The Discipline of Performance Improvement in Radiology

February 26, 2016
C. Matthew Hawkins, MD

The start of something great in radiology.

Some stories must be told. Even when they are not your own.

So here it goes. This is the story of a radiologist with a vision. Conviction. And an unwavering passion to make that vision tangible, despite institutional inertia and human blockade. His drive has cultivated a movement that will transcend our profession…if we allow it. 

Oh, how I hope we do.

David Larson (Stanford), through a variety of experiences during training and his early career, deduced that there had to be a better way of doing things; that our broken health care system could be fixed with a systematic approach to quality and improvement. He believed that rather than overly focusing effort and resources complying with arbitrary benchmarks and federally legislated standards, institutions could transform health care by scientifically implementing performance improvement programs that continuously evaluate quality, implement change when necessary, and monitor the effectiveness of interventions. Rather than “meeting a standard” or “aiming for compliance” – we should strive to “be the best at getting better.”

This type of thinking is transcendent. Instead of telling health care workers “how” they should do something – this approach empowers teams of people to solve problems and discover improved methods to perform their craft. It promotes engagement, coaching, introspection, and willingness to tolerate failure (in light of the underlying premise of improvement). It is the antithesis of “policies” and “standards” that are often unilaterally determined yet universally enforced. This mind-set suggests that only through trial and error, iterative attempts, and systematic methods can real improvement and value be achieve in health care. This value is realized in both reduced cost and improved outcomes. [[{"type":"media","view_mode":"media_crop","fid":"46263","attributes":{"alt":"lesson in radiology","class":"media-image media-image-right","id":"media_crop_4637267334449","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5358","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"©CoraMax/Shutterstock.com","typeof":"foaf:Image"}}]]

The scientific field of “improvement” has transformed manufacturing and service industries. Pioneers such as Demming and Crosby serve as role models, such that this ideal of performance improvement is founded by reality – not simply wishful thinking. Isn’t it time we learn from this scientific discipline and utilize its principles to transform medicine – health care – caring for the disease(d)?

In the radiology department at Stanford, a Radiology Improvement Team has been constructed and charged with helping members of the radiology team improve and solve problems. They are not relied upon for solutions – but rather deployed to aid dedicated teams in mapping processes, identifying areas for improvement, implementing interventions, and tracking sustainability of their efforts. The improvement team empowers front-line workers to influence behavior and execution – and inspire other co-workers. They do not solve the problems. They help others do so.

The improvement team is comprised of individuals trained in quality improvement methodologies. They are not necessarily physicians, nurses, or technologists (although they can be).  Rather they are experts at change management, program implementation, and team building. When accompanied by visionary physician leadership – this team becomes remarkably influential. 

The team in Palo Alto is aligned with the leadership structure of the department, and integrated throughout the enterprise. In a very short time, their squad has successfully improved workplace satisfaction for administrative associates and reduced the amount of time it takes to transport patients to and from the radiology department. They have reduced wait times for women being screened for breast cancer and slashed time-to-treatment for patients suffering from a stroke. Wouldn’t it be nice if this could be accomplished at all institutions?  (Pause) 

Why can’t it be?  Why shouldn’t it be?

While reading this story, do not be distracted by the definition of “quality.” For “quality” is in the eye of the beholder. The beauty of this transcendent approach is that while “quality” can depend on perception, “performance” cannot. Either you are getting better, staying the same, or getting worse.  There is not poetic license in the interpretation of “performance.”

Dr. Larson and his team have demonstrated that this approach works even in complex organizations. It has redefined “quality” – such that the definition used by members of this camp refer to “quality” as “consistent excellent performance;” a definition that offers a time-frame and degree of expected performance. This counters antiquated quality-assurance workers who aimed to investigate “never-events” and audit “compliance” – rather than driving behavior change and performance improvement.

The conundrum is that “performance improvement” in radiology is not yet a discipline. There is little guidance, literature, or precedent. In comparison – in the “discipline” of interventional radiology – there is literature and a body of knowledge that can help a new leader build an interventional oncology program or thrombolysis clinical care guidelines. In contradistinction, a radiologist charged with improving performance in his/her department usually has little (if any) guidance or formal training to help build their program. While the work at Stanford is a breakthrough, they need our community’s support and resources to allow for patients outside of Silicon Valley to reap the benefits of health care entities that embrace this methodology. Does this emerging discipline need its own society? Does it need a journal for scholarly publication? Does it need a formal fellowship training program for physician leaders?

I don’t know. 

But I do know that existing leaders would be wise to acknowledge this movement, embrace it – and re-organize existing radiology leadership structures such that performance improvement teams can influence change and improve performance throughout the organization, rather than function on the periphery in isolation from operational managers and business-types. I know that peer-reviewed journals would be wise to inspect the scholarly work stemming from radiology performance teams and consider it worthy of publication and impactful. I know that a culture change such as this can only be achieved by influencing our trainees to dive headfirst into the methodologies that are scientifically proven to improve performance in our profession.

This is only the beginning. A birthing. Thank goodness someone started it.

Thank you, David.