4/1/2014 1 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 2 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 on 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 organization’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.
Transcript
4/1/2014
1
IHI ExpeditionEliminating Overuse in Medical Imaging
Wednesday, April 2, 2014
These presenters have
nothing to disclose
Jim Duncan, MD, PhD
Kelly McCutcheon Adams,
LICSW
Expedition Coordinator2
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 on 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 organization’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.
4/1/2014
2
Audio Broadcast
3
You will see a box
in the top left hand
corner labeled
“Audio broadcast.” If you are able to
listen to the
program using the
speakers on your computer, you
have connected
successfully.
Phone Connection (Preferred)
4
To join by phone:
1) Click the
button on the right
hand side of the
screen.
2) A pop-up box will
appear with call in
information.
3) Please dial the phone number, the event
number and your
attendee ID to connect
correctly .
4/1/2014
3
Audio Broadcast vs. Phone Connection
If you are using the audio broadcast (through your
computer) you will not be able to speak during the
WebEx to ask question. All questions will need to come
through the chat.
If you are using the phone connection (through your
telephone) you will be able to raise your hand, be
unmuted, and ask questions during the session.
Phone connection is preferred if you have access to a
phone.
5
WebEx Quick Reference
• Welcome to today’s
session!
• Please use chat to “All
Participants” for questions
• For technology issues only,
please chat to “Host”
• WebEx Technical Support:
866-569-3239
• Dial-in Info: Communicate /
Join Teleconference (in
menu)
6
Raise your hand
Select Chat recipient
Enter Text
4/1/2014
4
7
When Chatting…
Please send your message to
All Participants
Expedition Director8
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.
4/1/2014
5
Today’s Agenda9
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 overuse
Explain strategies for reducing overuse in medical imaging
Plan tests to make changes in own environment
Utilize tools to assess what changes generate improvement
10
4/1/2014
6
Faculty11
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
of 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
organizations. 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
4/1/2014
7
Participant PDSA13
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 opportunities*
– Capture knowledge and store it in people, processes and technology
14
People
Processes Technology
4/1/2014
8
Learning Culture
Sustaining the Gains
Leveraging the lessons learned
– Develop a learning culture
– Failed predictions as an learning opportunities*
– 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
15
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
one 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
16
4/1/2014
9
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
17
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
18
Does your organization
use checklists for
medical imaging?– Invasive procedures (“Time-
out”)
– Imaging procedure (Universal
Protocol)
– Structured reports
– Room setup
– Start/end of days
– Other _________
– We don’t use checklists
4/1/2014
10
Well Designed Checklists & Processes
Provide feedback
– Internal (agree w/ predictions)
– External (cross-checking)
19
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
20
4/1/2014
11
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)
4/1/2014
12
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
4/1/2014
13
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
4/1/2014
14
Checklists in Medical Imaging
Preprocedure checklists
– Time-outs and universal protocol
Room setup; start/end of days
Structured reports
– An extension of standard work
27
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
28
4/1/2014
15
Improving Time-Out Performance29
30
Version 6
4/1/2014
16
St Louis Children’s Hospital
St Louis Children’s Hospital
4/1/2014
17
33
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”
34
4/1/2014
18
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
