4/1/2014 Wednesday, April 2, 2014 These presenters have nothing to disclose IHI Expedition Eliminating Overuse in Medical Imaging Jim Duncan, MD, PhD Kelly McCutcheon Adams, LICSW 2 Expedition Coordinator 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. 1
4/1/2014 Audio Broadcast 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. 3 Phone Connection (Preferred) 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 2
4/1/2014 5 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. 6 WebEx Quick Reference Welcome to today’s • session! Raise your hand 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 Select Chat recipient menu) Enter Text 3
4/1/2014 7 When Chatting… Please send your message to All Participants 8 Expedition Director 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
4/1/2014 9 Today’s Agenda Review your PDSA results Sustaining the gains Improvement outside of CT 10 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 5
4/1/2014 11 Faculty 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 6
4/1/2014 13 Participant PDSA Jo Wagner & John McKinzie: Reducing dual CT scans 14 Sustaining the Gains Leveraging the lessons learned People – Develop a learning culture – Failed predictions as an learning Learning Culture opportunities* – Capture knowledge and store it in Processes people, processes and technology Technology 7
4/1/2014 15 Sustaining the Gains Leveraging the lessons learned People – Develop a learning culture – Failed predictions as an learning Learning Culture opportunities* – Capture knowledge and store it in Processes Technology people, processes and technology People: flexible Respond to feedback & training – *IBM employee who made a mistake that Technology: rigid cost the company about one million Often expensive to replace dollars in 1940. Knowing that he was – about to be fired, the employee typed up Processes: intermediate his letter of resignation, and handed it to Well-designed processes make it easy – the CEO Thomas Watson. Watson to do the right thing and hard to do the responded: “Fire you? I’ve just invested wrong one million dollars in your education, and Ex: well designed software – you think I’m going to fire you?” 16 New Joint Commission Requirements Keeping protocols (default settings for the CT scanners) up to date 8
4/1/2014 17 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 18 Checklist Poll (Check all that Apply) How are checklists run? Does your organization – Memory use checklists for – Posted list medical imaging? – Whiteboard – Invasive procedures (“Time- – Electronic system out”) – Other ____________ – Imaging procedure (Universal How do you measure Protocol) checklist performance? – Structured reports – Periodic audits by manager – Room setup – “Secret shopper” – Start/end of days – Other ____________ – Other _________ – Don’t monitor performance – We don’t use checklists 9
4/1/2014 19 Well Designed Checklists & Processes Provide feedback – Internal (agree w/ predictions) – External (cross-checking) 20 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 10
4/1/2014 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) 11
4/1/2014 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 12
4/1/2014 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 13
4/1/2014 27 Checklists in Medical Imaging Preprocedure checklists – Time-outs and universal protocol Room setup; start/end of days Structured reports – An extension of standard work 28 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 – 14
4/1/2014 29 Improving Time-Out Performance 30 Version 6 15
4/1/2014 St Louis Children’s Hospital St Louis Children’s Hospital 16
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