1. Radiology Resident Quality Training Program Paul Nagy, PhD Fauzia Vandermeer, MD Charles Resnik, MD

2. 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

3. 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

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

5. The downsides Technology has sterilized relationships Continual subspecialization challenge consistency and coordination of care in the 24/7 world.

6. Death by a thousand cuts Coordination Handoffs Feedback Collaboration Communication Checklists Follow up The cumulative affect of small barriers inhibit these important behaviors.

7. 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?

8. ACGME Systems-based Practice Residents 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”

9. 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.”

10. Example (Patient Consent Forms) Not applicable – DNAR Procedures by team members Permission to destroy organs Potentially confusing for patient, radiologist

11. 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

12. Resident Projects Not another rotation! Projects are self paced (6 months - 2 years) Often they come up with their own problem We provide resources and mentoring. Residency directors kept in the loop Hand off to staff at completion Up to residents to take initiative

13. Steps to a quality project Effort (hrs) Researching problem Literature search Read quality material 6-8 Hrs Create team Define problem Map workflow Identify barriers Identify data Document Meetings 4-6 Hrs Collect & Analyze data Understand problem Group exercises Communicate with team Develop intervention 10-12 Hrs Collect & Analyze data Test solution Meet with team Communicate with team Develop intervention Document Improvement 6-8 Hrs Verify solution Present at Academy Publication (+40) 4-6 Hrs

14. 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

15. Tools Process People

16. UM PACS Context Button Portal.radiology.umm.edu

17. Context Integrated Form Manager

18. Radtracker.radiology.umm.edu

19. Technologist Report Cards

20. Resident Review Interpretation review Technical accuracy review Automated report change detection

21. Processes Tools Process People Take a set of activities and intertwining them to make an engine for quality.

22. Internally Promoting Quality Calendar of Events Meeting Agendas Quality Mission Roles and Members Committee Minutes Project Templates Links to Quality Tools

23. Project Templates

24. Engine of Quality Present and Control Improve Identify Identify Issues: Operations Safety Walk Peer Review Work on Issues: Image Quality Satisfaction Quality Clinic Present and Control: Quality Academy Operations

25. 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

26. 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