Review
FOCUS ON: Health Care Policy and Quality
October 23, 2015

Project Management for Quality Improvement in Radiology

Abstract

OBJECTIVE. This article outlines a structured approach for applying project management principles to quality improvement in radiology. We highlight the framework we use for managing improvement projects in our department and review basic project management principles.
CONCLUSION. Project management involves techniques for executing projects effectively and efficiently. We recognize the following phases for managing improvement projects: idea, project evaluation and selection, role assignment, planning, improvement, and sustaining improvement.
In recent years, quality improvement has been deemed to be an important component of medical practice management, including in radiology. Its teaching is mandated by the Accreditation Council for Graduate Medical Education (ACGME) [1, 2], the topic is included in American Board of Radiology (ABR) certification examinations [3], and completion of Practice Quality Improvement projects is required for ABR Maintenance of Certification [4].
Quality improvement means moving from a given level of performance to a higher level of performance [5]. Achieving lasting performance improvement requires organizations to change in substantive ways [6]. Making these changes in a complex environment such as a radiology practice generally requires a sophisticated degree of coordination of efforts [7]; it requires effective project management [8, 9]. However, few radiologists have formal training or experience in managing projects, which may decrease the likelihood of a project's success.
This article outlines a structured approach to managing quality improvement projects. We highlight the approach we use in our department and review a few basic project management principles.

Quality Improvement Project Management

The Project Management Institute defines a project as “a temporary group activity designed to produce a unique product, service, or result” [10]. A project is temporary, with a defined beginning and end, and uses limited organizational resources [11]. A project is unique in that it is not part of the ongoing operations of an organization, but is designed to accomplish specific focused goals. Projects often convene people who do not usually work together and generally require people who do usually work together to interact in ways different from those of their normal work.
Project management is the “application of knowledge, skills, and techniques to execute projects effectively and efficiently” [10]. Effective project management techniques help bring order to what can otherwise be a chaotic process, to help ensure that projects meet their objectives.
Improvement projects are similar to implementation projects in that they require assignment of roles and tasks, coordination, and active monitoring of project progress. However, for implementation projects, needed changes to systems and processes are largely known in advance; thus, the primary challenge lies in defining the tasks and coordinating the activities needed for successful implementation.
In contrast, for improvement projects, the current level of performance is known and a desired level of performance is specified, but the changes that will be needed to enable the organization to reach the desired level of performance are not known with surety in advance. This has a few significant implications: first, acquiring new knowledge—the knowledge of what organizational changes will best bring about the desired improvement—is an integral part of an improvement project; second, team members and stake-holders must keep an open mind regarding what organizational changes will best meet the project objectives; and third, uncertainty of the likelihood of success often is greater for improvement projects than for implementation projects.
The department management team is responsible for the performance of the ongoing operations of a department. The commissioning of an improvement project constitutes a temporary assignment to the improvement team to establish a better process to achieve desired outcomes. The improvement team therefore is given special dispensation by the managers to make changes in a focused area of the department while the team defines project objectives, understands process problems, and devises, tests, and implements solutions. For success to be enduring, when the improvement project is completed, the improvement team must successfully hand the process back to the management team— even if the improvement and management teams are made up of the same people.
Projects have a life cycle, with distinct phases, though the way these phases are performed may vary from project to project [12]. For improvement projects in our department, we recognize the following project phases: idea, project evaluation and selection, role assignment, planning, improvement, and sustaining improvement.

Idea Phase

Ideas for improvement projects are based on realizations that certain aspects of performance can and should be better than they currently are. Examples of unacceptable performance, such as safety events, negative feedback from patients or referring clinicians, poor financial performance, or non-compliance with external regulations, may trigger these realizations. Alternatively, opportunities for improvement may be recognized when levels of performance that were previously thought to be infeasible become feasible, such as examples from peer institutions and the published literature, vendor offerings, and ideas from individuals within the organization. Project ideas may originate from a variety of stakeholders, including managers and other leaders, internal and external customers, and frontline staff.
Many ideas can be executed, or problems can be solved, with a relatively small amount of effort and coordination. These should be handled through the routine problem-solving mechanisms embedded in the department's ongoing management activities. Problems too large or complex to be solved through daily management activities, requiring more focused coordinated efforts, are candidates for dedicated improvement projects.
Because the organization can only withstand a certain rate of change while also maintaining stability, not all improvement projects can or should be initiated immediately when the need is recognized. Rather, improvement ideas may need to be placed in a “parking lot” until they are ready to be undertaken as dedicated projects. Department leaders should continue to carefully monitor these ideas, because their urgency and importance may change over time.

Project Evaluation and Selection

Departments that are actively seeking opportunities to improve are almost certain to have more ideas for improvement projects than resources to execute them at any given time. Therefore, it is helpful to have a process for prioritizing which projects to undertake. In evaluating projects for selection, we perform a feasibility-impact analysis, seeking projects that are most likely to yield the greatest impact and are most likely to be successful, with the least amount of organizational effort and cost.
Prioritization of improvement projects begins with the mission and vision of the department. Our operational mission is focused on three areas: safety and quality, service to patients and referring clinicians, and efficient use of resources. We evaluate our projects on the basis of their ability to impact these areas. In evaluating the potential benefits of a project, we estimate the potential impact on safety and quality, patient satisfaction, referring clinician satisfaction, internal stakeholder priority, and department finances.
We define feasibility as our estimate of the organization's ability to successfully accomplish the project as a function of the cost. More difficult projects are considered to be a “heavier lift,” and less difficult projects are considered to be an “easier lift.” Specifically, we estimate the total personnel time needed (and availability of those personnel), direct financial costs to implement changes, magnitude of potential process changes, degree of coordination needed among departments or clinical areas to make those changes, and needed infrastructure investments, such as information technology systems or equipment.
Before a project is considered, an initial assessment of the problem and possible solutions is conducted. Findings from the assessment are brought to a prioritization meeting, and projects are then scored and displayed on a matrix that helps identify the projects that are likely to provide the highest yield (Fig. 1).
Fig. 1 —Project prioritization matrix. Projects are scored according to potential impact on organization's mission versus feasibility. In this example, patient safety is treated as third consideration. Projects are plotted on prioritization map, with potential impact on patient safety represented by bubble size. Tool is used as guide to help leaders determine which projects to commission. ED = emergency department, IR = interventional radiology, IT = information technology, STAT = immediate.
For each project, we also identify a highly motivated champion. The highly motivated champion is an individual in a position of authority to mobilize resources, make personnel adjustments, and change other organizational structures in all areas affected by the project as needed to ensure that the project will be successful. The individual should have a strong professional stake in the success of the project and be committed to doing whatever is required to help ensure the team's success.
A selection committee, consisting of clinical, administrative, and technical leaders, is convened for a gate review, to establish a portfolio of projects that can feasibly be accomplished in a specific time frame. These individuals are expected to represent their constituencies, to ensure that stakeholders are as engaged in the selection process as possible. The portfolio's composition is based on the projects' likely impact, feasibility, and expected support from the projects' highly motivated champions, balanced across the department. Project scoring alone does not determine prioritization, but rather helps inform the consensus-based decision of the committee. Projects not selected are deferred for future evaluation. Before the meeting, the quality improvement team performs a preliminary assessment of the projects and excludes the projects that are least likely to be selected.

Role Assignment

As projects are selected, individuals in the department are identified by department leaders as candidates for involvement in improvement projects on the basis of leadership potential and other qualities that are likely to make the project successful. Once projects are selected, individuals are matched to the projects in specific roles. We formally designate the following project roles: sponsor, leader, participant, and coach. The leader and participants form the project team; the sponsor and coach play supporting roles.
Improvement teams are multidisciplinary and may include physicians, administrative leaders and staff, technical and nursing leaders and staff, and trainees. All areas targeted for improvement must be represented, especially for processes that cross organizational boundaries. All individuals must be provided with the appropriate time, resources, instruction, and authority to perform the work assigned to them.

Project Sponsor

The project sponsor's role is to provide organizational oversight and support. It is to be expected that significant barriers will likely arise in the execution of any project, such as resource limitations, personnel conflicts, and communication barriers; it is the sponsor's role to help remove those barriers. Thus, the sponsor should meet with the project leader on a regular basis to ensure that the project is actively progressing. However, the sponsor must be sure to allow the project leader to lead the project. Because many projects require changes to both clinical and operational processes, we often assign both hospital administrative and physician leaders as cosponsors.

Project Leader

The project leader is the individual most responsible for the success or failure of the project. The leader's role is to direct and coordinate the activities of the project to ensure its success. Project leaders should be selected from the area of targeted improvement. The leader helps assemble the team, create the charter, manage the project, delegate and follow up on assignments, report on progress, alert the project sponsor when more help is needed, and ensure timely completion of the deliverables. Individuals selected to lead projects should have strong organizational and leadership skills, a clear vision of needed improvements, and sufficient authority to make needed changes. Leading a project usually requires a significant time commitment, which must be allocated up front. Generally, whenever a staff physician (as opposed to a trainee) is assigned to a project, he or she is designated as the project leader or coleader. Only individuals who can work well together should be assigned as coleaders.

Project Participants

A project participant's role is to provide expertise and help execute the tasks necessary to complete the project. Participants may be chosen on the basis of their experience, subject matter expertise, skills, leadership potential, or ability to work well in teams. They should be selected from the areas of targeted improvement and may include individuals at any level of authority in the organization. There must be participant representation from all areas of targeted improvement. Participants should be chosen who are eager to contribute, because they will be required to devote a significant amount of time and effort to the project. Accordingly, participants' time should be protected for project work. Generally, the project leader and sponsor select the participants, with input from the project selection committee.

Project Coach

The project coach is an expert in improvement methods who advises and supports the project team. The coach helps guide the project leader in each phase, ensures successful communication with the project sponsor, and alerts department leaders when the project may be veering off track. The coach is not expected to perform the tasks of the team but may be called on to help with tasks that require specialized improvement-related expertise, such as data analysis and display. The coach frequently coordinates behind the scenes with the sponsor to remove anticipated barriers before they are encountered by the team. The level of engagement of the coach may vary, depending on the needs of the team leader and participants.

Planning

Project planning begins in earnest once the project has been selected and roles have been assigned. Formal project planning begins with the project charter. In our project charter, we include the following: project title; start date; description of the issue, including the improvement opportunity or problem statement, relevant background, SMART (specific, measurable, attainable, relevant, and time-related) goal, and scope; and expected project resource requirements, including individuals assigned to the project and any additional resources that are likely to be needed (Fig. 2). The charter also specifies an expected project completion date as part of the goal.
Fig. 2 —Improvement project charter template. Text in blue provides instructions for sections to be filled out by team leader and vetted with other relevant leaders and stakeholders until consensus is achieved. ED = emergency department.
The charter should be vetted with the sponsor and any relevant stakeholders, as well as the project team. Charters typically undergo several revisions until agreement is reached.
A SMART goal is one that is specific, measurable, attainable, relevant, and time related [13]. The goal should contain a quantitative measure. It should specify that performance should increase from a current measured level to a specified level by a specified date. For example, a goal might be established to decrease the mean report turnaround time for routine radiographs from 2 hours to 30 minutes by May 1, 2016. The goal contains the “what” but not the “how.” In other words, although it specifies the level of performance that should be reached, it does not contain the strategies that will be used to enable the organization to reach that level of performance.
We encourage project teams to begin with an initial kickoff meeting, led by the project leader, in which the project formally moves from the planning phase to the improvement phase. In this meeting, the team should discuss the background, the objectives and scope of the project, and the roles of the team members. The sponsor should attend the beginning of the meeting to emphasize the importance of the work and then should be excused as the team begins the specific work of the project. The manager of the affected area should also attend to discuss how work-flow changes will be tested, implemented, and communicated. The coach should also attend this and other team meetings to the extent possible.

Improvement

The successful execution of most improvement projects depends on the completion of many tasks. We divide them into three major areas: measurement, research and testing, and communications and change management. We recommend that a team member be designated to lead each of these areas. The project leader typically leads research and testing.

Measurement

Measuring performance throughout the project enables all involved to track the project's progress. Data are usually best displayed with a run chart (i.e., a chart that tracks performance over time) (Fig. 3) or a control chart (i.e., a run chart with limits that indicate when the process has changed). Data should be continuously monitored, displayed, and disseminated to keep all relevant parties constantly informed about the project's progress. A data manager should be chosen from among the team participants. Most projects require minimal data analysis—a few simple statistical process control rules will typically suffice. Therefore, the assignment of a data manager is better made on the basis of organizational and communication skills rather than analytic skills.
Fig. 3 —Example of annotated run chart. Each point represents mean daily examination completion time. Dates that interventions were implemented are plotted on chart and described in key. Goal for this hypothetical project was to decrease mean daily examination completion time from 120 minutes to 30 minutes.
Data acquisition can be a significant challenge in improvement projects. Automated data extraction from existing electronic sources can help, but gaining access to those sources and displaying the data in a meaningful way can be time consuming and expensive. We recommend that teams begin by acquiring and displaying data with less automated methods, such as small-sample-size audits, tally sheets, and poster boards. As the project progresses, methods of acquiring and displaying data should become increasingly more automated, until, by the end of the project, measurement methods are embedded in the work flow.

Research and Testing

Developing and gradually implementing process changes that will result in improved performance is the core of the project. Before considering any change, we require that all team members observe the process for at least a few hours at the place where the work is performed. Even individuals who work in the environment on a daily basis should step back and quietly observe others working in the process, recording observations and any relevant data. Project teams should map out the current processes and then again objectively observe them to verify that their representations match what is actually occurring.
On the basis of their observations, team members should seek to understand underlying problems and their causes. Tools that may be helpful include a cause-and-effect (fishbone) diagram, failure modes and effects analysis, and the “five whys” exercise [14]. Once problems are identified, teams should attempt to determine the relative importance of those problems, such as with a Pareto chart [15].
Only after team members thoroughly understand the current state of the processes, the problems, and the causes of those problems should they then turn their attention to solving the problems. Several different improvement methods exist to accomplish this, but all major frameworks have roots in the plan-do-study-act approach of iterative improvement [16]. We recommend using a key driver diagram, in which several key drivers are identified [17]. We define key drivers as the four to six actions that must happen consistently or structures that should be in place for the team to reach its goals (Fig. 4). For example, a key driver for a radiography work-flow project might include a mechanism for the technologist to know when the patient is ready. Teams then develop and test possible interventions to achieve the goal of each key driver. For example, possible interventions to alert the technologist might include a requisition form placed in an inbox, an electronic alert, or an electronic work list on a monitor mounted in the control area. Not every proposed change will be successful; proposed changes must be tested and refined before being implemented. Some proposed changes will be discarded altogether. It is better to err on the side of testing too many interventions than to consider too few, though tests do not have to exactly replicate the finished product. For example, a team may test the usefulness of an electronic dashboard by starting with an inexpensive dry-erase board; if the visibility provided by the dry-erase board is not helpful to the process, then an electronic dashboard is also unlikely to be helpful. Learning from inevitable failures is strongly encouraged, but it should be as minimally impactful to the organization as possible. In conducting experiments that will inevitably contain some failures, we counsel our teams to “fail fast, fail small, and fail friendly.” In other words, preliminary testing should be accomplished as quickly as possible, on as small a scale as possible, and in as forgiving an environment as possible.
Fig. 4 —Key driver diagram. Key drivers describe most critical actions that must happen consistently or structures that should be in place for team to reach its goals. Interventions are specific process or organizational changes that may help achieve objectives of drivers and must be tested and refined.
Teams should also learn from others' experience by searching the literature, calling and visiting colleagues at peer institutions, and investigating analogous work environments elsewhere in the same institution. A common mantra in quality improvement is to “steal shamelessly,” meaning that individuals are strongly encouraged to use others' knowledge as a springboard for their own initiatives (though, of course, credit should always be given for others' ideas) [18].
As ideas for improvement are tested, refined, and implemented on a small scale, performance should reflect the team's success. We recommend annotating the run chart or control chart by indicating dates when interventions were implemented (Fig. 3). When desired performance is achieved on a consistent basis, interventions should then be documented and packaged in a way that will allow them to be permanently incorporated into the work flow and exported to other areas.

Communications and Change Management

Organizations contain many inherent mechanisms that are intentionally designed to maintain stability, making the organization resistant to change [19]. Because improvement requires organizational change, improvement efforts can be disruptive to an organization. Process changes can be especially frustrating to those frontline staff who are not directly involved in the improvement project.
In the book Leading Change, Kotter [20] emphasizes that communication of the vision is a critical step in an organizational change effort. Securing support from the frontline staff is essential for most process improvement projects. The project team should develop a simple, honest, and compelling story for change. They should engage with the staff in a dialogue, seeking input and addressing questions. They should identify potential key allies and detractors and develop a change strategy accordingly. Doing this will assist individuals in the organization in moving from temporarily adapting to the new changes to permanently adopting them, meaning that the changes are regarded as the new way of doing business.
As team members make changes, they need to keep people updated on what is happening, why the team is doing what it is doing, and the expectations of the affected personnel during the time of change. Team members should also recognize and thank those who provide support.

Sustaining Improvement

Although it may be tempting to consider the project complete once the desired level of performance is achieved, without deliberate mechanisms to sustain improvements, processes usually revert back to the initial state. During the improvement phase, process changes are initially made on a trial basis, using temporary measures such as reminders, feedback, and education. However, the degree of dedicated effort required to maintain these types of changes is difficult to sustain in the long run. If the new level of performance is to be maintained, the changes must be integrated into the daily operations. The following are a few strategies that can help accomplish this.

Ongoing Measurement and Reporting

For individual performance to be maintained at a high level, ongoing measurement and feedback must be continued. Measurements should be incorporated into the work-flow and automated to the extent possible. If measurement and reporting depends on individual effort, this must be incorporated into the appropriate individual's job description. The most effective measurement and feedback mechanisms tend to be those that also serve as real-time work-flow signals [21].
Performance measures are meaningless without context. It should be recognized beforehand what should be done when measures are outside a specified range. Generally, this requires the ability to drill down to responsible processes and individuals. Measures become powerful when they are routinely fed back to the source, accompanied by expectations of what action should be taken on the basis of the results.

High-Reliability Solutions

Process changes may take many forms, including education and feedback, standardization of procedures, and infrastructure and system changes. In general, processes that rely on education and feedback tend to result in lower consistency in outcome, or reliability, than those that rely on standardization of procedures, which tend to be of lower consistency than those that rely on changes to infrastructure and organizational culture [22]. As a general rule, high-reliability process changes are more effective and require less effort by the process owner to sustain than low-reliability solutions (Fig. 5).
Fig. 5 —Levels of reliability of different types of improvement strategies. Strategies that tend to rely on large amounts of ongoing effort on behalf of process owners tend to result in less-consistent achievement of desired outcomes. However, because these strategies tend to be more malleable, they constitute good first steps in evolution of process changes.

Use of Handoffs to Enforce Standards

In most modern work environments, multiple individuals tend to be involved in any given process. To ensure consistency, standards must be developed. Adherence to those standards can be enforced every time a patient, an image, or a piece of information is handed from one person to another. If it meets the standard, it passes through; if it does not meet the standard, then the process stops until the problem is resolved. In this way, everyone involved in the process becomes a quality inspector.

Stopping the Line

Many manufacturers embed mechanisms whereby any worker who sees a problem with any part can activate a signal that a problem exists [23]. (This is known as an “andon” in the Toyota Production System.) If the problem is not immediately resolved, then the entire production line is stopped. This forces team leaders and line managers to be immediately available to constantly help solve problems.

Embedded Checks

Just as frontline workers should routinely check the quality of each aspect of work that they produce, frontline managers and leaders should routinely check that the new processes that have been established are routinely being followed.
Once the improvement goal has been reached, the improvement team hands the process back to the operations team. We recommend that the team hold a dedicated project closure meeting with team members, sponsors, coaches, operational managers, and other stakeholders whereby the project is summarized and the critical operational changes are reviewed. This meeting should take place even if the improvement team is made up of the same individuals as the operations team. At this meeting, operational managers and improvement team leaders should clarify the expected interventions that should continue to occur on an ongoing basis. We also recommend that the improvement team meet on a separate, more informal, occasion to celebrate its success.

Effective Project Management Basics

Because local improvement projects often are not assigned a dedicated project manager, improvement project leaders frequently serve in that role. Therefore, it is helpful for project leaders to be familiar with a few general project management strategies.

Fundamental Responsibilities

The fundamental responsibilities of a project manager are, for every stage of a project, to clarify the objectives and define the tasks required to meet them, clearly set expectations of what is to be done by whom and by when, and follow up on each task [24]. Project managers keep people apprised of project progress, remind individuals as deadlines approach, and alert the appropriate individuals when it becomes evident that milestones may be missed.

Meeting Management

Because improvement projects depend on coordination among team members, those individuals must interact on a regular basis. This necessitates team meetings. However, meetings impose a significant cost on the project, both in terms of the actual personnel time and delays related to schedule alignment. Many essential activities can be accomplished without a formal meeting. For example, coordination may be accomplished through quick “huddles” or telephone calls, and information may be disseminated through e-mail, bulletins, postings on physical or electronic bulletin boards, and so forth. When deciding on whether a meeting is necessary, the team leader should consider whether the next steps needed for the project require multidirectional simultaneous communications with the entire team (Fig. 6). Clear assignment of team member roles and responsibilities at the outset can eliminate the need for many meetings by enabling frequent brief interactions between only the relevant team members. Leaders should not hesitate to cancel a previously scheduled meeting when it is no longer needed.
Fig. 6 —Guide for determining whether project meeting is required. Project meetings should be held only when necessary. Many project activities can be performed through other venues, such as brief huddles, one-onone discussions between team members (which may be in person or via electronic or other methods), group notifications such as e-mail, and small work groups.
When meetings are necessary, they should be planned in advance and have an agenda. The fewest number of people needed to accomplish the meeting objectives should be included. Meetings should be used mainly for clarification, coordination, and decision making, once all the relevant information has been provided. Large group meetings should not be used for problem solving; conversations that lead into problem solving at meetings should be set aside and continued outside the meeting. All project meetings should begin with a follow-up of prior action items and a review of the agenda of the current meeting. Project meetings should end with a brief summary of what was discussed and reiteration of action items and next steps.

Improvement Project Discipline

Adherence to sound project management techniques can help leaders avoid a common mistake to which physicians seem to be especially prone: quickly offering solutions before they have understood the problem in depth, achieved consensus on the objectives, incorporated the perspectives of all stakeholders, and considered a variety of alternative solutions. Once organizational and clinical leaders commission the team and clarify the objectives, they should provide the resources needed to be successful and then resist the temptation to micromanage. Rather, they should allow team members the freedom to research, develop, test, and implement solutions on their own, with regular check-ins and presentation of progress. Nonteam members' feedback should focus on helping to ensure that the team is adhering to a disciplined problem-solving approach rather than attempting to prescribe specific solutions to the problems the team is working on.

Conclusion

Quality improvement has become an important element of radiology practice. As with other projects, the likelihood of success of an improvement project is increased with effective project management techniques. However, most improvement projects do not have the benefit of a project manager. Therefore, it is helpful for those leading and participating in improvement projects to have at least a basic understanding of project management.
As radiology practices become increasingly complex and the performance that is required of them becomes increasingly demanding, effective improvement project execution is increasingly becoming critical to the success of the practice. Adherence to a well-designed project structure and incorporation of basic project management principles can significantly increase the likelihood of success of an improvement project, providing real value to radiology practices, referring clinicians, and patients.

Acknowledgments

We thank Wendy Bankes and Chris Alsip for their contributions to earlier versions of the framework described in this article.

Footnotes

Based on a presentation at the Radiological Society of North America 2013 annual meeting, Chicago, IL.
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Information & Authors

Information

Published In

American Journal of Roentgenology
Pages: W470 - W477
PubMed: 26496568

History

Submitted: April 9, 2015
Accepted: June 2, 2015

Keywords

  1. project management
  2. quality improvement

Authors

Affiliations

David B. Larson
Both authors: Department of Radiology, Stanford University School of Medicine, 300 Pasteur Dr, Stanford, CA 94305-5105.
L. Jake Mickelsen
Both authors: Department of Radiology, Stanford University School of Medicine, 300 Pasteur Dr, Stanford, CA 94305-5105.

Notes

Address correspondence to D. B. Larson ([email protected]).

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