Developing and piloting a peer quality improvement coaching protocol for front-line healthcare staff

BACKGROUND

Improving the quality of patient care remains a global necessity. Despite system and professional benefits, current evidence indicates that the spread of improvement principles among front-line healthcare workers remains poor.While education and training alone are unlikely to result in consistent improvement practice, coaching can play a critical role in sustainable, evidence-based improvement implementation. Peer quality improvement coaching (PQIC) places the power and agency in the shared relationship between coach and coachee to shape coachee quality improvement (QI) outcomes.Study objective was to develop and pilot an evidence-based protocol for implementation and evaluation of a PQIC for front-line staff engaged in small to intermediate improvement efforts.

METHODS

We conducted a multistage case-study design and implementation process. First, a systematised literature review identified themes about the theory and practice of QI coaching (QIC). Second, these themes guided the development of a PQIC protocol. Finally, the protocol was piloted and evaluated among staff in a single-centre tertiary maternity hospital. PQIC effectiveness was assessed using evaluation tools identified in the literature.

RESULTS

Effectiveness; strategies and models; moderating factors and methods for evaluation of QIC emerged from the literature. Together with Bloom's taxonomy and Kirkpatrick's educational model, these themes informed the development of this PQIC protocol. It was piloted in three steps: education, coaching and evaluation. A survey revealed that the participants in the education step achieved excellent scores. Following the coaching journey, the coached multidisciplinary team leaders completed their improvement initiatives and demonstrated increased QI knowledge and skills measured by the 'IHI improvement advisor self-assessment tool' and 'IHI assessment scale for collaboratives'.

CONCLUSION

Built on established education, peer coaching and QI concepts, this evidence-based PQIC protocol adds to international evidence on how to support front-line healthcare workers in their improvement efforts. Future research needs to assess protocol effectiveness across different settings.

The ACR Mammography Positioning Improvement Collaborative: A Multicenter Improvement Program Within a Learning Network Framework

PURPOSE/OBJECTIVE

To share the experience and results of the first cohort of the ACR Mammography Positioning Improvement Collaborative, in which participating sites aimed to increase the mean percentage of screening mammograms meeting the established positioning criteria to 85% or greater and show at least modest evidence of improvement at each site by the end of the improvement program.

METHODS

The sites comprising the first cohort of the collaborative were selected on the basis of strength of local leadership support, intra-organizational relationships, access to data and analytic support, and experience with quality improvement initiatives. During the improvement program, participating sites organized their teams, developed goals, gathered data, evaluated their current state, identified key drivers and root causes of their problems, and developed and tested interventions. A standardized image quality scoring system was also established. The impact of the interventions implemented at each site was assessed by tracking the percentage of screening mammograms meeting overall passing criteria over time.

RESULTS

Six organizations were selected to participate as the first cohort, beginning with participation in the improvement program. Interventions developed and implemented at each site during the program resulted in improvement in the average percentage of screening mammograms meeting overall passing criteria per week from a collaborative mean of 51% to 86%, with four of six sites meeting or exceeding the target mean performance of 85% by the end of the improvement program. Afterward, all respondents to the postprogram survey indicated that the program was a positive experience.

CONCLUSION

Using a structured improvement program within a learning network framework, the first cohort of the collaborative demonstrated that improvement in mammography positioning performance can be achieved at multiple sites simultaneously and validated the hypothesis that local sites' shared experiences, insights, and learnings would not only improve performance but would also build a community of improvers collaborating to create the best experience for technologists, staff, and patients.

Improving Prostate MR Image Quality in Practice-Initial Results From the ACR Prostate MR Image Quality Improvement Collaborative

OBJECTIVE

Variability in prostate MRI quality is an increasingly recognized problem that negatively affects patient care. This report aims to describe the results and key learnings of the first cohort of the ACR Learning Network Prostate MR Image Quality Improvement Collaborative.

METHODS

Teams from five organizations in the United States were trained on a structured improvement method. After reaching a consensus on image quality and auditing their images using the Prostate Imaging Quality (PI-QUAL) system, teams conducted a current state analysis to identify barriers to obtaining high-quality images. Through plan-do-study-act cycles involving frontline staff, each site designed and tested interventions targeting image quality key drivers. The percentage of examinations meeting quality criteria (ie, PI-QUAL score ≥4) was plotted on a run chart, and project progress was reviewed in weekly meetings. At the collaborative level, the goal was to increase the percentage of examinations with PI-QUAL ≥4 to at least 85%.

RESULTS

Across 2,380 examinations audited, the mean weekly rates of prostate MR examinations meeting image quality criteria increased from 67% (range: 60%-74%) at baseline to 87% (range: 80%-97%) upon program completion. The most commonly employed interventions were MR protocol adjustments, development and implementation of patient preparation instructions, personnel training, and development of an auditing process mechanism.

CONCLUSION

A learning network model, in which organizations share knowledge and work together toward a common goal, can improve prostate MR image quality at multiple sites simultaneously. The inaugural cohort's key learnings provide a road map for improvement on a broader scale.

Gap analysis of strategies for promoting interprofessional teams in healthcare units

PURPOSE

A healthcare unit's effectiveness largely depends on how well its interprofessional teams work together. Unfortunately, the strategies used to improve these teams often lack substance. This study analyzed these strategies and found a performance gap.

DESIGN/METHODOLOGY/APPROACH

This study took a unique mixed-method approach, systematically reviewing both qualitative and quantitative studies that identified strategies to enhance interprofessional teams in healthcare units. To gauge the effectiveness of these strategies, the researcher utilized an Importance-Performance Analysis (IPA) in four specialized clinical training centers in Hamadan province, Iran. The analysis of the IPA involved 35 experts from these centers as the statistical population.

FINDINGS

Based on a systematic review, there are seven categories: contextual, strategic, communication, organizational, individual, Human Resources Management (HRM), and environmental for promoting interprofessional teams with a total of 36 sub-indicator. Based on the IPA, the HRM aspect shows the most extensive performance gap. The individual and organizational aspects fall under resource wastage, and the environmental aspect is within the indifferent zone. Also, some critical sub-indicators, such as incentives/rewards, roles and responsibilities, financial resources, team-initiated innovation, the culture of respect, partner resources, humility, data availability, set expectations, and team availability, are in the weak areas.

PRACTICAL IMPLICATIONS

This research has identified critical areas for improvement in promoting teamwork in clinical training centers through a comprehensive gap analysis. It also presents practical policy solutions to address these weak points, providing a clear roadmap for enhancing interprofessional teams in healthcare units.

ORIGINALITY/VALUE

Improving teamwork in healthcare can be challenging, but it is possible with proper strategies and tools. One of the highlights of the recent study was the combination of systematic review studies with IPA to identify areas for improving interprofessional teamwork in clinical training centers.

Education Research: Sustained Implementation of Quality Improvement Practices Is Observed in Early Career Physicians Following a Neurology Resident QI Curriculum

Background and Objectives

The Accreditation Council for Graduate Medical Education and American Board of Psychiatry and Neurology expect engagement in quality improvement (QI) activities for all residents and practicing neurologists. Our neurology residency program instituted an experiential Neurology Residency QI Curriculum in 2015 for all residents. In this study, we aimed to characterize the role of QI engagement in the early-career paths of program graduates.

Methods

We distributed an online survey evaluating QI training, scholarship, and leadership (before, during, and after residency training) to all individuals who graduated from our residency program (graduation years 2017-2021). Primary outcomes were QI project leadership or mentorship and QI scholarship (projects, posters, and publications) after residency. Predictors of these outcomes were also evaluated using Fisher exact test.

Results

Twenty-nine of 50 graduates (58%) completed the survey. Median time from residency graduation was 3 years. Of the respondents, 14% actively participated in a QI project before residency, 83% during residency, and 48% after graduating. In addition, 41% had led or mentored a QI project and 34% had performed QI scholarship since residency. Fourteen percent of participants held formal roles in QI or patient safety, while 24% received formal full-time equivalents for QI work. Significant predictors (p < 0.05) of QI leadership included older age, time since graduation, rank, and participation in Clinical Effectiveness Leadership Training (CELT-an institutional QI faculty development course). Significant predictors (p < 0.05) of QI scholarship included older age, time since graduation, participation in CELT, and participation in QI scholarship during residency. QI training, participation, and/or project leadership before residency did not predict either QI leadership or scholarship after residency.

Discussion

Many neurology residency graduates continued to lead QI projects and produce QI scholarship in the early years after graduation. However, receiving protected time for leadership and academic work in this area is uncommon. Our findings suggest that more infrastructure, including training, career development, and mentorship, can foster neurologists interested in leading in quality and patient safety. In academic models, promotion pathways that support academic advancement for faculty leading in QI are needed.

Catalyzing System Change: 100 Quality Improvement Projects in 1000 Days

BACKGROUND

Health system change requires quality improvement (QI) infrastructure that supports frontline staff implementing sustainable innovations. We created an 8-week rapid-cycle QI training program, Stanford Primary Care-Project Engagement Platform (PC-PEP), open to patient-facing primary care clinicians and staff.

OBJECTIVE

Examine the feasibility and outcomes of a scalable QI program for busy practicing providers and staff in an academic medical center.

DESIGN

Program evaluation.

PARTICIPANTS

A total of 172 PCPH team members: providers (n = 55), staff (n = 99), and medical learners (n = 18) in the Stanford Division of Primary Care and Population Health (PCPH) clinics, 2018-2021.

MAIN MEASURES

We categorized projects by the Institute for Healthcare Improvement's (IHI) Quintuple Aim (QA): better health, better patient experience, lower cost of care, better care team experience, and improved equity/inclusion. We assessed project progress with a modified version of The Ottawa Hospital Innovation Framework: step 1 (identified root causes), step 2 (designed/tested interventions), step 3 (assessed project outcome), step 4 (met project goal with target group), step 5A (intervention(s) spread within clinic), step 5B (intervention(s) spread to different setting). Participants rated post-participation QI self-efficacy.

KEY RESULTS

Within 1000 days, 172 unique participants completed 104 PC-PEP projects. Most projects aimed to improve patient health (55%) or care team experience (23%). Among projects, 9% reached step 1, 8% step 2, 16% step 3, 26% step 4, 21% step 5A, and 20% step 5B. Learner involvement increased likelihood of scholarly products (47% vs 10%). Forty-six of 47 (98%) survey respondents reported improved QI self-efficacy. Medical assistants, more so than physicians, reported feeling acknowledged by the health system for their QI efforts (100% vs 61%).

CONCLUSIONS

With appropriate QI infrastructure, scalable QI training models like Stanford PC-PEP can empower frontline workers to create meaningful changes across the IHI QA.

Improving On-Time Starts for Pediatric Cardiac MRI

PURPOSE

Delayed start times for cardiac MRI examinations have resulted in longer patient fasts, extended wait times, and poor synchronization of anesthesia induction and contrast administration. The aim of this work was to improve on-time start rates from an initial baseline of 10%.

METHODS

A multidisciplinary team comprising members of the cardiac and radiology services used the Realizing Improvement Through Team Empowerment methodology to target the root causes of the delays and enhance workflow. The main factors identified as contributing to examination delays were late patient arrival, variations in patient preparation time, unavailability of equipment, and inefficient scheduling processes.

RESULTS

The implementation of various interventions, such as the use of standardized appointment scripts, ensuring timely patient preparation, and ensuring the availability of equipment when required, resulted in an increase in on-time start rates for cardiac MRI examinations to 34%.

CONCLUSIONS

The study's systematic approach proved to be valuable in both understanding and resolving the identified problems. Through the continuous application of plan-do-study-act cycles, the authors effectively pinpointed obstacles and tested multiple potential measures to overcome them. This approach made it possible to comprehend the issue and to implement targeted interventions to address it.

A quality-improvement approach to urgent-care antibiotic stewardship for respiratory tract infections during the COVID-19 pandemic: Lessons learned

OBJECTIVE

We investigated a decrease in antibiotic prescribing for respiratory illnesses in 2 academic urgent-care clinics during the coronavirus disease 2019 (COVID-19) pandemic using semistructured clinician interviews.

METHODS

We conducted a quality-improvement project from November 2020 to May 2021. We investigated provider antibiotic decision making using a mixed-methods explanatory design including interviews. We analyzed transcripts using a thematic framework approach to identify emergent themes. Our performance measure was antibiotic prescribing rate (APR) for encounters with respiratory diagnosis billing codes. We extracted billing and prescribing data from the electronic medical record and assessed differences using run charts, p charts and generalized linear regression.

RESULTS

We observed significant reductions in the APR early during the COVID-19 pandemic (relative risk [RR], 0.20; 95% confidence interval [CI], 0.17-0.25), which was maintained over the study period (P < .001). The average APRs were 14% before the COVID-19 pandemic, 4% during the QI project, and 7% after the project. All providers prescribed less antibiotics for respiratory encounters during COVID-19, but only 25% felt their practice had changed. Themes from provider interviews included changing patient expectations and provider approach to respiratory encounters during COVID-19, the impact of increased telemedicine encounters, and the changing epidemiology of non-COVID-19 respiratory infections.

CONCLUSIONS

Our findings suggest that the decrease in APR was likely multifactorial. The average APR decreased significantly during the pandemic. Although the APR was slightly higher after the QI project, it did not reach prepandemic levels. Future studies should explore how these factors, including changing patient expectations, can be leveraged to improve urgent-care antibiotic stewardship.

Optimization of non-endorectal prostate MR image quality using PI-QUAL: A multidisciplinary team approach

PURPOSE

To evaluate the utility of the PI-QUAL score in assessing protocol changes aimed to improve image quality from a non-endorectal coil prostate MR imaging protocol during a 9-month quality improvement (QI) project and to quantify the inter-reader agreement of PI-QUAL scores between radiologists, technologists, and physicists.

METHODS

This retrospective study audited 1,012 multiparametric prostate MRI examinations as part of a national QI project according to the PI-QUAL standard. PI-QUAL scores were used to inform MR protocol changes. Following the project, 4 radiologists, 2 technologists, and 1 medical physicist collectively audited an additional set of 150 examinations to identify statistical improvements in image quality using the two-tailed Wilcoxon rank sum test. The improvements due to individual protocol changes were assessed among subsets of the 1,012 examinations which compared examinations occurring before and after the isolated protocol change. Inter-reader variability was assessed using the percent majority agreement and the average standard deviation of PI-QUAL scores between evaluators.

RESULTS

During this QI project, PI-QUAL scores improved from 3.67 ± 0.75 to 4.16 ± 0.59 (p < 0.01) after implementing a series of protocol changes. Among a subset of 451 cases, we found that adopting R/L rather than A/P phase encoding reduced distortion in diffusion-weighted imaging (DW) from 21.6% (41/190 A/P phase encoded cases) to 11.5% (30/261 R/L phase encoded cases) (p < 0.01). Similarly, in the same 451 cases, adopting R/L phase encoding in T2WI reduced breathing motion artifacts from 34.6% (94/272 A/P phase encoding cases) to 12.8% (23/179 R/L phase encoding cases) (p < 0.01). DWI wraparound artifact was mitigated by employing a full-pelvis shim and enabling the abdomen shim option. The occurrence of low signal-to-noise ratio was reduced from 19.4% (19/98 cases without a weight-based threshold) to 6.3% (10/160) by instituting a weight-based threshold for using an endorectal coil (p < 0.01). The percent majority agreement was similar between radiologists, technologists and physicists, and all evaluators combined (72%, 77%, and 67%, respectively).

CONCLUSIONS

PI-QUAL can evaluate image quality changes resulting from protocol optimizations at both the exam- and series-levels. With training, radiologists, technologists, and physicists can perform PI-QUAL scoring with similar performance. Broadening the scope of the quality improvement team can result in meaningful and lasting change.

American College of Radiology initiatives on prostate magnetic resonance imaging quality

Magnetic resonance imaging (MRI) has become integral to diagnosing and managing patients with suspected or confirmed prostate cancer. However, the benefits of utilizing MRI can be hindered by quality issues during imaging acquisition, interpretation, and reporting. As the utilization of prostate MRI continues to increase in clinical practice, the variability in MRI quality and how it can negatively impact patient care have become apparent. The American College of Radiology (ACR) has recognized this challenge and developed several initiatives to address the issue of inconsistent MRI quality and ensure that imaging centers deliver high-quality patient care. These initiatives include the Prostate Imaging Reporting and Data System (PI-RADS), developed in collaboration with an international panel of experts and members of the European Society of Urogenital Radiology (ESUR), the Prostate MR Image Quality Improvement Collaborative, which is part of the ACR Learning Network, the ACR Prostate Cancer MRI Center Designation, and the ACR Appropriateness Criteria. In this article, we will discuss the importance of these initiatives in establishing quality assurance and quality control programs for prostate MRI and how they can improve patient outcomes.

The ACR Learning Network: Facilitating Local Performance Improvement Through Shared Learning

PURPOSE

The ACR Learning Network was established to test the viability of the learning network model in radiology. In this report, the authors review the learning network concept, introduce the ACR Learning Network and its components, and report progress to date and plans for the future.

METHODS

Patterned after institutional programs developed by the principal investigator, the ACR Learning Network was composed of four distinct improvement collaboratives. Initial participating sites were solicited through broad program advertisement. Candidate programs were selected on the basis of assessments of local leadership support, experience with quality improvement initiatives, intraorganizational relationships, and access to data and analytic support. Participation began with completing a 27-week formal quality improvement training and project support program, with local teams reporting weekly progress on a common performance measure.

RESULTS

Four improvement collaborative topics were chosen for the initial cohort with the following numbers of participating sites: mammography positioning (6), prostate MR image quality (6), lung cancer screening (6), and follow-up on recommendations for management of incidental findings (4). To date, all sites have remained actively engaged and have progressed in an expected fashion. A detailed report of the results of the improvement phase will be provided in a future publication.

CONCLUSIONS

To date, the ACR Learning Network has successfully achieved planned milestones outlined in the program's plan, with preparation under way for the second and third cohorts. By providing a shared platform for improvement training and knowledge sharing, the authors are optimistic that the network may facilitate widespread performance improvement in radiology on a number of topics for years to come.

Results of a Virtual Multi-Institutional Program for Quality Improvement Training and Project Facilitation

OBJECTIVE

The purpose of this project was to describe the results of a multi-institutional quality improvement (QI) program conducted in a virtual format.

METHODS

Developed at Stanford in 2016, the Realizing Improvement Through Team Empowerment program uses a team-based, project-based improvement approach to QI. The program was planned to be replicated at two other institutions through respective on-site programs but was converted to a multi-institutional virtual format in 2020 in response to the COVID-19 pandemic. The virtual program began in July 2020 and ended in December 2020. The two institutions participated jointly in the cohort, with 10 2-hour training sessions every 2 weeks for a total of 18 weeks. Project progress was monitored using a predetermined project progress scale by the program manager, who provided more direct project support as needed.

RESULTS

The cohort consisted of six teams (37 participants) from two institutions. Each team completed a QI project in subjects including MRI, ultrasound, CT, diagnostic radiography, and ACR certification. All projects reached levels of between 3.0 (initial test cycles begun with evidence of modest improvement) and 4.0 (performance data meeting goal and statistical process control criteria for improvement) and met graduation criteria for program completion.

DISCUSSION

We found the structured problem-solving method, along with timely focused QI education materials via a virtual platform, to be effective in simultaneously facilitating improvement projects from multiple institutions. The combination of two institutions fostered encouragement and shared learning across institutions.

Organization-Wide Approaches to Foster Effective Unit-Level Efforts to Improve Clinician Well-Being

Health care delivery organizations are positioned to have a tremendous impact on addressing the variables in the practice environment that contribute to occupational distress and that, when optimized, can promote clinician well-being. Many organizations are committed to this work and have clarity on how to address general, system-wide issues and provide resources for individual clinicians. While such top of the organization elements are essential for success, many of the specific improvement efforts that are necessary must address local challenges at the work unit level (department, division, hospital ward, clinic). Uncertainty of how to address variability and the unique needs of different work units is a barrier to effective action for many health care delivery systems. Overcoming this challenge requires organizations to recognize that unit-specific improvement efforts require a system-level approach. In this manuscript, we outline 7 steps for organizations to consider as they establish the infrastructure to improve professional well-being and provide a description of application and evidence of efficacy from a large academic medical center. Such unit-level efforts to address the unique needs of each specialty and occupation at the work unit level have the ability to address many of the day-to-day issues that drive clinician well-being. An enterprise approach is necessary to systematically advance such unit-level action.

Evaluation of Interventions Targeting Follow-up Appointment Scheduling After Emergency Department Referral to Ophthalmology Clinics Using A3 Problem Solving

Importance

Many patients seen for eye-related issues in the emergency department do not receive recommended follow-up care. Prior evidence supports that scheduling appointments is a barrier to accomplishing the transition to outpatient ophthalmology care.

Objective

To evaluate time until appointment scheduling following emergency department discharge with urgent outpatient ophthalmology referral.

Design, Setting, and Participants

The A3 problem solving process was implemented by a multidisciplinary team as part of a structured quality improvement program with the goal of reducing the mean time between urgent referral placement in the emergency department and outpatient ophthalmology appointment scheduling. The study was conducted at Stanford Health Care, an academic medical center in Palo Alto, California, affiliated with Stanford University School of Medicine. Using medical center administrative records, all patients discharged from the adult emergency department with an urgent outpatient referral to the Stanford Department of Ophthalmology from August 9 to September 19, 2020 (baseline; n = 43), and from October 26 to November 29, 2020 (after implementation of all interventions; n = 21), were included.

Interventions

Interventions developed to target the workflow of the ophthalmology resident, emergency department, ophthalmology clinic, and health system schedulers to address key drivers of the referral-scheduling process included medical record documentation guidelines, identification of responsible parties, preidentified appointment slots, patient education materials, and education of stakeholders, and were implemented by October 25, 2020.

Main Outcomes and Measures

Mean time between urgent referral placement (ie, emergency department discharge) and appointment scheduling with outpatient ophthalmology at baseline vs postintervention.

Results

At baseline, appointments were scheduled a mean (range) 2.8 (0-7) days after referral placement. In the 5 weeks following implementation of interventions, the mean (range) decreased to 1.3 (0-4) days, a difference of 1.5 days (95% CI, 0.20-2.74; P = .02). This corresponds to 642 (95% CI, 86-1173) days of reduced patient wait time annually. In addition, there was less variability in the number of days between referral and appointment scheduling after intervention compared with baseline.

Conclusions and Relevance

The results suggest improvement in efficiency of outpatient ophthalmology appointment scheduling of urgent emergency department referrals could be achieved through application of a quality improvement methodology by a multidisciplinary team representing key stakeholders in the process.

Increasing the Utilization of Moderate Sedation Services for Pediatric Imaging

Performing motion-free imaging is frequently challenging in children. To bridge the gap between examinations performed in children who are awake and in those under general anesthesia, a moderate sedation program was implemented at our institution but was seldom used despite substantial eligibility. In conjunction with a 5-month quality improvement (QI) course, a multidisciplinary team was assembled and, by using an A3 approach, sought to address the most important key drivers of low utilization, namely the need for clear moderate sedation eligibility criteria, reliable protocol routing order, consistent moderate sedation screening performed by registered nurses (RNs), and enhanced visibility of moderate sedation services to ordering providers. Initial steps focused on developing better-defined criteria and protocoling standard work for technologists and RNs, with coaching and audits. Modality-specific forecasting was then implemented to reroute profiles of patients who were awaiting scheduling or already scheduled for an examination with general anesthesia to the moderate sedation queue to identify more eligible patients. These manual efforts were coupled with higher reliability but more protracted electronic health record changes, facilitating automated protocol routing on the basis of moderate sedation eligibility and order entry constraints. As a result, scheduled imaging examinations requiring moderate sedation increased from a mean of 1.2 examinations per week to a sustained 6.1 examinations per week (range, 4-8) over the 5-month period, exceeding the team SMART (specific, measurable, achievable, relevant, and time bound) goal to achieve an average of five examinations per week by the QI course end. By targeting the most high-impact yet modifiable process deficiencies through a multifaceted team approach and initially investing in manual efforts to gain cultural buy-in while awaiting higher-reliability interventions, the project achieved success and may serve as a more general model for workflow change when there is organizational resistance. ^©RSNA, 2021.

Development and Progress of a Collaborative Learning Model for Quality Improvement in the Field of Palliative Care in India

Quality is central to healthcare and even more so in the field of palliative care. Palliative care approach is centered around discovering facets of care crucial to improving the quality of life of the patient; be it symptom control, emotional concerns, impact on social roles or reviving the sense of spiritual connectedness. Although there are essential and desirable standards for quality of services, the journey taken by a service, toward quality improvement (QI), is often complex and uncharted. It is up to individual service units to strive toward improvement and reach higher levels of quality. Evidence suggests using a structured methodology for successful improvement in healthcare quality, as most problems are complex and multifaceted. This article introduces the concept and application of QI methodology in the field of palliative care in India and provides an overview of the first cohort of QI projects, facilitated through an international collaborative. The sequence of training, the tools, and the key ingredients for success are enumerated.

Work Climate Scale in Emergency Services: Abridged Version

This study is based on a 40-item work climate scale in hospital emergency services (WCSHES). Teams working in these emergency services experience a heavy workload and have a limited amount of time with each patient. COVID-19 has further complicated these existing issues. Therefore, we believed it would be helpful to draft an abridged version of the 40-item WCSHES, considering both validity and reliability criteria, but giving greater weight to validity. One hundred and twenty-six workers between the ages of 20 to 64 (M = 32.45; standard deviation (SD = 9.73)) years old participated voluntarily in the study. The validity, reliability, and fit model were evaluated in an iterative process. The confirmatory factor analysis yielded appropriate global fit indices in the abridged 24-item version (Χ²(248) = 367.84; p < 0.01, RMSEA = 0.06 with an interval of 90% from 0.05 to 0.07, SRMR = 0.08, GFI = 0.9, AGFI = 0.96, CFI = 0.98, NFI = 0.95, and NNFI = 0.98), along with test criteria validity (ρ_XY = 0.68, p < 0.001) and excellent reliability (α = 0.94 and ω = 0.94), maintaining the same conceptualization and usefulness of the original scale. The abridged 24-item version was used to measure four work climate factors (work satisfaction, productivity/achievement of aims, interpersonal relations, and performance at work). Evidence of the usefulness of the new abridged scale is provided along with a description of our study limitations and future areas for development.

Program for Supporting Frontline Improvement Projects in an Academic Radiology Department

OBJECTIVE. The purpose of this study was to describe the results of an ongoing program implemented in an academic radiology department to support the execution of small- to medium-size improvement projects led by frontline staff and leaders. MATERIALS AND METHODS. Staff members were assigned a coach, were instructed in improvement methods, were given time to work on the project, and presented progress to department leaders in weekly 30-minute reports. Estimated costs and outcomes were calculated for each project and aggregated. An anonymous survey was administered to participants at the end of the first year. RESULTS. A total of 73 participants completed 102 projects in the first 2 years of the program. The project type mix included 25 quality improvement projects, 22 patient satisfaction projects, 14 staff engagement projects, 27 efficiency improvement projects, and 14 regulatory compliance and readiness projects. Estimated annualized outcomes included approximately 4500 labor hours saved, $315K in supply cost savings, $42.2M in potential increased revenues, 8- and 2-point increase in top-box patient experience scores at two clinics, and a 60-incident reduction in near-miss safety events. Participant time equated to approximately 0.35 full-time equivalent positions per year. Approximately 0.4 full-time equivalent was required to support the program. Survey results indicated that the participants generally viewed the program favorably. CONCLUSION. The program was successful in providing a platform for simultaneously solving a large number of organizational problems while also providing a positive experience to frontline personnel.

The Palliative Care-Promoting Access and Improvement of the Cancer Experience (PC-PAICE) Project in India: A Multisite International Quality Improvement Collaborative

Mentors at seven U.S. and Australian academic institutions initially partnered with seven leading Indian academic palliative care and cancer centers in 2017 to undertake a program combining remote and in-person mentorship, didactic instruction, and project-based learning in quality improvement (QI). From its inception in 2017 to 2020, the Palliative Care-Promoting Accesst and Improvement of the Cancer Experience Program conducted three cohorts for capacity building of 22 Indian palliative care and cancer programs. Indian leadership established a Mumbai QI training hub in 2019 with philanthropic support. In 2020, the project which is now named Enable Quality, Improve Patient care - India (EQuIP-India) focuses on both palliative care and cancer teams. EQuIP-India now leads ongoing Indian national collaboratives and training in QI and is integrated into India's National Cancer Grid. Palliative Care-Promoting Accesst and Improvement of the Cancer Experience demonstrates a feasible model of international collaboration and capacity building in palliative care and cancer QI. It is one of the several networked and blended learning approaches with potential for rapid scaling of evidence-based practices.

A realist synthesis of quality improvement curricula in undergraduate and postgraduate medical education: what works, for whom, and in what contexts?

BACKGROUND

With the integration of quality improvement (QI) into competency-based models of physician training, there is an increasing requirement for medical students and residents to demonstrate competence in QI. There may be factors that commonly facilitate or inhibit the desired outcomes of QI curricula in undergraduate and postgraduate medical education. The purpose of this review was to synthesise attributes of QI curricula in undergraduate and postgraduate medical education associated with curricular outcomes.

METHODS

A realist synthesis of peer-reviewed and grey literature was conducted to identify the common contexts, mechanisms, and outcomes of QI curricula in undergraduate and postgraduate medical education in order to develop a programme theory to articulate what works, for whom, and in what contexts.

RESULTS

18854 records underwent title and abstract screening, full texts of 609 records were appraised for eligibility, data were extracted from 358 studies, and 218 studies were included in the development and refinement of the final programme theory. Contexts included curricular strategies, levels of training, clinical settings, and organisational culture. Mechanisms were identified within the overall QI curricula itself (eg, clear expectations and deliverables, and protected time), in the didactic components (ie, content delivery strategies), and within the experiential components (eg, topic selection strategies, working with others, and mentorship). Mechanisms were often associated with certain contexts to promote educational and clinical outcomes.

CONCLUSION

This research describes the various pedagogical strategies for teaching QI to medical learners and highlights the contexts and mechanisms that could potentially account for differences in educational and clinical outcomes of QI curricula. Educators may benefit from considering these contexts and mechanisms in the design and implementation of QI curricula to optimise the outcomes of training in this competency area.

Fortifying Our Teams to Best Serve Our Patients: A Report of the 2019 Summer Intersociety Meeting

Continuing the thematic focus on fostering wellness and professional fulfillment in our workplace, the 2019 Radiology Intersociety Committee Conference focused on understanding and leading multigenerational workforces and developing high-functioning teams. To lead a multigenerational workforce and to understand and embrace traditional versus emerging cultures in our workplace, effective leaders should foster diversity of their teams. Sustaining such teams requires an understanding of different styles and preferences for bidirectional communication and clarity of information sharing and learning; active efforts may be needed to focus on practical approaches to succession planning, breaking down traditional hierarchies, clarifying role delineation, and managing authority gradients. An effective team requires attention to the well-being of team members and professional behavior in and out of the workplace. Conference participants unanimously endorsed multi-organizational support statements and activities assuring professional behavior of their members, along with the desire to explore codes of conduct and ethics.

Education Research: A novel resident-driven neurology quality improvement curriculum

OBJECTIVE

To describe and assess the effectiveness of a neurology resident quality improvement curriculum focused on development of practical skills and project experience.

METHODS

We designed and implemented a quality improvement curriculum composed of (1) a workshop series and (2) monthly resident-led Morbidity, Mortality, & Improvement conferences focused on case analysis and project development. Surveys were administered precurriculum and 18 months postcurriculum to assess the effect on self-assessed confidence with quality improvement skills, attitudes, and project participation. Scholarship in the form of posters, presentations, and manuscripts was tracked during the course of the study.

RESULTS

Precurriculum, 83% of neurology residents felt that instruction in quality improvement was important, but most rated their confidence level with various skills as low. Following implementation of the curriculum, residents were significantly more confident in analyzing a patient case (odds ratio, 95% confidence interval) (2.4, 1.9-3.1), proposing system changes (3.1, 2.3-3.9), writing a problem statement (9.9, 6.2-13.5), studying a process (3.1, 2.3-3.8), identifying resources (3.1, 2.3-3.8), identifying appropriate measures (2.5, 1.9-3.0), collaborating with other providers to make improvements (4.9, 3.5-6.4), and making changes in a system (3.1, 2.3-3.8). Project participation increased from the precurriculum baseline (7/18, 39%) to the postcurriculum period (17/22, 77%; p = 0.023). One hundred percent of residents surveyed rated the curriculum positively.

CONCLUSIONS

Our multifaceted curriculum was associated with increased resident confidence with quality improvement skills and increased participation in improvement projects. With adequate faculty mentorship, this curriculum represents a novel template for preparing neurology residents for meeting the expectations of improvement in practice and offers scholarship opportunities.

Implementing a Radiology Residency Quality Curriculum to Develop Physician Leaders and Increase Value for Patients

Diagnostic and interventional radiology residency programs must educate trainees on quality and patient safety topics to meet board requirements and prepare residents to become effective physician leaders. A quality curriculum should encompass process improvement methodology as well as instruction about crucial patient safety subjects. The authors have developed a standardized and structured approach to fulfill this need using didactic and experiential learning. The educational format includes short lectures, peer-to-peer instruction, and self-study, with the value of presented information reinforced by physician leaders and process improvement specialists. Equally important is a structured experience in departmental quality improvement wherein trainees learn the collaborative nature of effective durable process change in areas of interest to them. This curriculum is implemented during the 3rd year of radiology residency to leverage residents' knowledge and experience with radiology workflows and proximity to the American Board of Radiology Core Exam. Feedback from educators and trainees as well as objective examination data support this approach. This article shares guidance and lessons learned from the authors' radiology residency educational efforts and offers a framework for successful implementation of a comprehensive quality curriculum at any residency training program. This curriculum serves the dual purpose of developing skilled future physician leaders and promoting value for patients. ^©RSNA, 2020.

Social Media Tools for Department and Practice Communication and Branding in the Digital Age

With nearly 70% of adults in the United States using at least one social media platform, a social media presence is increasingly important for departments and practices. Patients, prospective faculty and trainees, and referring physicians look to social media to find information about our organizations. The authors present a stepwise process for planning, executing, and evaluating an organizational social media strategy. This process begins with alignment with a strategic plan to set goals, identification of the target audience(s), selection of appropriate social media channels, tracking effectiveness, and resource allocation. The article concludes with a discussion of advantages and disadvantages of social media through a review of current literature. ^©RSNA, 2018.

Interprofessional Teams: Current Trends and Future Directions

This article addresses the current and desired future state of interprofessional practice in pediatric hospital medicine. It focuses on identifying optimal team composition and work patterns, describing the value of parent involvement on both the patient's care team and on operational teams, describing the need for interprofessional education, and identifying outcomes associated with interprofessional teamwork. The article also identifies challenges and opportunities for growth as interprofessional teamwork increasingly becomes a standard practice within healthcare settings.

A Road Map to Foster Wellness and Engagement in Our Workplace-A Report of the 2018 Summer Intersociety Meeting

The 2018 radiology Intersociety Committee reviewed the current state of stress and burnout in our workplaces and identified approaches for fostering engagement, wellness, and job satisfaction. In addition to emphasizing the importance of personal wellness (the fourth aim of health care), the major focus of the meeting was to identify strategies and themes to mitigate the frequency, manifestations, and impact of stress. Strategies include reducing the stigma of burnout, minimizing isolation through community building and fostering connectivity, utilizing data and benchmarking to guide effectiveness of improvement efforts, resourcing and training "wellness" committees, acknowledging value contributions of team members, and improving efficiency in the workplace. Four themes were identified to prioritize organizational efforts: (1) collecting, analyzing, and benchmarking data; (2) developing effective leadership; (3) building high-functioning teams; and (4) amplifying our voice to increase our influence.

Process improvement for reducing side discrepancies in radiology reports

Background

Laterality errors in radiology reports can lead to serious errors in management.

Purpose

To reduce errors related to side discrepancies in radiology reports from thoracic imaging by 50% over a six-month period with education and voice recognition software tools.

Material and Methods

All radiology reports at the Thoracic Imaging Division from the fourth quarter of 2016 were reviewed manually for presence of side discrepancies (baseline data). Side discrepancies were defined as a lack of consistency in side labeling of any abnormality in the “Findings” to “Impression” sections of the reports. Process map and Ishikawa fishbone diagram (Microsoft Visio) were created. All thoracic radiologists were educated on side-related errors in radiology reports for plan–design–study–act cycle 1 (PDSA #1). Two weeks later, voice recognition software was configured to capitalize sides (RIGHT and LEFT) in the reports during dictated (PDSA# 2). Radiology reports were analyzed to determine side-discrepancy errors following each PDSA cycle (post-interventional data). Statistical run charts were created using QI Macros statistical software.

Results

Baseline data revealed 33 side-discrepancy errors in 47,876 reports with an average of 2.5 errors per week (range = 1–8 errors). Following PDSA #1, there were seven errors pertaining to side discrepancies over a two-week period. Errors declined following implementation of PDSA #2 to meet the target of 0.85 side-discrepancy error per week over seven weeks.

Conclusion

Automated processes (such as capitalization of sides) help reduce left/right errors substantially without affecting reporting turnaround time.

Improving Performance of Mammographic Breast Positioning in an Academic Radiology Practice

OBJECTIVE

The purpose of this project was to achieve sustained improvement in mammographic breast positioning in our department.

MATERIALS AND METHODS

Between June 2013 and December 2016, we conducted a team-based performance improvement initiative with the goal of improving mammographic positioning. The team of technologists and radiologists established quantitative measures of positioning performance based on American College of Radiology (ACR) criteria, audited at least 35 mammograms per week for positioning quality, displayed performance in dashboards, provided technologists with positioning training, developed a supportive environment fostering technologist and radiologist communication surrounding mammographic positioning, and employed a mammography positioning coach to develop, improve, and maintain technologist positioning performance. Statistical significance in changes in the percentage of mammograms passing the ACR criteria were evaluated using a two-proportion z test.

RESULTS

A baseline mammogram audit performed in June 2013 showed that 67% (82/122) met ACR passing criteria for positioning. Performance improved to 80% (588/739; p < 0.01) after positioning training and technologist and radiologist agreement on positioning criteria. With individual technologist feedback, positioning further improved, with 91% of mammograms passing ACR criteria (p < 0.01). Seven months later, performance temporarily decreased to 80% but improved to 89% with implementation of a positioning coach. The overall mean performance of 91% has been sustained for 23 months. The program cost approximately $30,000 to develop, $42,000 to launch, and $25,000 per year to maintain. Almost all costs were related to personnel time.

CONCLUSION

Dedicated performance improvement methods may achieve significant and sustained improvement in mammographic breast positioning, which may better enable facilities to pass the recently instated Enhancing Quality Using the Inspection Program portion of a practice's annual Mammography Quality Standards Act inspections.

Decreasing Stroke Code to CT Time in Patients Presenting with Stroke Symptoms

Guided quality improvement (QI) programs present an effective means to streamline stroke code to computed tomography (CT) times in a comprehensive stroke center. Applying QI methods and a multidisciplinary team approach may decrease the stroke code to CT time in non-prenotified emergency department (ED) patients presenting with symptoms of stroke. The aim of this project was to decrease this time for non-prenotified stroke code patients from a baseline mean of 20 minutes to one less than 15 minutes during an 18-week period by applying QI methods in the context of a structured QI program. By reducing this time, it was expected that the door-to-CT time guideline of 25 minutes could be met more consistently. Through the structured QI program, we gained an understanding of the process that enabled us to effectively identify key drivers of performance to guide project interventions. As a result of these interventions, the stroke code to CT time for non-prenotified stroke code patients decreased to a mean of less than 14 minutes. This article reports these methods and results so that others can similarly improve the time it takes to perform nonenhanced CT studies in non-prenotified stroke code patients in the ED. ^©RSNA, 2017.

Avoiding failure: tools for successful and sustainable quality-improvement projects

Involvement in successful and sustained quality improvement can be a very rewarding experience. However, it can be very difficult work. Up to 70% of attempted organizational change is not sustained. There are many reasons why quality-improvement projects might not be successful. In this article, the author reviews items associated with an increased or decreased likelihood of success. Such items have been categorized as structural issues, human issues and environmental context. This paper is intended to serve those embarking on quality-improvement projects as a resource to help position them for success.