Drive for greater quality moves away from blame culture to better systems

March 9, 2007

Discussion of mistakes, incompetence, and errors in radiology often leads to finger-pointing. Which radiologist missed that hairline fracture? Who scheduled that young woman for an abdominal CT scan, instead of requesting ultrasound? Whose desk did Mrs. Smith’s unreported chest x-ray sit on for three months? Why wasn’t contrast used in Mr. MacDonald's MRI scan?

Discussion of mistakes, incompetence, and errors in radiology often leads to finger-pointing. Which radiologist missed that hairline fracture? Who scheduled that young woman for an abdominal CT scan, instead of requesting ultrasound? Whose desk did Mrs. Smith's unreported chest x-ray sit on for three months? Why wasn't contrast used in Mr. MacDonald's MRI scan?

The search for a scapegoat may be all too common, given growing pressure from governments, medical insurers, and patient support groups on healthcare providers to clean up their act. Yet piling blame on individuals is not necessarily the best way to improve quality. Speakers at this morning's special focus session were scheduled to outline how departments, institutions, and even the radiology community as a whole can work together to raise standards.

Stakeholders' insistence on getting objective proof of quality in healthcare should not be tackled as one-off initiatives, according to Prof. James Thrall, chair of the radiology department at Massachusetts General Hospital in Boston, and professor of radiology at Harvard Medical School. Experience has also shown that even the most diligent, competent individuals will not get everything right all of the time if they are working on their own. What is needed, instead, are departments that accept accountability, and prioritize quality and safety in every practice and procedure.

"If we are going to achieve better quality, we have to frame it in the context of better systems of care, rather than simply flogging each healthcare worker to death to do better," Thrall said.

MGH's radiology department has been running a quality management program that adheres to these principles since 1991. One simple change involved creating a foolproof way to prevent misidentification in the outpatient x-ray department. Anyone arriving for an outpatient x-ray appointment now receives an identifying wrist band. As individuals are called up for a scan they are asked their name and date of birth. The technologist verifies that their answers match what is on the wrist band and the scheduling sheet before going ahead with the x-ray.

The switch from film-based imaging to a digital acquisition and storage system has also helped reduce errors. Electronic images don't get lost, stolen, or misplaced, Thrall said. Pieces of film, on the other hand, could be stored in the wrong folder, misfiled in the film library, or sit in someone's inbox for weeks on end. His department has also cut back its expenses by going digital. A single piece of x-ray films costs $1.60, whereas a CD-ROM that can store hundreds of images costs just $1.

The new emphasis on systems does not mean that individual expertise is no longer recognised or expected, though. The idea is to combine competency-based training with improvements in systems of care.

"You do not need to devalue the dedication of an individual. You are just in the happy position of giving that individual a better system to work in," Thrall said.

Prof. Bruce Hillman, professor of radiology at the University of Virginia, agrees that radiologists have nothing to fear from the quality revolution. Sure enough, doctors must increasingly demonstrate that what they do makes a positive difference. The philosophy of: "Trust me, I'm a professional" is no longer sufficient. But this is hardly an unreasonable request, given the rising cost of imaging and concerns over waste in radiology.

"We have a moral imperative to practise in a way that better helps clinicians make their patient-related decisions, and that better improves patient health." Hillman said. "This is something that we have never been asked to do before. We need to respond in a way that allows us to continue to practise, but also ensures that it will improve patient healthcare at a more reasonable cost."

One way for the radiology community to meet this goal is by conducting more high-quality research. This would provide solid evidence on which procedures and protocols are worthwhile and which should be abandoned.

"I would argue that about 70% of radiology practice is based on habit and anecdote, and has not been validated as best practice. What I'm saying is, 'Let's improve the evidence base, let's get more scientific understanding,'" Hillman said.

The majority of radiology research conducted at present is difficult to apply generally, he added. Studies tend to be quite specific to the institution in which they were carried out, and highly focused on specific issues. He would prefer to see more multicenter projects that tackle the big questions in radiology. Such studies would then be more applicable to more radiologists, and could help raise standards across the specialty.