IHI Expedition Eliminating Overuse in Medical Imaging Jim Duncan, - - PDF document

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IHI Expedition

Eliminating Overuse in Medical Imaging

Wednesday, April 2, 2014

These presenters have nothing to disclose

Jim Duncan, MD, PhD Kelly McCutcheon Adams, LICSW

Expedition Coordinator

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Kayla DeVincentis, CHES, Project Coordinator, Institute for Healthcare Improvement, currently manages web-based Expeditions and the Executive Quality Leaders Network. She began her career at IHI in the event planning department and has since contributed to the State Action

• n Avoidable Rehospitalizations (STAAR) Initiative, the

Summer Immersion Program, and IHI’s efforts for Medicare-Medicaid enrollees. Kayla leads IHI’s Wellness Initiative and has designed numerous activities, challenges, and educational opportunities to improve the health of her fellow staff members. In addition to implementing the

• rganization’s first employee health risk assessment, Kayla

is certified in health education and program planning. Kayla is a graduate of Northeastern University in Boston, MA, where she obtained her Bachelors of Science in Health Science with a concentration in Business Administration.

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Audio Broadcast

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Expedition Director

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Kelly McCutcheon Adams, LICSW has been a Director at the Institute for Healthcare Improvement since 2004. Her primary areas of work with IHI have been in Critical Care and End of Life Care. She is an experienced medical social worker with experience in emergency department, ICU, nursing home, sub- acute rehabilitation, and hospice settings. Ms. McCutcheon Adams served on the faculty of the U.S. Department of Health and Human Services Organ Donation and Transplantation Collaboratives and serves on the faculty of the Gift of Life Institute in

• Philadelphia. She has a B.A. in Political Science from

Wellesley College and an MSW from Boston College.

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Today’s Agenda

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Review your PDSA results Sustaining the gains Improvement outside of CT

Expedition Objectives

At the end of this Expedition, participants will be able to: List common examples of medical imaging

• veruse

Explain strategies for reducing overuse in medical imaging Plan tests to make changes in own environment Utilize tools to assess what changes generate improvement

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Faculty

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Jim Duncan, MD, PhD, is a Professor of Radiology and the Chief Quality and Safety Officer for the Mallinckrodt Institute of Radiology at Washington University School

• f Medicine. He maintains a clinical practice in

interventional radiology and divides his time between St. Louis Children's Hospital and Barnes-Jewish Hospital in

• St. Louis. Dr. Duncan works on multiple quality and

safety improvement initiatives for both local and national

• rganizations. He has a BS from the University of

Michigan as well as an MD and PhD in Cellular and Molecular Biology from Washington University. He completed the IHI Improvement Advisor Professional Development Program in 2012.

Session 5: Wrapping Up Our Expedition

Reviewing your PDSA results Sustaining the gains

– Tools for locking in improvements (checklists)

Other opportunities for improvement

– Fluoroscopic procedures

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Participant PDSA

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Jo Wagner & John McKinzie: Reducing dual CT scans

Learning Culture

Sustaining the Gains

Leveraging the lessons learned

– Develop a learning culture

– Failed predictions as an learning

• pportunities*

– Capture knowledge and store it in

people, processes and technology

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People Processes Technology

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Learning Culture

Sustaining the Gains

Leveraging the lessons learned

– Develop a learning culture

– Failed predictions as an learning

• pportunities*

– Capture knowledge and store it in

people, processes and technology

People: flexible

–

Respond to feedback & training

Technology: rigid

–

Often expensive to replace

Processes: intermediate

–

Well-designed processes make it easy to do the right thing and hard to do the wrong

–

Ex: well designed software

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People Processes Technology

*IBM employee who made a mistake that cost the company about one million dollars in 1940. Knowing that he was about to be fired, the employee typed up his letter of resignation, and handed it to the CEO Thomas Watson. Watson responded: “Fire you? I’ve just invested

• ne million dollars in your education, and

you think I’m going to fire you?”

New Joint Commission Requirements

Keeping protocols (default settings for the CT scanners) up to date

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New Joint Commission Requirements

Keeping protocols (default settings for the CT scanners) up to date Verifying that correct protocol is actually used

– Sounds like a job

for a preprocedure checklist

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Checklist Poll (Check all that Apply)

How are checklists run?

– Memory – Posted list – Whiteboard – Electronic system – Other ____________

How do you measure checklist performance?

– Periodic audits by manager – “Secret shopper” – Other ____________ – Don’t monitor performance

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Does your organization use checklists for medical imaging?

– Invasive procedures (“Time-

• ut”)

– Imaging procedure (Universal

Protocol)

– Structured reports – Room setup – Start/end of days – Other _________ – We don’t use checklists

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Well Designed Checklists & Processes

Provide feedback

– Internal (agree w/ predictions) – External (cross-checking)

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Well Designed Checklists & Processes

Provide feedback

– Internal (agree w/ predictions) – External (cross checking)

Recognize the importance of the default settings

– Ex: ranked lists instead of

alphabetical lists

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Role of Checklists

Process oriented

– Can be incorporated into technology

Written instructions

– Overcomes limitations of human memory

– Distractions as a factor that hinders performance

– Observable and thus allows crosschecking

– Single person: 1 in 10 chance of error – Two people: 1 in 100 – As a shared activity, it promotes

– Teamwork – Safety culture

Successful Checklists in Aviation

Grounded within the operational environment

– Each airline creates its own checklists – Avoid becoming a nuisance task

Two formats

– Call, do, response

– Checklist signals the desired behavior that is performed and

reported back

– Checklist is the driver (NASA, military and emergencies)

– Challenge, response

– Perform the task from memory, then confirm steps have been

correctly accomplished

– Checklist is backup (common in commercial aviation)

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Checklist Designs Problems with Checklists

Failing to run the checklist

–

Goal is completing the desired behaviors, not completing the checklist

Skipping steps

–

Esp with distractions and interruptions

Looking but not paying attention

–

Strong bias towards seeing the usual setup

Boredom

–

Flight crews change the language to keep it interesting

Failure to catch mistakes

–

Elements: monitoring and calling out an issue Human Factors (1993) 35;28

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Electronic Checklists

Checklist status linked to the aircraft’s sensors

–

Data is monitored by algorithms that can summon the appropriate emergency checklist

Electronic Checklists

Checklist status linked to the aircraft’s sensors

–

Data is monitored by algorithms that can summon the appropriate emergency checklist

Shouldn’t we do the same in medical imaging?

–

Embed checklist for time-out or universal protocol in the imaging equipment

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Checklists in Medical Imaging

Preprocedure checklists

– Time-outs and universal protocol

Room setup; start/end of days Structured reports

– An extension of standard work

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Preprocedure Checklists

St Louis Children’s Hospital: Pediatric Interventional Radiology

–

Oct 2008: New room, new team

–

Nov 2008: Central line flushed with 1000U/ml heparin rather than 100U/ml

–

Shut down the room for 2 weeks for additional training

–

Included changes to tray setup and time-out process

Even before this event: planned to install a recording system in the suite

–

Recording system became operational in Dec 2009

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Improving Time-Out Performance

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Version 6

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St Louis Children’s Hospital St Louis Children’s Hospital

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Data from Pediatric Interventional Radiology team at St Louis Children’s Hospital

Time-Outs

Became part of the pediatric team’s safety culture

– Proud that they do the “best time-outs” in the hospital – Reassuring that every procedure starts on the right foot – Promotes communication about procedure specific concerns

– Especially with addition of the “side bar”

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Time-Outs

Became part of the pediatric team’s safety culture

– Proud that they do the “best time-outs” in the hospital – Reassuring that every procedure starts on the right foot – Promotes communication about procedure specific concerns

– Especially with addition of the “side bar”

November 2013 – Installed recording systems in IR rooms at Barnes-Jewish Hospital Time-out successes

– Allergies: Heparin on tray, latex gloves – Preventing patient falls (safety strap) – Preventing mislabeled images

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Radiation Use: Fluoroscopic Procedures

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Uterine Fibroid Embolization

J Vasc Interv Radiol (2009) 20;769

Recordings Analyzed for Radiation Use

Abdominal Angiograms Pediatric Rm Adult Rm Dose Metric (µGym2)

20 40 60 80 100 120

Dose per sec (Fluoroscopy)

Pediatric Rm Adult Rm Dose Metric (µGym2)

0.0 0.2 0.4 0.6 0.8 1.0 1.2

Dose per Image (DSA)

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Recordings Analyzed for Radiation Use

Abdominal Angiograms Pediatric Rm Adult Rm Dose Metric (µGym2)

20 40 60 80 100 120

Dose per sec (Fluoroscopy)

Pediatric Rm Adult Rm Dose Metric (µGym2)

0.0 0.2 0.4 0.6 0.8 1.0 1.2

Dose per Image (DSA)

Digitial Acquisition Example

Std Setting: 1.2 microGy/frame Adj Setting: .12 microGy/frame

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Reviewing Fluoro Protocols

Baseline settings

– Dose required by the automatic exposure control circuit

Fluoro* DA* DSA* Adult IR 0.032-.045** 1.2-2.4 3-12 Peds IR 0.023** 0.54 1.2

*Dose/image is in microGy/frame and is measured by the photocell in the image receptor. **Adult default = 15 frames/sec; Peds = 7.5 frames/sec

Revised Protocols for Interventional Cases

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JACR 2013;10:847

New low dose protocols were available in April 2011

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Wrapping Up

Improvement requires measurement

–

You cannot improve things that you cannot measure

– Lord Kelvin, circa 1890 –

Although measurements are flawed, they are far superior to using emotion to make decisions

– W. Edwards Deming, circa 1960

Need to analyze and learn from the data

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Wrapping Up

Improvement requires measurement

–

You cannot improve things that you cannot measure

– Lord Kelvin, circa 1890 –

Although measurements are flawed, they are far superior to using emotion to make decisions

– W. Edwards Deming, circa 1960

Need to analyze and learn from the data Lots of opportunities to improve

– Someday when I am a grandfather

– My grandchild will fall and hit his or her head during my watch – I won’t have to worry about the ER we choose or the CT scanner’s settings.

I can tell my son and his wife that we fixed these problems years ago

– My focus will be on explaining how the fall happened during my watch

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Questions?

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Visualizing Data

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Google Fusion Table for Dual Chest CTs