- Email: [email protected]
Daily Readiness Huddles in Radiology—Improving Communication, Coordination, and Problem-Solving Reliability
Author’s Accepted Manuscript Daily Readiness Huddles in Radiology – Improving Communication, Coordination, and Problem Solving Reliability Lane F. Donnelly www.elsevier.com/locate/enganabound
PII: DOI: Reference:
S0363-0188(16)30063-9 http://dx.doi.org/10.1067/j.cpradiol.2016.09.002 YMDR458
To appear in: Current Problems in Diagnostic Radiology Revised date: 19 August 2016 Accepted date: 19 Cite this article as: Lane F. Donnelly, Daily Readiness Huddles in Radiology – Improving Communication, Coordination, and Problem Solving Reliability, Current Problems in Diagnostic Radiology, http://dx.doi.org/10.1067/j.cpradiol.2016.09.002 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Daily Readiness Huddles in Radiology – Improving Communication, Coordination, and Problem Solving Reliability
Lane F. Donnelly MD
Department of Radiology, Texas Children’s Hospital, Houston, TX 77030
Corresponding Author: Lane F. Donnelly MD Chief Quality Officer, Hospital Based Services Associate Radiologist-in-Chief Texas Children’s Hospital 6701 Fannin St, Suite 470 Houston, TX 77030 [email protected] office: 832-822-5333
1
Daily Readiness Huddles in Radiology – Improving Communication, Coordination, and Problem Solving Reliability
Abstract Deploying an intentional daily management process is a key part to create a high reliability culture. Key components described in the literature for a successfully daily management process include leadership standard work, visual controls, daily accountability processes, and the discipline to stick to the process over the long term.
We believe that the
institution of a daily readiness huddle has helped us better coordinate and communicate as a department and improved our ability to deliver imaging services on a daily basis. The Daily Readiness Huddle has enabled us to more rapidly identify issues and has brought accountability to seeing solutions to those issues brought to fruition. In addition, it has helped with team building, including between the radiologists and the non-physician staff.
2
Changes in the Radiology Work Environment In the past 25 years, there have been massive changes in delivery of radiology services. The types and sophistication of imaging modalities has exploded. The volume of imaging studies performed and the speed at which they are interpreted and reported has dramatically increased. Sub-specialization has dramatically accelerated.
Medical systems have
consolidated and become much larger. It is now the norm for radiology groups to cover over multiple sites, interface with numerous referring physicians as well as technologists with which they do not have well-defined relationships. Potentially, the radiologists may often not interface, or even see, these groups of people. Contributing to these issues, the creation of PACS and the electronic medical record has decreased the personal interactions between radiologists, radiologists and referring physicians, and radiologists and technologists. In the pre-PACS, pre-mega-healthcare system era, the radiologist knew and had relationships with most of the local physicians, as they had to come to the radiology department to actually see the “films” on a daily basis. They often worked in smaller groups of radiologists. They usually interfaced with significantly less referring physicians. They typically worked closely with a small group of technologists. More importantly, there were multiple “touchpoints” throughout the day where there were direct in-person interactions between these groups of people. Much of this related to the physical delivery of the “films”. During this previous era, the ability to identify issues and communicate between those involved in the process was informally built into the system, given the number of touch points that occurred throughout the day.
3
In today’s work environment, given the potential for electronic silos related to PACS and the electronic medical record combined with the spread-out geographic nature of current radiology teams and processes, there needs to be a more deliberate way to manage the delivery of imaging services. There needs to be a better way to reliably identify and communicate issues that leads to execution on the delivery of solutions. Having a defined process by which radiologists, technologists, radiology nurses, and administrative leaders come together briefly for a daily huddle improves communication and coordination and increases the reliability of imaging services delivered [1, 2].
Daily Management Processes in Medicine One of the most successful methods originating from the recent quality revolution in medicine is also one of the simplest – the huddle. Such systems have been shown to help rapidly identify abnormal states and promote execution of counter measures [1, 2]. These daily management processes were copied from those deployed in industry, particularly from companies such as Toyota [3-8], and are growing in use in medicine. Deploying a intentional daily management process is a key part in converting to high reliability culture [3]. To change culture, you need to change your daily management system and as a result change how your leaders lead and how accountability around identified issues is executed [1-3]. Key components described in the literature for a successfully daily management process include leadership standard work, visual controls, daily accountability processes, and the discipline to diligently stick to the process over the long term [3].
4
A daily readiness huddle (DRH) is a process by which radiology, or any clinical unit, comes together on a daily basis to assess their ability to deliver imaging services to the patients that will receive those services that day. The process is designed to identify and assess any concerns about aspects of delivering that care. Such huddles are optimally held at or near the delivery of services. The process is ideally conduction in person but can be done remotely using teleconference and web sharing solutions. The process is typically conducted in front of a visual board. Low-tech white board work exceptionally well [1, 2]. They are inexpensive and can easily be changed, as new iterations of the process are created. Tape, markers, and dry erasers are all that is needed. For huddle processes that involves staff at remote sites, screen sharing of electronic documents can also work well. The in-person aspect of the meeting is highly valuable, so if there is a way to bring people together briefly from nearby locations, it is worth the effort. Huddles are intended to be short and are often conducted standing [1, 2]. Huddle flow can be optimized by having two people run the huddle. One acts as the moderator and leads the discussion. The other acts as the data recorder. This helps keep up the pace of the huddle. When the same person is trying to both write and conduct the meeting, the cadence of the meeting can be awkward and slow.
Example of a Current Daily Readiness Huddle in Radiology Our DRH has four elements: metrics / goals, volume review, readiness assessment, and problem accountability. Anyone from radiology is invited to attend. Guests from other departments occasionally also attend. The targeted participants are radiologists, directors, 5
managers, front line staff with concerns, representatives from support services (informatics services, biomedical engineering), and virtual representatives from off-site locations (by phone). Data is visually displayed on a white board (Fig 1). The meeting is held in an area immediately adjacent to our largest radiology reading room and leadership offices. This promotes radiology faculty and leadership attendance. The meeting is brief – between 10 - 20 minutes. It is held at 9AM each morning. This scheduled time allows for managers and radiologists to report to their areas of work, assess their area, and identify any issues that need to be discussed. The meeting follows a standardized process so that it can be run by various people. Currently, the “host” rotates between 10 physician and administrative leaders. A quality coach helps write newly identified items on the board. An electronic summary of each DRH is emailed daily to all associates and physicians in radiology. This way even those not in attendance are aware of the issues discussed [1, 2].
Metrics / Goals Each DRH begins with a review of metrics and goals. Our department has a department scorecard with multiple metrics, many which get updated on a monthly basis. We have found that it is not helpful to review this type of data as part of the DRH. The metrics and goals reviewed are ones that lend them self to daily review. Metrics related to ongoing issues and improvement efforts are sometimes added temporarily. Current metrics that are part of the DRH include days since the last radiology-related serious safety event, days since the last wrong patient / wrong procedure event, days since the last MRI safety policy violation / event, first case
6
start times in MRI and interventional radiology, open staffing positions, and number of MRI and CT examinations needing to be protocoled (Fig 2) [1, 2].
Volume Review Imaging volumes by modality and location performed on the prior day and scheduled for the current day are emphasized (Fig. 3). These numbers are benchmarked against studies budgeted per day for that month. Outliers, either extra-ordinarily high or low in volume, are then discussed. The discussion of high volumes is on readiness. The discussion of low volumes emphasizes potential issues related to scheduling and back filling of open slots [1, 2]. Most common areas of concern in our department relate to high volumes in MRI, interventional radiology, and cases requiring anesthesia (we are a children’s hospital).
Readiness Assessment After completion of the volume discussion, a readiness assessment is performed. A series of categories with questions is reviewed each day. The purpose is to encourage attendees to raise concerns. We have chosen the categories of “S-MESA”: Safety, Methods, Equipment, Supplies, Associates (Fig. 3) [1]. The DRH host reviews the different prompts in a standardized fashion. The huddle starts with Safety. Concerns relating to patient or staff safety are discussed. Methods focuses on issues related to protocols and standard operating procedures. Are all of the procedures scheduled protocoled? Are there atypical situations or protocols in question? Equipment is an assessment as to whether the needed equipment is available. Is all of the
7
equipment operational and working? Are there any PACS or radiology informatics issues? Supplies is an assessment as to whether we have the proper supplies to meet service needs. Are there any issues with adequate amounts of contrast or interventional radiology supplies? Are any supplies on back order? Are there any national shortages or recalled products? Associates is an assessment as to whether we are appropriately staffed both related to number and qualifications of employees. Are there any unanticipated staff openings? Based on volumes in particular areas, are we going to have staffing shortages anywhere [1, 2]? Obviously, there are other categories that can be used to perform a readiness assessment, depending upon the nature of the services offered and size and complexity of the department. For example, based on the success of the DRH in radiology, our institution re-structured its institutional-wide daily operational brief to a similar format. Given the size and complexity of the organization, we elected to expand the categories of the readiness assessment to a more granular level. For the institutional readiness assessment, we use: safety, equipment, supplies, satisfaction, facilities, information services, and methods. Methods includes review of issues involving support services such as pharmacy, laboratory, respiratory, and imaging services.
Problem Accountability Systems The performance of the initial stages of the DRG results in a list of identified issues and concerns. We categorize these as identified issues as either Quick Hits or Complex Issues. Quick Hits are issues with anticipated quick resolution (24-48 hours) and do not require high level problem analysis or project management [1, 2]. Examples include informatics downtimes, inoperable imaging equipment under repair, or short staffing. Complex Issues are identified 8
problems with longer anticipated time to resolution. These types of issues benefit from a higher level of project management [1, 2]. These issues may require changes in information technology systems or space. They may also involve consensus building between multiple groups around a particular standard operating procedure. An identified issue may clearly be a Complex Issue when it is initially identified or may less commonly start as a perceived Quick Hit that lingers, does not resolve, and gets re-defined as a Complex Issue [2]. Complex Issues are recorded on a dedicated white board (Fig. 4) as well as tracked on an electronic spreadsheet. For each Complex Issues, the following are defined: title of the issue, a single owner, an assigned quality coach, date first identified, and report back date [1, 2]. The owner of the Complex Issue chooses the report back date. A maximum of 60 days are allocated to resolve the complex issue. Owners are however encouraged to complete their projects in the minimal amount of time required. If the issue is not resolved in those 60 days, the issue is escalated and a dedicated meeting is held with radiology leadership to discuss the lack of progress. Emphasis is placed on prioritization, barriers, and potential resourcing. For each Complex Issue, a defined problem-solving template is utilized. The template defines the problem, analysis, baseline data or background, implementation plan, communication plan, sustainability, system-wide implications and standardization, and timeline [2]. The target completion date is emphasized. The use of a standardized problem-solving template aids in improving our problem-solving abilities and communication on progress. There is a Complex Issues work flow diagram [2] and a quality coach check-list to help define expectations for the owners of Complex Issues and quality coaches. The quality coach assigned to each Complex Issue has multiple roles designed to keep the owner and problem
9
solving team on track. The quality coach sets up a meeting with the Complex Issue owner within 3 days of the assignment. The quality coach helps the Complex Issue owner complete the Complex Issue problem solving template. They help the owner define the problem, establish a timeline, identify team members, create an aim statement, and define metrics to be followed. The quality coach offers quality tools that may be applicable to the issue at hand. The quality coach helps schedule meetings and prepare agendas. The quality coach checks in periodically with the owner to make sure the project is on track. Our department has for individuals, of varying backgrounds, that function as quality coaches. The Complex Issues work flow defines the various steps and potential outcomes that occur during the complex issue management process. Projects are also tracked as part of the DRH process. Quick Hits and Complex Issues are reactive in nature as they are discovered primarily thought the DRH process. Projects are more strategic, pro-active, and tend to take longer to implement. Projects often take longer than 60 days. Many projects are chosen in an annual planning process but some also come up throughout the year. Initially after implementing the DRH process, we struggled with how owners reported back on Complex Issues and Projects as part of the DRH, related to the brevity of the process and complexity of the issues. In response to those challenges, we added an additional process called Walk-the-Wall. The project solving templates for up to eight Complex Issues or Projects are listed on a Walk-the-Wall board (Fig. 5). It occurs biweekly, immediately following completion of the DRH process. On the selected days, each owner and quality coach presents an update on progress made, encountered barriers, and any adjustments in the predicted time line. The process takes about 30 minutes. Visibility and accountability from the Walk-the-Wall process helps 10
bring projects to completion. We have a group which we refer to as the Radiology Value Creation Team which consists of the quality coaches, director of radiology, and chief quality officer for radiology. This group meets weekly and one of its tasks is to select which Complex Issues and Projects are to be featured on Walk-the-Wall. Items are selected for a number of factors including critical nature of the issue, need for high-end project management, or development of team members working on the particular project.
Daily Management Systems – Tiered Huddle Structures In large radiology departments, a tiered huddle system may be necessary. Front line DRHs may be necessary in each of the modality or organ-based divisions [1]. The issues that are identified at these huddles that are not able to be resolved at the modality level can be brought to a radiology-wide DRH. Likewise, tiered huddling may be helpful in some geographically spread out radiology systems where locations have a DRH and issues that have system implications are escalated to a system-wide radiology DRH. The DRH in radiology may also be part of a tiered huddle structure at the organizational level [1, 2]. Issues identified in the radiology DRH that need escalation can be brought to a higher level medical system level DRH. We currently have DRH processes for multiple modalities and locations. These meetings occur prior to the overall radiology DRH. We also have an institutional process referred to as the Daily Operational Brief to which issues in radiology that need to be escalated are brought.
11
Conclusions We believe that the institution of a DRH has helped us better coordinate and communicate as a department and improved our ability to delivery imaging services on a daily basis. It has improved our ability to more rapidly identify issues and brought accountability to seeing solutions to those issues brought to fruition. In addition, it has helped with team building between the radiologists and the non-physician staff. Finally, the DRH also serves in the informal capacity of being the daily touch point where everyone knows that they will be able to see and touch base with those with which they need to communicate. All of these issues have become of increasing importance in radiology as it has moved into the post-PACS and electronic medical record era (leading to potential electronic silos) as well as the medical system merger era (leading to large, multi-geographic mega-health systems).
12
References 1. Donnelly LF. Daily Management Systems in Medicine. Radiographics 2014;44:12091212 2. Donnelly LF. The Daily Readiness Huddle – A Key Component to a System of Care. Journal of HealthSystem and Policy Research 2016;3(1):22.1-22.7 3. Mann D. Creating a Lean Culture – Tools to Sustain Lean Conversions, 2nd Ed. Boca Raton, FL: CRC Press, 2010;3-103 4. Liker JK, Convis GL. The Toyota way to lean leadership – Achieving and sustaining excellence through leadership development. New York, NY; McGraw Hill, 2012;121-143 5. Koenigsaecker G. Leading the lean enterprise transformation. Boca Raton, FL: CRC Press, 2009;9-77. 6. Liker JK. The Toyota way. 14 Management principles form the world’s greatest manufacturer. New York, NY; McGraw Hill, 2004;1-159 7. Bussell J. Anatomy of a lean leader as illustrated by 10 modern CEOs and Abraham Lincoln. Northbrook, IL; UL LLC, 2012;1-150 8. Toussaint J, Gerard RA. On the mend. Revolutionizing healthcare to save lives and transform the industry. Cambridge, MA: Lean Enterprise Institute, 2010;1-138
13
Figure Legends Fig. 1. – DRH in Radiology being performed in huddle space with white boards.
14
Fig. 2. -- Board used for review of huddle related metrics.
15
Fig. 3. -- Board used for volume assessment (left) and readiness assessment (right). For the readiness assessment, Quick Hits identified through the S-MESA process are listed on the board adjacent to appropriate category.
16
Fig. 4. -- Board used for problem accountability system to manage Complex Issues. WTW = Walk-the-Wall.
17
Fig. 5. Photograph of Walk-the-Wall process. The Walk-the-Wall process is performed biweekly. Complex Issues or Project owners give updates noting progress made, barriers, and targeted completion date.
18
PII: DOI: Reference:
S0363-0188(16)30063-9 http://dx.doi.org/10.1067/j.cpradiol.2016.09.002 YMDR458
To appear in: Current Problems in Diagnostic Radiology Revised date: 19 August 2016 Accepted date: 19 Cite this article as: Lane F. Donnelly, Daily Readiness Huddles in Radiology – Improving Communication, Coordination, and Problem Solving Reliability, Current Problems in Diagnostic Radiology, http://dx.doi.org/10.1067/j.cpradiol.2016.09.002 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Daily Readiness Huddles in Radiology – Improving Communication, Coordination, and Problem Solving Reliability
Lane F. Donnelly MD
Department of Radiology, Texas Children’s Hospital, Houston, TX 77030
Corresponding Author: Lane F. Donnelly MD Chief Quality Officer, Hospital Based Services Associate Radiologist-in-Chief Texas Children’s Hospital 6701 Fannin St, Suite 470 Houston, TX 77030 [email protected] office: 832-822-5333
1
Daily Readiness Huddles in Radiology – Improving Communication, Coordination, and Problem Solving Reliability
Abstract Deploying an intentional daily management process is a key part to create a high reliability culture. Key components described in the literature for a successfully daily management process include leadership standard work, visual controls, daily accountability processes, and the discipline to stick to the process over the long term.
We believe that the
institution of a daily readiness huddle has helped us better coordinate and communicate as a department and improved our ability to deliver imaging services on a daily basis. The Daily Readiness Huddle has enabled us to more rapidly identify issues and has brought accountability to seeing solutions to those issues brought to fruition. In addition, it has helped with team building, including between the radiologists and the non-physician staff.
2
Changes in the Radiology Work Environment In the past 25 years, there have been massive changes in delivery of radiology services. The types and sophistication of imaging modalities has exploded. The volume of imaging studies performed and the speed at which they are interpreted and reported has dramatically increased. Sub-specialization has dramatically accelerated.
Medical systems have
consolidated and become much larger. It is now the norm for radiology groups to cover over multiple sites, interface with numerous referring physicians as well as technologists with which they do not have well-defined relationships. Potentially, the radiologists may often not interface, or even see, these groups of people. Contributing to these issues, the creation of PACS and the electronic medical record has decreased the personal interactions between radiologists, radiologists and referring physicians, and radiologists and technologists. In the pre-PACS, pre-mega-healthcare system era, the radiologist knew and had relationships with most of the local physicians, as they had to come to the radiology department to actually see the “films” on a daily basis. They often worked in smaller groups of radiologists. They usually interfaced with significantly less referring physicians. They typically worked closely with a small group of technologists. More importantly, there were multiple “touchpoints” throughout the day where there were direct in-person interactions between these groups of people. Much of this related to the physical delivery of the “films”. During this previous era, the ability to identify issues and communicate between those involved in the process was informally built into the system, given the number of touch points that occurred throughout the day.
3
In today’s work environment, given the potential for electronic silos related to PACS and the electronic medical record combined with the spread-out geographic nature of current radiology teams and processes, there needs to be a more deliberate way to manage the delivery of imaging services. There needs to be a better way to reliably identify and communicate issues that leads to execution on the delivery of solutions. Having a defined process by which radiologists, technologists, radiology nurses, and administrative leaders come together briefly for a daily huddle improves communication and coordination and increases the reliability of imaging services delivered [1, 2].
Daily Management Processes in Medicine One of the most successful methods originating from the recent quality revolution in medicine is also one of the simplest – the huddle. Such systems have been shown to help rapidly identify abnormal states and promote execution of counter measures [1, 2]. These daily management processes were copied from those deployed in industry, particularly from companies such as Toyota [3-8], and are growing in use in medicine. Deploying a intentional daily management process is a key part in converting to high reliability culture [3]. To change culture, you need to change your daily management system and as a result change how your leaders lead and how accountability around identified issues is executed [1-3]. Key components described in the literature for a successfully daily management process include leadership standard work, visual controls, daily accountability processes, and the discipline to diligently stick to the process over the long term [3].
4
A daily readiness huddle (DRH) is a process by which radiology, or any clinical unit, comes together on a daily basis to assess their ability to deliver imaging services to the patients that will receive those services that day. The process is designed to identify and assess any concerns about aspects of delivering that care. Such huddles are optimally held at or near the delivery of services. The process is ideally conduction in person but can be done remotely using teleconference and web sharing solutions. The process is typically conducted in front of a visual board. Low-tech white board work exceptionally well [1, 2]. They are inexpensive and can easily be changed, as new iterations of the process are created. Tape, markers, and dry erasers are all that is needed. For huddle processes that involves staff at remote sites, screen sharing of electronic documents can also work well. The in-person aspect of the meeting is highly valuable, so if there is a way to bring people together briefly from nearby locations, it is worth the effort. Huddles are intended to be short and are often conducted standing [1, 2]. Huddle flow can be optimized by having two people run the huddle. One acts as the moderator and leads the discussion. The other acts as the data recorder. This helps keep up the pace of the huddle. When the same person is trying to both write and conduct the meeting, the cadence of the meeting can be awkward and slow.
Example of a Current Daily Readiness Huddle in Radiology Our DRH has four elements: metrics / goals, volume review, readiness assessment, and problem accountability. Anyone from radiology is invited to attend. Guests from other departments occasionally also attend. The targeted participants are radiologists, directors, 5
managers, front line staff with concerns, representatives from support services (informatics services, biomedical engineering), and virtual representatives from off-site locations (by phone). Data is visually displayed on a white board (Fig 1). The meeting is held in an area immediately adjacent to our largest radiology reading room and leadership offices. This promotes radiology faculty and leadership attendance. The meeting is brief – between 10 - 20 minutes. It is held at 9AM each morning. This scheduled time allows for managers and radiologists to report to their areas of work, assess their area, and identify any issues that need to be discussed. The meeting follows a standardized process so that it can be run by various people. Currently, the “host” rotates between 10 physician and administrative leaders. A quality coach helps write newly identified items on the board. An electronic summary of each DRH is emailed daily to all associates and physicians in radiology. This way even those not in attendance are aware of the issues discussed [1, 2].
Metrics / Goals Each DRH begins with a review of metrics and goals. Our department has a department scorecard with multiple metrics, many which get updated on a monthly basis. We have found that it is not helpful to review this type of data as part of the DRH. The metrics and goals reviewed are ones that lend them self to daily review. Metrics related to ongoing issues and improvement efforts are sometimes added temporarily. Current metrics that are part of the DRH include days since the last radiology-related serious safety event, days since the last wrong patient / wrong procedure event, days since the last MRI safety policy violation / event, first case
6
start times in MRI and interventional radiology, open staffing positions, and number of MRI and CT examinations needing to be protocoled (Fig 2) [1, 2].
Volume Review Imaging volumes by modality and location performed on the prior day and scheduled for the current day are emphasized (Fig. 3). These numbers are benchmarked against studies budgeted per day for that month. Outliers, either extra-ordinarily high or low in volume, are then discussed. The discussion of high volumes is on readiness. The discussion of low volumes emphasizes potential issues related to scheduling and back filling of open slots [1, 2]. Most common areas of concern in our department relate to high volumes in MRI, interventional radiology, and cases requiring anesthesia (we are a children’s hospital).
Readiness Assessment After completion of the volume discussion, a readiness assessment is performed. A series of categories with questions is reviewed each day. The purpose is to encourage attendees to raise concerns. We have chosen the categories of “S-MESA”: Safety, Methods, Equipment, Supplies, Associates (Fig. 3) [1]. The DRH host reviews the different prompts in a standardized fashion. The huddle starts with Safety. Concerns relating to patient or staff safety are discussed. Methods focuses on issues related to protocols and standard operating procedures. Are all of the procedures scheduled protocoled? Are there atypical situations or protocols in question? Equipment is an assessment as to whether the needed equipment is available. Is all of the
7
equipment operational and working? Are there any PACS or radiology informatics issues? Supplies is an assessment as to whether we have the proper supplies to meet service needs. Are there any issues with adequate amounts of contrast or interventional radiology supplies? Are any supplies on back order? Are there any national shortages or recalled products? Associates is an assessment as to whether we are appropriately staffed both related to number and qualifications of employees. Are there any unanticipated staff openings? Based on volumes in particular areas, are we going to have staffing shortages anywhere [1, 2]? Obviously, there are other categories that can be used to perform a readiness assessment, depending upon the nature of the services offered and size and complexity of the department. For example, based on the success of the DRH in radiology, our institution re-structured its institutional-wide daily operational brief to a similar format. Given the size and complexity of the organization, we elected to expand the categories of the readiness assessment to a more granular level. For the institutional readiness assessment, we use: safety, equipment, supplies, satisfaction, facilities, information services, and methods. Methods includes review of issues involving support services such as pharmacy, laboratory, respiratory, and imaging services.
Problem Accountability Systems The performance of the initial stages of the DRG results in a list of identified issues and concerns. We categorize these as identified issues as either Quick Hits or Complex Issues. Quick Hits are issues with anticipated quick resolution (24-48 hours) and do not require high level problem analysis or project management [1, 2]. Examples include informatics downtimes, inoperable imaging equipment under repair, or short staffing. Complex Issues are identified 8
problems with longer anticipated time to resolution. These types of issues benefit from a higher level of project management [1, 2]. These issues may require changes in information technology systems or space. They may also involve consensus building between multiple groups around a particular standard operating procedure. An identified issue may clearly be a Complex Issue when it is initially identified or may less commonly start as a perceived Quick Hit that lingers, does not resolve, and gets re-defined as a Complex Issue [2]. Complex Issues are recorded on a dedicated white board (Fig. 4) as well as tracked on an electronic spreadsheet. For each Complex Issues, the following are defined: title of the issue, a single owner, an assigned quality coach, date first identified, and report back date [1, 2]. The owner of the Complex Issue chooses the report back date. A maximum of 60 days are allocated to resolve the complex issue. Owners are however encouraged to complete their projects in the minimal amount of time required. If the issue is not resolved in those 60 days, the issue is escalated and a dedicated meeting is held with radiology leadership to discuss the lack of progress. Emphasis is placed on prioritization, barriers, and potential resourcing. For each Complex Issue, a defined problem-solving template is utilized. The template defines the problem, analysis, baseline data or background, implementation plan, communication plan, sustainability, system-wide implications and standardization, and timeline [2]. The target completion date is emphasized. The use of a standardized problem-solving template aids in improving our problem-solving abilities and communication on progress. There is a Complex Issues work flow diagram [2] and a quality coach check-list to help define expectations for the owners of Complex Issues and quality coaches. The quality coach assigned to each Complex Issue has multiple roles designed to keep the owner and problem
9
solving team on track. The quality coach sets up a meeting with the Complex Issue owner within 3 days of the assignment. The quality coach helps the Complex Issue owner complete the Complex Issue problem solving template. They help the owner define the problem, establish a timeline, identify team members, create an aim statement, and define metrics to be followed. The quality coach offers quality tools that may be applicable to the issue at hand. The quality coach helps schedule meetings and prepare agendas. The quality coach checks in periodically with the owner to make sure the project is on track. Our department has for individuals, of varying backgrounds, that function as quality coaches. The Complex Issues work flow defines the various steps and potential outcomes that occur during the complex issue management process. Projects are also tracked as part of the DRH process. Quick Hits and Complex Issues are reactive in nature as they are discovered primarily thought the DRH process. Projects are more strategic, pro-active, and tend to take longer to implement. Projects often take longer than 60 days. Many projects are chosen in an annual planning process but some also come up throughout the year. Initially after implementing the DRH process, we struggled with how owners reported back on Complex Issues and Projects as part of the DRH, related to the brevity of the process and complexity of the issues. In response to those challenges, we added an additional process called Walk-the-Wall. The project solving templates for up to eight Complex Issues or Projects are listed on a Walk-the-Wall board (Fig. 5). It occurs biweekly, immediately following completion of the DRH process. On the selected days, each owner and quality coach presents an update on progress made, encountered barriers, and any adjustments in the predicted time line. The process takes about 30 minutes. Visibility and accountability from the Walk-the-Wall process helps 10
bring projects to completion. We have a group which we refer to as the Radiology Value Creation Team which consists of the quality coaches, director of radiology, and chief quality officer for radiology. This group meets weekly and one of its tasks is to select which Complex Issues and Projects are to be featured on Walk-the-Wall. Items are selected for a number of factors including critical nature of the issue, need for high-end project management, or development of team members working on the particular project.
Daily Management Systems – Tiered Huddle Structures In large radiology departments, a tiered huddle system may be necessary. Front line DRHs may be necessary in each of the modality or organ-based divisions [1]. The issues that are identified at these huddles that are not able to be resolved at the modality level can be brought to a radiology-wide DRH. Likewise, tiered huddling may be helpful in some geographically spread out radiology systems where locations have a DRH and issues that have system implications are escalated to a system-wide radiology DRH. The DRH in radiology may also be part of a tiered huddle structure at the organizational level [1, 2]. Issues identified in the radiology DRH that need escalation can be brought to a higher level medical system level DRH. We currently have DRH processes for multiple modalities and locations. These meetings occur prior to the overall radiology DRH. We also have an institutional process referred to as the Daily Operational Brief to which issues in radiology that need to be escalated are brought.
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Conclusions We believe that the institution of a DRH has helped us better coordinate and communicate as a department and improved our ability to delivery imaging services on a daily basis. It has improved our ability to more rapidly identify issues and brought accountability to seeing solutions to those issues brought to fruition. In addition, it has helped with team building between the radiologists and the non-physician staff. Finally, the DRH also serves in the informal capacity of being the daily touch point where everyone knows that they will be able to see and touch base with those with which they need to communicate. All of these issues have become of increasing importance in radiology as it has moved into the post-PACS and electronic medical record era (leading to potential electronic silos) as well as the medical system merger era (leading to large, multi-geographic mega-health systems).
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References 1. Donnelly LF. Daily Management Systems in Medicine. Radiographics 2014;44:12091212 2. Donnelly LF. The Daily Readiness Huddle – A Key Component to a System of Care. Journal of HealthSystem and Policy Research 2016;3(1):22.1-22.7 3. Mann D. Creating a Lean Culture – Tools to Sustain Lean Conversions, 2nd Ed. Boca Raton, FL: CRC Press, 2010;3-103 4. Liker JK, Convis GL. The Toyota way to lean leadership – Achieving and sustaining excellence through leadership development. New York, NY; McGraw Hill, 2012;121-143 5. Koenigsaecker G. Leading the lean enterprise transformation. Boca Raton, FL: CRC Press, 2009;9-77. 6. Liker JK. The Toyota way. 14 Management principles form the world’s greatest manufacturer. New York, NY; McGraw Hill, 2004;1-159 7. Bussell J. Anatomy of a lean leader as illustrated by 10 modern CEOs and Abraham Lincoln. Northbrook, IL; UL LLC, 2012;1-150 8. Toussaint J, Gerard RA. On the mend. Revolutionizing healthcare to save lives and transform the industry. Cambridge, MA: Lean Enterprise Institute, 2010;1-138
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Figure Legends Fig. 1. – DRH in Radiology being performed in huddle space with white boards.
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Fig. 2. -- Board used for review of huddle related metrics.
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Fig. 3. -- Board used for volume assessment (left) and readiness assessment (right). For the readiness assessment, Quick Hits identified through the S-MESA process are listed on the board adjacent to appropriate category.
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Fig. 4. -- Board used for problem accountability system to manage Complex Issues. WTW = Walk-the-Wall.
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Fig. 5. Photograph of Walk-the-Wall process. The Walk-the-Wall process is performed biweekly. Complex Issues or Project owners give updates noting progress made, barriers, and targeted completion date.
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