PEER ASSESSMENT IN RADIOLOGY

Transcription

1 PEER ASSESSMENT IN RADIOLOGY GREG BUTLER MD FRCPC FACR Chair Real Time Radiology Inc Zone Chief Radiology Nova Scotia Western Staff Radiologist (part time) Valley Regional Hospital

2 DISCLOSURE Founder and Chair Real Time Medical Inc 2

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5 WE LL REVIEW 1.RATIONALE FOR PEER REVIEW 2.OBJECTIVES 3.BARRIERS 4.THE OPTIMAL SYSTEM 5. IMPLEMENTATION 5

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7 QUOTED STATISTICS 1. 70,000 SERIOUS ADVERSE EFFECTS ON PATIENTS YEARLY IN CANADA 2. 23,000 PATIENTS DIE OF PREVENTABLE COMPLICATIONS 7

8 SUGGESTED REASONS CULTURE OF FINDING AND PUNISHING INHIBITS OPENESS OR MONITORING MEDICAL LEGAL RISKS SEEN AS A BARRIER TO IDENTIFICATION HIERARCHICAL CULTURE OF MEDICINE PERPETUATES THE ILLUSION THAT DOCTORS DON T MAKE ERRORS 8

9 WHAT IS THE REALY STORY? 1. ERROR IS UNAVOIDABLE IN ALL HUMAN ENDEAVOUR 2. ERROR RATES OF 30% HAVE BEEN IDENTIFIED IN RADIOLOGY, AND CARDIOLOGY (numerous papers, some quite recent) 3. ERROR RATES IN PRACTICE OF LAW HAVE BEEN QUOTED AS HIGH AS 44% AMONG LAWYERS ( The Good Lawyer. Seeking Quality in the Practice of Law. Linder and Levit. Oxford Press 2014) 4. RADIOLOGISTS NOT UNIQUE IN ERROR RATES JUST ONE OF THE EASIEST TO START PEER REVIEW WITH 5. OTHERS WILL FOLLOW 9

10 EXPECTATIONS AND SOCIETY 1. HIGHER DEMAND FOR QUALITY, TRANSPARENCY, AND ACCOUNTABILITY (eg Volkswagen, Toyota, GM) 2. ZERO TOLERANCE FOR ERRORS THAT COUNT (like aviation industry..but medicine more complex) 3. GOVERNMENT REPRESENTS THE PUBLIC 10

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12 OBJECTIVES OF PEER REVIEW 1. Satisfy government and the public that safety is insured 2. Documented Continuous Quality Improvement 3. Reduced pain and expense of medical legal engagement and audits 12

13 ELEMENTS OF THESE OBJECTIVES 1. ASSESSMENT is the least important part, but will get the most initial attention (Why we can t call it peer education 2. AIM TO MAKE IT MORE OF A COACH THAN A JUDGE (Larson et al Rethinking Peer Review: What Aviation can teach Radiology About Performance Improvement. Radiology 2011) ) 3. CONTINUOUS ANONYMIZED FEEDBACK 4. PART OF THE LARGER OBJECTIVE OF CQI (Continuous Quality Improvement as suggested by Deming ) 5. THE GOAL IS TO CREATE A SYSTEM AND CULTURE OF CONTINUOUSLY IMPROVING QUALITY 13

14 THE MOST IMPORTANT THINGS CAN T BE MEASURED Walter Edwards Deming DON T PUT TOO MUCH FAITH IN DATA DATA ONLY USEFUL IF IT HELPS UNDERSTAND THE SYSTEM AND MAKE NECESSARY IMPROVEMENTS QUALITY FEEDBACK APPROACH SHOULD ALLOW ALL PEOPLE IN THE ENTERPRISE TO IMPROVE PERFORMANCE OVER TIME DATA CAN DEMONSTRATE THIS IMPROVEMENT AND INSURE THAT THE ENTERPRISE IS ON THE RIGHT TRACK TOWARDS EVER INCREASING QUALITY AVOID HUNT AND IDENTIFY MENTALITY 14

15 UNDERSTANDING THE DATA (eg Discrepancies are not always errors) Accurate measurement is impossible (reviewers are human and subjective) Avoiding misinterpretation of data while achieving accountability and transparency Workflow and efficiency concerns Practical design, implementation and cost Palatability to radiologists Dangers to radioloigsts. Fear of discovery, dismissal, ridicule, and poaching. These can be all addressed by empowering rads to participate in design and implementation. 15

16 OPTIMAL SYSTEM ELEMENTS 1. ROBUST INFORMATICS MINIMIZES HUMAN INTERACTION 2. FULLY CUSTOMIZABLE TO MEET EVOLVING INSTITUTIONAL NEEDS 3. ANONYMOUS 4. ADVANCED METRICS GATHERING AND CONTINUOUS FEEDBACK, WITH EMPHASIS ON THE VALUE OF FEEDBACK 5. ALL SHIPS ARE RAISED APPROACH TO DEPARTMENTAL QUALITY 6. DEMONSTRATES CONTINUOUS PERFORMACE IMPROVEMENT 7. EASILY INSTALLED, STABLE, AND AFFORDABLE 8. AGNOSTIC TO PLATFORM BEING USED 9. SCALABLE TO INCLUDE NEIGHBOURING OR EVEN PROVINCE WIDE ENTERPRISE. 16

17 PEER ASSESSMENT APPROACHES RETROSPECTIVE (eg ACR RadPeer)- focused on the radiologist with no ability to directly impact the patient. PROSPECTIVE (Ability to intercept errors before they impact the patient) Scoring- Modification of Rad Peer with additional features to pick up poor reporting style, no content descriptive reporting, poor proof reading etc. Scoring used to help quantify and qualify discrepancies for the benefit of the reviewed radiologist as well as for anonymous data collectioon 17

18 SYSTEM IMPLEMENTATION 1. PROTECTIVE MEDICAL LEGAL FRAMEWORK 2. BUY IN BY RADIOLOGIST STAFF 3. TRAINING OF RADIOLOGISTS IN THE PRINCIPLES OF REVIEW 4. FINE TUNED DESIGN PARAMETERS (percentage of cases selected(5-10%), whether or not to hold reports on reviewed cases, at what point to break anonymity in the interest of identifying a problem that is not getting better, specialist reviews of generalist s work etc) 5. COMPLETE INTEGRATION INTO THE WORKFLOW SO THAT EFFICIENCY IS NOT ADVERSELY AFFECTED (WORK FLOW AUTOMATION CAN COMPENSATE FOR THE TIME IT TAKES TO DO A REVIEW 6. DISPUTE ADJUDICATION 18

19 REVIEWER EDUCATION NOT INTUITIVE FROM RADIOLOGY TRAINING ALL RADIOLOGISTS ARE REPORTERS AND REVIEWERS THE PROCESS OF REVIEWING MAKES ONE SHARPER AT REPORTING QUALITY AND CONSISTENCY OF REVIEWING COMES WITH PRACTICE AND EDUCATION 19

20 SYSTEM ADMINISTRATION 1. MONTHLY OR YEARLY CHECK ON DISCREPANCY RATES 2. IDENTIFY ANONYMOUS OUTLIERS AND DETERMINE WHEN INTERVENTION MIGHT BE NEEDED 3. PROMOTE A CULTURE OF MUTUALLY BENEFICIAL CONTINUOUS QUALITY IMPROVEMENT. 20

21 THE IDEAL SYSTEM A. ACHIEVES CONTINOUS RADIOLOGIST REPORTING QUALITY IMPROVEMENT THROUGH ANONYMOUS SELF ASSESSMENT B. INTERCEPTS IMPORTANT ERRORS BEFORE THEY AFFECT PATIENTS C. CUSTOMIZABLE TO CHANGING INSTITUTIONAL NEEDS AND FEEDBACK D. SATISFIES GOVERNMENT AND REGULATORS DESIRE FOR TRANSPARENCY AND ACCOUNTABILITY E. IS SEEN BY RADIOLOGISTS AS A PROTECTION RATHER THAN A THREAT 21

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23 WHO IS IT? 1. PHOTOGRAPH IS THE 7 TH MOST EXPENSIVE EVER SOLD ($2.3M) 2. ONLY AUTHENTICATED PHOTO OF THIS FAMOUS PERSON 3. WILLIAM McCARTY 23

24 WHY IS HE REMEMBERED TO THIS DAY? Not because he killed 21 men and robbed banks Not because he was especially good looking Because he was clever, personable and passionate about what he did HE GOT OFF TO A BAD START 24

25 LETS GET OFF TO A GOOD START! 25