ihi expedition eliminating overuse in medical imaging session 2...2/18/2014 1 ihi expedition...
TRANSCRIPT
2/18/2014
1
IHI ExpeditionEliminating Overuse in Medical Imaging
Wednesday, February 19, 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.
2/18/2014
2
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)
3
Raise your hand
Select Chat recipient
Enter Text
4
When Chatting…
Please send your message to
All Participants
2/18/2014
3
Expedition Support
All sessions are recorded
Materials are sent one day in advance
Listserv address: [email protected]
– Sends an email to all participants and faculty
– Use only for questions relevant to all participants
– To add yourself or colleagues, email us at [email protected]
5
Where are you joining from?
2/18/2014
4
Expedition Director7
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.
Today’s Agenda8
Your stories about overuse and good decisions
Measuring overuse
Action period assignment
2/18/2014
5
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
9
Schedule of Calls
Session 1 – The Harm Caused by Overuse in Radiology
Date: Wednesday, February 5, 1:00 PM – 2:30 PM ET
Session 2 – Measuring Overuse
Date: Wednesday, February 19, 1:00 PM – 2:00 PM ET
Session 3 – Strategies for Eliminating Overuse
Date: Wednesday, March 5, 1:00 PM – 2:00 PM ET
Session 4 – Measuring What Changes Lead to Improvement
Date: Wednesday, March 19, 1:00 PM – 2:00 PM ET
Session 5 – Sustaining the Gains
Date: Wednesday, April 2, 1:00 PM – 2:00 PM ET
10
2/18/2014
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 2: Measuring Overuse
Choosing a focus for your improvement effort
– Your examples of overuse in imaging
Measurement strategies
– Start simple: Leverage current data sources
– Using current performance as a baseline
12
2/18/2014
7
13
“All Teach, All Learn”
What examples of overuse did you find in your organization?
How is your organization measuring CT Dose?
13
Tell us about your frontline teams – how are they successfully eliminating overuse or measuring CT dose?
Starting to Measure
Dose per image– Data source: CT Dose Reports
14
Images per study
– Dual Scans
– Data source
– Billing records
2/18/2014
8
Poll Questions
How are you capturing CT dose information at your site?
– Not yet capturing information on CT doses
– Manual methods
– Mixture of manual and automated methods
– Fully automated process
– Not sure
15
Capturing CT Doses
Steps
– CT scan performed
– Scanner calculates
dose metrics
– CTDIvol, DLP
– Copy these values
into the Radiology
report
– Which value do we
enter into the report?
16
2/18/2014
9
Digression: Metrics versus Intent
Intent = preventing cancer
– Should be measuring DNA mutations that involve oncogenes
Intent = preventing skin injury
– Should be measuring cell death at particular skin locations
Rare that we measure exactly what we want
– Measurements as surrogates
– Cancer = radiation dose to sensitive tissues
– Skin injury = peak skin dose
Possible to learn from imperfect data
– Infer the result of interest
– Waiting for better data usually just delays improvement
17
Operational Definitions
"An operational definition is a procedure agreed upon for translation of a concept into measurement of some kind." - W. Edwards Deming
Example: Radiation dose for a Head CT– Need to define process for measuring “radiation dose”
– CTDI (CT Dose Index) is “dose/CT slice” measured in a phantom
– DLP (Dose Length Product) is CTDI x number of slices
– Other measures such as SSDE: size specific dose estimate
– Need a process for identifying which exams are “Head CTs”
– Names within Radiology Information Systems are not standardized
– “Head CT” vs “CT Head” vs “CT Brain” vs “Std Head"
– Options: CPT codes, RADLEX, etc.
18
2/18/2014
10
Data Standards in Medical Imaging
DICOM: Digital Imaging & Communications in Medicine– International standard: file format analogous to JPEG, TIFF,
PNG. Includes numerical values for each pixel as well as metadata
– Metadata fields: dose metrics, patient identifiers, date/time, etc.
– DICOM files are transferred, stored and viewed using Picture Archiving and Communications Systems (PACS)
CPT: Current Procedural Terminology– US standard: nomenclature for imaging procedures
– 70450 = noncontrast head CT
– CPT codes are used by Radiology Information Systems (RIS) to order exams, manage workflow, organize reports and bill procedures
19
Man vs Machine
Manual (invites human error)
– Dictation/transcription errors
– Data embedded in reports
– Applying rules
Assessing compliance
– Importance of feedback
– Timely
– Specific
20
2/18/2014
11
Improvement Cycle21
Improving Data Capture
Automated data capture
– Improved accuracy and reliability
– Much more detailed datasets
22
2/18/2014
12
Poll Question
Where would you go to look up CT doses for a series of
patients?
– Information is not available
– Radiology reports
– PACS (Picture Archiving and Communication System)
– RIS (Radiology Information System)
– Dose database
– Not sure
23
Analyzing Data
“We are drowning in data, what we seek is knowledge.”Deming
24
2/18/2014
13
Data Analysis
Importance of predictive models
– Quality = conformance to expectation
– Substantial deviation from expectation is an informative event
Visualizing data: CT volume at St Louis Children’s Hospital
25
Transforming Data into Knowledge
Data vs Information
– Data: raw numbers/observations
– Information: determined by patterns within the data
Knowledge is the ability to predict future events
26
2/18/2014
14
Learning and Knowledge
Learning
– We learn nothing new about the inner workings of our system
when the observed results agree with our expectations
Unexpected events are informative
– To learn about a system we need to find and study anomalies
– Use the new knowledge to manipulate the system so that it
fulfills our needs
27
What could have
happened in 2005 that
turned linear growth into
linear contraction?
Using Data to Understand the System28
Possible causes for the observed decrease in CT volume– External forces
– Decrease in overall volume?
– Importing outside CT studies?
– Made possible by DICOM standard
– Awareness– Image Gently
campaign led to changes in behavior
– Conversations about radiation doses from CT
2/18/2014
15
Communication Example
Sharing CT dose information with customers
– Patients, Referring Physicians, Medicaid, etc.
Simplify the conversation– Quality = conformance to expectation
– Use predictions as anchors
– Teach customers to monitor variation from prediction
Lab results as an analogy
“But Medicine is Different”
“You cannot apply ideas from _________* because people get hurt if we make mistakes”
*brewing beer, information theory, statistical process control, …
2/18/2014
16
Preparing for the next session
How comfortable are you and your team with:
– Explaining the different causes of variation?
– Creating and interpreting run charts?
– Creating and interpreting control charts?
31
Action Period Assignment
Pick a measure
– Examples
– CT Volume
– Compliance with CT recording
– CT Dose metrics for a common exam (e.g. CT Head)
– Dual scan rate
– Volume of imported studies
– You pick
Assess baseline performance in your system
– Looking for volunteers to submit their data
– Next session will include tools for analyzing data
2/18/2014
17
Assignment and Next Sessions
Assignment: Baseline measurements– Tracking 1-2 metrics of overuse in your organization
Session 3
– Testing strategies for improvement (PDSAs)
Session 4
– Determining what changes led to improvement
Session 5
– Sustaining the gains, expanding to all aspects of imaging
Questions?34
Raise your hand
Use the Chat
Just for fun:
Use the chat
to tell us your
diagnosis for
each of these
two images
2/18/2014
18
5x5 pixels .03K 9x9 pixels .08K 18x18 pixels .24K 37x37 pixels 1.0K
75x75 4K 300x300 64K 600x600 256K150x150 16K
Earth Rise Apollo 8 12/24/1968Pattern Recognition
8x5 pixels .04K 16x11 pixels .18K 32x23 pixels .75K 64x47 pixels 3.0K
128x94 12K 512x375 192K 1024x750 768K256x187 48K
Jackson Pollock Number 1 circa 1947Random Pattern
2/18/2014
19
Expedition Communications
Listserv for session communications:
To add colleagues, email us at [email protected]
Pose questions, share resources, discuss barriers or
successes
37
Next Session
Session 3 – Strategies for Eliminating OveruseDate: Wednesday, March 5, 1:00 PM – 2:00 PM ET
38