I am really honored to be able to kick off this talk about value and really talking about value through the patient and family members' eyes. So I first really feel that it's necessary to be able to share with all of you, kind of go through some of the terms that are thrown out. We've heard patient and family-centered care. We've heard patient-centered care. We've heard patient and family engagement. We've heard patient activation. All of these things kind of get all jumbled up together, but there's a few points that I want to make surrounding the word family. When you look at this photo, you see a group of animals that don't necessarily fit with one another on appearances, but in health care, we know that families come in many different shapes and sizes, and we have to recognize that unless we engage our families in health care, we're going to not end up with a high-quality and safe care that we are intending to provide. Family, when you think about the most vulnerable patients, those are the patients that need their families the most, the very young, the very old, and the chronically ill, and I want to start today by walking you through my family. So Jack, dad, who, pertinent to the story, happens to be a neurologist at the University of Michigan, Jessica, who just turned 22, Matthew, who just turned 20, and myself, normal family of four. I'd like to say we are a pretty functional family, a lot of love, a lot of emotion running through our home, but in one quick day, everything changed in our family. All of you, I'm sure you all remember where you were on September 11th. We all remember that. We all had those thoughts of, is the world ending, or is the world that I know ending? And that exact same thing happened to our family on a very micro level exactly 13 years ago today. 13 years ago today, I woke up knowing that my child had a brain tumor. I couldn't deny it any longer. The internet was live and well, and my husband also, you know, clearly felt the same way. We took her to the emergency department and got that dreaded diagnosis. The radiology, the scan showed that it was suspected medulloblastoma, which is what it did turn out to be. And those initial scans, you know, saying medulloblastoma, I clearly remember the neuro-oncologist and the pediatric neurosurgeon saying, this, you know, brain tumors, this is not one that gives me a pit in my stomach. And hearing those words was encouraging. It still was that point of, this was my personal 9-11, and nothing was ever going to be the same again. But to hear that it doesn't give me a pit in my stomach was definitely very encouraging. Being somewhat connected with my husband being a neurologist, we decided to send that pathology. So the radiology report said suspected medulloblastoma. The pathology report came back saying it is average risk medulloblastoma. We sent it to not one, not two, but three additional institutions to get quadruple confirmation on this diagnosis. And the first two came back saying it is average risk, but the third one came back saying something else. And I don't remember what those words were, but I remember the words very strongly in my mind, consistent with a poor prognosis. And that sent me on a spiral downward that I, it took me a while to recover from. And still to this day, I will never forget that, and looking back at some of these old records that I looked at over this past weekend, I had to stop, because it's still very hard for me to read some of these words that were on some of these reports. So as time went on, and Jessica, who is 13 years ago, 13 years from diagnosis, is getting her every three-month MRIs, then moved to every six-month MRIs, then moved to yearly MRIs. And I was very grateful that my husband, again, had these connections, because he reached out to one of our neuroradiologists, and we had the same person very consistently reading these scans over, you know, over the first several years. And these are words that came from reports that I looked at two days ago, from 2006 and 2007. No frank worrisome interval changes. No evidence for active neoplasm. Such lesions can develop into more significant findings. None show definite pathologic contrast, enhancement mass effect, or restricted diffusion. Susceptibility weighting images, again, show the same scattered areas, wah, wah, wah, wah, in my mind. But some of the words that really pop out were scary to me also. Such lesions can develop into more significant findings. What the heck does that mean? And I completely respect that radiologists have to write things in ways that are frightening, but it also brings up the point of, do we need to begin to have discussions with patient portals, because our patients do have access to this, do we need to start writing things in different language? A friend of mine whose son had medulloblastoma, had a recurrence of medulloblastoma, and just was treated, just had meningiomas removed last year. She said that when she's read the reports, she said, oh my gosh, the MRI reports described something like lighting up like a Christmas tree. So for me, when you think about the vacuum readings, and you think about the whole person patient-centered types of readings, I don't know, I'm not a radiologist, and I imagine, I know that there are benefits to both types of reads, but for me, the mother of Jessica, I really was grateful whenever our neuro-oncologist who had seen every single scan, or this neuroradiologist who had seen most of her scans, were able to think and explain to me why this lighting up like a Christmas tree was not something that they were concerned about. So moving on from my story, I want to accomplish a couple of things today. I'm going to weave stories in and out, but I also want to talk about what are the benefits to partnerships at the clinical level, at the organizational level, community and policy levels. There is room for patient and family voice at all of these levels, but today, I really am going to focus, just give you a taste of what this could look like at the direct care level and at the organizational level. So here's where I'm throwing out the word activation. That seems to be the new buzzword. We've gone from patient and family-centered care to patient and family engagement to patient and family activation. To me, engage and welcome the voice of your patients and families in everything that you say and do across the continuum. So I have activation in quotes because that does seem to be where we are moving, not just engaging people, but encouraging them to be active in their care. And a couple of studies here I just wanted to, you know, throw out so that you can pull them up and read them on your own. It really talks about how engaged patients or activated patients results in reduced risk of harm and reduced readmission rates. And we all know that that's going to, you know, come back and really help us financially in the end. We also know that when we partner with patients and families and create those relationships, they're going to be more satisfied. They're going to be more adherent to the care that's going to be necessary to help them achieve the best quality health. And they're going to be more likely to meet their needs. So the value, lots of words on this slide, basically for your information. It's a satisfaction model for patients as well as for staff. And Dr. Rawson's institution a number of years ago really showed that whenever you have a truly patient family-centered culture where you are engaging patients and families in all ways across the continuum, your staff satisfaction is very high. They had one unit that had very high turnover rate. Once they really created the change and created this culture, they had a wait list for people wanting to work on this unit. So it is a satisfaction model when it is done correctly. It's a safety model. Whenever we have a culture where we are saying people can speak up, we welcome you to speak up. And it's an outcomes model. And then when you do all of these things once again, it becomes a marketing, you know, everyone's going to want to go to your institution, everyone's going to want to have their radiology test done at your institution. So the principles of patient and family-centered care, by definition, it is planning, delivering, and evaluating health care that's grounded in mutually beneficial partnerships. So I want to make that clear also that when we're talking about patient and family-centered care, we're not talking about doing whatever the patient family says. We are a health care industry. There is nothing more valuable in this world than getting safe care. So safety is first and foremost and must be maintained. We also must recognize that this is about engaging at the direct care level as well as the institutional level. And if you remember nothing else today, I want you to remember the words with and to and for. Patient and family-centered care is what we do with our patients and families. Customer service is what we do to and for them, providing that warm blanket, providing that comfortable chair in your waiting area. But engaging them in conversation and decisions is what we're talking about when we talk about creating high reliable health care. We all know that health care is brought with huge risk. And it is an industry not unlike airline industry and nuclear power plants that there is always potential for many things, bad things to occur every second of the day. So how does patient family-centered care intersect with creating a highly reliable organization? It is by engaging the patient and the family. And looking at these three questions that are on your right, if your patients and families can answer yes to all three of those questions, you are well on your way to developing a culture that is highly reliable. We all know also that probably the worst thing that you can tell your patients and their families is to stay off the internet, because they're not going to stay off the internet. This data is pretty old, it's two years old, and that is really old in the digital world. But at this point in time, 86% of patients actually went online before they scheduled an appointment with their docs. And of those people, and actually let me share a funny little story, it's not a funny story, but it's a real story. Our dear friend of ours had a huge heart attack in May, 53 years old, LAD, his wife got him to the hospital and he survived it. So he's looking at, through the portal, looking at the radiology reports and seeing the results of these tests. And then he went online and diagnosed himself as going to die within five years, because of what he saw on the radiology reports on the portal, and then he looked up stuff online and he scared himself to death. He still stands firmly saying, I want the immediate results, I don't need someone to interpret them for me, I can go on the internet, I can look things up. But his wife is telling him, you just took probably a few years off of your life by all the worrying that you've just done, because when he actually talked to his physician, the physician talked him down from this place of, here's why I don't believe you are going to die within the next five years. So, but the reality is, is that we are going online and we need support and you need to help us figure out where it is that we need to get the best information. Shared decision making is a cycle of setting goals, providing people with decision aids so that they can know how to make the right decisions, developing care plans together that works in their lives, making sure that they understand what it is that's expected through teach-back mechanisms, and then reassessing goals, because over time we all know things change. So decision aids, absolutely, that written information makes a huge amount of difference. Some data that I saw recently, it said, so people that receive information in their physician's office don't remember 40 to 80 percent of it by the time they leave their office. And then of the information that they do remember, it's largely incorrect. So unless we were actually handing someone written documentation, we are really risking people really understanding what it is that they need to do to self-manage. We absolutely need to make sure that they are understanding what is expected of them by asking them to repeat back what it is that is expected of them to prepare for a test or whatever, you know, whatever it is. So I'm going to go through these very quickly. There are a lot of barriers that prevent us from really moving forward to these fully patient and family-centered culture. And these barriers really start with the health system, that we are fragmented. And I think everyone in here can agree that our communication and our care coordination is not as seamless as what it should and could be. There's a traditional culture of disrespect among staff and faculty that is visible to patients and families. I can't tell you, well, one time I went into a radiology, my daughter was having an MRI, and there was a miscommunication of what time her radiology test was, and the front desk was blaming the techs in the back, and the techs in the back were blaming the front desk. And that did not breed a lot of confidence and trust in my mind that they're, I'm thinking, take this off stage, argue it out in a place somewhere where I'm not. Because you can imagine how I feel with my daughter going in for an MRI, waiting to see if the cancer is coming back. Organizational leadership does not necessarily provide the resources that we need to be able to have a fully engaged culture. Our workflows, our policies are not necessarily supportive. And we all know time is one of our most valuable resources that we don't have enough of. Patient education materials are not very good. How many times do you hand something that has been copied and recopied, and you can barely read it at this point in time? So it's not memorable, it's not understandable, it's not supportive of people that are not health literate. And then we fear vulnerability, and we fear sharing and being transparent, which is what high reliability organization is all about. So we have a huge number of issues on the patient and family side, too, that are going to create barriers. And part of why I'm sharing this a little more lengthy than what I normally would share is that these are some of the things that you can go back to your institutions and begin to work on, how you can systematically begin to break down some of these barriers. Patients and families are passive recipients, many are, of health care, and they lack the information and confidence to fully engage in care. Only a small sector of the community is health literate. Normal patients, the people that need people the most, have less people available to them. People fear, I'm afraid to speak up because I'm afraid that you might not treat my loved one or me the same. My head tells me, of course you're going to, but my fear in my heart makes me afraid to speak up and say, can you wash your hands? Can you wash that port a little bit longer? Things that are going on within us because of our illnesses, because of our mental health conditions that occur from physical illness on top of it all, really reduce our ability to notice and retain certain information. And then advocacy groups out there, there's a lot of good ones and there's a lot of not so good ones, so getting people connected to the right ones is kind of tough. So speaking specifically about radiology, so you're now through patient and family culture and I know you're all in agreement that this is the direction that we need to go because this is what is going to provide value. These are my simple truths to radiology, my mom's truths to radiology. This is a team sport, including the primary provider, the specialist, the pathologist and the radiologist, and these things, these people need to match up so that we're not getting disrupted information from each other. Radiology and pathology reports are often life or death papers to the person receiving them. No news does not necessarily mean good news, and a lot of people think, well, since I didn't hear, everything must have been fine. And results can be fraught with miscommunication and breaks in communication, and our electronic health records actually hold promise as well as challenges for patients and families receiving the correct information. I'm giving a talk next week about diagnostic errors in patient and family engagement and so I threw this little stat in there. Pretty shocking, maybe not to all of you, but for me. Diagnosis errors are the most common type of error and they're the most expensive error to actually rectify. My favorite quote is from Sue Sheridan, who's the mother of a child that didn't get a diagnostic error that ended up with cerebral palsy, and her husband had an incorrect diagnosis, it was a spinal cord tumor and he ended up passing away, and she said, if bills can find us everywhere that we move, then why can't test results do the same? That's so true. There's never a problem with seeking out, you know, you owe this amount of money, but those test results we often miss out on. So the value can come in every phase of the radiology process, from preparing me for the test, to my arrival at the test, to performing the test, to you giving the results to me, and for us together determining what the next steps will be. So pre-appointment, some institutions, and again, I'm tossing out ideas for best practices. So improved efficiency, is there a way that we can do some things before we get to the appointment with a lot of these forms that need to be done? This hopefully would reduce wait times when we get there, and if you educated me adequately before I got there, this also is improving efficiency of your staff. Improving the experience, we have to engage the team. There are times when social worker, a mom shared with me one time when she got very difficult news about her son's heart, he had congenital heart disease, they pulled everyone together, including the social worker, to give her the difficult news that they needed to give. So having the team there to be able to improve the experience, and improve the outcome. And then recognizing that, this is sort of a hodgepodge thrown in here, but our families will go on social media and they will look to see where they want to get their care, and they will go then and share what is good and what is not so good about your institutions. So those experiences are out there for everyone to see, and we all know that. And then outcomes, and I really think my next couple of stories really are more about quality as opposed to clinical outcomes, but quality is an important outcome as well. So you can see Jessica and her little brother as she's going through treatment. She was pretty beaten down, 15 months of treatment, surgery, radiation, and chemotherapy. After she was through treatment, she had to have a growth hormone study. And with this growth hormone study, it meant that she had to go in in the morning, having not eaten, it's Michigan, it's winter, she has crappy veins from whatever the reasons are, she has Raynaud's, and after two and a half hours of poking and prodding her to do this test, they could not get the line into her. And the person looked at me, and up to this point, I said, I didn't say much of anything, I was there trying to comfort my daughter who, I tell you what's worse than a ranting, crying, screaming child is a child that is so tough, and then one tear slides down her face, and you know, and I said, we've got to stop, this has to end. And they said, so what do you think, do you have any ideas? And as soon as I was given permission to give an idea, I said, why can't you put a line into her at night, after she's eaten, after she's hydrated, because she still has suffered from morning vomiting from the location of her tumor, and I can flush it however many times you need me to flush it throughout the night, and we can come in at 7 in the morning, the line will be in, you can then run your test. And you know what the biggest issue became with implementing this idea? The biggest issue was, they couldn't figure out how to put this plan into the computer. And so finally, someone grabs a sticky, writes it on the sticky, and slaps it on the computer and said, you know, Jessica Parent will come in, blah, blah, blah. And it worked. So thinking out of the box is what I'm talking about here. Also, with her late day MRIs, because she still has morning vomiting, because we live in Michigan and it's cold, because her veins are really crummy, I never would schedule MRIs any time until later in the day after she's had a chance to eat and drink, and so that they can get the contrast in her, without causing too much grief for her. So the team, and this is something really important also. So this graph represents our child life specialists who worked with kids that needed anesthesia for radiation oncology, for brain tumors basically, because they needed to stay still. They're doing this type of work with VCUGs, with MRIs, so in the radiology area as well. But the data here showed that over a three year period, 36.67% of patients used sedation. Once they had Child Life prepare these kids to be able to have their radiation treatment without sedation, the very next year, 4.76% of the kids needed sedation. And they've been able to maintain this, pretty good numbers, through the data. The last data collected was 2015, with 4% of the, 4 percentage points. That is a huge drop. And think about the cost savings, and think about the quality of these kids that don't have to be NPO every day for six weeks while they're getting their neurosurgery. I also wanted to make sure that I'm clearly mentioning the importance of radiology staff. Radiology staff, the best situations are whenever I brought my daughter in, and they treated her like the little girl that she was, talking to her about her as a person, rather than just whisking her in to have this test done. There's a lot of anxiety surrounding these tests, and we watch everything. So the best staff also are the ones that, no matter what, continue to make that eye contact, continue to have a body language that's very positive. Because I am reading into everything, and if a tech came in to put in her IV and was not making contact with me, I had myself convinced they must have seen something on the scan, she's not looking at me, it's bad. It's crazy, but that's where we are in these situations. So having our techs and working with our techs and our nurses and our other staff, our clerks for entry and understanding these things are very important as well. That quote there really talks about how this mom felt a need to be there with her child, because this child needed to make sure, she needed to make sure this child was safe. As you can see by the words on here, things slipped up a bit one time, because they didn't realize that her child was as disabled as she was. So I did a quick survey with our families, asking about radiology reports and who they wanted to get the information from, and basically they said, we prefer to get it from the specialist who referred me there, and the least place we want to get it from is our portals. Portals need to be coupled with human interaction. And this you'll have, it's uploaded online, I asked them to define what value actually means to them, and value means a heck of a lot of stuff. And value means the human part of sharing the information on these test results. Thinking about when you are sharing information through the portal, you need to make sure that you're understanding with them what it is, how it is that they want to receive this information. So the platinum rule is treating others the way they want to be treated. And addressing these portal concerns. As I said before, I'm not here to say what the answers are, I'm here to encourage you to engage your patients and families in the development, the implementation, and evaluation processes of radiology, of the preparation process, of the testing process, of the sharing the information process, and coming up with ideas of what is going to work in this age of digital health where our patients and families do have information on the portals. Who on this sees a vase? Who sees two faces? Who can see both? So you usually see one versus the other first. And what we're talking about when we're talking about bringing patients and families to the table to become advisors and work with you, are those people that can share that different perspective, that can see things a little bit differently. Does anyone see a gorilla on this scan? Eighty-three or eighty-six percent of radiologists who looked at this scan looking for abnormal findings did not see the gorilla. Because that's not what they're trained to look for. But that patient in the family might just see that gorilla. So bringing them to the table to help you understand, you know, where you need to go is something that's important. Our advisors will bring their perspectives, they will bring their wisdom, they are not coming as professionals, they're coming as healthcare consumers and they are going to provide that perspective to you. You need to make sure that when you're bringing advisors that they are people that are passionate about the topic, that are able to generalize and think broadly, that are constructive. Those are the best qualities of our advisors to be able to sit at that table with you. And you need to understand that there's lots of ways that you can gain their experience, you can gain their voice, you can gain their voice from advisory councils, online surveys, panel presentations, they can be part of event reviews in radiology where there have been near misses or complete misses, and they can serve as educators. But you also need to understand that you need to teach staff how to welcome them and how to engage them effectively. So it's not just grabbing someone off the street and tossing them on a committee, it's working together. So finally, I want to share these end photos of my daughter. My daughter is a senior at the University of Michigan, she's graduating with a degree in English and Women's Studies. She studied abroad last year and you see her with her pillow somewhere in Scotland. You see her jumping off at the Louvre, I was with her on that trip. And you see her with her brother, you see her with her father just a few weeks before her 22nd birthday. I ask you all to remember the humanity behind the image and remember that every image has a name, every image has a story, and most of the images have a family that is very strongly affected by what it is, how you're changing their lives. So I want to offer you a perspective on providing value to patients as a radiologist. What I'd like to do is give you some tools to look for opportunities to provide more value. And I'm going to build on a lot of what Kelly has already said. So if you think about your workflow, you protocol studies, you interpret studies, you dictate them, you perform procedures, you work in a PAX and an EHR environment. That's the workflow of the radiologist. That's probably where we spend most of our clinical time. And when we think about the ways we bring value to patients, we talk about the diagnostic accuracy, rapid report turnaround time, communication of results, things that are tied to that workflow. But I want you to step back and look at this a little more holistically. You are a part of a much greater workflow and a much greater experience that the patient and the family actually sees. Their experience might begin long before that image is ever obtained. That experience might begin with scheduling, registration issues, education or preparation for that study. And it flows all the way through the actual performance of that exam and the interpretation out to when the report gets onto the patient portal. It might involve the training of the staff, the billing experience. That's actually a much broader workflow. And we have influence over those other steps. Rao and Lewin did a nice study looking at how radiology or radiologists as hospital-based physicians could provide added value services. They talked about patient safety, quality of images, cost containment. All of these things are things that many of us have already incorporated into our practice. But even in that practice, there are typical roles for patients. They receive care or they can be a patient in a clinical trial. There's some opportunities for us in looking at the way we interact with patients differently. So if you think about in your practice where you currently have interactions with patients and families, that may be predominantly when you do procedures. If you're an interventionalist or a breast imager or in PEDS, you probably have more interaction with patients and families than other diagnostic radiologists who spend more time interpreting the images rather than interacting with the patients around the images. So there is opportunity there. But what I really want to talk about is the opportunity to build partnerships with patients and families to improve the patient and family experience in radiology. So there are some fundamental concepts, and Kelly's talked about these, that are patient and family-centered care. None of these are earth-shattering, and they're all things if we were the patient, we would expect to be treated with respect and dignity. We'd expect people to share information, and we would want to participate and collaborate in the decision-making surrounding our own care. None of this is complex rocket science. Those of you who understand MR physics and use it every day, you should be able to understand this, and we need to think about how we implement this. So I want to start with the radiologist and work up to, from our individual behaviors up to our role in organizations. Think about you as an individual, as a human, as a radiologist. What are the things that you can do? So immediately what comes to mind for people usually when I ask that question is, what are the barriers to doing things? So you say, well, I'm not the head of my group, I'm not the hospital CEO, the technologists don't report to me, and we all have a long list of things. So I ask you, what can you do without permission or a budget? What changes can you put into place Monday without a permission or a budget? So it turns out that you can sit down when you talk to patients. If you sit down when you talk to patients, the patient perceives the time spent in the room as 40% longer. That improves patient satisfaction, compliance, it's a better interaction. And if Kelly says you add making eye contact to sitting down, you have an amazingly transformed experience and you didn't have to ask anyone's permission, you didn't need a new piece of equipment, and you didn't need a budget. That's under your control. And even if you only interact with patients once a week or once a month, making that one change for that patient is transformational for them. Sabiha Raouf, as a radiologist and a patient, decided she was going to create mad rounds. This is making a difference rounds. And you can find her full story on the Imaging 3.0 website at the ACR, where she talks about going in and talking to patients, not as a radiologist, but just as another person. The program she started was so popular that her hospital administrators didn't just mimic it, they joined it. They go with the radiologist to visit patients just to check on them, see how they're doing. No budget. One of the other really powerful things we can do is look at our vocabulary. Not just in our reports, but look at the vocabulary we use every day. If I tell you I'm going to bring you to the waiting room, I have set an expectation you're going to wait. If I tell you that I'm going to bring you to the patient lounge, I've already defined a completely different experience. So when I tell people that, they say, well, how can you remove that vocabulary, not just from yourself, but from other people? So at a staff meeting in our department, we had the entire staff chant, waiting room, over and over. And when they were done, I said, that's it. That's the last time you can ever use that phrase. Do we need to do it one more time so you can get it out of your system? The staff thought that was funny, but every time they said waiting room after that, they kind of went, hmm. And the vocabulary changed. If I invite you to be a patient representative, that's different than if I invite you to be a partner. Words, powerful, but not very costly. And you have control of your language. So what do patients want? I don't know. The only way you find out is by asking. And to do that, you have to create an environment exactly as Kelly said that they feel safe in to be able to share with you. So let's ask, why don't we ask the patients? Think about that. Why don't you ask the patients if there's anything else you could do for them? Why don't you ask them if you could help them with anything? Because we are terrified that they might ask for something we can't do. We're terrified they'll ask for something that will take a lot of time. And that's okay to be afraid. But if you take this out-of-patient and family-centered care and you put this into the clinical setting into your normal workflow, what would you do in your workflow if you were looking at an image and you saw something and you didn't know what it was? You have a whole thought process and algorithm over looking at finding out, finding a differential, calling a colleague. What if you saw a significant abnormal finding? You have an entire communication plan probably built out in your practice that says, I will call the ordering physician. If I can't reach them, I will call this person. If I can't reach them, you have escalation trees built out. Build one out for this. Imagine your staff's willingness to say, we as the staff interacting with the patients, we'll ask this question if you'll back us up when we don't know the answer. What did they do? What does staff do when they don't know the answer? Give them a pathway and they'll use it. So there are some other models I want to talk about for patients and interactions with patients. How many of you have renovated or replaced or installed a new piece of equipment in the last five years? Raise your hand. Almost everyone in the room. How many of you had an advisor, a partner that was a patient who was on that design team? Raise your hand. There's the opportunity. In the last two decades, we haven't put any equipment in the radiology department without a patient sitting at the design table. It didn't cost an awful lot. It took a little longer because we had to actually listen to people and learn what we were doing wrong and what was important to them. But that was an amazing experience, an amazing journey. To replace a piece of equipment with the person who's going to be lying on the table telling you why it doesn't belong at that angle or in that location or what the problem that that is going to cause for them. More and more hospitals are putting patients on quality committees. How many of you actually have a hospital where a patient serves on your quality committee? So for those of you who don't, picture that most difficult conversation you had about a root cause analysis, sentinel vent or a bad outcome. Picture what your institution did to improve that. And then think about how that conversation would have been different if there was one or two or three patients sitting in the room having that conversation with you, trying to figure out as partners how to improve. So what I'd like to do is take you through a series of opportunities quickly that talk about what we do and how our practices evolve and how you might look at those a little differently. First let's look at the patient portal. So in our world, the IT company and our IT partners said there were three questions you have to ask for the portal and there's only three questions. Do you want radiology reports in the portal? Yes, no. Do you want final or draft reports? And what delay do you want from when they're in the final status to when they're in the portal? There's no other variables. We sat down with our patients. It took 15 minutes to answer those questions. Yes, we want our reports. Yes, we want them final. And the rest of that 15 minutes really was talking about, well, when should that be released? And we talked about patients who had bad news on the reports. We talked about language in the reports. We talked about all sorts of things. And then the patient said, well, how do you do it now? And we said, well, once we hit sign, that's in the electronic medical record, and if you were standing in medical records, they would release that report to you immediately because it's signed and in the record. They said, so we actually already have immediate access to our reports? Yes. So why don't we just mirror that? So we decided, and that took us 15 minutes. The rest of the 45 minutes was the patients answering the fourth question, the one that didn't exist. They began to talk about what they would do when they got their report, that there would be words there they didn't understand, recommendations for other tests that they didn't know what they were. And they asked, is there a trusted source that you could refer us to? And to my embarrassment, I said, actually, there is. It's radiologyinfo.org. RSNA and ACR spent years building this out. And there's 1.6 million hits per month on radiologyinfo.org, videos, static webpages, English, Spanish, phenomenal resource, not password protected, open access and peer reviewed. They said, well, could you put the link in your report? We brought that to IT, and they said, yeah, we could change the footer on your report and put that link in. And the other department said, wait, if you have trusted resources, so do we. And rather than change all of the reports, our portal now has several icons on it with web links to things we as a medical staff think the patient should have access to when they're looking at our results. Having the patients at the table, they saw the question we didn't even know was there. And the cost of the answer? Negligible. But the value? Huge. This is the mindset challenge. Is the patient portal an interruption in your already very busy workflow? Or is the patient portal an opportunity to bring value to the patients, an opportunity to engage patients? If this is just another opportunity to bring value, now it's a design question. Put people in a room, have them discuss different ways of approaching it, move forward. When we redesigned our mammography, we did not do this with a team that was just radiologists. We actually did it with the surgeons, with the other oncologists, with patients, with nurses, with the clinic staff. And we redesigned it to be a very different experience. We didn't actually change the equipment in the process, but we changed the workflow for the staff, we changed the experience for the patient, and we decided that mammography should be a good experience. And all of the design went around trying to make that more like a spa-like environment where you were greeted and treated like you were walking into a high-end spa. So this is what our recovery room looks like. If you have a biopsy, do you want to lie on a stretcher in a hallway? Do you want to lie in a hospital bed? Or do you want to lie in a small private room where the murals are nested reflecting in mirrors in a way that just cocoons you into a unique environment? That was patient input. Waiting rooms is one of the things that drives me crazy because it really does say you're going to wait. So this is the waiting room in our cancer center as it was designed by patients. We still try and get them to call it a patient lounge, but you can see glass windows and trees, you see chairs of different sizes and shapes, different types of tables, micro-environments for patients and their families to be together. This is one of our MRI scanners. This is what happens when the patients help you design the MRI. The colors are no longer beige, the room doesn't look claustrophobic like it's a closet, and you get to say things like, my MRI has a skylight in it. I'm sorry about the colors. What an amazing experience for someone who comes in, lies on the table and looks up and sees a blue sky with trees reaching over them. When we designed this, we had a very long discussion about where the changing room should be. If the changing room is in the hallway, the patient walks through the hallway in a gown. That's not respectful for the patient's privacy. If the changing room opens onto the control room, that's not efficient for the staff. Our staff felt so strongly that we should protect the patient's privacy, we redesigned the workflow in the MRI scanners. So our patient dressing room opens onto the control room, so the patient does not walk through the hallway in a gown. Every time I tell someone that, they ask the obvious question, what happened to your volume? It went up over 30%. When we designed our children's hospital in the mid-90s, we did something rather radical for the 90s. We asked the patients, those were the children, we asked the children and their parents to be on design teams for all aspects of the hospital. And again, rather amazing things happened. In the environment at the time, parents left the room when rounds occurred, when the doctors came in. Visiting hours were only for parents, siblings weren't allowed, and the visiting hours were defined and confined to daytime, which is often when parents work. So if you're a parent and you think back to that time when your child was sick, where did you want to be? Next to them, not in the cafeteria. By the time we opened the children's hospital, we had no visiting hours because we didn't have any visitors. We had partners. I have worked in a hospital that hasn't had visiting hours for 20 years. Patients and families, families come to visit their loved one when they can. And it didn't destroy the hospital or the workflow. We had the opportunity to redesign the radiology department for children in the past two years. So we again went back to children, and 20 years later, children have different expectations. They're a little more digitally oriented, their idea of a good experience is different. So I want you to think about what you consider the single most important question to ask a child before they have their radiology exam. We ask them what their favorite color is. Because when they come in to have an x-ray or fluoro study, we're going to change the room to that color. When we remodel, we put color wheels in, and we just rotate the wheel until we get the shade of red or green or blue they want. If they're having a fluoro procedure, which is longer, they have a choice of not only the lighting, but also of the sound themes they get to listen to. What did this do? It made the patients more relaxed. We gave the children more control of their procedure. They're better able to cooperate. If they can cooperate, the procedure time goes down, and you can actually take care of more patients in the same room, in the same pieces of equipment. And staff loves to work in this environment. If you continue to think about how you can work in patient and family-centered care as a radiologist, RSNA Cares is a phenomenal program. The ACR has a patient and family-centered care commission, five committees, over 100 volunteers. There are already radiologists who have found ways to practice in organizations and bring value. So what local infrastructure do you need to actually do this? Well, you would not randomly pull someone off the street and say, I want you to read the spine MRIs today. You probably would interview them. You might do some training. You might do some orientation. The same is true for patients. We recruit patients. We interview patients. We have a team of patient advisors, partners that work with us on projects. But we also have to train our staff on how to work with patients. So are there other resources available to you? Well, it turns out that the issue of the Journal of the American College of Radiology that just came out this week, the entire issue is on patient and family-centered care. It's open access, which means you can download all of the articles for free. It also means you can email the PDFs to your hospital CEO, your departmental administrator, and say, other people are doing this. Should we be looking at this? This gives you the opportunity to have the discussion, regardless of reporting relationships, regardless of organizational boundaries or silos. This gives you the opportunity to look at the informatics articles that are there. Look at the organizational articles. Look at the patient articles that are in the JACR and the experiences they're describing. And if I haven't attracted enough of your attention from that, look at the graphic novel. Look at the comic book that's in there that describes the patient's experience through two different sets of eyes, trying to reach a different audience. Thomas Edison said that opportunity is missed by most people because it's dressed in overalls and looks like work. This is work. We have a lot of work to do to improve our patient's experience, but I do believe that that is part of the value that radiologists can bring to health care locally and nationally. And in the last two years, as patient and family-centered care has been embraced by ACR, RSNA, and a number of other organizations, that is an acronym and an abbreviation that is now commonly heard in radiology meetings, but we can't say that about all the other professional societies. In two years, we have been able to make this a topic and a conversation in our profession. We are emerging as radiologists as the leaders. So it's a journey, not a single event. There is no one stopping point, but it begins with having patients be partners in the co-creation. Thank you. I also want to echo Jim's statement about the papers and the special issue on patient and family-centered care. So this talk is actually a paper that we just released this week on trying to look at quality improvement methods to improve patient experience. And this was, I really want to thank Jeff Jensen, who is just a wonderful radiology resident we have at Johns Hopkins, Lisa Allen, who is our chief experience officer, and Vince Blasco, who is our head CT technologist, who also runs a lot of our quality education within our department, trying to look at this. And so when you think of quality improvement, most people, as everyone who has a background in quality improvement has done a QI project, most people think of process engineering. They think of people looking at counting steps or counting, having a little time stop, having a little watch and trying to measure time, when I think they're really missing the bigger picture of what quality improvement is intended to be. So my takeaway message for today, put it up front, is this one, is that quality improvement is really a progressive management methodology. And it's really designed to empower employees, to engage them, to fix broken systems, to take a system's perspective and a lens, to see things as a process, and with that, create a culture to lead change in healthcare. And so yes, you want to do a quality improvement project to fix a problem, because that's something you can focus on, but it's about the process. How do you become patient and family-centered care oriented? How do you change the values and the roles of all the people in your organization? And quality improvement is actually a cookbook, it's a process, and it's a recipe for how to actually lead that change towards that centeredness. The roots of it comes from the 1950s, anyone here, anyone have a management 101 class for this guy Douglas McGregor in the 1950s, studied different managers, and he came upon this classification of managers between Theory X and Theory Y, anyone have heard of this theory before? And so he came up, he studied managers, and he studied workers in the workforce, and he came upon these two types of managers. The first manager is called Theory X, and that manager has a pessimistic view of their workers. They think that they wouldn't be there if they weren't getting paid. No one really likes to work, they're just doing it because they have to, they feel the workers would try to avoid responsibility, they believe that they need to be managed and observed and sometimes micromanaged, and they require threat or punishment to deliver their work. So this is the foundation of the progressive management movement, and as a result this often leads to poor results, and what was interesting was part of his study was he found this was actually a self-fulfilling prophecy. So if you treat your employees like they need to be managed, if you treat them like they don't enjoy their work, that actually will be self-fulfilled. He also found there were different types of managers that felt differently, that their role was actually people do look for meaning in work, they accept and can seek responsibility, they're willing to commit to objectives, they want to apply a degree of imagination, ingenuity, and creativity, and these people can be performers, and what's interesting about this was that this is not just a few high performers in an organization or just a couple of the leaders, this is something that all of the workers can be able to contribute to and create creativity and imagination to the work. So this was actually the foundation of the quality improvement management methods. So you may have heard of them. Do you know how many QI methods there are? So you may have heard of Lean, the Toyota production system, you may have heard of Six Sigma, so Six Sigma came out of Motorola in the early 1980s, and it really is a western style of scientific management where we try to look for failure and we scientifically measure it and its mean and standard deviation, and we use these processes to reduce that probability of failure. Toyota came up with the Lean production system, which is really a little more focused on flow and waste and visual indicators, but they both have the same combinational components around them. And what's interesting, what you might not know, is that there's over 150 quality improvement management methods, and these two are just the latest, and they're like the Borg, where they just roll up previous methods before them, and so now, instead of Six Sigma and Lean, we call it Lean Sigma, where we take the pieces of each that we like, based upon the type of problem we're trying to solve and how we're trying to approach that problem. So these are just recipes of tools and processes to be able to lead change. At the heart of them, they come up with, there's three fundamental quality improvement methods and tenets and beliefs. Those three tenets are that a belief that the front line has the ability to solve their own problems. This is a fundamental belief that there is no cavalry. There's no QI quality expert team that's going to come in and fix your problems, and a belief that the people doing the work are the best able to see the problem and prove it. So the person, the manager, the chair, the CEO, are the farthest away from the front line, the farthest away from the problem. We call them the HIPPO, the highest paid person's opinion, and those are actually some of the least effective at understanding what the actual problem is on the front line. And so it's a belief that people doing the work are the best able to see the problem and improve it, and a belief that everyone is responsible for quality. So there is no cavalry. There is no group that's going to come in and fix your problems. Management consultants can come in and share your best practices and benchmark you to other sites, but they can't actually, they really are relatively ineffective. And so we've seen a lot of QI processes and groups trying to use them have failed, not understanding this is actually a management method where you have to give up some authority as the leadership of an organization, and you are empowering the front line and giving them autonomy, and being able to ask them to take a leadership role in your organization and to bring their creativity to work to be able to lead this change. And so for me, I see two major benefits for patient experience and how this relates to that. And the first, of course, is that good news is the QI management empowers the front line and we actually fix broken processes, so it's great to do a QI project with a focus on patient family and centered care. That's wonderful. QI projects should be focused on the front line. They're fixing things that are slowing them down, making it harder for them to do their job, making it harder for them to focus on the PECUS. So just fixing those broken systems in healthcare help them be able to deliver better patient care. But there's a second benefit, which is equally powerful, and that is by asking the front line to fix things that are slowing them down, whether it's their paperwork, whether it's registration, or things that they feel are stupid but they never, don't ask them or point to them to actually go around and fix that, is that they actually raise employee engagement. So you're asking your employees to form teams, to think creatively, to be able to come upon solutions. And this is actually an exercise in leadership. This is them learning to create a team and be able to learn how to lead. And this actually improves employee engagement, improves their satisfaction and retention with their job. This will also, if you have good management, you'll have happier employees. Having happier employees will lead toward better patient experiences, because the front line now feels they're part of the organization, they understand the mission of the organization, and they're not just feeling like they're a cog in the wheel of the process. So I think there's dual benefits around this. So there's actually many QI projects that you can be doing, helping you, not only focusing on patient and family-centered care, but also on improving employee engagement. So here's the original framework, was done by Gertese in 1993, and came upon these six main categories for understanding patient, family, and centered care. And I just put together in our paper, we go into more detail. Here are some potential examples, there's tons of QI projects you can be working on. Here are some potential projects that you can be thinking about based upon those different categories. Whether it's going to be respect for patient's values and preferences, as Jim described, understanding the environment from the patient's eyes, music feedback during the MR and PET, imaging appropriateness, being able to understand the preference for pediatric anesthesiology, a lot on coordination of care. The patient's a ping-pong ball between orthopedics and radiology, between the emergency department, between all the different specialties that they go through, and understanding that from their perspective. Understanding how we can ease scheduling and coordination, access and wait times, and communication. Understanding report accuracy, timeliness, and Jim and Kelly both mentioned really this new role of report access from the patient portals. Physical comfort, emotional support, involvement of family and friends. There's actually many QI projects that can help you create the new values within your organization to get your team to say, this is something that we want to be able to, this is a goal that we want to set out, and quality improvement can be a method for how to achieve that goal. So I wanted to talk about really, there's three fundamental components to a good quality project to be able to make sure that you're able to execute and deliver. In truth, the QI is just a cookbook for how to deliver change in an inexpensive process to be able to try to bring a team together. It involves team building, and so there's basically a component of bringing a group together to understand a problem and to focus it on the gaps, try to understand, it can be a perception of a problem as well. There's a project management component, and then the big part of it is learning to listen to data. And this is, and I'll talk a lot more about data, because this is usually one of the challenges with patient pharmaceutical, how do we get the data to be able to focus on the patient. So I do want to quickly mention those three components. So for me, team building is a big process. So you're actually, yes, the person's an employee of yours. They belong in scheduling, or they're a technologist or an anesthesiologist. It's very important when we look at doing a quality improvement project. So we were doing a QI project with orthopedics, where patients were taking too long to go down from orthopedics and come back up with their ankle x-ray of their cast. And it's important to bring in people from different perspectives, bringing in the orthopedics registration, the radiologists, radiology technologists, the radiology scheduling, and to make sure that we can then see this problem from the same perspective. So a lot of what we're doing is actually doing what we call the forming, storming, norming of just team building. And one of the best ways to do that, of course, is to have a common purpose. And the best common purpose is to have empathy with the patient. And so this is really a lot of, what's interesting is you come into a problem, like orthopedics is very upset with radiology because our patients are not coming back in time and messing up with their appointments upstairs. And you come in with the perception of values. They don't think we care about the patients. And we think they come, send them down in waves, and you start bringing these people together and you start beginning to create common understanding. When you bring people together in a group, what you will find is a natural tendency towards vesting. So anything that you'd want to touch, you want to succeed. So if you're part of a group, you're going to want it to be successful. So generally, you'll find that there's this process within QI for building this team and creating identity within this team. And it starts off with sharing people's perceptions of the problem as well. So what you'll see is often our customers, if you will, say orthopedics, might have a very oversimplification of the process. They might see there's only three steps for a patient to get an x-ray of an ankle with a cast. And we actually can share what there's actually about 45 to 50 steps that we do when we pull up their priors. So we're having to make sure to verify their order and going through all the steps that we do. So some of it is just brainstorming and mapping the workflow. So when you start going through this process, you start developing empathy around this process. And then what you'll find is you are beginning to exercise leadership development skills. You're getting people to become more creative and you're asking them to start brainstorming out of the box why we're having these reoccurring problems. And part of a good QI team is actually beginning to leveraging the strengths of the team and see what other people play. Someone might be good at Excel. Someone might be good at observing or understanding the process. And I find this is how we start building vesting. So I think a good… What's interesting, we did this big project with orthopedics where they were very upset with us and we thought they were sending them down in waves. And what happened was is they came in with their pet theories. And no one's going to get rid of their pet theory until you start presenting them with data. And so we just proved their pet theory that when their patients come down, our techs take off for lunch. And by looking at the data, it also just proved their theory, our theory, that they were coming down in waves. And once you start getting past your pet theories, you start trying to understand the data, then you start beginning to come up with far more creative processes. And what was very interesting in this case was that we had been bickering for about a decade with orthopedics about the simmering problem between orthopedic patients. And even though we were two floors below them, they were threatening to send all their patients across town for better service. We found that once we started beginning to work as a team together, we didn't find a lot of obvious solutions. But the hospital was just stunned that we were actually working together and being creative. And what we ended up doing was we found space in orthopedics to move four rooms upstairs into orthopedic suites. It became part of the orthopedic team. Our schedulers became specialized in the orthopedic surgeons, their protocols. And we also had a waiting room in the middle, so there's no hiding of the patients in the process with the technology. So what was interesting was, while we start going through this process, you don't see that solution coming in. You can actually begin getting to it by beginning to work into it. And this is the other big part of why what I like about QI projects is one of the biggest problems we have in healthcare is just how many organizational boundaries we have. We have tremendous boundaries, even within the department, between our sections, between the technologists and the nurses. Now you think about what boundaries we have with other departments in a hospital, whether it's orthopedics or emergency medicine or peri-op or internal medicine. We're a land of 1,000 boundaries, and one of the important parts of building these virtual teams, bringing them together, beginning to get them to vest, is that you start spanning organizational boundaries. Most problems in healthcare congregate around organizational boundaries because there's a handoff, there's lack of communication and coordination. So this is where we look for and expect to see a lot of challenges. And so one of the big important parts of the QI project is actually building a team that can span a boundary and share values across organizational boundaries. So once you start doing this, you start seeing the art of the possible. So team building is an incredibly important part, and what I like about Lean and Six Sigma and QI methods is that they really can guide you in that process. Then there's a project management part where there actually just needs to be execution. You need to have people that meet as teams. They need to be able to do brainstorming and root cause analysis, mapping your workflow, identifying your failure modes. This is where you start getting everyone's pet theories out on the table, and you begin looking for which ones are causing the biggest grief. You do want this to be data-driven, and this is where you start having hypotheses for what is the problem, and right now it's just a pet theory until you can test it with data. And you begin to observe the workflow. You begin to try to understand it from the front line's perspective. And this is also where you start changing your perspective and your values by being able to be gaining the empathy of what actually is going on and observing instead of just trying to think you know what the problem is, and this is where data collection analysis become very important. And so I wanted to mention a few patient experience projects, and so patient experience is the instantaneous experience of the patient when they go home and they ask for the overall summary with an HCAP survey that's called patient satisfaction, which is basically accumulation of all the individual patient experiences. And so if you can look at just the individual experience, so there's some really, what we did as part of our paper, we did a meta-analysis of all other, a lot of literature out there, and there's actually many radiology projects out there in the literature around QI projects. I just wanted to mention a few and talk about typical types of data sources that you're going to be looking for when you're doing a QI project on patient experience. And the first one, of course, is waiting times. Waiting times and access times are really easy to measure because they're the time it was ordered, the time that it was scheduled to be performed, and there's the waiting times because we typically now can have time that the patients arrive and the time that they actually begin. And so those are nice concrete things to work on. They're very good starter projects for quality improvement. Jason Itry has a wonderful article, an overview of patient family-centered care in Radiographics in 2015. It's a very nice paper. And here's a study that he did using a runtime chart where they looked at the percentage of patients being seen within 5 minutes of their scheduled appointment time in the outpatient environment for CT. And he was able to bring a team together to work on the problems and slowly be able to improve that to over 90% of patients being seen within 5 minutes of their appointment, which is really a pretty remarkable achievement using Lean Six Sigma methods. So wait times is a clear one to go after. Another one that's very typical, we often use QI for patient safety and cost because our numbers are also fairly easy to measure. There's a really nice paper by Dan Durand, how he started bringing in child life specialists into the workflow of the MR scheduling for anesthesia for pediatrics and found working closely with pediatric patients, they were able to drop general anesthesia by 15%, which had a great cost reduction as well as improving patient safety and the additional risk of anesthesia. I think what was interesting about the study was they found a much greater improvement in patients between the ages of 5 and 10 than they did in 11 to 18. And so it's interesting to listen to the data and understand what it's trying to tell you for understanding the patient's perceptions and which ones will actually need anesthesia. So cost and safety and wait times are pretty straightforward. I think other data sources that are not as typical that we use in QI are complaint data. There's a good study at Mass General where they took 10 years of complaint data and found all the complaint data related to radiology and see what sort of things were in there that they could look for for doing QI projects. They found quite a few. So operational issues were about half of their complaints and that was related often to delays in either access to care or in the communication of it. Safety, where patients didn't feel safe, and I think what was interesting was cleanliness is really an indicator of a patient as a predictor of safety. They feel an environment is unclean. They will feel that it also is going to be an unsafe environment. And then professionalism, were they treated with respect and dignity? And then of course a lot of the complaints were multifactorial. So complaints is already after you've failed and so it's always good to do root cause analysis and to have response team, but it's a bit of a whack-a-mole where you're trying to be reactive to responding to failures instead of trying to be more front-forward looking. A very common one to look at as a source of data is the HCAHPS. Has anyone heard of HCAHPS, the Hospital Consumer Assessment of Healthcare Providers and Systems? This is basically managed by an independent third party, Prescani, where when a patient goes home, they get a letter in the mail to rate their service, how was their communication with doctors and nurses and the responsiveness of the hospital, pain control, communication about medicines, discharge information, cleanliness. What's good about this is that it's great because it's their overall satisfaction with their hospital experience. It's hard to pull radiology out, but radiology has a big hand in their experience. Most patients have radiology services and they go into a hospital so it can have an impact on them, but it's just one piece of the puzzle. What's happening now is the CMS value-based payment method is actually tying 30% reimbursement tied to these HCAHPS numbers. This has become very important for the hospital leadership to make sure that the patient satisfaction numbers are important, but it's sometimes harder to tease out the role of radiology. There was a good study done in Ohio State by Lange in 2013 where what they did there was they actually had a training program for technologists. They spent a voluntary training program of 16 hours working on the CULB learning cycle of understanding rapport with patients, relaxation techniques, reframing, and understanding how to be interactive and participatory, and they found an 80% improvement in HCAHPS scores. Even though it's much broader than just radiology, they found that they really had an influence on the scores. I think what was really interesting was just by making the technologist more receptive and more empathetic with the patients, improved the perception of the patients on the technical proficiency of the procedures that were performed. So there was an increase also in they felt that they were more skillful in their job because they felt that their better rapport was built out. So HCAHPS is a big one. I find there's another one that might be more relevant is we find a lot of groups build custom forms that they can hand out to patients. Sometimes they're harder because they're not managed through an independent organization, but as part of a QI project, it's certainly appropriate to work with your patient experience officer to build custom forms that can be more tailored to this. One that was built for outpatient radiography—sorry about the spelling—was done again by the Jason Itry in this radiographic study and focusing on CT outpatients, but they actually had a nice—and ultrasound—was they had this great outpatient survey for patients that were sent about how the registration experience was, the facility, the tests, and the personal issues. And this really gave them very specific data that they could work on and they spent a few years being able to slowly improve this process. And so I think this is becoming a valuable source of data and a signal for us to listen to to be able to improve. So when we think of quality improvement, we often think of using it just to solve patient safety issues, just to solve efficiency and handoff issues for communication, and I really see quality improvement is really an effective tool to be used for improving patient experience as well. Great. Thank you.

value in healthcare

family engagement

patient safety

chronic illnesses

patient-centered care

communication

shared decision-making

patient satisfaction

quality improvement

healthcare transparency

radiologists