In its “To Err is Human” report nearly two decades ago, the Institutes of Medicine launched the healthcare-wide conversation about quality improvement through error reduction. Today, the topic is still prominent in all specialties, including radiology.
According to industry experts at the 2017 Radiological Society of North America annual meeting in Chicago, greater quality and decreased errors mean having a better understanding of the barriers to improvement and the role patients and families can play.
Overall, says Danny Kim, MD, associate professor and director of quality and safety with NYU Langone Health, there are four types of barriers to improving quality: technology, liability, reimbursement and culture.
Each barrier presents unique challenges.
Technology. For radiology, the most important technologies in use are the electronic health record, computerized physician order entry, clinical decision support, PACS, health information exchanges and medical devices.
“Health information technology is an important tool in the diagnostic process. It captures information that informs the diagnostic process, sharpens clinical workflow and decision-making, and it facilities information exchange among healthcare providers,” Kim says. “But, there are barriers to using it to improve diagnostic performance.”
For these tools, the list can be extensive:
1. Poor usability: poor efficiency and navigation
2. Cluttered displays: impedes data mining
3. Poor data: lack of accuracy, reliability or amount
4. Inappropriate or incomplete histories
5. Unsupported decision-making: not enough information to inform diagnosis
6. Poor transmission: ineffective strategies for passing information to referring physicians
7. Downtime: maintenance or unanticipated
To be effective, Kim says, the tools must fit into how providers already do their jobs. If using the technology is too complicated or takes too long, it’s a distraction.
Liability. Claims of medical malpractice don’t often hit diagnostic radiologists, he says, pointing out that between 7 percent and 8 percent of these providers face claims for errors. Roughly 2 percent to 3 percent end up making payments.
Even though the claims are rare, it can still be hard to admit when a mistake happens. Sometimes providers haven’t been trained in how to correctly disclose an error or their leadership has given them mixed messages about what to say. Others can feel personal embarrassment or have a lack of confidence in addressing the issue.
But, not all mistakes are created equal.
“We need to distinguish between risky and reckless behavior,” he says.
And, the responses need to correspond to error severity. If the mistake is a normal human error —an unintentional miss—Kim recommends consoling the clinician who likely feels remorse. If the behavior is risky, such as a copy and paste error in a patient record, offer additional coaching and training. In cases of reckless behavior, such as prescribing an inappropriate medication for a pregnant patient, discipline is likely necessary.
Reimbursement. Although there’s a continued push to move healthcare toward more value-based payments, fee-for-service still rules the land, he says, and it undermines the need to pivot toward a different approach to imaging.
“Fee-for-service is still predominant in the United States, and it doesn’t incentivize high quality and efficient care,” he says. “Instead, it incentivizes more diagnostic imaging because of higher payments.”
And, currently no substantial consequences exist for ordering unnecessary imaging and there are no real rewards for engaging in coordinated care efforts. Instead, the focus on meeting billing requirements does nothing to improve patient care, he says.
Culture. Improved quality and diagnostic performance can also be hampered by the punitive culture within radiology, Kim says.
For example, the hierarchical nature of both academic and private practices can make it harder for younger providers to admit errors or even make suggestions for changes. They could worry about career stagnation if they share too much information or push too hard in a new or different direction.
“It’s not easy to communicate about medical errors with those people who can determine your future,” he says. “Not everyone shares the same viewpoints, and unfortunately, that lack of communication can detrimentally impact performance.”
A desire to maintain the status quo, fear of change or even change fatigue can stand in the way of changing office culture, he says.
Include patients and families to improve care
A central aspect of improving the quality of care and controlling errors is concentrating on including patients and families in designing the best treatment plans, said Jeff Myers, diagnostic pathology professor and vice chair of clinical affairs and quality at the University of Michigan.
“We have to find a way to create patient- and family-centered care,” he says. “It’s a restoration of our purpose. It’s about the transformation of care, population management and cost reduction.”
To reach this goal, he recommends practices and facilities create a patient- and family-advisory council. This group can teach providers not only about what information they’d like to have about their care and any mistakes that occur, but also how they’d like to receive the details.
It’s that face-to-face conversation and interaction that can positively impact patient relationships and improve the quality of care provided. In many cases, it’s more important than the digital tools at your fingertips.
“We have to quit focusing on what we can do when it comes to modern technology,” Myers says. “We must talk about what we should do with it to put it to work for patients.”