THE VOICE OF EXPERIENCE
How a Culture of “Commitment to Respect” Enhances Quality of Care and Patient Satisfaction Scott D. Flamm, MD, MBA, Carl Creagh, MS (OD), Jack Gray, MBA, Patrick O’Keefe, MD, Frank Ricaurte, MD, Jean Triner, MA INTRODUCTION AND BACKGROUND
As the landscape of health care evolves, the skill sets needed for radiologists to succeed must expand beyond technical expertise and image interpretation skills into operations management, systems development, and, perhaps most important, management of people through enhanced interpersonal skills. Research has shown that treating people with respect releases chemicals in the brain that enable people to perform to the best of their ability [1]. Our experience suggests that when interactions between radiologists and their team members are consistently positive, these encounters result in optimized clinical care delivery and an improved patient experience. Team dynamics are particularly important in an enterprise as large as Cleveland Clinic’s Imaging Institute, which performs >1.8 million radiology examinations each year via the coordination of >180 radiologists, nearly 500 radiology technologists, >90 radiology nurses, and >160 administrative personnel. Approximately half of these personnel work on the main campus, with the rest spread across 9 regional hospitals. Cleveland Clinic’s goal of excellence in health care has led to high survey scores by objective third parties such as the Press Ganey outpatient survey and the Hospital Consumer Assessment of Healthcare Providers and Systems. Internally, Cleveland Clinic emphasizes quality
measures, frequent employee surveys, and delivery of the best possible patient care. Cognizant of the potential for improvement in these areas, the leaders of the Imaging Institute decided in July 2011 to focus specifically on enhancing patients’ experience. Research has shown that patient experience and employee satisfaction are closely linked [2,3]. The first half of a daylong Imaging Institute retreat was therefore devoted to this topic. THE PROBLEM
At this retreat, a panel composed of a representative sampling of technologists, nurses, nurse practitioners, and administrative staff members offered candid comments about their experiences working in the Imaging Institute. A common theme emerged: the respect that panel representatives received (or did not) from other Imaging Institute personnel affected how they felt about their work and thus how they delivered quality care. One panel member stated that in 10 years of working with a particular radiologist, this physician had never called her by her name. Instead, he addressed her as “Hey there.” WHAT WE DID
This discussion with the frontline caregiver panel served as a launching pad for an intensive Imaging Institute staff exercise to create guiding principles called Commitment to Respect. These guidelines were designed to improve communication
ª 2013 American College of Radiology 1546-1440/13/$36.00 http://dx.doi.org/10.1016/j.jacr.2013.11.009
among the radiologists, nurses, technologists, and administrative personnel and, in the process, to enhance teamwork, increase employee satisfaction, and ultimately improve patient care and satisfaction. To gauge whether these guidelines were being adopted, Imaging Institute leadership requested the design and implementation of a survey to obtain input from caregivers about the radiologists’ current attitudes and interpersonal behaviors in the clinical setting. The goals of this survey were to (1) create a tool to improve interpersonal behaviors and reinforce the Imaging Institute’s Commitment to Respect guidelines, (2) establish a process by which radiologists could receive direct but anonymous feedback that would encourage professional and personal growth, and (3) drive a positive patient experience through enhanced teamwork and collaboration. Core Team
A core team was formed to establish the respect survey process and move it forward. Team membership was representative of the large geographic footprint of the Imaging Institute, and the team was chaired by a physician to assist with physician acceptance of the initiative. A radiologist from regional operations was asked to lead the team; two additional radiologists representing the main campus and regional operations were asked to be members. Internal and external organizational development consultants [4] were added as team members to 1
2 The Voice of Experience
complement the clinical background of the physicians and to provide an objective perspective. The team achieved close communication through weekly conference calls and in-person meetings. Minutes were maintained and project plans were established to ensure that follow-up tasks were accomplished in a timely manner. Survey Design and Management
The core team’s initial tasks were to create the survey on the basis of the respect guidelines and to contract with a vendor to manage the survey mechanics. All of the core team members were involved in developing the vendor survey request for proposal and in the interview and selection process. The vendor was chosen on the basis of the company’s references, cost, and knowledge of Cleveland Clinic [5]. In addition to creating the survey, the team reviewed the annual performance review (APR) procedure for radiologists to determine how the respect survey results could be integrated into this process. In the Imaging Institute, performance over the past year (encompassing a matrix of clinical, academic, and administrative productivity) is assessed for each radiologist with respect to the year’s goals, and new goals are established through discussions with the section heads, department chairs, and the institute chair. The core team rewrote the APR format to include the feedback radiologists receive from the respect survey. Specifically, a category called “Commitment to Respect” was added to the APR form as a stand-alone criterion. This addition to the APR contains the composite respect survey score and correlates the score to performance rating criteria. The team also incorporated an encompassing review of performance behaviors felt to be important to patient care and professional relationships.
Table 1. Sample survey questions Question
Rating*
The radiologist consistently displays a professional demeanor. The radiologist creates an environment that encourages respect among employees. The radiologist manages workplace stress in an appropriate way that minimizes the impact on others. The radiologist recognizes people in ways they appreciate.
54321 54321 54321 54321
*Rating scale: 5 ¼ completely agree with the statement, 4 ¼ generally agree with the statement, 3 ¼ neither agree nor disagree with the statement, 2 ¼ generally disagree with the statement, 1 ¼ completely disagree with the statement.
Drafts of the respect survey underwent multiple iterations. The final format consisted of 18 ratings questions (based on a 5-point scale) and an open-ended comments component (see Table 1 for sample questions). The survey would be administered through a customdesigned web-based interface. Each radiologist would be assessed by randomly chosen personnel from 4 groups: peer radiologists, nurses, technologists, and administrative staff members. Each radiologist would typically have 8 to 10 respondents to ensure adequate sampling. Solidifying Buy-In
Changes in culture require a visionary leader and strong support from an intermediary layer of champions of the vision. For this initiative, the institute and departmental chairs embraced the idea and introduced it to the section heads and regional department chairs, who in turn championed the concept and shared the program’s purpose with all Imaging Institute physicians, nurses, technologists, and administrative staff members through section or departmental meetings. Institute leadership conducted multiple presentations to share recent Press Ganey and Hospital Consumer Assessment of Healthcare Providers and Systems scores, and the respect guidelines and survey plan were shared as part of the overall process of continual improvement. These presentations were given at monthly radiology staff meetings and in a
series of “town hall”estyle meetings focused on the nurses, technologists, and administrative staff members at the main campus and the regional facilities. The institute chair also sent a series of institute-wide e-mails explaining the program and assuring institute personnel of the anonymity of their survey responses. Pilot Survey
When the online survey tool was complete in February 2012, the core team initiated pilot testing in 3 areas: the cardiovascular imaging section at the main campus and the imaging departments at 2 regional hospitals. The pilot testing was highly successful, with an 85% response rate, and radiologists at the pilot sites were quite positive in their acceptance of the survey feedback. On the basis of these initial results, the survey was rolled out to the entire Imaging Institute in July 2012. Data Collection and Analysis
The results of each survey were made available on a web-based interface that could be individually customized to show varying degrees of granularity for composite answers. The section heads were provided with access to the anonymized results for their departments’ radiologists. Section heads shared these results and comparisons with institute-wide data with each of their radiologists in one-on-one meetings. To ensure anonymity of feedback, only overall themes from individual comments were provided.
The Voice of Experience 3
Fig 1. Outpatient experience scores have increased since the implementation of the Commitment to Respect process.
As the survey has now been completed 2 times across the Imaging Institute (July 2012 and March 2013) and 3 times in the pilot groups (February and July 2012 and March 2013), the core team has gathered enough data to perform emerging trend analyses. INITIAL RESULTS AND OUTCOMES
Overall, the ratings radiologists gave themselves for the desired respect behaviors were higher than the ratings they were given by nurses, technologists, and administrative personnel. Verbatim comments provided the most insight because of their candid wording. These initial results demonstrated the need for a professional development process that would help radiologists improve in areas of weakness and build on their strengths. Several differences between the main campus and regional hospitals were apparent from the survey results. Regional radiologists rated themselves higher on questions regarding managing workplace stress and valuing every member of the care team than did their main campus colleagues. Regional technologists
were more likely to give radiologists higher ratings in categories such as “responding to requests” and “creating an environment that fosters respect” than main campus technologists. Regional nurses were more likely to rate radiologists higher on “taking time to understand patients’ needs” than main campus nurses. Since the implementation of the respect survey, outpatient survey scores have trended upward, likely because of enhanced patient experiences reflecting the Imaging Institute’s adherence to the respect guidelines (Fig. 1). In addition, it is believed that collegiality and teamwork increased across the institute as a result of the respect guidelines and the behavioral feedback provided by the survey. This is reflected in increased respect survey scores from nurses from 2012 to 2013 (from 4.4 to 4.5 on a 5-point scale). These results suggest that the respect process is successfully advancing the 3 goals outlined earlier. NEXT STEPS
The subsequent steps in this process include (1) continuing to provide radiologists with feedback
and opportunities to build on strengths and address needs, (2) obtaining feedback on the survey process itself and making improvements, (3) keeping Imaging Institute leadership and employees apprised, and (4) sharing information with other Cleveland Clinic institutes as requested. Each radiologist will be given the opportunity to use the newly created staff development template. This development tool is strongly encouraged for interpersonal behavior improvement for staff members whose survey scores fall at the lower end of the scale. This tool will also be highly beneficial for staff members who score well and desire to further improve their teamwork and leadership skills. Particular encouragement will be given to those who are interested in taking on institute leadership responsibility. Staff members whose survey scores fall below a threshold on any question will be asked to work on the area needing improvement. Resources, including internal and external courses, coaching, and special task force or development opportunities, are available to physicians in the Imaging Institute, all of whom have
4 The Voice of Experience
continuing medical education hours available to them for this type of training. A mini-survey will be used to determine the effectiveness of the respect process. All Imaging Institute radiologists will be given the mini-survey and asked to provide feedback about how beneficial the respect survey has been to them; they will also be asked to suggest possible survey enhancements. The core team will review the mini survey responses and convene with other staff members to determine whether changes are needed in the respect initiative, the survey instrument, or the scoring scale. The core team will continue to communicate with Imaging Institute leadership to obtain their perspective on and support for any proposed changes. At meetings for the imaging section heads, regional staff meetings, and town hall meetings for main campus imaging employees, representatives of the core team will periodically provide updates and encourage ongoing candid
input. The core team will also share with other institutes within Cleveland Clinic or other interested medical institutions the changes achieved to date and desired next steps.
providing superior patient care and an enhanced patient experience.
CONCLUSIONS
We are grateful for the editorial assistance of Megan M. Griffiths, scientific writer for the Imaging Institute, Cleveland Clinic, Cleveland, Ohio.
We implemented the Commitment to Respect program to enhance collaboration and promote an integrated team approach to patient care within the Imaging Institute. The successful incorporation of this program within the institute’s culture is a credit to the vision of the Imaging Institute leadership. Equally important was the creation of a disciplined and focused cross-disciplinary core team encompassing business, behavioral, and clinical elements. Although the program’s incorporation within the department is still at an early stage, we are already seeing a positive impact on daily operations and an improvement in team skills. Embedding the process more seamlessly within the department is expected to further improve teamwork and reinforce the value of respect in
ACKNOWLEDGEMENT
REFERENCES 1. Fox A. The brain at work. HR Magazine 2008;53:36-43. 2. Geyer S. Hand in hand: patient and employee satisfaction. Trustee 2005;58:12-9. 3. Collins KS, Collins SK, McKinnies R, Jensen S. Employee satisfaction and employee retention: Catalysts to patient satisfaction. Health Care Manag (Frederick) 2008;27: 245-51. 4. International Coach Federation, Cleveland Charter Chapter. Jean Triner. Available at: http://www.icf-cleveland.org/content.aspx? page_id¼80&club_id¼508298&member_ id¼1577994. Accessed October 23, 2013. 5. Direct Opinions. Home page. Available at: http://www.directopinions.com. Accessed October 23, 2013.
Scott D. Flamm, MD, MBA, and Carl Creagh, MS (OD), are from the Imaging Institute, Cleveland Clinic, Cleveland, Ohio. Jack Gray, MBA, is from Direct Opinions, Cleveland, Ohio. Patrick O’Keefe, MD, and Frank Ricaurte, MD, are from Regional Radiology, Cleveland Clinic, Cleveland, Ohio. Jean Triner, MA, is from Triner Associates, Inc, Cleveland, Ohio. Scott D. Flamm, MD, MBA, Cleveland Clinic, Imaging Institute, Cardiovascular Imaging Laboratory, J1-4, 9500 Euclid Avenue, Cleveland, OH 44195; e-mail: [email protected].
How a Culture of “Commitment to Respect” Enhances Quality of Care and Patient Satisfaction Scott D. Flamm, MD, MBA, Carl Creagh, MS (OD), Jack Gray, MBA, Patrick O’Keefe, MD, Frank Ricaurte, MD, Jean Triner, MA INTRODUCTION AND BACKGROUND
As the landscape of health care evolves, the skill sets needed for radiologists to succeed must expand beyond technical expertise and image interpretation skills into operations management, systems development, and, perhaps most important, management of people through enhanced interpersonal skills. Research has shown that treating people with respect releases chemicals in the brain that enable people to perform to the best of their ability [1]. Our experience suggests that when interactions between radiologists and their team members are consistently positive, these encounters result in optimized clinical care delivery and an improved patient experience. Team dynamics are particularly important in an enterprise as large as Cleveland Clinic’s Imaging Institute, which performs >1.8 million radiology examinations each year via the coordination of >180 radiologists, nearly 500 radiology technologists, >90 radiology nurses, and >160 administrative personnel. Approximately half of these personnel work on the main campus, with the rest spread across 9 regional hospitals. Cleveland Clinic’s goal of excellence in health care has led to high survey scores by objective third parties such as the Press Ganey outpatient survey and the Hospital Consumer Assessment of Healthcare Providers and Systems. Internally, Cleveland Clinic emphasizes quality
measures, frequent employee surveys, and delivery of the best possible patient care. Cognizant of the potential for improvement in these areas, the leaders of the Imaging Institute decided in July 2011 to focus specifically on enhancing patients’ experience. Research has shown that patient experience and employee satisfaction are closely linked [2,3]. The first half of a daylong Imaging Institute retreat was therefore devoted to this topic. THE PROBLEM
At this retreat, a panel composed of a representative sampling of technologists, nurses, nurse practitioners, and administrative staff members offered candid comments about their experiences working in the Imaging Institute. A common theme emerged: the respect that panel representatives received (or did not) from other Imaging Institute personnel affected how they felt about their work and thus how they delivered quality care. One panel member stated that in 10 years of working with a particular radiologist, this physician had never called her by her name. Instead, he addressed her as “Hey there.” WHAT WE DID
This discussion with the frontline caregiver panel served as a launching pad for an intensive Imaging Institute staff exercise to create guiding principles called Commitment to Respect. These guidelines were designed to improve communication
ª 2013 American College of Radiology 1546-1440/13/$36.00 http://dx.doi.org/10.1016/j.jacr.2013.11.009
among the radiologists, nurses, technologists, and administrative personnel and, in the process, to enhance teamwork, increase employee satisfaction, and ultimately improve patient care and satisfaction. To gauge whether these guidelines were being adopted, Imaging Institute leadership requested the design and implementation of a survey to obtain input from caregivers about the radiologists’ current attitudes and interpersonal behaviors in the clinical setting. The goals of this survey were to (1) create a tool to improve interpersonal behaviors and reinforce the Imaging Institute’s Commitment to Respect guidelines, (2) establish a process by which radiologists could receive direct but anonymous feedback that would encourage professional and personal growth, and (3) drive a positive patient experience through enhanced teamwork and collaboration. Core Team
A core team was formed to establish the respect survey process and move it forward. Team membership was representative of the large geographic footprint of the Imaging Institute, and the team was chaired by a physician to assist with physician acceptance of the initiative. A radiologist from regional operations was asked to lead the team; two additional radiologists representing the main campus and regional operations were asked to be members. Internal and external organizational development consultants [4] were added as team members to 1
2 The Voice of Experience
complement the clinical background of the physicians and to provide an objective perspective. The team achieved close communication through weekly conference calls and in-person meetings. Minutes were maintained and project plans were established to ensure that follow-up tasks were accomplished in a timely manner. Survey Design and Management
The core team’s initial tasks were to create the survey on the basis of the respect guidelines and to contract with a vendor to manage the survey mechanics. All of the core team members were involved in developing the vendor survey request for proposal and in the interview and selection process. The vendor was chosen on the basis of the company’s references, cost, and knowledge of Cleveland Clinic [5]. In addition to creating the survey, the team reviewed the annual performance review (APR) procedure for radiologists to determine how the respect survey results could be integrated into this process. In the Imaging Institute, performance over the past year (encompassing a matrix of clinical, academic, and administrative productivity) is assessed for each radiologist with respect to the year’s goals, and new goals are established through discussions with the section heads, department chairs, and the institute chair. The core team rewrote the APR format to include the feedback radiologists receive from the respect survey. Specifically, a category called “Commitment to Respect” was added to the APR form as a stand-alone criterion. This addition to the APR contains the composite respect survey score and correlates the score to performance rating criteria. The team also incorporated an encompassing review of performance behaviors felt to be important to patient care and professional relationships.
Table 1. Sample survey questions Question
Rating*
The radiologist consistently displays a professional demeanor. The radiologist creates an environment that encourages respect among employees. The radiologist manages workplace stress in an appropriate way that minimizes the impact on others. The radiologist recognizes people in ways they appreciate.
54321 54321 54321 54321
*Rating scale: 5 ¼ completely agree with the statement, 4 ¼ generally agree with the statement, 3 ¼ neither agree nor disagree with the statement, 2 ¼ generally disagree with the statement, 1 ¼ completely disagree with the statement.
Drafts of the respect survey underwent multiple iterations. The final format consisted of 18 ratings questions (based on a 5-point scale) and an open-ended comments component (see Table 1 for sample questions). The survey would be administered through a customdesigned web-based interface. Each radiologist would be assessed by randomly chosen personnel from 4 groups: peer radiologists, nurses, technologists, and administrative staff members. Each radiologist would typically have 8 to 10 respondents to ensure adequate sampling. Solidifying Buy-In
Changes in culture require a visionary leader and strong support from an intermediary layer of champions of the vision. For this initiative, the institute and departmental chairs embraced the idea and introduced it to the section heads and regional department chairs, who in turn championed the concept and shared the program’s purpose with all Imaging Institute physicians, nurses, technologists, and administrative staff members through section or departmental meetings. Institute leadership conducted multiple presentations to share recent Press Ganey and Hospital Consumer Assessment of Healthcare Providers and Systems scores, and the respect guidelines and survey plan were shared as part of the overall process of continual improvement. These presentations were given at monthly radiology staff meetings and in a
series of “town hall”estyle meetings focused on the nurses, technologists, and administrative staff members at the main campus and the regional facilities. The institute chair also sent a series of institute-wide e-mails explaining the program and assuring institute personnel of the anonymity of their survey responses. Pilot Survey
When the online survey tool was complete in February 2012, the core team initiated pilot testing in 3 areas: the cardiovascular imaging section at the main campus and the imaging departments at 2 regional hospitals. The pilot testing was highly successful, with an 85% response rate, and radiologists at the pilot sites were quite positive in their acceptance of the survey feedback. On the basis of these initial results, the survey was rolled out to the entire Imaging Institute in July 2012. Data Collection and Analysis
The results of each survey were made available on a web-based interface that could be individually customized to show varying degrees of granularity for composite answers. The section heads were provided with access to the anonymized results for their departments’ radiologists. Section heads shared these results and comparisons with institute-wide data with each of their radiologists in one-on-one meetings. To ensure anonymity of feedback, only overall themes from individual comments were provided.
The Voice of Experience 3
Fig 1. Outpatient experience scores have increased since the implementation of the Commitment to Respect process.
As the survey has now been completed 2 times across the Imaging Institute (July 2012 and March 2013) and 3 times in the pilot groups (February and July 2012 and March 2013), the core team has gathered enough data to perform emerging trend analyses. INITIAL RESULTS AND OUTCOMES
Overall, the ratings radiologists gave themselves for the desired respect behaviors were higher than the ratings they were given by nurses, technologists, and administrative personnel. Verbatim comments provided the most insight because of their candid wording. These initial results demonstrated the need for a professional development process that would help radiologists improve in areas of weakness and build on their strengths. Several differences between the main campus and regional hospitals were apparent from the survey results. Regional radiologists rated themselves higher on questions regarding managing workplace stress and valuing every member of the care team than did their main campus colleagues. Regional technologists
were more likely to give radiologists higher ratings in categories such as “responding to requests” and “creating an environment that fosters respect” than main campus technologists. Regional nurses were more likely to rate radiologists higher on “taking time to understand patients’ needs” than main campus nurses. Since the implementation of the respect survey, outpatient survey scores have trended upward, likely because of enhanced patient experiences reflecting the Imaging Institute’s adherence to the respect guidelines (Fig. 1). In addition, it is believed that collegiality and teamwork increased across the institute as a result of the respect guidelines and the behavioral feedback provided by the survey. This is reflected in increased respect survey scores from nurses from 2012 to 2013 (from 4.4 to 4.5 on a 5-point scale). These results suggest that the respect process is successfully advancing the 3 goals outlined earlier. NEXT STEPS
The subsequent steps in this process include (1) continuing to provide radiologists with feedback
and opportunities to build on strengths and address needs, (2) obtaining feedback on the survey process itself and making improvements, (3) keeping Imaging Institute leadership and employees apprised, and (4) sharing information with other Cleveland Clinic institutes as requested. Each radiologist will be given the opportunity to use the newly created staff development template. This development tool is strongly encouraged for interpersonal behavior improvement for staff members whose survey scores fall at the lower end of the scale. This tool will also be highly beneficial for staff members who score well and desire to further improve their teamwork and leadership skills. Particular encouragement will be given to those who are interested in taking on institute leadership responsibility. Staff members whose survey scores fall below a threshold on any question will be asked to work on the area needing improvement. Resources, including internal and external courses, coaching, and special task force or development opportunities, are available to physicians in the Imaging Institute, all of whom have
4 The Voice of Experience
continuing medical education hours available to them for this type of training. A mini-survey will be used to determine the effectiveness of the respect process. All Imaging Institute radiologists will be given the mini-survey and asked to provide feedback about how beneficial the respect survey has been to them; they will also be asked to suggest possible survey enhancements. The core team will review the mini survey responses and convene with other staff members to determine whether changes are needed in the respect initiative, the survey instrument, or the scoring scale. The core team will continue to communicate with Imaging Institute leadership to obtain their perspective on and support for any proposed changes. At meetings for the imaging section heads, regional staff meetings, and town hall meetings for main campus imaging employees, representatives of the core team will periodically provide updates and encourage ongoing candid
input. The core team will also share with other institutes within Cleveland Clinic or other interested medical institutions the changes achieved to date and desired next steps.
providing superior patient care and an enhanced patient experience.
CONCLUSIONS
We are grateful for the editorial assistance of Megan M. Griffiths, scientific writer for the Imaging Institute, Cleveland Clinic, Cleveland, Ohio.
We implemented the Commitment to Respect program to enhance collaboration and promote an integrated team approach to patient care within the Imaging Institute. The successful incorporation of this program within the institute’s culture is a credit to the vision of the Imaging Institute leadership. Equally important was the creation of a disciplined and focused cross-disciplinary core team encompassing business, behavioral, and clinical elements. Although the program’s incorporation within the department is still at an early stage, we are already seeing a positive impact on daily operations and an improvement in team skills. Embedding the process more seamlessly within the department is expected to further improve teamwork and reinforce the value of respect in
ACKNOWLEDGEMENT
REFERENCES 1. Fox A. The brain at work. HR Magazine 2008;53:36-43. 2. Geyer S. Hand in hand: patient and employee satisfaction. Trustee 2005;58:12-9. 3. Collins KS, Collins SK, McKinnies R, Jensen S. Employee satisfaction and employee retention: Catalysts to patient satisfaction. Health Care Manag (Frederick) 2008;27: 245-51. 4. International Coach Federation, Cleveland Charter Chapter. Jean Triner. Available at: http://www.icf-cleveland.org/content.aspx? page_id¼80&club_id¼508298&member_ id¼1577994. Accessed October 23, 2013. 5. Direct Opinions. Home page. Available at: http://www.directopinions.com. Accessed October 23, 2013.
Scott D. Flamm, MD, MBA, and Carl Creagh, MS (OD), are from the Imaging Institute, Cleveland Clinic, Cleveland, Ohio. Jack Gray, MBA, is from Direct Opinions, Cleveland, Ohio. Patrick O’Keefe, MD, and Frank Ricaurte, MD, are from Regional Radiology, Cleveland Clinic, Cleveland, Ohio. Jean Triner, MA, is from Triner Associates, Inc, Cleveland, Ohio. Scott D. Flamm, MD, MBA, Cleveland Clinic, Imaging Institute, Cardiovascular Imaging Laboratory, J1-4, 9500 Euclid Avenue, Cleveland, OH 44195; e-mail: [email protected].
