steps, we're looking at the places where they pause and sit, and then we sit back and look, and we look at how we can perhaps streamline and improve that process. The classic situation is, and I think the physicians in the room are probably the most likely to fall into this trap, is we look at this process and we say, I know where the problem is, and it's right here! For every simple question, there is an answer that is simple, neat, and wrong. And we tend to fall in that quickly because we are diagnosticians. We want one answer. Here's an example of that. So in my practice in MRI, we probably redesigned the IV start area three or four times because we were all convinced that that was where the delay was. And it took our patients an hour and 20 minutes to have an MR scan because of the IV start. That's not where it was. The IV start time was six minutes. The problem was we were warehousing our patients in subweights where they were sitting by themselves on the order of 20 minutes at a pop because they were in line so that the machine was ready. We were optimizing the machine, not optimizing our patient. So we got rid of subweights. We redesigned the space. The patient now goes in much more of a one-piece flow, and our patients are happier, and the time they spend with us is substantially less. Again, it's a relay, but it's not a race. Information flows. Patients flow. They have their own processes. They have their own unique sets of handoffs, and we have to pay attention to all of them. Standard work. Standard work is not, again, proscriptive. Standard work is more concepts and guidelines, and if you had the perfect patient, this is how they would flow, but the individual expert knows they have to adapt on the fly and do what is important for that patient. But you want to really be sure you understand what does the handoff zone look like? What is the standard expectation of that baton handoff? And each one of them is going to be a little different to be successful carrying the baton across the finish line. It's also continuous improvement when you approach outcomes. We're going to specify how the work is going to get done in a perfect situation, but our experts are going to deal with it on the fly. They're going to make a perfect handoff, and our team is going to be successful. Once you have that in mind, you can then loop back around and review, revise, and repeat, and the team works together on that. They work together on what can be improved and how it can be improved. So as far as outcomes, we're looking at experts working in standard processes, using their unique knowledge and ability to take care of our patients while adapting on the fly. We want seamless transitions. We want first-time quality. We need to understand that there are very few big bangs here. There are lots of ah-ha moments, little small things, but there are very few explosive changes that you'll find. And that's okay. That's the way it works. It's continuous improvement. I could do a half-hour rant on metrics, but I'll spare you. Choose your metrics carefully. Metrics that you use to measure your workflow are not necessarily the metrics you'll use on the back end to control it. I think, at least at the starting position, you want to be looking at the percent first-time quality, how often the handoffs occur, how often, how many of the four things that I need did I get each time, and customer and team satisfaction. Be very wary of time and money. Time and money becomes a sense of speed and hurrying, and expenses are not the point. Expenses, cost containment, less people, you can see where that path goes. Try to stay away from those metrics. They can be, they're important. I wouldn't be Pollyanna enough to say they're not important, but they are not overarching. So we're going to change directions a little bit, and we're going to talk about training for lean. So I want to get you to think a little bit about how and why you might put a lean program into your institution or in your practice. And the challenge is to convince your department or your team that they need to do this or a similar process. So I'm going to take you through really an approach to training. In a world of limited resources, we're going to have to increase the value of services we're providing, but we're going to have to do that with less resources. Most of us probably work in environments where people say you need to work smarter, not harder, but then they don't tell you how to do that. And then when you don't change your practice and you use the same resources you have in the same way, you're unsuccessful. So there are some things lean will help you with, but there are also a lot of things lean won't help you with. You have to realize that lean will not take care of the disruptive physician in your practice. It won't take someone who's unproductive and somehow make them productive. It may not change someone's bad attitude into a good attitude, and it probably won't help you if you're in a lawsuit. But there are some things lean will do, and the challenge is getting a program launched and getting people's engagement. So if you're going to try and start a lean program, you're going to have several questions that are just straight logistical questions. Who gets trained? How many people? How? Where? And I'll go through these in a little bit of detail. So one question is who should get trained? In a number of academic practices, they'll choose a single physician and send them for an extended course, a week or sometimes longer, to become the lean trained physician or the lean champion in the department. If you have a quality officer that might be a nurse or a technologist, they might be the one that is sent for lean training. You may decide that this is something that the leadership team needs to do, and then the senior leadership of your department or your practice would go and get trained. Some people would argue that middle management should be trained, because they're the ones who are probably going to lead the projects. Or others would argue that it's frontline staff, and that they should be trained. So the challenge of how many to train is really important to think about. If you're going to have only one person trained, who are they going to work with when they come back, and they have a whole new vocabulary, a whole new way of thinking, and nobody knows what they're talking about? That's a recipe for failure. That's not going to launch a lean program. If you train several people, as you've seen in earlier presentations, it is an opportunity to change culture. The training material itself is challenging. For those of us who are in education, who train people who are from multiple different generations, everybody learns at a different pace and in a different way. There are reading materials on lean, there's coursework and lectures, there are simulations and interactive exercises you could do. But the challenge often becomes where to do this. Do you want to have a half dozen senior physicians leave the department in the same week and go get trained in another state? Do you want to have them off campus in someplace local, eligible for multiple interruptions to be called back to the hospital? And these are all tradeoffs that you have to work through when you consider trying to launch a lean training program. I will tell you that I don't think you can learn lean from a book or a lecture. You learn lean from doing lean projects. You learn it by interacting with people, by working with the tools. You can do that somewhat in a simulation environment, but you also can do that in your practice, in your daily work. And that's really how people, I think, learn lean and how they internalize it and how you change culture. So one of the challenges for lean is that there are a lot of different techniques. You could actually spend days and weeks teaching people in depth how to do some of these tools and the science behind them. And that's probably not necessary and that's probably not practical. So as you're looking at your lean programs or trying to design them or implement them, choose some of the tools you think people need to have up front. Choose some of the tools they might need to be aware of and let them know that there are lots of other tools and hopefully you create enough of a thirst for knowledge in them that they're able to look for additional tools when they need them. This is a radiographics article that Johnny had put out back in 2012. It's a really good place to start for people if you're trying to explain to them what lean is or if you're just trying to review some of the techniques for yourself. So let's say that you've decided that you want to launch a lean program and you call the leadership or your partners in and you say, there is waste in our processes in radiology and healthcare. Lean is going to let us learn techniques to identify and remove waste, then we're going to go out and we're going to remove the waste and inefficiency from our practices. That's what you said. What did they hear? They might have heard the word waste and probably not much after that. They probably heard you say that they were wasteful, they were inefficient, they were doing a bad job, and everything after that they didn't hear. They heard you attack them, they heard you attack their practice and their professionalism, and they are completely turned off and not participating in the program you're about to launch that needed their help and their buy-in. When we talk about waste as people who are involved in lean, we see it as opportunity. When you talk to people outside of the lean circles and you talk about waste, they think you're talking about them and you have to really choose your words carefully. The other challenge you have with this is as you're trying to engage people, you're going to have to convince them that this is something that isn't going to cost them their job. When we did our lean training in our institution, we began by telling people that we had more work than we could do and we needed everybody who was here. We weren't getting rid of any people. We were trying to get them to do things that were more valuable than the things that were wasting their time. We took the ownership that there were badly designed processes. That was our fault. What we were trying to do was get them to help us redesign the processes so they could do things that were more important. You really have to sell to people that this isn't so that you can get rid of the two senior partners or the two junior members of the group or that you're not going to downsize staff. Otherwise, you won't have any buy-in. There are a lot of lean consultants, some of you who've probably had the opportunity to work with them, who will pitch lean to the hospital administration as a way to downsize staff. If you haven't had that perspective, the technologists that you work with probably have already heard about that. They've heard lean is a way to get less technologists and less nurses. They're worried about their jobs as soon as you say lean. They don't hear anything else after that. That's going to be one of the challenges to launching a program. One of the other things is if you're trying to teach someone or convince them to be part and to get engaged in a lean program, you want to show them. You don't want to tell them why this is important. If you use examples inside of radiology, it's too close, it's too personal, and again, feels like they're being attacked. Think of examples from outside of radiology. One of the ways we look at this is we say, did you watch a football game? How long was the football game? Well, you watched TV for a couple of hours. Okay, well, if there were 15-minute quarters and there were four of them, what did you do the rest of the time? If you did do things the rest of that time, were those value-added activities or were they waste? Were there some things that occurred during that cycle of the last football game you watched that you might have been willing to give away because they weren't really added value to that activity? That is not threatening to our staff. It's not threatening to our colleagues. That actually gives them a mindset that maybe there was some opportunity to get rid of something that was wasteful in the process. Let me share with you what we did. We started our journey and said we are going to train a lean champion. Then we recognized that he or she would have no one to play with when they came back. We said we're going to train three people. We looked at what it would cost us to send three people out, time out of the office, travel, hotel, tuition, et cetera. We found we could actually import a lean program. We brought the program to Augusta, Georgia. We had 18 people trained. They were off campus, but they were close to the hospital. The downside to that, one of the radiologists got paged a lot, spent a lot of time in the hallway, not as much time engaged in the process. The other people engaged in the process, we were able to compartmentalize them for the day. We also provided a variety of material. All the slides and handouts were going to be on a thumb drive. Everybody got it at the beginning. Actually, they got it in advance. We also had textbooks and other written material that was printed and available for them. We had other things that were sample templates, spreadsheets, all built out so that they could hit the ground running. All of this material was what we got ready for them as they entered the program. One of the other things that we did is we tried to decide what we thought the output of the lean program should be. A common practice would be many people will bring a small project with them to lean training. When they bring that project, that project becomes the material you're going to use for simulation. You want to improve a particular process, and that is what you'll work with on fishbone diagrams. That might be what you use for sidewalks or for value stream mapping. Each of the small groups is working on different projects that are brought by the people who are attending the program. Over the course of the program, projects start to percolate up. You have a project or several projects that look very interesting, that have matured as you've gone through several different tools. Those projects are almost competing internally to see which would be the project that the group wants to take on. It's an interesting way of building consensus around a project so that at the end of the workshop, the output of the workshop is actually a lean project that everybody who attended is engaged in and is ready to participate in that project. That's one common approach that people use. There are some other ways to do it. You can actually take those several smaller projects and continue to advance them. Rather than doing one big project, you might try and do several small projects. If you have really good project management skills and a good project management office in your institution, they can help you manage multiple simultaneous projects. If you don't have that skill set or you don't have those types of people, your projects probably will not advance as quickly. It will be hard to do multiple projects in parallel unless you have enough people to be able to support and have built up the type of infrastructure that Ella was talking about earlier where you have this occurring on a very local level. Another way that people look at this is you actually could, after your training, then begin the discussion of what project you want to tackle and just separate it completely from the workshop. You might also want to look at metrics. How would you know your training was successful? You could use attendance. You could say everybody showed up who was assigned to show up and that was a successful workshop. You could survey them and see if they thought it was valuable. You could try and find some measurement of value that resulted from the projects you were going to do, but value can be short-lived. You might have to actually look at whether it's sustainable. One approach that I like for this is I think about it as an oncology patient. I'm looking for five-year survival. If we do an improvement, we're not going to celebrate that we got it done and then stop looking at it. We want to know that that improvement is still in place and still doing what we originally intended five years from now. That's the standard work that was mentioned. That's making the changes and keeping them in place and becoming a higher reliability organization. What are some ingredients for successful training? Engagement has to be one of them. You have to engage supervisors and managers and frontline staff. This is not a top-down process. This has to be all stakeholders engaged. You're going to introduce a common vocabulary and if you don't have everybody in your organization and in your department speaking that language, you're going to have some challenges when people start to talk about waste or efficiencies and they're not all going to hear the same message. What you're really looking for is a commitment to the process. You're not looking for compliance with a single rule. You're looking to move forward without actually being terribly prescriptive about it. The approach and the philosophy we have in our institution on this is the people who are closest to the problems are closest to the solutions. As radiologists, we're probably not in the best position to determine how the technology's workflow should be done or the front desk staff should become more efficient. We can tell them what we think, but unless we're going to sit at their desk for a couple of days and actually do the work they're doing, we probably aren't going to understand the nuances and see the opportunities that they would see. If you want those types of wastes removed at that step in the organization, then you have to have engagement at that level because really the people who are closest to the problem see the solutions. If you don't engage them, they're not going to share with you the solutions they see. What we're really talking about when we talk about lean is we're talking about change. There are lots of different ways to approach change. I think that radiologists are uniquely positioned to lead change. Think about the first study that you read as a radiologist. Think about the tools that you used and think about your workflow today. Most of you probably did not on that last study you read before you flew to Chicago. You did not have a film, a light box, a multiviewer, and a bright lamp. You did not have a microphone or a cassette recorder, and there probably weren't a lot of transcriptionists that you were working with on Friday. We have experienced in our own professional careers huge transformation and huge changes. We are uniquely positioned to help the rest of medicine change and to help lead change within radiology through a lean process or other continuous quality improvement processes. Has anyone heard the term burning platform? This is a common phrase. This comes from a rather tragic story of an explosion on an oil rig. There was one man who woke up to find the oil rig was on fire, ran to the edge, saw the ocean below him, saw the oil rig behind him ready to blow up, and he jumped into the ocean. There was a burning platform and he jumped off of it. He was one of the few people that survived that explosion. When asked why he jumped, he said, if I stayed there, it was certain death. I took my odds with the uncertainty of freezing to death and drowning in the ocean. There are a number of change management people who actually will tell you this is how you get people to buy into change. You convince them there's no other alternative. This is the Viking approach. If we arrive on the shore and we're going to burn the boats so there's no place else to go except this way, we can't retreat because we burnt the retreat options. This you see in IT projects sometimes where this is the thing you have to do. There is no choice. It's essential. It's necessary. It's a crisis. That is one way to motivate people. That is motivation by fear. That will only drive people so far. If you have been in environments where burning platforms are routine, you get immune or numb to the concept that this is today's burning platform that requires some emergent change in your behavior, then you don't get engaged and you don't buy into that change management process. Peter Fuda and some other innovative change management leaders have a different perspective. They actually talk about a burning desire. If I want to convince you to go back to your institutions and put a lean program in, or if you want to go back to your institution and convince other people, you could tell them that you're getting a 10% reduction in payment. You could tell them that you have a layoff of people. You could tell them there's not enough resources and we have to do this. You could scare them and you'll get a certain amount of buy-in. You could also tell them that you have a mission. You have a value. You have a desire to actually preserve the good care you're providing and improve the care you're providing for the patients you take care of. You could reach into them and get something else, something that's a shared value or a shared passion. I'd much rather reach something in your soul that says you need to do the impossible. I'd much rather raise that army to go do a project than people who are scared and worried. This is a very different concept of transformation and a different concept of how to implement programs. I hope that's helpful for you because I think you can get a lot more people engaged if you have a common passion. For those of us in medicine, taking care of people is a pretty common passion and a common value that we share. Here's the sad part. If we're talking about process improvement and change management, 70% of the change management projects fail. They fail to actually reach the targets that they had set prospectively. If you put in a CT scanner, if you put in a PAC system, if you've put in a new information system, if you upgraded your software for your information system, did it actually do all the things it was supposed to do when it was supposed to do it in the way it was supposed to? Not a lot of projects look like that. In our industry, in our profession, failure on change management projects means bad outcomes for the patients. It means hospitals that close, physician replacement, leadership replacement, but 70% is the accepted failure rate for change management projects. Fortunately, the business literature has a list of reasons why the projects fail. Not only do we see the high failure rate, we also know why they're going to fail. Projects systematically fail to follow all of these steps. Cotter outlined this in a brilliant analysis of multiple projects that had failed in business. One of them was the sense of urgency. Another was having a coalition, a group of people who actually were going to guide this project and make sure it stayed on task and got the resources that it needed. A number of projects had no vision or they didn't communicate the vision. If you're going to lead a performance improvement project, someone other than you should know the end point. You need to over-communicate that. Everybody on the team who's involved needs to understand why this is important, what their role is, how we're going to move forward together. If you don't do that, it's probably not going to happen. You also need to have that environment where instead of having people be afraid, they're actually finding an obstacle and they want to raise it. They want to raise the obstacle so they can get resources to remove the obstacle so you can stay on track and get the mission accomplished. That's a very different environment than we're going to get this done by Monday and this is the target and everybody just keeps nodding. That's a different way of doing it. Short term wins are also important. If you run a long project, people need to see successes. They need to be convinced that that pathway is the right pathway. We unfortunately see a lot of projects where they declare victory too early and never actually complete the project or can't sustain the success because they haven't anchored it into the corporate culture. If lean and change management are journeys, journeys take time. There are distractions. People lose interest. They can't focus on these things long term. You really have to have short term wins programmed in there. They have to have continued reminders of why this is important but also see progress. Again, it has to be over communicated. Two take home points. Lean is a process improvement technique. You can use that to change culture. You can use that to change your environment. It is just a process improvement technique. It does require engagement of people. You have to realize that the projects we're going to undertake, most of them are probably going to fail for predictable reasons. If you start to incorporate those checklists and tools that identify those steps into your process, you're more likely to actually get your project completed successfully. We're going to talk a little bit more about change management and employee engagement in the era of lean. Change management is an interesting topic. It's something that people don't generally like to talk about. If you talk to a group, it's like here. Half the people are yawning. They're like, I've already heard it. It's not that hard. We do this all the time at work, at my house. I used to think I was good at change management until I had teenagers. Then I realized I was terrible. It's something that is really important. It's something that we do poorly, as you heard from our previous speaker. What we're going to talk about today is a little bit of a commonly known structure for change management and how this would look like in radiology. Change is inevitable. It's difficult. It's not always bad. Often change is very good. It's an opportunity. As leaders in radiology, you have to realize that you can't change people. They're going to make the choice to change, but you can provide an environment and you can encourage them to make that choice. Communication is going to be critical to this whole thing. There's a well-known speaker named Simon Sinek, S-I-N-E-K, on YouTube. He's kind of a TED sensation. If you haven't heard of him, it's a five-minute talk on the importance of communication and the importance of why, of communicating your vision very clearly. Leaders don't control change. They guide, shape, and influence it. Oftentimes, the most important thing you can do as a leader is to communicate and to clear the barriers for the people that work with you and for you to make the change that's necessary. What we're going to do today is we're going to look at a couple of different frameworks. The primary framework for the talk is going to be the COTR framework, of which there are eight discrete steps. So we'll kind of go through these steps and I'm going to use a radiology example. That's a real life example at our institution of how this kind of works and how it fails. And then we'll talk a little bit about emotional engagement or what I call the switch strategy based on a book by the Heath brothers that many of you may have heard of called Switch. And the important thing here is that it's critical to win the hearts and minds of the people at your institution and your environment. And it really deals in it, what I call the what's in it for me thing. Because often a lot of people are inherently selfish and if they don't see value in what they're doing and if that value doesn't appeal to their personal interest, they're not going to buy into it. And again, we're going to talk about a case-based approach and I'll set the stage later on, but basically it's around the implementation of self-edit dictation and structured dictation. So if you forget everything else, I wanted to do two take-homes, Leading Change by John Cotter, the Harvard Business School professor and Switch by Chip and Dan Heath. One of them is at Stanford, the other one's out in North Carolina. Both of these books are really, really, really kind of the, I mean, the Cotter book is kind of the quintessential change management book. If you don't have time to read them, there are also summaries that are really good on the internet and if you can't do that, you can see YouTube videos and TED Talks of less than 15 minutes that'll summarize both of them. Both very, very good. So let's talk a little bit about our case today. So this is an ongoing change management issue in diagnostic imaging at MD Anderson. So we did a recent transition from remote dictation. We were probably one of the last places in the country where people used to talk into microphones and phones and somebody off in the distance would type it and then they'd send it back to you and you'd review it. And probably about six months ago, we made a decision to transition to a nuanced product, PowerScribe 360, and so we're gonna implement. So that's gonna happen. So that part was, it's gonna happen, the transcriptionist and the remote transcription is going away, so that's gonna happen, but now how can we make this a positive change and how can we also integrate structured dictation? So that was the big thing we wanted to try to do because in academic centers and in a lot of other places, I'm sure, but especially in an academic center, I mean, my verbose dictation is an expression of my academic freedom and it's really, I mean, to infringe on that is just, you're gonna have a picket out in front of the reading room, so this was a very large culture shift to move to a structured dictation. So we're a large academic department of over 120 radiologists and like many of you, we're being asked to do more with less, so there's increasing pressure for the clinical radiologists to produce more, more work RVUs, more protocoling and the academic radiologists are also asked to produce more and there are fewer grant funding opportunities out there. So we've got this ongoing just sense of pressure in our environment. In addition, we have this importance of quality and some people understand what that means and some people aren't really sure what that means, but they hear it all the time. So we've got to somehow tie this into quality and then we just kind of have this inherent underlying old school attitude of, you know, that's not the way that we do it and we've been doing it this way since 1950 and why do we need to change? So this is a little bit of kind of what we were dealing with when we started out. So we thought, well, this would be a great opportunity to take some of this framework that we hear at these talks and see if it actually works in radiology. So these are the eight steps and we're gonna go through each one and I'll kind of explain a little bit of what this looks like in a real radiology change management example. So the first one, before we get into the Cotter, we'll also kind of dial a little bit of the Switch philosophy in. So Cotter has the eight steps while the Heath brothers in Switch, they talk about kind of a visual metaphor of a rider on an elephant and the idea is that the rider for a short period of time can direct the elephant wherever but over a long period of time, the elephant's gonna kind of go where the elephant wants to go. In the same sense, if you use fear as your sense of urgency, you can probably get people to do something for a while but ultimately, if you don't have their inherent buy-in, it's gonna go wherever they take it. So it's very important to analyze who you're trying to influence and what are the buttons that need to be pushed in order to influence them appropriately. Okay, so creating a sense of urgency. So again, we're transitioning from a voice dictation to a auto dictation and auto self-edit dictation with a structured format. So why? I mean, the key to any change management is why. We have to be very clear, why are we doing this? Why as a clinical radiologist, why should I be doing this? So we put a lot of effort into clarifying why we were doing what we were doing and how it provides benefit to everyone involved. So for the clinical radiologist, one of their biggest stressors was increasing productivity. So we explained to them very clearly and we went through this that by using a template, often when we pulled their dictations, 80% of what they said was repeated. So we could build out a template that would cut a lot of time. So it actually would increase their productivity. They would be able to sign those reports and they could easily review the prior reports because in our previous system, you would dictate Friday at four o'clock in the afternoon and then you'd spend your Saturday not cuddled up with a bathrobe in the New York Times, you'd log back in and you'd have to review all of your reports and sign them all off on the wrist. So we said, well, if you do it this way, you can sign the reports at the end of the day. And also if we use a structure, see our cases, most of our patients have had anywhere from three to 10 previous CT scans have been on multiple different therapies. So you want to determine, are they getting better, worse, all this other stuff. If you use a structured format, it's very easy to figure out exactly where that information is on the previous CT and the one before that and the one before that, as opposed to a huge block of text that you have to go digging through. So we designed the discussion very specifically for the clinical radiologists why you would want to do this. Also, this was a big deal for the referring physicians. Not only is it easy for them to see where the information that they desire, but it was an opportunity for us to engage with the referring physicians. So when we designed the liver MR template, we sat down with all the people who ordered the liver MR, including the surgeons, the hepatologists, the medical oncologists, and we could build out a structured dictation that matched their needs. So that obviously gave us a market advantage so that the patient, their patients, they would always send their patients to MD Anderson because they would get the report that they wanted as opposed to an outside imaging source. And also, this was a huge advantage for research because we didn't realize this until we got into a discussion with them. Turns out that they all have to hire a bunch of people to manually extract information from our reports. Well, if we build out the templates with discrete data elements, we can basically off the back end pull these data out of the reports and populate their own databases. So this was a very big advantage financially for the research portion of the institution. The biggest example of this was prostate MR where we had four different specialties together and we had a large NIH grant that ended up funding the construction of one of these templates such that we no longer had to manually extract all this information. So it was actually a winner all the way around. Now, for the physician scientists, again, this creates discrete data elements which are very easily searched, far more effective than a large text field with actual language processing. So now, if every single time we do a chemoembolization, we use a structured dictation, it's really simple. By the click of a button, we can pull and do a huge data search of our entire database and pull all kinds of information very, very quickly where before, we'd have to throw five residents and a fellow at it and give them six months. So again, very important for the scientists. Administration, very important. It's much easier to bill. We use a program called CodeWrite that scans the documents to help with the coding and billing. Well, if you use a structured document and a structured dictation, makes it very, very simple to bill and it's far more efficient. So again, specifically designing the why, the sense of urgency for each of the different people involved in the process. And this cannot be oversold. You're going to have to communicate it to each individual group. So we thought we had a pretty good sense of urgency and then there's a little bit of the fear factor that the future involves PQRS and PQRS is going to increase. It involves national registries, all other types of reporting, all the way from hospital compare to leapfrog to individual physician compare, all this other business. And if we don't use structured documentation, it's going to be very difficult to participate in any of these registries or some of these voluntary, various voluntary issues that have financial implications. So after we had this, where we pretty much were confident that all the different players understood why we were going to do this and what was in it for them and why it would be a good thing for them, we went on to building a guiding coalition. So what does this mean? Basically what this means is that you have to have a team that is representative of your entire department, of the entire process, of all the people that are going to be potentially affected by this change. So pick influential radiologists and they don't necessarily have to have a title. You need visionaries, you need people that can communicate, that understand what you're trying to accomplish and they can tell their friends and partners. And then you want to sell them first. So for example, we figured out who we thought the radiologists were that got it. We picked a few IT people, we brought in some of the technologists and nurses. And then what we did is we actually went across the street to Texas Children's who already had this and we showed them all of this stuff. And once they saw it, it was like a revival. They came back and they were so jazzed up about it, they started to spread the word and that was incredibly productive. And one thing I learned about that, it seems a little deceptive, but it's used all the time is influence networks. And this is something that we actually used to choose people. And some of you may or may not be familiar with an influence network and there are software available that will help to program this. But what it does is it allows, there are certain influencers within your departments or in your groups. And these are the people that connect other people. Well, it turns out that some people connect to a whole lot of people and other people don't. And so what you can do is if you can figure out who listens to who and who's connected to who, you can actually punch it into a program and you come up with one of these influence network maps and you can very strategically figure out who are the people that you need to influence. And once you figure out like, oh, I want that person and this person and this person and I need this person. Once you figure out who, that's your guiding coalition right there. So there's actually a little bit of science to this. This was very helpful because it turns out you don't have to win everybody over. You just have to win the right people over. And when you can create an influence network map like this, you can very easily determine who those people are. So you've got your guiding coalition together. This is a well thought out team. You've got technical leaders, you've got institutional, the administration, and you've got your radiologists and your visionaries. Administration is really important because any change effort requires resources. And I'm sure your institutions are much more efficient than mine, but often as a state entity, we tend to require more resources than we think we required in the beginning. So it's not uncommon for things to go over time or over budget. And if they do, then there better be somebody on the team who can write a check to keep it going. So often administration or the institutional participation on your coalition is really critical. All right, so form a strategic vision and initiative. So this is kind of where you're kind of getting into directing the rider. You're going into the hearts and minds. So you've got an idea of what you're trying to do. You've got your group together. Okay, now what does this mean? What does it mean? So we're gonna do templates. Okay, what's that mean to me? I'm a thoracic radiologist. What does this mean? So you have to get into the details of what is it that you're really gonna do and what's it gonna look like for everyone who's involved. For in our case, what is a template? Are we gonna have all templates? Are we gonna have 10 templates, 20 templates? And again, this is where radiologists as visual physicians need examples. We communicate one-on-one, we communicate through email, but what it was really, really effective in our group is to show examples. So we showed mock-ups of what the SIR quality registry looks like and what these templates look like. We used examples from other specialties. The American College of Cardiology has multiple different templates that they use for echo and for procedures and kind of what a template would look like and what kind of information you could get from a template. And then we had to determine when are we gonna use these things? Is this an all or nothing thing? Well, it turns out this was a real opportunity for flexibility because a top-down approach is not gonna be effective. We need to use templates. Well, are we gonna use them a lot or a little? And that's where we kind of look to our guiding coalition and some of our different groups to figure out what would be most effective. So for interventional radiology, we do a whole lot of procedures that share commonality. So templates were immediately embraced. Other areas, not so much. So some areas may use more of the structured dictation and templates than others. So then how are they gonna be created? And this is where you can gain some traction with the people involved in the process. So what we did is we actually pulled the top 10 to 20 dictations of every single subspecialty. So the abdominal imaging section, we just pulled their top 10 dictations. Interventional pulled their top 10, neuro top 10. And we told them, all right, here are your top 10. Maybe you can, as a group, come up with a structured format for this. And if they did, then we'd give them a few more and they would decide. So they designed the templates themselves. So some of them are very long, some of them are very short, but the point is it met their individual need and it allowed them to kind of create their own destiny, if you will, because they have to use it. And again, you're gonna have to get into some details, but the more you can hand this off to the individuals involved in the process, the better. So the enlist the volunteer army. Now this is motivating the elephant. So basically, how do you get the people involved in the process to now run the change? It cannot be run with your guiding coalition. It can't be your chairman or your group president just pounding a gavel down all the time saying we need to do this. At some point, people need to buy in. So how did we do this? We continued to over communicate constantly, constantly showing demonstrations of what we're doing. And strategic communication is really important and it goes back to that influence network. Again, you don't have to win everybody, but you have to win certain people. So what you wanted to do, what we decided to do is focus on specific influential individuals and get a lot of interaction with them and then they could work within their small social circle to engage more people. Radiologists, again, very, very visual. So we had a lot of templates built out. We had demonstrations to show how this would potentially work. We got a lot of feedback. And then we engaged our customer. And as Dr. Krekke talked about earlier, you're not the customer. So we brought in GU Medical Oncology. They were very involved. They wanted to be part of this MR prostate template. And then once everybody else found out that GU was involved, we had a line of people. The neurosurgeons wanted to be involved, the orthopods, the medical oncologists. Everybody wanted to be involved because they're subjected to our reports. And I use that word subjected because that's what they tell us. They get it and some of them they hate and some of them they love. So why can't they be involved? And this was a great opportunity for them to help design what the reports would look like. So part of Leadership 101, removing barriers. As a physician leader, you're not the one that's gonna make the change. You're gonna engage people to make the change, but you need to enable them by removing barriers. And these can be anything from financial barriers to institutional support. And again, this is the importance of having administration on board with this is if you need more resources or if physicians need to be taken offline to be engaged in that type of stuff. The other thing, this was a little bit of an IT project. So it's critically important to have adequate IT resources. So when the template started to be built, of course, some of them are gonna be wrong. Nothing ever works correctly. So you have to prepare for failure from the beginning. So the importance is that you've gotta make sure that you can fix things quickly. Because if you can't, it allows the naysayers to get in there and start chirping. So you wanna make sure that you've got plenty of support to move things along quickly. Generating short-term wins. This is a key deal, key deal, because this gets the what's-in-it-for-me strategy. So what's the rock in your shoe? What's the biggest hassle of your day? And so we thought about this and we got different groups together. And for one group, it was the portable chest X-ray. I mean, nobody goes to work and says, well, I just can't wait to bust out 50 portables today. That is so rewarding. And so what we did is we really worked on the templates and on the workflow and we made that really easy. And then pretty quickly, we went over the thoracic section. And then it's commonly performed procedures. I'm an interventional radiologist. We do 5,000 image-guided biopsies. And the format is, I mean, for me to sit there and dictate for five minutes a lung biopsy that was just like the last lung biopsy is torture. So we built out all these templates, made it a whole lot easier. Then we had administrative problems with billing. So we got the administrators in there with all the coding people and we made sure that worked. And then the same thing with the PQRS and the registry. We're a large participant in the ACR dose registries. We're involved in the SIR registry. So when you can win over that small group, then all of a sudden, you're getting more people on your side. But those are easy things to do that show some success and will help people engage more into your entire process of change. So sustained acceleration. Prepare for failure from the beginning. 70%, as you heard, 70% of change efforts fail. So something about your effort is going to fail. And you've gotta figure out what's the highest likelihood of failure, what things are probably gonna fail, and then from the beginning, try to design around them. And we've been involved in enough IT projects to know that something always breaks. It never works the way it's supposed to. There are always glitches. And so that's where we made sure that we had plenty of IT resources from the beginning so that when the build was delayed or the templates didn't work or the dictation system broke, that we could fix it very, very quickly. Also, we did a lot of positive feedback very quickly. Departmental leadership. If you have individuals or groups that have done incredibly well, recognize them quickly. And by recognizing them, obviously, they'll engage further. Open-door communication. We had lots of opportunities for discussion, both face-to-face discussions, town hall meetings, online chats, the whole thing. Communication is just paramount in these type of efforts. Instituting change. This is kind of the whole hardwire it into culture because far too often we do large changes and then we move on to the next shiny object and that change effort kind of disappears. So we need to make efforts to build these changes into our culture and we can, with an IT build, that's at times a little bit easier because you can build the templates in and you can essentially encourage people, almost force them into using certain things, but you can also incentivize people. So we decided we didn't really want to force people into using things, but we would just incentivize them. We had reports of transparency, so we looked at people's turnaround times and we also linked it to faculty recognition and then the big winner was referring physician feedback. When the radiologist realizes that their turnaround time is slow and that the referring physicians do not like their reports, it's amazing how fast they'll change. And then sometimes, frankly, you have to have the difficult conversation to a person who just refuses to change. At times you can coach them and if necessary, you can coach them out of your organization. So in conclusion, change is difficult. I think it's a real opportunity for many things in your organization to be spun in a positive way and people will resist it. It's just human nature. Oftentimes people are comfortable where they are and they don't want to go anywhere different. Both Cotter and the Heath brothers provide some pretty good ideas and good structure, but please don't underestimate the difficulty of this or the value of indirect influence. So again, if you can find the right people to influence, it makes it a lot easier. And also always consider the what's in it for me, that the bottom line with physicians is that no physician wants to provide poor care and if you can link your change effort to better patient care, you'll often get a lot of physicians on board really quickly.

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