ACR Bulletin

Covering topics relevant to the practice of radiology

The ACR Learning Network: In It for the Long Haul

ACR Learning Network participants commit to improving mammogram quality and find other unexpected gains.

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You really have to take your time when you’re doing something this important and figure out what the problem is, why it’s happening, all of the possible reasons. It was refreshing.

—Lynn Rudin
October 02, 2023

Note: This is the second in a three-part series on the ACR Learning Network and its first cohort of 22 sites that participated in quality improvement collaboratives. The first article of the series, Collaborating on Quality, explored prostate image quality.

For participants of the ACR Learning Network, quality improvement has become an art, appreciated not just for its final outcome but for the effective, methodical process involved. Because when you allow yourself the time to gather the details, engage the right people and gain support from other practices going through the same challenges, the path to improvement becomes clear.

Practices or departments that apply to the ACR Learning Network, launched in April 2022, sign on to join a cohort that goes through a rigorous, structured process to make measured quality improvements in one of several areas, including patient positioning to improve mammogram quality. Other collaboratives, or project areas of improvement, include prostate MR image quality, lung cancer screening and recommendations follow-up.

One of the things that helped was briefly explaining to the patients why we’re doing what we’re doing, so they don’t think we’re just trying to torture them.

—Angela Sie, MD

Recognizing the need to properly train new RTs in mammography and in the midst of an overhaul on positioning, Angela Sie, MD, medical director of breast imaging at Long Beach Memorial Hospital, took on the role of physician leader after being accepted into the ACR Learning Network cohort. The experience was different than she expected.

“I thought we would go through what we needed to train our technologists, but it was much more about how to work as a team, how to figure out what works best for us, how to communicate and have it stick,” Sie says. “It started with how to evaluate the images, the basics, but it really helped us in terms of getting buy-in from the administrators by helping them to understand how important positioning is and how we need resources to succeed.”

Sie’s team was able to create a new job: a positioning coach for new technologists.

Having the resources to succeed is a critical aspect of any endeavor. So is commitment. “When you’re looking at an organization that is as large as we are,” says Cleveland Clinic Clinical Manager Lynn Rudin, “some of the projects we start, because we are so very stretched, they either fall along the wayside or they become not as important. I used this opportunity to say, ‘We are committing to doing this through a really important organization, and it’s going to give us exactly what we need to stay on task.’”

Challenges at busy radiology practices often need to be solved quickly, but the Learning Network asked groups to slow down and examine how positioning affects image quality, piece by piece. “We didn’t have to make a rash decision,” Rudin says. “You really have to take your time when you’re doing something this important and figure out what the problem is, why it’s happening, all of the possible reasons. It was refreshing.”

Outcomes and the Need for Feedback

The role of the positioning coach at Sie’s organization is to work with new technologists and explain the importance of positioning and the parameters that radiologists use to evaluate mammograms. The positioning coach also helps other technologists learn to speak to patients during positioning.

“One of the things that helped was briefly explaining to the patients why we’re doing what we’re doing, so they don’t think we’re just trying to torture them,” Sie says. Her team also employed simple positioning solutions, such as marking the floor with a piece of tape to indicate where a patient should stand during imaging.

After participating in the ACR Learning Network twice, Chirag R. Parghi, MD, chief medical officer at Solis Mammography, better appreciates the challenges technologists need to account for during patient positioning to capture the greatest amount of breast tissue. But working more closely with technologists during the project uncovered an additional need.

“Our technologists crave meaningful feedback,” Parghi says. “If I do not give feedback, then I am practicing in silos. Every patient experience is an opportunity to learn, grow and reflect, and the more we engage in that process, the better we do overall.”

In addition to feedback from radiologists, Sie stressed the importance of training technologists to critique their own images. “Looking at prior images, seeing what they can improve or do better, just to be aware of these things is helpful,” she says.

Rudin says those technologists who excel in certain areas of imaging or patient experience are remembered for their special skills, and the project made those characteristics more apparent. “This project really gave our technologists the opportunity to go up a level, to experience data collection and to hone their skills,” she says. “I found out who was the most organized, who was the most energetic, so now I can use that on other projects.”

Unexpected Benefits

In quality or process improvement projects, the ultimate goal can sound quite technical, such as reduce patient return by 10% or increase turnaround time by five days. But as Parghi says, “The actual challenge is deep introspection, flexibility and objective measurement of failure or success, a very deep look inward. It can seem like you’re just trying to reach this external goal, but the goal happens almost as a byproduct of the process.”

For Rudin, it was a lesson in time management and organization. “The project just really brought everyone together,” she says.

The network aspect of the project provided an unanticipated level of support for teams addressing similar and unique challenges. Audrey Strain, modality manager at Stanford Healthcare, participated as a team lead in the project.

“We were looking for ways to help our patients relax to improve positioning, and someone in the network mentioned that, to make it a friendlier environment, they replaced their patient locker numbers with names of famous women,” Strain says. When she spoke with her staff members about doing the same, the interest was infectious.

“The whole department submitted names of famous women, voted on name and added short bios,” she says. “It’s a lot more fun to think Ruth Bader Ginsburg has your purse rather than locker number three. Patients seem to agree, as well, since they often comment on this aspect of their visit on our surveys.”

Beyond suggestions for positioning, Strain appreciated the additional insight from crowdsourcing solutions to common concerns in room and staffing models and general business process. She says, “This network and the connections have been helpful.”

Sustaining Improvements

Evaluating the quality of mammography images takes time and administrative buy-in. ACR Learning Network projects require administrative leadership commitment to ensure participants have time set aside to do the work. “We needed administrative buy-in to sustain this effort, to create the role of positioning coach,” Sie says. “We need to be able to constantly self-evaluate and improve our quality.”

Joining the ACR Learning Network requires commitment from numerous roles, and the process is far from quick, but it’s worth it, participants say. “A breast center is only as good as the images,” Sie says. “It’s important to spotlight positioning techniques and for everyone to recognize how much it should be valued, tracked and improved to make sure we’re doing the best we can.”


ACR Learning Network – Learn about the benefits and timetables for the Learning Network collaboratives.

Benefits of Participation in the ACR Learning Network

• Receive rigorous training in proven quality improvement (QI) strategies and processes through the ImPower Program and quality coach training that a site can use for future QI work.

• Obtain guidance from national leaders to get the most out of participation and achieve sustained diagnostic excellence.

• Become a regional and/or national leader in one of the collaboratives’ focus areas and continue participation in the Learning Network community.

• Obtain continuing education credits for ImPower program participation and complete a quality improvement initiative.

Learn how to apply at the ACR Learning Network  web page.

Author Raina Keefer,  contributing writer, ACR Press