Transcript TEAMS - radiologynegotiation

Team Building in Radiology: Are
There Applications for Your
Practice?
Jay Harolds
Group decision making is better than that of
the smartest person in the group.
Krueger
Teams Help In
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Quality improvement
Reengineering
Productivity
Patient satisfaction
Outcomes
Referrals
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Patient care
Increasing profit
Planning for new ventures
Scheduling
Choosing and installing new equipment
Service recovery
• Transforming the organization
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Morale
Understanding of the issues
Participation in solving problems
Encourage creativity and experimentation
Utilize everyone’s expertise and experience
Sharing of power
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Feel part of a shared mission.
Leadership education and experience
Cooperation
Build pride
Create happiness, energy
Cut across organizational silos
Communication
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Support for organizational decisions
Support for the leader
Bottom up leadership
Servant leadership
(Harolds, JACR, 2004)
Stages of the Development of a Team
• Forming
– Initial meetings
– Focus on self
– Needs more information
• Storming
– Competing ideas on issues
– Conflict on how to run the team
– Tolerance, respect, patience are important
• Norming
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Agree on how to work together
Develop mutual trust
Improved motivation
Must preserve individuality to preserve
creativity
• Performing
– Team works well together
– Good decisions are made
– Not all teams get to this stage!
• Adjourning (or Transforming)
– Team breaks up (or continues)
Tuckman, BW. 1965, 1977
Establishing Team Norms
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Listen with respect
No personal attacks
Acknowledge differences
Acknowledge the importance of emotions
Address outbursts
Raise questions about team procedures
• Goal setting
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Realistic
Measurable
Plan and date to achieve them
Accountability
• Address team effectiveness
• Address team problems
• Help each other
• Where possible, support some aspect of a new
idea
• Encourage creativity
• Determine the way decisions are made
• Not allowing dominating behavior
• Asking if it is OK to change the subject
Goleman
Team Leader Role Includes
• Monitor the emotional mood and reasons
– Individuals
– The team
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Keeping on track
Often the administrative liaison
Ask members what strong points each has
Keeping everyone involved and motivated
• Help establish
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Norms
Procedures
Direction
Agenda
Tone
Roles
Goleman
Project Managing Cycle
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Initiation
Definition
Planning
Realization
Have SMART Objectives
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Specific
Achievable
Realistic
Time-Specific
www.learnmarketing.net/smart.htm
Shewhart cycle of CQI
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Plan
Do
Check
Act
FAST
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Friendly
Accurate
Safe
Timely
CARE
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Communication
Accountability
Respect
Empowerment
SIX SIGMA
• Sigma refers to standard deviation
• At Six Sigma-3.4 defects per million
opportunities
• Expensive-Training, personnel, space
• Emphasis on financially important projects
• More top down management
• Often multiple teams
• Data gathered.
• Processes with greatest variation found.
• These have the greatest potential for
improvement.
Physician Resistance to Teams
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Time commitment
Pride in individual decision making
Lack of experience, knowledge
CQI reduces variance, such as different
– Procedural protocols for each physician
– Catheters for each physician
– Individual ways of doing things
Tips for Starting Up a Team
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Set very specific guidelines
Develop a mission statement
Set goals and a timeline for completion
Determine how to evaluate success.
Monitor the effects on quality and output.
Team size: Often 5-8, but can be 12 or
more. The big teams have communication
issues.
• Team composition– Differing backgrounds help.
– Specific knowledge or skills may be required.
– Sometimes teams are within a department or
across an institution, and some include
customers and/or community leaders.
– Need to be team players!
• Administrative support
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Time
Resources
Meeting space
Clerical help
Training in teamwork
A liaison person to the administration
Reward the whole team for success.
Tips for running a team
• Quickly start on one small aspect of the
problem-and find a solution.
• Start each meeting positively such as saying
“How and when can we achieve the
objectives we talked about at the last
meeting?”
• During the meeting point out areas of
consensus, discord, and emotionality.
• At the conclusion of the meeting point out
productive aspects of the session.
• Do not impose your views on the team.
• No hypercritical remarks!
• Give everyone a chance to save face before
the final decision-which ideally should be a
win-win for everyone.
• Confront team members with specific
examples of unhelpful conduct.
• Focus on issues, not personalities.
• Conflicts may be due to the value systems,
professional roles, and goals of the
individuals.
• Listen carefully, repeat the words of the
other person to make sure you understand
them, and ask questions.
• Some people require structure, with
supervision and deadlines. For others this is
counterproductive.
• Some people are better at being an advisor
to the team rather than being a team
member.
• The leader should generally accept the
recommendations of the team.
• To routinely overturn team decisions will
cause team service not to be seen as being
of value.
Poor Results Could Be Due To
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Poor choice of members of the team.
Lack of information.
Lack of time.
Lack of support services
Lack of access to expert advice
Failure to focus on the most important issues.
Focus on personalities and private agendas.
Poor support from the leader.
• Feeling the teamwork is not important
– The results will be ignored
– Not as valuable for advancement as other work
• Having a disruptive person
– Arrives late
– Doesn’t do the work
– Makes negative comments.
• Inadequate education on how to do the work.
Team Project: Improve Report Turn
Around Time
• The team might have representatives from:
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Technologists
Schedulers
Transporters
Unit clerks
Transcriptionists
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Nurses
Radiologists and nuclear medicine physicians
PACS and IT administrators
Residents
Receptionists
File room personnel
Business office personnel
Registration desk personnel
• It might also include a patient care
representative, a referring clinician, a
representative from parking, etc.
• It may have an advisor such as a statistician
for surveys and analysis of data.
• It should have access to a secretary and an
administrative liaison.
• There may need to be 2 or more teams!
Gather data and examine the issues
• Transportation issues:
– Wheelchair vs. stretcher. Height of stretcher.
– Number of transporters and during various
times and days.
– Are the transporters from nuclear medicine,
radiology, or elsewhere?
– Do transporters have voice communication
equipment?
• Ward clerk/ unit nursing issues
– Are orders entered promptly?
– Are patients NPO if appropriate?
– Do patients get oral contrast for CT on the
floor?
– Are nurses alert about not giving some
medications before studies?
– Are orders appropriately labeled stat?
– Are signed reports promptly charted?
• Reading stations
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PACS vs. view boxes vs. motorized viewers.
Enough reading stations?
Suitable light?
No excessive noise or distractions?
For PACS, are queues set so studies do not drop
off if not read in one day?
• Transcriptionists vs. Voice recognition
– Delays with transcriptionists-how much and
what time of the week day or weekend? Can off
site transcriptionists help?
– Voice recognition-slows reading by as much as
25% (JACR, 2005). Suitable for what studies
at what times and days of the week?
• Are residents quickly checked on studies or
do they get checked at the end of the day?
• Does anyone check daily on the unread
studies not even in the queues?
• Do staff promptly sign reports?
• Are there enough radiology nurses?
• Are there enough people to move patients?
• Is work flow for imaging physicians and
technologists optimized?
• Does everyone operate in independent
silos?
• Are studies in nuclear medicine all
processed at the end of the day or
continuously?
• What is morale like in the department?
People work better when they are happy and
feel appreciated.
• Is equipment tied up waiting unduly long
for a cardiologist to stress a patient or a
nuclear medicine physician to do an
injection for a lymphoscintigraphy?
• Do the radiologists and nuclear medicine
physicians if needed come in on staggered
shifts?
• Are there too many delays from poorly done
studies?
• Is there a confusion factor from many
doctors having different protocols for the
same study done for the same reason?
• Are there enough physicians in the
department?
• Would radiology or nuclear medicine
assistants or physician assistants help
getting the work out?
• Will cross training help?
• Are reports stat faxed or printed to referring
physicians or the floor to decrease the
demand for call reports?
• Is time wasted in having someone else reread a study because the report dictated by
someone else hasn’t been typed?
• Are there enough equipment rooms to work
in emergency and add on patients?
• Is the registration desk area efficiently run?
• Are there delays from inadequate parking or
patients getting lost finding the department?
• Are the people in the department adequately
trained and supervised, or are there delays
from that?
• Are supplies readily available, or are there
delays from getting them?
• Best technologists optimally utilized?
• Preventive maintenance done during busy
times?
• Repair response time?
• Scheduling delays?
• Internet scheduling available?
Chart Each Step of the
Process/Hour/Day
• The number of patients.
– Outpatients
– Inpatients-transportation type needed
• The number of patients utilizing each piece of
equipment.
• The type of study.
• Whether routine or stat.
• The number of personnel of each type available
and being utilized.
• The time from when the
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study is ordered until patient arrives.
patient arrives until the study is done.
image is done until ready to read.
image is available until interpreted.
dictation is typed.
typed report is signed.
the signed report is available to clinicians.
• Chart results of quantitative surveys, interview
results, and unsolicited complaints on the
satisfaction of
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patients
clinicians
clinician schedulers
departmental physicians
technologists
other members of the health care team
Measure the Report Turn Around
Progress
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Every modality
Every part of the department
Every physician
Every other departmental member,
generally and for stat reports.
• Monitor the number of orders with the
request to have the report called.
• Monitor the number of calls or personal
appearances from clinicians for a report.
Monitor Quality
• Error rates
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Retake rates of images/image quality
Mislabeling of images
Physician errors
Typographical errors
Wrong study
Inappropriate study
If the Team is Doing Poorly
• Consequences for people who will not cooperate?
• Lack of motivation or leadership?
• Needs more time, more resources, different
members, or more training?
• Are people being bullied?
• Is there “groupthink” instead of creativity?
• Appropriately praising/ rewarding team members
for their efforts and successes?
Team Project: Are Clinical Work
Incentives A Good Idea?
• If clinical production by radiologists has a
big incentive, what value is placed on:
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Quality of work?
Reviewing multiple old studies.
Calling reports appropriately?
Developing protocols?
Administrative work in the department?
Giving free opinions/reads to clinicians?
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Research?
Teaching?
Taking time to be kind to patients?
Hospital committee work?
Society work?
• It may decrease morale. People
– Don’t like to be controlled.
– May fight to get less complex studies.
– May fight to avoid rotations where
• no PACS
• inefficiency
• a long drive between institutions
– May spend less time proof reading reports.
– May fight to do studies that generate a higher
output per unit time for them.
– May fight to check only upper level residents
and fellows, and teach them less.
• Arenson articles on RVU’s
• Another approach, reward by clinical
division-but do all members do the same
type of work?
• If clinical work output is monitored and
incentivized, monitor and incentivize
multiple other areas as well!
Options besides teams include
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Executive action.
Board meeting.
Ask colleagues who faced similar problems.
Leadership retreat
Hiring consultants.
How to Have a Productive Meeting
Running Meetings, Pocket Mentor, Harvard Business School Press
Don’t Call a Group Meeting When
• The following will suffice
– Memo
– Phone call
– Face to face discussion with one person
• Not enough preparation time
• A cooling off period is needed
Meeting Purpose
• To solve a problem
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Define it!
Causes?
Consequences?
Solutions and resources needed?
Agreement
• Other types of meetings
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Informational
Brainstorming
Obtain consent to an idea
“Who does what and when”?
Before the Meeting
• In advance, speak to people about their
views to encourage them to
– Prepare
– Listen to you
• In advance, brief the leaders
• Who is invited
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Experts
Stakeholders
Leaders
Implementers of a decision
Others who need to know
• Number of participants
– No more than 8 for decision making
– No more than 18 for brainstorming.
• Meeting duration: 30 to 120 minutes
Agenda
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Purpose
Objectives
Attendees
Place, date, start and stop time
Each topic
– Presented by whom
– How long
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Attach supporting information
Distribute in advance!
Begin with easy topics
Don’t save the hardest topic for the end
Delineate tasks
– Leader
– Minute taker
– Expert
Equipment
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Projector
Pointer
Computer
Flip chart
Video/teleconference set up
Test in advance!
During the Meeting
• Begin and conclude the meeting as
scheduled.
• “Praise in public, criticize in private”
• Decide in advance how decisions will be
made.
• Inform about any limitations of solutions
– Resources
– Organizational decisions
• Review and stay on the purpose and agenda
• Praise and positive comments
• Intervene if someone
– Monopolizes the talking
– Is not courteous
• Go over meeting accomplishments often,
and always at the end.
• The leader has everyone give an opinion,
and then restates each or writes them on a
flip chart.
• If few participate:
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Ask people by name.
Ask if any other point needs to be discussed.
Separate in to work groups.
Ask for input on an opposing view point.
• Write down but do not discuss ideas
irrelevant to the agenda.
• If there will not be enough time, solicit
opinions about how to deal with that.
• Action plan-who does what when
• Thank the participants.
• Time of next meeting.
When the Meeting is Not Going Well
• Latecomers -ask why?
• Interrupters-ask to jot down notes before
speaking.
• Dominant talkers-ask that others be let to
speak or call on others.
• Repeating points-ask if want to make any
new point.
• Controversial point-Jot it down, and say
we’ll return to it later.
• Remind people to keep on the agenda.
• Inject humor.
• If disruptions continue
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Ask what is happening
Call for a break
Go on to another agenda item
Consider if the leader is the problem
Consider if there is not enough information
Does the group want a solution the organization
won’t accept?
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Is there an embarrassing issue?
Is the meeting too long?
Are people mentally exhausted?
Are people hungry?
Attack ideas, not people.
OK to be ardent, but don’t lose control
• End early if necessary
After the Meeting
• Meeting evaluation
• Memo summarizes meeting and future
action
• Provide resources for the plan
• Meet with those who didn’t like the meeting
References
• Harolds, JA. Effective Radiology Teams, J
Am Coll Radiol 2005; 2:151-158.
• Reinus, WR. Economics of Radiology
Report Editing Using Voice Recognition
Technology. J Am Coll Radiol 2007; 4:890894.
• Harolds, JA. Selected Important
Characteristics for Enlightened Medical
Leaders. J Am Coll Radiol 2004; 1:338342.
• Arenson, RL et al. Measuring the
Academic Radiologist’s Clinical
Productivity: Applying RVU Adjustment
Factors. Acad Radiol 2001; 8:533-540.
• Arenson, RL. Measuring the Academic
Radiologist’s Clinical Productivity: Survey
Results for Subspecialty Sections. Acad
Radiol 2001; 8:524-532.
• www.en.wikipedia.org/wiki/Teamwork
• www.learnmarketing.net/smart.htm
• Drucker, PF. The Practice of Management,
1954.
• Tuckman, BW. Developmental sequence in
small groups. 1965
• Tuckman, BW. Stages of Small Group
Development Revisited. 1977
• Krueger, AB. “Economic Scene”. The
New York Times. December 7, 2000, C2.
• Running Meetings. Pocket Mentor.
Harvard Business. 2006