Radiology Resident Quality Training Program

Paul Nagy, PhDFauzia Vandermeer, MD

Charles Resnik, MD

Systems-Based Practice

“Very few doctors understand what is happening to the health care system in which they practice, why the system is changing so rapidly, and what they can do about it.”

Relman, Academic Medicine, 1998

Goals

• Non didactic physician leadership training• Lightweight practical training in quality

methods• Create a learning culture of quality• Leverage IT as important tool for quality

We do the big things well• Exponential growth in medical knowledge• Technological marvels abound in Radiology

The downsides

• Technology has sterilized relationships• Continual subspecialization challenge

consistency and coordination of care in the 24/7 world.

Death by a thousand cuts

• Coordination• Handoffs• Feedback• Collaboration• Communication• Checklists• Follow up

The cumulative affect of small barriers inhibit these important behaviors.

Quality Manifesto

• A learning culture is built by launching 100’s of small projects to fix the cracks in our system.

• Large multiyear system upgrades merely enable a higher potential. You still need to roll up your sleeves and customize it to your local workflow and culture.

• What are you waiting for?

ACGME Systems-based PracticeResidents must demonstrate an awareness of and responsiveness to the larger context

and system of health care, ..Residents are expected to:

(5) work in interprofessional teams to enhance patient safety and improve patient care quality; and,

(6) participate in identifying system errors and implementing potential systems solutions.

(8) be trained to identify existing systems problems that compromise their ability to provide the

most efficient and effective patient care. They must be trained to analyze systematically the problems, develop solutions, implement solutions, and evaluate the effectiveness of the intervention.

“Program Requirements ACGME Radiology”

Education in practice mgmt

“When the researchers compared the five-year results from two medical schools, they found that students were significantly more satisfied with their education.”

Example (Patient Consent Forms)

• Not applicable– DNAR

• Procedures by team members

• Permission to destroy organs

• Potentially confusing for patient, radiologist

Resident Quality Requirements

• Core Curriculum in Quality– Attend Quality Academy for didactic training in Quality

Management– Participate in Peer Review conference– Perform one Quality Improvement Project– Present Quality Improvement Project at the Quality Academy

• Satisfies ACGME requirements for Practice-based Learning and Improvement and Systems-based Practice

Resident Projects

Not another rotation!Projects are self paced (6 months - 2 years)Often they come up with their own problemWe provide resources and mentoring.Residency directors kept in the loopHand off to staff at completionUp to residents to take initiative

Steps to a quality project

Effort (hrs)

Researching problemLiterature searchRead quality material

6-8 Hrs

Create teamDefine problemMap workflowIdentify barriersIdentify dataDocument Meetings

4-6 Hrs

Collect & Analyze dataUnderstand problemGroup exercisesCommunicate with teamDevelop intervention

10-12 Hrs

Collect & Analyze dataTest solutionMeet with teamCommunicate with teamDevelop interventionDocument Improvement6-8 Hrs

Verify solutionPresent at AcademyPublication (+40)

4-6 Hrs

Project List• Patient Consent Forms• Mild contrast reaction medication access• Surgical followup• Pathology biopsy concordance• OR miscount handoff• ED Pneumonia • ED appropriateness of CT orders• Delayed study sending into PACS• Resident dictation accuracy• ACR appropriateness guidelines• Interventional resident consult checklist• Uncompleted studies delaying reporting process

Tools

UM PACS Context Button

Portal.radiology.umm.edu

Context Integrated Form Manager

Radtracker.radiology.umm.edu

Technologist Report Cards

Resident Review

• Interpretation review• Technical accuracy review• Automated report change

detection

Processes

Take a set of activities and intertwining them to make an engine for quality.

Internally Promoting Quality

Calendar of Events

Meeting AgendasQuality MissionRoles and

MembersCommittee

MinutesProject

TemplatesLinks to Quality

Tools

Project Templates

Engine of QualityIdentify Issues:

OperationsSafety WalkPeer Review

Work on Issues:Image Quality

SatisfactionQuality Clinic Present and Control:

Quality AcademyOperations

Six Sigma/ Lean Certification

• Special Elective• Elective requirements also developed to provide more in depth training

in all “pillar” areas for residents interested in pursuing further study– Reading list on Quality– Attend one Operations meeting– Attend one Quality Leadership meeting– Attend one Image Quality meeting– Participate in safety walkabout inspection– Perform a survey design exercise– Submit an abstract on a project to a national meeting– Submit a peer review manuscript for publication– Act as a mentor to a junior resident on a Quality Project

Univ of Maryland Results

• 25/32 residents have started a project• 11 2009 Abstracts to RSNA• 7 2009 Presentations on quality at RSNA• Six Sigma/Lean certification