PAUL NAGY, PhD
QUALITY MATTERS
The Opportunity for the Medical Physicist in Quality Improvement As medical physicists, we have an opportunity to help lead quality improvement efforts beyond the traditional borders of the technical aspects of our profession. Our backgrounds and training uniquely suit us to provide leadership at a time when health care will need to restructure from a fee-for-service model toward a safer and accountable care organization. Medical physicists are the most technically trained individuals in radiology and radiation oncology, who have direct exposure to clinical operations. We work closely with the frontline providers in radiology to assist them, and at the same time we can step back and see the larger process. In many quality problems, the frontline providers can be too close to the problems and caught up with existing broken processes. A trusted physicist can provide the neutrality to help groups work more effectively to provide systems-based approaches. I was trained as a diagnostic medical physicist at an academic medical center in the early 1990s. My view of quality as a graduate student was performing phantom analysis on imaging equipment to measure image quality in terms of contrast, noise, and resolution limits. As part of these activities, I was able to work closely with technologists performing quality control surveys and radiologists in evaluating and correcting imaging artifacts. I was able to cross many organizational lines and gain a systemic perspective. Today I serve as the director of quality for a department of radiology and help coordinate a vast array of improvement projects, most of which are not related to the technical quality of the imaging equipment. Over the past 15 years, I
have had the privilege to mentor more than 100 quality improvement projects in radiology. I find that this role is a novel path for physicists. What I find surprising is just how rewarding this role is and how well my education and experiences in training have prepared me for it. In 1995, I had the opportunity to work for GE Medical Systems in x-ray tube engineering, as the company launched a new management program called the Six Sigma Quality Management System. Receiving a small dose of management skills through Six Sigma was a revelation to me. I have always enjoyed working with modeling data based on experimental observations. What I learned from Six Sigma training was that by combining a data-driven focus with lightweight project management tools and change management techniques, I could achieve far greater results. I learned to synthesize results into graphs as an effective way to communicate. As physicists, we are trained to solve technical problems. What I have come to appreciate is that even with the most technical of problems, there are nontechnical aspects with which we often struggle involving communication and behavior. Consider controlling dose creep in computed radiography or protocol variation in CT. Quality management methods have tools for effectively influencing behavior by creating an atmosphere of transparency, building feedback mechanisms, and role-modeling behavior among peers [1]. I found that I could be more effective by using quality management techniques as a complement to my technical skills. I returned to academic medicine in 2000 and
ª 2014 American College of Radiology 1546-1440/14/$36.00 http://dx.doi.org/10.1016/j.jacr.2014.03.001
went on to become director of quality for the departments I served. I have stumbled into an immensely rewarding role as a physicist providing analysis and guidance to clinical teams reinventing processes in radiology. Starting in 2015, the ABR will require physicists to conduct quality improvement projects as part of their maintenance of certification [2]. I see this as an opportunity to become more involved and add greater value to our practices and enrich our careers. For physicists not working directly for radiology departments, quality improvement partnerships are harder but not impossible. Consider techniques to expand your sphere of influence and create boundary-spanning leadership [3]. Physicists have a responsibility to supervise the quality of technologists, and effective physicists learn to build strong relationships with those groups. Letting sites know that you have an interest in helping them with quality improvement can strengthen your relationships and find new ways to provide value. USE QUALITY PROJECTS TO FORGE RELATIONSHIPS
Medical physicists need to perform quality projects to maintain their ABR certification. Use that as a springboard. Instead of doing a project on your own, look for a radiologist partner to work on a project together. Radiologists are required to perform quality projects as well by the ABR. Joint projects are acceptable as long as each principal provides leadership to the project. Many quality projects bring together people from across the 1
2 Quality Matters
department to solve process problems that cross through their areas. Working on a quality project is an act of team building. Bringing together individuals for a period of time to solve a problem will create new relationships, and effective projects must build sufficient trust in the team to overcome organizational resistance to change. These new relationships can open new opportunities for physicists. A technologist group may not be comfortable sharing problems and asking for help from a physicist with whom they don’t have a strong personal relationship. Working on an unrelated quality project can open those doors. WHERE TO START
I started working on quality projects related to image quality and radiation dose. I found great satisfaction moving beyond these projects into ones that worked on reducing contrast reactions, reducing time to imaging for patients with stroke, and ensuring rapid coordination with the operating room on missing sponge counts. First, use your quality improvement project as a method to build relationships and trust. If you find the process interesting, consider offering support for other projects. Let leadership know that you would be interested in helping others with their quality projects. The physicist is a natural fit to assist in the data analysis. Local quality improvement teams often struggle with data analysis. Assistance could entail helping to build and interpret runtime charts or running statistical
inference tests to assess the effectiveness of interventions. WHERE TO GO FURTHER
There are a couple of places a physicist should learn to mentor quality to others. The heart of quality management has progressive management ideas about empowering the front line to be agents of change for continuous innovation [4]. Quality has its own jargon, such as poka-yoke for errorproofing processes and gemba for leadership walkabouts. More important is learning the activities that lead a group through a quality project [5]. Building effective teams requires facilitation skills. Once an accurate workflow map has been generated, a facilitator needs to lead a group discussion around potential failure modes. It is important to have these points of the project be noncritical and inclusive so that good ideas are not squashed. The best experience in learning quality management is practice. Quality improvement is a highly applied management technique that depends greatly on the environment in which it is applied [6]. To get started, there are several weeklong training courses in the basics of health care quality improvement, either through societies such as the American Society of Quality or directly from academic medical systems. I am also fortunate to belong to an academic medical center that has residents. Residents are required to learn about quality improvement as part of the ACGME’s core competency of
systems-based practice. I continue to mentor and teach residents performing quality projects and find them to be great partners in working on projects. CONCLUSIONS
Quality is a genuine opportunity for medical physicists to support clinical operations and add tremendous value by fixing broken health care processes. Physicists often get to see more of the systemic process than frontline personnel and are well prepared for data-driven analysis. Physicists who enjoy working closer with clinical staff members and have an appreciation for quality management could find this a deeply rewarding role, just as I have. REFERENCES 1. Grenny J, Patterson K, Maxfield D, McMillan R, Switzler A. Influencer: the new science of leading change. 2nd ed. New York: McGraw-Hill; 2013. 2. American Board of Radiology. Maintenance of Certification participation guidelines. Available at: http://www.theabr.org/moc-rptime. Accessed February 2013. 3. Ernst C, Chrobot-Mason D. Boundary spanning leadership: six practices for solving problems, driving innovation, and transforming organizations. New York: McGrawHill; 2010. 4. Liker J. The Toyota way: 14 management principles from the world’s greatest manufacturer. New York: McGraw-Hill; 2009. 5. George M. The Lean Six Sigma pocket toolbook: a quick reference guide to 100 tools for improving quality and speed. New York: McGraw-Hill; 2004. 6. Davenport TH, Prusak L, Wilson HJ. What’s the big idea? Creating and capitalizing on the best new management thinking. Cambridge, MA: Harvard Business Press; 2003.
Paul Nagy, PhD, Johns Hopkins University, Department of Radiology, 600 North Wolfe Street, Baltimore, MD 21287; e-mail: [email protected].
QUALITY MATTERS
The Opportunity for the Medical Physicist in Quality Improvement As medical physicists, we have an opportunity to help lead quality improvement efforts beyond the traditional borders of the technical aspects of our profession. Our backgrounds and training uniquely suit us to provide leadership at a time when health care will need to restructure from a fee-for-service model toward a safer and accountable care organization. Medical physicists are the most technically trained individuals in radiology and radiation oncology, who have direct exposure to clinical operations. We work closely with the frontline providers in radiology to assist them, and at the same time we can step back and see the larger process. In many quality problems, the frontline providers can be too close to the problems and caught up with existing broken processes. A trusted physicist can provide the neutrality to help groups work more effectively to provide systems-based approaches. I was trained as a diagnostic medical physicist at an academic medical center in the early 1990s. My view of quality as a graduate student was performing phantom analysis on imaging equipment to measure image quality in terms of contrast, noise, and resolution limits. As part of these activities, I was able to work closely with technologists performing quality control surveys and radiologists in evaluating and correcting imaging artifacts. I was able to cross many organizational lines and gain a systemic perspective. Today I serve as the director of quality for a department of radiology and help coordinate a vast array of improvement projects, most of which are not related to the technical quality of the imaging equipment. Over the past 15 years, I
have had the privilege to mentor more than 100 quality improvement projects in radiology. I find that this role is a novel path for physicists. What I find surprising is just how rewarding this role is and how well my education and experiences in training have prepared me for it. In 1995, I had the opportunity to work for GE Medical Systems in x-ray tube engineering, as the company launched a new management program called the Six Sigma Quality Management System. Receiving a small dose of management skills through Six Sigma was a revelation to me. I have always enjoyed working with modeling data based on experimental observations. What I learned from Six Sigma training was that by combining a data-driven focus with lightweight project management tools and change management techniques, I could achieve far greater results. I learned to synthesize results into graphs as an effective way to communicate. As physicists, we are trained to solve technical problems. What I have come to appreciate is that even with the most technical of problems, there are nontechnical aspects with which we often struggle involving communication and behavior. Consider controlling dose creep in computed radiography or protocol variation in CT. Quality management methods have tools for effectively influencing behavior by creating an atmosphere of transparency, building feedback mechanisms, and role-modeling behavior among peers [1]. I found that I could be more effective by using quality management techniques as a complement to my technical skills. I returned to academic medicine in 2000 and
ª 2014 American College of Radiology 1546-1440/14/$36.00 http://dx.doi.org/10.1016/j.jacr.2014.03.001
went on to become director of quality for the departments I served. I have stumbled into an immensely rewarding role as a physicist providing analysis and guidance to clinical teams reinventing processes in radiology. Starting in 2015, the ABR will require physicists to conduct quality improvement projects as part of their maintenance of certification [2]. I see this as an opportunity to become more involved and add greater value to our practices and enrich our careers. For physicists not working directly for radiology departments, quality improvement partnerships are harder but not impossible. Consider techniques to expand your sphere of influence and create boundary-spanning leadership [3]. Physicists have a responsibility to supervise the quality of technologists, and effective physicists learn to build strong relationships with those groups. Letting sites know that you have an interest in helping them with quality improvement can strengthen your relationships and find new ways to provide value. USE QUALITY PROJECTS TO FORGE RELATIONSHIPS
Medical physicists need to perform quality projects to maintain their ABR certification. Use that as a springboard. Instead of doing a project on your own, look for a radiologist partner to work on a project together. Radiologists are required to perform quality projects as well by the ABR. Joint projects are acceptable as long as each principal provides leadership to the project. Many quality projects bring together people from across the 1
2 Quality Matters
department to solve process problems that cross through their areas. Working on a quality project is an act of team building. Bringing together individuals for a period of time to solve a problem will create new relationships, and effective projects must build sufficient trust in the team to overcome organizational resistance to change. These new relationships can open new opportunities for physicists. A technologist group may not be comfortable sharing problems and asking for help from a physicist with whom they don’t have a strong personal relationship. Working on an unrelated quality project can open those doors. WHERE TO START
I started working on quality projects related to image quality and radiation dose. I found great satisfaction moving beyond these projects into ones that worked on reducing contrast reactions, reducing time to imaging for patients with stroke, and ensuring rapid coordination with the operating room on missing sponge counts. First, use your quality improvement project as a method to build relationships and trust. If you find the process interesting, consider offering support for other projects. Let leadership know that you would be interested in helping others with their quality projects. The physicist is a natural fit to assist in the data analysis. Local quality improvement teams often struggle with data analysis. Assistance could entail helping to build and interpret runtime charts or running statistical
inference tests to assess the effectiveness of interventions. WHERE TO GO FURTHER
There are a couple of places a physicist should learn to mentor quality to others. The heart of quality management has progressive management ideas about empowering the front line to be agents of change for continuous innovation [4]. Quality has its own jargon, such as poka-yoke for errorproofing processes and gemba for leadership walkabouts. More important is learning the activities that lead a group through a quality project [5]. Building effective teams requires facilitation skills. Once an accurate workflow map has been generated, a facilitator needs to lead a group discussion around potential failure modes. It is important to have these points of the project be noncritical and inclusive so that good ideas are not squashed. The best experience in learning quality management is practice. Quality improvement is a highly applied management technique that depends greatly on the environment in which it is applied [6]. To get started, there are several weeklong training courses in the basics of health care quality improvement, either through societies such as the American Society of Quality or directly from academic medical systems. I am also fortunate to belong to an academic medical center that has residents. Residents are required to learn about quality improvement as part of the ACGME’s core competency of
systems-based practice. I continue to mentor and teach residents performing quality projects and find them to be great partners in working on projects. CONCLUSIONS
Quality is a genuine opportunity for medical physicists to support clinical operations and add tremendous value by fixing broken health care processes. Physicists often get to see more of the systemic process than frontline personnel and are well prepared for data-driven analysis. Physicists who enjoy working closer with clinical staff members and have an appreciation for quality management could find this a deeply rewarding role, just as I have. REFERENCES 1. Grenny J, Patterson K, Maxfield D, McMillan R, Switzler A. Influencer: the new science of leading change. 2nd ed. New York: McGraw-Hill; 2013. 2. American Board of Radiology. Maintenance of Certification participation guidelines. Available at: http://www.theabr.org/moc-rptime. Accessed February 2013. 3. Ernst C, Chrobot-Mason D. Boundary spanning leadership: six practices for solving problems, driving innovation, and transforming organizations. New York: McGrawHill; 2010. 4. Liker J. The Toyota way: 14 management principles from the world’s greatest manufacturer. New York: McGraw-Hill; 2009. 5. George M. The Lean Six Sigma pocket toolbook: a quick reference guide to 100 tools for improving quality and speed. New York: McGraw-Hill; 2004. 6. Davenport TH, Prusak L, Wilson HJ. What’s the big idea? Creating and capitalizing on the best new management thinking. Cambridge, MA: Harvard Business Press; 2003.
Paul Nagy, PhD, Johns Hopkins University, Department of Radiology, 600 North Wolfe Street, Baltimore, MD 21287; e-mail: [email protected].
