I'm going to tell you a bit about my story and how my journey in terms of becoming a QI leader and then developing a QI leader. And if you see this little sign, this is something you may want to remember for your SAMS question. So this is an image of our new hospitals and new facilities at Stanford. This is Lucille Packard Children's Hospital, and this is the new adult medical center. This was opened just a couple of weeks ago, now a large, beautiful facility. And what this represents really is growth in our department. And I know that there's been growth around the country in imaging, especially if you look at the number of trainees that have in the job market that exists. And we are now dealing with that growth. So in our department specifically, our chair, Sam Gambir, looked at the department and its explosive growth. And he had about 25 to 30 people reporting directly to him. And it just didn't make sense to continue with that arrangement. So this was my role as an associate chair for performance improvement. And so Dr. Gambir rearranged the department where the clinical division chiefs and the associate chairs and directors now report up through the vice chair, which is my role. And then all of the research apparatus, the division chiefs and associate chairs and directors on the research side report up through our research vice chair. So now there are two individuals who have come into the role. One focuses on the clinical performance improvement, we call it, more on the physician side, and one on the hospital side, we call that the quality improvement side. So what we're looking at is I now made a transition from really being in a support role as an associate chair for quality improvement to more in-line authority, where I write the performance evaluations of the division chiefs who write the performance evaluations of the staff radiologists. And so that has, and now my job is a leader over the quality improvement associate chairs. And so that has changed my perspective, certainly. So back when I was a young, energetic quality improvement leader, I kept thinking, well, these are the things I need from my organizational leader. And now as an older, wiser organizational leader who doesn't get nearly enough exercise, I now think, well, this is what I need from my quality leader. And now I look at, okay, let's look at both perspectives, and I thought it would be valuable to share with you kind of how I see that. So what do we even mean by the quality leader? When we start with the basic question of what do we even mean, what is quality? And the way we define it at Stanford is essentially it's consistent, excellent performance. So that may be clinical quality, it may be patient referring, clinician experience, efficiency, physician, staff, wellness. It's basically in some way that we want to perform well that we can do that on a consistent basis. So who is responsible for quality? And of course, the answer is everyone is responsible for quality, but that's not sufficient because if everyone's responsible for quality, then no one's responsible for quality if we just leave it at that. So the way that we look at it is really it's led, everyone is responsible, but it's led by the organizational leader. So ultimately, it's the responsibility of the organizational leader, but supported and with specific initiatives led by the quality leader. So that's how we view it. So there are two major aspects. There's quality assurance and there's performance improvement. There's a bit of overlap, but in general, we can think about it kind of two ends of the spectrum. When we think about quality assurance, we think of things like equipment QA and QC, MRI safety, contrast reaction management, some policies, image quality, compliance, modality certification, peer review. So all these things that you just got to do. But then there's the other end of the spectrum, and that's things like how do you improve your organization, like improvement projects or improving your workflows, active daily management, daily management systems, performance metrics, training programs, technologist coaching, peer learning. And then there are some that are in between, that there's some overlap. Many of our IT projects fall in that category, other policies, QI education, QI committees. And so if you look at the spectrum here, really what you're moving on the spectrum is from an exercise in administration, more towards management, more towards leadership, where we're talking about organizational change. And the answer is I need all of these things from a QI leader. So again, we see this, there are these two categories of line authority and support teams. And if I think about what do I need from each? So if I need from, as an organizational leader, from my improvement leader, first of all, I need them to understand improvement strategies. But the organizational leader also needs to understand improvement strategies and improvement methods to a certain degree, especially from a higher level perspective. The organizational leader really needs to have a vision and then share the vision. So I bring this as an example. Does anyone know who this photographer is? Ansel Adams. Ansel Adams. That's exactly right. Yeah. And what, does anyone know what valley this is? Yosemite Valley. Yosemite Valley. Uh-huh. Yeah. So this is, Ansel Adams basically, along with many others in his generation, through these magnificent images, captured a vision of the American, especially the West, but the wild areas of the United States that people had no idea about until they saw it, really rallying support for preservation of these important landmarks. And so if you look at it, so I showed you the images of these medical centers, but if you look closely, these are actually, these are artist's renditions. These were done before the medical centers were ever built, but we had a very clear idea of where we were going, very specific, and it was beautiful, and it was exciting, and we worked for many years towards it. So that's really what we should be doing when we're in, as a leader or as a quality improvement leader, but especially as a leader, we should be able to take the, create this vision based on our values and then structure that into priorities and then goals and then projects that now, in a concrete way, we march towards that vision. So we view it as the organizational leader's role is to maintain and articulate the vision, but they're not the only one to come up with a vision. We shouldn't just look to our leader to say, okay, tell us what our vision is. That is something that everyone should contribute to. We should all contribute to that vision. So then if I look to my improvement leader, I would like them to understand the vision, support that vision, and really now contribute meaningfully to that vision. Then the organizational leader should lead the transformation and provision the transformation. If we want to be a different place, that's what improvement is all about, then we need to make it happen and give the resources to make it happen. And then the improvement leader is the one who really can help bring about that transformation. So if I'm an improvement leader, I'm going to ask my organizational leader, you need to invest in me. You need to protect my time. You need to provide leadership, support for leadership development, and support my projects that I'm focusing on, my initiatives. And if I'm the organizational leader, I say to the improvement leader, fine, great, we'll do it. But you know what? You've got to study. Study like crazy. And I'm going to show you why. There's a lot to learn. You've got to do it well. If you're telling everybody else to do something well, then you better start with yourself and you better take this seriously. So get the training you need. Find other improvement leaders and learn from them. Spend time observing. Respect the people who are doing the work. Get to know them and their processes. Get started on a few improvement projects. Set up programs so that it's reproducible and really support other people's improvement efforts rather than just your own. So does anyone know who this individual is? We generally don't see him at this age. This is W. Edwards Deming, really kind of the founder of modern quality improvement methodology. And he talked about four domains of improvement skill. He called it profound knowledge, a system of profound knowledge. And he talks about that these are, these categories are systematic development of knowledge, data and variation, psychology and sociology, and systems thinking. And so I would add to that project and task execution. So this is what I need from my improvement leader. My improvement leader needs to essentially become a reasonable design engineer, a statistician, an organizational designer, a systems manager, and a project manager. So all of these have a defined methodology and skill set associated with it. So they need to learn all of these to some extent. So I'm going to walk through each of those. So touching on systematic development of knowledge. So this is really where we come up with the PDSA cycle, the Plan, Do, Study, Act cycle. But it's more than that. It's how can we come with no idea of what's going on to go investigate a problem that generates some understanding. We come up with ideas for solutions. But those solutions aren't going to work at first. And that's OK. So we experiment with them. We come up with a model. And we test that model. And then we prototype that model. And eventually, we implement that model. And then we have a new process that's been implemented. And we need to make sure we can control it, that it stays effective, and we have sustained improvement over time. So if we think about it, then a lot of what we talk about is this generation of knowledge from it goes from just individual opinions, often uninformed opinions. But that's OK. It's a place to start. And then you go and investigate more. And you have these individual mental models that form in our minds that then you discuss it with others and come up with shared mental models, and then documented models, and then guidelines, and then protocols, and then algorithms. So if we think about AI, really a lot of what we're talking about, believe it or not, is AI can translate our individual mental models or our shared mental models into a concrete algorithm, which is why it incorporates biases and other undesirable effects as well as desirable effects. So that's what we need to be able to do in a systematic way when we're trying to improve a process. We need to understand data and variation. So can we translate amorphous performance elements into a measure? So if you haven't read Douglas Hubbard's book called How to Measure Anything, I do recommend it, at least the first half of the book. And he defines a measure as a quantitative reduction in uncertainty. So if you don't know how to measure something, well, find something that reduces your uncertainty, and that's a form of a measure. And those measures can be refined over time. You need to be able to extract data from relational databases. You need to be able to create and interpret run charts and control charts. And then you need to be able to automate the data extraction, process it, and display it in a way that is meaningful and helpful for individuals. So this is another major skill set that improvement leaders need. The third domain, psychology and sociology. Essentially we need to understand how change works and how it doesn't work, human psychology and human sociology. So this was actually a figure that was put on the cover of AJR a couple years ago, looking at the concept of if these represent individual teams. For example, this may be a radiologist and a technologist, an administrator, an IT professional. I'm not pointing at the screen, sorry about that. So these individuals basically represent the radiology team, and these individuals, let's say, represent an emergency department team. Well, we need to be able to work together effectively as a team, but we also need to be able to work across teams as colleagues in different areas, and then we need to be able to work with our own colleagues who are our peers and support each other in an effective way. And these are different skill sets. They require a level of understanding that isn't intuitive. It is based on this concept of social identity, of how individuals adhere to other people within their group and how they relate to others outside of their group. It's focused on these concepts of teamwork, collaboration, and collegiality. There's an important element of fair process. So when you decide you're going to do something different, how are people incorporated into that decision? And then incentives. Incentives can be very powerful. Often they're used, honestly, not well, and they can be extremely damaging. So you've got to be very careful about that. So this is a skill set that the improvement leader needs to develop and requires a lot of time and study to develop that. The fourth category is systems thinking, and this is difficult to define, but really it's understanding that we don't live and work in an island. We are surrounded and incorporated into a very complex system in whatever health system we're in. So we need to be able to understand how processes link together in a complex organization, be able to see the big picture, and watch out for unintended consequences. There's a concept of organizational learning. If something is learned in one part of the organization, can it be learned across the organization and over time? And a lot of it is diplomacy between competing units. How do we work towards global optimization rather than local sub-optimization? And then finally, project and task execution. We need people who can see a problem, scope it out, and turn it into a project, recognize what tasks need to be done and who needs to do it, do a stakeholder analysis to see how it's going to affect each individual, come up with a timeline with milestones and deliverables, and then execute, along with project tracking, follow-up, coordination, recalibration, and communication. So again, there's a whole field of study around project management, and this is a skill that an improvement leader needs to have. So when I think of what is needed on both sides, the improvement leader, this is a lot to do, and this can disrupt the organization. So as an improvement leader, I'm going to need my organizational leader to engage with me, to meet with me on a regular basis, provide resources as needed, provide guidance, and share pertinent information, including data. They need to trust me. And I, as an organizational leader, look to the improvement leader and say, you need to earn that trust. So you ask for needed resources when you need them, but I'm going to expect a plan. Don't just say, I need more people. Have a specific strategy and a plan. Expect I'm going to give you feedback and redirection, and that's okay, because this is going to be a dialogue. Be open and honest with me, and give me bad news, and give me bad news early. Don't be afraid of that, because I need to know that so that we can have an honest dialogue. I need to keep confidences strictly. You can do a lot of damage as an improvement leader because of the sensitive information that we have. One thing that we commonly say in our improvement group, show, don't tell. If you've got data, don't tell me about the data. Show me the data. If there's information that you have, or if you come to a conclusion, walk me through it with the information that you have. Don't just talk to me about it. I need you to anticipate problems beforehand. Know what's coming down the pike, how things can go sideways, and then mitigate them. I need you to execute and follow through and be true to your word. And finally, I need you to be patient, because change doesn't happen immediately. So learn from your mistakes and improve over time. So the model that we use, at least we work towards, is this concept articulated by General Stanley McChrystal in the book, Team of Teams. It's this concept of eyes on, hands off. So I, as an organizational leader, am going to be watching very carefully, but I'm going to try to intervene as little as possible. But we need to have that visibility, and I'll perhaps provide gentle nudges. I'll provide coaching and mentoring. I'm going to provide you with a platform, and I'm going to give you time in front of people in the radiology department. But if I give you that time, you need to utilize it really well and give a compelling story to motivate people. I'm going to pave the way ahead of you, and you won't even have any idea that I'm doing this. I'm going to be working with other leaders in the organization, making things easier for you, removing obstacles. And then you're going to create ripples, and I'm going to come behind, and I'm going to smooth over those ripples. I'm going to help smooth that conflict. So as an improvement leader, I expect you to build a team and build a program. So you need someone who can do data. You need to incorporate effective QI methods. You need to cover the QA, the policies, the safety, and you need to lead QI training in the department. I need you to be a role model. I need you to be the one who is demonstrating and modeling the behavior that you're trying to promote. You need to be the one who's teaching quality improvement with enthusiasm, and you need to empower others to improve. So if you're successful, at the end of the day, the organizational leader ends up grooming a new organizational leader from that improvement leader. And if you're successful as an improvement leader, then the improvement leader grooms new improvement leaders from the members of the department. And both end up improving and building improvement capability in the department, meaning that we as an organization, if we want to be better at something, we know how to do it, because we have a true and tried process that we've used before. So this is real. These are the selfies that we take after each of our class. We have more of these. You can see how my forehead ages over time. I'm the one with the longest arm, so I take the selfie. But you look at the smiles on these people's faces, and if we structure it right, then improvement, as hard as it is, is extremely satisfying and even joyful, because it allows us to make change in the organization that seemed impossible before. But it requires organizational leaders and improvement leaders that can make that possible for the individuals. So really, at the end of the day, if I'm doing this correctly, I, as an organization, will see that my main responsibility is to develop people. And I, as a quality leader, realize that my main responsibility is also to develop people. Thank you. I'll admit that probably this talk could be more aptly titled, How to Not Mess Up When You're Starting a Quality and Safety Program. Or it could be entitled, Please, Please Don't Make the Same Mistakes I Did. Though, in the spirit of full disclosure, I did not make every mistake I'm about to present to you. They are crowdsourced from other quality and safety leaders as well. Now, let's just imagine for a moment that you've been given the job of your dreams. Or maybe it's the job of your nightmares. But either way, you've been confidently told, your chair, that you now, as the lead for quality and safety in the department, are going to take the job, and it's going to be well done. And now, you just have to figure out how to do it. So you get to work, and you start to realize just everything that you need to do. And what you suspected becomes clear that starting or reworking a quality and safety program is really a complex job. And it's not straightforward. There are a lot of challenges that are going to trip you up along the way, and a lot of them you're not going to expect. So I'm going to share with you some hard-learned lessons that I learned and that my other colleagues have learned when you're getting a program started. Some of these are my thoughts. Some come from the other authors of a paper that we've written in Radiographics on this topic. So in 20 minutes, I can't share everything, but I encourage you to check out that article if you want more details. So you're tasked with building the program that fits your department. But I'm here to tell you that if you lack understanding of the history and the baseline and status of quality and safety in your department, that you might end up developing misdirected and unwelcome program initiatives. I'm going to give you a personal example. When I first started in my position, one of the first initiatives that I pursued was to try to increase the sharing of errors among our colleagues. It seemed like this was probably the most effective way to try to improve our clinical work. So I spoke to my chair, I spoke to the chief medical officer, I spoke to the patient safety officer, and that initiative aligned with their goals too. So I said, okay, we're gonna go ahead. But what I didn't understand, because honestly I didn't ask, was that in the very remote history of our department, at least anecdotally, there'd been a perception that prior leadership had saved up lists of errors to be used against people if needed. Anybody ever feel like that happens in their departments? Anybody ever feel like maybe that perception exists? So whether this is true or not, I won't know because I wasn't there, but it doesn't matter because that was the institutional memory that had persisted. So when I jumped in and I started talking about sharing errors and identifying what we were doing wrong, people were immediately suspicious of the intent, and my road was initially quite rocky. So what could I have done differently? Well, instead of just talking to leadership about their visions for the future, I really had needed to understand the past. And instead of just talking to leadership, I needed to talk to my colleagues, to the technologists, to the nurses, to the administrative staff. And I needed to ask them, what was your experience of the managerial response to errors? What prior projects were useful? Which ones did you think were a waste of time? What are you worried about as I set forth on this journey to improve quality and safety? And what are your hopes for the work that I will do? So in retrospect, even though I had identified an appropriate initiative, I really hadn't gone about it the right way, and I really could have smoothed my path significantly if I had done more reconnaissance before I started. So as Confucius says, study the past if you define the future. Now, part of your job is gonna be to prevent anticipate errors. There are so many pitfalls here, but I think the most important one to address and for you to understand is that the inconsistent application of just culture can really undermine your work. Just culture, I'm sure a lot of you have heard about, it's a management philosophy which assumes that even the most highly trained professionals make mistakes and that many mistakes are the outcomes of faulty systems that we are working in. So in a just culture, human error is consoled, at-risk behavior is coached, reckless behavior is disciplined, and just cultures understand that there's extraordinary value in identifying at-risk behavior because that's where errors can be prevented. So what's the pitfall? Excuse me. The pitfall here is that if your department leadership is saying that they have the just culture, but not rigorously and consistently applying the methodology of a just culture, the reality may not be the same. And I'd argue that inconsistent application of just culture is actually more harmful than outright lack of a just culture because the inconsistency really erodes trust. So the result is that people aren't willing to share errors because they're worried about discipline and repercussions. So what can you do? There's a couple of really important steps. The first is that you need to make certain that you secure support for implementation of just culture. You can't just throw down some words in a policy that say that you have a just culture. You need to choose a program, commit to that program, train for the program, and make sure that you have the support of hospital leadership. Next, you need to practice. You don't just become a just culture overnight. It's not easy to change your approach to error. And I'll tell you, I could tell you, about a few times that my hair was on fire and my blood was boiling before I remembered that I had to go pick up my just culture algorithm to decide what really happened. I had jumped to conclusions. And so you really have to retrain how you think about error so that it's not reflexive. And just like a team sport, you need to get your team together to learn how to do this. At Lahey, I meet with our operations managers once a month and we choose a real life safety report and we run through a mock interview with a person who was involved in the safety report and then we go through the just culture algorithm together. And by practicing and practicing, we figure out how to use the algorithm and where some of the weak points are. And then finally, you need to be transparent. Your staff need to understand that the model that's being used to evaluate their errors is gonna be consistent. And once you make the decision using the algorithm, some of us actually take out the card and we walk through with the staff. This is how we came to the decision about what's gonna happen next. And as you do this, you need to be consistent and persistent. It's said that it takes three years to build a just culture but just three seconds to destroy it, right? So if the key to a just culture is that your employees can rely on being treated fairly, they need to be treated fairly consistently. The moment that you deviate that, let's just say you disciplined someone for a human error because there was a bad outcome, you're gonna break the trust that it took you years to build and you're gonna be going back to the beginning. So for those of you who are interested on how to do this, we've recently released an article on how we're doing at our institution that gives very specific case scenarios that you can use to make this a reality in your mind. So another potential pitfall, if you're using scored peer review to review random cases, you might actually not understand the extent of error in your department. Well, why is it? It turns out that when peers have to score peers, how many people are using scored peer review models in their practices? Raise your hands high. Okay, how many people are using non-scored peer review practices? Okay, so we have a smaller number. And how many people have found in their scored peer review models that you're 99% concordant? Raise your hands high. It's really hard using scored peer review models to get people to actually point out other people's errors because they're worried about the implications of their scores on their professional evaluations of their colleagues and their colleagues' careers. So what happens? Well, I'll tell you, in our institution, people skipped cases that had mistakes in them. They just decided not to score them. They weren't fully honest in their reviews. And we found that we had very few cases to learn from. So the other thing is, is how many of you find that when you're going through your multidisciplinary conference preparation that you find mistakes that people have made in the past? Raise your hands high so I can see, right? How many people find that when you're reviewing the prior for a case that you just happened to pick up that you find a mistake in the past, right? And there's a lot more of those that you're gonna find through those daily operations than you're gonna find in random peer review. So what can you do to get a better understanding of error in your clinical practice? I would suggest that you consider using a peer learning model. This model encourages identification of cases with learning opportunities, whether they're misses or perhaps they're great calls, but it doesn't involve any scoring. And our experience, as well as experience at multiple other institutions, demonstrates that peer learning significantly increases the number of cases that have been identified for learning purposes and improves morale within the department. Fortunately, now there's a lot in the literature. If you look up names like Lane Donnelly, David Larson, you're gonna, a few of the people you're seeing here, Jonathan Kreskel, you're gonna find a lot about peer learning that's gonna really help you make this transition. Now, there are a lot of pitfalls when it comes to keeping patients safe, certainly beyond a 20-minute talk. But the one I really wanna highlight for you today is the lack of engagement of frontline staff and safety efforts. How many people in this room have a QI committee in your department? Raise your hands high. How many of them have frontline technologist staff on that committee, not their managers? Right, okay. So this is what happens. We create these committees and we charge these committees with improving quality and safety, but it creates a top-down approach. And the real people, the ones who are on the front lines, the ones who are the final step between us and something bad happening to a patient aren't involved in this work. So those committees at the time, these committees, although very well-intended, often are missing a crucial component of how we improve quality and safety, and that's by elevating the skills of our frontline staff members to manage that. So what steps can you take to narrow that gap between the leadership infrastructure and the reality on the ground? Well, the first thing I would recommend that you do is you do a culture of safety survey to figure out what your reality is. This asks questions like whether staff feel like their mistakes are held against them or whether they feel mistakes lead to positive change. There's a free standardized survey on the Agency for Healthcare Research and Quality website, and you can actually even send them your results and they'll process the data for you and send it back. Next, you need to designate people on the front lines who are charged with increasing safety. At Lahey, we have a team of technologists who we call safety champions who are charged with doing high-reliability organization audits, and they help us make sure that we're prepared for the joint commission. So rather than us telling them, these are the steps that you need to take to make this happen, they do the work themselves and tell us where they need more resources to make things a reality. So these staff become the experts in their modality and can be a voice for culture of safety among their colleagues. Finally, you need to consider taking action to decrease authority gradients in your department. These exist when there's either a real or perceived differentiation of professional status amongst colleagues. For instance, one can imagine that a resident or a technologist may not be willing to engage in attending about a safety concern. That resident or technologist may fear that they're gonna look incompetent, maybe they're gonna be embarrassed, or maybe there might even be reprisal. So there are techniques that can be used to break these gradients down, and you can do either formal team training like TeamSTEPPS training, or you can work with individuals to really help them build up their language skills to teach them how to speak up in these situations. I particularly like this advocacy inquiry approach to authority gradients. I think it's pretty straightforward and easy to remember. There's a lot more to say about authority gradients, and I would just recommend to you that you look up Bettina Sievert's paper in radiology on this topic to learn a little bit more about it. So it's a lot to talk about quality and safety data. How many people of you came into your quality and safety position as a data management expert? Not one single hand in the audience, right? So we come into this job that's really data dependent, and yet a lot of us are trying to figure out how to get through. So I just want to acknowledge that we don't arrive in this position as data experts, and some of us really need to push ourselves to generate quality specific data and to figure out how to use it so that we avoid making program decisions based on assumptions or good intentions. So where do you start? This can be really intimidating, but I want to tell you there's resources out there for you. You don't have to just start creating these metrics or picking them out of thin air. You can look to the registries that are offered by our professional societies. These registries ensure that you're aware of and focusing on the data that's relevant across practices and across geographic regions. Now it's up for discussion whether the benchmarks that are set by these averages in the database should be our goals or whether we can actually do better. There's a lot of disagreement about that, but I have to tell you that even just knowing what those metrics are and what the benchmarks are is helpful. Our practice in particular has found, we just started participating in GRID and we found that it's been really useful to see how we compare to other academic practices and things like wait times, turnaround times, and other metrics of user experience. One of our most important and one of our most difficult tasks is building capacity for patient and family-centered care. I think for a lot of us this doesn't feel like an area of our expertise. We go through our residency programs which train us to interpret images and how to do procedures, but they don't really tell us how to manage patient experience. I think that that's changing now in residency programs, but for a lot of us that wasn't the case. So what happens? As a result, a lot of departments have activities and infrastructure that are focused on the technologists and the radiologists, but they're not centered on the patients. And patients stand at the sidelines, right? Uncomfortable in our care because they're not really sure where their place is in our department. I chose this cartoon specifically because it tells a story similar to an experience my friend had last October. She had a breast mass, and when she showed up for her biopsy, the check-in desk was decorated with skulls and crossbones and tombstones. Now, while that was intended to be festive for Halloween, everybody just wants to have a good time around the holidays. You can imagine that in her eyes that was a deeply unwelcome visual sight, and it really hit her hard, and she was really uncomfortable. So it just highlights that we need to see our environments and our processes through our patients' eyes. So how do you start focusing on patient and family-centered care? Now, there have been a lot of really good opportunities presented at this conference about this topic, and I'm not gonna go into details of specific projects, but what I wanna do is give you my thoughts from a program management perspective. So the first thing you have to do is you have to designate somebody to lead this. It has to be part of your program goals. It's not gonna happen by accident. It has to be explicit, and there needs to be accountability. We spend so much time fighting fires in our roles, like I just can't even tell you how many times I have to call risk management a day and how many all, you know, the MRI's broken or there's a ventilator in the magnet. I mean, there are serious things that happen that distract us from our jobs, and if this isn't part of what your program goals are with somebody who's being held accountable on a routine basis, it's gonna get pushed to the side. The second thing that you need to do is you need to find opportunities for patient voices in your practice. Some practices use press ganey surveys. We do too, but we found that they offered very limited specific and actionable items. So I'm really grateful to our operations managers who actually make certain that they stop patients in our hallways every month. They make certain that they talk to 10 patients face-to-face every month to say how was your experience and what could we have done better? Those in-person interviews have actually given us invaluable data on how we can improve our processes for our patients, and then we also ask our operations managers to sit in our waiting rooms and to go through our processes as if they were our patients so that they can start seeing it as if they were through our patients' eyes. I'd encourage you not to make this work too complicated from the start. We've all been patients, and start with what you know you would want for yourself. Think about wayfinding, check-in process, and if you start researching this topic, you're really gonna see there's a lot out there now in the radiology literature, but also in the nursing literature to support you. You may, for future purposes and questions asked, wanna know about this ADET model, which is a model that can be used to train staff to communicate better with families, acknowledge, introduce, give them the duration, explain while they're there, and thank them for allowing you to take care of them. Now, raise your hands if this task is on your plate. You have to do a job that there's not enough time, people, or expertise to do. Oh, come on, guys, really? There's more of you out there. I see, too, some people wish they had more hands, right? Just like this woman, right? So there are very few programs out there that are lucky enough to not deal with this, and this is the reality for many of us. And what happens? Well, you get limited program scope, you get stalled projects, you get incremental change, and you get loss of participant interest. And honestly, I don't know how this woman's smiling, because I find, kind of think she probably looks more like this, right? I mean, this is how a lot of us feel at the end of our day, and how do we make certain that we can get our jobs done? So first, you need to delegate, right? I was talking about this with somebody earlier today. Things like, you don't need to be the one to talk to every radiologist in your department about every error. A lot of you are in subspecialized practice, you have section heads, and those section heads can take responsibility for reviewing the cases that come out of their section and talking with their section members. Same thing for dose. You maybe have a dose management project, but that doesn't mean that you need to be the one to edit every protocol. Your section heads and other people in your practice need to take responsibility. The next thing you can also consider is developing strategic alliances to support your work. For instance, if you need help with workflow, but you can't hire a consultant, reach out to a local business school. When I was a resident at Boston University, we worked with the Boston University School of Management, and we had graduate students come in and help us with our nuclear medicine workflow. There are other opportunities out there besides skill sets that you particularly have. Also, partnering with insurance companies and vendors are other ways to get more specific, skilled support to support your work. And then finally, make certain that you just don't assume that your parent organizations aren't gonna give you resources or don't have resources. There may be resources for data management, for operations management that you weren't aware of. I found out completely by accident that we actually had team training in-house that I could call to come work with our neuro IR and our interventional radiologists, but I found that out by accident at a root cause analysis. So you have to start asking questions about resources are available for you and not make assumptions. Now finally, every person in this room, whether by title or not, is working to improve quality, and by definition, then you are leading change. Now, I'll ask you to raise your hand if you're a born leader among us. Anyone? I've got one born leader in the room, that's fantastic. I have to say, I was not a born leader. I've had to work pretty hard to get the skill sets that I need in order to create change. And there are things like how to manage crucial conversations, conflict negotiation, change management, project management that we learn over time, but it requires additional training and expertise and support, just like David Larson was just saying. So if you and your supervisor don't take specific interest in fostering your leadership skills, it might result in really ineffective program management and stagnation. So what can you do? Number one, you do an honest self-assessment. You really sit down and say, these are the things that I think I need to work on, and you ask for other people to give you input on that too. Second, you sign up for training. We're really lucky in radiology to have the Radiology Leadership Institute. We also, your organizations probably have leadership programming available that you can try to take part in. And then you need to seek mentors. It's a myth that you need just one mentor, really. I think that this has been talked about earlier in this conference. You need multiple mentors in different places for different reasons, and I'll tell you that some of my best mentors are my colleagues who have the same position that I have at other institutions, and we do a lot of peer-to-peer mentoring. And then also, I end up looking for a lot of support from non-traditional resources. I look on Twitter, I look on social media, I look in the Harvard Business Journal. I mean, that's a traditional resource. But you're seeing what I'm saying. Don't just depend on what's available to you at your institution. You really need to be proactive and increase the flow of this content to yourself. So we're out of time, and there's a lot more that could be said. And this is the article that I wrote with several colleagues from Massachusetts, both including private practices and bigger practices than mine. And so we tried to really get the spectrum of what people might need across the board. So I'd encourage you to take a look at that. Thank you. So it's probably a bit of a misnomer because it's just an operational plan in general. But I think you can use it. And the examples I'll give are how I work and lead informatics rather than quality. To do this, I like to start with a story. And stories have to start with a setting. So I'm going to take the Wayback Machine. I'm going to go back to the year 2008. And so in the year 2008, my chair is sitting next to me now, it was the Beijing Olympics. The Dark Knight was rising for the first time. There was a different presidential election and probably a different tone in politics. The financial crisis was just about to happen. And I was a young buck. And fortunately, Lane saw promise in me, hired me, and gave me leadership opportunity. And what I did, and my secret to success at that time, was work. I kept working. And I didn't stop working. And I kept trying to reach that goal. And what it turned out is that I was successful. But I was successful for, I think, two reasons. One, I provided a rudder to my team. I helped give them some direction. I showed them where we wanted to go. And then I pushed the accelerator down and pushed them forward. And that was effective for some time. But it wasn't purely effective. I was headstrong and blind with inexperience. And so that left, just like Jen, with multiple arms. I also had multiple arms and was running everywhere. And I needed multiple legs as well. And so the reality, I was flying by the seat of my pants. And while I thought I had a beautiful mind and was leading effectively, people on my team just saw gibberish. They didn't necessarily see the direction we were going. They knew that they were doing lots of work and that we were being effective. But they couldn't see our path forward and how the pieces led to the next level. And so based on the feedback that my team gave me, we started to add more organization to our planning process. And so the first year, this was in 2010, the date up at the top. So two years in, we started with just identifying, these are our projects, and told them these are our projects at a time. And how do we get from A to Z? How do we get to the end of the project? We asked them to sort of plan out where the project would go to define their goals and move forward. Over the next couple years, we made it look fancier. We had a larger operational plan. We had goals or percent that we wanted to achieve for each quarter. And the project charters became more and more detailed. We eventually built bigger scorecards. But what we were finding with this process, so while we were achieving, we were doing things at the last minute. And the people on my team still felt like they were rushing. They didn't really know where they were going. And that changed when we brought in a project manager. This was not a new hire. We gave someone a new role, gave her the power to be the project manager, let her have some training in project management, but she's not formal project manager trained. And so she helps to manage our portfolio of projects to keep us organized and to keep us moving forward. And she built similar dashboards. And behind each step or each project on the dashboard, we would have milestones, which help us to know where we are and they serve as sort of gates to pass through to know that we're on time or on target with our projects. And then there are detailed project plans that really lay out every single step of what we wanna do. Sometimes the projects are not extremely well defined at the beginning. We don't know, we can't predict every single step we're gonna do, and that's okay. As we progress closer to different milestones, the detail gets added in. And so by the end, we hope to have a well-oiled machine that's really working in concert and all the cogs are working together. So I wanted to talk a little bit about the operational planning process and it's big, bold letters. We try to keep it formal, although it's not really that formal. That's my DeLorean warming up. So before we talk about operational planning, I think it does help to have a strategic plan and to know what the difference between a strategic plan is and an operational plan. The strategic plan is something that's forward thinking. It requires a three-part assessment. It says, where are we now, where do we wanna be, and how do we get there? It should be informed by the mission and vision of your institution. The stakeholders are usually the leaders in the institution who are building the strategic plan, and that's often the highest level leaders at the institution or within your department. Operational planning is different. Operational planning, it says, based on the strategic plan, how do we get there, and how do we get it there each year? And so strategic plans happen every five to seven years, sometimes once a decade. Operational planning happens every year. It's determined by the managers, and so if our goal is to get to China, we're not gonna get to China this year, but maybe by the end of the year, we're gonna be in San Francisco. And so we're getting part of the way there. The operational plan is determined by those managers and completed by the frontline staff. It should answer four questions, what, who, when, and how much. And so what are we gonna do, who's gonna do this, when does it need to be done by, and how much money is it gonna cost to get there? This is the plan and the process that I came up with. I came up with it mostly because the steps rhyme and they get to the end and we can stepwise through. So it's accumulate, ruminate, germinate, formulate. Define, refine, assign, plan. Review, do, study, assess, and don't forget to celebrate. So we'll go through each of those steps, what it means, and I'll show in the tools we use. You can use almost any tool to do operational planning. We use some online software that's free. You can do it in office style software. It doesn't really matter. There's fancy software you could use as well. So accumulate, this happens throughout the year. And so anytime someone says we should do this, we write it down on a list. And our project manager maintains that list. Hopefully we're starting to think about more of the different ideas over time as we get closer to when we wanna kick off our operational planning process. Our fiscal year is July to June. So there's not many things added to the list in July. There's a lot of things added in April. We want to create that list of all the potential projects. Doesn't matter if we're gonna do it or not. We wanna have all of our ideas. Our goal is to be done with this really two months before the new fiscal year. And this could be any list, any document. It could be on your phone, doesn't matter. This is sort of that list, an example of that list for us. The next one is starting to ruminate. It's thinking about those different ideas and how well do they fit into the strategic plan. How is it going to help you get to where you wanna be? Sometimes there are projects that you wanna do that you just can't do because it doesn't fit into the resources that you have or the goals the institution has. And so they get marked down. There's a lot of different tools as you're ruminating and starting to even formulate the plan on how to assign if you're gonna do it or not. It relates to things like the importance of the project, the resources required, the length of time it's gonna take. Our goal during the rumination phase is to identify the high priority projects. And we do this through different meetings in our department. And so we end up, we hope to have a list like this. We color code it just to know what we're gonna do. Something green we definitely are doing. Gray is off the list. Yellow is maybe. We don't like the color red. It's too close to Ohio State and we're not Ohio State fans. I'm a Michigan fan. I have to throw that at Lane every once in a while because he reminded me how badly I got beat this weekend. The next is germinate. So we're circulating the potential projects for feedback. I ask my team for their thoughts on the potential plan. We've not assigned the tasks to anyone yet. We want everyone to think of the ideas, to think of the items on the list. Hope is that we're able to call the list or sometimes we need to revise the list. This should be happening somewhere around six weeks before the fiscal year starts. And again, this mostly happens in team meetings. But we'll often introduce the ideas and then give them time to think about it, ask for feedback offline or via email. And that can happen to anyone on the leadership team that we ask for them to give us that feedback. During this, so we've circulated the list, we want socialization. We're not really adding anything to that plan. The color is still the last column. The hope is that people are talking about the projects, thinking about the projects. We're then formulating. So this is formulating the first draft of our plan. Our goal is to have a working document of the operational plan. We're trying to make sure that it fits together, that we have enough resources, particularly people resources to be able to do this, understanding how much time things will take. We have in our mind who's gonna accomplish these projects, but we've not truly assigned them. We still have not assigned names to them because we want the team still thinking about that. And so this really happens behind the scenes in leadership team meetings. And so on this, we've added is it going to fit and how much resources. It's adding more of that matrix and formalizing it to our list. Define, so this is where we wanna define the metrics of success. We want each project to be defined and to understand what success looks like. This helps the staff to know that they are achieving what is needed for the project. Initially, when we first started doing this, we asked each team member to define their own metrics of success. And we found that they struggled with that. They knew that we had, or particularly, I had something in mind that I wanted them to accomplish, and they felt like they were trying to read my mind. And so after discussions and feedback from them, we decided to say that this is what the goal of success is, and it's negotiable, and we try to make sure it's an achievable goal. But we wanna put numbers around it, times around it. And the goal is, again, that this is happening in leadership meetings, so that the leaders on my team are talking about it. Is this something that the people can do? Do they have enough time to do it? And with the time, does that fit in with the other projects? We can't have five deadlines all happening at the same time that take multiple people resources. And then we have competition in the team for that time, and neither project gets done effectively. So we do put our metrics in. Sometimes there are multi-part goals, there's two or three steps that define success. It depends on the project. Then we are refining. And so that's when we go over the project plan with the team. We want to review the goals with them and get their feedback. This is part of buy-in. I don't want my team to feel like things are pushed on them. The goal is that they are giving us feedback and that they have a voice within the operational planning process. And that is really the main purpose of this refined step, is getting that employee engagement. And so this happens both on team meetings as well as individual one-on-one meetings with team members. And so we're taking their suggestions, that's the column that's added here, the feedback that it seems like that's too rushed of a goal or we need to dial back on percent completion, for example. Now we assign them. So until this step, we've not told anyone who's going to be doing which project. And that's because we want them thinking about all of the projects. At the assigned step, though, we do assign them. And in the background, we know who's gonna get which one. For the most part, we're trying to use, we use these projects as ways for the staff to grow. And so we've tried to find opportunities that will grow their skills. Sometimes that's advancing a skill set they already have. Sometimes it's giving them skills that they don't already have, but we think will help to open doors for them in coming years. And so this is the step where we do that. As we're assigning it, we do wanna make sure that employees on the team have, that work is distributed fairly, but fairly doesn't necessarily mean that everyone gets the same amount of work. Some people have a greater capacity for work, and sometimes that's just because of their experience. The goal, again, is to give them tasks that are appropriate for their skill set, but push them forward a little bit. And so a new employee is going to get an easier project to complete, and probably fewer projects than my most seasoned employee. And so we reveal these in a leadership meeting. And again, we have discussion around it. It doesn't necessarily just come down from up top. And so we've added the column about who the project is assigned to. It's in the middle here, so it's next to the colors at that point. Now we're asking the employees to do the work. Up until this point, it's all been happening behind the scenes, either in team meetings or from the leadership meetings. But the planning step is where the employee builds the first draft of their project plan. So I've talked about a strategic plan. I've talked about an operational plan. A project plan is something completely different. And I touched on it a little bit earlier, but that's all of the steps needed to actually complete your project. And again, it can vary quite a bit. And so depending on the complexity of the project, the project plan will be more or less detailed. That's okay. Most times that's happening in a spreadsheet application. And so this is an example of a simple project. The different colors represent different times. So quarter one, quarter two, quarter three. So this is, like I said, a relatively simple project. And this one is complex. And you'll notice that we're only seeing in about a third of the project. The scroll bar on the far side, it only goes about a third of the way down. And so this one was for a major PACS upgrade. And we have lots of testing, lots of steps that need to be accomplished. The previous one was for a more simple system, adding it in, adding a new feature to a system. We review the project plan. So the projects haven't yet started work for the most part. We're going over the project plans and the milestones, not in excruciating detail. This is before the year has started, before they've done their work. We just want to make sure that they're thinking about it the right way, that they have some of the steps planned out and making sure that they're actually thinking the project through. So this ensures that they've done that planning work. This is a little bit after the new fiscal year starts. And we go over these projects in team meetings. And so it's going through the milestones that they've identified. Mostly the milestones are the important thing. And again, that tells us how on task they are as they progress through the year. So now the do part. The do is one step and we're many steps in, but this is one where all the work happens. This can take up to a year for our projects. Some of them are very complex. Some of them don't kick off for three or four months after the year starts. But they take hours and hours of work. And we review the projects every week in team meetings, especially active projects. But most of it's happening during the day-to-day. This is the main function of what we're hoping to accomplish for the year. That's not the only thing they're doing, though. And so on my team, that means providing support, providing education, doing all of the other day-to-day type things. And really the goal, again, we want them to drive towards milestones. That tells us and tells them if they can achieve their milestones, they can achieve their project. And that's how we have it set up. So they're going through their project plan. Items get crossed off. That's when they're green. Items that are in progress here are the yellow or orange color and blue are some of those future tasks. Throughout the year, we study their projects and their progress on their projects. Usually quarterly we ask for updates that are a bit more formal. This is in part to keep the team abreast of the projects and so that everyone is aware of what's going on. Many times these are projects, like I said, they last the entire year. And so we want them to be refreshed on what's going on and what each team member is doing. And so we've had a structured format. And so the first thing we ask them to do is just give an update on what the project is and what are the goals of the project. Then we ask for their current overall project status. So is it on target? Is it behind? Or do they need help? What milestones are they working on now? And many times that's more than one milestone. Sometimes they converge at a single time. And then what's their current project updates? We ask if there are any anticipated issues, if they need help from the leadership team in breaking down barriers, or if we need to get involved to help them. And if they need any decisions. I realize that often I am the roadblock to a lot of projects, that they need my time or they need me to make a decision. and so this becomes a formal way for them to ask for that help or that decision. And so they're reviewing their project plan to come up with this presentation. As they're giving this, we assess their projects, and in the background, we are determining from the leadership team the potential for overall project success. Our goal is to help the team, but sometimes we need to help take corrective action. Sometimes we need to identify that there are barriers, even if they're afraid to ask for that help, and smash those barriers down. Sometimes we need to escalate with a vendor or with resources within the hospital. We try to do this on a stoplight style, so we hope our projects are mostly green, sometimes they're yellow, and hopefully they're never red. And again, on our project plan, those are outlined. Grays are when sometimes projects have to die, the resources change, or the needs of the department change, so they become grayed out. The blue ones are on target, and our upcoming green ones have been accomplished. And at some point, the project ends, and we've achieved our goal. It's so important to celebrate that. Our people, our staff, are working really hard. This is the entire year of work, in many cases, the major output of their work. And so we want to celebrate success. That can mean lots of things. We try to have team lunches, celebrate events throughout the year, to have parties after work. Sometimes it's just public praise, and so when we launch a project, I always make sure the email recognizes the work that they've done when we're talking about it into the department. Celebration isn't just disco balls. Sometimes it's pizza party disco with DJ cats, and so it can be a fun time. So the hope is that operational planning provides the roadmap for your department, for your teams, and helps you figure out the four questions, what, who, when, and how much. The operational planning process that I've used is illustrated here. It's in those 13 steps, with the most important one, I think, is celebrating that success. Thank you. So we've seen about being a QI leader, developing a quality and safety program, operational planning for a year. You've got all these ideas. You're going to go back to your home base or whatever and re-energize and do all these things. So what I'm going to talk about is a couple things to think about in the broader context of that, of quality, because you will have two things that are going to be part of this process. One is time. There is going to be time required to do all of these things that Drs. Larson, Broder, and Tobin talked about, and then also you'll have a tremendous story to share. So what might that look like? So I'm in private practice. I think context is important, and I also sit on the board of directors of the region's largest health system. So quality can be thought about in several different ways. It's basically, on a very simplistic level, how good something is, how bad something is. It could also involve a comparison. What is something compared to something else? We all do it, okay? We've been doing it for multiple decades. A measure of excellence, being free from defects, deficiencies, and significant variation, standardization could be thought of as quality. And then the Institute of Medicine, the degree to which health care services for individuals and populations increase the likelihood of outcomes, and the real key here is outcomes with the current knowledge. A couple more definitions, as we're talking about bringing everything together, is value-add, this concept of value, and then on top of that, we're going to add value-add. So that must be something extra, something more special, additive. And so we always have expectations. So what is something else in addition to that, especially in the current marketplace? And really what we're trying to do, even with all these programs with quality improvement and that, is we really not only are differentiating ourselves, and we have the patients at the center, but we're a competitive bunch, okay? Systems are competing with systems. Physicians are competing with physicians. And yes, we do tie money to a lot of these things. So one thing is context is very important. And from a spatial perspective, what is important in my neck of the woods, which is only just about an hour and a half east of here, is certainly markedly different from the previous speakers in their region. So everyone is in their own ecosystem. So when you talk about quality, value-add, and branding, you have to understand your local entity, and it can be markedly different. Second thing is temporal. You know, things are moving at a more rapid and rapid pace. We are now in the era of monitoring, okay? Many decades ago, it was, yes, it was the latest scanner. It was the latest technologies and all this. How much time, if you think about it now, in your entities do you spend or other people spend monitoring? And how good are we? It is no longer now just generated interpretation of a study. It is way beyond that. So things will change over time. Ten years from now, things are going to look markedly different. And then contrast, and it's kind of funny. Some of these same things are when we talk about CTs and MRs. Contrast resolution, again, different departments will have different things. The radiology department will have different quality, value-add, and branding than the cardiology department. So important to keep these in mind. So what do we mean by brand? So brand is basically everything, the information tied to a particular group, organization, or individual. That's a way to look at that. A couple of different definitions. But one of the key things when we're talking about branding is what is differentiating us from someone else? And QI programs and all that all have this, okay? Everybody's got, everyone should have a QI program, but what is our QI program? What makes us different? So differentiation is going to be a key, especially if you're going to be in competition. Let's be clear, we are in competition and there are dollars and cents tied to that. This is certainly different than marketing. So marketing would be the actions to promote, okay, whereas the brand is really all the information tied. Branding has to be something substantiative. It cannot be something relatively superficial. You can't just have hospital rooms and lots of hospital rooms. And if you're lucky, you even have beds and you've even got stairs to get to them. You've got to bring something more than just saying what you have. And certainly in this world, it seems like everyone has access to a megaphone. If not a megaphone, certainly a microphone. And if you want to be virtually present, which I know we have people virtually, you can have a virtual presence. And so it just seems the marketplace is getting more and more crowded. So when we look at branding, there's a couple things to keep in mind as you, in the context of your QI program and everything. One is what is your uniqueness, okay? Two is you're going to have to have outcomes. What it is for your particular region, your ecosystem, your immediate environment. And it can be within the broader context of some larger national guidelines and stuff. But you will need to have outcomes. One of the things is I think sometimes, and you can take this too far in the other direction, if you're spending all this time and energy, again, becoming a QI leader, developing a quality and safety program, developing an operational plan. You know what? You want to showcase the great stuff you're doing. And I think sometimes it always seems like things are expected, but maybe just take a pause and showcase. And you're going to have to do this. Do not rest on your laurels. And I'll share a quick story. So I am now on the board of directors of our region's largest health system. And would it surprise you that just less than eight years ago, this same health system was going to kick out our practice after a 100-year relationship. So keep that. If 100 years doesn't give you sweat equity, you're going to always have to continue to prove yourself. You're going to have to continue to reintroduce yourself, reintroduce your quality program, your quality initiatives. Definitely check with the market. You may have done something great. If it does not resonate with a lot of your stakeholders, from a lean perspective, one could think of that as waste on one level, even though there is benefits. So definitely get feedback. And the feedback, accept the positive and the negative. It will no longer, you will think you have done the greatest things, and it may fall on deaf ears. Do not be discouraged. Getting feedback is important for the next iteration. So that's what branding certainly should be. There certainly are some things that branding should not be. And we want to brand everything we think we have the best product, the best process, we have all this stuff. But there are a few things that we certainly want to make sure that branding is not. We don't want to make something ordinary seem extraordinary. And it seems like in this world, everything is extraordinary. But the fact of the matter is, is much of it is still ordinary. So keep that in mind as you're looking at this. You don't want to undertake either a costume or a veil or a mask or something, or don the appearance of something else. The other thing that we want to do, and it really, it's something that oftentimes we have to be careful of, and we may not even know that we're doing it, where we're trying to generate a demand for something when there really is nothing that really needs to be demanded of. Or there was never really any demand. So why should we go out and even generate more when there was none there? Oftentimes we forget about these things when we're branding because we just want to showcase and everything. And really in medicine, the bottom line is, if you're going to have a successful QI program and a QI entity, you really want to be authentic. Deliver the deliverables. There really should be no gap between what you're showcasing and what you're actually doing. And I think this becomes harder because we all think, you know, all of us feel that we're in the top 5% of health systems. We all have our ratings. We all are all there, okay? But the fact of the matter is, make sure that if you are involved in a QI program and everything, make sure it is absolutely authentic. So when we talk about branding, it is just one type of way that one can certainly innovate. There's various ways to innovate. And one of the things that I'll show you how our practice decided to innovate was we knew we were doing a lot of things. And I'll showcase all the things that we were doing, but we weren't really capturing it. But then from a branding perspective now, when people see our practice locally, they identify what our practice is now about. And it was a variation of one of the value equations, typically outcomes over cost or other things. We put our own spin on it. Basically the numerators, basically all the things that are involved other than image interpretation, those are basically the outputs. And the inputs is basically are all your waste. The time, everything will come at the cost of time and money. Do not kid yourself. All these things will come at the cost of those things. So how did we brand not only our quality, but our value? And this was the way that we decided to do it, okay? All of you do things other than interpret images if you're a radiologist. And this was our initial capture at over 30 items of things that you do that don't get paid for. So that's great. So now I have to do all these things or whatever, I'm expected to do all this more and more and more time, effort, money, and I'm not getting paid for it. But everyone tells us, all the speakers, and I'm guilty of it too, I'm going to ask you to do more. But it's important to understand these things because all the quality improvement things you're going to be doing are going to require resources. Now this is not a static list. So this was when I first published this in 2015, I updated this last year, and we've added a couple updated. We've thrown out peer review. We have now added peer learning. We've gotten rid of technologist and staff feedback, but more engagement, okay? This is a team sport. We've added physician well-being. It is part of the conversation. It is no longer now suck it up or those things. That is long gone. And then the other thing is continued practice improvement. And that is going to be the pillar for what helps your group. What does the time look like? So when you add up all those things, and my practice has now been doing this since 2013, would it surprise you, and my practice has about 35 members in it, that over last year we spent over 17,000 hours doing everything that I've showed on some of those previous slides, unrelated to billing a CPT code. So these will come at the cost. We do have it broken down by radiologist. Most of the radiologists in my practice, they are not here, so I've stripped away the names, because typically what physicians all want to do is to see where their bar is compared to everyone else. All of you do it. I know it. So but this provides context. Some people will be able to do more, will have more time to do more, but this has to be part of the conversation. Because all those activities from the three previous speakers involve most of the categories I showed, and it will come at the cost of time. So we translate this. Here's your typical work, RVU productivities. Everyone in our practice essentially gets paid the same. But then what we do, this only tells you part of the story. You have to add the value part, the yellow part on it. That's how much we're asking our members to do. So what does that look like? And not everyone is going to be the same. And the people that have low bars are typically people that either just started the practice or retired at the beginning of the year. So about 23% of everything that we do during the course of a typical year is related to, is unrelated to film interpretation, image interpretation. So all those things. So think about that. It is a massive time commitment. But you have to build this in into your workflow, into your QI programs, into your value programs. You have to have this conversation, otherwise your programs may not succeed to the extent that you would like them to succeed. So that was the time input. We certainly measure outcomes. We generate an annual report. And showcasing the story, this is now what our clients come to know as part of our brand. We share this with the CEOs and the presidents of all of our health system hospitals on an annual basis. And we do talk about outcomes. And then the quality bucket, these are some of the things that we've talked about. We've got over 30 different items. But whatever it is, showcase it. Because this will now become part of your brand. And we've been now doing this for over seven years. And you don't have to pick one activity for each of these boxes. It can be mind numbing. Look for activities that can maybe, you can hit a lot of these buckets together. And you probably are hitting and you don't even know it. And so one of the things that we did several years ago, and again, I'm in private practice. I do not have residents. We have limited research support and all those things. So this is typically, it's becoming more like everyone else. Breakfast, lunch, dinner, after hours, nights, and weekends is when you're doing a lot of these things. So we showed that, and I'm a breast imager, that we were able to tie a lot of these things together into a singular project. And we demonstrated markedly improved outcomes that reduced costs for patients. We identified breast cancers at an earlier stage. We reduced the amount of unnecessary short-term follow-up, unnecessary short-term imaging, and reduced our callback rate. But we were now, this is now becoming part of our culture. This is probably, you probably won't see slides like this too much at RSNA. But I will certainly tell you, this is probably one of the most important slides you will see at this conference. Because everything that we do, everything that you do, has to get into the hands of the people that are in leadership that are making decisions related to finances and things like that. You've got a great brand. You've got a great story that you've just spent years developing. Share the story with members of your C-suite. And share them on a regular basis. And so that is really key. And this has been talked about not only in the field of medicine, but in the world of accounting. It seems everybody wants to jump to finances. And finances are certainly important. Finances is only one of six critical areas of oversight that a health system board member has. It seems like everybody only talks about finances. But in the reality, it's only one out of six buckets. So you have to show your non-financial value and your non-financial quality. And you have to report it. Not only within your practice or within your department, showcase it outside your department. One of the greatest benefits of me being on the health system board is our hospital has an annual QI symposium. And I get to be one of the judges on there. And I'll tell you, sharing and seeing what other people are doing in your health system, it's very gratifying. So in summary, how might we sum up everything that the previous speakers have talked about and bring all this together? Because you will have a great story to share. And you want to brand it. You want to own it. And you want to certainly share it. And so a couple things to keep in mind. This will come at the cost of time. Do not kid yourself. And do not kid your leaders and everything. This will come at the cost of time. Account for the time. However you see fit in your practice. Account for that. But definitely showcase the outcomes. And the reason you want to balance the both is you have to make sure that the people understand that their outcomes do come at the cost of time, effort, and money. What is your differentiation? What is your competitive edge? We are in a competitive thing. With health care costs approaching 20% of GDP, there's going to be more competition. We may not like it. Most of us do not like it. But it is part of the reality. So how can you differentiate yourself? Definitely be authentic in your QI program. No cheating. No making things up. I mean, it's, you know, we're back to elementary school here. But again, be authentic. Have something great. But have something real. And definitely report and display. In a world of megaphones, microphones, Twitter, Facebook, Snapchat, LinkedIn, a few things that, I don't know, my teenage daughters use, I can't even pronounce some of these things. The world is a crowded place. But definitely report in your immediate ecosystem and share it. Thank you.

Quality Improvement

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Stanford Hospital

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