IHI Expedition Eliminating Overuse In Medical Imaging .

4/1/2014Wednesday, April 2, 2014These presenters havenothing to discloseIHI ExpeditionEliminating Overuse in Medical ImagingJim Duncan, MD, PhDKelly McCutcheon Adams,LICSWExpedition Coordinator2Kayla DeVincentis, CHES, Project Coordinator, Institutefor Healthcare Improvement, currently manages web-basedExpeditions and the Executive Quality Leaders Network.She began her career at IHI in the event planningdepartment and has since contributed to the State Actionon Avoidable Rehospitalizations (STAAR) Initiative, theSummer Immersion Program, and IHI’s efforts forMedicare-Medicaid enrollees. Kayla leads IHI’s WellnessInitiative and has designed numerous activities, challenges,and educational opportunities to improve the health of herfellow staff members. In addition to implementing theorganization’s first employee health risk assessment, Kaylais certified in health education and program planning. Kaylais a graduate of Northeastern University in Boston, MA,where she obtained her Bachelors of Science in HealthScience with a concentration in Business Administration.1

4/1/2014Audio BroadcastYou will see a boxin the top left handcorner labeled“Audio broadcast.”If you are able tolisten to theprogram using thespeakers on yourcomputer, youhave connectedsuccessfully.3Phone Connection (Preferred)To join by phone:1) Click thebutton on the righthand side of thescreen.2) A pop-up box willappear with call ininformation.3) Please dial the phonenumber, the eventnumber and yourattendee ID to connectcorrectly .42

4/1/2014Audio Broadcast vs. Phone Connection5If you are using the audio broadcast (through yourcomputer) you will not be able to speak during theWebEx to ask question. All questions will need to comethrough the chat.If you are using the phone connection (through yourtelephone) you will be able to raise your hand, beunmuted, and ask questions during the session.Phone connection is preferred if you have access to aphone.WebEx Quick Reference6 Welcome to today’s Raise your handsession!Please use chat to “AllParticipants” for questionsFor technology issues only,please chat to “Host”WebEx Technical Support:866-569-3239Dial-in Info: Communicate /Join Teleconference (in Select Chat recipientmenu)Enter Text3

4/1/2014When Chatting 7Please send your message toAll ParticipantsExpedition Director8Kelly McCutcheon Adams, LICSW has been aDirector at the Institute for Healthcare Improvementsince 2004. Her primary areas of work with IHI havebeen in Critical Care and End of Life Care. She is anexperienced medical social worker with experience inemergency department, ICU, nursing home, subacute rehabilitation, and hospice settings. Ms.McCutcheon Adams served on the faculty of the U.S.Department of Health and Human Services OrganDonation and Transplantation Collaboratives andserves on the faculty of the Gift of Life Institute inPhiladelphia. She has a B.A. in Political Science fromWellesley College and an MSW from Boston College.4

4/1/2014Today’s Agenda9Review your PDSA resultsSustaining the gainsImprovement outside of CTExpedition Objectives10At the end of this Expedition, participants will beable to:List common examples of medical imagingoveruseExplain strategies for reducing overuse inmedical imagingPlan tests to make changes in own environmentUtilize tools to assess what changes generateimprovement5

4/1/201411FacultyJim Duncan, MD, PhD, is a Professor of Radiology andthe Chief Quality and Safety Officer for the MallinckrodtInstitute of Radiology at Washington University Schoolof Medicine. He maintains a clinical practice ininterventional radiology and divides his time between St.Louis Children's Hospital and Barnes-Jewish Hospital inSt. Louis. Dr. Duncan works on multiple quality andsafety improvement initiatives for both local and nationalorganizations. He has a BS from the University ofMichigan as well as an MD and PhD in Cellular andMolecular Biology from Washington University. Hecompleted the IHI Improvement Advisor ProfessionalDevelopment Program in 2012.Session 5: Wrapping Up Our ExpeditionReviewing your PDSA resultsSustaining the gains– Tools for locking in improvements (checklists)Other opportunities for improvement– Fluoroscopic procedures6

4/1/201413Participant PDSAJo Wagner & John McKinzie: Reducing dual CT scans14Sustaining the GainsLeveraging the lessons learned– Develop a learning culture– Failed predictions as an learningopportunities*PeopleLearning Culture– Capture knowledge and store it inpeople, processes and technologyProcessesTechnology7

4/1/201415Sustaining the GainsLeveraging the lessons learned– Develop a learning culture– Failed predictions as an learningopportunities*PeopleLearning Culture– Capture knowledge and store it inpeople, processes and technologyProcessesTechnologyPeople: flexible–Respond to feedback & trainingTechnology: rigid–Often expensive to replaceProcesses: intermediate–Well-designed processes make it easyto do the right thing and hard to do thewrong– Ex: well designed software*IBM employee who made a mistake thatcost the company about one milliondollars in 1940. Knowing that he wasabout to be fired, the employee typed uphis letter of resignation, and handed it tothe CEO Thomas Watson. Watsonresponded: “Fire you? I’ve just investedone million dollars in your education, andyou think I’m going to fire you?”New Joint Commission Requirements16Keeping protocols(default settings forthe CT scanners)up to date8

4/1/2014New Joint Commission Requirements17Keeping protocols(default settings forthe CT scanners)up to dateVerifying thatcorrect protocol isactually used– Sounds like a jobfor a preprocedurechecklist18Checklist Poll (Check all that Apply)Does your organizationuse checklists formedical imaging?– Invasive procedures (“Time––––––out”)Imaging procedure (UniversalProtocol)Structured reportsRoom setupStart/end of daysOtherWe don’t use checklistsHow are checklists run?– Memory– Posted list– Whiteboard– Electronic system– OtherHow do you measurechecklist performance?– Periodic audits by manager– “Secret shopper”– Other– Don’t monitor performance9

4/1/2014Well Designed Checklists & Processes19Provide feedback– Internal (agree w/ predictions)– External (cross-checking)Well Designed Checklists & Processes20Provide feedback– Internal (agree w/ predictions)– External (cross checking)Recognize the importance of thedefault settings– Ex: ranked lists instead ofalphabetical lists10

4/1/2014Role of ChecklistsProcess oriented– Can be incorporated into technologyWritten 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 cultureSuccessful Checklists in AviationGrounded within the operational environment– Each airline creates its own checklists– Avoid becoming a nuisance taskTwo formats– Call, do, response– Checklist signals the desired behavior that is performed andreported back– Checklist is the driver (NASA, military and emergencies)– Challenge, response– Perform the task from memory, then confirm steps have beencorrectly accomplished– Checklist is backup (common in commercial aviation)11

4/1/2014Checklist DesignsProblems with ChecklistsFailing to run the checklist–Goal is completing the desired behaviors, not completing the checklistSkipping steps–Esp with distractions and interruptionsLooking but not paying attention–Strong bias towards seeing the usual setupBoredom–Flight crews change the language to keep it interestingFailure to catch mistakes–Elements: monitoring and calling out an issueHuman Factors (1993) 35;2812

4/1/2014Electronic ChecklistsChecklist status linked to the aircraft’s sensors–Data is monitored by algorithms that can summon the appropriate emergencychecklistElectronic ChecklistsChecklist status linked to the aircraft’s sensors–Data is monitored by algorithms that can summon the appropriate emergency checklistShouldn’t we do the same in medical imaging?–Embed checklist for time-out or universal protocol in the imaging equipment13

4/1/2014Checklists in Medical Imaging27Preprocedure checklists– Time-outs and universal protocolRoom setup; start/end of daysStructured reports– An extension of standard workPreprocedure Checklists28St Louis Children’s Hospital: Pediatric Interventional Radiology––Oct 2008: New room, new teamNov 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 processEven before this event: planned to install a recording system in the suite–Recording system became operational in Dec 200914

4/1/2014Improving Time-Out Performance2930Version 615

4/1/2014St Louis Children’s HospitalSt Louis Children’s Hospital16

4/1/201433Data from Pediatric InterventionalRadiology team at St LouisChildren’s HospitalTime-Outs34Became 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”17

4/1/2014Time-Outs35Became 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 IRrooms at Barnes-Jewish HospitalTime-out successes– Allergies: Heparin on tray, latex gloves– Preventing patient falls (safety strap)– Preventing mislabeled imagesRadiation Use: Fluoroscopic Procedures3618

4/1/2014Uterine Fibroid EmbolizationJ Vasc Interv Radiol (2009) 20;769Recordings Analyzed for Radiation UseAbdominal Angiograms1201.2Dose per sec (Fluoroscopy)1001.0800.8600.6400.4200.20Dose Metric (µGym2)Dose Metric (µGym2)Dose per Image (DSA)0.0Pediatric Rm Adult RmPediatric Rm Adult Rm19

4/1/2014Recordings Analyzed for Radiation UseAbdominal Angiograms1201.2Dose per sec (Fluoroscopy)1001.0800.8600.6400.4200.20Dose Metric (µGym2)Dose Metric (µGym2)Dose per Image (DSA)0.0Pediatric Rm Adult RmPediatric Rm Adult RmDigitial Acquisition ExampleStd Setting: 1.2 microGy/frameAdj Setting: .12 microGy/frame20

4/1/2014Reviewing Fluoro ProtocolsBaseline settings– Dose required by the automatic exposure control circuitAdult IRPeds 1.2*Dose/image is in microGy/frame and is measured by the photocell inthe image receptor.**Adult default 15 frames/sec; Peds 7.5 frames/secRevised Protocols for Interventional CasesNew low dose protocols were available in April 2011JACR 2013;10:8474221

4/1/201443Wrapping UpImprovement requires measurementYou cannot improve things that you cannot measure– Lord Kelvin, circa 1890– Although measurements are flawed, they are far superior to using emotion tomake decisions– W. Edwards Deming, circa 1960–Need to analyze and learn from the data44Wrapping UpImprovement requires measurementYou cannot improve things that you cannot measure– Lord Kelvin, circa 1890– Although measurements are flawed, they are far superior to using emotion tomake decisions– W. Edwards Deming, circa 1960–Need to analyze and learn from the dataLots 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 watch22