Welcome to this year's RSNA Quality Improvement Symposium. My name is Bettina Siebert, and I'm the coordinator of this year's program on building high-functioning teams. Before we get started, I would like to say a big thank you to all of the presenters and the staff at RSNA for their dedication and effort in making this year's virtual meeting possible. In three one-hour sessions, we will look at how radiologists work together in teams. Session one is focused on interventional radiology teams, teams that work together mostly in person. Session two focuses on diagnostic radiology teams, which is currently mostly done in a virtual environment, and Dr. Naval Arani from Kansas University Health Systems will be moderating the session. In our third session, we will look at multidisciplinary teams, the role that the radiologist plays in these teams, and what value we can add. And this session will be moderated by Dr. Jonathan Flug from the Mayo Clinic. In our first session, we will first hear about the importance of high-functioning teams. High-functioning teams require strong contemporary leadership, and Dr. David Larson from Stanford University will tell us about new skill sets for leaders of such teams. Very important for the functioning of these teams is communication. Dr. Amber Lyles from University of Michigan will speak on communication from TeamSTEPPS to WhatsApp. Dr. Marta Heilbrunn from Emory University will share with us how building frontline problem solvers can improve our team function. And finally, Dr. Aldo Roque from Beth Israel Deaconess Medical Center will speak on closing the loop on biopsy results and the unique role that the radiologist can play in this setting. Thank you very much again for joining us, and I hope that you will enjoy the presentations. In the next few minutes, we will be talking about the importance of high-functioning teams. We will reflect on what makes a team, how a high-functioning team is slightly different, why do we need high-functioning teams, actually why we want high-functioning teams. And I hope that by the end of this presentation, I can convince you that we want to work in high-functioning teams, and this will require dedication, it will require resources to contribute to making these teams be high-functioning, and it's all going to be worth it. So what makes a team? Google has looked at this and they differentiate between teams and workgroups. Teams are working on a specific project. Their work, the work of the individual members, is highly interdependent. They interact a lot as a group to plan, solve problems, make decisions, whereas in workgroups, a lot of this is not the case. Workgroups are of low interdependence. Similar definitions of a team have been given by Richard Hackman, who says it's important, again, that people are interdependent and have a common goal. And this definition has also been accepted by the TeamSTEPPS program. So high-functioning teams have a few additional characteristics to purpose or share a goal. There are values that are shared in that team. The team is empowered within the institution, within the policies and guidelines to work independently. Strong relationships are present. Communication is optimized. Teams are very flexible to be able to adapt to changing circumstances. The team members are very dedicated to optimal productivity and quality. Team members provide recognition and appreciation for themselves, which is why morale in such teams is usually very high, because people appreciate a sense of belonging to this very special group of people. Why do we need teams? Organizations put teams together to complete complex and difficult tasks, to do things that individuals cannot complete on their own, where we need others' help. Also to address our complex environments. Our environments are increasingly stressful. They are ever-changing, so the support of others is helpful. Also, when quick decisions are needed, the information that our team members may be holding and bringing to the table is very helpful in making good decisions quickly. Also, in our high-stakes environment, when we have others that we can rely on, we can rely on their insight when we make some difficult decisions. It is very beneficial for everybody to work in teams. But there are some other reasons why we want high-functioning teams in addition. Teams are now the fundamental units of organization. In addition, teams, particularly diverse teams, have better outcomes, and teamwork creates higher job satisfaction. Let's look again at how much time we actually spend doing teamwork. A study published in the Harvard Business Review showed that over the last two decades, teamwork has increased by over 50%. Some people spend as much as 75% of their work communicating with colleagues, and only very little time is left for actual task completion, meaning that this then also has to occur and be part of the team activity. Therefore, everybody has to be more efficient when they work together as teams. Let's look now at the diverse teams that have better outcomes. It makes a lot of sense because people coming from different backgrounds, different experiences, will have a different way of reasoning, look at problems differently, actually interpret problems differently to begin with, have other ways, different ways of solving them, and will be able to look at a much more complete picture of a problem. They can also easier avoid bias that may be present in teams that are not as diverse, and they have been shown to process facts more carefully. Because of all of these advantages, they do have better outcomes. In the business world, the overall business outcome is better, but also financial targets are more often met or exceeded, and teams are more innovative than regular teams. Of course, working in a high-functioning team is also better for our job satisfaction. This is a study that was done in nursing staff in five different hospitals, and nursing staff who graded that the degree of teamwork in their unit was high had a high degree of job satisfaction. This was true not only for their role but for their occupation as well, and this has been shown in other studies as well where teamwork was the most important predictor for job satisfaction. Up to 47% of staff reported that and was much more important than organizational culture and leadership, particularly if there was an opportunity also to participate in leadership in the team. Of course, there are other factors that come into play here, the interdependence and the appreciation that we get from team members that make us part of a much bigger enterprise are factors that lead to greater job satisfaction. A few years ago, Google set out to identify what makes the perfect team, what is the secret ingredient of very effective teams, and they looked at team composition and team dynamics in about 180 of their teams. For team composition, so the individual team members, they looked at skill sets, personality traits of people, introverts or extroverts, what is their degree of emotional intelligence, and then for team dynamics, are there any unwritten rules, group norms that everybody agrees on that makes the functioning a whole lot easier, and they found two interesting things. One was that the average social sensitivity of group members was higher in the high-functioning team groups and that the conversational turn-taking was very well regulated. In high-functioning teams, everybody was participating in meetings, speaking about the same amount of time over the course of the meeting, and social sensitivity, what that means is that people were able to, from tone of voice or facial expressions of their group members, to identify their emotional state and it was easier for them to adjust their own response to the interaction. This had also been shown already by a study published in Science in 2010 with similar observations and the additional finding of that the proportion of women in the group was of additional benefit. Now when we're looking at people feeling empowered to speak up, that is a concept that has been named psychological safety by Amy Edmondson and it's a belief that we will not be embarrassed or humiliated when we share a new idea or ask questions or raise concerns and it's a feeling that the team is a safe space to talk about these things that matter to us. There were other things in the study that also were found to have impact, but psychological safety was by far the most important. Others we see listed here, dependability, that people would finish their work on time, that there was common knowledge about the roles that people played and the goals that the team had, but also that members had found meaning in their work and felt that their work had impact and created change. So in conclusion, high-functioning teams are critical in healthcare, not only for patients but also for ourselves. We need to solve challenging problems in increasingly complex environments. In high-functioning teams we achieve better results, particularly when they are diverse and this leads to higher job satisfaction for us. And as Aristotle said, in this sense the whole is greater than the sum of its parts, certainly true for high-functioning teams, but if we decide that's the route we want to go, we do need to dedicate development to our teams, we need to invest in diversity and inclusion and we need to find ways to create psychological safety for our team members. Thank you very much for your attention. Hi everyone, it's great to be speaking to you today. The title of my talk is New Skillsets for Leaders of High-Functioning Teams, but I hope that you'll find that these aren't actually new skillsets and really are rather intuitive. I do have the following disclosures. I'd like to start to have you think about where you were in the situation you found yourself in, in March of this year, with the onset of COVID-19 and all of the many, many changes that were happening all around you. If your medical center was anything like ours, you found that there were numerous urgent problems that had to be solved very quickly and all seemingly at once. It required rapid formation of many teams that had to quickly identify and resolve problems and you had to keep everyone engaged and productive as you went forward during this very stressful time of rapid change. So if we think about teamwork in normal times versus teamwork in a pandemic, in normal times there's time to carefully select the team, whereas in a pandemic or any other crisis, the team is made up of really who's available. In normal times, there's time to get to know each other, whereas in a pandemic, the team needs to quickly become productive. In normal times, the problem is generally defined before the team is even assembled, whereas in a pandemic, problem identification is actually part of the project itself. In normal times, the project is generally planned with a series of meetings, whereas in a pandemic, planning and execution have to go hand in hand. They happen at the same time. In normal times, the project is constituted of a series of linear steps meant to work towards achieving a goal, whereas in a pandemic or a crisis, the team needs to simultaneously tackle multiple issues all at once. And in normal times, teams are formed for months and years and have generally some stability, whereas in a pandemic, teams are formed for days or weeks and then need to disband and move on to other important things. So all of this activity and the way teams have worked together during this time of crisis actually is something that has been described by a term that was coined several years ago by Amy Edmondson, which she called teaming. So I'm going to talk in the few minutes that we have together about what teaming is, when is it most useful, and how is it done. So we're going to start with a case study. And this case study actually comes straight from the book. It's what Amy Edmondson puts right there at the very beginning to frame the whole book. And this is the case. On Friday afternoon at a major urban medical center, there's a patient with increased white cell count, increased respiratory rate, and pallor, who the physicians are concerned about infection. And so an order is placed for an abdominal pelvic CT just after noon. And then two hours later, an NG tube is placed for oral contrast. An hour and a half after that, the radiograph is performed for confirmation of NG tube placement. Then at 6.30, the radiograph is read and oral contrast is started. Well, contrast is injected, and then the scanner is unavailable for a couple of hours in the evening. And in the meantime, then at 10 o'clock p.m., the patient becomes hypotensive and is transferred to the ICU. Then on Saturday at noon, the patient is stable enough for the CT, but at that point, the nurse reminds the ordering physician that CT is only done for emergencies on the weekend. And so on Saturday evening, then the resident is located to remove the NG tube, which is no longer needed because it was only needed for the CT scan. Finally, on Tuesday, four days after the original order, the process is all restarted and a CT is performed. So the question I have for you is, first of all, can you envision this happening at your institution? Second, who is to blame? And third, what might have helped? I think the answer, at least at our institution, is not only can I envision this happening, this happens so frequently that it hardly even registers as a problem. And yet this is something that's considered to be outrageous to the lay public. Who's to blame? Well, the reality is, and this is what Edmondson talks about in her book, no individual is to blame per se. They're all doing their job. So what might have helped? That's what we're going to continue to talk about. So teaming, as Edmondson describes it, is teamwork on the fly. And teaming is determined by the mindset and practices of teamwork and less by the design of the team. So really it's about the people and how they approach teamwork. It requires coordination and collaboration without stable team structures. So that requires people who can collaborate whenever the need arises and, in fact, is looking for opportunities to collaborate. The teams are organized in a way that they can and will learn as they go, not simply to execute and get stuff done, so to speak. Excuse me. When is teaming most useful? Well, when it requires a task that has three elements. First, the task requires three elements. First, when the task requires integration of perspectives from different disciplines. Second, the task is novel or unpredictable. And third, the task requires a high degree of communication, especially among individuals without a previously established relationship. And this is especially true in the setting of complex systems in which we all work, where subspecialized individuals must work together interdependently and especially in a fast-paced or high-stakes environment like healthcare. So if you think of the continuum from routine operations to complex operations to innovation operations where the uncertainty increases as you go from left to right, teaming is more useful and more needed, really, as you go into complex and innovative operations rather than routine operations. So it's why it's increasingly necessary in our increasingly complex work environment. With teaming, the concept is that individuals are organized more to learn rather than just to execute. So that means then that rather than learning before doing and then just going and doing your job, when you're organized to learn, you learn from the doing. So getting together and starting the work is actually part of the learning. Rather than depending on separate individual expertise where individuals just do their job in their own silo or their own swim lane, when we organize to learn, we integrate that expertise. And so the expertise then becomes greater than the sum of its parts. Instead of giving employees little flexibility to keep them doing their same job that they've always done, when we organize to learn, team members experiment through trial and error. And those roles are somewhat fluid as we figure out what needs to be done and how the team can work together to do it. Instead of the goal being to drive out variance without learning about it, when we organize to learn, we analyze that variance first to learn and then improve over time. When we organize to execute, generally water cooler conversations, so to speak, are about the weather or things other than work because the last thing people want to talk about is work. Whereas when we're organized to learn, generally those side conversations are about the work itself. When we organize to execute, the objective is to improve productivity now. Whereas when we're organized to learn, the objective is to improve productivity over time. So it's more of an investment up front that pays off over time in the behaviors and attitudes and mindset of the people. So what is the teaming process? It's actually relatively straightforward if we think about it. It starts with the recognition of the need for teaming. Then individuals get together, they communicate effectively, and they coordinate their steps, their actions, and their handoffs. And then you start to see independent action unfold as they work effectively together. And then there is a really important step, and that is reflection and feedback where they pause, look around, say, how are we doing, what are we doing well, what can we improve in how we're doing? And over time, as this is repeated, then this teaming mindset is adopted, and this cycle then is repeated over and over. And this, as it's adopted by individuals throughout the institution, then really changes the culture. Edmondson describes the four pillars of teaming, as she calls it. First of all is speaking up. Teaming is really critically dependent on honest, direct conversation between individuals, including asking questions, seeking feedback, and even discussing errors. Next is collaboration. It requires a collaborative mindset as well as behaviors, both collaborating within individuals in the team or in the unit, as well as those outside of the team or the unit. Third is experimentation. So teaming involves a tentative, iterative approach to action, recognizing uncertainty in all interactions. In other words, we haven't worked together before, so let's try this, see how it works, and if it doesn't work, let's resolve that we're going to improve it over time. And finally, reflection. So this is the use of explicit observations, questions, and discussions of processes and outcomes. How are we doing? What can we do better? And this must happen regularly. That may be daily or weekly or maybe at most monthly, but somehow there's got to be this time that we can get together and discuss how we're doing. So let's go back to our case study. If we use a teaming approach, it might look something like this, where radiology, administrative, nursing, and medical leadership connect to recognize the problem. A team of frontline staff is assembled to solve the problem. The team clarifies the goal, establish measures, works together to understand the issues, develops potential solutions, and each then works with their own group to adjust their processes as needed. The team iteratively experiments with different changes. They refine their approach, their proposed changes. They work with their leaders and staff to implement, and probably most importantly, on an ongoing basis, the staff work collaboratively to adjust for each case as needed. So in conclusion, teaming starts with adopting the mindset to collaborate and learn. It's most helpful when the task is unpredictable and requires cooperation. And the four major pillars are speaking up, collaboration, experimentation, and reflection. And all the cooperative behaviors that emerged during the pandemic, that was teaming. We should be doing more of it and not just during a pandemic. Thank you. Hello, my name is Amber Lyles, and I'm an integrated IRDR resident at the University of Michigan. I'm thrilled to be here to talk with you today about communication within high-functioning teams with a focus on some communication tools that may help improve communication within your organization. I have no relevant financial disclosures. As we discuss communication and teamwork, I want you to think about these two questions and really challenge yourself towards improvement. First, are you thinking regularly about how your team is communicating? Second, are you acting regularly around how your team is communicating? With those questions in mind, our objectives today are to discuss the importance of effective communication in healthcare, to identify frequent barriers to effective communication, to describe and compare a variety of communication tools available to healthcare teams in hopes that you'll be able to understand better how your team can use effective communication to improve practice performance. So what is communication? At the most basic level, it's the exchange or transfer of information between two or more individuals. There are many different theories and models to describe communication, but I like this model, which describes roles and interactions of the sender and receiver, as well as other factors that come into play, such as noise or the barriers to communication, as well as the chosen medium for communication, also known as the communication channel. Keep this model in mind as we continue, as we'll discuss each of the major factors in this process. Why is communication important? Why should we spend time today discussing it? It's because it affects our outcomes. First, it is a major contributor to patient safety. JACO did a study over a 10-year period with data published just a few years ago, and they found that two-thirds of medical errors are due to ineffective communication. When communication goes wrong, the costs are high. A study out of a Harvard-associated organization a few years ago found that 30% of medical malpractice claims resulted directly from miscommunication. And we know that communication impacts patient satisfaction and even compliance with care. And this is not just a result of patient-provider interactions or relationship. It is also a result of team communication. But it isn't just about your patients. Communication has an impact on you and your team. Effective team communication results in increased individual well-being and decreased burnout, as well as overall increased work satisfaction. And the reasons are many-fold, but include increased self-confidence, improved interpersonal relationships and conflict resolution, and less emotional exhaustion. The importance of communication in health care cannot be overemphasized. It affects every aspect of what we do. There are, however, many barriers to communication that we face on a daily basis. This is the so-called noise in the communication model that I showed you earlier. Barriers include, but are not limited to, lack of awareness, individually or profession-focused culture, hierarchy, time constraints, diverse communication styles, conflict, fatigue, and more. We don't have time to get into strategies to overcome each of these barriers, but I want you to consider what might be the top two barriers to communication in your organization and consider how best you might address them with some of the tools discussed later. So how do we get where we want to be, where the team prioritizes and continuously refines its communication skills to maximize potential for patient safety and team well-being? Well, I suggest that we start with these three things. One, incorporate communication education into your organization's training program. Two, make communication and safety part of your organization's culture. Three, use technology when appropriate. We'll first discuss communication training programs. And I know you're thinking, why? Why would I spend my time on yet another training program? And if you're asking yourself that question, you're not alone. This is my husband, a pediatric ophthalmologist, and one of his colleagues. Just last month, we were discussing another training program through our institution, and I heard nearly every one of these comments. And the burden of these programs can be overwhelming. So how can I convince you that a communication training program may be helpful? Well, one meta-analysis performed in 2010 looked at 48 different studies which evaluated formal processes and tools to improve teamwork and communication. This is what they found. Most studies show a positive association between intervention and improved non-technical skills, such as improved communication and staff well-being. However, many of the studies are designed in such a way that the evidence is considered low-level. Those studies that have a moderate to high level of evidence are those that are based on simulation or team training with a focus on concrete and easily measurable outcomes, suggesting that these types of programs would be most desirable. Just this year, another similar meta-analysis looking at communication found that seemingly small communication interventions not only positively affect patient outcomes, but also have secondary effects of improving staff well-being. However, one issue that sabotaged several included studies was staff buy-in. If your staff doesn't buy into it, then you may struggle to have success with any program or intervention you choose. There's no silver bullet to buy in, but here are a few tips. One, consider all stakeholders and include them in the planning. Two, consult those on the front lines. You need to figure out how a training program or new communication intervention might impact staff in ways that you haven't even thought of. Three, investigate potential barriers before implementation. Know what the challenges are going to be. Four, consider starting small. Similar to a PDSA cycle, if you roll out a huge program without a trial period, you may struggle with long-term change. So let's discuss two communication training programs, both developed by the Agency for Healthcare Research and Quality and backed by the strongest evidence that we have in this space. The first is the Team Strategies and Tools to Enhance Performance in Patient Safety Program, also known as TeamSTEPPS, which provides an evidence-based framework to optimize team performance in healthcare. It also includes a robust communication toolkit to help users overcome common communication challenges. The second is the Comprehensive Unit-Based Safety Program, which is a team-based program focused on reducing healthcare-associated infections, but is widely adaptable to solve other safety questions or problems. You might recognize this symbol if you've ever worked through the TeamSTEPPS curriculum. It is a program which is based on five key principles, including team structure, communication, leadership, situation monitoring, and mutual support. It recognizes that communication has a foundational role in creating effective teams. And one thing that I love about TeamSTEPPS is it has a free app available through Apple or Google. I encourage you to download the app and familiarize yourself with some of the tools and concepts introduced there. Next, we're going to discuss a few of the evidence-based communication tools from TeamSTEPPS. First, the two-challenge rule. This is used when somebody voices a concern which is initially ignored. It says, in our organizational culture, team members should state their observation at least twice to ensure they are being addressed. And if there is any concern for safety breach, any team member can speak up to stop an action. This is about creating a culture which extinguishes hierarchy. The next tool, which many of you have likely heard of, is SBAR. This tool is specifically designed to help the sender of the message organize the thought in such a way that it can be effectively received by the receiver. The sender first tells us what is happening, then the background, then their assessment of the problem and what they think should be done or what they need. The next two communication tools in the TeamSTEPPS toolkit are call out and check back. Call out is an action taken by a sender when they call out vital information directly to all team members and may direct responsibility to a specific individual. Check back, on the other hand, is an action taken by a receiver as they accept the message and provide feedback to the sender, ensuring that the message is interpreted correctly. Here, I've given you an example of call back and check back working in conjunction, which they often do. The CUSP program relies on many of the same communication tools in TeamSTEPPS, but does add another tool which can really help team members gain respect and understanding for one another. It is called the shadowing another professional tool and is exactly as it sounds. This is similar to the gimbal walk and includes time that an individual tries their best to replicate another individual's experience. If your organization has little collaboration between disciplines or poor culture scores, this may be something that you consider doing, although it definitely has a time and financial cost. One relatively new way to communicate is through mobile messaging apps, which are considered a disruptive technology in the space of healthcare communication. You've probably heard of some of them listed here, with WhatsApp being the most universally recognized, and many papers discussing mobile messaging apps have been published over the past five years or so. Overall benefits include more secure messaging than regular text messages, increased efficiency and ease of use when compared to traditional healthcare communications such as pagers, improved team dynamics and communication with smoothing of the hierarchy, and even some of these applications can be integrated into the EMR, allowing even greater functionality. But there are some problems as well. There may be unintended recipients or notifications that you don't want others to see, and it may be harder to separate yourself from work when it's in the form of a text message. Additionally, there are some issues with data security depending on the app settings, and while I personally love WhatsApp for communicating with, say, my co-fellows, there are some out there who advocate using apps specifically designed for healthcare, which have decreased ease of use, but better privacy and security features. The mobile messaging apps can be a great benefit for team communication, but also pose some risks. So what are some best practices? First, follow your institutional policies and guidelines. If there is no policy, err on the side of caution. As far as security is concerned, make sure your device is encrypted, use secure Wi-Fi, and try to decrease the number of third party apps on your device. Even though it is cumbersome, use two-factor authentication when able. Do not share devices and avoid screen lock notifications. Certainly there are several challenges to more advanced technology for healthcare communication, but I am convinced this will transform the way that we work in healthcare. In conclusion, we've discussed the importance of communication for the delivery of high quality patient care. We've also discussed how identification of communication barriers can help you address specific problems in your organization. And lastly, we spent time discussing communication tools, which can improve team dynamics and communication with the ultimate goal of improving patient care. Thank you for your time and attention. Thank you very much Bettina Seward for inviting me to speak in this year's RS&A Quality Improvement Symposium. I'm Marta Halpern from Emory University, where I'm the Vice Chair for Quality, and I will be sharing with you our journey in building frontline problem solvers over the next few minutes. Emory Healthcare, led by John Lewin, is in the midst of a lean transformation journey. At Emory, we call this Empower, where we are moving from a traditional management style to a lean management style. And we're taking as our underlying principle, the Toyota quote of, we build people before we build cars. My objectives in this session is to help you appreciate the mindset transformation that is at the foundation of our Emory Empower journey. I want to describe to you our first pass at creating daily standard work, visual management systems, and then I want to link that work to building frontline problem-solving skills and developing strategies to grow these skills. So the principles of our lean journey. The leaders are going to drive the culture, whether it's the floor shop or the clinical area, it really reflects that leadership principle. And we believe that people naturally want to perform and that great businesses are going to develop great people. We also accept that failures are usually system failures and not people's failures. So in order to be responsive to improvement efforts at the bottom, the top has to have the skills and the ability to listen. So if we think about the lean system, typical lean initiatives focus on the methods, 5S, value stream, mass being, but a successful lean journey really requires executing changes in management systems, methods, and mindset. Changes to the management system include new systems for deploying strategies to engage, ensuring alignment across departments and disciplines, managing daily activities, and addressing daily problems. The changes to the methods include application of things like 5S and others, and also the application of a rigorous methodology as a fundamental means to learn and improve process. Changes in mindset are going to include acting as learners and coaches, seeing administrative and clinical processes in fundamentally new ways, with eyes to see and eliminate waste and issues with our patients and what gets in the way of us providing the care that we really want to provide. So if we think about it, really the changes in the mindset are the most important changes in this lean journey. We have to think differently in order to do differently. So a big part of the lean management system is actually transitioning to the servant leadership, and we're going to focus, we need to do this in order to be able to focus on supporting the front line. So if you think about traditional management with the CEO at the top and driving down the decisions, what we're going to do is really flip that where our clinicians, our staff, and our patients, those at the front line, are going to drive down and the systems and the problems and the CEO is going to have to support. So let me just take a minute to step back and reflect on front line. The Merriam-Webster first definition would mean that our patients are our opponents on a battlefield, and so thus it would suggest that our goal would be to advance our objectives at the expense of theirs. A second definition talks about this being struggle. Do we really think that doing healthcare work at its core is potential or actual conflict or struggle? If that's the reality, then we're perpetually in a state of conflict or potential state of conflict, and so should not at all be surprised that we are getting burned out, and I think many of us have had to, over the last number of months, think about what this looks like. But what if we use this definition? We're acknowledging that this is a place where the work is visible. Because it is visible, this is a place where we would want to excel. In fact, this should be the place where we put our most advanced tactical units, and the Oxford definition really supports that idea, is that the most important or influential position in a debate or movement is the front line. So to take that back into a reality, if we under-resource and under-invest in this most important layer of our organization, the layer that facilitates patient access, the layer that interacts directly with our patients, how can we actually expect to be a high-performing or high-reliability organization? So what is the lean value proposition at Emory? Well, we believe that our true north of extraordinary patient care, to be effective, our health services need to deliver higher and more reliable quality, safer care, and faster patient access, and accomplish this all at the lowest possible cost. However, lean is really a system for delivering on mutual success. Toyota talks about this as mutual prosperity for the customer, the patient, the staff, and the enterprise. That means success for the patient is measured by the quality, cost, timeliness, and empathetic delivery of care. And it means success for caregivers and staff is measured by reasonable, meaningful work that is supported by the organization's leadership. This also means that the enterprise delivers profitability to shareholders and contributes positively to society. So we have a foundation of mission and vision that has a business purpose that supports our caregiver and staff requirements, meets our objectives, our true north metrics, to get us to actually our goal of a true north. So our value proposition is going to drive the strategy that we undertake. So what is the strategy at Emory? Our strategy is actually to link our change models. We want leaders who are learners, who are teachers, and who remove the risk and fear of failure. And we want staff who clearly communicate what is going well, where the problems exist, and try new ways of doing. And we want to be able to embrace the mantra of no problem is a problem. So what are some of the initiatives that we've undertaken at Emory at the front line? The first thing that we've done is we've built a daily management system of huddle boards. And then secondary, I want to talk to you about the ways that we've really pushed into frontline problem solving through 5S and Kanban and inventory management systems. Our daily management systems and huddle boards started almost two years ago. We're on the way of enforcing our communication and establishing a set method of communication throughout all of our different practices. And then what we have done beyond that, if you really think of it, this, we have taken all of these huddles and we've built in a tiered system so that we are communicating from our tier one at our modality level into operating unit tier two's, system level tier three's, and radiology department tier three's. And the idea is in doing this, we're able to escalate our problems up and down the tree from the frontline up to leadership and actually communicate back strategies and priorities as well as exchange information. Of course, during COVID, one of the things that we've done is we've transitioned many of our huddles into an electronic board that we meet daily. And this is an example of what our current daily tier three huddle looks like. So what have we actually learned while we've been implementing our huddle boards? We've seen that there have been some heterogeneous adoption and embracement. We have some areas that are doing really well and others that are really struggling. But one of the things that's been really important is through this daily communication, we have seen the team come together, team appreciation increased. So as we rolled out the huddles and coached on what the goals were, we realized the engagement and willingness to present problems, to embrace the no problem is a problem mindset was not really yet ingrained in our frontline or did not necessarily feel safe. So to address this, we'd say we need to help our frontline solve a problem that could easily be recognized as a system problem rather than as a personal failure. So what do you think? Do we have a problem? I don't know. Maybe here. Do we have a problem? So how does 5S and Kanban support the frontline? The process of setting the rooms in order requires our staff to use the space to participate, lean, and learn. We did this project. We addressed these issues during regular work hours. We took three to four days and we staffed up for coverage so that the people who were doing the work could actually devote their time to it. We framed the 5S as an exercise in A3 thinking. And we also had our frontline leaders explain the process. So they were the ones who saw what they did and explained the results to the department and hospital leadership as a chance to show both their understanding and their value to the organization. The key programs and lean management of 5S that we taught them include sort, set in order, shine, standardize, and sustain. And this is what it looks like afterwards. Clearly a space that we all can be incredibly proud of working. And so we also built into it the idea of sustaining with a Kanban system that taught the idea of standard work where we have visual management that indicates and manages their stock levels with the goal to facilitate just-in-time approach to inventory levels, which of course we modified during COVID where we wanted to build up a greater reserve. But also this facilitates our staff and leader standard work. And just because I'm so proud of my team, I want to let you hear from one of my own workers how we did this. Okay, sterile towels, sterile towels. Stop. Pick from the other bin. Okay, sterile towel, pack of sterile towels. We have your Kanban card. Okay, they got to reorder this. To be ordered. Okay, so now I'm going to take this card here. This item is on order. Check the Kanban board for status. And now the next person behind me will take from the bottom bin. Okay. And what the process is. In working together to solve the problem of a very, very messy space, we taught our frontline about the power of standard work, of metrics, and of their value to the organization. So really, again, we created a space where we allowed our frontline to see what they're doing and see how they can do it. I would like to acknowledge my outstanding and growing team in quality and radiology at Emory, who are both leading and facilitating our transformation. And I'd like to end with a reminder that the value proposition is going to drive their strategy. So if our value is extraordinary patient care, our strategy is around supporting and growing our people and changing our mindset throughout the entire organization. We're going to use visual indicators to demonstrate the complexity of our environment. We are developing a shared language that identifies the problems and improvement opportunities. And we fundamentally believe that the frontline is the place where the problems are solved. Thank you so much for your time and attention. Good morning. My name is Dr. Olga Baruch, and I work at Beth Israel Dickness Medical Center in Boston. Today, we're going to talk about how we should be closing loop on the biopsy results. So first, let me start from this case. This is a case that was discussed at CRICO, which is the Risk Management Foundation for Harvard Medical Institutions. Fifty-three-year-old woman died from endometrial cancer, and that was after her biopsy report, endometrial biopsy report, indicated that there was insufficient tissue for diagnosis, which was mistakenly related to her as being normal. This was settled for $1.5 million. There are a couple of lessons that could be learned from this very sad case. First, CRICO recommends that physicians need to understand their role and responsibilities regarding test results and follow-up care in order to prevent serious patient consequences. Another lesson is that physicians are actually responsible to personally review abnormal results from studies they order and ensure that the results and next steps are pursued in a timely way and documented also in medical records. Furthermore, office practices should have a process and policies that will reliably deliver all test results to the ordering physicians. So that's where actually radiology comes, right? We are not necessarily ordering physicians, but we should make sure that those results are reliably delivered to an ordering physician. So what exactly, how does it relate to radiology? What is the current status of image-guided biopsies? We get an order. Nobody likes order for here, but that's what we get. We do the biopsy, and then it goes into this black hole. Hopefully, somebody will take care of the results, whether it's an appropriate treatment, etc. What we forget is there are cases where we didn't get it. Whether we did it because we didn't get the actual lesion, we kind of missed it as in this case that is shown here, or the tissue was insufficient for pathology to make full diagnosis where the lesion was necrotic or there was adjacent inflammation that we biopsied instead of the actual lesional tissue. There could be multiple reasons. Overall, up to 10% of biopsies, CT-guided biopsies, will have discordant or indeterminate results. Then the question is, who is going to judge whether this result is just indeterminate, discordant, insufficient, or just benign? If it was benign, you could forget about it and the patient does not need any follow-up imaging. Maybe it's actually discordant and there is a cancer underlying and there is a further need for further imaging or biopsies or surgery, etc. The good news is the majority of those discordant cases will be caught on time. Our referring physicians are very good. They have high clinical suspicions. They will refer a patient for some sort of additional sampling. However, not all of them in those cases will result in lawsuits. Most importantly, patient delay in diagnosis, delayed diagnosis of cancer, misdiagnosis, etc. This is really important from patient perspective. The other component of it is that some patients will be referred to unnecessary surgery where we actually could just repeat the biopsy. That led us to implement RADPATH meetings. What are those RADPATH meetings? We meet weekly with our CT interventional team and we review all CT-guided biopsies that were performed in the last week that results have become available and we review those for concordance with the imaging findings. If we have anything discordant, we provide recommendations of what needs to be done next. Usually we do it as we form our opinion. We also discuss with the referring physician to make sure that everybody is on board. We created those three categories. First, concordant, that's an easy one, with imaging appearance consistent with the tissue diagnosis of cancer on imaging, looks suspicious for cancer, pathology shows cancer. Discordant is when there is no lesional tissue on pathology to explain targeted lesion, so normal lung and it's supposed to be lung cancer. Or there is a benign pathology with malignant imaging appearance, so organizing pneumonia, it's the most common one. We get on pathology while the imaging looks like a speculated lesion, really we should pursue it further. Then there is indeterminant, when pathology may explain the imaging findings, but imaging findings are still quite concerning, so we have other options to do. What are those follow-up options? We can repeat the biopsy and frequently when we review the case we can say we could have done it a little bit differently and we could have gotten a different part of the tissue. Imaging follow-up is another option, but the problem here is delay. Then the surgical biopsy, again, it's definitely a valid option, however it's much more invasive, it's general anesthesia, etc., so we can proceed with repeat biopsy which will get results quicker. Our goals were to reduce the delay in diagnosis when pathology is benign, but the radiological suspicion for malignancy is high. We wanted also to reduce potential delay in diagnosis due to pursuing imaging follow-up when we actually should have done repeat biopsy, and also reduce potential morbidity from surgical biopsy when we actually do percutaneous biopsy. Here, by the way, the star shows, highlights the same equations. The first case, as you can see here, a 57-year-old patient with growing right level of lesion. Here you can see multiple samples that were obtained from the lesion, but as you can see here on the first image, we were just lateral to it and afterwards we actually had some hemorrhage, which kind of obscured lesion. It looked like we were in it, but we really were in the hemorrhage which was adjacent to the lesion on multiple sampling. Not surprisingly, we did not get the malignant diagnosis from here. What should be the next step? Well, we said we can re-biopsy it. We could sample it more medially, and we did just 10 days later, and the pathology showed metastatic lesion in the sodium carcinoma. The patient was treated appropriately. Another case, 54-year-old woman with biliary obstruction. You can see here the pancreatic cancer in the pancreatic head. You can see the biliary obstruction, but what we also see here is this reticular lymph node, which is very small and also sits in front of this intercostal vessel. The biopsy was performed, and you can see it looks kind of appropriate. We see it in the vessel, in the area where the lesion is. Maybe we're too medial, but it's really kind of hard to judge. Unfortunately, the biopsy was discordant. We only got fragments of fibric connective tissue and hemorrhage, and no malignancy identified. What is the next step? Well, next step we said, you know what, this was very small, and we could resample it, but let's see if there's any other signs of disease. We performed PET CT, which highlighted this lesion, less of a superclinical area, which were then sampled under ultrasound, and the diagnosis was obtained as poorly differentiated carcinoma. So, we reviewed our results before and after introduction of concordancy meeting. We had approximately 500 cases in each. Overall, discordant results were seen in about 11-12%, very similar numbers. However, the difference was after the introduction of this REDPATH meeting that we performed many more pericrutaneous biopsies. That's the change. So, potentially, this change would bring the diagnosis quicker than imaging follow-up, and also with much less morbidity as compared to surgery. That's a potential. We could see there is a trend for less time to diagnosis and less delay, so 41 days versus 56 days, but larger a cohort is needed to show that. We also asked our referring physicians what is their opinion, and they felt that there is an added value for radiologists providing this clinical management recommendation based on imaging pathological review after the biopsy, and we should continue this practice. In summary, about 10% of image-guided biopsies, pathology will be discordant with imaging findings. Prompt review by radiology may decrease time to diagnosis of malignancy and prevent significant delays in diagnosis of rare discordant cases. It is important, and it is also important that we do it as radiologists because this review requires expertise, and expertise that we are uniquely qualified to perform. If you have any questions, I will be happy to answer through the email or in the Q&A. Thank you.

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