Transcript CLINICAL IMPACT OF ROUTINE INPATIENT PHYSICIAN ROUNDS …

DEPARTMENTAL CQI IMPLEMENTATION:
REALITIES
Richard L. Baron, M.D.
Chair, Dep’t of Radiology
University of Chicago
CQI Implementation:
Background
• Department Goal: incorporate CQI
process into routine sectional operations
• Sectional bonus compensation pool:
– 2/3 objective; 1/3 subjective
– 3 measurable areas for improvement
• Clinical service; education; academic
• Meet mutually pre-agreed upon criteria
CQI Planning Requirements
• Clinical focus (not administrative)
• Incorporated into routine (as frequently as
possible)
• Must incorporate all physician members of
section, including residents & fellows
• Should engage external people interfacing
with operational procedures
• Must not be a single, end point but
continuous evaluation and analysis
PROCESS
•
•
•
•
•
Choosing CQI project
Getting started
Recording data
Analysis of data
Instituting Change
Pulmonary Embolism CTA: CQI Project
The Problem:
• Many MDCT PE studies are done on an
emergency basis after hours
• Large variations in exam quality occur
• Lack of consistency in results, due to many
practical issues of training and implementation
of scan protocols.
• Beta test site for not yet released CT equipment
Chest Imaging Section, U of C
Pulmonary Embolism CTA: CQI Project
Analysis of quality
• Indentify all PE CT scans over weekly periods
• Review reports for non-diagnostic/suboptimal
scans
• Review for opacification (HU>200), motion, noise.
• Classify and quantitate causes of poor quality
• Intervene with improvements
• Remeasure
Chest Imaging Section, U of C
Pulmonary Embolism CTA: CQI Project
Interventions:
•
•
•
•
•
•
•
•
Tracker location: Change to from PA to descending aorta
Tracker image: Improve quality with higher mA
I.V. location and size: Specify above wrist at least 20g
Arm position: Raised with hands on scanner
Contrast bolus: Increase rate from 4 to 5cc/sec
Record new breath-hold instructions: Avoid deep breath
Eliminate obsolete or redundant protocols from scanners
In-service training session for all technologists
Chest Imaging Section, U of C
Pulmonary Embolism CTA QA Project
Pulmonary Embolism QA Project
September : 25% Non-diagnostic
January: 5% Non-diagnostic
Chest Imaging Section, U of C
Issues
•
•
•
•
•
Choosing CQI project
Getting started
Recording data
Analysis of data
Instituting Change
– Remeasure, Reanalyze
– Handle Depression
MSK CQI Project
• PLAN: Improve radiographic quality/patient care
• METHOD: Two days/mo all plain films evaluated by
attendings/fellow
– Type of Exam; Location; Quality of exam
– Cases rated as poor discussed at MD – Tech
quarterly meetings
• RESULTS:
– Certain clinics had better quality than others
– Certain exam types had repeated lower quality
– No change seen in any of above during process and
quality was actually measured lower at end of project
• ACTION:
– Cases rated as poor discussed in quarterly tech
meetings
Peds Radiology CQI Project
• PLAN: Improve clinical history for portable radiographs
• METHOD: Review one week of Requisitions/Records
– 2 radiologists (attending and resident)
– 3 pediatricians (intensivist and 2 residents)
• RESULTS:
– 139 requests in 32 patients
– 53 adequate; 86 inadequate
•RESULTS @ 5 Months:
– 138
requests 30 patients
– 49 adeq; 89 inadequate
• ACTION:
– Two educational lectures @ morning rounds
– Pediatric intensivists personally contacted
– Pediatric residents rotating through radiology educated
CULTURE
STRATEGY
CULTURE EATS
STRATEGY FOR LUNCH
SEVEN DAYS A WEEK
Issues
• Choosing CQI project
–
–
–
–
•
•
•
•
Look around operations. What are problems
Individual approach to problems rather than sectional
Tackling something too big
Tackling something too small without recurring
analysis problems or not meaningful enough
Getting started
Recording data
Analysis of data
Instituting Change
Issues
• Choosing CQI project
• Getting started
– Daily focus on clinical work, academic work
– Sectional approach – personalities
– Lack of experienced approach
• Doesn’t recognize not getting started properly
– Data collection overwhelming (need to simplify)
• Recording data
• Analysis of data
• Instituting Change
Issues
•
•
•
•
•
Choosing CQI project
Getting started
Recording data
Analysis of data
Instituting Change
– MD willingness to integrate meaningfully with
nonradiologist management to effect change
Issues
• Choosing CQI project
• Getting started
• Recording data
– Systematic
– Proper data
– Time Consuming
• Analysis of data
• Instituting Change
– Remeasure, Reanalyze
Must become part
of routine (almost
daily) procedures
General Issues
• Physicians not trained in management
– Few management minded MDs get training
– Academicians attend specialty meetings - lack of presence
• Physician workload interferes
– Priorities of immediacy
• Education lacking
– Importance of process to department
• Department functionality
• Image of Department in Hospital
• Finances of Department
– Efficacy of CQI to improve patient outcomes and physician work effort
• Physicians are individual process oriented – the realities require group
oriented processes
• Physicians and personnel from other departments may be difficult to
engage (for same reasons as above)
DEPARTMENTAL CQI IMPLEMENTATION:
FUTURE AT UCH
• Choosing CQI projects
– Carefully to ensure early success
– Start within department before tackling out of
department
• Getting started
– Provide simple, but substantial assistance
•
•
• Department administrative support
• Other physician CQI leaders
• Won’t wait for sections to ask for help
Recording data
Analysis of data
• Instituting Change
– Each section works closer with Department CQI
Committee, with monthly reporting and integration
with all aspects of Department