abr non‐interpretive skills chew.pdfb. iom six (6) quality improvement aims c. six core...
TRANSCRIPT
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University of WashingtonDepartment of Radiology
RadiologyReviewCourseABRNon‐interpretiveSkills
March30,2015
Annemarie Relyea‐Chew, JD, MSAssociate Professor – Radiology
Adjunct Associate Professor – BIMEUniversity of Washington School of Medicine
Disclosure
Licensed attorney‐at‐law:
Washington State
Commonwealth of Massachusetts
Federal
Cited cases or legal opinions discussed during this presentation do not necessarily reflect the policies of the University of Washington.
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Disclosure of Commercial Interest
Neither I nor my immediate family members have a financial relationship with a commercial organization that may have a direct or indirect interest in the content of this presentation.
Non‐interpretiveSkillsDomains*
Quality Improvement
Patient Safety
Professionalism & Ethics
Compliance & Regulatory
Research & Screening
Imaging Information
*Acknowledgement of primary source:
http://www.theabr.org/sites/all/themes/abr‐media/pdf/Noninterpretive%20Skills%20Domain%20Specification%20%26%20Reso
urce%20Guide.pdf
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Whyisthisimportant?
Core & Qualifying Examinations
Maintenance of Certification
Core Competencies
Institutional Metrics
Practice Quality Improvement project for MOC
PPACA or Affordable Care Act
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Recentupdates:
The ABR revised the Quality and Safety core study guide in February 2015.
Changes are high‐lighted
The remaining topics are currently unchanged
http://www.theabr.org/sites/all/themes/abr‐media/pdf/Core_Exam_Quality_and_Safety_Syllabus_1st_ed_FINAL.pdf
Bibliography and Suggested Reading List (partial)
Abujudeh HH, Bruno MA. Quality and Safety in Radiology. New York, NY: Oxford University Press; 2012.Abujudeh HH, Kaewlai R, Asfaw BA, Thrall JH. Quality initiatives: key performance indicators for measuring and improving radiology department performance. Radiographics 2010;30(3):571‐580. Abujudeh H, Pyatt RS, Bruno MA, et al. RADPEER peer review: relevance, use, concerns, challenges and direction forward. J Am Coll Radiol 2014;11(9):899‐904. ACR‐AAPM Practice Parameter for Diagnostic Reference Levels and Achievable Doses in Medical X‐Ray imaging. http://www.acr.org/~/media/796DE35AA407447DB81CEB5612B4553D.pdf. ACR‐AAPM‐SIIM Practice Guideline for Digital Radiography. http://www.acr.org/~/media/3E08C87AD6E6498D9E19769E5E5E390D.pdf. ACR‐AAPM Technical Standard for Management of the Use of Radiation in Fluoroscopic Procedures. http://www.acr.org/~/media/f22c9d1ff46f43aab001f9ed0466b7e9.pdf. ACR Dose Index Registry. National Radiology Data Registry (NRDR) website. https://nrdr.acr.org/Portal/DIR/Main/page.aspx. ACR Manual on Contrast Media v9. American College of Radiology website. http://www.acr.org/quality‐ safety/resources/contrast‐manual.
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Addedoramended
Quality & Safety Core Exam p. 21
Graphs and Charts
Quality & Safety Core Exam: 22
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PartI(a)Coreexaminationreviewforqualityandsafety
Conceptual Framework
1. General Quality Improvement
A. Definitions
B. IOM Six (6) quality improvement aims
C. Six Core Competencies – MOC
D. Best Practices
E. * Value in Healthcare
F. *Quality Measures and Key Performance Indicators
G. Methodologies
H. QI Tools
Qualityimprovement
Institute of Medicine (IOM):
Crossing the Quality Chasm:
A New Health System for the 21st Century 2001
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InstituteofMedicine
6 Aims for Quality Improvement
Safety
Effectiveness
Patient‐Centeredness
Timeliness
Efficiency
Equality
CORECOMPETENCIES
Medical Knowledge
InterpersonalCommunication
Patient CareProfessionalism
Systems‐BasedPractice
Practice BasedLearning & Improvement
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QITerminology
Quality Assurance – QA
a term generally associated with enforcement
*Quality Control – QC
accuracy
precision
reliability
Quality Improvement ‐ QI
Terminology:Qualityimprovement(QI)
formal approach to the analysis of quality
measurement of performance using statistics
systematic efforts to improve
can be both prospective and retrospective
function is to make things better, not attributing blame
create or improve systems to prevent errors
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QITerminology:Value,quality,KPIs
Value in Healthcare: Best defined as “the efficient, or low cost, use of resources, which produces the desired level of quality.”
To measure value must measure quality and compare costs to accepted benchmarks
quality benchmarks
key performance indicators (KPIs)
Benchmarks
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PDSA: plan, do, study, act
Six Sigma (DMAIC)
Lean: lean process improvement
PQI: practice quality improvement
CQI: continuous quality improvement
TQM: total quality management
MethodologiesandQITools
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PDSA:Plan,do,study,act
Determine the object of the study
Baseline assessment
Analyze & compare with benchmarks
Implement improvement
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Plan‐Do‐Study‐Act
Ihttp://www.ihi.org/Pages/default.aspxHI Model for Improvement
TheToyotaWay
The long view
Right process will yield correct results
Human development
Corporate philosophy
*team success not individual merit
Solving root problems improves community learning
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– improvement or gradual improvement
human resources are the most important company asset
processes must evolve by gradual improvement rather than radical changes
improvement must be based on statistical/quantitative evaluation of process performance
Kaizan
LeanPhilosophy: Reduce and eliminate waste
Kanban (pull systems or just‐in‐time):
systems are designed to alert readiness for the creation/preparation of new inventory rather than the standard model of overproducing inventory that is unused.
Example from the lean ‘toolkit’ 5 “s”
Sorting
Straightening
Systematic cleaning
Standardizing
Sustaining
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http://healthit.gov/providers‐professionals/national‐learning‐conso
Six‐Sigma
Measure
Analyze
Design or Improve
Control or Validate
Define
(6σ or 3.4 errors or defects/million)
DMAIC or DMADV
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Lean‐six‐sigma
http://ricklapenna.com/six‐sigma/
Ishikawaor‘fishbone’diagrams
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Charts
Flow Charts Pareto Charts
ControlchartorShewart charts
View process variations: performance data plotted over time, centerline, upper & lower statistical limits: http://www.skymark.com/resources/tool
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ROCcurve
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PartI(b)Coreexaminationreviewforqualityandsafety
Conceptual Framework
II. Patient Safety
A. National Patient Safety Goals
B. Epidemiology of Error
C. Types of Errors
D. Human Errors
E. *The Skill, Rule, and Knowledge‐based Classifications
F. *High Reliability Organization (HRO)
G. *Communication
H. *Culture of Safety
I. Definitions of Error Types
J. Tools for Evaluating Risk and Adverse Events
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Pleaseberesponsiblefor:
Contrast Safety
Reactions and Management
Treatment of Contrast Reactions
MR Contrast Agents
Extravasation
BLS & ALS
* Administration of contrast to women who are breast‐feeding
* Guidelines for Contrast Warming – see ACR Manual on Contrast Media
ContrastMedia
http://www.acr.org/Quality‐Safety/Resources/Contrast‐Manual
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Pleaseberesponsiblefor:
**Universal Protocol – 3 part process
I. Pre‐procedure verification process
II. Mark the procedure site
III. Perform a time out
*Medicationreconciliation
Six ‘rights’ of medication reconciliation:
Right patient
Right medication
Right route
Right dose
Right time
Right documentation
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PatientSafety
To Err is Human IOM
1999 from the IOM Quality of Health Care Project
Estimated:
44,000 ‐ 98,000 deaths/per yr
1. Decentralized healthcare system
2. Failure of licensing systems
3. Liability system
4. No incentives to improve safety
AHRQ was funded in 2000
(NQF) National Quality Forum
TypesofError
I. Diagnosiserror or delayfailure to employ indicated testsuse of outdated methods or testsfailure to act on test or monitoring results
II. Treatment Errorsperformance of an intervention, operation, testadministrating the treatmentdose or method of using a drugdelay in treatment or responding to abnormal testinappropriate – not indicated ‐ care
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TypesofError
III. Preventative Errors
Failure to provide prophylactic treatment
Inadequate monitoring or follow‐up of treatment
IV. Other:
*communication failure
equipment failure
other system failure
PatientSafetyTerminology
Active error or failure (at point of contact with patient, ‘sharp end’)
Latent error (the end holding the ‘sharp end’) or blunt end
ADE: adverse drug event
ADR: adverse drug reaction
Adverse event: any injury caused by medical care
pneumothorax from tube placement
nosocomial infections
iatrogenic events
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PatientSafetyTerminology
Close‐call (near miss): event that fortuitously did not produce patient injury.
*Skill, Rule, and Knowledge‐based information processing
*High Reliability Organization (HRO): organizations that manage a high‐risk environment by adopting behaviors and models that result in fewer errors.
*Failure Mode and Effect Analysis (FMEA): tool for identifying error risk based on an analysis of lower level errors.
http://www.ihi.org/Pages/default.aspx
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PatientSafetyTerminology
*Hawthorne (or observer) effect: if aware that one is being observed, behavior changes and productivity (appears) to increase
*Weber effect: after introduction of a new agent/intervention, adverse event reporting increases and tends to plateau at ~ 2 years
e.g., hand washing, contrast adverse events
Authority Gradient: balance of decision making power or command hierarchy.
*Forcing Function: a design that prevents a target action from being performed or allows its performance only if another specific action is performed first.
FORCING FUNCTION
Sentinel Event Alert 53: Managing risk during transition to new ISO tubing connector standards.
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NationalPatientSafetyGoals(NPSG)
Diagnostic imaging specific (inpatient and ambulatory)
Patient identification (how many types?)
Critical results: protocol
Hand hygiene: protocol
Infection prevention: examples
Falls: in, out
Universal protocols
http://www.jointcommission.org/standards_information/npsgs.aspx
DiagnosticImaging
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*ACRPracticeParametersforCommunicationofDiagnosticImagingFindings
www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Comm_Diag_Imaging.pdf
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TheJointCommission(TJC)
Sentinel event: unexpected occurrence involving
Death;
OR permanent harm;
OR severe temporary harm and intervention required to sustain life.
An event can be considered a sentinel event even if the result was none of the above.
**Immediate investigation and response
http://www.jointcommission.org/assets/1/6/CAMH_24_SE_all_CURRENT.pdf
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Sentinel or Never Events Example: Diagnostic Imaging
Unintended retention of foreign object in patient
Guide wire left in patient following catheter insertion
Patient death or serious disability associated with fall
Patient falls while being moved onto diagnostic imaging table
Patient death or serious disability associated with medication error
Wrong epinephrine dose administered during management of a allergic reaction to contrast
Interventional procedure performed on wrong body part
Chest tube inserted into right instead of leftpleural space
Interventional procedure performed on wrong patient
Biopsy performed on a patient with name similar to that of the intended patient
Wrong interventional procedure performed on patient
Nephrostomy tube inserted when Foley catheter was intended
Intra‐or postprocedural death in an ASA Class I patient
Cardiac arrest occurs during radiofrequency ablation of liver tumor performed with patient under anesthesia
ASA = American Society of Anesthesiologists, FDA = Food and Drug Administration
ExamplesofSentinelorNeverEventsinDiagnosticImaging
ExamplesofSentinelorNeverEventsinDiagnosticImaging
Sentinel or Never Events Example: Diagnostic Imaging
Patient death or serious disability associated with use of contaminated drugs, devices, or biologics
Abscess develops due to insertion of contaminated biopsy needle
Patient death or serious disability associated with device that is used or functions other than as intended
Vein is lacerated during insertion of a metallic stent that is FDA approved only for use in bile ducts
Patient death or serious disability associated with intravascular air embolism that occurs while patient is being cared for in a healthcare facility
Large air embolus develops as a complication of catheter insertion into a pulmonary abscess
Patient death or serious disability associated with burn
Patient with transdermal patch develops aseverethermal injury during MRI
Patient death or serious disability associated with use of restraints
Patient suffers a MI while restrained on a stretcher in a radiology holding area waiting for a preliminary read after imaging
ASA = American Society of Anesthesiologists, FDA = Food and Drug Administration
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Fig 1 Human reliability curve
Abujudeh and Bruno. “Just Culture”: Is Radiology Ready? JACR 2015;12:4 - 5
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PATIENT SAFETY EVENT
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RootCauseAnalysis(RCA)
Focusesonprevention,notblameorpunishment(cornerstone:noonecomestoworktomakeamistakeorhurtsomeone)
Focusesonsystemlevelvulnerabilitiesandlatenterrorsratherthanindividualperformance
‐ Communication‐ Environment/Equipment‐ Training‐ Rules/Policies/Procedures‐ Fatigue/Scheduling‐ Barriers
RCA:Fishbone
Kruskal, et al. Radiographics 2008;28:1237‐1250.
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‘Swiss‐cheese’model
Reason J. Human error: models and management. BMJ. 2000 Mar 18; 320(7237): 768–770
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MRISafety
http://www.rad‐planning.com/newsletter/2012/1203_2_MRI_fires.html
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Gadolinium
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ContrastMedia
http://www.acr.org/Quality‐Safety/Resources/Contrast‐Manual
Gadolinium&NSF
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ChoosingWisely®“Fivethingspatientsandphysiciansshouldquestion”
ACR Recommendations:
1. Don’t do imaging for uncomplicated headache;
2. Don’t image for suspected PE without moderate of high pre‐test probability of PE;
3. Avoid admission or preoperative chest x‐rays for ambulatory patients with an unremarkable history and physical exam;
4. Don’t do CT for the evaluation of suspected appendicitis in children until after an US has been considered as an option;
5. Don’t recommend follow‐up imaging for clinically; inconsequential adnexal cysts.
http://www.choosingwisely.org/doctor‐patient‐lists/american‐college‐of‐radiology/
Elementsofinformedconsent
purpose and nature of the procedure or treatment
method by which the procedure or treatment will be performed
risks, complications, and expected benefits or effects of the procedure or treatment
risk of not accepting the procedure or treatment
any reasonable alternatives to the procedure or treatment and the likely risks and benefits
right to refuse the procedure or treatment
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InformedConsent
Patient has the right to withhold consent
Patient has the right to withdraw consent
Adequate information (benefits, potential risks)
Absence of coercion – (ie., obtain before entering suite)
Decision‐making capacity
Reasonable decision making
Emergencies: a physician may provide treatment or perform a procedure without consent “to prevent serious disability or death or to alleviate great pain or suffering.”
InformedConsent
ACR‐SIR Practice Guidelines:
When obtaining informed consent for image‐guided procedures that may be associated with higher levels of radiation an explanation of the likelihood and characteristics of deterministic injury should be included in the consent discussion prior to the procedure.
http://www.sirweb.org/clinical/cpg/Informed_consent_Final7109Ed01.pdf
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ALARAandDoseManagement
GE & Toshiba overdose cases in CT perfusion studies
Cedars‐Sinai: ~ 206 patients received radiation over 8 x over expected levels
California enacted SB 1237 requiring dose reporting in radiology reports DLP or CT dose index
ALARAandDoseManagement
March 2009: California hospital fined $25,000 by state regulatory agency for massive CT radiation dose to pediatric patient. Technologist error
2 year old boy 151 CT scans in 65 minutesBurns, substantial chromosomal damage
5.3 Gy to the brain and salivary glands, 7.3 Gy to the skin, and 1.54 Gy to the lenses of both eyes
http://www.nytimes.com/2009/10/16/us/16radiation.html?_r=0
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ImageGently®Campaign
StepLightly(fluoroscopy)
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Attributions
The Core Examination Guide (ABR) Feb. 2015
Bibliography and suggested reading
The Non‐interpretive Skills Guide (ABR) 2014
ACR: Appropriateness Criteria®
Practice Parameters & Technical Standards
NGC: http://www.guideline.gov/
HHS: Health and Human Services
AHRQ: Agency for Healthcare Research and Quality
CMS: Centers for Medicare and Medicaid
IOM: Institute of Medicine
