Radiology Review Course ABR Non interpretive Skills

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1 Radiology Review Course ABR Non interpretive Skills March 30, 2015 Annemarie Relyea Chew, JD, MS Associate Professor Radiology Adjunct Associate Professor BIME University of Washington School of Medicine University of Washington Department of Radiology 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. 1

2 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 interpretive Skills Domains* Quality Improvement Patient Safety Professionalism & Ethics Compliance & Regulatory Research & Screening Imaging Information *Acknowledgement of primary source: urce%20guide.pdf 2

3 Why is this important? Core & Qualifying Examinations Maintenance of Certification Core Competencies Institutional Metrics Practice Quality Improvement project for MOC PPACA or Affordable Care Act 3

4 Recent updates: The ABR revised the Quality and Safety core study guide in February Changes are high lighted The remaining topics are currently unchanged Bibliography and Suggested Reading List (partial) Abujudeh HH, Bruno MA. Quality and Safety in Radiology. New York, NY: Oxford University Press; Abujudeh HH, Kaewlai R, Asfaw BA, Thrall JH. Quality initiatives: key performance indicators for measuring and improving radiology department performance. Radiographics 2010;30(3): 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): ACR AAPM Practice Parameter for Diagnostic Reference Levels and Achievable Doses in Medical X Ray imaging. ACR AAPM SIIM Practice Guideline for Digital Radiography. ACR AAPM Technical Standard for Management of the Use of Radiation in Fluoroscopic Procedures. ACR Dose Index Registry. National Radiology Data Registry (NRDR) website. ACR Manual on Contrast Media v9. American College of Radiology website. safety/resources/contrast manual. 4

5 Added or amended Quality & Safety Core Exam p. 21 Graphs and Charts Quality & Safety Core Exam: 22 5

6 Part I (a) Core examination review for quality and safety 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 Quality improvement Institute of Medicine (IOM): Crossing the Quality Chasm: A New Health System for the 21 st Century

7 Institute of Medicine 6 Aims for Quality Improvement Safety Effectiveness Patient Centeredness Timeliness Efficiency Equality CORE COMPETENCIES Practice Based Learning & Improvement Medical Knowledge Systems Based Practice Interpersonal Communication Professionalism Patient Care 7

8 QI Terminology Quality Assurance QA a term generally associated with enforcement *Quality Control QC accuracy precision reliability Quality Improvement QI Terminology: Quality improvement (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 8

9 QI Terminology: 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 9

10 Methodologies and QI Tools PDSA: plan, do, study, act Six Sigma (DMAIC) Lean: lean process improvement PQI: practice quality improvement CQI: continuous quality improvement TQM: total quality management 10

11 Determine the object of the study PDSA: Plan, do, study, act Baseline assessment Analyze & compare with benchmarks Implement improvement 11

12 Plan Do Study Act Ihttp:// HI Model for Improvement The Toyota Way The long view Right process will yield correct results Human development Corporate philosophy *team success not individual merit Solving root problems improves community learning 12

13 Kaizan 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 Lean Philosophy: 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 13

14 learning conso Six Sigma (6σ or 3.4 errors or defects/million) Define Measure Control or Validate Analyze Design or Improve DMAIC or DMADV 14

15 Lean six sigma sigma/ Ishikawa or fishbone diagrams 15

16 Charts Flow Charts Pareto Charts Control chart or Shewart charts View process variations: performance data plotted over time, centerline, upper & lower statistical limits: 16

17 ROC curve 17

18 Part I(b) Core examination review for quality and safety 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 18

19 Contrast Safety Please be responsible for: 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 Contrast Media Safety/Resources/Contrast Manual 19

20 Please be responsible for: **Universal Protocol 3 part process I. Pre procedure verification process II. Mark the procedure site III. Perform a time out *Medication reconciliation Six rights of medication reconciliation: Right patient Right medication Right route Right dose Right time Right documentation 20

21 To Err is Human Patient Safety 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 Types of Error I. Diagnosis error or delay failure to employ indicated tests use of outdated methods or tests failure to act on test or monitoring results II. Treatment Errors performance of an intervention, operation, test administrating the treatment dose or method of using a drug delay in treatment or responding to abnormal test inappropriate not indicated care 21

22 Types of Error III. Preventative Errors Failure to provide prophylactic treatment Inadequate monitoring or follow up of treatment IV. Other: *communication failure equipment failure other system failure Patient Safety Terminology 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 22

23 Patient Safety Terminology 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. 23

24 Patient Safety Terminology *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. 24

25 National Patient Safety Goals (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 Diagnostic Imaging 25

26 *ACR Practice Parameters for Communication of Diagnostic Imaging Findings es/comm_diag_imaging.pdf 26

27 The Joint Commission (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 27

28 Examples of Sentinel or Never Events in Diagnostic Imaging Sentinel or Never Events Unintended retention of foreign object in patient Patient death or serious disability associated with fall Patient death or serious disability associated with medication error Example: Diagnostic Imaging Guide wire left in patient following catheter insertion Patient falls while being moved onto diagnostic imaging table Wrong epinephrine dose administered during management of a allergic reaction to contrast Interventional procedure performed on wrong body part Interventional procedure performed on wrong patient Wrong interventional procedure performed on patient Intra or postprocedural death in an ASA Class I patient ASA = American Society of Anesthesiologists, FDA = Food and Drug Administration Chest tube inserted into right instead of left pleural space Biopsy performed on a patient with name similar to that of the intended patient Nephrostomy tube inserted when Foley catheter was intended Cardiac arrest occurs during radiofrequency ablation of liver tumor performed with patient under anesthesia Examples of Sentinel or Never Events in Diagnostic Imaging Sentinel or Never Events Patient death or serious disability associated with use of contaminated drugs, devices, or biologics Example: Diagnostic Imaging 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 Patient death or serious disability associated with intravascular air embolism that occurs while patient is being cared for in a healthcare facility Vein is lacerated during insertion of a metallic stent that is FDA approved only for use in bile ducts Large air embolus develops as a complication of catheter insertion into a pulmonary abscess Patient death or serious disability associated with burn Patient death or serious disability associated with use of restraints Patient with transdermal patch develops asevere thermal injury during MRI Patient suffers ami 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 28

29 Fig 1 Human reliability curve Abujudeh and Bruno. Just Culture : Is Radiology Ready? JACR 2015;12:4-5 29

30 PATIENT SAFETY EVENT 30

31 Root Cause Analysis (RCA) Focuses on prevention, not blame or punishment (cornerstone: no one comes to work to make a mistake or hurt someone) Focuses on system level vulnerabilities and latent errors rather than individual performance Communication Environment/Equipment Training Rules/Policies/Procedures Fatigue/Scheduling Barriers RCA: Fishbone Kruskal, et al. Radiographics 2008;28:

32 Swiss cheese model Reason J. Human error: models and management. BMJ Mar 18; 320(7237):

33 MRI Safety planning.com/newsletter/2012/1203_2_mri_fires.html 33

34 Gadolinium 34

35 Contrast Media Safety/Resources/Contrast Manual Gadolinium & NSF 35

36 Choosing Wisely Five things patients and physicians should question ACR Recommendations: 1. Don t do imaging for uncomplicated headache; 2. Don t image for suspected PE without moderate of high pretest 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. patient lists/american college of radiology/ Elements of informed consent 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 36

37 Informed Consent 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. Informed Consent 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. Ed01.pdf 37

38 ALARA and Dose Management 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 ALARA and Dose Management 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 minutes Burns, 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 38

39 Image Gently Campaign Step Lightly (fluoroscopy) 39

40 Attributions The Core Examination Guide (ABR) Feb Bibliography and suggested reading The Non interpretive Skills Guide (ABR) 2014 ACR: Appropriateness Criteria Practice Parameters & Technical Standards NGC: HHS: Health and Human Services AHRQ: Agency for Healthcare Research and Quality CMS: Centers for Medicare and Medicaid IOM: Institute of Medicine 40

41 Thank you. If you have any questions please contact me: 41